WHEN CANCER ISN’T REALLY CANCER

One of the hardest jobs as a physician is to tell a patient and family that they have been diagnosed with cancer. As a urologist dealing with prostate, bladder and kidney cancer, I often give potentially life-threatening diagnosis while simultaneously reassuring hope and optimism, a skill that requires a deft mastery of the art of medicine.

But what happens when that diagnosis won’t have any impact on longevity or health? How does one give a perceived life-threatening diagnosis while reassuring the patient that it really isn’t in the least? I find this to be almost more of a challenge than the first scenario.

As clinicians have come to understand the biology of cancers, it is clear that certain “cancers” will have no impact on longevity. For instance, the emerging standard of care for low grade, low volume prostate cancer (often categorized as very low risk) is active surveillance and no treatment.  This has changed dramatically even in the relatively short time I have been in medicine, from the early 2000’s to now. Similarly, low grade bladder cancer behaves much more like a benign polyp rarely if ever becoming serious or life-threatening.

The biology of these diseases, including the lower grade variants, were often described generations ago, often when the clinical implications were not entirely stood. As a result, we as clinicians are limited by old nomenclature that is outdated. Invariably, trying to talk down the “c” word to a patient is difficult, often met with reticence from the patients and /or family. Fortunately, I am mostly successful in educating my patients, but every subsequent visit by these patients is often riddled with anxiety, waiting for the “other shoe to drop”.

It would be far more helpful to doctors and patients alike to have different terminology altogether for these indolent variants of disease. This is not a novel idea, but has been pushed by many organizations, including the National Cancer Institute. In fact, Dr. Otis Brawly, the chief medical officer for the American Cancer society, stated succinctly, “We need a 21st century definition of cancer, instead of a 19th century definition, which is what we’ve been using” (https://well.blogs.nytimes.com/2013/07/29/report-suggests-sweeping-changes-to-cancer-detection-and-treatment/).

Even these proposals tend to be inadequate. Replacing the term cancer to pre-cancer or other variant may help, but any association with the word cancer already sets a psychological impact.  Re-classifying and re-naming some these tumors to reflect their true clinical behavior (which will only get easier to do with genomic testing) would give patients more peace of mind with their treatment (or in some cases no treatment).

(Let me know your thoughts and any new names you may have to describe these disease states. As a reference, The word cancer is derived from the Latin cancer, meaning crab or creeping ulcer.)

 

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