Panel Recommends Major Changes for Cutting Down Cancer Overdiagnosis and Overtreatment

Eileen Koutnik-Fotopoulos

November 2013, Vol 4, No 9 - Economics of Cancer Care

For the past 30 years, awareness and screening have led to an emphasis on the early diagnosis of cancer. The goals were to get screened and to catch cancer early to reduce the rate of late-stage disease and to decrease cancer mortality. However, improved screening has resulted in the overdiagnosis and overtreatment of cancers that are not life-threatening, without significantly decreasing the death rate from the disease. In March 2012, the National Cancer Institute (NCI) convened a meeting to review the evidence on overdiagnosis.

In a recently published article, a working group has issued a call for major changes in the way the medical profession classifies and thinks about cancer, and in the way screening programs are designed (Esserman LJ, et al. JAMA. 2013;310:797-798).

The working group outlined 5 major recommendations for the NCI to consider.

  1. The first is for physicians, patients, and the general public to recognize that overdiagnosis is common and occurs frequently with cancer screening. Overdiagnosis is common in breast, lung, prostate, and thyroid cancers. Whenever screening is used, the fraction of tumors in this category increases. “By acknowledging this consequence of screening, approaches that mitigate the problem can be tested,” wrote the working group.
  2. The second recommendation is to reserve the term “cancer” for describing lesions with reasonable likelihood of lethal progression if left untreated. For example, premalignant conditions should not be labeled as cancers, nor should “cancer” be in the name. Diagnostic tools that identify indolent or low-risk cancers also need to be adopted and validated.
    Another change is to reclassify such cancers as indolent lesions of epithelial origin (IDLE) conditions. The writing group suggests that “multidisciplinary effort across the pathology, imaging, surgical, advocate, and medical communities could be convened by an independent group (eg, the Institute of Medicine) to revise the taxonomy of lesions now called cancer and to create reclassification for IDLE conditions.”
  3. The third recommendation is to create observational registries for lesions with low malignant potential. This would improve information about related disease progression and help patients and clinicians decide on a treatment plan.
  4. The fourth recommendation is to mitigate overdiagnosis by developing strategies to reduce the detection of indolent disease, such as reducing low-yield diagnostic evaluations, reducing the frequency of screening examinations, focusing screening on high-risk populations, and raising thresholds for recall and biopsy.
  5. The final recommendation is to expand the approaches to cancer progression and treatment. “Future research should include controlling the environment in which precancerous and cancerous conditions arise, such as an alternative to surgical incisions,” wrote the working group.

The panel noted that these recommendations are only initial approaches. Policies that prevent or reduce the chances of overdiagnosis and overtreatment are needed. Physicians and patients are urged to have open discussions about these complex issues. The media also must begin to better comprehend and communicate these messages to the public about the potential hazard of overdiagnosis and overtreatment of cancer to ensure that the approach to screening for cancer can be improved.