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Well – Did You Have Cancer Or Was It … Should It Be Downgraded Or Re-Named?

Well – Did You Have Cancer Or Was It … Should It Be Downgraded Or Re-Named?
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Posted by:
Greg Lance – Watkins
Greg_L-W

eMail: Greg_L-W@BTconnect.com

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Hi,

in my medical ignorance I have long felt that certain areas labelled cancer were so different from others and that cancer seemed to be rather too much a catch all, where many treatments were a fine line between whether the disease was killed or the patient – perhaps increasing life expectation of cancer patients has been in part an ever more precise nomenclature defining cancer!

It’s Not Cancer: Doctors Reclassify a Thyroid Tumor

By GINA KOLATAAPRIL 14, 2016

Photo

A noninvasive follicular thyroid neoplasm with papillary-like nuclear features, or Niftp, a type of tumor that was previously considered a kind of cancer, but has been downgraded by a panel of doctors. Credit Yuri Nikiforov

An international panel of doctors has decided that a type of tumor that was classified as a cancer is not a cancer at all.

As a result, they have officially downgraded the condition, and thousands of patients will be spared removal of their thyroid, treatment with radioactive iodine and regular checkups for the rest of their lives, all to protect against a tumor that was never a threat.

Their conclusion, and the data that led to it, was reported Thursday in the journal JAMA Oncology. The change is expected to affect about 10,000 of the nearly 65,000 thyroid cancer patients a year in the United States. It may also offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.

The reclassified tumor is a small lump in the thyroid that is completely surrounded by a capsule of fibrous tissue. Its nucleus looks like a cancer but the cells have not broken out of their capsule, and surgery to remove the entire thyroid followed by treatment with radioactive iodine is unnecessary and harmful, the panel said. They have now renamed the tumor. Instead of calling it “encapsulated follicular variant of papillary thyroid carcinoma,” they now call it “noninvasive follicular thyroid neoplasm with papillary-like nuclear features,” or NIFTP. The word “carcinoma” is gone.

Many cancer experts said the reclassification was long overdue. For years there have been calls to downgrade small lesions in the breast, lung and prostate, among others, and to eliminate the term “cancer” from their name. But other than the renaming of an early stage urinary tract tumor in 1998, and early stage ovarian and cervical lesions more than two decades ago, no group other than the thyroid specialists has yet taken the plunge.

In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary. Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early-stage prostate lesions were called cancerous tumors. Meanwhile, imaging with ultrasound, M.R.I.’s and C.T. scans find more and more of these tiny “cancers,” especially thyroid nodules.

“If it’s not a cancer, let’s not call it a cancer,” said Dr. John C. Morris, president-elect of the American Thyroid Association and a professor of medicine at the Mayo Clinic. Dr. Morris was not a member of the renaming panel.

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Scientists Seek to Rein In Diagnoses of Cancer JULY 29, 2013

Dr. Barnett S. Kramer, director of the division of cancer prevention at the National Cancer Institute, said, “There’s a growing concern that many of the terms we use don’t match our understanding of the biology of cancer.” Calling lesions cancer when they are not leads to unnecessary and harmful treatment, he said.

At major medical centers, many patients with encapsulated thyroid tumors are already being treated less aggressively. But, thyroid experts say, that is not the norm in the rest of the country and the rest of the world.

The word cancer is a problem, said Dr. Bryan R. Haugen, a thyroid cancer specialist at the University of Colorado, Denver, who was also not a member of the renaming panel.
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“If you keep cancer in there a lot of people are going to be aggressive,” he said.

The reclassification drive began two years ago when Dr. Yuri E. Nikiforov, vice chairman of the pathology department at the University of Pittsburgh, was asked his opinion about a small thyroid tumor in a 19-year-old woman. It was completely encased in a capsule and the lobe of her thyroid containing it had been removed to establish a diagnosis.

Over the last decade, Dr. Nikiforov had watched as pathologists began classifying noninvasive tumors as cancers and attributed the change to rare cases in which patients had a tumor that had broken out of its capsule, did not receive aggressive treatment and died of thyroid cancer. Worried doctors began treating all tumors composed of cells with nuclei that looked like cancer nuclei as if they were cancers. But this young woman’s story drove Dr. Nikiforov over the edge.

“I told the surgeon, who was a good friend, ‘This is a very low grade tumor. You do not have to do anything else.’ ” But the surgeon replied that according to practice guidelines, she had to remove the woman’s entire thyroid gland and treat her with radioactive iodine. And the woman had to have regular checkups for the rest of her life.

“I said, ‘That’s enough. Someone has to take responsibility and stop this madness,’ ” Dr. Nikiforov said.

He brought together the international panel of experts — 24 renowned pathologists, two endocrinologists, a thyroid surgeon, a psychiatrist who knew the impact a cancer diagnosis could have, and a patient. The group collected a couple of hundred cases from multiple centers throughout the world — patients who had tumors that were contained within fibrous capsules and those that had broken out. All agreed that by the current criteria every one of those tumors would be classified as a cancer. And all of the patients had been followed for at least 10 years. The patients with the encapsulated tumors had not been treated after their tumors were removed.

None of the patients whose tumors stayed within their capsules had any evidence of cancer after 10 years. But some of the patients whose tumors had broken out of their capsules had complications, including death, from thyroid cancer despite treatment.

“This study said it is not the presence of nuclear features but the presence of invasion that can make the difference between cancer and noncancer,” Dr. Nikiforov said. Patients whose tumors are confined within their capsules “have an excellent prognosis,” he said. “They do not need a thyroidectomy. They do not need radiotherapy. They do not need to be followed up every six months.”

But if those tumors are not cancers, what should they be called?

“Ten different names were submitted and the voting went on, back and forth,” said one member of the panel, Dr. Gregory W. Randolph, director of the thyroid and parathyroid surgical clinic at Harvard’s Massachusetts Eye and Ear Infirmary. They finally settled on NIFTP, in part because its acronym, which he pronounced “Nift-P,” was catchy, he said. The new name, the reclassification, he added, is “just awesome,” because it explicitly defines those small nodules in the thyroid as nonmalignant.

In an editorial he and his colleagues submitted to the journal Thyroid, they report that eight leading professional societies from around the world signed on to the declassification and to the new name. They write in the editorial that doctors may be violating the principle of “first, do no harm” in treating patients with these tumors as though they have invasive cancer.

Dr. Nikiforov says he owes it to patients with reclassified tumors to tell them they never had cancer after all. At the University of Pittsburgh Medical Center, he and others are going to start reviewing medical records and pathology reports to identify previous patients and contact them. He estimates there have been about 50 to 100 each year at the medical center. They no longer have to go back for checkups. They lose the shadow of cancer that the diagnosis hung over their lives.

Informing these patients, Dr. Nikiforov said, “is a moral obligation of doctors.”

To view the original article CLICK HERE

Regards,
Greg_L-W.

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Redefining Cancer & Cancer Diagnosis

Redefining Cancer & Cancer Diagnosis

From: Greg Lance-Watkins (Greg_L-W)

Greg_L-W@BTconnect.com

 

Hi,

some interesting thoughts on the reclassification within the general term ‘Cancer’:

Scientists Seek to Rein In Diagnoses of Cancer

A radiologist uses a magnifying glass to check mammograms for breast cancer.Damian Dovarganes/Associated Press
A radiologist uses a magnifying glass to check mammograms for breast cancer.

A group of experts advising the nation’s premier cancer research institution has recommended sweeping changes in the approach to cancer detection and treatment, including changes in the very definition of cancer and eliminating the word entirely from some common diagnoses.

The recommendations, from a working group of the National Cancer Institute, were published on Monday in the Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”

While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group’s views, the report from such a prominent group of scientists who have the clear backing of the National Cancer Institute brings the discussion to a much higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.

“We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.

The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.

The advent of highly sensitive screening technology in recent years has increased the likelihood of finding these so-called incidentalomas — the name given to incidental findings detected during medical scans that most likely would never cause a problem. However, once doctors and patients are aware a lesion exists, they typically feel compelled to biopsy, treat and remove it, often at great physical and psychological pain and risk to the patient. The issue is often referred to as overdiagnosis, and the resulting unnecessary procedures to which patients are subjected is called overtreatment.

Harold VarmusHiroko Masuike/The New York Times Harold Varmus

Officials at the National Cancer Institute say overdiagnosis is a major public health concern and a priority of the agency. “We’re still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold Varmus, the Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”

One way to address the issue is to change the language used to describe lesions found through screening, said Dr. Laura J. Esserman, the lead author of the report in the Journal of the American Medical Association and the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. In the report, Dr. Esserman and her colleagues said they would like to see a multidisciplinary panel convened to address the issue, led by pathologists, with input from surgeons, oncologists and radiologists, among others.

Ductal carcinoma in situ is not cancer, so why are we calling it cancer?” said Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco.

Such proposals will not be universally embraced. Dr. Larry Norton, the medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, said the larger problem is that doctors cannot tell patients with certainty which cancers will not progress and which cancers will kill them, and changing terminology does not solve that problem.

“Which cases of D.C.I.S. will turn into an aggressive cancer and which ones won’t?” he said, referring to ductal carcinoma in situ. “I wish we knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer.”

Dr. Norton, who was not part of the report, agreed that doctors do need to focus on better communication with patients about precancerous and cancerous conditions. He said he often tells patients that even though ductal carcinoma in situ may look like cancer, it will not necessarily act like cancer — just as someone who is “dressed like a criminal” is not actually a criminal until that person breaks the law.

“The terminology is just a descriptive term, and there’s no question that has to be explained,” Dr. Norton said. “But you can’t go back and change hundreds of years of literature by suddenly changing terminology.”

But proponents of downgrading cancerous conditions with a simple name change say there is precedent for doing so. The report’s authors note that in 1998, the World Health Organization changed the name of an early-stage urinary tract tumor, removing the word “carcinoma” and calling it “papillary urothelial neoplasia of low malignant potential.” When a common Pap smear finding called “cervical intraepithelial neoplasia” was reclassified as a low-grade lesion rather than a malignancy, women were more willing to submit to observation rather than demanding treatment, Dr. Esserman said.

“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” she said. “The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term ‘cancer’ for those things that are highly likely to cause a problem.”

The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett’s esophagus, small thyroid tumors and early prostate cancer. But even after aggressively treating those conditions for years, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.

The National Cancer Institute working group also called for a greater focus on research to identify both benign and slow-growing tumors and aggressive diseases, including the creation of patient registries to learn more about lesions that appear unlikely to become cancer.

Some of that research is already under way at the National Cancer Institute. Since becoming director of the institute three years ago, Dr. Varmus has set up a list of “provocative questions” aimed at encouraging scientists to focus on critical areas, including the issue of overdiagnosis and molecular tests to distinguish between slow-growing and aggressive tumors.

Another National Cancer Institute program, the Barrett’s Esophagus Translational Research Network, or BETRNet, is focused on changes in the esophageal lining that for years have been viewed as a precursor to esophageal cancer. Although patients with Barrett’s are regularly screened and sometimes treated by burning off the esophageal lining, data now increasingly suggest that most of the time, Barrett’s is benign and probably does not need to be treated at all. Researchers from various academic centers are now working together and pooling tissue samples to spur research that will determine when Barrett’s is most likely to become cancerous.

“Our investigators are not just looking for ways to detect cancer early, they are thinking about this question of when you find a cancer, what are the factors that might determine how aggressively it will behave,” Dr. Varmus said. “This is a long way from the thinking 20 years ago when you found a cancer cell and felt you had a tremendous risk of dying.”

To view the original article CLICK HERE

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