April 19, 2022 – Low-grade prostate tumors should no longer be called “cancers,” a change recommended by a team of experts that would likely ease anxiety among patients and their families and reduce unnecessary treatment.
Doctors often advise men with low-risk prostate tumors to wait and see if the disease worsens – an approach called “active surveillance” – rather than rushing to treat the condition. After all, low-grade tumors rarely cause harm, and therapies such as radiation and surgery can often be worse than the disease itself and carry serious side effects, including impotence and urinary leakage.
Yet doctors still label these lesions “cancer,” and as a result, some experts say, many men opt for treatment they don’t need.
In a new paper likely to stoke debate, a group of experts, including one patient, argue that overtreatment could be reduced by removing the word “cancer” from low-risk disease. Tumors that rate 6 on the Gleason score – considered the lowest risk -- cannot invade other organs but scare patients into undergoing risky treatments, they argue. Fewer than 1% of men with grade 6 prostate tumors go on to experience cancer that spreads or die from cancer within 15 years of the first diagnosis, they report.
“No matter how much time a physician may spend down-playing the significance of a GS6 diagnosis or emphasizing the phrase ‘low-risk,’ the words ‘you have cancer’ have a potent psychological effect on most men and their families,” they wrote in a paper published Monday in the Journal of Clinical Oncology.
Dropping the “C” word for low-risk tumors, which make up about half of 268,000 prostate cancer diagnoses annually in the United States, is not a new idea. An independent panel convened by the National Institutes of Health proposed just that in 2011. However, support from doctors for the shift appears to be growing, says Scott Eggener, MD, an oncologist and professor of surgery at the University of Chicago, who co-authored the new article.
Eggener said active surveillance has been increasing dramatically in the United States, to about 60% of patients with low-risk tumors.
“We feel like the landscape is right now to be talking about this issue,” Eggener says.
Reducing unnecessary treatment, the authors argue, could reduce the cost of health care -- and boost the benefit of testing for prostate cancer, which the U.S. Preventive Services Task Force says is not happening enough.
Also, patients with prostate cancer diagnoses face increased risk of depression and suicide, disqualification or higher rates for life insurance, and questions from family and friends if they choose surveillance over treatment – all of which might be helped by a change in terminology.
The word “cancer” has been dropped from bladder, cervical and thyroid conditions and prostate abnormalities that used to be classified as Gleason 2 through 5, they say.
Keeping the Status Quo
But some doctors disagree with dropping the word cancer.
From a scientific standpoint, tumors rated a grade 6 have molecular hallmarks of cancer, says Jonathan Epstein, MD, a professor of pathology, urology, and oncology at the Johns Hopkins University in Baltimore. More important, Epstein says, the classification does not guarantee that more serious cancer is not present, only that it has not been found yet in tissue samples.
Eggener acknowledges that while GS6 does have molecular markers associated with cancer – a fact that’s “challenging to reconcile with” – giving it another name “would still require surveillance, and since the window of opportunity for curing localized [prostate cancer] is typically measured in years or decades.”
Still, Epstein worries that dropping the cancer designation may cause some patients to skip active surveillance, which involves repeated imaging and biopsies. Without such monitoring, he said, “if they do have higher grade cancer that’s unsampled, it will pose a threat to their life.”
Gleason 6 tumors “may progress, some significantly, or be incompletely sampled at the time of diagnosis. Both clinicians and patients need to understand such risk,” says Peter Carroll, MD, a urologist at the University of California, San Francisco, who is critical of the proposed name change.
Regardless of what it’s called, tumors like these need close monitoring, says Joe Gallo, a 77-year-old Pennsylvania man whose high-risk cancer was detected during active surveillance. “If I had taken a laid-back, or less, approach” to monitoring, Gallo says, “necessary treatment may have been delayed and my condition may have become more serious.”
Some advocates say patients and their families need to be educated that cancer exists on a scale of severity.
Mark Lichty, 73, chairman of a support group called Active Surveillance Patients International, received a Gleason 6 diagnosis 17 years ago. He resisted treatment against medical advice, and the cancer never progressed.
Lichty said active surveillance has been more widely adopted in Sweden, where doctors reassure patients that treatment is unnecessary and support systems exist. “Yes, a diagnosis of cancer is frightening,” he says. But “we can do a lot better in how we communicate the diagnosis.”