The Doctor’s Surgery
What’s in a name? When the name is cancer, quite a lot, as anyone knows who has been diagnosed with cancer – or has been told he doesn’t have cancer.
A recent debate in the British Medical Journal illustrates the importance of terminology. On one side of the debate, the author, a specialist in breast cancer, argues that certain cancers are so indolent – they progress so slowly and cause death so rarely, if ever – that they should no longer be called cancer because of the patient’s resultant anxiety when diagnosed with them.
Diagnosing a lesion as cancerous when it’s non-threatening leads to over-investigation and over-treatment, on the principle of better-safe-thansorry. As if this were not bad enough, statistics of survival are distorted – in the direction of both under- and overestimation – by the inclusion of different kinds of cancer in the same category.
On the other side of the debate, a histopathologist has argued that, since cancerous lesions fall on a continuum of malignancy rather than being a simple dichotomy – malignant or benign – we shouldn’t shy away from the word. If the impression were given to patients that they had had unnecessary operations because they had not had ‘real’ cancer, they would become confused and angry.
The same condition, cancer of the prostate, is used to back up both sides’ arguments. On one side, it’s argued, ‘ultra-low risk prostate cancer’ has such high survival rates – 98 per cent at 10 years – that, because it is initially diagnosed by measuring the Prostate Specific Antigen, screening by means of this test has fallen from favour because doctors think the cancer is innocuous.
On the other side, it’s argued that, because 30 per cent of those with a biopsy diagnosis of ‘ultra-low risk prostate cancer’ in fact have higher-risk cancers of the prostate in other parts of the gland when it has been removed and examined histopathologically, one can only know a prostate cancer is ultra-low risk by a complete prostatectomy. Therefore, the argument that ultra-low risk prostate cancer should be recategorised as a non-cancer because none of the men died from it after a prostatectomy is not valid.
Instead of a change of nomenclature, the histopathologist says, ‘If the public were educated that “benign” signifies very low risk rather than no risk, anxietyinducing labels could be avoided.’
He gives a puzzling example, seeming to undermine his argument that a change of nomenclature was beside the point: ‘Recently, the World Health Organisation renamed a subtype of kidney cancer as multilocular, cystic, renal neoplasm of low malignant potential because it had not been proved to recur or metastasise. Since these tumours have a benign outcome, an alternative approach would be to expand the pathological spectrum of benign, multilocular, renal cysts to include this type of tumour.’
In these enlightened times of patient choice, it should be left to the patient to decide whether he would rather have a multilocular, cystic, renal neoplasm of low malignant potential or a benign, neoplastic, multilocular, renal cyst.
There are dangers to overtreatment and undertreatment. We are naturally inclined to overtreat. A friend recently had an operation for a cancer scare that turned out to have been unnecessary, subsequently causing him an epileptic fit that meant he lost his driving licence.
When I was bitten by a tick that occasionally causes an infection, I was told it was unnecessary to take antibiotics. I took antibiotics. After all, better safe than sorry.