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Reexamining the Definition of Cancer


Welcome back. I'm Ira Flatow.

When your hear the word cancer, what does it mean to you? The big C, right? Fear, uncertainty. But not all cancers are created equal. Not all are equally harmful. They are not all treated the same way. This week, a group of doctors published recommendations in the Journal of the American Medical Association for refining the definition of cancer. They say our current definition can lead to overdiagnosing cancer, it can lead to patients undergoing unnecessary treatment, and that we should reexamine our approach to cancer detection and treatment.

Laura Esserman is one of the authors of the viewpoint and director of the Carol Franc Buck Breast Cancer Center, professor of surgery and radiology at the University of California in San Francisco. Welcome to SCIENCE FRIDAY.

LAURA ESSERMAN: Thank you very much. Happy to be here.

FLATOW: You're welcome, Dr. Esserman. Larry Norton is deputy physician-in-chief of the breast cancer programs and medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering here in New York. Welcome, Dr. Norton.

LARRY NORTON: Thank you very much. And hi, Laura.

ESSERMAN: Hi, Larry.

FLATOW: Dr. Esserman, why do we need a new definition of cancer?

ESSERMAN: Well, I think - our goal is to make sure that the public is aware that the story about cancer is more complex than what I think we have appreciated in the past. And, you know, the goal of all the early detection programs was simply to catch cancer early, and that would solve all the problems. And, unfortunately, it's going to be a little bit more complicated. So we want people to know that if you - and so there are two aspects of it. One is what we focus on when we're screening, and also how we adjust treatment once we have a diagnosis, and for the public to understand that just because you have a cancer, that doesn't mean every cancer is a killer cancer.

So, increasingly, going forward, we want to start to use some of the tools and techniques not only to test new aggressive treatments, but to figure out how to do less safely in the settings where we begin to believe we can do less safely. And so I think that's very important. And I also think it's important that - people are very panicked that they - if something is called an abnormality, it isn't necessarily something that's cancer. And I think we can adjust our threshold for what we biopsy, so we can avoid doing harm.

A perfect example is in the lung cancer screening recommendations that just came out. If you look carefully, you're going to see tons of little nodules on lung - on the CT screens, but even lesions that are a centimeter have only a 1 percent, 1.5 percent chance of being cancer. So those probably should not be the targets for biopsy, because the biopsy can cause harm and cause perhaps a collapsed lung.

So we're trying to make sure that both the imaging community, the - our physician community and the patient community understand that they don't have to panic over every abnormality, and that going forward, they're going to start to see recommendations where people are given the options to try treatments that are less aggressive, and they should welcome that and not be afraid of it.

FLATOW: Mm-hmm. Just think, if the public really - I don't think - most people don't understand that there are a hundred types of cancer.


FLATOW: And, you know, they hear the word basal cell carcinoma and - or something on their - or their nose has something from the sun, which is very easily curable, but they may just freak out.

ESSERMAN: That's correct. And I think it also - everyone, then, wants to take every nevus off or, you know, that - and we just try to show that, you know, just going early and finding things smaller, in fact, you're going to increase that reservoir of slow growing or indolent cancers, and we want - don't want people to think necessarily those are all the same and require the same aggressive treatment.

FLATOW: Dr. Norton, would you agree, or do you think that we could go too far in the opposite direction and not...

NORTON: Yeah. That's the issue I see, that everything that Laura's saying is totally, factually true, is that we're, right now, at a revolutionary period of understanding what cancer really is. And, you know, frankly, you know, many of us in the profession try not to use the term. We talk about it much more specifically. It does have connotations that may not be realistic, as Laura just mentioned.

You know, we're studying the biology of the disease in ways. Cancer is not just growth. It's also the possibility to spread the cells to other parts of the body, where they can cause trouble. You mentioned the basal cell carcinoma. I actually call it basal cell epithelioma, to try to get that word out of it. But if that grows too big and is left there for too long, it actually can cause a whole lot of trouble. So you have to be very cautious. It's not an absolute.

And in the absence of absolutes, we have to make decisions, yin-yang decisions in terms of the pros and the cons of any approach. So, you know, for instance, Laura just mentioned, well, only 1 percent of such and such can be cancer. Well, if you happen to be in that 1 percent, it's a big deal not taking care of it. And if you're...

ESSERMAN: So, I would agree with you, Larry, though...

NORTON: On the other hand, you know, obviously, you know, a lot of people would be undergoing things that could be, you know, very unpleasant or even potentially dangerous to take care of it. So making those distinctions is very - is critically important. And I think a lot of people expect that things are very clear-cut in medicine, but they never have been.

And one of the really interesting things about this contemporary period is that the public is becoming aware of the fact that every decision, there's always pros and cons. And we welcome the patients being involved in understanding those pros and cons so they can help make the right decision that's right for them.

ESSERMAN: And I - Larry and I, I think, agree very much on this. And I - what we want is to encourage more thoughtful discussion. So if you think that something's pretty low risk, instead of necessarily putting a needle in it, like a 1-centimeter nodule, repeat the scan in a short period of time. And if it looks stable, then you can leave it alone.

There are - you can use disease dynamics. And, you know, I'm not talking about - certainly, I agree that cancer is very serious and terrible. You know, I'm a practicing physician. I take care of people all the time. But I see on the screening side that there are a lot of things that I think that we could let go of that turn out to be nothing.

And if you'd just be a little more thoughtful about it, you know, but people have to know, it's OK. And taking a little time does not going to put anyone at risk if the worst thing that you - that it could be is a very slow-growing lesion. Or, in the case of these kind of very low-grade in-situ carcinomas, we actually have a trial that's open by one of the groups that Dr. Norton was - used to be head of, to really test a different approach.

Can we give a hormone therapy to see if we can suppress the growth and make them go away, treat them more like prevention? In order to try some new approaches, people have to understand, there are some things that are very slow-growing, there's no emergency to do something about, like a Gleason 3 plus 3 prostate cancer or, you know, some of these very low-risk thyroid lesions.

So I think that there's - and we think it's an opportunity for the community to start thinking more about the things that Dr. Norton was talking about: What are the things that we can do to be clear about distinguishing the killer cancers from those that aren't?

FLATOW: But is your primary care physician, your family physician knowledgeable enough about these changes, or about the...

NORTON: Yeah. Well, you're talking about another - you're talking about a very interesting other aspect of this, which is, really, simultaneously with this tremendous explosion of knowledge about biology. And we need to get better and better at being able to look at changes in cells and say: What's the likelihood? Is it gonna hit one way or the other? We're not quite there yet, and I don't want to make promises to the public, then, and say that we know more than we do. So we have to be a little careful of that.

But we really are making strides, and it's a very exciting future. But simultaneously with that, is there's a lot of thought about how to disseminate information, very sophisticated information better to everybody who is involved in these decisions, including the primary care doctor. There's been huge revolutions in computerization of information, and how information will be transmitted and applied.

I'm involved in a project now - several projects now, in fact, at the American Society of Clinical Oncology and Memorial Sloan-Kettering with trying to develop decision aids to help people who are not true experts in a given disease make really sophisticated decisions, the same decisions that a true expert who spends all their time spending that particular disease would make. And that's happening simultaneous with this tremendous advance in our information about cancer.

ESSERMAN: Right. And, you know, I think that, you know, I think it's important, though, for people to understand, if you're going to screen, you will necessarily find more cancers that are slow-growing. That's the nature of screening. And that, you know, if you have - are told that you have cancer, you want to know what type. We've made huge strides in breast cancer by really trying to refine the types of cancers.

And, you know, we know that in certain - what we call luminal A tumors in post-menopausal women, we don't have to be so aggressive with doing either radiation or mastectomy. That actually came out of another important cooperative group study, demonstrating that some of these tumors you can be less aggressive with. This is something that people should welcome.

So we want to push that kind of concept forward. And I think that the idea of risk-based screening, I think, in the future could be something very important, that, you know, every cancer is the same, not everyone is at risk for the same kinds of things, that we need to expand our notions of how to get more benefit and less of the side effects or harms out of it. So, for example, if you're going to screen for lung cancer, only screen the people at very highest risk, or you will do more harm than good.

NORTON: There's another aspect of this, though, which I think ought to be brought forward, is that sometimes screening does pick up bad cancers.

ESSERMAN: Of course.

NORTON: Not every cancer that's picked up by screening is a slow-growing one, or one with a low likelihood of spreading to other parts of the body. There are particular kinds of breast cancer that, even when they're small, they are very aggressive, and they do require therapy. So it's both ends.

ESSERMAN: Right. And that's actually really important, that...

NORTON: And I think that we have to be careful of this - of what you said before, the pendulum swinging, you know, to one side or the other, you know, as cancer is a bad word, malignancy is even worse word. Indolence might also be a loaded word, because it might be - say, somebody has got an indolent cancer, and it turns out not to be. And we may not have...

ESSERMAN: Well, but, Larry, would you agree that a three...

NORTON: ...may not have perfect ability to do that. So we have to be very precise and careful about our communication.

ESSERMAN: Well, but I think that what we want to say is that we would like to reserve the word cancer for those kinds of lesions that really are more serious. And a five-millimeter, HER2-positive breast cancer might still be a very dangerous cancer in a 42-year-old, whereas, you know, a two-centimeter, hormone-positive cancer may not be. So we're just trying to make sure the public understands it's a little bit more complicated. And that makes it not quite so simple, but it's an important conversation that people have to have.

FLATOW: You know, it's a confusing conversation, too, to the public.


FLATOW: It's - how do you walk that line between well-informed, and just being, oh, no, not another redefinition going on here. You know, it's almost like you're talking about food additives or, you know, stuff - vitamins and things. Oh, no, another study just contradicted the last study.

NORTON: Right. Well, I think you hit the nail on the head. It's the communication that's important, and not necessarily the terminology. If terminology helps the communication, then that's a very, very valuable thing. But communicating the explosive complexity of cancer, and how we're really deciphering it now, and what an exciting time this is and how it's going to help individuals, that's a very important thing to communicate.

ESSERMAN: So I would say a good thing to say is one size doesn't fit all. Makes - and that's true both for going after abnormal findings on images, that we can do a better job of refining what to go after. And one size doesn't fit all when you're diagnosed with a cancer. Cancer is not an emergency. Take your time to learn about what you have and what your true choices are. There's time for a second opinion. Cancer's not an emergency.

FLATOW: Mm-hmm. I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR. I'm talking with Dr. Laura Esserman and Dr. Larry Norton. That's an interesting that you just said. You probably say it a lot, Dr. Esserman. Cancer is not an emergency. Take your time...

NORTON: It sometimes is. Leukemias can be.

ESSERMAN: Unless you have leukemia, it's - but otherwise, it's not.

NORTON: Yeah. But, I mean, there are cancers that you really have to treat right away, like leukemias. But things like breast cancer, prostate cancer, those things - colon cancer - we're talking about...

ESSERMAN: Thyroid cancer.

NORTON: ...but the way I phrase it is: Spend some time to make the right decision rather than moving very quickly and making the wrong one.

ESSERMAN: We agree totally.

FLATOW: And how would you spend that time? What's the best way to spend that time?

NORTON: Well, I got - let me just jump in here, is that part of this - part of the confusion about this is the fact that not every cancer is the same, not every cancer type is the same, not every patient is the same. And if a layperson who is not immersed in this area tries to understand it all, it will be confusing and it's even confusing to experts.

Dr. Esserman and I are experts in breast cancer, but when we hear discussions about lymphoma, for example, it's a whole other level of complexity, so that what you have to do is get the information that's useful to you to make the decision that's right for you, and not necessarily try to have a total comprehensive knowledge of the whole field.

And the important thing there is getting to the right person, getting to somebody with a lot of experience, with a lot of knowledge or the ability to communicate. Very often, we'll all find that patients will see somebody who I know, is an excellent commission, but the communication is not excellent. For some reason, the two people really aren't talking the same language.

So you have to find somebody who not only knows what they're talking about, but can communicate it to you. And finding the right doctors are very important to that.

ESSERMAN: And actually, making sure that you write down your questions and think about what it is that you want to know and sharing those questions when you first walk into the room can be very helpful.

FLATOW: Do you think that social communities are a help or a hindrance here now, people just giving out...

ESSERMAN: Well, they can be both. So it can be helpful to know that people did something different. But, again, what Dr. Norton said was everybody isn't the same, and every cancer isn't the same. So when they say, well, my Aunt Sally, you know, had chemotherapy and she did - didn't, you know, whatever, that that may or may not apply to you. You have to understand that you have your own situation, and you want to go someone that you know understands the field and can give you choices and make sure that, you know, sometimes there are a number of different choices that we can offer, and the outcomes are different, and you just have to be able to have that conversation.

And, you know, some people are very risk-averse and don't want to - and want to do more. They have to understand, well, what is it that they're getting for that? Are - is that - am I truly saving my life? You know, there's a lot of people who have a kneejerk reaction when they hear cancer. Oh, my gosh. I have to have surgery. I have to have it out. You know, when we have more serious cancers, we actually like to give some of our systemic treatments first. And that's what we do with our more serious treatments, so we can see how the treatment's working.

And - but the old theory - and I'm a surgeon so I can say that - that just operating first isn't always the best answer. And, you know, even with our in situ cancers, there are some now where we want to try and - that we have the time and we have the opportunity to offer some other options.

FLATOW: Wait and watch.

ESSERMAN: Find out at their clinical trials.

FLATOW: Yeah, yeah. And, of course, doctors always want to do something, right?

ESSERMAN: Right. But some patients...

NORTON: Well, not always. I mean, I think you can't put doctors all in one category anymore than you put patients and their diseases in one category. There's whole lots of different approaches. And certainly, the people that Laura and I work with do want to spend a lot of time, make sure that we communicate well.

And watchful waiting can be a very reasonable thing, but you have to understand the pros and cons of that approach in the individual situation, to then make a good decision, that's the right decision for you. I just - I'm just...

ESSERMAN: And I think people need to think that more is not always better. You know, we used to do radical mastectomies, and we discovered that wasn't better, because people participated in trials and felt like it was reasonable to try something different. So when you're - and what we want to do is make sure that we can start to test, you know, ideas of doing less and being more precise. That's a whole goal, to be more precise in our treatments, precision medicine. That's what people should be hoping for and demanding.

FLATOW: Mm-hmm. All right.

ESSERMAN: And, you know, we want to encourage the community to have these conversations, the scientific community, to do a better job of developing biomarkers or tests that help us distinguish what it really takes to be a serious cancer. All these things will help us and the whole community to have this conversations.

FLATOW: And not to mention personalized medicine, which is a whole another topic we'll get into some other time. Thank you, doctors, for taking time to be with us today.

NORTON: Oh, it's a real pleasure. Thank you so much.

ESSERMAN: You're very welcome. Thanks.

FLATOW: You're welcome. Larry Norton is deputy chief physician-in-chief for breast cancer programs and medical director of the Evelyn Lauder Breast Center at Memorial Sloan-Kettering here in New York. Laura Esserman is director of the Carol Franc Buck Breast Cancer Center, professor of surgery and radiology at the University of California, San Francisco. That's about all the time we have for today. Transcript provided by NPR, Copyright NPR.