Call It Cancer

A couple of recent editorials in The Oncologist have reacted to the recent NIH consensus panel on prostate cancer and this panel's statement that it may be "a mistake" to call low-grade, low-volume prostate cancer a cancer on the basis that it may cause unnecessary anxiety and provoke unnecessary action when the majority of men with this diagnosis are elderly and never experience morbidity or mortality with this disease.

Bruce Chabner and Matthem Smith (editorial, free registration required) opine that:

Although we agree that the connotation of lethality for some patients is unfortunate, the diagnosis of cancer depends on pathological findings (my emphasis), specifically, pathological appearance and invasive behavior. Indolent cancers occur as part of the spectrum of breast cancers, lymphoma, and other forms of malignancy, and those will continue to be called cancer.

Marshall Lichtman in another editorial draws comparison with the tortured terminology of myelodysplasic syndromes ("refractory anemia" "excess blasts") and the detrimental effects this mislabeling had on the understanding of this disease:

A profound error was made of the sort that Drs. Chabner and Smith are trying to help us avoid when the clonal cytopenias and oligoblastic myelogenous leukemia were designated myelodysplasia. By using such anachronisms (and euphemisms) as refractory anemia, and illogical terms as “excess blasts”—as if one can have an excess of malignant cells akin to excess fat cells—a neoplasia is thereby mislabeled a dysplasia, thus setting back thinking about the disorders by 50 years.

The confusion of students trying to understand why a disease with leukemic blast cells in blood and marrow is not called leukemia and of basic scientists thinking they were studying a preneoplastic condition was entirely unnecessary, if the correct language had been chosen.

This got me thinking about a similar and frequent situation I find myself with the term "carcinoid tumor"--a term that, at a minimum obscures and at worst is just downright wrong, in terms of clearly indicating the malignant potential of tumors showing typical characteristics.  So what does atypical carcinoid tumor mean?  As awkward as it is to explain metastatic carcinoid tumor in tumor board conferences, I can only imagine how it would be explaining to a patient, especially if that patient has done some research on the Internet prior to our visit.

What we call things does indeed matter and we, as pathologists, should make every effort to use terminology that reflects the behavior of what we are trying to describe.  It is some comfort that some of our oncology colleagues recognize our contribution to the diagnostic process but we must also be accountable for being complicit in using and perpetuating confusing and abstruse language.

Comments

[Mark D. Pool, M.D.]

Dr. Cogbill's statement of "how humble our understanding is of cancer, generally" is, I find, insightful. One wouldn't necessarily perceive that humility if you were attending the 2012 ASCO national meeting this weekend.

[Mark D. Pool, M.D.]

Thanks for your comment.

[Christopher Cogbill]

So very well put, Dr Pool. My chosen field is hematopathology and I admit we have much work to do as it pertains to being clear and unambiguous with terminology. For instance, "lymphoma", one of the critical entities in our diagnostic parlance, is riddled with imprecision when taken into context with much of the rest of pathological diagnostic precision. Myelodysplastic syndromes are still difficult for me to explain to medical students and residents, let alone the public, and I am nearly a fellow - about to be trained to be an expert in the field.

Perhaps it is reflective at how humble our understanding is of cancer, generally. To ascribe a perfect nomenclature would be to minimize the complexity of this diverse process. To begin with, we might follow the lead of current molecular taxonomy, once a perplexing mess of abbreviations and goofy-doof names (e.g. Sonic hedgehog, Snail, Slug, etc.) We have to start somewhere, bringing a process with numerous permutations of variety down to earth. I think we can all agree there would still be a long way to go, but at least we'd all know where square one was.