Murali Varma, consultant histopathologist
The controversy about renaming some low risk cancers1 is partly related to the perception of “benign” and “malignant” as biologically distinct conditions, when there is a continuum of increasing risk from benign to “good cancer” and “bad cancer.”2
The distinction between good and bad cancer is generally accepted to be arbitrary, with any risk of metastasis being interpreted as low or high by different patients and health professionals. But the minimum risk threshold for diagnosis of cancer is just as arbitrary, with a low threshold resulting in overdiagnosis (and overtreatment) and a higher threshold risking underdiagnosis (and undertreatment). This is analogous to the arbitrary cut-offs used to diagnose and stratify diseases like hypertension, where a diastolic pressure of 101 mm Hg does not confer a substantially higher risk than 99 mm Hg.
Overdiagnosis of clinically insignificant “cancers” could have serious consequences. In addition to harming some patients with overtreatment, other patients (including those with non-cancerous diseases) may be harmed by the diversion of funds in overstretched healthcare services.
Experts who feel that the cancer label could be removed from some low risk tumours are uncomfortable labelling them as benign and suggest alternative terminology such as “indolent lesions of low malignant potential” and “tumour of uncertain malignant potential.”34 But these expressions of prognostic uncertainty could themselves induce anxiety, especially if clinical or radiological follow-up is recommended.
An alternative approach could be to raise the arbitrary risk threshold for the pathological diagnosis of cancer so that very low risk cancers are categorised as benign. If the lay population could be educated that benign signifies very low risk rather than no risk at all, then anxiety inducing labels could be avoided.
- Competing interests: None declared.
- Full response at: https://www.bmj.com/content/362/bmj.k3528/rr-2.
- R Hurley. Overdiagnosis and the cancer label. Editor’s choice. BMJ2018;362:k352810.1136/bmj.k3528 .
- B NickelR MoynihanA BarrattJP BritoK McCaffery. Renaming low risk conditions labelled as cancer. BMJ2018;362:k3322. 10.1136/bmj.k3322 30100549
- LJ EssermanIM ThompsonB Reid. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol2014;15:e234-42. 10.1016/S1470-2045(13)70598-9 24807866
- J Rosai. Handling of thyroid follicular patterned lesions. Endocr Pathol2005;16:279-83. 10.1385/EP:16:4:279 16627915
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