Slow-Growing Prostate Cancer Is Still 'Real Cancer'

Zosia Chustecka

February 08, 2012

February 8, 2012 — Low-grade low-volume prostate cancer often grows very slowly, and men presenting with this diagnosis might never experience morbidity or mortality as a result of the condition. However, hearing the emotionally charged term "cancer" could cause unnecessary anxiety and prompt men to undergo unnecessary treatment. In such cases, a term other than cancer could be used.

This proposal was most recently aired by a panel of 14 experts convened for the National Institutes of Health (NIH) State-of-the-Science Conference on active surveillance for prostate cancer.

The panel concluded that active surveillance is a viable option that should be offered to low-risk prostate cancer patients, but they also stated that "strong consideration should be given to removing the anxiety-provoking term 'cancer' for this condition."

However, in an editorial published online February 2 in the Oncologist, 2 experts argue against any nomenclature change.

Removing the term cancer from the diagnosis of a low-grade low-volume prostate cancer would be a mistake, say Bruce Chabner, MD, and Matthew Smith, MD, both from the Massachusetts General Hospital in Boston.

Changing the name will simply confuse the issue.

"Changing the name will simply confuse the issue," Dr. Chabner noted.

"I am concerned about the rush to change the perception of prostate cancer," he said in a statement. "While it is certain that we unnecessarily treat or overtreat elderly patients with low-grade disease," he explained, "prostate cancer — like other cancers — has the potential to kill."

Currently, we do not know "which patients will progress and in which patients the disease will remain stagnant," he said. "That uncertainty needs to be communicated to our patients as we discuss screening and treatment."

Words Matter

At the recent NIH meeting, panel chair Patricia Ganz, MD, from the Jonsson Comprehensive Cancer Center at the University of California at Los Angeles, noted that "cancer is a continuum, but how we name it and how we talk about it influences treatment choices. We should not downplay that it is part of the neoplastic spectrum, but it is not as threatening as a highly invasive cancer."

No alternative or replacements terms were proposed at that meeting.

However, indolent lesions of epithelial origin (IDLE) tumors has previously been suggested as an alternative. That term was coined to describe the early lesions of breast cancer seen in ductal carcinoma in situ, but it was also proposed to cover slow-growing low-risk prostate cancer.

In their editorial, Drs. Chabner and Smith argue against any new terminology. They point out that indolent cancers occur as part of the spectrum of breast cancer, lymphoma, and other forms of malignancy, and those will continue to be called cancer.

"Prostate cancer, in all its manifestations, is a real cancer," they write. They emphasize that it is potentially fatal; approximately 15% of patients diagnosed with prostate cancer die from it.

The connotation of lethality for some patients is unfortunate.

They agree that "the connotation of lethality for some patients is unfortunate."

It is clear that patients with a favorable presentation usually progress very slowly; for elderly men, a period of active surveillance might not place them in danger of eventual death resulting from cancer, they write. "The same can be said for small, estrogen-receptor-positive breast cancer in elderly women, a presentation that may not require aggressive therapy."

However, for patients who are younger than 70 years and who have a life expectancy of 15 years or more, the outcome of active surveillance is less clear, they note. In this younger age group, the actual benefits of active surveillance, compared with aggressive intervention, have yet to be proven in a clinical trial. They point out that, if left untreated, some of these younger men with favorable findings at presentation — perhaps 10% to 20% — will live long enough to develop metastatic disease, and some will die as a result of its dissemination.

"Because of this uncertainty, many younger patients will choose to proceed with treatment," they note.

Drs. Chabner and Smith touch on the uncertainty surrounding the use of prostate-specific antigen screening and the controversy that erupted after the US Preventive Services Task Force recommended against its widespread use in the general population.

Patients deserve to know about these uncertainties to make informed decisions, Drs. Chabner and Smith conclude. "Ignoring the fact that it is cancer or renaming it something else does not help the discussion."

Dr. Chabner reports consulting for Sanofi, Redwood, Allergan, Epizyme, PharmaMar, and GlaxoSmithKline; receiving honoraria from Eli Lilly; and having an ownership interest in PharmaMar, Gilead, Merck, Epizyme, Human Genome Sciences, Curis, Onyx, Rigel, and Bristol-Myers Squibb. Dr. Smith has disclosed no relevant financial relationships.

Oncologist. Published online February 2, 2012. Abstract

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