Addressing overdiagnosis and overtreatment in cancer: a prescription for change

Summary

A vast range of disorders—from indolent to fast-growing lesions—are labelled as cancer. Therefore, we believe that several changes should be made to the approach to cancer screening and care, such as use of new terminology for indolent and precancerous disorders. We propose the term indolent lesion of epithelial origin, or IDLE, for those lesions (currently labelled as cancers) and their precursors that are unlikely to cause harm if they are left untreated. Furthermore, precursors of cancer or high-risk disorders should not have the term cancer in them. The rationale for this change in approach is that indolent lesions with low malignant potential are common, and screening brings indolent lesions and their precursors to clinical attention, which leads to overdiagnosis and, if unrecognised, possible overtreatment. To minimise that potential, new strategies should be adopted to better define and manage IDLEs. Screening guidelines should be revised to lower the chance of detection of minimal-risk IDLEs and inconsequential cancers with the same energy traditionally used to increase the sensitivity of screening tests. Changing the terminology for some of the lesions currently referred to as cancer will allow physicians to shift medicolegal notions and perceived risk to reflect the evolving understanding of biology, be more judicious about when a biopsy should be done, and organise studies and registries that offer observation or less invasive approaches for indolent disease. Emphasis on avoidance of harm while assuring benefit will improve screening and treatment of patients and will be equally effective in the prevention of death from cancer.

Introduction

On March 8–9, 2012, the National Cancer Institute convened a meeting to assess the problem of cancer overdiagnosis, which occurs when tumours that would otherwise not become symptomatic are identified and treated. When this overdiagnosis is not recognised, it can lead to overtreatment. Participants of the meeting agreed that with the deployment of increasingly sensitive imaging tests, more lesions are being identified and labelled as cancer. This Personal View describes the initial steps to address the increasing problem of overdiagnosis and overtreatment.

The word cancer encompasses a range of disorders, from those that are always lethal if left untreated (or even if treated) to indolent lesions with extremely low potential for metastatic progression and death.¹ Several other diseases show a similar range of severity—eg, diabetes can progress slowly or rapidly, as can rheumatoid arthritis, hepatitis, coronary artery disease, and inflammatory bowel disease. Unfortunately, when patients hear the word cancer, most assume they have a disease that will progress, metastasise, and cause death. Many physicians think so as well, and act or advise their patients accordingly. However, since many tumours do not have the unrelenting capacity for progression and death, new guidance is needed to describe and label the heterogeneous diseases currently referred to as cancer.