Physicians and patients should engage in open discussion” about the complex issues of cancer screening, overdiagnosis, and overtreatment, according to a report from the chairs of a National Cancer Institute working group tasked with developing a strategy to improve the current approach to cancer screening and prevention.
Working group Co-Chair Ian M. Thompson, Jr, MD, told The ASCO Post that often when patients hear the terms cancer or malignancy, “the potential for their own mortality strikes them, and all of a sudden it becomes an emotional response instead of an intellectual response.” When that happens, he said, it is important that the patient be presented with precise data about long-term risks and that the physician “engage the patient in a conversation, so that the patient fully understands the risks of taking an aggressive vs a less aggressive approach.”
Dr. Thompson, who is a urologic oncologist, said, “A good example is low-grade prostate cancer that is low-volume. Almost nobody ever dies from that disease. When the patient fully understands the risk, he may say, ‘You mean to tell me, I don’t have to do anything because not doing anything is just as good as doing something?’ That patient may leave the office having decided not to pursue any treatment. However, the physician should be prepared for the patient calling the office after sharing his decision with his family. They might well have responded incredulously, “You have cancer, and the doctor is not going to do anything about it?”
Concern About Missed Diagnoses?
Asked if policies and programs intended to reduce the risk of overdiagnosis and overtreatment could cause concern about missed diagnoses, Dr. Thompson responded, “of course.” He said that he asks himself that question every time he sits down with one of his patients on active surveillance for prostate cancer.
“Certainly at the beginning of the conversation, before they opt for active surveillance, you have a very long discussion with them, and periodically you renew that discussion. As new data become available, you update them on the new data. So you are continuously asking yourself the question about missed diagnoses,” he said.
“On the other hand, taking a patient to the operating room for an extraordinarily low-risk tumor—which is an unusual circumstance for me personally—and putting the patient through the operative risk of that procedure and the potential side effects afterward, to me is a moral and ethical swamp where I don’t want to go,” Dr. Thompson commented.
“In the case of the patient who opts for radiotherapy, where we know there may be a 1% to 2% risk of a secondary malignancy from that treatment, while the tumor itself poses less than a 1% risk, you are doing harm,” he continued. “We are always struggling with that possibility, and I think in every oncologic discipline, when you see someone with a potentially lethal tumor and you embark on a treatment, you always ask yourself if the net benefit of the treatment will be greater than the net harm. But the overarching principle underlying all this is, above all, don’t make them worse,” he said.
“Another challenge is that a lot of these conversations occur in the primary care office. So we have to educate our primary care physicians as well,” he noted. ■
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