The Sequence 2/10-2/16
Is It Cancer? The Evolving Definition of a Complex Disease
Is It Cancer? The Evolving Definition of a Complex Disease
In the intricate world of cancer diagnosis, the word ‘cancer’ can apply to everything from abnormal cells that have the risk of leading to cancer to malignant tumors that have already spread throughout the body. Many of the names applied to these various pathologies are medical terms that are decades old and can be confusing to patients who are trying to figure out what is going on in their bodies. There’s a push by some oncologists to rename them, replacing the term ‘cancer’ with more accurate descriptions of the current nature of the disease
A recent article by the New York Times discusses some of the opinions expressed by oncologists on the subject. Here, I discuss what actually defines cancer and give examples of when this discussion is relevant.
When is it cancer?
Cancer starts with mutated cells that keep replicating themselves and blending in with healthy tissue. By definition, cancer cells grow uncontrollably and spread to other parts of the body if left untreated. I think the definition alone can be interpreted differently and cause confusion: Should abnormal cells that have the potential to turn into cancer be called cancer, or is it cancer only after the cells are already growing uncontrollably? Should the speed of the growth into cancer be taken into consideration? What about the probability the cells will grow into cancer? What should those cutoffs be?
The problem with using the word ‘cancer’ in situations when cancerous cells have not yet spread is that without understanding the nuances of that particular pathology, patients can interpret the diagnosis as one that has great urgency. However, many times diagnoses of conditions that we call cancer are easily managed without harsh treatments such as radiation. Oftentimes, abnormal cells that have not yet spread have even been there for quite a while and will continue to stay put right where they are.
When does the discussion of whether something should be called cancer come into play?
The main focus of the discussion is ductal carcinoma in situ, or DCIS, a frequent breast cancer diagnosis. In DCIS, cancer cells are confined to the lining of the milk ducts. Most of the time, the abnormal cells remain in the milk ducts just waiting to be removed. As we discussed, the definition of cancer is centered around cells that grow uncontrollably and spread to other parts of the body. This is where it gets tricky. Even though most of the time, the abnormal cells will never spread beyond their original location or cause problems in cases of DCIS, the cells will eventually transform into invasive breast cancer in approximately one in four patients.
Another thing to consider here is that for those one in four patients, the growth happens slowly. Meaning, active monitoring is likely sufficient to ensure the cells do not turn cancerous without preventive surgical intervention or radiation. One clinical trial of nearly 1,000 women with DCIS showed that patients who were being actively monitored did not experience a higher rate of cancer than patients treated with surgery after two years. In the opinion of Dr. Laura J. Esserman, a surgeon and oncologist at the University of California, the word ‘cancer’ does not reflect biological reality. Cancer “is a blight, something that will grow and take over and kill you,” she said. “If the condition is not that, then the name isn’t correct.”
This discussion is not limited to breast cancer. A handful of other conditions exist in this ambiguous space, including early-stage cancers of the lung, thyroid, esophagus, bladder, cervix, prostate and skin. While some are still called cancer, such as early-stage prostate cancer, others have been renamed: Abnormal cervical cells, for example, are now referred to as dysplasia. Other alternative names for such cancers could be called abnormal cells, low-grade lesions, stage 0 cancer, precancer, or a risk factor for cancer. To Dr. Esserman, renaming such conditions is an “ethical imperative” to spare patients undue anxiety and to shift the current treatment expectations from invasive surgery to active monitoring.
What’s the takeaway?
While the traditional definition of cancer emphasizes uncontrolled growth and the ability to spread, many conditions currently classified as cancer exhibit slow or even stagnant progression. This can lead to unnecessary anxiety and aggressive treatment for patients whose condition may not pose an immediate threat. However, the risk that these slowly-changing pathologies of abnormal cells may progress to cancer is very real and very important. Renaming these conditions to reflect their current state in the body while providing detailed education and counseling on the full risks of the conditions may help to more accurately manage disease, lessen anxiety, and empower patients to make treatment decisions proportional to the risks at hand.
https://www.nytimes.com/2025/01/28/health/cancer-diagnosis-language.html?
https://www.cancer.gov/about-cancer/understanding/what-is-cancer
https://www.mayoclinic.org/diseases-conditions/dcis/symptoms-causes/syc-20371889
https://www.aacr.org/blog/2022/10/12/ductal-carcinoma-in-situ-the-weight-of-the-word-cancer
https://jamanetwork.com/journals/jama/article-abstract/2828218
https://profiles.ucsf.edu/laura.esserman