Earlier this year, Laura J. Esserman, MD, MBA, Director of the UCSF Breast Cancer Center, and Scott Eggener, MD, urologic oncologist and Co-Director of the High Risk and Advanced Prostate Cancer Clinic at The University of Chicago Medicine, penned a guest essay in The New York Times titled "Not Everything We Call Cancer Should Be Called Cancer." Their argument is that the word "cancer" scares people who receive the diagnosis and causes urgency to pursue potentially aggressive treatment. While some diagnoses require rapid treatment, not all do. "Some cancers have extraordinarily low risks of altering the quality or length of life but get lumped in with those that do. That often leads to unnecessary treatment, disfigurement, side effects, and a constellation of other psychological, relationship, and financial issues," the authors noted in the essay. Esserman is spearheading the WISDOM Study (Women Informed to Screen Depending On Measures of Risk), which is testing a personalized approach to breast cancer screening (e.g., genetic risk factors, lifestyle, and breast density) compared with annual mammograms.
1 How would you summarize why not all cancers should be called cancer?
"When most people hear they have cancer, they think they've got something that's going to grow rapidly and kill them if they don't get treatment. But when you have something that isn't necessarily going to become a cancer-and it itself isn't lethal-why are we calling it cancer?
"For instance, for people with certain low-risk prostate cancers (with Gleason 6 grade), many of those people don't ever need any treatment. And the treatments people do get (as a precaution) can have really serious consequences, both physical and psychological. So, I think it's really important to think about whether there are better ways to do things. But part of the reason it's hard to get people to think about doing something different is because the word cancer is so scary and people think, 'Oh my gosh, I need to do something.'"
2 What is the research needed to convince people the field should change course?
"We need to start trying different approaches to respond to low-risk cancer diagnoses. We don't know a lot of the answers right now because we always treat. When you start to do things differently-doing less or a different approach-you're actually very surprised by what happens. For instance, 97 percent of people are treated for their ductal carcinoma in situ (DCIS); about 25 percent get a mastectomy and 15 percent get a bilateral mastectomy. It's a lot. And many of these people probably don't need that-perhaps as many as half (Cancer Commun 2022; https://doi.org/10.1158/2767-9764.CRC-22-0263).
"People say DCIS can't go away, and that's actually not true. I've followed people for over a decade and their DCIS has regressed based on imaging and hasn't come back. I think about DCIS as an opportunity for prevention. What kind of DCIS do you have? What kind of invasive cancer are you at risk for? For the small number of people who are at risk for high-grade, fast-growing tumors that have an immune component, then you can start thinking about some kind of local immunotherapy. I've been running a Phase I trial for patients that direct injection into the DCIS of a PD1 inhibitor plus an mRNA-based immune stimulating cocktail. The results are very promising. Think of it as an in-situ vaccine trying to stimulate your immune cells to come and finish off the DCIS. That's a very exciting trial.
"For people with endocrine-positive or hormone-positive DCIS (which accounts for a vast majority of cases), there's research that suggests very low doses of tamoxifen (using 5 mg instead of 20 mg) is very safe and much better tolerated. (J Clin Oncol 2023; doi: 10.1200/JCO.22.02900). "So, by using MRI, different imaging tools, and other information about the tumor, we can start to sort out who's got a risk factor for getting cancer and who has focal disease who needs surgical treatment. We turned this into a multicenter platform trial called RECAST DCIS.
"This trial will be open at more than 20 sites across the United States and should be open in the next 1-4 weeks. We're testing the standard risk-reducing medication (such as baby tamoxifen or aromatase inhibitors) against some new endocrine risk-reducing approaches, including a combination with testosterone, a selective endocrine receptor degrader, and an active metabolite of tamoxifen. We are looking for new agents that may be even more effective and tolerable to reverse DCIS.
"Screening trials like WISDOM will help, too. The point of that trial is to identify people at high risk for breast cancer, but to distinguish between fast-growing and slow-growing tumors, as the approach to screening and prevention should be different. As well, we want to be able to identify women with lower risk and screen them less frequently. That's going to lead to fewer people being called back for biopsies they don't need without causing harm."
3 If certain cancers do undergo a name change, how does that happen?
"I think we have to work in a multidisciplinary way with pathologists who are putting the label of cancer into the term DCIS. In the same way we used to call cervical cancer cervical carcinoma in situ and then changed it to cervical intraepithelial neoplasia, names can change. Some lesions that used to be called bladder cancers or thyroid cancers no longer have the term cancer in the label.
"First we have to come up with a term that doesn't panic people and make them do more than they need or feel like it's an emergency, because it's not an emergency. You have time to think about it and decide what you need to do. Then we need to convene the right people-pathologists, surgeons, radiologists, and some forward-thinking medical oncologists. I think it's very important that it includes a broader range of people. Groups like the NCI or the CDC Division of Cancer Prevention and Control can step in to bring these stakeholders together."