7/30/2013

The lead story in today’s New York Times, on the right hand column of Page One, is entitled “Scientists Urge Narrower Rules to Define Cancer”. The main thesis of the article, which chronicles a study published yesterday in the Journal of the American Medical Association, is something I have been saying to many of you for quite some number of years.

Perhaps the following anecdote will underscore the issue:

Several years ago a patient came to me for a routine visit. When I asked her “What’s new?” she replied that she had been diagnosed with breast cancer since our last visit. I was quite surprised and requested her records (It was a well known cancer institution slightly north of NYU Medical Center). It turned out that her final diagnosis was “Ductal Carcinoma-in-situ (DCIS)”. She had been told that she had “Stage 0 breast cancer”. I informed her that she did NOT have breast cancer.

On the first day of their pathology course in the second year of medical school, students are taught that one of the hallmarks of malignancy (cancer) is INVASION. The phrase in-situ means there is no invasion. This woman believed that she was a “breast cancer survivor”. The psychological ramifications of having had cancer had obviously taken their toll.

While it is true that some patients with Ductal Carcinoma-in-situ (DCIS) may proceed to invasive cancer, the accepted treatments for this are quite varied and have to be individualized. They include, prophylactic mastectomy, or radiation, or therapy with drugs such as tamoxifen or Evista, or even careful surveillance. I am not suggesting that such diagnosis be taken lightly, however it is inappropriate to tell such a patient that she has had cancer.

The same is true for Carcinoma-in-situ of the cervix. I’ve told many of you that have had cervical dysplasia, that Carcinoma-in-situ is more appropriately thought of as “super severe dysplasia”. It is unfortunate that is has that cancer word “Carcinoma” in it.

Furthermore, this article in today’s Times makes reference to “incidentalomas”. These are findings on an imaging study, which may have been there for quite some time and are often totally innocuous but can lead to increased patient anxiety, further testing, and even unnecessary surgery. When I was president of the North American Menopause Society (NAMS), I chose the topic “Incidental Findings in Imaging” for my Presidential Symposium at their 2011 annual meeting. Many of you have incidental findings on your pelvic sonograms ranging from fibroids to benign cysts to dilated benign fallopian tubes, etc. I have often warned many of you to be very careful that if you have an imaging study for some other reason your biggest jeopardy would be the misinterpretation of such findings, leading to unnecessary surgery in some cases.

In summary, I applaud the scientists from the National Cancer Institute in their attempts to fix the misclassification of many of these benign findings that are extremely frightening to patients as outlined above. To read the original New York Times article online, click here.

As always, if you have any further questions, please do not hesitate to contact us. Until then, I remain yours in health.

Dr. Goldstein