Medical Wisdom Project

Overtreating Early Cancer

No thoughts on avoiding medical harm would be complete without arming you with some nuanced facts about this insidious, most feared disease called cancer. In 2020, it was estimated that cancer would kill 606,000 people in the US, maintaining its position as a leading cause of death, second only to heart disease. People will go to incredibly painful and debilitating treatment lengths to try to overcome cancer. Fear of it drives us to try to achieve certainty that cancer will not return when, rationally speaking, such certainty may not be possible. And in the quest for certainty, we may make trade-offs we don’t see unless we have medical wisdom.

Treating small, stable abnormalities with guns blazing may shorten your life unnecessarily.

Americans see cancer as a black-and-white issue. If your body has betrayed you by producing abnormal cells, then you need to find every last cell and destroy them before they destroy you. Right?

Unfortunately, that is not possible. We all have abnormal cells, which our immune systems are constantly searching for and destroying. Rapidly increasing numbers of abnormal cells are a failure of our body’s immune system, a product of outside influences that overwhelm the body’s defenses, or a combination of both. Physicians know this. They also know that once cells become aggressive and invasive, it is very hard to stop them. Despite a trillion dollars spent since President Nixon declared war on cancer in 1971, we are just now beginning to develop effective nondebilitating treatments for this multifaceted family of diseases.

Another perspective that most Americans have is that all groups of abnormal cells a pathologist might label as cancer are bound to develop into a lethal disease if not treated. In fact, sometimes that is true, but sometimes it is not. Cancer is a collection of atypical cells that can proceed in many different ways at different speeds, and it may proceed nowhere at all. When going somewhere quickly, cancer will produce visible evidence in fairly short order. Finding definitive evidence of lethal cancer in microscopic quantities is an impossible task.

And treating small, stable abnormalities with guns blazing may shorten your life unnecessarily. It is well documented that chemotherapy and radiation both substantially increase your risk of developing other conditions later in life—a fact that clinicians know for certain but don’t always thoroughly explain in treatment option briefings.

The third thing that you should know about cancer—doctors know it but don’t share it because it is confusing—is that we sometimes do not know if a collection of unconventional cells is cancer at all. Pathologists have a very difficult job; you should sympathize with them. Cells of different tissues and organs have a huge number of varieties, and pathologists have to predict their future behavior based on simple appearance and organization (architecture). If the cells differ greatly in appearance from surrounding cells, they are more likely to be invasive cancer. If they vary in size or shape from what is expected, they are more likely to be invasive cancer. If they are caught in the act of dividing, they are more likely to be invasive cancer. If their architecture appears to be contained, they are less likely to be invasive cancer. But abnormal cells have no labels on them that say I am lethal, or I am not going anywhere. So the pathologist has to make a call, often under pressure. Some pathology determinations are easy, but most are not. In a research trial, seven expert pathologists from major teaching hospitals were shown twenty-five specimens of prostate tissue from biopsies performed at Johns Hopkins Hospital. For thirteen of the specimens, they agreed there was no cancer, and for one specimen they all agreed there was invasive cancer present. For the remaining eleven specimens, however, the diagnosis was split. No pathologist wants to miss a cancer, so there is an understandably strong incentive to lean to the side of overdiagnosis. If a group of abnormal cells is called benign when it isn’t, lawsuits often ensue. If a group of abnormal cells is called cancer and it isn’t, we likely come to a very different conclusion—it was successfully treated.

Americans see cancer as a black-and-white issue. If your body has betrayed you by producing abnormal cells, then you need to find every last cell and destroy them before they destroy you. Right?

I recognize that this is delicate territory and that this scenario is idealistic. It applies only to some commonly operable solid tumors, and not to blood cancer, brain cancer, pancreatic cancer, and other forms. But perhaps it gives some perspective on how to treat cancer in a nuanced way, rather than implementing an all-out intensive search-and-destroy mission. For many cancers, these steps are not possible. But even in dire cases, I believe we need to make choices based on quality of life that go beyond the drastic choices so common in American medicine. Atul Gawande’s bestseller, Being Mortal, has excellent insights on this. I highly recommend it. On one end of the spectrum, stage I cancer is often overtreated, leading to the unnecessary suffering of patients who would have survived their disease without such treatment. On the other end of the spectrum, stage IV cancer is also often overtreated, leading to the unnecessary suffering of patients with no chance of survival.

The good news is that your body generally does an excellent job of killing rogue cells and an even better job if you keep your immune system working well. It’s also good news that our black-and-white view of cancer is wrong. And it’s also good news that most of the time a suspicious image is not a lethal cancer.

The Facts

The Path of Wisdom

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