‘Incidentalomas’ and Stage Zero Cancer — A Semantic Dilemma with Medical Consequences

By George Johnson | July 29, 2013 8:57 pm

One of the measures by which oncologists describe the severity of a malignancy is according to its stage, with Stage 4 being the most deadly. There is a certain amount of arbitrariness to the labeling scheme, and the details vary according to the type of cancer. But Stage 4 refers, in general, to those that have spread, or metastasized, beyond the original site — to a distant lymph node or organ. Advanced Stage 4 cancers are almost never curable, and the treatments can be so devastating that it is often not clear whether a few extra months of life is something to be desired.

Then there are what the doctors call Stage 0 — abnormal cells that may or may not ever become a problem. Tara Parker Pope wrote about these today in the New York Times, and she introduces a term I hadn’t encountered before: incidentalomas — “the name given to incidental findings detected during medical scans that most likely would never cause a problem.” Some of these, many oncologists and researchers are coming to believe, should not even be called cancer. The word is so terrifying that it leads to overtreatment, which can have its own dangerous side-effects.

The occasion for the piece, which is posted in the Well blog, is a commentary published today in the Journal of the American Medical Association: “Overdiagnosis and Overtreatment in Cancer.”

The word “cancer” often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.

Examples include ductal carcinoma in situ, early prostate cancer, and Barrett’s esophagus, which can lead, though it hardly ever does, to cancer of the esophagus. The dilemma is that for any individual case, there is no reliable way to determine whether the suspicious cells will later evolve into a true malignancy.

Parker Pope’s thoughtful discussion of the issues has attracted an enviable number of intelligent comments from readers. This one is my favorite:

Overtreatment is when someone else has something that might be cancer. When you have it, well, I’m guessing most people would want it out.

However low the odds, once a true cancer manifests itself, it is there 100 percent.

 

For a preview of The Cancer Chronicles, including the table of contents and index, please see the book’s website.

@byGeorgeJohnson

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Whether a subtle new pattern shows up in an experiment on the Higgs boson, an epidemiological report about a suspected cancer cluster, or a double-blind trial purporting to demonstrate ESP, it can be maddeningly difficult to distinguish between what we see and what we think we see. "Fire in the Mind" takes a look at the big questions behind today’s science news.

About George Johnson

George Johnson writes about science for the New York Times, National Geographic Magazine, Slate, and other publications. His nine books include The Cancer Chronicles: Unlocking Medicine's Deepest Mystery (August 2013), The Ten Most Beautiful Experiments, A Shortcut Through Time, and Fire in the Mind. He is a winner of the AAAS Science Journalism Award and has twice been a finalist for the Royal Society science book prize. Co-founder and director of the Santa Fe Science Writing Workshop, he can be found on the Web at talaya.net. Twitter @byGeorgeJohnson.

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