By Oscar L. Bronsther, M.D.
Once a patient has been diagnosed with cancer and the tumor has been removed, both physician and patient must ask, “what’s the best next step?”
The decision to pursue additional treatment has traditionally been driven by the desire to prevent systemic metastasis, which is responsible for approximately 90 percent of all solid tumor cancer deaths.[i] For example, women who make the decision to undergo double mastectomy following a breast cancer diagnosis are doing what they think is best for their health, but the choices is currently made without knowing if the cancer will metastasize.
However, current literature indicates, for example, that only approximately 30 percent of breast cancer tumors are biologically capable of metastatic spread.[ii] Yet the majority of these patients are treated with aggressive therapies. The end result is that the medical community is potentially over treating patients because traditionally there has been no reliable way to understand if a patient has an aggressive versus an indolent tumor.
The Dilemma of Cancer Overtreatment
This problematic situation mirrors another: recent years have witnessed a sharp rise in the debate over whether various cancers are being overdiagnosed and subsequently overtreated. A 2014 report on this topic in The Wall Street Journal offered a host of valuable insights, suggesting, for example, that overtreatment may be a consequence of zealous screening and more advanced diagnostics finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many of these “abnormalities” are subsequently being identified as cancer or precancer and aggressively treated, even though they would be better left alone; and the treatments—including surgery, radiation and chemotherapy—can have lifelong negative side effects.[iii]
Indeed, the idea that not all cancers are deadly is already starting to transform attitudes toward treatment of some of their forms. For example, as the Journal noted, experts say as many as 60 percent of prostate cancer tumors detected via screening grow so slowly that they pose little threat in a man’s lifetime, and treating them with surgery or radiation carries a significant risk of impotence or incontinence. On a similar note, a 2014 commentary in the Journal of the American Medical Association noted that more than 100,000 people are treated for basal-cell cancers annually even though they died of other causes within a year.[iv]
Authorities have also weighed in on the debate about overtreatment. For example, Otis W. Brawley, M.D., chief medical officer of the American Cancer Society, told the Journal, “I am confident that somewhere between 10 percent and 30 percent of women with localized invasive breast cancer would be just fine if we just watched them. But I cannot look into a patient’s eyes and say, ‘You’re one of the 10 percent to 30 percent that should not be treated.’”
Brawley went on to note that tiny lesions which would never have been detected a few decades ago are now routinely biopsied and analyzed. Treatment that might be unnecessary is an all-too-common consequence of ignorance about the many factors that could affect how those cancer cells develop. The Journal further noted that in the absence of certainty, many doctors and patients are opting for more aggressive treatment; in breast cancer, for example, nearly 20 percent of women with early-stage tumors now elect to have both breasts removed, up from 3 percent in 1998. And Laura Esserman, M.D., a breast-cancer surgeon at the University of California, San Francisco, told the Journal that “early detection does save lives—but we need to sort out who that might be.”
Meanwhile, overtreatment—in addition to taking a serious toll on the health and emotional wellbeing of those undergoing unneeded procedures—may also be straining the economy as well. A 2015 report in Health Affairs estimates that the U.S. spends $4 billion a year on unnecessary medical costs due to mammograms that generate false alarms and on treatment of certain breast tumors unlikely to cause problems.[v]