POST January/February 2015

25 percent.
In thyroid and prostate cancers, however,
the figures are even higher, he says.
Essentially, cancer is defined as abnormal
cells that divide without control and are able
to invade other tissues or parts of the body
through blood and lymph systems. But the
rate at which these abnormal cells divide and
spread is difficult to determine and depends on
myriad factors well beyond the organs that are
affected. In other words, simply having cancer,
counter to common belief, does not necessarily
mean that it will kill you or even pose a health
problem.
It is estimated that every second, millions
of cells in our body divide, copying their
DNA. Biologist and cancer researcher Robert
Weinberg, of Massachusetts Institute of Technology,
notes in his work that with every cell
division there are imperfections. If we lived
long enough, Weinberg states, we all would
eventually get cancer.
In the last two to three years, a movement
has been building in oncology that not
all cancer needs to be treated; in fact, some
cancers are not cancer at all. At odds with this
are hypersensitive screening technologies that
can detect the smallest and in some cases the
most harmless lesions.
But research shows in some cases that
cutting-edge screening has not affected mortality
rates, and some tumors that were treated
were actually indolent, meaning they either
would have stopped growing or grown very
slowly. Some untreated tumors even regress on
their own. But the treatments used to eliminate
them can leave lasting health problems.
An article published last May by the
world’s leading medical journal, Lancet
Oncology, outlined the pervasive problem of
overtreating and overdiagnosing cancer. Indolent
disease, the article states, accounts for 15
percent to 75 percent of all cancers, depending
on the organ affected.
Chunkit Fung M.D., a medical oncologist
at Strong Memorial Hospital, says a deeper
understanding of the biology of a particular
cancer is required to better predict how it will
behave. A classification system, he says, needs
to be developed that is based on the genetic
mutations each cancer has. That way treatment
can be personalized instead of simply
grouped by the organ affected.
“I think the discussion is not about just
screening, but also about are we overtreating
some of the cancers, such as prostate
cancer, which is a very low, indolent disease
“We, in the United States,
have been taught since
we were on our mother’s
knee that cancer was bad
and that the way to deal
with it is to find it early
and cut it out.”
that might not even cause any problems in
some patients. But at the same time, we don’t
really have a good way to stratify (cancers) to
determine what are the really aggressive ones
that can really cause problems for patients, not
just in prostate cancer or breast cancer, but in
many different cancers,” Fung says.
Thyroid cancer is one example where improved
screening technologies did not improve
outcomes. From 1975 to 2009, the incidence
of thyroid cancer tripled, but the death rate remained
constant, Lancet’s article shows. When
the incidence rises and the death rate is flat,
that’s how you can tell overdiagnosis is going
on, Brawley explains.
The increase in incidence in thyroid cancer
is due almost entirely to the ability now to
detect small cancers less than 2 centimeters,
which previously went undetected, and now
often get treated even though they most likely
will never grow.
In prostate cancer, 20 percent to 70 percent
of patients are said to be overdiagnosed.
Brawley suspects the figures are probably 50
percent to 60 percent.
“In the case of prostate cancer, I’m really
frightened that a large number of men
have not been truly informed about what we
know and what we don’t know,” he says. A
man who gets treatment for prostate cancer
believes it is because of that treatment that he
is still alive, when the chances are more likely
that he is a victim of overtreatment, Brawley
explains. “They have the misconception that
prostate cancer screening is better than it actually
is,” he says.
For example, 90 percent of glandular
prostate cancers, many of which may have
been found to be inconsequential cancers, are
treated with radiation or surgery, Lancet’s
article states. For 15 percent to 20 percent of
these cases, sexual, urinary, and gastrointestinal
side effects result. Occasionally, the Lancet
article notes, radiation treatments to stop a
cancer that never would have caused harm
will lead to future, malignant cancer that will;
repeated biopsies can lead to sepsis in men,
increased costs, and emotional and psychological
disruption for patients and their families.
In the case of Rochester local Connie
Kenneally, the treatment offered for her stage
IV renal cancer could have left her severely
debilitated. Kenneally got her metastatic diagnosis
in late 2011, when there was little to no
support for a wait-and-see approach. But what
if her doctors were wrong, she wondered, and
the cancer did not progress?
Most people, Kenneally says, will do exactly
what their doctors tell them. It’s certainly
what her brother and some of her closest
friends urged her to do.
“One of my friends said, ‘For once, can’t
you just do what you’re told?’” Kenneally
recalls.
Instead, Kenneally set out to get some
evidence whether her tumors, which at the
time cumulatively measured slightly more than
6 centimeters, would likely grow. To find out
if her tumors might be indolent, or slow-growing,
as she suspected, she researched many
avenues, including genomic testing companies,
immediately after her diagnosis. Through testing
to determine her genetic alteration, a few
studies suggested she may not have the gene
mutation that would indicate an aggressively
growing tumor.
Kenneally enrolled in a clinical observation
trial at Cleveland Clinic and was able to
avoid toxic treatments. Instead of facing a life
sentence, Kenneally, through objective, coolheaded
research and testing may or may not
have saved her life, but at the very least she
saved herself from the damage acutely toxic
treatments would have caused.
“My issue is that no one considered indolent
tumors until Brian Rini at the Cleveland
Clinic put it on the table. It was clearly not
an option. That is my issue,” Kenneally says.
“Drugs are always the primary answer to cancer
when you see an oncologist, just as surgery
is the primary answer when you go to see a
surgeon.”
At any point following a cancer diagnosis,
doing what is right is hard to know when the
cancer itself might grow fast, slow, or not at
all. Undertreating, for physicians as well as
patients and their family, is often scarier than
overtreating.
Physicians, for example, might be sued for
undertreating patients if the cancer wors-
Issue 9 January / February 2015 | POST 35