Mitigating Cancer Overdiagnosis Jatoi, Ismail
Indian journal of surgical oncology,
12/2022, Letnik:
13, Številka:
4
Journal Article
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Overdiagnosis refers to the detection of cancers that pose no threat to life and would never have been detected in the absence of screening. It is now a major public health concern throughout the ...world because advancements in screening technology have substantially increased the detection rates of non-lethal cancers. Cancer overdiagnosis leads to unnecessary treatments, putting patients unnecessarily at risk for the potential morbidity and mortality that may arise from those treatments, and it wastes healthcare resources. Patients may also suffer unnecessary anxiety, job discrimination, financial hardships, and other detrimental effects on quality-of-life following cancer overdiagnosis. In this article, I provide examples of cancer overdiagnosis as a consequence of screening for thyroid, breast, and pancreatic cancers. To mitigate the adverse effects of cancer overdiagnosis, we should adopt only those screening strategies that have been shown in randomized trials to reduce cancer mortality, and we should inform patients about the potential benefits and risks of cancer screening, particularly the risk for overdiagnosis.
Genetic testing is now widely utilized to identify women with a hereditary predisposition for breast cancer. Women who carry mutations that increase breast cancer risk may consider three options to ...reduce risk: screening, chemoprevention, and prophylactic surgery. Yet, no randomized trials have specifically assessed the efficacy of these options in mutation carriers. In many developed countries, mammography is regarded as the optimal means of screening for breast cancer in the general population. However, breast MRI is a more sensitive screening tool, and for mutation carriers, any breast cancer screening strategy should incorporate screening with MRI. In randomized trials of women at high risk for developing breast cancer, chemoprevention reduces that risk, but it has not been shown to reduce mortality. Finally, observational studies suggest that, in mutation carriers, prophylactic surgery may reduce the risk of developing breast cancer by 90-95%. There are several prophylactic mastectomy procedures to choose from, and these are generally done in conjunction with breast reconstruction. In this article, we discuss management of women who carry mutations that have been associated with an increased breast cancer risk. Mutation carriers should be informed of the potential risks and benefits of the three available options to reduce breast cancer risk.
Summary With the advent of sentinel lymph node biopsy, surgical methods for accurately staging the axilla in patients with early-stage breast cancer have become progressively less extensive, with ...formal axillary lymph node dissection confined to a dwindling group of patients. Although details of methods for sentinel lymph node biopsy have yet to be standardised, this technique is now widely practised and accepted as standard of care worldwide. In the past 5 years, attention has focused on minimisation of surgical morbidity by restricting further axillary surgery or considering radiotherapy in patients with a small tumour burden in their sentinel nodes. This change in approach to patients with positive sentinel lymph node biopsies has increased the complexity of axillary management, and any policy of de-escalation and avoidance of morbidity must not compromise patient outcomes. This trend for de-escalation has accompanied a shift in understanding of how any residual tumour burden can be adequately managed without surgical extirpation and reliance on effective adjuvant therapies. Indications for omission of completion axillary lymph node dissection in patients with two or fewer nodes containing macrometastases demand further clarification, together with the roles of preoperative imaging in defining axillary nodal burden, deselection of patients for sentinel lymph node biopsy, and provision of radiotherapy. Downstaging of biopsy-proven node-positive patients with neoadjuvant chemotherapy could safely permit sentinel lymph node biopsy alone when the index node has been successfully retrieved at surgery, while nodal deposits of any size continue to mandate completion axillary lymph node dissection. Developments in molecular imaging technologies and percutaneous biopsy techniques could potentially render sentinel lymph node biopsy redundant in the future.
This editorial summarizes the key points of the PB Desai Oration, delivered by the author at the National Conference of the Indian Association of Surgical Oncology in Kolkata, India, on September 21, ...2019.
In Memoriam: Dr. Bernard Fisher Jatoi, Ismail
Indian journal of surgical oncology,
03/2020, Letnik:
11, Številka:
1
Journal Article
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Odprti dostop
Very few individuals have so profoundly influenced the field of surgical oncology as has Dr. Bernard Fisher, who died on October 16, 2019, at the age of 101. Fisher is widely known for his work on ...the treatment and prevention of primary breast cancer, where he championed breast-conserving surgery, the use adjuvant systemic therapies, and chemoprevention (i.e., the use of anti-estrogens to prevent breast cancer). However, Fisher’s impact extends far beyond the field of surgical oncology. He questioned the value of observational studies in clinical decision-making and emphasized that large randomized trials with unambiguous endpoints (i.e., all-cause mortality) should form the basis for patient management.
Jatoi and Sah discuss clinical practice guidelines and the overuse of health care services. Among other things, clinical practice guidelines can enhance the delivery of evidence-based health care, ...yet the specialty bias and fee-for-service conflicts of interest threaten the validity and may lead to unnecessary overuse of health care services.
Summary The heterogeneous nature of ductal carcinoma in situ has been emphasised by data for breast-cancer screening that show substantial increases in the detection of early-stage non-invasive ...breast cancer but no noteworthy change in the incidence of invasive and distant metastatic disease. Indolent non-progressive forms of ductal carcinoma in situ are managed according to similar surgical strategies as high-risk disease, with extent of resection dictated by radiological and pathological estimates of tumour dimensions. Although adjuvant treatments might be withheld for low-risk lesions, surgical treatments incur potential morbidity, especially when mastectomy and breast reconstruction are done for widespread low-grade or intermediate-grade ductal carcinoma in situ. Low rates of deaths from breast cancer coupled with overdiagnosis within screening programmes have prompted a fundamental rethink of approaches to the management of both low-risk and high-risk ductal carcinoma in situ. Changes include active surveillance for low-risk lesions and a watchful waiting policy with intervention when invasive local recurrence after breast-conserving surgery is detected. Prediction of ipsilateral invasive recurrence is likely to be improved by integration of molecular biomarkers with conventional histopathological parameters. Moreover, further genetic interrogation of ductal carcinoma in situ might lead to a reclassification of some low-grade lesions as non-cancerous entities.
Because of its rarity, male breast cancer is often compared with female breast cancer.
To compare and contrast male and female breast cancers, we obtained case and population data from the National ...Cancer Institute's Surveillance, Epidemiology, and End Results program for breast cancers diagnosed from 1973 through 2005. Standard descriptive epidemiology was supplemented with age-period-cohort models and breast cancer survival analyses.
Of all breast cancers, men with breast cancer make up less than 1%. Male compared with female breast cancers occurred later in life with higher stage, lower grade, and more estrogen receptor-positive tumors. Recent breast cancer incidence and mortality rates declined over time for men and women, but these trends were greater for women than for men. Comparing patients diagnosed from 1996 through 2005 versus 1976 through 1985, and adjusting for age, stage, and grade, cause-specific hazard rates for breast cancer death declined by 28% among men (P = .03) and by 42% among women (P approximately 0).
There were three intriguing results. Age-specific incidence patterns showed that the biology of male breast cancer resembled that of late-onset female breast cancer. Similar breast cancer incidence trends among men and women suggested that there are common breast cancer risk factors that affect both sexes, especially estrogen receptor-positive breast cancer. Finally, breast cancer mortality and survival rates have improved significantly over time for both male and female breast cancer, but progress for men has lagged behind that for women.
To develop recommendations for management of patients with breast cancer (BC) with germline mutations in BC susceptibility genes.
The American Society of Clinical Oncology, American Society for ...Radiation Oncology, and Society of Surgical Oncology convened an Expert Panel to develop recommendations based on a systematic review of the literature and a formal consensus process.
Fifty-eight articles met eligibility criteria and formed the evidentiary basis for the local therapy recommendations; six randomized controlled trials of systemic therapy met eligibility criteria.
Patients with newly diagnosed BC and
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mutations may be considered for breast-conserving therapy (BCT), with local control of the index cancer similar to that of noncarriers. The significant risk of a contralateral BC (CBC), especially in young women, and the higher risk of new cancers in the ipsilateral breast warrant discussion of bilateral mastectomy. Patients with mutations in moderate-risk genes should be offered BCT. For women with mutations in
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or moderate-penetrance genes who are eligible for mastectomy, nipple-sparing mastectomy is a reasonable approach. There is no evidence of increased toxicity or CBC events from radiation exposure in
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carriers. Radiation therapy should not be withheld in
carriers. For patients with germline
mutations, mastectomy is advised; radiation therapy is contraindicated except in those with significant risk of locoregional recurrence. Platinum agents are recommended versus taxanes to treat advanced BC in
carriers. In the adjuvant/neoadjuvant setting, data do not support the routine addition of platinum to anthracycline- and taxane-based chemotherapy. Poly (ADP-ribose) polymerase (PARP) inhibitors (olaparib and talazoparib) are preferable to nonplatinum single-agent chemotherapy for treatment of advanced BC in
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carriers. Data are insufficient to recommend PARP inhibitor use in the early setting or in moderate-penetrance carriers. Additional information available at www.asco.org/breast-cancer-guidelines.
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