Sunday, June 17, 2018
Health

Cancer doctors struggle over when to use c-word

CLEARWATER — Dr. Peter Blumencranz knows the scientific case against aggressively treating certain precancerous conditions. But he also knows what can happen in an exam room.

He tells a patient with ductal carcinoma in situ — often called "stage zero breast cancer" — that she shouldn't panic. A few abnormal cells are lodged in a milk duct and may never grow into a dangerous cancer. He tells her she has options — but no guarantees. For some patients, that's not enough.

"They'll say, 'This has tied me up so much. ... I just want my breasts off. I don't want to deal with it again,' " said Blumencranz, a surgical oncologist and medical director of the Morton Plant Mease Comprehensive Breast Program. "I try to talk them out of (mastectomy), but sometimes it's hard."

Such interactions between doctors and patients illustrate the complexity of the growing debate about how to deal with conditions that may — or may not — become a deadly cancer.

Late last month, a group of prominent experts advising the National Cancer Institute concluded that screening for certain cancers — breast, prostate, lung and thyroid — has detected many abnormalities that aren't dangerous and don't require treatment. In such cases, the chemotherapy, radiation and radical surgeries can be worse than the disease they are trying to prevent, the scientists wrote in an article published in the Journal of the American Medical Association.

Prostate cancer patients can develop post-treatment impotence and incontinence. Post mastectomy, women may face extensive reconstructive surgery or emotional anguish. Some can develop painful lymphedema. All surgeries carry risks such as infections, reactions to anesthesia, even death.

During the past three decades, improved screening has increased the overall number of cancer detections. But for certain cancers, there haven't been comparable reductions in cancer-related deaths, the authors noted. This fact suggests that in many cases, the cancers that have been found would not have been fatal. Meanwhile, deadlier cancers may crop up so rapidly, they evade annual screenings.

The researchers argue for renaming some conditions to exclude the word "cancer" so that patients will be less likely to push for treatment that could cause more harm than good. That means, for instance, dropping the word "carcinoma" from ductal carcinoma in situ.

Such changes could be years in the making — and shouldn't happen until scientists figure out how better to distinguish the harmless cases from the lethal ones, say some local doctors.

"I'm sure that we do overdiagnose and overtreat certain patients," said Dr. Jack Steel, a Tampa Bay Radiation Oncology surgeon who treats many prostate cancer patients. "The problem is, we don't know which ones."

• • •

Dr. Lodovico Balducci, a geriatric oncologist at Moffitt Cancer Center, pointed out that screening has shrunk deaths from cervical and colon cancers. Yet he is convinced by numerous studies that too many men have had risky and painful treatment for prostate cancers that might not have ever spread.

"I think there's a delicate balance that we need to exercise," he said.

But he has seen enough complicated cases to know that it's impossible to be definitive. One such patient is Ofelia Granadillo. She took aggressive action in 1997 after another doctor told her she had ductal carcinoma in situ (in one of her breasts). She had both breasts removed, a decision that left her with a sense of sadness — but, also, security.

"The doctors kept saying 'You're cured,' " recalled Granadillo, now 71, of Tampa.

But six years later, cancer was back — in her bones. It may have started in just a single breast cancer cell left behind, as mastectomies never can remove 100 percent of the breast tissue.

She wishes her doctors had been even more aggressive in her treatment, and opposes down-playing the c-word.

" 'Cancer' has an emotional impact that's so tremendous that it makes you stand up and listen," she said.

After battling metastatic cancer for 10 years, she intends to try for two more decades. A gregarious retired social worker, she still works a couple of days a week at the University of South Florida. She swims and goes to her grandson's baseball games. Her response to thinning hair from chemotherapy: a new hairstyle.

• • •

Doctors say their conversations about cancer have evolved. Not only are there better treatment options, genetics can predict risk for a number of cancers. Many patients realize a cancer diagnosis often is not a death sentence.

"Have things changed? I'll say," said Blumencranz. "If you look at breast cancers, stages one and two, most of those are cured these days."

But many patients still seek the most aggressive action. The standard treatment for DCIS, for instance, is a lumpectomy, sometimes followed with radiation. But one study found that the number of women with DCIS in one breast getting double mastectomies more than tripled between 1998 and 2005.

Improving how cancer is classified would help, but it is less critical than refining the screening process, said Dr. Mike Diaz, director of patient advocacy for Florida Cancer Specialists. Lung cancer patients, for instance, have benefited in this regard.

Initial studies showed screening subjected too many patients to unnecessary and invasive procedures, he said. But after more scrutiny, the U.S. Preventive Services Task Force said that patients who meet high-risk criteria do benefit from low-dose CT scan screening.

Dr. Malcolm Root, a urologist with Florida Urology Partners in Tampa, said the wait-and-see approach is growing in popularity with men with early prostate cancer. Some of them are elderly men more likely to die of something else first; others are younger men who want to avoid unnecessary treatment. In many cases, it may make sense. But without good predictors, he said, some patients may learn too late whether that approach was the right one.

"For some of these guys we just watch," he said, "it's going to be a mistake."

Jodie Tillman can be reached at [email protected] or (813) 226-3374.

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