- Email: [email protected]
Addressing overdiagnosis and overtreatment in cancer
Correspondence
indolent lesions of epithelial origin increase the number of patients who perceive themselves to be victims of underdiagnosis, this perception will occur in the context of a harsh legal system that thrives on lay juries listening to paid experts who excel at retrospectively identifying missed cancer diagnoses. By contrast, the many current victims of overdiagnosis are not regarded as potential plaintiffs, but instead as cancer survivors who exist anonymously in the epidemiology data of Esserman and colleagues. I declare no competing interests.
Elliott Foucar [email protected] University of New Mexico School of Medicine, Albuquerque, NM 87131, USA 1
2
Page DL, Simpson JF, Jensen RA. Re: When and to what end do pathologists disagree? J Natl Cancer Inst 1998; 90: 1014–16. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–42.
We believe that the labelling of non-melanoma skin cancers as an indolent lesion of epithelial origin and not as cancer, as suggested by Laura Esserman colleagues,1 sends a potentially dangerous message to patients and their families. We do not think the authors have considered the ramifications of their comments. Published data suggest a watchand-wait approach for patients with non-melanoma skin cancer is often harmful to patients.2 Basal cell carcinoma grows rapidly—on average, doubling in size yearly. Squamous cell carcinoma grows even more rapidly, has a 2·1% fatality rate, and metastasises in up to 3·7% of patients within 4 years of initial treatment. Of course, the numbers would be much higher with a watch-and-wait approach.
e307
Although basal cell carcinoma rarely metastasises, if left untreated, it can commonly invade local structures, causing haemorrhage, blindness, infection, and disability. Prediction (even in patients with significant comorbidities) of who will and will not die of their skin cancer is impossible. It is cruel to deny patients treatment when we, as physicians, know it can save their lives. We cannot understand why anyone would oppose such treatments, particularly when dermatologists render treatments inexpensively, under local anaesthesia, and in the office setting. Additionally, there are now 263 000 patients immunocompromised after solid organ transplants who are alive in the USA. These patients typically develop several aggressive skin cancers. It is irrational to spend billions of dollars on these transplants only to let these patients—if left untreated— die of skin cancer. Having markers predictive of clinical outcome might be useful, but they do not exist at present. The costs of treating skin cancer, when detected early, are low. The costs of finding such a predictive marker profile would almost certainly be at least as much as the currently proven and timehonoured treatments, thus resulting in little cost savings. We are also alarmed with the suggestion that dermatologists should do fewer skin cancer screenings. Lives are saved by screening.3 Melanoma has been increasing at a rate of 4% per year and is detected frequently during screening. Non-melanoma skin cancers are increasing in the USA at epidemic proportions.4 Recent estimates also suggest that the number of fatalities per year from cutaneous squamous cell carcinoma in the USA is approaching that of
melanoma, and screening also has a positive effect on the early detection of these carcinomas.5 We dermatologists take very seriously our obligation to provide the highest standard of care by using appropriate, cost-effective treatment. The decision of how to approach and treat a skin cancer should rest with the patient in consultation with their dermatologist. Renaming a destructive and sometimes fatal disease—to make it sound harmless—is a disservice to our patients. Rather than suggesting a semantic change that is potentially harmful, it would be more constructive to start planning how to best manage the epidemic at hand. We declare no competing interests.
*Brett M Coldiron, J Ramsey Mellette Jr, George J Hruza, Thomas N Helm, Carlos A Garcia [email protected] American Academy of Dermatology, 930 East Woodfield Road, Schaumburg, IL, 60173, USA (BMC); American College of Mohs Surgery, Milwaukee, WI, USA (JRM); American Society for Dermatologic Surgery, Rolling Meadows, IL, USA (GJH); American Society of Dermatopathology, Deerfield, IL, USA (TNH); and American Society for Mohs Surgery, Huntington Beach, CA, USA (CAG) 1
2
3
4
5
Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–42. Kricker A, Armstrong B, Hansen V, et al. Basal cell carcinoma and squamous cell carcinoma growth rates and determinants of size in community patients. J Am Acad Dermatol 2014; 70: 456–64. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer 2012; 118: 5395–402. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States 2006. Arch Dermatol 2010; 146: 283–87. Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013; 68: 957–66.
www.thelancet.com/oncology Vol 15 July 2014
indolent lesions of epithelial origin increase the number of patients who perceive themselves to be victims of underdiagnosis, this perception will occur in the context of a harsh legal system that thrives on lay juries listening to paid experts who excel at retrospectively identifying missed cancer diagnoses. By contrast, the many current victims of overdiagnosis are not regarded as potential plaintiffs, but instead as cancer survivors who exist anonymously in the epidemiology data of Esserman and colleagues. I declare no competing interests.
Elliott Foucar [email protected] University of New Mexico School of Medicine, Albuquerque, NM 87131, USA 1
2
Page DL, Simpson JF, Jensen RA. Re: When and to what end do pathologists disagree? J Natl Cancer Inst 1998; 90: 1014–16. Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–42.
We believe that the labelling of non-melanoma skin cancers as an indolent lesion of epithelial origin and not as cancer, as suggested by Laura Esserman colleagues,1 sends a potentially dangerous message to patients and their families. We do not think the authors have considered the ramifications of their comments. Published data suggest a watchand-wait approach for patients with non-melanoma skin cancer is often harmful to patients.2 Basal cell carcinoma grows rapidly—on average, doubling in size yearly. Squamous cell carcinoma grows even more rapidly, has a 2·1% fatality rate, and metastasises in up to 3·7% of patients within 4 years of initial treatment. Of course, the numbers would be much higher with a watch-and-wait approach.
e307
Although basal cell carcinoma rarely metastasises, if left untreated, it can commonly invade local structures, causing haemorrhage, blindness, infection, and disability. Prediction (even in patients with significant comorbidities) of who will and will not die of their skin cancer is impossible. It is cruel to deny patients treatment when we, as physicians, know it can save their lives. We cannot understand why anyone would oppose such treatments, particularly when dermatologists render treatments inexpensively, under local anaesthesia, and in the office setting. Additionally, there are now 263 000 patients immunocompromised after solid organ transplants who are alive in the USA. These patients typically develop several aggressive skin cancers. It is irrational to spend billions of dollars on these transplants only to let these patients—if left untreated— die of skin cancer. Having markers predictive of clinical outcome might be useful, but they do not exist at present. The costs of treating skin cancer, when detected early, are low. The costs of finding such a predictive marker profile would almost certainly be at least as much as the currently proven and timehonoured treatments, thus resulting in little cost savings. We are also alarmed with the suggestion that dermatologists should do fewer skin cancer screenings. Lives are saved by screening.3 Melanoma has been increasing at a rate of 4% per year and is detected frequently during screening. Non-melanoma skin cancers are increasing in the USA at epidemic proportions.4 Recent estimates also suggest that the number of fatalities per year from cutaneous squamous cell carcinoma in the USA is approaching that of
melanoma, and screening also has a positive effect on the early detection of these carcinomas.5 We dermatologists take very seriously our obligation to provide the highest standard of care by using appropriate, cost-effective treatment. The decision of how to approach and treat a skin cancer should rest with the patient in consultation with their dermatologist. Renaming a destructive and sometimes fatal disease—to make it sound harmless—is a disservice to our patients. Rather than suggesting a semantic change that is potentially harmful, it would be more constructive to start planning how to best manage the epidemic at hand. We declare no competing interests.
*Brett M Coldiron, J Ramsey Mellette Jr, George J Hruza, Thomas N Helm, Carlos A Garcia [email protected] American Academy of Dermatology, 930 East Woodfield Road, Schaumburg, IL, 60173, USA (BMC); American College of Mohs Surgery, Milwaukee, WI, USA (JRM); American Society for Dermatologic Surgery, Rolling Meadows, IL, USA (GJH); American Society of Dermatopathology, Deerfield, IL, USA (TNH); and American Society for Mohs Surgery, Huntington Beach, CA, USA (CAG) 1
2
3
4
5
Esserman LJ, Thompson IM, Reid B, et al. Addressing overdiagnosis and overtreatment in cancer: a prescription for change. Lancet Oncol 2014; 15: e234–42. Kricker A, Armstrong B, Hansen V, et al. Basal cell carcinoma and squamous cell carcinoma growth rates and determinants of size in community patients. J Am Acad Dermatol 2014; 70: 456–64. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer 2012; 118: 5395–402. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States 2006. Arch Dermatol 2010; 146: 283–87. Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013; 68: 957–66.
www.thelancet.com/oncology Vol 15 July 2014