September, 2015

Spectral Evidence

By Michael J. Katin, MD

August, 2015, will be remembered for many scientific revelations, but it was at the very end of the month that the media became obsessed with a report that can have a direct impact on thousands of persons and reawakens debate on the philosophy of oncology care in general.

"Breast Cancer Mortality After a Diagnosis of Ductal Carcinoma in Situ" was first released on line by JAMA Oncology on August 20 and on that very same day The New York Times published a long article, accompanied by a color picture of a woman who had undergone mastectomy for ductal carcinoma in situ, stating "She now believes it was unnecessary." Probably 99.98% of all cancer specialists would have felt the same way when she had the mastectomy four years ago, but that didn't make it into the caption. The general tone of this newspaper article, as well as others, was that treatment for ductal carcinoma in situ is usually excessive and, human nature being what it is, many readers could infer that to mean that treatment for many other types of cancer are excessive as well. In fairness, the New York Times article quoted Dr. Monica Morrow raising questions about the results and Dr. Otis Brawley, asking whether subgroups would be at greater risk and need special attention, but these could be dismissed as antediluvian practitioners unwilling to embrace new concepts.

There is a disease usually called lethal midline granuloma. This is rare but if one were unfortunate enough to have it, the terminology alone was quite disheartening ("Is it serious, Doctor?"). The name has been retained (M31.2 in ICD10) but whenever possible is called something else, such as ulcerating midline lymphoma, usually extranodal NK/T-cell lymphoma ("Is it serious, Doctor?"). The point being, terminology may well have a lot to do with the aggressiveness of treatment a patient is willing to undergo. This relates to the dilemma that lobular carcinoma in situ of the breast is not thought to require treatment but has a similar name to ductal carcinoma in situ. At this point, even lobular carcinoma in situ hasn't been renamed lobular neoplasia or some other entity to reduce the concern of someone given the diagnosis ("Carcinoma..is it serious, Doctor?"). This "diagnosis" is worthwhile as a risk factor for someday finding breast cancer even though it isn't supposed to be a direct precursor and shouldn't be dismissed altogether. The reason this comes up is that the journal article from JAMA Oncology was accompanied by an editorial by Laura Esserman, MD, MBA, and Christina Yau, PhD, "Rethinking the Standard for Ductal Carcinoma In Situ Treatment." It turns out that Dr. Esserman previously contributed an essay to CNN, in February of this year, about "Time To Change How We Think About Cancer." In this, she referred to her article in JAMA from 2009, "Rethinking Screening for Breast Cancer and Prostate Cancer," addressing the dilemma that incidence of cancers went up after screening started but then never returned to pre-screening levels, and that the relative fraction of early stage cancers increased but the incidence of regional cancers had not decreased. As a result of this, she and one of her co-authors, Ian Thompson, came up with the term IDLE, standing for Indolent Lesion of Epithelial Origin. Although at this point there has been more rethinking than about anything else other than the Iraq war, the use of this new term could help to relieve anxiety in persons with these diagnoses (as long as, of course, the diseases are truly indolent ).

Speaking of idle diseases, cancer of the prostate, which is no longer considered a dangerous disease, has had a decrease in diagnosis ever since, in 2011, the U. S. Preventive Services Task Force assigned a grade of "D" to PSA screening. A report by Daniel A. Barocas, et al. quantitated a 28% decrease in diagnosis in the following year. Interestingly, a grade of "D" equaled a recommendation against the service on the grounds that there was "moderate or high certainty " of no net benefit or higher risk than benefits. Interestingly, at Harvard a "D" indicates "minimal command" of course material or "minimal participation" but still "worthy of course credit to the degree," and summarized as "passing but unsatisfactory." Obviously, better to get a "D' from Harvard than from the USPSTF.

If certain types of cancer are reclassified as IDLE, lethargic, torpid, or phlegmatic, calculations of cancer incidence can be reduced and build false hope in the population. This same approach is used to calculate unemployment statistics, by not counting persons not actively looking for work (idle?) and in law enforcement, in which less vigorous classification of an act can lead to much more respectable crime rates. There should be concern than downplaying the seriousness of any type of cancer will reduce the general public's interest in supporting diagnosis and treatment, let alone research. Interestingly, this approach also reduces interest in spending on medically related items and makes it easier for persons to accept less aggressive intervention.

It's all a matter of perspective, anyway. There may be excessive concern about risks/side effects/inconvenience/rudeness of screening and treatment versus the benefits. As always, history gives examples of two opposite approaches. In 1478, Pope Sixtus IV (certainly someone who was already conflicted, at least numerically) gave his blessing, no pun intended, to the Spanish Inquisition, an extension of inquisitions that had begun in the thirteenth century, reaching a peak by the beginning of the sixteenth century. The guiding principle of the Inquisition was that it was "better a hundred innocent people die than a single heretic is freed," but with the logical assumption that after their deaths, God would recognize those that "were His." The current Pope will be in the United States this month and it might be good to request a second opinion.

In contrast, in 1692 citizens in Salem, Massachusetts, learned they could get their friends and neighbors in trouble by accusing them of witchcraft based on "spectral evidence," i.e., visions and dreams without physical proof. Cotton Mather, a high-profile minister, encouraged the court to not base convictions on accusations that could not be documented, and got the attention of his father, Increase Mather, president of Harvard and developer of the Harvard grading system, who got the attention of Governor William Phips, who had approved the start of the trials and then, as a good politician, reversed his decision and forbade any further hearings. Increase Mather's rationale was that "It were better that ten suspected witches should escape than one innocent person should be condemned." Again, risks vs. benefits. The long-term result of erring on the side of minimizing potential negative effects? Heretics and witches everywhere.

It will be interesting to see which trend prevails over the next few years. It is only hoped that cancer is not taken lightly to the point that it ceases to be feared.

Emanuel Countdown: The Emanuel Countdown will be suspended for several months, to be replaced by a tribute to each of the 37 persons currently seeking the position of President of the United States. The Emanuel Countdown will resume after the nominees of both parties have been selected. The clock, however, will still be running.

Donald Trump (to the meter of Rudyard Kipling's "Gunga Din")

When you're on the campaign trail
You know the odds are that you'll fail
Since there's only one can get the nomination.
But you try for months and years
Committing money, sweat, and tears
And you hope you find the winning combination.
One by one they made their case
For the Presidential race
When their candidacies hit a major bump
For a tweet came through the air
That we needed to prepare
For an announcement by the famous Donald Trump.

It was Trump, Trump, Trump
Yes, that guy from The Apprentice, Donald Trump
Though he's not a politician
Is he going to be wishin'
To be inaugurated President Donald Trump?

Then to New York reporters went
To be there for the event
As if to demonstrate once more celebrity power.
And the Donald did appear
With his entourage in gear
To give the speech from his eponymous Tower.

It was Trump, Trump, Trump
Here to tell you the beliefs of Donald Trump
Though some may have been amended
From years past, now they seem splendid
To the passionately conservative Donald Trump.

And the hairstyle that he wore
Was henna red afore
And more than just a little grey behind.
In his custom-tailored suit
He was prepared for photo shoots
And was definitely ready for prime time.
He would close the southern border
And establish law and order
And be ready to do everything required
To keep Putin in his place
And Kim Jong-Il to have a taste
Of guided missiles when he says the words, "You're Fired!"

Yes, it's Trump, Trump, Trump
He'll show up in more spots than did Forrest Gump.
Plus a windfall for the media
A hot first lady from Slovenia
If her husband gets elected, Donald Trump.
And he's got a lot of plans
To make the GDP advance,
Since business is the business that he knows.
With the art of making deals
He'll get Obamacare repealed
And he'll make the budget surplus overflow.
He can charm the holy rollers
And control the ayatollahs
He'll do his best to make America great again,
And with appointees that are shrewder
Ivanka, Eric, and Donald Jr.,
We'll have people competent to negotiate again.

Yes, it's Trump, Trump, Trump
There's no one who's better speaking on the stump.
Though there's Mexicans who hate you
As do the losers that debate you
You're a better bet than Jeb is, Donald Trump.