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Pⁿ Blog
The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Tuesday, May 20, 2014
Lightning or Lightning Bug?
You have cutaneous basal cell carcinoma.  You have pancreatic adenocarcinoma.  Both contain the word "carcinoma," ie. CANCER, yet the clinical difference is as great as the distinction between a lightning bug and lightning.  (Apologies to Mark Twain for twisting his original quote, "The difference between the right word and the almost right word is the difference between lightning and a lightning bug.")  Pathologists understand the distinction, as do most clinicians, but patients not so much.  Sadly, given the shortened exposure many current medical students have to pathology, I fear that their level of sophistication in this regard is likely to approach that of the general public over time. 
We have discussed this topic before, but like a bad relative looking for a handout, it keeps coming back!  A recent personal view article in Lancet Oncology [ Volume 15, e234-e242, May 2014.]  discusses a National Cancer Institute (NCI) expert committee's recommendations in this regard.  In brief, the panel recommended that the word "cancer/carcinoma" be eliminated from indolent, slow growing lesions with little or no impact on mortality.  Instead the group recommended that such lesions be labelled as "IDLE,"  indolent lesion of epithelial origin.   Setting aside my extreme dislike for the confusion of "origin" with "differentiation," the authors' hearts are in the right place.  However, it strikes me that this is essentially a diagnostic "dumbing down" to deal with the lack of understanding of both patients and, increasingly, clinicians.  In some cases, many examples of carcinoma in situ for example, it may well be appropriate to eliminate the word "carcinoma" as has been done in gynecologic pathology and other areas as well. 
It is also clear that increased use of screening is going to preferentially detect more and more indolent cancers, since more aggressive tumors pass through this phase and become symptomatic much more rapidly.  Imagine, for example, the futility of trying to screen the general population for acute leukemia.  The related issue is whether screening and early detection leads to significant improvement in patient survival when balanced against the significant cost and morbidity of overtreatment.
Overall, though, this is a thought provoking paper that provides brief and well-written reviews of the prime offenders in the world of overdiagnosis and overtreatment.  Included in this list are:  thyroid carcinoma, prostatic carcinoma, Barrett's esophagus, ductal carcinoma in situ, atypical nevi, and several others. 
There is also a very cogent discussion, with a flow chart, addressing the factors from both the patient's and clinician's perspectives that tend to reinforce the use of overly aggressive therapy. 
Prof. Louis-Jacques van Bogaert Ph.D. said:
In the French terminology a basal cell "carcinoma" is called basal cell epithelioma (a benign epithelial cell tumor) as opposed to squamous cell carcinoma. It avoids any confusion including for the patient.
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.