Is Gleason 6 cancer? The answer is more than just a ‘name’

Despite the innovations made to enhance smarter screening and conservative management for low-grade prostate cancer, overdiagnosis, and overtreatment remains a major health care problem. Driven by the primary goal of reducing harm to the patients, relabeling of nonlethal grade group 1 (GG 1) prostate cancer has been proposed but faced varying degrees of support and objection from clinicians and pathologists. GG 1 tumor exhibits histologic (invasive) and molecular features of cancer but paradoxically, if pure, is unable to metastasize, rarely extends out of the prostate, and if resected, has a cancer-specific survival approaching 100%. Most of the arguments against relabeling GG 1 relate to concerns of missing a higher-grade component through the unsampled area at biopsy. However, the designation of tumor benignity or malignancy should not be based on the shortcomings of a diagnostic procedure and sampling errors. This review explores possible solutions, mainly the feasibility of renaming GG 1 in radical prostatectomy (RP) with ramifications in biopsy diagnosis, acceptable for both pathologists and clinicians. One workable approach is to rename GG 1 in RP with a cautious neutral or nonbenign non-cancer term (eg, acinar neoplasm) using “defined criteria” that will stop the indiscriminate reporting of every GG 1 in biopsy as carcinoma including eventual insignificant microtumors in RPs. Use of a corresponding noncommittal term at biopsy while commenting on the possibility of an undersampled nonindolent cancer, might reduce the pathologist's concerns about upgrading. Dropping the word “carcinoma” in biopsy preempts the negative consequences of labeling the patient with cancer, including unnecessary definitive therapy (the root cause of overtreatment). Renaming should retain the status quo of contemporary grading and risk stratifications for management algorithms while trying to minimize overtreatment. However, the optimal approach to find answers to this issue is through multidisciplinary discussions of key stakeholders with a specific focus on patient-centered concerns and their ramifications in our practices. GG 1 renaming has been brought up in the past and came up again despite the continued counterarguments, and if not addressed more comprehensively will likely continue to reemerge as overdiagnosis, overtreatment, and patient’s sufferings persist.

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“…It is important to emphasize that words matter in medicine, what we say and how we say it have important health care implications. 67…”

Section: Patients Come Firstmentioning

confidence: 99%

“…A feasible approach is to rename these tumors with a cautious neutral term such as prostate “acinar neoplasm” in RP with criteria. It is important to emphasize that words matter in medicine, what we say and how we say it have important health care implications 67 …”

Section: Motivations For a Nomenclature Changementioning

confidence: 99%

Renaming Grade Group 1 Prostate “Cancer” From a Pathology Perspective: A Call for Multidisciplinary Discussion

Paner

Zhou

Simko

et al. 2023

Advances in Anatomic Pathology

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Decision Making in Prostate Cancer

Nadamuni,

D’Amico,

Donovan

et al. 2023

N Engl J Med

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The influence of the “cancer” label on perceptions and management decisions for low-grade prostate cancer

Berlin

Ramotar

Santiago

et al. 2023

JNCI: Journal of the National Cancer Institute

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BACKGROUND Grade Group 1 prostate cancer (GG1) should be managed with active surveillance (AS). Global uptake of AS remains disappointingly slow and heterogeneous. Removal of cancer labels has been proposed to reduce GG1 overtreatment. OBJECTIVE Determine the impact of GG1 disease terminology on individual’s perceptions and decision-making. DESIGN, SETTING, AND PARTICIPANTS Discrete choice experiments (DCE) were conducted on 3 cohorts: healthy men, canonical partners (partners), and patients with GG1 (patients). Participants reported preferences in a series of vignettes with two scenarios each, permuting KOL-endorsed descriptors: biopsy (adenocarcinoma/acinar neoplasm/PAN-LMP/PAN-UMP), disease (cancer/neoplasm/tumor/growth), management decision (treatment/AS), and recurrence risk (6%/3%/1%/<1%). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Influence on scenario selection were estimated by conditional logit models and marginal rates of substitution (MRS). Two additional validation vignettes with scenarios portraying identical descriptors except the management options were embedded into the DCE. RESULTS AND LIMITATIONS Across cohorts (194 healthy men, 159 partners, and 159 patients), non-cancer labels PAN-LMP or PAN-UMP and neoplasm, tumor or growth were favored over adenocarcinoma and cancer (p < 0.01), respectively. Switching adenocarcinoma and cancer labels to PAN-LMP and growth, respectively, increased AS choice by up to 17%: healthy men (15% [95CI 10-20%], from 76% to 91%, p < 0.001), partners (17% [95CI 12-24%], from 65% to 82%, p < 0.001) and patients (7% [95CI 4-12%], from 75% to 82%, p = 0.063). Main limitation is the theoretical nature of questions perhaps leading to less realistic choices. CONCLUSIONS “Cancer” labels negatively impact perceptions and decision-making regarding GG1. Relabeling (i.e., avoiding word “cancer”) increases proclivity for AS and would likely improve public health.

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Is Gleason 6 cancer? The answer is more than just a ‘name’

Cited by 5 publications

References 7 publications

Renaming Grade Group 1 Prostate “Cancer” From a Pathology Perspective: A Call for Multidisciplinary Discussion

Renaming Grade Group 1 Prostate “Cancer” From a Pathology Perspective: A Call for Multidisciplinary Discussion

Decision Making in Prostate Cancer

The influence of the “cancer” label on perceptions and management decisions for low-grade prostate cancer

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