Jane McCredie: Word power

WHEN Shakespeare’s Juliet lamented “What’s in a name?” she certainly didn’t have disease processes in mind.

But how does her argument that names don’t matter — things are what they are regardless of what we choose to call them — stand up when it comes to medicine?

A working group from the US National Cancer Institute is not the first to suggest the labels we apply can have a real impact on patient outcomes.

In fact, they argue in JAMA, that as one of several strategies to mitigate cancer overdiagnosis, we should rethink our use of the term cancer, applying it only to those lesions “with a reasonable likelihood of lethal progression if left untreated”.

“The word ‘cancer’ often invokes the specter of an inexorably lethal process”, they write. “However, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime.”

Calling something cancer is always going to up the stakes, making patients (and perhaps doctors too) more inclined to opt for unnecessary, even harmful, interventions.

So which conditions might deserve a name change?

These authors identify breast and prostate screening as sources of many unwarranted cancer diagnoses, suggesting premalignant conditions such as ductal carcinoma in situ or high-grade prostatic intraepithelial neoplasia be reclassified as IDLE (indolent lesions of epithelial origin) conditions.

Of course, it’s not always going to be easy for clinicians to determine which lesions will remain indolent and which are likely to develop a burst of potentially lethal energy.

But getting rid of some of the more scary words such as cancer, carcinoma and neoplasia would presumably make a calm discussion on management options easier.

The authors suggest this is likely to become a bigger issue as more screening options become available, identifying lung, thyroid and skin cancer screening as areas of concern.

Applying a disease label can pose a risk to patients in other areas too.

A paper in the BMJ last week argued that expanded diagnostic criteria have led to many low-risk older people being diagnosed with chronic kidney disease.

This labelling brings with it not just the risk of unnecessary treatment, but also the less easily defined consequences of telling an asymptomatic person they have a disease.

Studies in hypertension suggest disease labelling may increase psychological distress and absenteeism from work and decrease quality of life, the authors write.

Words have power, as Juliet found out to her cost, and cancer may be one of the most powerful words of our age.

Perhaps it should be used more sparingly.
 

Jane McCredie is a Sydney-based science and medicine writer.