The change may offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.
An international panel of doctors has decided a type of tumor that was classified as a cancer is not a cancer at all.
As a result, the panel officially downgraded the condition, and thousands of patients will be spared removal of their thyroid, treatment with radioactive iodine and regular checkups for the rest of their lives, all to protect against a tumor that was never a threat.
The experts’ conclusion — and the data that led to it — were reported Thursday in the journal JAMA Oncology. The change is expected to affect about 10,000 of the nearly 65,000 thyroid-cancer patients a year in the U.S.
It may also offer grist to those who have been arguing for the reclassification of some other forms of cancer, including certain lesions in the breast and prostate.
Most Read Nation & World Stories
- A mysterious, devastating brain disorder afflicts dozens in one Canadian province
- One of the world’s longest-running experiments sends up sprouts
- Colonial Pipeline paid hackers nearly $5 million in ransom
- What is happening in Jerusalem and Gaza?
- Two planes collide midair above Denver, no one injured
The reclassified tumor is a small lump in the thyroid that is completely surrounded by a capsule of fibrous tissue. Its nucleus looks like a cancer but the cells have not broken out of their capsule, and surgery to remove the entire thyroid followed by treatment with radioactive iodine is unnecessary and harmful, said the panel, which also renamed the tumor.
Instead of calling it “encapsulated follicular variant of papillary thyroid carcinoma,” it will be “noninvasive follicular thyroid neoplasm with papillary-like nuclear features,” or NIFTP. The word “carcinoma” is gone.
Many cancer experts said the reclassification was long overdue. There have been calls for years to downgrade small lesions in the breast, lung and prostate, among others, and to eliminate “cancer” from their name.
But other than the renaming of an early-stage urinary-tract tumor in 1998, and early-stage ovarian and cervical lesions more than two decades ago, no group other than the thyroid specialists has taken the plunge.
In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary.
Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early-stage prostate lesions were called cancerous tumors.
Meanwhile imaging with ultrasound, MRIs and CT scans find more and more of these tiny “cancers,” especially thyroid nodules.
“If it’s not a cancer, let’s not call it a cancer,” said Dr. John Morris, president-elect of the American Thyroid Association and a professor at the Mayo Clinic. He was not on the renaming panel.
Doctor led effort
The reclassification drive began two years ago, when Dr. Yuri Nikiforov, vice chairman of the pathology department at the University of Pittsburgh, was asked his opinion about a small thyroid tumor in a 19-year-old woman. It was encased in a capsule, and the lobe of her thyroid containing it had been removed to establish a diagnosis.
Over the past decade, Nikiforov had watched as pathologists began classifying noninvasive tumors as cancers and attributed the change to rare cases in which patients had a tumor that had broken out of its capsule, did not receive aggressive treatment and died of thyroid cancer. Worried doctors began treating all tumors composed of cells with nuclei that looked like cancer nuclei as if they were cancers.
But this woman’s story drove Nikiforov over the edge.
“I told the surgeon, who was a good friend, ‘This is a very low-grade tumor. You do not have to do anything else.’ ” But the surgeon said that according to practice guidelines, she had to remove the entire thyroid and treat the woman with radioactive iodine. And the woman had to have regular checkups for the rest of her life.
“I said, ‘That’s enough. Someone has to take responsibility and stop this madness,’ ” Nikiforov said.
He brought together the international panel — 24 renowned pathologists, two endocrinologists, a thyroid surgeon, a psychiatrist who knew the impact a cancer diagnosis can have and a patient. The group collected a couple of hundred cases from centers throughout the world — patients who had tumors that were contained within fibrous capsules and those that had broken out. All agreed that by the current criteria, every one of those tumors would be classified as a cancer.
All the patients had been followed for at least 10 years. The patients with the encapsulated tumors had not been treated after their tumors were removed.
None of the patients whose tumors stayed within their capsules had any evidence of cancer after 10 years. But some of the patients whose tumors had broken out of their capsules had complications, including death, from thyroid cancer despite treatment.
“This study said it is not the presence of nuclear features but the presence of invasion that can make the difference between cancer and noncancer,” Nikiforov said.
Patients whose tumors are confined within their capsules “have an excellent prognosis,” he said. “They do not need a thyroidectomy. They do not need radiotherapy. They do not need to be followed up every six months.”
Voting on new name
But if those tumors are not cancers, what should they be called?
“Ten different names were submitted and the voting went on, back and forth,” said one member of the panel, Dr. Gregory Randolph, director of the thyroid and parathyroid surgical clinic at Harvard’s Massachusetts Eye and Ear Infirmary. They finally settled on NIFTP, in part because its acronym, which he pronounced as “Nift-P” was catchy, he said. The new name, the reclassification, he added, is “just awesome,” because it explicitly defines those small nodules in the thyroid as nonmalignant.
In an editorial he and his colleagues submitted to the journal Thyroid, they report that eight leading professional societies from around the world signed on to the declassification and to the new name. They write in the editorial that doctors may be violating the principle of “first, do no harm” in treating patients with these tumors as if they have invasive cancer.
Nikiforov said he owes it to patients with reclassified tumors to tell them they never had cancer after all. At the University of Pittsburgh Medical Center, he and others are going to review medical records and pathology reports to identify previous patients and contact them. He estimates there have been 50 to 100 each year at the medical center. They no longer have to go back for checkups. They lose the shadow of cancer that hung over their lives.
Informing these patients, Nikiforov said, “is a moral obligation of doctors.”