医学专家提议重新定义“癌症”

Scientists Seek to Rein In Diagnoses of Cancer
By TARA PARKER-POPE July 31, 2013
健康
医学专家提议重新定义“癌症”
TARA PARKER-POPE 2013年07月31日
A group of experts advising the nation’s premier cancer research institution has recommended sweeping changes in the approach to cancer detection and treatment, including changes in the very definition of cancer and eliminating the word entirely from some common diagnoses.
为美国主要的癌症研究机构担任顾问工作的一组专家建议，应当对癌症的诊断和治疗方法进行彻底改革，其中包括改变癌症的定义本身，并把这个词从一些常见的诊断中彻底去除。
The recommendations, from a working group of the [要查看本链接请先注册并登录], were [要查看本链接请先注册并登录] in the Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called [要查看本链接请先注册并登录], which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.
这些建议来自美国国家癌症研究所([要查看本链接请先注册并登录])的一个工作组，并在周一发表在了《美国医学会杂志》(The Journal of the American Medical Association)上。例如，他们说，一些癌前病症，例如影响乳房的原位导管癌([要查看本链接请先注册并登录])，许多医生认为这不是癌症，应当去掉“癌”这个字进行重命名，这样患者就不会太害怕，也不太会寻求可能是不必要的，且有潜在伤害的疗法，包括乳房切除手术。
The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”
这个工作组中包括一些癌症研究领域的顶尖科学家。工作组还建议，许多在乳房、前列腺、甲状腺和肺部等部位进行的癌症筛查中发现的病变，完全不应被称为癌症，而是应当被重新归类为IDLE症状，意思是“上皮源慢性病变”(indolent lesions of epithelial origin)。
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Damian Dovarganes/Associated Press
一名放射科医生使用放大镜在乳房X线照片上检查乳癌。
While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group’s views, the report from such a prominent group of scientists who have the clear backing of the National Cancer Institute brings the discussion to a much higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.
显而易见的是，上述一些或全部用词转变，即便真的会出现，也只能是在多年以后，而一些癌症专家也会对工作组的观点表示强烈反对，但这份出自这样一组顶尖科学家、并得到国家癌症研究所明确支持的报告，会把争论带到一个更高的层次，并很有可能会改变美国对癌症的讨论、它的定义、治疗方法和未来的研究。
“We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.
“我们需要一个21世纪的癌症定义，而不是19世纪的癌症定义，而我们一直都在使用后者，”美国癌症学会(American Cancer Society)首席医疗官奥蒂斯·W·布劳利博士(Otis W. Brawley)说。布劳利并未直接参与这份报告的撰写。
The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.
呼吁转变的原动力来自医生、科学家和患者权益倡导人士越来越强烈的担忧。他们害怕，几十万名男男女女正在接受不必要的、有时会有损外貌且有害的疗法，来治疗癌前和癌性病变，而这些病变的发展如此缓慢，很有可能永远都不会产生损害。
The advent of highly sensitive screening technology in recent years has increased the likelihood of finding these so-called incidentalomas — the name given to incidental findings detected during medical scans that most likely would never cause a problem. However, once doctors and patients are aware a lesion exists, they typically feel compelled to biopsy, treat and remove it, often at great physical and psychological pain and risk to the patient. The issue is often referred to as overdiagnosis, and the resulting unnecessary procedures to which patients are subjected is called overtreatment.Officials at the National Cancer Institute say overdiagnosis is a major public health concern and a priority of the agency. “We’re still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold Varmus, the Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”
近年来，高敏度筛查技术的出现，提高了发现这类所谓“偶发瘤”的可能性。偶发瘤指医学扫描检查时意外发现的肿瘤，这些肿瘤几乎永远不会出现任何问题。然而，一旦医生和患者得知了这样一个病变的存在，他们通常会觉得应该要进行活检、治疗并摘除它，这往往会为患者的生理和心理带来巨大的痛苦和风险。这种问题通常被称为过度诊断，而患者因此而承受的不必要的治疗则称为过度治疗。国家癌症研究所有关负责人称，过度诊断是一个公共卫生领域的重大问题，也是该研究所的一个研究重点。“我们还是无法说服人们，乳房X线照相术、前列腺特异抗原(PSA)测试和其他筛查手段所发现的问题，并非总是传统意义上‘会杀死你’的恶性症状，”国家癌症研究所主任、诺贝尔奖获得者哈罗德·瓦默斯博士(Harold Varmus)说，“正如公众正在逐步认识到这一点，一些科学家也正在认识到这一点。”
One way to address the issue is to change the language used to describe lesions found through screening, said Dr. Laura J. Esserman, the lead author of the report in the Journal of the American Medical Association and the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. In the report, Dr. Esserman and her colleagues said they would like to see a multidisciplinary panel convened to address the issue, led by pathologists, with input from surgeons, oncologists and radiologists, among others.
加州大学旧金山分校(University of California, San Francisco)卡罗尔·弗兰克·巴克乳房保健中心(Carol Franc Buck Breast Care Center)主任劳拉·J·埃瑟曼博士(Laura J. Esserman)是这份《美国医学会杂志》报告的主要作者，她说，解决这一问题的方法之一，是更改筛查中发现病变的名称。在报告中，埃瑟曼博士和她的同事表示，他们希望召开一次多学科小组会议来探讨这一问题，由病理学家领导，由外科医生、肿瘤专家和放射科医生等参加。
“Ductal carcinoma in situ is not cancer, so why are we calling it cancer?” said Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco.
“原位导管癌并非癌症，所以我们为何非要管它叫癌症呢？”埃瑟曼博士说。她是加州大学旧金山分校的外科和放射学教授。
Such proposals will not be universally embraced. Dr. Larry Norton, the medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, said the larger problem is that doctors cannot tell patients with certainty which cancers will not progress and which cancers will kill them, and changing terminology does not solve that problem.
这些提议不会被所有人接受。纪念斯隆-凯特琳癌症中心(Memorial Sloan-Kettering Cancer Center)的伊夫琳·H·劳德乳房医学中心(Evelyn H. Lauder Breast Center)的医疗总监拉里·诺顿博士(Larry Norton)说，更大的问题是，医生无法明确地告诉患者，哪种癌症不会发展，哪种癌症则会致死，而修改术语无法解决这一问题。
“Which cases of D.C.I.S. will turn into an aggressive cancer and which ones won’t?” he said, referring to ductal carcinoma in situ. “I wish we knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer.”
“哪些原位导管癌病例会演变成恶性癌症，哪些不会？”他说。“我很希望我们知道这个答案。但并没有非常精确的方法，通过在显微镜下观察组织和肿瘤，就能明确地知道这是生长速度缓慢的癌症。”
Dr. Norton, who was not part of the report, agreed that doctors do need to focus on better communication with patients about precancerous and cancerous conditions. He said he often tells patients that even though ductal carcinoma in situ may look like cancer, it will not necessarily act like cancer — just as someone who is “dressed like a criminal” is not actually a criminal until that person breaks the law.
诺顿博士没有参与此项研究报告的工作，他承认，医生们的确需要投入精力，更好地与病人就癌前和癌性病变进行沟通。他说，他常常跟病人说，即便原位导管癌可能看似癌症，但它的表现未必和癌症一样，就像有人“打扮得像个罪犯”，其实未必真的是罪犯，除非此人违反了法律。
“The terminology is just a descriptive term, and there’s no question that has to be explained,” Dr. Norton said. “But you can’t go back and change hundreds of years of literature by suddenly changing terminology.”
“术语只是一种描述性的说法，毫无疑问，这一点是需要解释的，”诺顿博士说。“可是即使突然改变术语，也不能回过头去修改几百年的医学文献。”
But proponents of downgrading cancerous conditions with a simple name change say there is precedent for doing so. The report’s authors note that in 1998, the World Health Organization changed the name of an early-stage urinary tract tumor, removing the word “carcinoma” and calling it “papillary urothelial neoplasia of low malignant potential.” When a common Pap smear finding called “cervical intraepithelial neoplasia” was reclassified as a low-grade lesion rather than a malignancy, women were more willing to submit to observation rather than demanding treatment, Dr. Esserman said.
但是那些赞成通过简单地改变名称而将癌性病变降级的人表示，有过这样的先例。这份报告的作者指出，在1998年，世界卫生组织(World Health Organization)改变了一种早期尿路肿瘤的名声，移除了“癌”一字，称它为“低度恶性潜能乳头状尿路上皮肿瘤”(papillary urothelial neoplasia of low malignant potential)。一个常见的被称为“宫颈上皮内瘤变”(cervical intraepithelial neoplasia)的子宫颈抹片检查结果被重新分级，定义为低度病变，而不是恶性肿瘤之后，女性就会更愿意接受观察，而不是要求治疗，埃瑟曼博士说。
“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” she said. “The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term ‘cancer’ for those things that are highly likely to cause a problem.”
“改变我们用来判断不同病变的语言至关重要，这样做能让病人们相信，他们不必针对扫描检查中发现的每一个问题，都进行激进治疗，”她说，“对于大众来说，问题是一听到‘癌’这个字，就以为如果不治疗就会死。我们应该把‘癌’这个字留给那些极有可能会产生问题的病症。”
The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett’s esophagus, small thyroid tumors and early prostate cancer. But even after aggressively treating those conditions for years, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.
然而，问题是，由于医生们还没有明确的方法，根据这些症状来区别良性、生长缓慢的肿瘤和恶性病灶，他们就会把每一个病例都当成可能会恶化的来治疗。结果是，医生们会发现并治疗大量似乎具有癌前病变或早期癌症的患者，如原位导管癌、一种称为巴雷特食管(Barrett’s esophagus)的病症、小甲状腺肿瘤和早期前列腺癌。但是即使对这些病症进行多年激进治疗，侵入性癌症也没有出现相应的减少，这说明过度诊断和过度治疗极其普遍。
The National Cancer Institute working group also called for a greater focus on research to identify both benign and slow-growing tumors and aggressive diseases, including the creation of patient registries to learn more about lesions that appear unlikely to become cancer.
美国国家癌症研究所的研究小组也呼吁医学界更多关注如何识别良性的、生长缓慢的肿瘤和恶性疾病，进行更多这方面的研究，包括集中汇总患者的临床资料，来增进对那些看来不太可能演变成癌症的病变的了解。
Some of that research is already under way at the National Cancer Institute. Since becoming director of the institute three years ago, Dr. Varmus has set up a list of “provocative questions” aimed at encouraging scientists to focus on critical areas, including the issue of overdiagnosis and molecular tests to distinguish between slow-growing and aggressive tumors.
美国国家癌症研究所已经在进行一些相关的研究。三年前成为研究所主任以来，瓦默斯博士已列出了一系列“挑战性问题”，目的在于鼓励科学家关注关键领域，其中包括过度诊断的问题，以及通过分子检测来区别生长缓慢的肿瘤和恶性肿瘤的问题。
Another National Cancer Institute program, the Barrett’s Esophagus Translational Research Network, or BETRNet, is focused on changes in the esophageal lining that for years have been viewed as a precursor to esophageal cancer. Although patients with Barrett’s are regularly screened and sometimes treated by burning off the esophageal lining, data now increasingly suggest that most of the time, Barrett’s is benign and probably does not need to be treated at all. Researchers from various academic centers are now working together and pooling tissue samples to spur research that will determine when Barrett’s is most likely to become cancerous.
美国国家癌症研究所的另一个项目——巴雷特食管转化研究网络（Barrett’s Esophagus Translational Research Network，简写BETRNet）主要关注于食管内膜的变化，这种变化多年来被视作是食管癌的前兆。虽然患有巴雷特食管的病人会定期接受扫描检查，有时候通过去除食管内膜来进行治疗，但现在有越来越多的数据显示，多数时间，巴雷特食管都是良性的，可能根本就不需要治疗。许多学术机构的研究人员如今进行合作，将组织样本收集起来促进研究，进而确定巴雷特食管何时最容易癌变。
“Our investigators are not just looking for ways to detect cancer early, they are thinking about this question of when you find a cancer, what are the factors that might determine how aggressively it will behave,” Dr. Varmus said. “This is a long way from the thinking 20 years ago when you found a cancer cell and felt you had a tremendous risk of dying.”
“我们的研究人员现在不只是在寻找及早发现癌症的方法，他们也在考虑这样一个问题：发现癌症时，靠哪些因素判断其影响会有多么严重？”瓦默斯博士说。“而20年前发现癌细胞时，就会感觉有极大的可能会死掉。现在和那时的想法完全不同了。”