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[Multiple synchronous cancer]
2009년 2월 11일 EndoTODAY (암호: smcgi)를 다시 읽었습니다.
내시경검사를 받는 환자들은 상당히 큰 육체적, 정신적 부담을 느낍니다. 가능하다면 검사를 적게 하는 것이 좋을 것입니다. 제 외래에는 1, 2차 의료기관에서 내시경을 통하여 위암을 진단받고 CD에 저장된 훌륭한 사진과 조직검사 유리 슬라이드를 가지고 병원을 찾은 환자들이 많습니다. 이들에게 내시경 재검을 권해야 하는지 고민입니다.
제가 가지고 있는 원칙은 이렇습니다. 수술을 필요로 하는 환자는 일단 재검을 권합니다. 개복하의 위절제술은 환자들이 평생 한번 경험하는 중대한 일이므로 재검을 통한 반복적인 확진이 반드시 필요하다는 생각 때문입니다. 간혹 위암으로 의뢰되었으나 양성위궤양으로 최종 진단된 예도 있으며, 단순 위염으로 결론난 환자도 있습니다 ("남의 위를 소중히 생각하자").
오늘의 증례처럼 distal antrum의 AGC Borrmann type II로 의뢰되었으나 내시경 재검에서는 antrum lesser curvature와 lower body에 각각 조기위암이 추가로 발견된 예도 있습니다. 또한 최근의 위암 환자들은 상당수가 건강검진을 통하여 무증상 단계에서 진단되기 때문에 환자 스스로 진단에 대한 의심을 가지는 경우도 많습니다. 재검을 통한 확진이 환자에게 주는 이익은 무시할 수 없습니다.
내시경 치료의 적응증이 되는 환자는 사진이 좋다면 내시경 재검을 권하지 않고 있습니다. 여러 이유가 있습니다만 (1) 내시경 재검이 오히려 치료방침 결정에 혼선을 가져올 수 있다는 점과 (2) 반복적인 조직검사가 내시경 치료를 어렵게 할 수 있다는 점을 중요시 하고 있습니다.
[2013-7-23. 추가] 요컨데 위암환자를 의뢰받았을 때, 수술 candidate는 반드시 내시경 재검을 하고, ESD candidate는 외부 자료가 좋다면 재검하지 않고 치료에 들어가고 있습니다. 한 병원에서도 ESD 전 반드시 내시경 재검을 하는 선생님도 계십니다. 자료는 부족하니 철학의 차이라고 할 수 있습니다.
JAMA 최근호 viewpoint를 소개합니다. 제목은 Overdiagnosis and Overtreatment in Cancer입니다. Screening이 활발한 시대의 과잉치료에 대한 문제제기입니다. 문제 해결을 위한 몇 가지 방안도 제시되어 있습니다. 무척 설득력이 있는 내용입니다. 아래는 그 중 하나입니다. Indolent disease 진단을 줄이는 방법은 효과가 낮은 검사를 줄이는 것이다는 말입니다. 어떤 종류의 병은 진단한 후 어떻게 할지 고민하기 보다는 진단하지 않는 것이 낫다는 이야기입니다.
Mitigate overdiagnosis. Strategies to reduce detection of indolent disease include reducing low-yield diagnostic evaluations appropriately, reducing frequency of screening examinations, focusing screening on high-risk populations, raising thresholds for recall and biopsy, and testing the safety and efficacy of risk-based screening approaches to improve selection of patients for cancer screening. The ultimate goal is to preferentially detect consequential cancer while avoiding detection of inconsequential disease.
JAMA 논문에는 아래 table과 같은 흥미로운 내용도 있습니다. 모든 암이 screening을 한다고 다 좋은 결과가 오는 것은 아니라는 의미입니다. 암 진단은 많아지는데 암 사망은 줄지않는 그런 종류의 screening도 있다는 것입니다. 즉 하지 않아야 할 screening도 있다는 것입니다. 관련하여 2011년 8월 29일 EndoTODAY와 Less is more를 꼭 읽어보시기 바랍니다. 건강검진이 난무한 시대에 사는 의사는 확고한 철학을 가질 필요가 있습니다.
New York Times (너무 좋은 내용이라 전문을 옮깁니다)와 중앙일보에 관련 기사가 실렸습니다. 저는 90%쯤 찬성합니다. 과잉진단과 과잉치료에 넌저리가 납니다.
[2013-8-1. New York Times] Scientists Seek to Rein In Diagnoses of Cancer
A group of experts advising the nation’s premier cancer research institution has recommended changing the definition of cancer and eliminating the word from some common diagnoses as part of sweeping changes in the nation’s approach to cancer detection and treatment.
The recommendations, from a working group of the National Cancer Institute, were published on Monday in The Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, 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.
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.”
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 backing of the National Cancer Institute brings the discussion to a higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.
“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.
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.
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 are called overtreatment.
Cancer researchers warned about the risk of overdiagnosis and overtreatment as a result of new recommendations from a government panel that heavy smokers be given an annual CT scan. While the policy change, announced on Monday but not yet made final, has the potential to save 20,000 lives a year, some doctors warned about the cumulative radiation risk of repeat scans as well as worries that broader use of the scans will lead to more risky and invasive medical procedures.
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 E. 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.”
An expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified.
An expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified. 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.
"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.
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.
“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.”
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.
“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.”
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.
“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.”
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 years of aggressively treating those conditions, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.
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.
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.
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.
“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.”
[2013-8-1. 중앙일보] 암입니다. 과잉 진단이 과잉 공포 불러
IHT는 암 분류를 바꿔야 한다는 요구 이면에는 연간 수십만 명이 불필요하고 때론 해롭기까지 한 암 진단 및 치료를 받고 있는 현실이 있다고 지적했다. 특히 생체 촬영 및 판독 기술이 발달하면서 놔둬도 암으로 발전하거나 전이를 일으키지 않을 종양까지 제거 및 치료 대상이 되는 게 문제라고 했다. 연구팀의 보고서도 지난 35년간 암 진단 건수가 크게 늘어난 데 비해 말기 암 진단 비율과 암 전이로 인한 사망률이 현격히 줄지 않았다고 지적했다. 암이라고 보기 모호한 초기 단계가 많이 진단됐다는 의미다.
국내에서도 논란의 중심에 있는 것이 갑상샘암이다. 갑상샘암은 생존율(5년 생존율 99.8%)이 높은 데다 대개 자라는 속도도 느리다. 그래서 ‘거북이 암’이라고 불린다. 그런데 이 갑상샘암 환자는 2000년 3288명에서 2010년 3만6021명으로 10배 이상으로 불어났다. 반면 같은 기간 전체 암 환자는 10만1772명에서 20만2053명으로 두 배로 늘어나는 데 그쳤다. 갑자기 한국인이 암에 잘 걸리게 된 걸까. 이에 대해 한국개발연구원(KDI) 윤희숙 연구위원은 “초음파 진단기기가 동네 의원까지 확대되면서 지나친 검사를 하기 때문”이라고 지적했다. 지난해 11월 ‘한국 1차 의료 발전방향의 모색’이란 보고서를 통해서다. 윤 연구위원은 “외국에선 증상이 없을 경우 초음파 검사를 하지 않는 게 일반적”이라며 한국의 과잉 진료 현실을 꼬집었다.
하지만 반론도 적지 않다. 전암 단계거나 생존율이 높다고 알려진 암일지라도 치명적으로 바뀔 수 있다는 이유에서다. 삼성서울병원 오영륜(병리학) 교수는 “유방상피내암을 제거하지 않고 그대로 두면 주변으로 퍼지는 침윤성암으로 바뀔 위험이 8~10배 높아진다고 알려져 있다”고 지적했다. 현실적인 어려움도 있다. 이진수 국립암센터 원장은 “갑상샘의 경우 사망률이 낮아 문제가 되는 측면이 있다”면서도 “의사가 놔두자고 해도 환자들은 가만 있지 않고 적극적인 치료를 요구한다”고 말했다. 국내에서도 암의 분류에 대한 논의를 시작해야 한다는 의견도 있다. 삼성서울병원 김선욱(내분비대사내과) 교수는 “현재 과학기술로는 잠재암과 진행암을 구별하기 어려운 것이 사실이지만 암의 분류에 대해 진지한 고민을 해야 한다는 보고서의 취지엔 동의한다”고 말했다.
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