College of American Pathologists Discourages Informing Most Non-Invasive EFVPTC Patients about NIFTP Reclassification

An article published recently in Cap Today Online, a publication of the College of American Pathologists, has opined that most patients who have already been treated for the type of thyroid cancer (noninvasive encapsulated follicular variant) need not be informed that their “cancer” has been reclassified.

The authors, Paul N. Staats, MD and Benjamin L. Witt, MD, write (responding to a hypothetical question) in their article  entitled “Cytopathology in Focus:  The Significance of NIFTP for Thyroid Cytology“:

Should I go back and reclassify all my old thyroid surgical pathology diagnoses?

Probably not. As most patients will have already received definitive treatment of their NIFTP, reclassification is unlikely to have an impact on their management going forward. For patients very recently diagnosed as noninvasive follicular variant PTC, discussion with the treating physicians about reclassification and management options for the patient may be appropriate. Our opinion is that patients were accurately diagnosed within the constructs of the time and that applying new or novel principles to prior diagnoses is not a worthwhile endeavor.

This opinion would appear to be in conflict with that of other authors. For example, an article published last year in Thyroid, advises physicians to retroactively inform such patients that their diagnosis has changed when possible.  See a summary of this article here.

As noted in that post, In the opinion of the Mt. Sinai team who wrote in Thyroid, pathologists are ethically obligated to review cases and contact patients about a  change in diagnosis.  The justification for the widespread adoption of this policy is that a cancer diagnosis causes “clinically significant” stress and also creates financial burdens for patients.  Perhaps most important of all is the primacy of a patient’s basic legal right to information about their own condition.

The Antidote to Overdiagnosis – Is it Oversight?

 

“I hope that the investigators are successful in their terminology reform efforts, I encourage them to include among their goals the search for a better understanding of why the specialty of pathology was unable to escape from its stubborn devotion to turning lesions with a low or poorly defined risk into cancer. Also, why is there no backup mechanism analogous to the US Food and Drug Administration’s review to detect and respond in a timely fashion to a systemic problem like hazardous diagnostic criteria becoming the standard of care?”

Pathologist and Author,  Elliot Foucar, addressing the work of Laura Esserman et al in The Lancet

 

In 2014, Dr. Laura J. Esserman and colleagues published an influential paper which proposed a new term, IDLE (Indolent Lesion of Epithelial Origin), for many types of indolent tumors which are currently being labeled as “cancers”.  Among a number of cogent points of the article is this one: ” new guidance is needed to describe and label the heterogeneous diseases currently referred to as cancer.”

As noted by  Dr.Elliot Foucar, a retired pathologist who still publishes papers about errors in pathology, it has fallen to researchers outside of the discipline of surgical pathology to call attention to the problem of cancer overdiagnosis.  Foucar blames the failure of pathologists to challenge and police their system of an expert opinion “gold standard” for the intervention by outsiders such as Esserman et al  into the problem of over treatment of indolent tumors which are labeled as cancers.

Since its publication, Esserman’s article has been cited 274 times, and has brought a significant degree of attention to the problem of overdiagnosis.