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Yuri Nikiforov: Hello everyone. I hope that the experience from thyroid, because I believe the thyroid is the first cancer type where we reclassified some cancers as non-cancerous, will be helpful for your discussion.

So, why did we do it? We did it because of a situation very similar to prostate. In the early 2000s, thyroid cancer was rapidly growing, pretty much doubling in, like, 10-15 years. And very few people died of that cancer. So there was a high interobserver variability in diagnosing a specific type of cancer, which we called encapsulated follicular variant of PTC. To today's discussion, it was not invasive, it was encapsulated, but it had morphologic features of cancer, of papillary carcinoma, and based on morphologic features it was called cancer. Okay? And there are multiple studies in the literature demonstrating that this is a highly indolent cancer type. The patient didn't die from the cancer, and yet it was treated, in many cases, with radioactive iodine.

So what did we do? I served as the president of the Endocrine Pathology Society, and I decided, sort of, to tackle this issue. And I created a group, a Working Group for Re-examination of the Encapsulated Follicular Variant of PTC.

Since pathological criteria are very important, maybe in contrast to what you are discussing today, the core of the group were pathologists. There were 24 pathologists from several countries and continents; I think it is very important. Then we had clinicians; we had endocrinologists and surgeons. I brought in a psychiatrist, because I wanted to be sure that people understand the psychological impact of the word "cancer." There was a molecular pathologist, a biostatistician, and a thyroid cancer survivor. And I think it was a very big, very, very good decision, because it helped us to reach consensus within the group.

So, what did we do? This group of pathologists evaluated about 200 cases of so-called encapsulated... not so-called; at that time, called encapsulated follicular variant of PTC. They had very similar features of invasive cancer, but one group was non-invasive, and another group was invasive. This was done blindly, not knowing the follow-up. And then, when everybody submitted their diagnosis... and I have to say also that we standardized the diagnostic criteria; we found that even with nuclear features of cancer, the non-invasive tumors had zero problems on long follow-up, median follow-up 13 years. And Group 2, these invasive cancers that behave like cancers, a number of patients died of this disease. So this allowed us to offer a data-driven reclassification of this type of cancer.

So the paper came out, and the entity was called non-invasive follicular thyroid neoplasm with papillary-like nuclear features; a very long name. There are several reasons for the name, I don't think that we now have time to discuss, but the acronym was NIFTP, and there is something that was very easy to use, and it's actually how this entity is called now.

So the paper was published in JAMA Oncology on April 14, 2016, and I said that we were lucky because the story was picked up by the New York Times, was published on the second page of the New York Times, and really went to the press. And why I said it was very good? Because it immediately, immediately became known to hundreds and hundreds and thousands of people around the world.

Next, I have animation. I said that in one month, there were 80,000 people who read the paper, and in a year, it was 500,000. So about half a million people read this paper, so that really helped to disseminate the knowledge.

And we were also lucky because next year, the WHO was issuing a reclassification; it was a big fight, a big battle, but we were able to get it into the WHO Classification. And this was pretty much the last step that we needed in order to get it accepted around the world.

In my opinion, it's subjective, my opinion, what factors led to the success in doing. First of all, I said it was a data-driven reclassification. It's not literature review, it's not generally what I feel and what I know. In the current world, you need data in order to convince everybody that what you're trying to do makes sense.

I said it's important to be international, and I mean maybe two, three countries if you really want to be sure that your entity is accepted everywhere. Multidisciplinary, that's exactly what you have. I said if you decide to go for it, you have to think very, very carefully about the new entity name. From our experience, I can tell you it matters, and it's manageable. It has to fit the interests and understanding of psychologists, in your case it's pathologists, and patients, clinicians, and so on and so forth. For example, a clinician told us that if we keep the word cancer... because the contender to the name was carcinoma in situ; and we were told, the clinicians told us that if you keep cancer even, like, in situ, they will continue to treat this patient with radioactive iodine. That's why we kind of had to remove even "in situ" from the name of it.

So it has to be done based on reproducible diagnostic pathological criteria. Remember, this is very important. It needs to be clearly defined patient management. In my opinion, it needs to be published in a high-ranked journal, and you have to try to get media involved because this is the only way how you really spread the knowledge across. And it's very important, in my opinion, to get included in the WHO Classification.

That's, I believe, are the components of success if you would like to try to do the same. Thank you.