Point-Counterpoint: Clinical Pragmatism Should Prevail Over Biological Orthodoxy: "Pro" Perspective.
Point-Counterpoint: Clinical Pragmatism Should Prevail Over Biological Orthodoxy: "Pro" Perspective.
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观点对立：临床实用主义应胜过生物学正统观念：“专业”观点。
DOI：
10.1097/ju.0000000000003512
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Tosoian,JeffreyJ
中科院分区：
文献类型：
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作者：
Penson,DavidF;Tosoian,JeffreyJ
尽管AUA指南优先建议对低风险疾病进行主动监测（AS），1但最近对SEER（监测、流行病学和最终结果）eProstate With Watchful Waiting数据集的分析表明，AS/观察等待率在美国男性中低风险疾病在2018年仍然只有60%。显然，AS的摄取仍有改善的空间，因为美国每5名男性中就有2人仍在接受手术、放射或其他干预措施治疗其低风险1级（GG 1）疾病。这代表了对这种常见疾病的严重、持续的过度治疗，反过来可能导致在人群水平上弊大于利。这实际上是对公众健康的威胁。为了最大限度地减少这种威胁，我们必须继续增加AS在低风险疾病中的应用。低风险前列腺癌患者摄取AS存在几个障碍。其中最强大的是与癌症诊断相关的焦虑和“未经治疗”的恶性病变的心理负担。这种对观察到潜在的“危及生命”病变的恐惧也导致患者因焦虑而选择退出AS。例如，在欧洲PRIAS研究中，最初选择AS的患者中约有10%由于焦虑/心理负担而在第10年选择积极干预。如果GG 1前列腺癌在临床上对相当一部分男性是一种危及生命的疾病，那么人们可以理解这种焦虑，但观察性研究表明并非如此。例如，在约翰霍普金斯AS队列中，1,800名低风险和极低风险前列腺癌患者随访15年，前列腺癌特异性死亡率仅为0.1%。5此外，低风险GG 1疾病的发病风险也极低。例如，在Sunnybrook队列中，993名先前未被诊断为GG 2或更高疾病的男性中只有2名在随访期间在15年时发生转移。值得注意的是，虽然转移的风险不是零，但它仍然相当低，远低于与手术或放射相关的长期性，泌尿或肠道功能障碍的风险。那么，为什么患者选择接受潜在的病态干预，如手术或放射治疗一个几乎没有或根本没有机会造成有意义的临床伤害的肿瘤实体？我们认为这主要与前列腺癌的命名有关，特别是用“癌症”一词来描述Gleason 6/GG 1疾病。GG 1疾病当然符合癌症的科学/病理学定义。具体地说，它表现出基底细胞层的损失，并表现出局部微侵入周围前列腺组织。然而，作为临床医生，我们认识到这些特征并不等同于GG 1疾病侵入前列腺包膜以外和/或转移到身体其他部位的能力，这就是为什么我们将这些肿瘤归类为“低风险”。然而，患者并没有做出这些区分。他们听到“癌症”一词，想到的是外行人对这个词的定义，在韦伯斯特的字典中解释为“一种潜在无限生长的恶性肿瘤，通过侵袭局部扩张，通过转移全身扩张”（https：//www.韦氏。com/dictionary/cancer）。事实上，我们认为许多患者将癌症视为“某种邪恶或恶性的破坏性传播”（同一来源的另一种定义）。在我们将GG 1疾病重新命名为癌症以外的疾病之前，患者在被诊断患有这种常见肿瘤时将继续经历毫无根据的焦虑，并将选择积极的干预措施，尽管他们的临床医生敦促他们不要这样做。
Although the AUA guidelines preferentially recommend active surveillance (AS) for low-risk disease, 1 a recent analysis of the SEER (Surveillance, Epidemiology, and End Results) eProstate With Watchful Waiting data set documents that the AS/watchful waiting rate in American men with low-risk disease was still only 60% in 2018. 2 Clearly, there is room for improvement in the uptake of AS, as 2 out of every 5 men in the US are still receiving surgery, radiation, or other interventions for their low-risk, grade group 1 (GG1) disease. This represents significant, continued overtreatment in this common disease, and in turn likely results in more harm than benefit at a population level. This effectively represents a threat to public health. To minimize this threat, it is imperative that we continue to increase the uptake of AS in low-risk disease. Several barriers exist to the uptake of AS for lowrisk prostate cancer. One of the most powerful is the anxiety associated with a cancer diagnosis and the psychological burden of leaving a malignant lesion “untreated.” 3 This fear of observing a potentially “life-threatening” lesion also results in patients opting out of AS due to anxiety. For example, roughly 10% of patients who initially elected AS in the European PRIAS study opted for aggressive intervention by year 10 due to anxiety/psychological burden. 4 One could understand this anxiety if GG1 prostate cancer were clinically a life-threatening disease for a significant proportion of men, but observational studies indicate it is not. For example, there was only a 0.1% prostate cancerespecific mortality rate in 1,800 men with low-and very lowerisk prostate cancer followed for 15 years in the Johns Hopkins AS cohort. 5 Furthermore, the risk of morbidity in low-risk, GG1 disease is also exceedingly low. For example, only 2 of 993 men in the Sunnybrook cohort without previously having been diagnosed with GG2 or higher disease during follow-up developed metastasis at 15 years. 6 It is worth noting that while the risk of metastasis is not zero, it is still quite low and much less than the risk of long-term sexual, urinary, or bowel dysfunction associated with surgery or radiation. 7Why then do patients elect to undergo potentially morbid interventions like surgery or radiation for a neoplastic entity that has little or no chance of causing meaningful clinical harm? We assert that it is primarily related to the nomenclature of prostate cancerdspecifically the use of the term “cancer” to describe Gleason 6/GG1 disease. GG1 disease certainly meets the scientific/pathological definition of cancer. Specifically, it demonstrates a loss of the basal cell layer and expresses local microinvasion into the surrounding prostate tissue. As clinicians, however, we recognize that these characteristics do not equate with the ability of GG1 disease to invade beyond the prostatic capsule and/or to metastasize elsewhere in the body, which is why we categorize these tumors as “low risk.” Patients, however, do not make these distinctions. They hear the term “cancer” and think of the layman’s definition of the term, elucidated in Webster’s dictionary as “a malignant tumor of potentially unlimited growth that expands locally by invasion and systemically by metastasis”(https://www. merriam-webster. com/dictionary/cancer). In fact, we opine that many patients view cancer as “something evil or malignant that spreads destructively”(an alternate definition from the same source.) Until we rename GG1 disease something other than cancer, patients will continue to experience unfounded anxiety when diagnosed with this common tumor and will opt for aggressive interventions, despite their clinicians urging them not to.