Letter to the Editor
Is an Early Diagnosis of COPD Clinically Useful?
¿Es clínicamente útil un diagnóstico temprano de EPOC?
António Duarte-de-Araújoa,b,c,
, Pedro Fontea,b,d, Pedro Teixeiraa,b, Venceslau Hespanhole,f, Jaime Correia-de-Sousaa,b,g
Corresponding author
a Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
b ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
c Respiratory Department, H. Sª Oliveira, Guimarães, Portugal
d Minho Family Health Unit, Braga, Portugal
e Department of Pneumology, Centro Hospitalar de S. João, Porto, Portugal
f Faculty of Medicine (FMUP), University of Porto, Portugal
g Horizonte Family Health Unit, Matosinhos, Portugal
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Sª Oliveira, Guimarães, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Minho Family Health Unit, Braga, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Pneumology, Centro Hospitalar de S. João, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Faculty of Medicine (FMUP), University of Porto, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Horizonte Family Health Unit, Matosinhos, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Es clínicamente útil un diagnóstico temprano de EPOC?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An early diagnosis of a disease among people who feel well, reducing future morbidity and mortality, is important in many chronic diseases, especially in malignancy. An early diagnosis should benefit patients. However, even in such disorders, an early diagnosis can turn indolent pathologies into illness and screening can result in an excess of diagnoses.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> This is over-diagnosis, a growing problem in high-income countries. It can be considered when the treatment of the diagnosed conditions, sometimes indolent situations that would never cause patients harm, cannot improve patients’ outcomes, exposing them to unnecessary risks and therefore being potentially harmful.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,3</span></a> Chronic Obstructive Pulmonary Disease (COPD) represents one of the most significant health problems at international level. It is the only leading cause of death with rising mortality and morbidity. COPD is considered to be an underdiagnosed and undertreated disorder, especially in its mild and moderate degrees. Although the need for an early detection makes sense, when can an early diagnosis become an over-diagnosis?</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over-diagnosis and misdiagnosis represent two different concepts.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Over-diagnosis means identifying problems that were never going to cause harm.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> It has two major causes: ‘over-detection’ and ‘over-definition’. Misdiagnosis consists in giving a wrong diagnosis to a person who is really ill.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> In primary health care, many COPD diagnoses are made without a spirometry confirmation, using inadequate algorithms and with difficulties establishing the correct differential diagnoses.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Spirometry has an important role in the early diagnosis of COPD. In the early stages of the disease the clinical manifestations are inconstant, usually minor and not valued by patients. Symptoms are frequently accepted as normal or expected, attributed to smoking, and patients do not seek medical attention until the disease is more advanced and their symptoms are already compromising daily activities. Although we acknowledge that the early pathological changes in COPD are not captured by spirometry,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> we do not currently have any marker to detect early onset of the airway disease, though, the use of spirometry, depending on the values of reference used, may be a cause of over-diagnosis, especially in the elderly.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Some authors argue that pharmacological interventions in the early stages of COPD, when a faster disease progression is known to occur,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,9</span></a> are of significant importance as they could delay its progression, like in many other chronic disorders. However, there is a wide range in FEV<span class="elsevierStyleInf">1</span> decline in patients with COPD, and there is no tool to identify patients who would benefit from treatment to prevent the deterioration of respiratory function. Moreover, no markers of the disease are known to predict which patients with a recent onset of the disease will progress to a greater severity.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Until now, the presence of symptoms in mild COPD – a significantly different concept than early COPD – is the best predictor of acceleration in FEV<span class="elsevierStyleInf">1</span> decline. Asymptomatic patients with mild airflow limitation do not present a faster decline in FEV<span class="elsevierStyleInf">1</span> neither have worse quality of life than healthy individuals.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> However, they frequently present mild unreported exacerbations that impact patients’ health status, and can be related to a small excess of FEV<span class="elsevierStyleInf">1</span> decline.</p><p id="par0025" class="elsevierStylePara elsevierViewall">An early diagnosis of COPD in people who feel well requires a significant amount of time, effort and costs. The US preventive Services Task Force (USPSTF) did not find evidence that screening for COPD using spirometry in asymptomatic people improves health outcomes (health-related quality of life, morbidity or mortality), and four of five trials assessing the effects of screening in smoking cessation did not report significant differences in abstinence rates. Therefore, the USPSTF concludes with moderate certainty that screening for COPD in asymptomatic people has no net benefit.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Many other published guidelines also recommended against screening for COPD in asymptomatic patients. The major goals in the treatment of COPD are the reduction of symptoms and exacerbations, and improvement of exercise tolerance and health status. However, the evidence achieved by most of the published RCTs related to pharmacological therapy can be applied only to patients with a severe or a very severe disease, because they do not use asymptomatic participants. Moreover, adherence to inhaled medications in COPD patients is strongly related to symptoms and to the functional severity of the disease.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> A good adherence profile is then not expectable in patients with early disease, or with mild COPD.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Lung cancer screening with low-dose computed tomography can be useful to improve early-stage detection, increasing resectability and survival. COPD and cigarette smoking are two known independent risk factors for lung cancer. Because of that, some authors argued that the early diagnosis of COPD in smokers can help to select candidates for lung cancer screening.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> It is infrequent to see a normal spirometry in patients with lung cancer.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Calabrò et al. demonstrated that even a small reduction in FEV<span class="elsevierStyleInf">1</span>% is a significant predictor of increased risk for lung cancer. Airflow obstruction can be understood as a surrogate marker for carcinogenic damage of the airways,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> and screening for lung cancer can be done using a decrease in FEV<span class="elsevierStyleInf">1</span>%. These could be an important argument to support the importance of an early diagnosis of COPD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We need an early diagnosis with demonstrated benefits to the patients but, without an accurate knowledge on markers of the disease activity, mainly in the early stages of COPD, guiding therapy and helping to understand the different accelerated declines in lung function, an early diagnosis can turn out to be an over-diagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Overdiagnosis: how cancer screening can turn indolent pathology into illness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 30 | 11 | 41 |
| 2024 September | 50 | 11 | 61 |
| 2024 August | 84 | 30 | 114 |
| 2024 July | 70 | 24 | 94 |
| 2024 June | 75 | 24 | 99 |
| 2024 May | 96 | 34 | 130 |
| 2024 April | 48 | 19 | 67 |
| 2024 March | 61 | 23 | 84 |
| 2024 February | 49 | 23 | 72 |
| 2023 August | 4 | 1 | 5 |
| 2023 March | 14 | 4 | 18 |
| 2023 February | 104 | 8 | 112 |
| 2023 January | 73 | 45 | 118 |
| 2022 December | 125 | 28 | 153 |
| 2022 November | 159 | 36 | 195 |
| 2022 October | 116 | 33 | 149 |
| 2022 September | 72 | 30 | 102 |
| 2022 August | 75 | 38 | 113 |
| 2022 July | 56 | 47 | 103 |
| 2022 June | 46 | 43 | 89 |
| 2022 May | 54 | 33 | 87 |
| 2022 April | 53 | 30 | 83 |
| 2022 March | 52 | 36 | 88 |
| 2022 February | 21 | 17 | 38 |
| 2021 November | 1 | 0 | 1 |
| 2021 June | 1 | 2 | 3 |
| 2021 March | 2 | 2 | 4 |
| 2021 February | 1 | 0 | 1 |
| 2020 December | 0 | 2 | 2 |
| 2020 October | 1 | 4 | 5 |
| 2020 September | 2 | 2 | 4 |
| 2020 August | 3 | 2 | 5 |
| 2020 July | 12 | 4 | 16 |
| 2020 June | 40 | 25 | 65 |
| 2020 May | 1 | 1 | 2 |
| 2020 April | 13 | 4 | 17 |
| 2020 March | 150 | 2 | 152 |
| 2020 January | 4 | 7 | 11 |
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