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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An early diagnosis of a disease among people who feel well&#44; reducing future morbidity and mortality&#44; is important in many chronic diseases&#44; especially in malignancy&#46; An early diagnosis should benefit patients&#46; However&#44; even in such disorders&#44; an early diagnosis can turn indolent pathologies into illness and screening can result in an excess of diagnoses&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> This is over-diagnosis&#44; a growing problem in high-income countries&#46; It can be considered when the treatment of the diagnosed conditions&#44; sometimes indolent situations that would never cause patients harm&#44; cannot improve patients&#8217; outcomes&#44; exposing them to unnecessary risks and therefore being potentially harmful&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3</span></a> Chronic Obstructive Pulmonary Disease &#40;COPD&#41; represents one of the most significant health problems at international level&#46; It is the only leading cause of death with rising mortality and morbidity&#46; COPD is considered to be an underdiagnosed and undertreated disorder&#44; especially in its mild and moderate degrees&#46; Although the need for an early detection makes sense&#44; when can an early diagnosis become an over-diagnosis&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over-diagnosis and misdiagnosis represent two different concepts&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Over-diagnosis means identifying problems that were never going to cause harm&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> It has two major causes&#58; &#8216;over-detection&#8217; and &#8216;over-definition&#8217;&#46; Misdiagnosis consists in giving a wrong diagnosis to a person who is really ill&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> In primary health care&#44; many COPD diagnoses are made without a spirometry confirmation&#44; using inadequate algorithms and with difficulties establishing the correct differential diagnoses&#46;<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&#46; In the early stages of the disease the clinical manifestations are inconstant&#44; usually minor and not valued by patients&#46; Symptoms are frequently accepted as normal or expected&#44; attributed to smoking&#44; and patients do not seek medical attention until the disease is more advanced and their symptoms are already compromising daily activities&#46; Although we acknowledge that the early pathological changes in COPD are not captured by spirometry&#44;<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&#44; though&#44; the use of spirometry&#44; depending on the values of reference used&#44; may be a cause of over-diagnosis&#44; especially in the elderly&#46;<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&#44; when a faster disease progression is known to occur&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> are of significant importance as they could delay its progression&#44; like in many other chronic disorders&#46; However&#44; there is a wide range in FEV<span class="elsevierStyleInf">1</span> decline in patients with COPD&#44; and there is no tool to identify patients who would benefit from treatment to prevent the deterioration of respiratory function&#46; Moreover&#44; no markers of the disease are known to predict which patients with a recent onset of the disease will progress to a greater severity&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Until now&#44; the presence of symptoms in mild COPD &#8211; a significantly different concept than early COPD &#8211; is the best predictor of acceleration in FEV<span class="elsevierStyleInf">1</span> decline&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> However&#44; they frequently present mild unreported exacerbations that impact patients&#8217; health status&#44; and can be related to a small excess of FEV<span class="elsevierStyleInf">1</span> decline&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">An early diagnosis of COPD in people who feel well requires a significant amount of time&#44; effort and costs&#46; The US preventive Services Task Force &#40;USPSTF&#41; did not find evidence that screening for COPD using spirometry in asymptomatic people improves health outcomes &#40;health-related quality of life&#44; morbidity or mortality&#41;&#44; and four of five trials assessing the effects of screening in smoking cessation did not report significant differences in abstinence rates&#46; Therefore&#44; the USPSTF concludes with moderate certainty that screening for COPD in asymptomatic people has no net benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Many other published guidelines also recommended against screening for COPD in asymptomatic patients&#46; The major goals in the treatment of COPD are the reduction of symptoms and exacerbations&#44; and improvement of exercise tolerance and health status&#46; However&#44; 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&#44; because they do not use asymptomatic participants&#46; Moreover&#44; adherence to inhaled medications in COPD patients is strongly related to symptoms and to the functional severity of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> A good adherence profile is then not expectable in patients with early disease&#44; or with mild COPD&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Lung cancer screening with low-dose computed tomography can be useful to improve early-stage detection&#44; increasing resectability and survival&#46; COPD and cigarette smoking are two known independent risk factors for lung cancer&#46; Because of that&#44; some authors argued that the early diagnosis of COPD in smokers can help to select candidates for lung cancer screening&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> It is infrequent to see a normal spirometry in patients with lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Calabr&#242; et al&#46; demonstrated that even a small reduction in FEV<span class="elsevierStyleInf">1</span>&#37; is a significant predictor of increased risk for lung cancer&#46; Airflow obstruction can be understood as a surrogate marker for carcinogenic damage of the airways&#44;<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>&#37;&#46; These could be an important argument to support the importance of an early diagnosis of COPD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We need an early diagnosis with demonstrated benefits to the patients but&#44; without an accurate knowledge on markers of the disease activity&#44; mainly in the early stages of COPD&#44; guiding therapy and helping to understand the different accelerated declines in lung function&#44; an early diagnosis can turn out to be an over-diagnosis&#46;</p></span>"
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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,
Corresponding author
duartearaujodr@sapo.pt

Corresponding author.
, Pedro Fontea,b,d, Pedro Teixeiraa,b, Venceslau Hespanhole,f, Jaime Correia-de-Sousaa,b,g
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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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An early diagnosis of a disease among people who feel well&#44; reducing future morbidity and mortality&#44; is important in many chronic diseases&#44; especially in malignancy&#46; An early diagnosis should benefit patients&#46; However&#44; even in such disorders&#44; an early diagnosis can turn indolent pathologies into illness and screening can result in an excess of diagnoses&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> This is over-diagnosis&#44; a growing problem in high-income countries&#46; It can be considered when the treatment of the diagnosed conditions&#44; sometimes indolent situations that would never cause patients harm&#44; cannot improve patients&#8217; outcomes&#44; exposing them to unnecessary risks and therefore being potentially harmful&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3</span></a> Chronic Obstructive Pulmonary Disease &#40;COPD&#41; represents one of the most significant health problems at international level&#46; It is the only leading cause of death with rising mortality and morbidity&#46; COPD is considered to be an underdiagnosed and undertreated disorder&#44; especially in its mild and moderate degrees&#46; Although the need for an early detection makes sense&#44; when can an early diagnosis become an over-diagnosis&#63;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over-diagnosis and misdiagnosis represent two different concepts&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Over-diagnosis means identifying problems that were never going to cause harm&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> It has two major causes&#58; &#8216;over-detection&#8217; and &#8216;over-definition&#8217;&#46; Misdiagnosis consists in giving a wrong diagnosis to a person who is really ill&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> In primary health care&#44; many COPD diagnoses are made without a spirometry confirmation&#44; using inadequate algorithms and with difficulties establishing the correct differential diagnoses&#46;<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&#46; In the early stages of the disease the clinical manifestations are inconstant&#44; usually minor and not valued by patients&#46; Symptoms are frequently accepted as normal or expected&#44; attributed to smoking&#44; and patients do not seek medical attention until the disease is more advanced and their symptoms are already compromising daily activities&#46; Although we acknowledge that the early pathological changes in COPD are not captured by spirometry&#44;<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&#44; though&#44; the use of spirometry&#44; depending on the values of reference used&#44; may be a cause of over-diagnosis&#44; especially in the elderly&#46;<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&#44; when a faster disease progression is known to occur&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> are of significant importance as they could delay its progression&#44; like in many other chronic disorders&#46; However&#44; there is a wide range in FEV<span class="elsevierStyleInf">1</span> decline in patients with COPD&#44; and there is no tool to identify patients who would benefit from treatment to prevent the deterioration of respiratory function&#46; Moreover&#44; no markers of the disease are known to predict which patients with a recent onset of the disease will progress to a greater severity&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Until now&#44; the presence of symptoms in mild COPD &#8211; a significantly different concept than early COPD &#8211; is the best predictor of acceleration in FEV<span class="elsevierStyleInf">1</span> decline&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> However&#44; they frequently present mild unreported exacerbations that impact patients&#8217; health status&#44; and can be related to a small excess of FEV<span class="elsevierStyleInf">1</span> decline&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">An early diagnosis of COPD in people who feel well requires a significant amount of time&#44; effort and costs&#46; The US preventive Services Task Force &#40;USPSTF&#41; did not find evidence that screening for COPD using spirometry in asymptomatic people improves health outcomes &#40;health-related quality of life&#44; morbidity or mortality&#41;&#44; and four of five trials assessing the effects of screening in smoking cessation did not report significant differences in abstinence rates&#46; Therefore&#44; the USPSTF concludes with moderate certainty that screening for COPD in asymptomatic people has no net benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Many other published guidelines also recommended against screening for COPD in asymptomatic patients&#46; The major goals in the treatment of COPD are the reduction of symptoms and exacerbations&#44; and improvement of exercise tolerance and health status&#46; However&#44; 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&#44; because they do not use asymptomatic participants&#46; Moreover&#44; adherence to inhaled medications in COPD patients is strongly related to symptoms and to the functional severity of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> A good adherence profile is then not expectable in patients with early disease&#44; or with mild COPD&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Lung cancer screening with low-dose computed tomography can be useful to improve early-stage detection&#44; increasing resectability and survival&#46; COPD and cigarette smoking are two known independent risk factors for lung cancer&#46; Because of that&#44; some authors argued that the early diagnosis of COPD in smokers can help to select candidates for lung cancer screening&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> It is infrequent to see a normal spirometry in patients with lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Calabr&#242; et al&#46; demonstrated that even a small reduction in FEV<span class="elsevierStyleInf">1</span>&#37; is a significant predictor of increased risk for lung cancer&#46; Airflow obstruction can be understood as a surrogate marker for carcinogenic damage of the airways&#44;<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>&#37;&#46; These could be an important argument to support the importance of an early diagnosis of COPD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We need an early diagnosis with demonstrated benefits to the patients but&#44; without an accurate knowledge on markers of the disease activity&#44; mainly in the early stages of COPD&#44; guiding therapy and helping to understand the different accelerated declines in lung function&#44; an early diagnosis can turn out to be an over-diagnosis&#46;</p></span>"
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ISSN: 15792129
Original language: English
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