Progress to More Nuanced Medicine

Medicine is making progress to refine patient care.
Medicine is making progress to refine patient care.

Medicine in many ways moves in the direction of nuanced patient care. Hardly a week goes by without seeing a paper in a peer-reviewed journal reporting the identification of novel factors for improving risk stratification and predicting how patients with genitourinary diseases will respond to treatment. These findings often help to fine-tune patient management.

Such is the case with Gleason score 7 prostate tumors. Over the years, studies have documented that Gleason pattern 3 + 4 = 7 is associated with better prognoses than Gleason pattern 4 + 3= 7 tumors. This difference is reflected in a proposed and widely supported new prostate cancer (PCa) grading system consisting of 5 grade groups, with grade group 1 reflecting the lowest risk disease and grade group 5 the highest. The new grading system separates 3 + 4 and 4 + 3 cancers into grade groups 2 and 3, respectively, a distinction that could affect treatment decisions.

Recent examples of the stepwise advances in understanding that promise more nuanced medical care are numerous. In a paper published in The Lancet Oncology, investigators showed that PCa patients with a certain variant genotype are more likely to experience resistance to androgen-deprivation therapy following disease recurrence after radical prostatectomy. The researchers concluded that this genetic biomarker potentially could be useful in identifying patients who might warrant early escalated therapy because their cancer is likely to behave more aggressively. 

Researchers reported in the Clinical Journal of the American Society of Nephrology that they identified 3 urinary biomarkers that, when measured at the time of diagnosis of acute kidney injury (AKI) and added to a clinical risk model, can predict the likelihood of AKI progression among patients with cardiorenal syndrome. And a study published in Kidney International adds to evidence suggesting that conventional thrice-weekly hemodialysis (HD) may not always be the best option for patients with end-stage renal disease. The study found that mortality risk did not differ significantly between incremental HD (2 or fewer sessions per week) and conventional in-center HD. The authors stated that incremental HD could offer patients better preservation of an arteriovenous fistula and preservation of residual kidney function.

Therapeutic decisions have long been influenced by patient characteristics such as age, life expectancy, and comorbidities, and disease severity as indicated by signs and symptoms and pathologic features. Mounting evidence of, and a growing appreciation for, the clinical value of novel genetic biomarkers, biochemical indicators, and pathologic features, however, could well move medicine into a new paradigm in patient care in which a one-size-fits-all approach is abandoned in favor of precise nuanced care.

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