Progress Means Change
Reflections on Two Articles About Pleural Disease
This issue of Deutsches Ärzteblatt International contains two articles on malignant diseases of the pleura (1, 2). Michael Ried and Hans-Stefan Hofmann, in their article, discuss malignant pleural effusion due to pleural carcinosis, one of the more common findings affecting cancer patients, which confers a poor prognosis with a median survival time of less than twelve months. In all new cases of pleural effusion of uncertain cause, fluid should be obtained by puncture for cytological analysis. Palliative treatment involves either talcum pleurodesis or the implantation of a permanent, tunneled pleural catheter.
The other article, by Volker Neumann and co-authors, concerns malignant, diffuse pleural mesothelioma. This is a reportable occupational disease that can be induced even by relatively brief and low-level exposure to asbestos. The diagnosis must be confirmed by biopsy; tissue samples are obtained either in a CT-guided semi-invasive procedure or by open surgery. The available forms of multimodal treatment should be performed in specialized centers.
The goal of treatment: improving quality of life
Most patients with either of these two diseases cannot be cured; the physician’s main goals, therefore, are to relieve suffering and to afford the patient the highest possible quality of life. In the pursuit of these goals, different patients may be best served by different treatments. The physician must determine the optimal treatment individually in each case, by discussing the options with the patient. This is an instance of the general rule that individualized treatment is indicated for patients with incurable diseases who can only be offered palliative therapies. As illustrated by both of these articles, scientific progress creates new treatment options. As the number of options rises, the need for discussion to pick the best option rises as well. Technical progress does not obviate the need for specialized medical care, but rather increases it, as only specialists have the requisite knowledge about all therapeutic options to be able to discuss them with patients. Moreover, nearly all patients today download a mass of information about their disease from the Internet, yet such information is largely of dubious quality, and most patients are incapable of judging its relevance or irrelevance to their own illness.
Exaggerated expectations of cure because of misinformation via the Internet
As an example of this phenomenon, consider the numerous reports and discussion fora concerning laser therapy for pulmonary metastases—a method that is only useful in selected situations and lacks any application to pleural carcinosis. In general, the Internet now arouses exaggerated expectations of cure, whereas, in earlier times, the incurability of a disease was discussed earlier, and more extensively, by the physician and the patient. The very essence of medicine (at least, in all modern cultures) involves both curing and caring, and the two are of equal importance (3). The time has now come to lay a new emphasis on our need to care for the patient and to resist the hopeless insistence on cures that has emerged as a by-product of technical progress.
The long latency of mesothelioma has been forgotten
It is good to see pleural mesothelioma being recognized in the pages of Deutsches Ärzteblatt International as the most important asbestos-related disease—though not, of course the only one. Now that asbestos has been forbidden in Germany for at least 25 years (in the former East Germany, that is; it has been forbidden even longer in the former West Germany), we might easily imagine that the diseases it induces are no longer of any major importance. Yet we would then be forgetting the very long latency from asbestos exposure to the development of cancer, which alone accounts for the probable rise in the incidence of mesothelioma that is predicted to occur in the next few years. An even more important fact is that the occupational safety measures that have long been in place in Germany are still not being observed in much of the world today. In many countries, including a good number of industrialized countries such as Canada, Russia, and China, asbestos continues to be used in large quantities. Many people from asbestos-using countries came to Germany in the wake of the worldwide decline of communism, and many more will do so in the current wave of globalization. Pleural mesothelioma must, therefore, be remembered as an important element in the differential diagnosis of pleural effusion or chronic pleural pain, so that the disease can be diagnosed earlier and thereby treated more effectively. As far as possible, a consideration of asbestos and its harmful effects should be put on the agenda of international political negotiations, whenever working conditions in the countries with which we do business are at issue.
Pulmonary and bronchial diseases on the rise
It is no coincidence that two pulmonary diseases are now being presented in a single issue of Deutsches Ärzte-blatt International. Diseases of the lungs and bronchi have become markedly more common around the world in recent decades. According to data of the World Health Organization, four pulmonary diseases are now among the top ten fatal diseases in the world: obstructive airway disease (asthma and COPD), pneumonia, tuberculosis, and bronchial carcinoma (4). All of these diseases except tuberculosis become more common with age, and we can therefore expect the number of sufferers to rise in the years to come, as the population as a whole grows older. Pulmonary diseases are also important risk factors for the development of (and worse outcomes in) other chronic diseases, such as coronary heart disease or diabetes (5). German national research policy has recognized this fact by creating the German Center for Pulmonary Research (Deutsches Zentrum für Lungenforschung) (6).
In recent decades, medical advances have lengthened the average human life span, paradoxically making malignant diseases and all their complications even more significant in medical practice than before. We can only meet this challenge by developing and pursuing new models of interdisciplinary care. The two pleural diseases discussed here are good illustrations of the ways in which therapeutic progress can be used to improve patients’ quality of life, even if the disease from which they suffer is, at present, incurable.
Conflict of interest statement
Prof. Welte has received payment for carrying out clinical phase III trials on behalf of Eli Lilly Pharma.
Translated from the original German by Ethan Taub, M.D.
Prof. Dr. med. Tobias Welte
Medizinische Hochschule Hannover (MHH)
Klinik für Pneumologie
30625 Hanover, Germany
Cite this as:
Welte T: Progress means change—reflections on two articles about pleural disease. Dtsch Arztebl Int 2013; 110(18): 311–2.
Prof. Dr. med. Welte
|1.||Ried M, Hofmann HS: The treatment of pleural carcinosis with malignant pleural effusion. Dtsch Arztebl Int 2013; 110(18): 313–8 VOLLTEXT|
|2.||Neumann V, Löseke S, Nowak D, Herth FJF, Tannapfel A: Malignant pleural mesothelioma—incidence, etiology, diagnosis, treatment and occupational health. Dtsch Arztebl Int 2013; 110(18): 319–26 VOLLTEXT|
|3.||Pellegrino ED, Thomasma DC: Helping and Healing. Religious commitment in Health Care. Washington: Georgetown University Press, 1997, Caring and Curing pp 26–38.|
|4.||Lopez AD, Murray CC: The global burden of disease, 1990–2020. Nat Med. 1998; 4: 1241–3 CrossRef MEDLINE|
|5.||Barnes PJ, Celli BR: Systemic manifestations and comorbidities of COPD. Eur Respir J. 2009; 33: 1165–85 CrossRef MEDLINE|
|6.||Seeger W, Welte T, Eickelberg O et al.: The German centre for lung research—translational research for the prevention, diagnosis and treatment of respiratory diseases. Pneumologie. 2012; 66: 464–9 MEDLINE|