Art and Science and Decisions
We all know that the art of medicine is sometimes as important as the science. While there certainly are situations in which the data and treatment course are clear, there are all too many others when there is an uncharted fork in the road. It is at these unmarked intersections that the art and science of medicine converge. What does this mean for us, the patients? I think it means that the most important decision we make is choosing our doctor(s). No matter how much we read and ask and listen, we can't possibly learn what they know. We depend on their training and knowledge, but we rely also on their instincts. What have they seen in similar situations? What is their best well-educated guess about which treatment to select? What is their gut instinct about how to best care for us?
One moment when this often happens is around the decisions about adjuvant chemotherapy for early breast cancer. Sometimes, it is very clear whether or not chemo is needed. All too often, there is a lot of gray, and we are unsure how to best proceed. An editorial in the new Journal of Clinical Oncology by Sporano and Solin addresses this dilemma very well. Unlike much medical journalism, it is also beautifully written and a delight to read. Here is a quote and a link to read more:
The "art of medicine" is a commonly used phrase, acknowledging that although modern medical practice involves the application of science, the application of scientific principles may vary widely.1 For example, although there is unequivocal scientific evidence that adjuvant chemotherapy reduces recurrence and mortality in early-stage breast cancer,2 clinicians often weight multiple factors when considering an adjuvant chemotherapy recommendation. The conundrum often faced by clinicians and patients about the role of chemotherapy in early-stage breast cancer is reflected by the musing of Yogi Berra, well known for his skills both as a New York Yankee and unwitting philosopher—although it is clear that a path must be chosen, it is unclear which path that should be.
Enhanced knowledge of the biology of breast cancer, and technological advances which facilitate application of that knowledge in clinical specimens, offers potential to empower clinicians and patients toward making more informed decisions.3 Toward that end, it has been nearly a decade since distinct breast cancer genotypes were first characterized,4 and 5 years since the first multiparameter gene expression assays became commercially available for early-stage breast cancer, >including a 70-gene assay5 and a 21-gene assay.6 Numerous other multiparameter assays have been developed, and several others are also commercially available.7,8 Some evidence suggests that these assays provide comparable prognostic information.9 Although there is compelling evidence regarding the clinical validity of these assays in providing prognostic information about distant disease recurrence, there is little information about their clinical utility—that is, how does the test result influence clinical decision making, and do patients benefit from that change? In the current issue of Journal of Clinical Oncology, Loet al10 provide important new information regarding the clinical utility of one of these assays, the 21-gene recurrence score (RS), and Mamounas et al11 provide new information regarding the clinical validity of the same assay in predicting locoregional rather than distant disease recurrence.
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