VOLUME
33
䡠
NUMBER
20
䡠
JULY
10
2015
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
On Nonharming: The Debate Continues in Stage I Testicular Cancer TO THE EDITOR: The originally Greek principle of “primum non nocere” (“first, do no harm”) is said to have been translated into Latin by Scribonius Largus, the private physician of the emperor Tiberius Claudius. Scribonius Largus apparently recommended this strategy to his colleagues to improve the image of Roman medics, who at the time had a reputation as poisoners. In the context of the editorial recently published in Journal of Clinical Oncology, “Active Surveillance for Clinical Stage I Testicular Cancer,”1 this statement probably means that you should not harm a patient by giving adjuvant treatment. As a profession, we have made some progress since the time of Scribonius Largus (approximately 50 AD). However, the case vignette presented by Vaughn1 in his editorial illustrates that despite our best intentions, we may expose individual patients to even greater harm by trying to avoid harm. Most physicians would agree in retrospect that despite the attempt to avoid adverse effects of adjuvant treatment, the patient presented was eventually exposed to even greater toxicity with intensive combination chemotherapy. Whereas we agree on the importance of avoiding unnecessary treatments, we do believe that adverse effects of potential later and eminently more extensive treatments should be added to the equation, and information on these treatments and adverse effects should be given to patients.2 Patients differ not only with respect to the absolute magnitude of any particular risk, but also according to the individual interpretation of this risk in the context of their personality, individual plans, and psychosocial circumstances. Therefore, many patients may
well prefer to opt for an immediate, projectable, and less toxic (albeit potentially unnecessary adjuvant treatment) to reduce their risk of later and more toxic salvage treatment. More often than not, they have good reasons for such a decision. With respect to stage I testicular cancer, we think informed consent is the way forward: why not let the patient decide what he considers the greater harm—potentially unnecessary adjuvant treatment or the risk of more toxic salvage treatment later?
Silke Gillessen Cantonal Hospital, St Gallen, Switzerland
Maria De Santis Kaiser Franz Josef Hospital; and Applied Cancer Research–Institute for Translational Research and Ludwig Boltzmann Institute and Cluster Translational Oncology, Vienna, Austria
Christian Rothermundt Cantonal Hospital, St Gallen, Switzerland
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Vaughn DJ: Primum non nocere: Active surveillance for clinical stage I testicular cancer. J Clin Oncol 33:9-12, 2015 2. Oldenburg J, Aparicio J, Beyer J, et al: Personalizing, not patronizing: The case for patient autonomy by unbiased presentation of management options in stage I testicular cancer. Ann Oncol 26:833-838, 2015
DOI: 10.1200/JCO.2015.61.1632; published online ahead of print at www.jco.org on June 1, 2015
■ ■ ■
Journal of Clinical Oncology, Vol 33, No 20 (July 10), 2015: pp -2319
© 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
2319
Correspondence
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
On Nonharming: The Debate Continues in Stage I Testicular Cancer The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Silke Gillessen No relationship to disclose Maria De Santis
© 2015 by American Society of Clinical Oncology
No relationship to disclose Christian Rothermundt No relationship to disclose
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
33
䡠
NUMBER
20
䡠
JULY
10
2015
JOURNAL OF CLINICAL ONCOLOGY
C O R R E S P O N D E N C E
On Nonharming: The Debate Continues in Stage I Testicular Cancer TO THE EDITOR: The originally Greek principle of “primum non nocere” (“first, do no harm”) is said to have been translated into Latin by Scribonius Largus, the private physician of the emperor Tiberius Claudius. Scribonius Largus apparently recommended this strategy to his colleagues to improve the image of Roman medics, who at the time had a reputation as poisoners. In the context of the editorial recently published in Journal of Clinical Oncology, “Active Surveillance for Clinical Stage I Testicular Cancer,”1 this statement probably means that you should not harm a patient by giving adjuvant treatment. As a profession, we have made some progress since the time of Scribonius Largus (approximately 50 AD). However, the case vignette presented by Vaughn1 in his editorial illustrates that despite our best intentions, we may expose individual patients to even greater harm by trying to avoid harm. Most physicians would agree in retrospect that despite the attempt to avoid adverse effects of adjuvant treatment, the patient presented was eventually exposed to even greater toxicity with intensive combination chemotherapy. Whereas we agree on the importance of avoiding unnecessary treatments, we do believe that adverse effects of potential later and eminently more extensive treatments should be added to the equation, and information on these treatments and adverse effects should be given to patients.2 Patients differ not only with respect to the absolute magnitude of any particular risk, but also according to the individual interpretation of this risk in the context of their personality, individual plans, and psychosocial circumstances. Therefore, many patients may
well prefer to opt for an immediate, projectable, and less toxic (albeit potentially unnecessary adjuvant treatment) to reduce their risk of later and more toxic salvage treatment. More often than not, they have good reasons for such a decision. With respect to stage I testicular cancer, we think informed consent is the way forward: why not let the patient decide what he considers the greater harm—potentially unnecessary adjuvant treatment or the risk of more toxic salvage treatment later?
Silke Gillessen Cantonal Hospital, St Gallen, Switzerland
Maria De Santis Kaiser Franz Josef Hospital; and Applied Cancer Research–Institute for Translational Research and Ludwig Boltzmann Institute and Cluster Translational Oncology, Vienna, Austria
Christian Rothermundt Cantonal Hospital, St Gallen, Switzerland
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Vaughn DJ: Primum non nocere: Active surveillance for clinical stage I testicular cancer. J Clin Oncol 33:9-12, 2015 2. Oldenburg J, Aparicio J, Beyer J, et al: Personalizing, not patronizing: The case for patient autonomy by unbiased presentation of management options in stage I testicular cancer. Ann Oncol 26:833-838, 2015
DOI: 10.1200/JCO.2015.61.1632; published online ahead of print at www.jco.org on June 1, 2015
■ ■ ■
Journal of Clinical Oncology, Vol 33, No 20 (July 10), 2015: pp -2319
© 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
2319
Correspondence
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
On Nonharming: The Debate Continues in Stage I Testicular Cancer The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Silke Gillessen No relationship to disclose Maria De Santis
© 2015 by American Society of Clinical Oncology
No relationship to disclose Christian Rothermundt No relationship to disclose
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
