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TO TREAT or NOT TO TREAT - THAT IS THE QUESTION
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06/01/19 09:11
Prof.Seegenschmiedt 
06/01/19 09:11
Prof.Seegenschmiedt 

TO TREAT or NOT TO TREAT - THAT IS THE QUESTION

Sufficient Time Required to Define Progression and Initiate Treatment

or "Finding The Moment of Kairos"

It is important to recognize that Dupuytren Disease (DD) is a symptom complex that may involve different types of clinical signs and symptoms such as:

(1) Invisible signs or symptoms
like "itching, tingling, pain symptoms etc",

(2) Visible signs like nodules and cords
including "wrinkling, puckered or dimpled skin, U-shaped compression zones in the hand palm,
contractions in the interdigital spaces, which distort from primarily U-shaped web spaces into a V shape
,
(3) Palpatory signs
like "round shaped nodules (knots) or longitudinal shaped cords and their relative consistency (soft to hard)"

(4) Functional signs
like "limited finger bending or extension, compromised finger and thumb spreading, inability of table top test etc."

All these symptoms may result eventually in functional changes (profession, leisure and daily activities) and disabilities (deterioration of normal functions) and overall changes of the Quality of Life (including various psychosocial dimensions of DD, e.g. avoidance of hand-to-hand contact and other usual hand activities).

Nevertheless, Dupuytren and Ledderhose Disease both do not appear to affect the survival of the affected individual.

Thus, there is no "Emergency Decision" but always a "Careful Shared Decision Making" between the affected person and the treating and fully knowledgeable medical specialist required.

When it is meaningful TO START treatment ?

Given this context in pursuing a treatment plan, the involved clinical specialist (radiation oncologist / therapist, hand surgeon) should always carefully weigh the potential benefit of a particular treatment to the individual person against that potential treatment's risk for adverse events, the severity of those adverse events, and the reversibility of any occuring adverse events.

For some individuals thoughtful counseling regarding the nature of DD and the typical disease course may be sufficient to alleviate concerns, and the counselled individual may choose not to pursue further treatment.

After a careful education on normal hand (or foot) function and possible exclusion of other diseases which may be the reason for any observed symptoms (e.g. pain, itching, tingling sensations, etc.) sufficient time is required to affirm the potential disease-related symptoms.

Moreover, a minimum period of 3 - 6 months is usually required to observe, document and finally define such "progressive symptoms" for Dupuytren Disease. A specific time protocol with 4-week intervals for regular reporting and documentation of symptoms appears to be a useful instrument ("diaries" should only include "new symptoms" or "special observations").

The risks and benefits of the various treatment alternatives including a "wait and see strategy", and the common agreement on realistic treatment goals (if the affected individual desires treatment and is willing to engage in treatment), then a shared decision making process regarding the specific treatment plan can be conducted.

At the present time there is no agreed-upon minimum symptom complex necessary prior to any intervention in DD which includes radiotherapy. Nevertheless, it should not be recommended to irradiate the hand (or foot) of an affected individual without even palpating a single nodule and not following the progression of that nodule for a minimum period of 3 - 6 months.

Thus, I would always strongly recommend NOT TO TREAT without a comprehensive documentation of the disease progression of the observed subjective symptoms (measured on VAS = visual analogue scales or NRS = Numeric Rating scales (0 to 10) or the objective findings (number, size, consistency of nodules and cords, etc.) and the measured functional changes (individual finger angulation, finger spreading, function tests like "table top" etc.) .

One should always keep in mind, that there is not only a "TOO LATE SITUATION" for the use of radiotherapy but also a "TOO EARLY SITUATION" for any intervention in DD including the option of prophylactic radiotherapy.

This requires the art of living with an appropriate mixture of KAIROS ("finding the right moment") and CHRONOS ("acting according a strictly defined time line") - time will be always an individual concept in DD and requires a careful and meaningful shared decision-making process and sufficient patience and dialogue between the affected individual and the physician.

Edited 07/20/19 10:02

Attachment
Chronos - The Timeline.jpg Chronos - The Timeline.jpg (12x)

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Kairos - The Right Moment.jpg Kairos - The Right Moment.jpg (9x)

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06/01/19 20:50
mikes 
06/01/19 20:50
mikes 
Re: TO TREAT or NOT TO TREAT - THAT IS THE QUESTION

That articulation of the pros and cons, risks and rewards, decision timing, etc., was superb - i.e. extremely helpful.

If only other physicians, particularly general practitioners, would analyze and explain matters in the same manner.

Thank you much!

07/22/19 10:50
Ophelien_Champlain 
07/22/19 10:50
Ophelien_Champlain 

Re: TO TREAT or NOT TO TREAT - THAT IS THE QUESTION

I second the above reply written by mikes.

Thank you very much

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contractions   deterioration   documentation   radiotherapy   Nevertheless   Sufficient   decision-making   practitioners   knowledgeable   Progression   observations   alternatives   intervention   symptoms   comprehensive   disease-related   individual   reversibility   Functional   Treatment