01 December 2021

Preventive maintenance

How many letters "p" in the word "medicine"

Yulia Verklova, Forbes

Preventive medicine has been presented as something new and breakthrough in the last few years. In fact, the postulate "The disease is easier to prevent than to cure" is soon a hundred years old. The topic of prevention is not new. Therefore, for persuasiveness and modernization, it is built up with other "p": they talk about 3p-, 4p- and even 5p-medicine. What does this give us?

Preventive dispensaries appeared in Russia immediately after the Civil War — in 1922. At the same time, the sanitary enlightenment started: workers were explained how to live in order to live for a long time with the help of lectures and propaganda posters. In the 30s, preventive inspections at enterprises entered the system and the concept of occupational hygiene appeared. Universal full medical examination — a population survey — was introduced in the USSR from the mid‐80s of the last century.

In the USA, the National College of Preventive Medicine was founded in 1954 under the same slogan "It is easier to prevent than to treat" and with the same accents: education, occupational hygiene, screening.

So now it's even embarrassing to pretend that preventive medicine did not exist in the pre-computer era. However, it is equally wrong to think that replacing the Greek root prophylaktikos with the English progressive is a purely marketing ploy. A lot has really changed in the XXI century.

2p‐medicine — Preventive & Predictive 

Medicine from the 20s to the 90s of the last century could be called 2p‐medicine, or 2p‐medicine: preventive and predictive.

Preventive medicine is prevention — the prevention of diseases and the elimination of the risks of their development. In the popular view, it is often reduced to a healthy lifestyle. And this sometimes creates problems.

"People who lead a healthy lifestyle (or what they consider to be such) often avoid doctors and medical institutions. They are not examined and, as a rule, have a very rough idea of their own health. They rebuild their lifestyle, diets, and regime not because there have been some changes in their body that need to be taken into account, but solely because they have read some new theory or advertising of new dietary supplements. As a result, paradoxically, it is the healthy lifestyle, people who are passionate about prevention, who make up the risk group," explains David Matevosov, PhD, head of the Department of Personalized Medicine, head of the Premium Medical Center, gastroenterologist, hepatologist.

Predictive (or predictive) medicine is a survey of a healthy population — screening of those diseases that in a particular country become the main cause of disability and premature death. Or even not the diseases themselves, but the risks of their development. WHO recommends it "if the prevalence of the disease is high enough to justify the effort and cost." In other words, all screening programs around the world focus on the health of the nation as a whole and on the average person in this nation.

The problem is that there is no "average person" in nature. No matter how banal, all people are different.

3p-medicine — Preventive, Predictive, Personalized

Personalized medicine is taking into account your personal circumstances and peculiarities when developing examination and treatment programs.

"In fact, we are talking about a shift in emphasis — from the health of the nation as a whole and an increase in average life expectancy to the health of an individual. What joy do you get from the fact that the total mortality in the world from breast cancer has decreased if all your relatives have died from pancreatitis? Preventive medicine in our time cannot but be personalized," says Elena Pshinnik, endocrinologist at the clinic "K+31 Petrovsky Gate".

The decoding of the human genome and the study of possible mutations in its various segments have brought medicine to a fundamentally new level.

"The tests that we use in our work," says David Matevosov, "allow us to predict more than 200 genetically determined diseases. However, genetics is a relatively inaccurate science. Studies are regularly published that identify a new set of genes responsible for a particular disease, and review the role and significance of already known mutations. In order for prevention tactics to change quickly in accordance with new knowledge, notifications are sent to the patient's personal account: "there is new data, your risks have been revised."

In fact, personalization involves not only a constant connection between the doctor and the patient, but also the patient's connection with the primary source — with the researcher, who literally at this moment makes a discovery concerning you personally. As well as communication of the geneticist with the clinician, so that they jointly develop a personalized diagnostic and treatment plan for a specific patient.

Here a funny paradox arises: you will learn about changes in world science literally day by day, and about changes in your own body — not so quickly. But health and life expectancy are only a quarter determined genetically. Other parameters depend on external conditions. Any event — a wedding, a funeral, a broken leg — changes your internal settings. You're not going to retake blood every day. Or will you? In fact, this is already a question of the patient's involvement in the health monitoring process. Somewhere at this intersection, 3p-medicine is being built up with another "p".

4p-medicine — Preventive, Predictive, Personalized, Participative

"Preventive medicine combines several fundamental points: the ability to predict the development of the disease, the prevention of the development of the disease, the personalization of events and participation (the active role of the patient in this process), — says Zhanna Dorosh, director of the medical service of JSC "Medicine" (Academician Roitberg clinic), PhD, associate professor. — Recently, the term "preventive medicine" has been replaced by "anti-age medicine", thereby emphasizing the main goal of this direction - the prevention of the occurrence of illness and the preservation of active longevity."

Participation in Latin means "complicity". In Russia, instead of the term "participation", a more understandable one is often used: "patient orientation". But they understand it quite straightforwardly: the doctor should be polite to the patient, explain everything to him in detail and get written consent from him before any medical manipulation. In fact, the topic is much more extensive and complex.

"Participatory medicine assumes that the patient is not an object of research and not a model for medical manipulation, but an active subject of the process. He is able to control his own health, but he needs detailed instructions from doctors and tools that allow him to monitor the work of the body, even when the doctor is not nearby. Medicine, when building a prevention and treatment plan, should take into account the patient's living conditions and their variability," explains Svetlana Bunova, Chief physician of the European Medical Center, MD, professor.

Even WHO noted: "A person lives in his own circumstances 24/7, not just at the moment when he goes to the doctor." Let's say you had a headache and increased blood pressure yesterday. Today you made an appointment with a doctor, he measured your blood pressure — it is normal, and the head is gone. In the old paradigm, this would mean that the problem disappeared by itself. But in the concept of "4p" it means: "An alarm has been received, we are monitoring the dynamics."

The European Association of 3p Medicine at the Congress in 2019 allocated a separate block to the topic of technologies that allow a person to monitor his physical condition non-stop in order to see a doctor on time. Ideally, you should immediately send the data to the doctor.

5p-medicine — Preventive, Predictive, Personalized, Participative, Process

Precision (precise, point, targeted) medicine was completed to the first three "p" simultaneously with the participative, so they are often confused or considered synonyms. However, this is not entirely true. It is more correct to say that participative and precision are components of personalized.

The concept of "precision", or "precise", should be interpreted in the most literal sense — as an effect not on the body as a whole or even on a cell, but on a specific cell molecule. It so happened that this topic is developing now mainly in the mainstream of cardiology and oncology — there is a social request.

According to WHO statistics, every fourth death in the world is due to cardiovascular diseases (CVD). In Russia — every second. According to the estimates of the European Society of Cardiology (ESC), our country belongs to the regions of high risk for mortality from CVD.

"Unfortunately, the topic of family dyslipidemia is very underestimated in our country. This is a hereditary pathology in which the level of low—density lipoproteins and lipoprotein Lp (a) in the blood is always elevated - regardless of diet and lifestyle. It is she who is the main cause of the development of coronary heart disease, heart attacks and strokes in 30-40-50 years. Unfortunately, only 5% of hereditary dyslipidemias are diagnosed in time in Russia," says Gennady Konovalov, MD, Professor, scientific director of the MEDSI CDC on Belorusskaya, head of the Center for Diagnostics and Innovative Medical Technologies, member of the NOA, chairman of the Scientific Council of MEDSI GC, creator and project coordinator of the federal network of lipid clinics MEDSI. The study of the genes responsible for heart attacks and strokes in young people began in the mid-90s of the last century. However, genetic testing for predicting cardiovascular risks is still a controversial issue: it is expensive and not always justified.

"The diagnosis of familial hyperlipidemia is easy to establish even without genetic tests," explains Gennady Konovalov. "It is enough to focus on three main symptoms: elevated cholesterol levels in the patient and his close relatives, cases of coronary heart disease in the family under the age of 55, cholesterol deposits on the skin."

Ophthalmologists, dermatologists, gastroenterologists could and should refer patients with signs of dyslipidemia to cardiologists. It is important that the patients themselves know which changes should be responded to immediately.

Genetic tests to identify mutations that increase the risk of cancer are more in demand. The most famous are the genetic markers of breast cancer BRCA1 and BRCA2. In world practice, it is also not customary to do them all in a row.

"BRCA testing is recommended primarily for patients with a personal and family history indicating a high probability of developing a BRCA gene mutation, and for patients with already established breast cancer who require chemotherapy," says Olga Vul, head of the department, oncologist of antitumor drug therapy at Meditsina JSC (Academician Roitberg Clinic). Genetic testing against the background of an already established disease is necessary for the choice of therapy.

"Cancer cells need certain molecules to survive, multiply and spread. These molecules are usually activated by genes and give cells a signal for uncontrolled division. Having identified the mutation, we can identify a target for attack and prescribe targeted therapy — a drug that specifically acts on this "signal" molecule, but does not damage other cells," explains Gelena Gens, MD, chief oncologist of the K+31 clinic network, head of the Oncology Clinic, Personalized Treatment and Prevention of Cancer. "Currently, medicine uses two types of targeted drugs to stop the growth of tumors: small molecules and monoclonal antibodies." Targeted therapy for genetic mutations can also be successfully applied in cardiology. Statins are almost always prescribed to achieve cholesterol targets in the blood. But with hereditary forms of dyslipidemia, they may not have any effect at all or even cause deterioration. If atherosclerosis is associated with mutations in the PCSK9 gene, then monoclonal antibodies to PCSK9 are used. This helps prevent heart attacks and strokes in people who would have been doomed 10 years ago.

"These drugs make it possible to achieve target cholesterol levels in patients with a very high risk of complications of coronary heart disease in familial forms of dyslipidemia. When such drug therapy does not have an effect, apheresis technologies are used — direct extraction of cholesterol from the blood," says Professor Konovalov.

Despite the complexity of technologies and the scale of intervention, such measures relate specifically to preventive medicine, since they prevent diseases leading to disability and death. 

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