Intended for healthcare professionals

Rapid response to:

Practice What Your Patient is Thinking

When you live with a degenerative illness, no symptoms are mild

BMJ 2018; 361 doi: (Published 09 May 2018) Cite this as: BMJ 2018;361:k1670

Rapid Response:

Categorisation is inevitable and essential for routine medical practice.

I absolutely agree that apparently 'mild' symptoms can have a devastating effect on quality of life. Acknowledging and dealing with this fact is critical in any doctor-patient relationship.

Equally, I am uncomfortable with the notion that "classifying... severity of a disease" should not be done and that treatments should be discussed without reference to disease "severity scale".[1]

Legally, not discussing the severity of disease would severely compromise "informed consent".

Medically, daily clinical practice of all specialities involves objective categorisation of diseases and pre-diseases into various categories such as mild/moderate/severe or low/intermediate/high risk. For example, discussion of anti-coagulation for atrial fibrillation, statins for primary prevention or adjuvant chemotherapy for breast cancer needs risk categorisation.[2] [3] [4]

Comparison of a patient with general population is not only inevitable but also essential as it can have a positive effect too. Prostate cancer patients with low-risk, grade 1 cancer feel immensely reassured by the fact that their life expectancy is likely to match that of their peers, thus avoiding unnecessary over-treatment of their cancer.[5]


1 McHugh B. When you live with a degenerative illness, no symptoms are mild. BMJ 2018;361:k1670. doi:10.1136/bmj.k1670
2 Staerk L, Wang B, Preis SR, et al. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. BMJ 2018;361:k1453. doi:10.1136/bmj.k1453
3 Ryan A, Heath S, Cook P. Managing dyslipidaemia for the primary prevention of cardiovascular disease. BMJ 2018;360:k946. doi:10.1136/bmj.k946
4 Mayor S. Some breast cancer patients with low genetic risk may not need chemotherapy, trial shows. BMJ 2016;354:i4635. doi:10.1136/bmj.i4635
5 Seibert TM, Fan CC, Wang Y, et al. Polygenic hazard score to guide screening for aggressive prostate cancer: development and validation in large scale cohorts. BMJ 2018;360:j5757. doi:10.1136/bmj.j5757

Competing interests: No competing interests

13 May 2018
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospital NHS Trust