Diagnostic staging and stratification in psychiatry and oncology: clarifying their conceptual, epistemological and ethical implications.

Staging and stratification are two diagnostic approaches that have introduced a more dynamic outlook on the development of diseases, thus participating in blurring the line between the normal and the pathological. First, diagnostic staging, aiming to capture how diseases evolve in time and/or space through identifiable and gradually more severe stages, may be said to lean on an underlying assumption of "temporal determinism". Stratification, on the other hand, allows for the identification of various prognostic or predictive subgroups based on specific markers, relying on a more "mechanistic" or "statistical" form of determinism. There are two medical fields in which these developments have played a significant role and have given rise to sometimes profound nosological transformations: oncology and psychiatry. Drawing on examples from these two fields, this paper aims to provide much needed conceptual clarifications on both staging and stratification in order to outline how several epistemological and ethical issues may, in turn, arise. We argue that diagnostic staging ought to be detached from the assumption of temporal determinism, though it should still play an essential role in adapting interventions to stage. In doing so, it would help counterbalance stratification's own epistemological and ethical shortcomings. In this sense, the reflections and propositions developed in psychiatry can offer invaluable insights regarding how adopting a more transdiagnostic and cross-cutting perspective on temporality and disease dynamics may help combine both staging and stratification in clinical practice.

Reuniting philosophy and science to advance cancer research.

Cancers rely on multiple, heterogeneous processes at different scales, pertaining to many biomedical fields. Therefore, understanding cancer is necessarily an interdisciplinary task that requires placing specialised experimental and clinical research into a broader conceptual, theoretical, and methodological framework. Without such a framework, oncology will collect piecemeal results, with scant dialogue between the different scientific communities studying cancer. We argue that one important way forward in service of a more successful dialogue is through greater integration of applied sciences (experimental and clinical) with conceptual and theoretical approaches, informed by philosophical methods. By way of illustration, we explore six central themes: (i) the role of mutations in cancer; (ii) the clonal evolution of cancer cells; (iii) the relationship between cancer and multicellularity; (iv) the tumour microenvironment; (v) the immune system; and (vi) stem cells. In each case, we examine open questions in the scientific literature through a philosophical methodology and show the benefit of such a synergy for the scientific and medical understanding of cancer.

[Oncology and psychiatry: Towards mutual connections/relationships]. / Oncologie et psychiatrie - Pour une relation réciproque féconde.

Oncology has been proposed as a model of scientificity, in order to promote scientific approaches to psychiatry. In this article, another type of relation between oncology and psychiatry is explored, which promotes the idea of a mutually enriching dialogue and underlines the contributions of psychiatry to oncology. The ways in which both fields address epistemological and ethical issues in their respective approaches to disease is also examined. We argue that these two disciplines can learn from one another in the common context of chronic conditions, thanks to the potential of big data collection and their biostatistics treatment for the identification of markers - sources of individualization -, as well as thanks to the renewed attention given to the temporal and processual dimension of these diseases, in particular within the framework of "staging" models.

Title: Oncologie et psychiatrie - Pour une relation réciproque féconde. Abstract: L'oncologie est souvent considérée par les défenseurs d'une psychiatrie scientifique comme un modèle médical à imiter. Psychiatres, oncologues et philosophes, nous proposons dans cet article une autre manière d'envisager les relations entre oncologie et psychiatrie, en promouvant l'intérêt d'un dialogue entre ces disciplines, convaincus de leur potentiel enrichissement réciproque et, en particulier, des apports possibles de la psychiatrie à l'oncologie. Nous proposons d'étudier chacune des manières de faire face aux difficultés épistémologiques et éthiques rencontrées dans l'approche des maladies. Nous pensons que psychiatrie et oncologie peuvent apprendre l'une de l'autre, dans le contexte commun de maladies chroniques qu'il s'agit de gérer plutôt que de guérir, grâce au potentiel qu'offrent le recueil de données massives et leur traitement biostatistique pour l'identification de marqueurs permettant d'individualiser les traitements, ainsi que grâce à l'attention renouvelée accordée à la dimension temporelle et processuelle de ces maladies, notamment dans le cadre de modèles de « stadification ¼ (ou staging).

Can populations be healthy? Perspectives from Georges Canguilhem and Geoffrey Rose.

Canguilhem criticized the concept of "public health": health and disease are concepts that only apply to individuals, taken as organic totalities. Their extension to a different level of organization is purely metaphorical. The importance assumed by epidemiology in the construction of our knowledge of the normal and the pathological does, however, call for reflection on the role and the status of the population level of organization in our approach to health phenomena. The entanglement of the biological and the social in human life and in contemporary societies justifies this level of analysis for better understanding the complexity and the interaction of health determinants both at the level of individuals and their interactions and at that of the population. But is this population level just a useful level of analysis that makes it possible to bring to light the social determinants of health at the individual level, or does it rest instead on characteristics of the population that are irreducible to individual characteristics, but which are nevertheless important for understanding and taking action with respect to both population and individual health? Defending this second alternative, I show how the epidemiological point of view, and in particular that of social epidemiology, leads us to rethink the possibility of a concept of "population health" that is not reducible to the sum of individual instances of health.

[The exposome: Tensions between holism and reductionism]. / L'Exposome - Tensions entre holisme et réductionnisme.

In a post-genomics context, the concept of the exposome was introduced by Christopher Wild to advance a unified approach of exposures and consolidate different disciplinary fields of environmental health research. The exposome approach is characterized by the will to develop an integrative, longitudinal and more precise analysis of exposures, through the identification of biomarkers. The application of this plastic concept constitutes a privileged field of exploration of current issues and tensions, notably between holism and reductionism. This article analyses this concept and the associated promises. Improving the integration of biological, environmental and social data, the exposome concept supports practical interactions in the field of environmental health research and the advent of novel crosswise concepts to understand aetiology, such as 'embodiment' or 'sociomarkers'.

TITLE: L'Exposome - Tensions entre holisme et réductionnisme. ABSTRACT: Dans un contexte post-génomique, le concept d'exposome a été introduit par Christopher Wild pour proposer une approche unifiée des expositions et fédérer différents champs disciplinaires de la recherche en santé et environnement. L'approche « exposomique ¼ se caractérise par la volonté de développer une analyse à la fois intégrative, longitudinale et plus précise des expositions, et cela principalement grâce à l'identification de biomarqueurs. L'usage du concept d'exposome, qui se révèle particulièrement plastique, constitue un terrain d'exploration privilégié des enjeux et tensions entre approches holiste et réductionniste dans les sciences de la santé. Cet article propose une analyse de ce concept, ainsi que des promesses qui lui sont associées.

A systematic analysis of ICSD-3 diagnostic criteria and proposal for further structured iteration.

The main objective of this theoretical review is to systematically analyze the type of International Classification of Sleep Disorders-3 (ICSD-3) diagnostic criteria by labeling each of them in order to propose an overview of the way in which the diagnostic criteria are organized. Labeling of diagnostic criteria using a rigorous iterative process of "aggregation" and "generalization" was conducted and inter-rater reliability calculation (Cohen's Kappa with three raters) was calculated. 241 criteria from 43 main sleep disorders of the ICSD-3 were labeled into nine types (Clinical manifestation 86.0% of sleep disorders, Objective markers 53.5%, Distress 30.2%, Disability 30.2%, Duration 30.2%, Frequency 58.1%, Age in 18.6%, Exclusion condition 81.4% and Associated condition 34.8%), with a high inter-rater reliability (Cohen's Kappa = 0.85). This analysis assumes that the structuring of the ICSD-3 diagnostic criteria is based on the Harmful Dysfunction Analysis (HDA). Some criteria correspond to the dysfunction part of the HDA while others refer to the harmful part. However, the approach does not seem to be homogeneous across the nosological classification. The use of a structured definition of sleep disorder and a framework to organize the ICSD diagnostic criteria is discussed with regard to the reliability and validity of criteria for diagnosing sleep disorders.

Epidemiology and the bio-statistical theory of disease: a challenging perspective.

Christopher Boorse's bio-statistical theory (BST) of health and disease argues that the central discipline on which theoretical medicine relies is physiology. His theory has been much discussed but little has been said about its focus on physiology or, conversely, about the role that other biomedical disciplines may play in establishing a theoretical concept of health. Since at least the 1950s, epidemiology has gained in strength and legitimacy as an independent medical science that contributes to our knowledge of health and disease. Indeed, it not only provides important information about disease distribution and aetiology, but the risk-factor approach it employs seems to challenge BST's binary conception of health and disease. The objective of the article is to show, firstly, how important information deriving from descriptive and analytical epidemiology forms part of our contemporary medical concepts of health and disease, and secondly, that these elements are not taken into account by BST in a satisfactory way. The article's central contention, therefore, is that if the project of defining the theoretical concept of health is to be maintained, more importance should be accorded to the contribution made by epidemiology--alongside physiology--in defining health.

Qu’est-ce que la ®sante de la population¼? / ¿Qué es la “salud de la población”?

La noción de salud pública parece presuponer la salud de la población. Ahora bien, el concepto de salud está más fácilmente utilizado a nivel de la individualidad orgánica: su aplicación a una población o a un colectivo parece problemática a primera vista. Desde luego, se hace necesario reflexionar sobre este concepto de salud de la población que, sin embargo, nosotros utilizamos. Si el análisis filosófico de los conceptos de salud y enfermedad se ha concentrado sobre los usos de estos a niveles individuales e infra-individuales, aquí queremos mostrar la importancia de una reflexión sobre el nivel supra-individual. A partir de desarrollos recientes de la epidemiología contextual o de la epidemiología social, argumentamos sobre la importancia de dar un contenido al concepto de salud de la población que haga de él algo más que una extensión por analogía del concepto de salud individual o de la suma de todos los casos de salud individual.

La notion même de santé publique semble présupposer celle d’une santé de la population. Or le concept de santé est plus aisément utilisé au niveau de l’individualité organique : son application à une population ou à un collectif semble à première vue problématique. Il apparaît dès lors nécessaire de réfléchir à ce concept de santé de la population que nous utilisons pourtant. Si l’analyse philosophique des concepts de santé et de maladie s’est concentrée sur les usages aux niveaux individuels et infra-individuels de ces concepts, nous voulons montrer ici l’importance d’une réflexion sur le niveau supra-individuel. À partir des développements récents de l’épidémiologie contextuelle ou de l’épidémiologie sociale, nous argumentons pour l’importance de donner un contenu à ce concept de santé de la population qui fasse de lui davantage qu’une extension par analogie du concept de santé individuelle ou que la somme des santés individuelles.