Introduction
Chronic
rhinosinusitis (CRS) is defined as a long-lasting (>12
weeks) inflammation of the nasal cavity and paranasal sinuses,
characterized by symptoms of nasal blockage/congestion or nasal
discharge, possibly associated to facial pain/pressure and a
dysregulated sense of smell [1]. CRS is a generic term that may be
useful to establish diagnosis, but widely incomplete to define the
complexity of differing clinical patterns of the disease.
During the last 40 years, clinicians and researchers have underlined the
importance of considering the subjective dimension of diseases to
achieve a more global and coherent vision about the patient and the
effects of the whole health-care process. This perspective was driven by
the clinical necessity to go beyond the limits of ‘disease-centered
medicine’ in order to reach a more global perspective of
‘patient-centered medicine’ [2]. In this perspective, any
information directly provided by the patients about a health condition
and its treatment (defined as Patient Reported Outcomes - PROs)
represents a fundamental component of any treatment paradigm aimed to
provide a personalized approach [3]. In 1948 the World Health
Organization defined “health” as a state of complete physical, mental,
emotional, and social well-being and not merely the absence of disease
or infirmity [4]. According to it, we must be aware that patients
with chronic rhinosinusitis barely fulfill this definition.
In the past 15 years, an expanding body of literature was built on CRS
reporting its high socio-economic impact, reduced quality of life (QoL)
and direct and indirect costs on societies, as also abundantly
underlined in the European Position Paper on Rhinosinusitis and Nasal
Polyps (EPOS) [1]. CRS with nasal polyps (CRSwNP) is relatively
common particularly in asthmatics, affecting about 2-4% of the general
population [5-7], but with increasing prevalence among unselected
asthmatics (7-15%) [8] and up to 50% in patients with severe
asthma, particularly those with late-onset eosinophilic severe asthma
[9]. The economic and social burden of rhinosinusitis, both acute
and chronic, is enormous [10,11]. Costs of medication,
hospitalization, physician’s examinations and surgery account only for
direct health care expenses, while there is a concurrent and likewise
substantial indirect cost from absenteeism, disability and therefore
loss in productivity and work performance [12]. Absenteeism and
lower quality of life – according to SF-36 and other health-related QoL
measures – are linked especially to some forms of rhinitis such as
recurrent acute rhinosinusitis (RARS) and CRS both with and without
polyps, with also high prevalence (15-25%) of related depression and
anxiety [12]. In the USA, rhinosinusitis is in the top 10 most
costly health conditions to employers. The current direct costs for the
management of CRS are between $10 and $13 billion per year, with the
highest direct costs in patients who had recurrent polyposis after
surgery. Indirect costs from absenteeism and presenteeism (decreased
productivity at work) significantly add to the economic burden of the
disease. Overall, in the USA, the total indirect costs related to CRS
were estimated to be of $20 billion per year [1].
Moreover, the possible correlation between CRS and asthma can amplify
the burden of both conditions synergistically [13]. Widely accepted
is indeed the concept of rhinobronchial syndrome [14-16], which has
been introduced to highlight the link between upper and lower airways
pathophysiology.
In EPOS 2020 [1] a new concept has been emphasized, which is the
multidisciplinary approach based on the precision medicine methodology.
Precision medicine, that President Obama sustained in his 2015 Precision
Medicine Initiative, was defined by him as “a bold new research effort
to revolutionize how we improve health and treat disease” [17].
Precision medicine goes beyond the “one-size-fits-all” approach,
taking into account individual differences in people’s genes,
environments and lifestyles. This concept was widely introduced with the
paradigm of the “4-P Medicine”: Prediction, Prevention,
Personalization, Participation [18]. The first three Ps were
introduced at the beginning of the century, then extended with the
fourth one in 2008 by the molecular biologist and oncologist Leroy Hood
[19]. This extension has been labeled as “a driving force for
revolutionizing healthcare”, since the individual’s participation is
the key to put into practice the other three aspects [20].
The same 4P paradigm has been applied to CRS [21-23]. Being a
chronic disorder, the primary fact is that medicine cannot cure CRS
patients, but it has the duty to improve its course, lower the impact on
QoL and on social costs, also by means of predicting – hence avoiding
– possible undesirable progression and maintaining wellness
(Prevention). Participation is fundamental: it consists in keeping the
patient at the core of the treatment plan, encouraging counselling to
maintain adherence and compliance. In the whole scenario, as the
response to treatment is influenced by several factors, patients
stratification is fundamental to set the correct diagnostic and
therapeutic path for each. Identifying markers that may be predictive of
response means to actualize the concept of target therapy (Precision)
and predicting the response to it (Prediction). On the basis of the
model adopted for oncological patients, each clinic should establish a
multidisciplinary team to plan the correct personalized treatment for
CRS patients (Figure 1).