© 2004 American Thoracic Society
Rebuttal from Dr. CalverleyDr. Kerstjens makes an impassioned attack on the failings of the GOLD classification but is, perhaps, a victim of his own rhetoric. His indictment is that the classification is not evidence based, does not help our understanding of pathophysiology, is clinically irrelevant, and relies on the FEV1. He does not, however, have any better and equally practical alternative to the GOLD systemClassifying disease severity usually begins with a proposal based on expert opinion that is subsequently validated. This was certainly true for the TNM classification of tumor progression. This approach offered no new insight into pathophysiology when introduced and was not directly related to the patient's symptoms, yet few would suggest that we seek some alternative way of tumor staging. GOLD has highlighted the role of inflammation as an important pathophysiological mechanism, as well as identifying other processes relevant to disease progression and symptom generation. Our present knowledge precludes our using other measures of the impact of these diverse processes. In fact, there is an internal inconsistency in criticizing the GOLD scheme for its lack of an evidence base while implying that other approaches would be better, even though the evidence to support their use in this way is absent or fragmentary. As noted already, GOLD goes to some length to support the use of symptom-based outcome in the evaluation of individual treatment success. When data are published that allow such measures to be included in a practical management scheme the GOLD science committee will identify it and the GOLD classification will be changed. Although the FEV1 is not the only important variable in COPD assessment, it does predict mortality (1), it is available as part of the diagnostic process, it is an objective measurement that is reproducible between centers, and it has been used in all previous attempts to classify disease impact in COPD. Ignoring our best validated tool would be a foolish step. As another Dutchman recently pointed out, GOLD "enables worldwide harmonisation of epidemiological, clinical and experimental research studies in patients with COPD" (2). Changing the classification at this time would damage this process for no good reason. REFERENCES
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