You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


The general public and the non-specialist physicians watch a debate that, at least, leaves some doubts regarding management.

Several organizations have criticized the use of the prostate specific antigen (PSA) for early diagnosis of prostate cancer, based on the recommendation against this screening by the United States Preventive Services Task Force (USPSTF).^([@B1])^ This statement was based on a study from the Unites States, which did not demonstrate reduced survival of prostate cancer patients, or that the use of PSA significantly increased the diagnosis of this tumor.^([@B2])^ Moreover, many prostate biopsies are unnecessary considering that the PSA has low specificity. The diagnosis of indolent tumors that do not progress made PSA a major villain. This document, published in 2012, has already led to a decreased number of tests ordered by American clinicians.^([@B3])^

On the other hand, several urology societies still recommend men aged between 55 and 69 years to be submitted to the test, provided all risks are explained, since the "benefits surpass the risks".^([@B4])^ In Brazil, the "Blue November" campaign, supported by the Brazilian Society of Urology (SBU), is launched every year, in November, when males are informed about health care, specially prostate cancer.^([@B5])^

Putting the emotional debate aside, several aspects should be addressed. The study that was the basis for the USPSTF recommendation has been criticized by contamination of the control group (males who should not have their PSA dosed and many of them ordered the test at their own discretion). Yet, an European study^([@B6])^ with a similar design showed that early diagnosis of prostate cancer decreased the risk of death by 21%, in 11 years. It is true that a meta-analysis including these two investigations demonstrated that early diagnosis of prostate cancer did not result in lower mortality rates.^([@B7])^

The current level of knowledge does not allow us to simply state early diagnosis of prostate cancer should not be searched and give up this condition. Prostate cancer is the most frequent neoplasm in males and ranks second in mortality, after lung cancer.

Giving up the early diagnosis policies will take us back to 1987 -- the pre-PSA era - when patients searched medical care already presenting metastases and with no possibility of curative treatment. Unarguably, the use of PSA radically decreased the number of cases with advanced and metastatic tumors, unlike mammography, which did not reduced the cases of breast cancer.^([@B8])^

Prostate cancer screening is far from being perfect, but can be and has been improved. The use of other indicators, such as free/total PSA ratio and multiparametric resonance magnetic, in addition to search for new markers, have decreased the number of unnecessary biopsies and helped detecting the cases of indolent tumors.

In 1980, the estimated life expectancy for males in Brazil was 59.6 years.^([@B9])^ It is known that untreated high-risk localized prostate tumor leads to death within 10 years.^([@B10])^ Therefore, not making its diagnosis in men aged 50 years would not change much the average survival of Brazilian individuals, at that time. In 2007, the life expectancy was 68.7 years,^([@B9])^ and this impact on survival may be significant, and even more, in the developed countries, where life expectancy is higher.

Many questions have not been answered yet, regarding the economic impact of treating a larger number of metastic cases; the impact of PSA and early diagnosis in prolonging survival of prostate cancer patients; and the impact of giving up screening of males aged 45 to 50 years, considering that high-risk tumors occur quite often.

Before having all these answers, it seems irresponsible to not inform patients about our doubts and simply state that an early diagnosis should not be made. The decision must be shared and, ultimately, the patient will choose what to do -- but aware of the risks of his option.

Editorial

Câncer de próstata: qual a mensagem correta?

Glina

Sidney

1

Pasternak

Jacyr

1

Hospital Israelita Albert Einstein, São Paulo, SP, Brasil.

Autor correspondente: Sidney Glina -- Avenida Albert Einstein, 627/701 -- Morumbi -- CEP: 05652-900 -- São Paulo, SP, Brasil -- Tel.: <PRESIDIO_ANONYMIZED_PHONE_NUMBER> E-mail: glina\@einstein.br

O público em geral e os médicos não especialistas assistem a um debate que, no mínimo, deixa dúvidas sobre como se comportar.

Várias organizações vêm condenando o uso do antígeno prostático específico (PSA) para o diagnóstico precoce do câncer de próstata, baseadas na recomendação da *United States Preventive Services Task Force* (USPSTF)*,* ^([@B1])^ que condenou o rastreamento dessa neoplasia. Esta declaração baseou-se em um estudo americano, que não mostrou diminuição da sobrevida dos pacientes com câncer de próstata e nem que o uso do PSA aumentou significativamente o diagnóstico desse tumor.^([@B2])^ Associado ao número de biópsias prostáticas desnecessárias, pois o PSA tem baixa especificidade, o diagnóstico de tumores indolentes, que não evoluiriam, transformaram o PSA em um grande vilão. O documento de 2012 já produziu uma redução no número de exames solicitados pelos clínicos americanos.^([@B3])^

Por outro lado, várias sociedades de urologia ainda recomendam que homens entre 55 e 69 anos façam os exames, desde que esclarecidos de todos os riscos, pois os "benefícios ultrapassariam os riscos".^([@B4])^ No Brasil, o "Novembro Azul" é uma campanha apoiada pela Sociedade Brasileira de Urologia (SBU), realizada anualmente no mês de novembro, na qual o homem é esclarecido sobre os cuidados com sua saúde, especialmente sobre o câncer da próstata.^([@B5])^

Deixando de lado o debate emocional, vários aspectos precisam ser considerados. O estudo que serviu de base para a recomendação da USPSTF vem sendo criticado pela contaminação do grupo controle (homens que não deveriam fazer dosagens de PSA e boa parte o fez por conta própria). Por outro lado, estudo europeu^([@B6])^ que tinha desenho semelhante mostrou que o diagnóstico precoce do câncer de próstata diminuiu o risco de morte em 21% em 11 anos. Verdade que uma metanálise, que incluiu os dois estudos, mostrou que o diagnóstico precoce do câncer de próstata não reduziu a mortalidade.^([@B7])^

O estágio atual do conhecimento não pode simplesmente dizer que não deve se buscar o diagnóstico precoce do câncer de próstata e abandonar esta doença. O câncer de próstata é a neoplasia que mais afeta os homens e é o segundo que mais mata, após o câncer de pulmão.

O abandono da políticas de diagnóstico precoce vai nos devolver a 1987, na era pré-PSA, quando os pacientes buscavam ajuda médica com quadros já metastáticos e sem possibilidade de tratamento curativo. É inquestionável que o uso do PSA diminuiu radicalmente o número de casos com tumores avançados e metastáticos, ao contrário da mamografia, que não diminuiu estes casos na neoplasia de mama.^([@B8])^

O rastreamento do câncer de próstata está longe de ser perfeito, mas pode e está sendo aperfeiçoado. O uso de outros indicadores, como a relação do PSA livre/total, a ressonância magnética multiparamétrica e a busca de novos marcadores tem diminuído o número de biópsias desnecessárias e ajudado a identificar os casos de tumores indolentes.

Em 1980, a expectativa de vida média do homem no Brasil era de 59,6 anos,^([@B9])^ e, como sabemos que o tumor de próstata de alto risco localizado não tratado leva ao óbito em 10 anos,^([@B10])^ provavelmente não diagnosticá-lo aos 50 anos não alterava muito a sobrevida média do homem brasileiro. Em 2007, esta expectativa média passou a ser de 68,7 anos,^([@B9])^ e esse impacto na diminuição da sobrevida pode ser significativo -- e maior ainda nos países desenvolvidos onde a expectativa é maior.

Muitas questões ainda precisam ser respondidas, entre elas qual vai ser o impacto econômico de se tratar um número maior de casos metastáticos; qual o impacto do PSA e do diagnóstico precoce no prolongamento da sobrevida dos pacientes com câncer de próstata; e qual o impacto do abandono do rastreamento em homens entre 45 e 50 anos, quando muitas vezes os tumores são de alto risco.

Antes de se ter todas as respostas, parece irresponsável não informar aos pacientes todas as nossas dúvidas e dizer simplesmente que não se deve fazer o diagnóstico precoce. A decisão deve ser compartilhada e, em última análise, o paciente escolhe o que fazer -- mas consciente dos riscos de sua escolha.