Rarely do blog posts anger me. I understand the purpose of blogs, and know that I write to stimulate thinking and discussion. But this morning I read a post that has really got my blood boiling. Comparative effectiveness could impede cancer therapy progress
Give me a break. Talk about the arrogance of basic science research over comparative effectiveness research. The author claims that we need not compare current diagnostic or therapeutic options because funding such research would detract from the more important basic science research.
This post acted like Ipecac on me. I am mad.
Comparative effectiveness (CE) research, a relatively new concept in the lexicon of US medicine, pushed to the forefront by health care reform, appeals to the data-driven orientation of oncologists but could put the rapid pace of progress in cancer therapy at some risk. Research to compare similar treatments could “use up” thousands of patients who might otherwise be considered for participation in studies of newly developing therapies. In addition, the energy and resources that are currently devoted to developing studies that test the efficacy of new drugs and technologies are not limitless and might be taxed by CE research.
So this author says that we should not try to provide the best possible care now, but rather we should explore new therapies. But how do we now that new therapies have worth? Are we allowed to compare those new therapies to existing therapies? If so which therapy or diagnosis should we use as the standard. We could do CER to figure out the standard – but given his argument, those studies decrease our ability to make progress.
I call BS on this post. Basic research and translational research are very important, but we have patients right now who need diagnostic and treatment strategies. If we had this attitude we would never have learned that antiarrythmic drugs increase mortality, or estrogens increase CAD in post-menopausal women, or many other important clinical advances.
I cannot imagine the mind behind this post. He opposes CER because it might take energy from MORE IMPORTANT RESEARCH. He is so wrong in so many ways that I may become apoplectic.
{ 6 comments… read them below or add one }
DB,
I read his post twice. Nowhere did I read that he was opposed to CER. He said we need to be careful how we coordinate it with other types of research, and how we allocate our research resources, which to me sounded a note of caution, but it did not come across as an attack to me. You call BS. Well, maybe he was wrong on some points, but with all the greatest respect I have to call straw man.
I call straw man argument, too, and not even a particularly convincing straw man argument either.
In fact, I scratched my head after I clicked on the link, having finished your little rant about Leff's post,, wondering if we had read the same post. I don't even think that Leff was even wrong on a single point. I agree with him. In fact, I'd go one step further and say that CER is being represented as some sort of panacea when in fact it tends to leave more questions unanswered than it answers. Worse, by the time it provides the answer to the question of which treatment is better, all too often the standard of care has moved on and its answer is no longer relevant.
Ditto Robert W.Donnell- The author points to caution. CER, if its focus is on cost containment, may take resources away from innovation. I see no arrogance, and no claim that CER is worthless. The author doesn't claim that basic science trumps clinical science. In fact, the author does not make the distinction between basic and clinical research, but rather between research that looks for better tools to tackle present clinical problem, and research that uses the tools we have at hand. It seems DB's past fondness for "externalities" disappears when the unforseen consequences for CER are considered. Perhaps a better way to respond to another's thought (other than to read what is written), is to keep one's blood from boiling the pituitary.
The author Dr. Leff has a point, CER could steer patients away from new therapy research, which might be bad.
Dr. Centor has a point -that attitude could be construed as antithetical to the care of patients currently.
Both of those are theoretical concerns that can't be ignored and it is not clear to me who carries the day on this argument.
However, one must be slightly cautious of Dr. Leff's motivation because of his position as the CEO of a company that provides communication tools for biopharmaceutical companies.
His argument, far more than Dr. Centor's has a conflict of interest, that CER might steer patients away from developing therapies, yes, but by doing so it also carries negative economic implications for his company and those he works for.
I know I will hear all the arguments that we need biopharmaceutical companies to provide new therapies. Of course we do. But to pretend there is not an economic incentive as well as a scientific one is to be naive or intellectually dishonest. It doesn't mean Dr. Leff is all wet, as Dr. Centor seems to feel but it does mean we should watch where he is coming from.
The line between self interest and selflessness in medicine today is becoming ever more blurry.
Dr. C– I have to agree with most of the other commenters. I think if you put on your old SMDM hat (and cool off your hothead), you can see his editorial as essentially advocating a value of information (VOI) analysis just as Milt Weinstein taught us. And given that the number of oncology patients willing to enroll in studies is a scarce resource (which btw continues to be a terrible shame), as are the funds needed to conduct the studies, it is perfectly appropriate to ask what the value of the information gained from the study will be. And an important part of that analysis, as the article puts it, is less what the value of the information is now, but what it will be when the study is actually fully accrued and completed. Many of our cooperative group studies fail on this count– poorly conceived, and long to accrue, such that when the result comes out, it is essentially useless. Again, he doesn't castigate CER as a whole, just CER that doesn't actually help. And I think your response is more demagogic than academic.
One thought that might bridge your point with his is that perhaps we do need to reimagine the clinical trials paradigm in oncology somewhat. Every patient not on a study represents data wasted, and I firmly believe there is a role for more inclusive trials that enroll more broad swaths (read that as more representative) of patients, perhaps in the phase 4 setting, and perhaps under the aegis of CER. One could imagine a unified EMR to help facilitate collecting such data in a systematic way, much as organizations like Kaiser can address these questions in-house.
An otherwise loyal reader,
Happy o
Hi folks. Interesting exchange. For another view of this, see Starzl's Randomized Trialomania paper. http://d-scholarship.pitt.edu/5200/1/31735062133016.pdf
The paper can now be judged through the lens of history and it seems to hold water.