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Lessening Cancer Care Costs: Oncologists Should Speak Openly About The Possibility of Death

We’ve reached the second half of our discussion on Bending the Cost Curve in Cancer Care. The authors of the NEJM paper, Drs. T. Smith and B. Hillner, go on to consider how doctors’ behavior influences costs in Changing Attitudes and Practice. Today’s point on the list: “Oncologists need to recognize that the costs of care are driven by what we do and what we do not do.”

In other words (theirs): “The first step is a frank acknowledgment that changes are needed.” A bit AA-ish, but fair enough –

The authors talk about needed, frank discussions between doctors and patients. They emphasize that oncologists/docs drive up costs and provide poorer care by failing to talk with patients about the possibility of death, end-of-life care, and transitions in the focus of care from curative intent to palliation.

They review published findings on the topic: Read more »

*This blog post was originally published at Medical Lessons*

Why Negative Medical Studies Are Good

This is a guest column by Ivan Oransky, M.D., who is executive editor of Reuters Health and blogs at Embargo Watch and Retraction Watch.

One of the things that makes evaluating medical evidence difficult is knowing whether what’s being published actually reflects reality. Are the studies we read a good representation of scientific truth, or are they full of cherry-picked data that help sell drugs or skew policy decisions?

That question may sound like that of a paranoiac, but rest assured, it’s not. Researchers have worried about a “positive publication bias” for decades. The idea is that studies showing an effect of a particular drug or procedure are more likely to be published. In 2008, for example, a group of researchers published a New England Journal of Medicine study showing that nearly all — or 94 percent — of published studies of antidepressants used by the FDA to make approval decisions had positive results. But the researchers found that when the FDA included unpublished studies, only about half — or 51 percent — were positive.

A PLoS Medicine study published that same year found similar results for studies long after drugs were approved: Less than half — 43 percent — of studies used by the FDA to approve 90 drugs were published within five years of approval. It was those with positive results that were more likely in journals.

All of that can leave the impression that something may work better than it really does. And there is at least one powerful incentive for journals to publish positive studies: Drug and device makers are much more likely to buy reprints of such reports. Such reprints are highly lucrative for journals. Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Ear Infections: To Treat Or Not To Treat?

Ear infections used to be a devastating problem. In 1932, acute otitis media (AOM) and its suppurative complications accounted for 27 percent of all pediatric admissions to Bellevue Hospital. Since the introduction of antibiotics, it has become a much less serious problem. For decades it was taken for granted that all children with AOM should be given antibiotics, not only to treat the disease itself but to prevent complications like mastoiditis and meningitis.

In the 1980s, that consensus began to change. We realized that as many as 80 percent of uncomplicated ear infections resolve without treatment in three days. Many infections are caused by viruses that don’t respond to antibiotics. Overuse of antibiotics leads to the emergence of resistant strains of bacteria. Antibiotics cause side effects. A new strategy of watchful waiting was developed.

Current Medical Guidelines

In 2004, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) collaborated to issue evidence-based guidelines based on a review of the published evidence. Something was lost in the transmission: The guidelines have been over-simplified and misrepresented, so it’s useful to look at what they actually said. There were six parts:

1. Criteria were specified for accurate diagnosis.

  • History of acute onset of signs and symptoms
  • Presence of middle ear effusion (ear drum bulging, lack of mobility, air-fluid level)
  • Signs and symptoms of middle ear inflammation: Either red ear drum or ear pain interfering with normal activity or sleep

They stressed that AOM must be distinguished from otitis media with effusion (OME). OME is more common, occurs with the common cold, can be a precursor or a consequence of AOM, and is not an indication for antibiotic treatment. Read more »

*This blog post was originally published at Science-Based Medicine*

The Link Between Oral Sex And Head And Neck Cancer

USA Today published a pretty accurate article regarding the rise of certain head and neck cancers with the increased popularity of oral sex and number of sexual partners.

The factor that creates this link is the human papillomavirus (HPV) which is associated with tonsil and tongue cancer. Alcohol and tobacco use is more highly linked with such oral cancers, but HPV does appear to be an independent risk factor.

A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer — cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased.

Of greater concern is that “French” kissing may also potentially be a mode of transmission.

The good news (if you’re a young non-smoker diagnosed with HPV-positive tumors) is that about 85 percent of non-smoking people with HPV-positive tumors survive. That number drops to 45 or 50 percent in people who smoke and are HPV-negative. Read more »

*This blog post was originally published at Fauquier ENT Blog*

Abortion Doesn’t Cause Mental Illness

Here’s yet another study showing that abortion does NOT lead to future psychiatric problems. From The New York Times:

The New England Journal of Medicine has taken on one of the pillar arguments in the abortion debate, asking whether having the procedure increases a woman’s risk of mental-health problems and concluding that it doesn’t. In fact, researchers found, having a baby brings a far higher risk.

The study, by Danish scientists (and financed in part by the Susan Thompson Buffett Foundation, which supports research on abortion rights), is the most extensive of its kind to date. It studied 365,550 Danish women who had an abortion or gave birth for the first time between 1995 and 2007. Of those, 84,620 terminated their pregnancies and 280,930 gave birth.

In the year after an abortion, 15.2 out of 1,000 sought psychiatric help (defined as admission to a hospital or clinic), which was essentially the same as the rate of that group (14.6 per 1,000) in the nine months before the abortion. In contrast, among women who went on to give birth, the rate at which they sought treatment increased to 6.7 per 1,000 after delivery from 3.9 per 1,000 before.

Why do first-time mothers have a lower overall rate of mental illness both before and after pregnancy than those who choose termination? The researchers suggest that those who have abortions are more likely to have emotional problems in the first place. Compared with the group who give birth, those who have abortions are also statistically more likely to be struggling economically, and to have a higher rate of unintended pregnancies.

And why do first-time mothers seem to nearly double their risk in the year after giving birth? That is likely to have something to do with the hormonal changes, decreased sleep, and increased stress of parenting, which women who terminate do not experience.

Can we please talk about something else? Like maybe how to help these young women with the issues and unmet contraceptive needs that led to unplanned pregnancy in the first place?

*This blog post was originally published at The Blog That Ate Manhattan*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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