Monday, 13 November 2017

Measuring the value of anti-cancer drugs

Cristina Roure



Anti-cancer drugs, especially palliative drugs, are toxic, costly and sometimes of little benefit, as a result their value to the patient and society are often questionable. It’s also true that significant improvements in the survival rates are threatened by the difficulty in accessing them, due to their unsustainable cost.

Some scientific societies, such as the American ASCO, but also the European ESMO and other organizations, are developing instruments to quantify the value of cancer drugs. The objective is to provide clear and unbiased information for governmental or syndicate decision making, regarding the access to drugs and to synthesize, in a single metric, the balance between the magnitude and the relevance of the expected clinical benefits and its cost, that is its value. See what it’s all about in this video presentation of the instrument developed by the ESMO: Magnitude of Clinical Benefit Scale (ESMO-MCBS):



JAMA has published an excellent article (1) that compares five of these tools and is accompanied by an editorial (2) that points out its strengths and weaknesses. Reading the article, I thought that it would be very difficult to establish a universal value in the treatment of cancer because, as Michael Porter points out, defining health value implies clearly defining common goals that unite the interests of all parties (3). Some interests, such as accessibility, effectiveness, safety and cost are convergent and all are included in one way or another in these tools. But there are others, which, because they are linked to the individual characteristics and values ​​of each person, or are not common variables in clinical trials, are not included, despite being extremely important.

Consider the case of those elders in the group with the highest incidence of cancer and account for 70% of deaths from this disease (4), but are under-represented in most of the research in oncology, a fact that conditions that all decisions must be taken from the extrapolation of results. Neither do we choose the most interesting variables for the elderly with cancer, such as the benefit they would obtain in terms of personal independence, maintenance of functional capacity, comfort or convenience and burden of treatment, toxicity and efficacy in a situation of multi-morbidity and poly-pharmacy. Oncology clinical trials, on the other hand, focus on overall or progression-free survival, variables thought for the younger population, in which the primary goal is to delay premature cancer death.

Investigations carried out in elderly populations demonstrate that more than 40% of elderly people with cancer notice a deterioration of their capacity to perform instrumental activities of daily living and, although there are tools to evaluate functional dependence or to stratify risk of toxicity of chemotherapy in the elderly, such as the Karnofsky index (4), in clinical oncology studies are absent.

As survival time lengthens and cancer becomes a chronic disease, it’s more necessary to develop new models of geriatric oncology care with a comprehensive view of the person with cancer that contemplates comprehensive geriatric assessment, which integrates, among others, some elements as important as co-morbidity and poly-pharmacy. In the video, Professor Hans Wildiers, an oncologist at the University of Leuven, discusses his experience in implementing comprehensive geriatric assessment in elderly patients with cancer.



We welcome therefore the initiatives of ESMO, ASCO, NCCN, ICER and the abacus drug calculator of the Memorial Sloan Kettering Cancer Centre, because they represent a rigorous effort to rationalize access to new drugs against cancer, but let’s admit that it will be necessary to widen our horizon if we want more person-centred tools that provide a more adequate response to individual decision-making.

As Margaret McCartney says, the pursuit of higher-quality health care necessarily involves a bifocal vision: a relentless campaign to promote new models of evidence synthesis combined with a strong commitment to people-centred care based on respect for diversity and individuality of values ​​and preferences (5).


Bibliography

1. Chandra, A, Shafrin, J, Dhawan, R. Utility of Cancer Value Frameworks for Patients, Payers, and Physicians.JAMA. 2016;315(19):2069-2070.
2. Basch, E. Toward a Patient-Centered Value Framework in Oncology.JAMA 315.19 (2016): 2073-2074.
3. Porter M. What Is Value in Health Care?. N Engl J Med 2010; 363:2477-2481.
4. Magnuson A, Dale W, Mohile S. Models of Care in Geriatric Oncology. Curr Geriatr Rep. 2014 Sep; 3(3): 182–189.
5. Mc Cartney M, Treadwell J, Maskrey N, Lehman R. Making evidence based medicine work for individual patients. BMJ 2016; 353: i2452


Monday, 6 November 2017

Precision medicine in the elderly care


Marco Inzitari


One of the challenges launched by President Barack Obama ($215 million for 2016) is the "Precision Medicine Initiative" a concept that goes against the treatment focused on the "average-patient". According to this initiative, as a first step, cancer treatments should be oriented to the specific genetics of the patient. For this reason, we often refer to the future of oncology as a "precision medicine". As another example, to continue with oncology, the Watson Intelligent System (IBM) will provide support to oncologists for informed and well fitted decision-making, analyzing patients' medical records and looking for possible evidence-based options.

Monday, 30 October 2017

Prediabetes epidemic in sight








Prediabetes is a terminology that, recently, is used when a person is detected with higher than normal levels of blood glucose, but there is no pathology. Prediabetes could be understood as a disposition to develop diabetes in the future, a disease that, in turn, represents a condition that puts one at risk of serious affections such as nephropathy, retinopathy or cardiovascular disorders, among others. Due to this chain of risks, and with a healthy intention to reduce morbidity and mortality, the American Diabetes Association (ADA) led a study to consider that glycosylated haemoglobin (HbA1c) is a test that can be done without any preparation or need for fasting and see if it can become a new criterion for detecting prediabetes. The concern arises when, according to this diagnostic extension, it’s estimated that in millions of pre-diabetics would show up: in China 493, in the US 86 and in Spain 6, to cite three countries from which I have data.

Monday, 23 October 2017

The Patient Revolution according to Victor Montori








In 2016, Victor Montori, a professor of medicine and diabetes doctor at the Mayo Clinic, launched The Patient Revolution, a foundation whose mission is to help make truly patient-centred treatment a reality. In his new book, Why We Revolt, Montori argues that “industrial medicine” has corrupted the mission of medicine to the point where doctors are now incapable of caring for the people who place their trust in them (for further information about the author in this same blog, search for “Montori, V." entries in the tags [top-right-hand column].

Monday, 16 October 2017

The face as a mirror... of the pocket!

Pedro Rey


As this is my first post on this blog, let me introduce myself. I am a researcher into behavioural economics, a field that uses ideas from psychology to enrich the study of economic problems. More specifically, at present we are working on a project that – as I will explain at the end of this piece, and for various reasons – may have interesting implications in the field of medicine.

Our research aims to answer a simple question: what is the relationship between how much consumers like the products they buy and how much they are willing to pay for them?

Monday, 9 October 2017

An extensive model for complex chronic patients








The emergent phenomenon of multi-chronicity and geriatric fragility is analyzed from all points of view: demographic, epidemiological, the use of resources and the economic impact, to mention only the most outstanding. Now familiar with the tendency, we’re facing the challenge of finding out how to provide appropriate services to patients who, due to the precariousness of their health, or their social circumstances, or both, suffer instability and become frequent and directionless visitors.

This group of complex patients, although not too large, is stressing the rigidities of health systems in three ways: a) the saturation of hospital emergency services consuming ambulances and observation beds is unable to give effective responses to the needs of these people, b) lack of coordination of transfers between levels, especially between the hospital and primary care, and c) poly-medication due to prescription fragmentation.

Monday, 2 October 2017

What do chronic patients want?








Fragmentation of services is a disgrace for complex chronic patients, for people with combined health and social needs, for fragile people and, in short, for the elderly population. Hence, most governments are engaged in service integration initiatives, but progress is slow and the results are disappointing because systems are too fragmented: in budgets, in access rights, in circuits, in professional cultures, in institutions, in public and private providers, etc. However, the British have proposed a merger of services by 2020, and since they recognize that, as things stand, offering people-centred care will be a bulky process, in the summer of 2013 they launched a project, “People helping people", a project that is ambitious in vision but modest in methodology and budget.

What is "People helping people"?

The program is working on 25 pilot areas that volunteered to test (as previously done in Torbay) different ways of coordinating and integrating services in order to promote patient-centred care, for which they rely on a single operative objective of elaborating, on the part of all the actors, of individualized plans that adapt to each person’s particular needs and way of life. In terms of methodology, the project has adopted the "triple aim" (Institute for Healthcare Improvement), which develops the following principles: a) improve patient experience, b) improve the health and well-being of the population, and c) reduce the waste and, therefore, the cost per capita.

Monday, 25 September 2017

Hospitalizations and patients’ experiences








Peter Pronovost, a renowned expert in clinical quality and safety, argues that it’s a mistake for hospitals to focus on patient satisfaction surveys and states that instead it would be more helpful to ask selected patients what proposals they would make in order to improve the hospitalization experience. For example, one of the people Johns Hopkins chose for this assignment was Podge Reed Jr., a double lung transplant patient who had amassed six hospitalizations, two surgical and four medical, eight anaesthesia outpatient procedures, more than one hundred visits to appointments and 700 laboratory tests. With this curriculum, the hospital felt that Mr.Reed should be a person with a clear opinion.

In the article, Jane Hill, Johns Hopkins’ Patient Relations Director, says that most hospitalised people, although appreciating the technical quality of services, also ask to be treated with kindness and care. Not surprising, given that being bedridden in a hospital is not a pleasant experience for anyone. As a result of patients' contributions, Jane Hill has developed a Decalogue that should be read as a basis for transforming hospitalization rooms, on one hand from the perspective of tasks, functions and competencies and on the other hand, with a view of patients’ experience.

Monday, 18 September 2017

Sleeping well, a determinant of health








There are some health determinants that we can’t do much about such as those that are marked by our genetic endowment, our family, the place where we have to live and the historical moment that is contemporary to us. Other factors, however, are linked to the lifestyle we decide to lead, such as sleeping well (in quantity and quality) a factor that doesn’t yet occupy a prominent place in the collective imagination. However, many studies aim towards common sense: if one sleeps well, the next day is better, and vice versa. That is why I was not surprised by the finding of a Finnish research that associates sleeping insufficient hours with drowsiness and life quality for adolescents or another collected from Harvard Health Publications that limited sleep to five hours a night for one group of students at the Singapore institute for a week and compared their abilities to another group who had slept for nine hours each night, with predictable results of cognitive impairment due to lack of sleep.

Monday, 11 September 2017

Value Based Medicine (VBM)








Evidence-based medicine (EBM), after 25 years, has generated substantial advances in research methodology and has made it possible to distinguish more clearly between good and bad treatments, to identify biases of any order and even evidence of conflicts of interest between research and industry. However, a group of English authors (The importance of values in EBM, Kelly MP 2016) believes that, despite the uncontested advances, EBM has put too much focus on the technical aspects and has forgotten that values ​​have a lot of influence at all stages of the evidence-building processes.

What do we mean when we talk about values?

Science strives to understand the world as it is, but conversely, values ​​are what humans reflect upon. Seen this way, the conflict is served and, therefore EBM should learn to navigate better between these two waters according to the authors of the article quoted below, "Values may act as heuristics – shortcuts in our thinking of which we are barely aware – which get us to quick answers to complicated problems. They form the lens through which we perceive and act on our world. Values are often tricky to pin down because they are such a pervasive part of things we take for granted. A necessary first step towards achieving this is to make our values as explicit as we can, so that we can reflect on them individually and deliberate on them collectively".

Monday, 4 September 2017

Do we need "bonsai" hospitals?

Joan Escarrabill


The ideal size of the hospital and the minimal activity (number of procedures) it has to do to ensure quality is a recurring debate. Sometimes the issue of the hospital size is related to the primary care’s ability to solve and, therefore, the possibility of closing acute beds (and redistributing the budget that was intended for its operation). In the 2009 EESRI edition, in Table 10 (page 21), there’s a very significant information: the number of acute beds per 1,000 inhabitants. According to this document, in Catalonia we have 2.4 beds per 1,000 inhabitants and in the whole of Spain 2.5. Only Turkey (2.3) and Finland (1.9) have fewer beds per 1,000 inhabitants than we do. Despite the data, there are people who insist on the convenience of closing acute beds if the primary care resolution capacity increases. It seems to me that there’s a better question: too many beds or too many hospitals?

Monday, 28 August 2017

Parachute trial: on the subject of knee arthroplasties








The concept "parachute trial" has been adopted to visualize that when a treatment is really effective perhaps one should not invest money in demonstrating what everyone knows, just as no one would think to make an essay on the effectiveness of the parachute. The New England Journal of Medicine has published a clinical trial (Skou 2015) that evaluates the clinical effectiveness of knee arthroplasty, and the journalist of the magazine asks: Did it have to be done? Arthroscopic knee replacements are one of the most significant advances in modern medicine. Everyone knows that many older people who could not leave the house, invalidated by pain, now not only go out every day to the market square but they often go cruising. Seen like this, is this not a "parachute trial"? A waste?

Monday, 21 August 2017

Keep calm and leave the mobile for a while

Josep Mª Monguet


The trade fairs tend to present the technological innovations somewhat passed by the commercial magic, which puts at risk the necessary objectivity to evaluate what they will actually contribute. This is aggravated if we consider that technology is nowadays advancing much faster than human capabilities. As technological innovation progresses exponentially, the adaptive and changing capacity of individuals and organizations is logarithmic.

In general, to take advantage of the new options that technology offers, you have to know where you want to go and what to do to get there; the problem is that we just grope. The good news, however, and the fair is a good exponent, is that so many of us are doing it that the possibilities for progress don’t stop multiplying. Remember Edison when he said he had discovered 10,000 ways of not making a light bulb.

Monday, 14 August 2017

Emergency services specific to the elderly








Elderly care is best resolved at the primary care level, with a geriatric orientation and in a community setting. However, sometimes older people need to go to the emergency room for a variety of reasons, such as a fracture, fibrillation, retention, sudden choking or blockage, to name just a few reasons. What happens then is easy to imagine, the geriatric patient is subjected to a triage that leads to a box full of devices, with many people asking the same things repeatedly, some of them with very little tact and almost always with little respect for intimacy, not to mention the discomfort caused by the racking in the corridor, bells and alarms, noise from machines and monitors, and a long etcetera, that easily produces the disorientation of the elderly patient, or delirium in the worst cases.

Monday, 7 August 2017

Improving by playing


David Font




Volkswagen launched a campaign, The Fun Theory, aiming to improve habits by introducing game techniques. Let's look at an example.


Anna Sort, a nurse, a professor at several universities and an expert in gamification (a new word) in health, in her blog Lost Nurse in the Digital Era defines gamification as "the use of playing techniques in activities that initially contained no play" with the objective of involving people and solving problems. She argues that we are all potential players and that video games have introduced the game into many aspects of our lives. Mechanics such as collecting, awarding points, providing feedback, promoting exchanges or personalizing, favour motivation and involvement. The challenge is to transform any activity into fun and to make the game difficult enough for people to be enthusiastic about solving it, without finding it impossible.

Monday, 31 July 2017

Evidence in the care continuum - one of the keys to the telemedicine’s success or failure?

Josep M. Picas



It’s notorious that there are a great number of experiments, publications and studies on the application of telemedicine. Over the last few years, this phenomenon that we could label as the "apps revolution" has given telemedicine a great boost. However, the results, in many cases, have not reached the expectations. 

Many studies have tried to identify the causes of this unsuccessful outcome. In a brief reference, we could mention the professionals’ inertia and resistance to change in their work processes, errors of design, i.e. not being focused on patients, regulatory aspects, lack of resources and patient adherence problems caused by, to name just two, little health literacy or the digital gap issue.

Monday, 24 July 2017

Justice and equity in the health system

Xavier Bayona



Should we review the principle of justice from an ethical perspective? If so, we’ll notice that it’s a principle of minimums (of coexistence) faced with the principle of happiness – a principle of maximums ("individual justice") and, unfortunately, we’re often erring by thinking we speak of justice when in fact we speak of happiness (or individual convenience). Similarly, from the bioethical standpoint, justice can be defined as the fact of treating each one appropriately, in order to reduce situations of inequality (ideological, social, cultural, economic, etc.). On the other hand, equity is defined as giving each individual no more and no less of what they need. Following these definitions, when we speak of justice and equity, deep down, we are doing a reiteration, because they are synonymous.

Monday, 17 July 2017

Dying in the hospital: some considerations

Gloria Gálvez


Health inequalities are related to individual and social factors. The way people live, work and grow old as well as the political, social or economic factors that accompany them, vary greatly according to the place where they live. Death, which could be "the great equalizer", doesn’t appear to be equal at all, as Dr. Puri states in his article "Unequal Lives, Unequal Deaths," in which she argues that social and health differences during life, are also present at the time of death. As a group of Danish authors suggest in BMJ Supportive & Palliative Care: "Socioeconomic position and place of death of cancer patients” for people with fewer resources it’s more difficult to benefit from a worthy death in their own home.

When a patient chooses to die in a health institution he does it for different reasons. Higginson et al., In "Dying at home - is it better: A narrative appraisal of the state of the science" identified, besides the socioeconomic level, other determinant elements as the preferences of the patients, the access to the home attendance or the support of the family. Let's look at each one separately.

Monday, 10 July 2017

Cancer committees - a brake on shared clinical decisions?








Cancer committees are instruments for the coordination of cancer practice that have existed for many years. Now, however, a joint German-US research group (with the collaboration of Glyn Elwyn) wanted to know not only the quality of the work of these committees but also how they address the demand for greater involvement of patients in clinical decisions, and an observational study has been carried out on 15 cancer committees of the University Cancer Center Hamburg-Eppendorf. From the publication of this paper, I would like to highlight two key aspects: a) the reality of the organizational quality of cancer committees, and b) how these committees contemplate patients' preferences.

a) Organizational quality of cancer committees

The first observation is that the majority of the tumour committees’ members are doctors in senior positions and, on the other hand, the presence of young doctors is scarce. The participation of other professionals, also important for cancer patients, such as nurses or psycho-oncologists has not been observed in any of the cases. Researchers believe that the hierarchical influence of key members of the committees and the need to close many cases in a short time are limiting factors for productive and quality multidisciplinary work. In summary, the observation notes that guidelines and recommendations are generally applied with margins too scarce for other considerations.

Monday, 3 July 2017

Buurtzorg, a nurse work project with blue ocean strategy








10 years ago, the home care scenario for people with complex social and health needs in the Netherlands followed a bureaucratic scheme based on nursing work on one hand, social work on the other, in addition to the home support actions offered by companies, many of them from the cleaning service world. Jos de Blok, a community nurse, dissatisfied with this fragmented model, put an entrepreneur hat on, assembled a small group of nurses with whom he shared vision and discussed as much at large about a new model of care based on real needs of people. In an interview, Jos de Blok says, "What I wanted to show was that if you are a good nurse, you should know how to focus on the relationship and to build trust with patients in order to make them live with the maximum of independence possible. "

Monday, 26 June 2017

I do therefore I am or the bias of intervention in medicine

Cristina Roure


This week, thanks to a post of Sergio Minué in the blog "El Gerente de Mediado", I discovered the recent publication of "Ending Medical Reversal" The book refers to situations in which new studies more robust than the pre-existing ones contradict the standards of commonly accepted practices, which have now proved ineffective or even harmful.

Some will recall such vivid examples as the use of protein C activated in sepsis, high dose chemotherapy combined with autotransplant of stem cell in metastatic breast cancer, the aprotinin in cardiac surgery, or hormone replacement therapy in postmenopausal women. All of them were used for years until proven harmful.

I have not been able to read the book yet, but I read a report by the same author; Dr. Vinay Prasad in Mayo Clinical Proceedings exposes his vast research. Over ten years, 363 studies evaluating established practices were published, out of which 146 (40%), between 12 and 19 per year, were revoked (1). The author explains in the following video that such revocations usually occur after the precipitous adoption of new therapies based on incomplete or inadequate studies.

Monday, 19 June 2017

Chronic Complex Patients and the Blue Ocean Strategy








The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

Monday, 12 June 2017

The diagnostic process and medical errors








The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).

Monday, 5 June 2017

Life quantity or more quality?








Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.

Monday, 29 May 2017

Caesarean section as a consumer good








In private medicine in Brazil, the rate of caesarean section has reached 90% of births. In that country, gynaecologists and midwives, if any, have lost the job of helping women to give birth, and some obstetrical clinics only work to schedule and during office hours. Bad research has not helped either. In the year 2000, a team of researchers led by Dr. Mary Hannah revealed that the caesarean section was a safer practice in breech presentations, information that had an almost immediate impact on clinical practice. Four years later it was found that the research had been poorly done and that its conclusions were wrong, but gynaecologists had already lost the skills (not easy) to practice vaginal births for breech babies. The result is that nowadays the breech foetal position is, assumed to be equivalent to caesarean section, despite the lack of evidence that supports the indication.

Monday, 22 May 2017

Beyond the reforms (on the subject of Franco Basaglia)








What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Monday, 15 May 2017

The controversy of health checks








The National Health Service announces health checks by making use of the mood of the "Full Monty" or "The Calendar Girls." Let yourself be undressed for a good cause - they say - your body deserves it. In Spain, on the other hand, this approach is more typical to the private offer. "The best way to take care of your health is to open your eyes to possible diseases and not hesitate to undergo periodic tests to prevent them," says "10 Minutos" magazine in an article on the subject. Many private centres have "Medical check-ups" and most insurers and clinics offer health check-ups, as can be seen in an announcement from the Quirón Teknon Hospital: "basic preventive check-up: previously € 820 - now € 690; advanced preventive check: was € 1,800 - now € 1,520". The Sanitas proposal that offers the possibility of choosing between "checks: classic, integral and complete" is also interesting just as the National Conference of Marketing and Sales Management of the Health Sector that says "the most demanded from the iGlobalMed platform are the health checks for managers who are going to work abroad". To end this journey through the world of health reviews, see the clip below from the University Hospital of Navarre website:

Monday, 8 May 2017

What if I decide to do nothing?








TIME magazine has surprised us with a question on its front page: "What would happen if I decided to do nothing?" Desiree Basila, a 60-year-old teacher, had just been diagnosed with ductal carcinoma in situ (DCIS) and, overwhelmed by the aggressiveness of the treatment proposals offered to her, began to investigate on her own and realized that there were many unknown elements about the progression of this type of injury and also saw that there was no agreement in the scientific community on what should be the most appropriate therapy for her case. For this reason she made a bold decision and asked her oncologist to do nothing, which resulted in two checks a year and a treatment with Tamoxifen, a drug that blocks estrogens that could cause the tumour to grow.

The case of Desiree Basila is quite valuable because when she made this decision, 8 years ago, it was not yet known that the mortality of women with DCIS, regardless of the type of treatment they adopt, is 3.3%, a figure comparable to that of the general population, and it was also not known that chemotherapy has no effect on tumours in initial staging. But to better understand the pressure that Desiree had to endure, it should be added that the attitude of most oncologists, even in the case of DCIS, was, and remains, "the sooner the better and the more the better."