Is It Time for Medicine-Based Evidence?
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ABSTRACT: The use of stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer is growing rapidly, particularly since it has become the recommended therapy for unfit patients in current European and North American guidelines. As three randomized trials comparing surgery and SABR closed prematurely because of poor accrual, clinicians are faced with a dilemma in individual patient decision-making. Radiation oncologists, in particular, should be aware of the data from comparative effectiveness studies that suggest similar survival outcomes irrespective of local treatment modality. The necessity of obtaining a pathological diagnosis, particularly in frail patients prior to treatment remains a challenge, and this topic was addressed in recent European recommendations. Awareness of the high incidence of a second primary lung cancer in survivors, as well as other competing causes of mortality, is needed. The challenges in distinguishing focal scarring from recurrence after SABR also need to be appreciated by multidisciplinary tumor boards. With a shift in focus toward patient-centered decision-making, clinicians will need to be aware of these new developments and communicate effectively with patients, to ensure that treatment decisions are reflective of patient preferences. Priorities for additional research in the area are proposed. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.Radiotherapy and Oncology 12/2014; 114(2). DOI:10.1016/j.radonc.2014.11.036 · 4.86 Impact Factor
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ABSTRACT: A large body of comparative effectiveness research (CER) focuses on the use of observational and quasi-experimental approaches. We sought to examine the use of clinical trials as a tool for CER, particularly in mental health. Examination of three ongoing randomized clinical trials in psychiatry addressing issues that would pose difficulties for nonexperimental CER methods. Existing statistical approaches to nonexperimental data appear insufficient to compensate for biases that may arise when the pattern of missing data cannot be properly modeled such as when there are no standards for treatment, when affected populations have limited access to treatment, or when there are high rates of treatment dropout. Clinical trials should retain an important role in CER, particularly in cases of high disorder prevalence, large expected effect sizes, difficult-to-reach populations, or when examining sequential treatments or stepped-care algorithms. Progress in CER on mental health will require careful consideration of appropriate selection between clinical trials and nonexperimental designs and on allocation of research resources to optimally inform key treatment decisions for each patient.Journal of clinical epidemiology 08/2013; 66(8 Suppl):S29-36. DOI:10.1016/j.jclinepi.2013.02.013 · 5.48 Impact Factor
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ABSTRACT: Comparative effectiveness research (CER) has captured the attention of the biomedical community, including physicians, other health care professionals, and clinical researchers; the public, including patients and their advocates; and policy makers, including funding agencies and health care insurers. This keen interest is based, at least in part, on the hope that the findings from CER will provide useful information to help clinicians make evidence-based decisions, will incorporate patient preferences and patient-centered perspectives, and, ultimately, will improve the quality of care and help control health care costs.JAMA The Journal of the American Medical Association 04/2012; 307(15):1643-5. DOI:10.1001/jama.2012.490 · 30.39 Impact Factor