Is It Time for Medicine-Based Evidence?

JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/2012; 307(15):1641-3. DOI: 10.1001/jama.2012.482
Source: PubMed
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    • "Les métaanalyses et les essais contrôlés randomisés représentent le gold standard dans le paradigme de la médecine basée sur les preuves. En radiothérapie, ces essais sont cependant difficiles à mettre en oeuvre pour des raisons essentiellement financières, institutionnelles , d'implication médicale et d'évolution rapide des techniques dont peuvent bénéficier favorablement les patients [7]. Les essais comparant deux techniques d'irradiation par exemple (classique et innovante) peinent à inclure. "
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    ABSTRACT: Stereotactic body radiation therapy for lung cancer is now well established for patients who are not eligible to surgery. These patients can benefit from a curative treatment, which is a new therapeutic indication. Protocols are effective and well tolerated even for the most fragile patients. Three randomized trials comparing stereotactic body radiation therapy and surgery failed due to poor accrual. However, taking into account the favourable available data, the choice of stereotactic body radiation therapy in first intention arises. The treatment decision has to be discussed in a multidisciplinary way, while considering the opinion of the patient, who must be clearly informed about the principle of both therapeutic options.
    Cancer/Radiothérapie 09/2015; DOI:10.1016/j.canrad.2015.06.014 · 1.41 Impact Factor
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    • "CER assists all healthcare stakeholders in healthcare in making informed decisions to improve outcomes at the individual and population levels. The contrasting merits between randomized control trials (RCTs), the gold standard in CER, and observational studies have recently been highlighted as they pertain to specific challenges in oncology such as rising costs and rapidly evolving technology [27] [28]. The challenges of performing RCTs, even when there is a good clinical question, have been clearly illustrated in lung SABR. "
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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 · 4.36 Impact Factor
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    • "posttraumatic stress disorder (PTSD), because dropout is unlikely to occur at random, inferences drawn from these data may not be valid without statistical adjustment; however, such adjustments may not be feasible. For example, the use of inverse probability weighting requires that the weights appropriately model the true pattern of dropout [13], which is difficult to do without knowing the reasons for dropout. Patients may drop out for several reasons, including early improvement , failure to improve, or other reasons [35]. "
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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 · 3.42 Impact Factor
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