Many US cancer survivors still lost in transition : The Lancet
Thursday, May 17, 2012
2012 CDC/NCI report - United States Cancer Statistics (USCS)
Cancer - NPCR - USCS - View Data Online
| The 1999–2008 United States Cancer Statistics (USCS): Incidence and Mortality Web-based Report
marks the tenth time that the Centers for Disease Control and
Prevention (CDC) and the National Cancer Institute (NCI) have jointly
produced official federal cancer incidence statistics for each state
having high-quality cancer data. The report is produced in collaboration
with the North American Association of Central Cancer Registries. This year's report features information on more than one million invasive cancer cases diagnosed during 2008 among residents of all 50 states, six metropolitan areas, and the District of Columbia. Incidence data are from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology and End Results (SEER) Program. Data from population-based central cancer registries in these states and metropolitan areas meet the selected criteria for inclusion in this report. The report also provides cancer mortality data collected and processed by CDC's National Center for Health Statistics (NCHS). Mortality statistics, based on records of deaths that occurred during 2008, are available for all 50 states and the District of Columbia. Report Highlights
United States Cancer Statistics (USCS)View Data Online1999–2008 Cancer Incidence and Mortality DataThis Web-based report includes the official federal statistics on cancer incidence from registries that have high-quality data and cancer mortality statistics for each year and 2004–2008 combined. It is produced by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI), in collaboration with the North American Association of Central Cancer Registries (NAACCR). |
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Cancer Data by Statepaywalled: Presence of a sarcomatous component outside the ovary is an adverse prognostic factor for primary ovarian malignant mixed mesodermal/mullerian tumors: a clinicopathologic study of 47 cases
Blogger's Note: also known by short form MMMT
Abstract
Primary ovarian malignant mixed mesodermal tumors are uncommon. There exist few data in the literature on the significance of the sarcomatous (sarcoma) component (SC) in these tumors. Here we investigated this aspect in 47 such tumors, with particular interest in whether the presence of SC outside the ovary confers a worse prognosis. .......................We advocate listing the specific extraovarian tumor component (SC and/or CC) in the pathology report for primary ovarian malignant mixed mesodermal tumors.Gamma knife surgery for brain metastases from ovarian cancer.
numerous tables including:
Table 1 Patient characteristics of 16 patients with 119 brain metastases
Conclusions
Brain metastases from ovarian cancer are
rare, but their incidence is increasing as patient survival has been
extended by
successful platinum-based chemotherapy and improved
imaging techniques have enabled the identification of smaller lesions.
In our study, the median survival from brain metastases
was 12.5 months, and the local control rate was 86.4 %. The KPS and
total volume of brain metastases were important factors
predictive of survival. Our results suggest that GKS is an acceptable
therapy for brain metastases from ovarian cancer.
Conflicts of interest
None.
Open Access
update March 15th Grants.gov - Find Grant Opportunities - Opportunity Synopsis
Grants.gov - Find Grant Opportunities - Opportunity Synopsis
The synopsis for this grant opportunity is detailed below, following this paragraph. This synopsis contains all of the updates to this document that have been posted as of 03/15/2012 . If updates have been made to the opportunity synopsis, update information is provided below the synopsis.....
News : Many Primary Care Docs Don't Know Long-Term Effects of Chemo: Survey
Blogger's Note: general/non-ovarian cancer specific
HON - News : Many Primary Care Docs Don't Know Long-Term Effects of Chemo: Survey
"....The findings highlight the need for more communication between the different doctors involved in a patient's care, one expert stressed.
The burden of that communication lies not only with doctors (oncologists and primary care physicians) but also with patients, said Dr. Stephanie Bernik, chief of surgical oncology at Lenox Hill Hospital in New York City.....
paywalled- Gynecologic Oncology - Response to: “Management of ovarian cancer has changed”
ScienceDirect.com - Gynecologic Oncology - Response to: “Management of ovarian cancer has changed”
In Press, Accepted Manuscript, Available online 15 May 2012
Joyce N. Barlin, Dennis S. Chi
Close preview |
Related articles | Related reference work articles Abstract - No abstract is available for this article.
paywalled - Gynecologic Oncology - Comparison of ERCC1/XPF genetic variation, mRNA and protein levels in women with advanced stage ovarian cancer treated with intraperitoneal platinum
ScienceDirect.com - Gynecologic Oncology - Comparison of ERCC1/XPF genetic variation, mRNA and protein levels in women with advanced stage ovarian cancer treated with intraperitoneal platinum
Abstract
Objective
Approximately 20% of patients receiving platinum-based chemotherapy for epithelial ovarian cancer (EOC) are refractory or develop early recurrence. Identifying these patients early could reduce treatment-associated morbidity and allow quicker transfer to more effective therapies. Much attention has focused on ERCC1 as a potential predictor of response to therapy because of its essential role in the repair of platinum-induced DNA damage. The purpose of this study was to accurately measure protein levels of ERCC1 and its essential binding partner XPF from patients with EOC treated with platinum-based therapy and determine if protein levels correlate with mRNA levels, patient genotypes or clinical outcomes.Methods
ERCC1 and XPF mRNA and protein levels were measured in frozen EOC specimens from 41 patients receiving intraperitoneal platinum-based chemotherapy using reverse transcription polymerase chain reaction and western blots. Genotypes of common nucleotide polymorphisms were also analyzed. Patient outcomes included progression free (PFS) and overall survival (OS).Results
Expression of ERCC1 and XPF were tightly correlated with one another at both the mRNA and protein level. However, the mRNA and protein levels of ERCC1 were not positively correlated. Likewise, none of the SNPs analyzed correlated with ERCC1 or XPF protein levels. There was an inverse correlation between mRNA levels and patient outcomes.Conclusion
Neither genotype nor mRNA levels are predictive of protein expression. Despite this, low ERCC1 mRNA significantly correlated with improved PFS and OS.paywalled - Gynecologic Oncology - Hormonal therapy for recurrent low-grade serous carcinoma of the ovary or peritoneum
ScienceDirect.com - Gynecologic Oncology - Hormonal therapy for recurrent low-grade serous carcinoma of the ovary or peritoneum
Objective
To determine whether hormonal therapies have efficacy in patients with recurrent low-grade serous carcinoma of the ovary or peritoneum.Methods
We searched departmental databases for patients with histologically-confirmed, evaluable, recurrent low-grade serous ovarian or peritoneal carcinoma who received hormonal therapy at our institution between 1989 and 2009. We retrospectively reviewed patients' medical records for demographic, disease, hormonal therapy, and estrogen receptor and progesterone receptor expression data. We used the Response Evaluation Criteria in Solid Tumors version 1.1 to determine patients' responses to hormonal therapy. Because patients could have received more than one evaluable hormonal therapy regimen, we chose to define the outcome metric as “patient-regimens.” Median time to disease progression (TTP) and overall survival (OS) were also calculated. Regression analysis was also performed.Results
We identified 64 patients with recurrent low-grade serous carcinoma of the ovary or peritoneum. Patients' median TTP and median OS were 7.4 and 78.2 months, respectively. Patients received 89 separate hormonal patient-regimens, which produced an overall response rate of 9% (6 complete responses and 2 partial responses). Sixty-one percent of the patient-regimens resulted in a progression-free survival duration of at least 6 months. Patient-regimens involving ER +/PR + disease produced a longer median TTP (8.9 months) than patient-regimens involving ER +/PR − disease did (6.2 months; p = 0.053). This difference approached but did not reach statistical significance.Conclusions
Hormonal therapies have moderate anti-tumor activity in patients with recurrent low-grade serous carcinoma of the ovary or peritoneum. Further study to determine whether ER/PR expression status is a predictive biomarker for this rare cancer subtype is warranted.paywalled - Gynecologic Oncology - A phase II study of a urokinase-derived peptide (A6) in the treatment of persistent or recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma: GOG
ScienceDirect.com - Gynecologic Oncology - A phase II study of a urokinase-derived peptide (A6) in the treatment of persistent or recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma: A Gynecologic Oncology Group study
Conclusion
A6 was well tolerated but had minimal activity in patients with persistent or recurrent EOC/FTC/PPC.paywalled- Gynecologic Oncology - Economic impact of paclitaxel shortage in patients with newly diagnosed ovarian cancer ($8,699,872 monthly.
ScienceDirect.com - Gynecologic Oncology - Economic impact of paclitaxel shortage in patients with newly diagnosed ovarian cancer
Objective
To determine the potential economic impact of a paclitaxel drug shortage in patients with newly diagnosed, untreated ovarian cancer.Methods
A modified Markov state transition model with a 6 cycle time horizon compared two scenarios: (1) Standard treatment (STD): paclitaxel 175 mg/m2/carboplatin AUC 5 × 6 cycles; (2) Paclitaxel drug shortage (DS): docetaxel 75 mg/m2/carboplatin AUC 5 × 6 cycles. Adverse events, quality of life, and costs of chemotherapy, neuropathy, febrile neutropenia, and anemia were incorporated. Key assumptions: (1) Costs and consequences were assigned only to grade 2 + neuropathy, febrile neutropenia, and grade 3–4 anemia; (2) Grade 2 + neuropathy prompted a switch from paclitaxel/carboplatin to docetaxel/carboplatin or from docetaxel/carboplatin to carboplatin alone; (3) Febrile neutropenia resulted in inpatient hospitalization followed by G-CSF prophylaxis.Results
The mean cost of 6 cycles of chemotherapy was $4939 in the STD and $16,107 in the DS scenario, for a cost difference of $11,168 per patient over 6 cycles of treatment. STD was the dominant strategy (less expensive and more effective than the drug shortage scenario). In sensitivity analysis, DS was more costly over a wide range of clinical estimates in each arm. A drug shortage that affects approximately 50% of women initiating chemotherapy is expected to impact 779 women and cost third party payers an additional $8,699,872 monthly.Conclusions
Our model indicates that chemotherapy drug shortages can have a significant negative impact on the average cost of primary treatment for ovarian cancer and have the potential to negatively impact health system costs.paywalled - Gynecologic Oncology - Predictors of severe and febrile neutropenia during primary chemotherapy for ovarian cancer
ScienceDirect.com - Gynecologic Oncology - Predictors of severe and febrile neutropenia during primary chemotherapy for ovarian cancer
Objective
To identify factors that increase the risk of neutropenic events in women with advanced ovarian carcinoma receiving initial chemotherapy.Methods
Multi-center retrospective study of women with FIGO stage III–IV epithelial ovarian cancer treated postoperatively with multi-agent intravenous chemotherapy from 1995 to 2008. Outcomes were severe (SN; absolute neutrophil count [ANC] < 500/mm3) and febrile neutropenia (FN; ANC < 1000/mm3 and temperature > 38.1 °C). Cumulative risk of neutropenic events was estimated by Kaplan Meier method. Multivariate analysis was by Cox proportional hazard regression.Results
Three hundred twenty-six patients met inclusion criteria. There were 251 SN events among 140 (43%) patients and 24 FN events among 22 (7%) patients. Univariate predictors of SN were body surface area < 2.0 m2 (p = 0.03), body mass index (BMI) < 30 kg/m2 (p < 0.01), Caucasian race (p < 0.01), treatment on research protocols (p < 0.01), non-carboplatin-containing regimens (p < 0.01), and planned relative dose intensity (RDI) > 85% of standard (p = 0.02). Women over age 60 were more likely to develop FN (p = 0.05). Multivariate predictors of SN were treatment on research protocols (hazard ratio [HR] 1.93; p < 0.01), Caucasian race (HR 2.13; p = 0.01), and planned RDI > 85% (HR 1.69; p = 0.05); predictors of FN were age > 60 (HR 2.84; p = 0.05) and non-carboplatin containing regimens (HR 4.06; p < 0.01).Conclusion
While SN is fairly common, FN occurs infrequently in women with EOC undergoing taxane and platin-based chemotherapy and primary prophylactic growth factor support is not indicated. However, women older than 60 years of age receiving non-carboplatin containing regimens are at higher risk for FN and warrant closer surveillance.paywalled - Gynecologic Oncology - Progression-free and overall survival of a modified outpatient regimen of primary intravenous/intraperitoneal paclitaxel and intraperitoneal cisplatin in ovarian, fallopian tube, and primary peritoneal cancer
ScienceDirect.com - Gynecologic Oncology - Progression-free and overall survival of a modified outpatient regimen of primary intravenous/intraperitoneal paclitaxel and intraperitoneal cisplatin in ovarian, fallopian tube, and primary peritoneal cancer
Highlights
► GOG 172 showed improved outcomes for optimally debulked ovarian carcinoma patients treated with IV/IP chemotherapy compared to IV chemotherapy.► The regimen has not been widely accepted due to its inpatient administration, toxicity profile, and limited completion rate.
► A modified GOG 172 treatment regimen improved convenience, toxicity, and tolerability, with outcomes similar to those of GOG 172.
paywalled - Gynecologic Oncology - Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery
ScienceDirect.com - Gynecologic Oncology - Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery
Abstract
Objective
To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery.Methods
We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30 days after surgeryResults
Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6 weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p = 0.015) and had younger median age 49 years, 51 years, and 46 years, respectively; p = 0.035. Nineteen (2.3%) patients experienced pulmonary complications — symptomatic atelectasis (n = 9), pneumonia (n = 5), acute respiratory failure (n = 2), hypoxemia (n = 1), pneumomediastinum (n = 1), and pneumothorax (n = 2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers.Conclusion
In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.paywalled: Current advances in the management of malignant germ cell and sex cord-stromal tumors of the ovary
Current advances in the management of malignant germ cell and sex cord-stromal tumors of the ovary:
Abstract | References
No abstract is available for this article.
paywalled: Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma
Blogger's Note/Opinion: in ovarian cancer this issue is seemingly underreported; from a patient's perspective it is underreported, abstract does not indicate expertize/impact/outcomes according to surgical skill/professional nor long term effects/in depth cause-related issues;
Medscape: Ileus occurs from hypomotility (decreased motility) of the gastrointestinal tract in the absence of mechanical bowel obstruction. Presumably, the muscle of the bowel wall is transiently impaired and fails to transport intestinal contents. This lack of coordinated propulsive action leads to the accumulation of gas and fluids within the bowel.....
~~~~~~~~~~~~~
Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma:
Objective
Thorough primary cytoreduction for epithelial ovarian carcinoma (EOC) improves survival. The incidence of postoperative ileus (POI) in these patients may be underreported because of varying POI definitions and the evolving, increasingly complex contemporary surgical approach to EOC. We sought to determine the current incidence of POI and its risk factors in women undergoing debulking and staging for EOC.
Methods
We retrospectively identified the records of women who underwent primary staging and cytoreduction for EOC between 2003 and 2008. POI was defined as a surgeon's diagnosis of POI, return to nothing-by-mouth status, or reinsertion of a nasogastric tube. Perioperative patient characteristics and process-of-care variables were analyzed.
Results
Among 587 women identified, the overall incidence of POI was 30.3% (25.9% without bowel resection, 38.5% with bowel resection; P =.002). Preoperative thrombocytosis, involvement of bowel mesentery with carcinoma, and perioperative red blood cell transfusion were independently associated with increased POI. Postoperative ibuprofen use was associated with decreased POI risk. Women with POI had a longer length of stay (median, 11 vs 6days) and increased time to recovery of the upper (7.5 vs 4days) and lower (4 vs 3days) gastrointestinal tract (P <.001 for each).
Conclusions
The rate of POI is substantial among women undergoing staging and cytoreduction for EOC and is associated with increased length of stay. Modifiable risk factors may include transfusion and postoperative ibuprofen use. Alternative interventions to decrease POI are needed.
press release: In drug-approval race, US FDA ahead of Canada, Europe (range: 322-393 days)
In drug-approval race, US FDA ahead of Canada, Europe
Public release date: 16-May-2012
The U.S. Food and Drug Administration (FDA) generally approves drug therapies faster and earlier than its counterparts in Canada and Europe, according to a new study by Yale School of Medicine researchers. The study counters perceptions that the drug approval process in the United States is especially slow.
Led by second-year medical student Nicholas Downing and senior author Joseph S. Ross, M.D., assistant professor of internal medicine at Yale School of Medicine, the study will be published May 16 online by the New England Journal of Medicine.
Regulatory review represents the final step in the process of bringing new medical technologies from the lab to the bedside. Efficient regulatory review processes may enable patients to get access to promising new therapies sooner, while ensuring drug safety.
"The perception that the FDA is too slow implies that sick patients are waiting unnecessarily for regulators to complete their review of new drug applications," said Downing, who decided to conduct the study because there have been no recent comparisons of the FDA's regulatory review speed with those of regulating agencies in other countries.
Downing, Ross, and colleagues reviewed drug approval decisions of the FDA, the Canadian drug regulator, Health Canada, and the European Medicines Agency (EMA) between 2001 and 2010. They studied each regulator's database of drug approvals to identify novel therapeutics as well as the timing of key regulatory events, allowing regulatory review speed to be calculated. Canada and Europe were chosen as a comparison because they face similar pressures to approve new drugs quickly while ensuring they do not put patients at risk.
The team found that the median total time to review was 322 days at FDA, 366 days at EMA and 393 days at Health Canada.
"Among the subsample of drugs approved for all three regulators, the FDA's reviews were over three months faster than those of the EMA or Health Canada," said Downing. "The total review time at the FDA was faster than EMA, despite the FDA's far higher proportion of applications requiring multiple regulatory reviews."
Downing added that most new drug therapies were first approved for use in the U.S. "Examining novel drugs approved in multiple markets, we found that 64% of medicines approved in both the U.S. and in Europe were approved for U.S. patients first, and 86% of medicines approved in both the U.S. and Canada were also approved first in the U.S." he said.
###
Other authors on the study included Jenerius A. Aminawung, Nilay D. Shah, Joel B. Braunstein, and Harlan M. Krumholz.The study was funded by the Pew Charitable Trusts.
Citation: New England Journal of Medicine, doi: 10.1056/NEJMoa1200223
Regulatory Review of Novel Therapeutics — Comparison of Three Regulatory Agencies — NEJM (U.S./Canada/Europe) note references to safety
Regulatory Review of Novel Therapeutics — Comparison of Three Regulatory Agencies — NEJM
"In conclusion, we found that among novel (new) therapeutics approved between 2001 and 2010, the FDA reviewed applications more quickly, on average, than did the EMA and Health Canada, and the vast majority of these novel therapeutics were first approved for use in the United States. Our findings contradict recent criticisms of the speed of review by the FDA and lead to questions about whether the speed of the review process is justified as an emphasis for PDUFA V, particularly since the FDA continues to outpace its European and Canadian peers."
Functional profiling of clear cell ovarian cancer. | 2012 ASCO Annual Meeting Abstracts
Functional profiling of clear cell ovarian cancer. | 2012 ASCO Annual Meeting Abstracts
Abstract:
Background: Clear cell ovarian cancer represents up to 15% of epithelial ovarian cancers. In comparison to other subtypes, clear cell ovarian carcinomas have a poorer prognosis and are relatively resistant to standard platinum based chemotherapy. Recently, loss of function mutations in the tumour suppressor gene ARID1A were identified in up to 50% of ovarian clear cell carcinomas. We have adopted an integral functional and molecular profiling approach as a route to identify new genetic dependencies and therapeutic targets for this disease.
Methods: Clear cell ovarian cancer cell lines were functionally profiled using high throughput screening with chemical and siRNA libraries. This has been integrated with molecular profiling data generated from exome and transcriptome sequencing to aid the discovery of novel targets.
Results: Using functional screens we have now identified critical gene dependencies and potential therapeutics in a series of clear cell ovarian cancer models. The comparison of functional viability profiles for models characterized by ARID1A loss of function mutations is now enabling an analysis of synthetic lethal effects that could be used to target clear cell ovarian cancers carrying these mutations.
Conclusions: The work undertaken so far provides the framework for the discovery of therapeutic targets for clear cell ovarian cancer using an integrated approach. Revalidation of these preliminary results is now underway to characterize new genetic dependencies for this disease.
ASCO '12 Abstract Dump: Cancer Stocks in Focus - TheStreet (financial)
ASCO '12 Abstract Dump: Cancer Stocks in Focus - TheStreet
.....While investors were flooded with new cancer drug data Wednesday, ASCO did hold back some of the some important and potentially stock-moving research for a more high-profile release at the meeting itself.
The following pages summarize new and important cancer drug data released tonight by ASCO from research abstracts for its upcoming annual meeting.......
paywalled: Two-marker Combinations for Preoperative Discrimination of Benign and Malignant Ovarian Masses
Two-marker Combinations for Preoperative Discrimination of Benign and Malignant Ovarian Masses
Abstract
Background:
When caring for patients with
ovarian neoplasms, correct preoperative discrimination of benign and
malignant disease
is deemed vital. In this study, we tested serum
biomarkers' alone and in combination, to achieve this aim.
Conclusion:
A combination of CA-125
with HE4 could facilitate the identification of women at risk for
ovarian
cancer.
paywalled: Long-term results of screening with magnetic resonance imaging in women with BRCA mutations : British Journal of Cancer
Long-term results of screening with magnetic resonance imaging in women with BRCA mutations : British Journal of Cancer
Background:
The
addition of breast magnetic resonance imaging (MRI) to screening
mammography for women with BRCA mutations significantly increases
sensitivity, but there is little data on clinical outcomes. We report
screening performance, cancer stage, distant recurrence rate, and breast
cancer-specific mortality in our screening study.
Methods:
From 1997 to 2009, 496 women aged 25 to 65 years with a known BRCA1/2
mutation, of whom 380 had no previous cancer history, were enrolled in a
prospective screening trial that included annual MRI and mammography.
Results:
In
1847 screening rounds, 57 cancers were identified (53 screen-detected, 1
interval, and 3 incidental at prophylactic mastectomy), of which 37 (65%) were invasive. Sensitivity of MRI vs mammography was 86% vs 19% over the entire study period (P<0.0001), but was 74% vs 35% from 1997 to 2002 (P=0.02) and 94% vs 9%
from 2003 to 2009 (P<0.0001), respectively. The relative
sensitivities of MRI and mammography did not differ by mutation, age, or
invasive vs non-invasive disease. Of the incident cancers, 97%
were Stage 0 or 1. Of 28 previously unaffected women diagnosed with
invasive cancer, 1 BRCA1 mutation carrier died following relapse of a 3 cm, node-positive breast cancer diagnosed on her first screen at age 48 (annual breast cancer mortality rate=0.5%).
Three patients died of other causes. None of the 24 survivors has had a
distant recurrence at a median follow-up of 8.4 years since diagnosis.
Conclusion:
Magnetic resonance imaging surveillance of women with BRCA1/2
mutations will detect the majority of breast cancers at a very early
stage. The absence of distant recurrences of incident cancers to date is
encouraging. However, longer follow-up is needed to confirm the safety of breast surveillance.
media: Doctor-bashing’s not the cure for health-care costs
......the government has gone to war against the doctors again.....
"Politicians and bureaucrats are always attracted to simple ways to control health-care spending. In the early 1990s, they decided the best way to control spending was to cut down on doctors. This brilliant idea resulted in a doctor shortage that has taken the past decade to fix......
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