abstract: Physician Knowledge and Awareness of CA-125 as a Screen for Ovarian Cancer in the Asymptomatic, Average-Risk Population - CDC study

Physician Knowledge and Awareness of CA-125 as a Screen for

Abstract

Effective early detection strategies for ovarian cancer do not exist. 

Current screening guidelines recommend against routine screening using CA-125 alone or in combination with transvaginal ultrasonography (TVS). 

In this study, the authors used the 2008 DocStyles survey to measure clinician beliefs about the effectiveness of CA-125 and TVS in the asymptomatic, average-risk population in the United States. 

To assess the need for provider education, the authors used the 2008 HealthStyles survey to examine public awareness of CA-125. 

Of 1,250 physician respondents, 40.4% said both CA-125 and TVS were effective screens, and 28.3% said neither was an effective ovarian cancer screen in the asymptomatic, average-risk population. 

Obstetrician/gynecologists [OB/GYNs] more often had responses consistent with current guidelines: 56.5% of OB/GYNs, compared with 34.4% and 29.8% of family/general practitioners and internists, respectively, said neither CA-125 nor TVS was an effective screen. 

Almost one third of women (patients/the public) surveyed reported having heard of CA-125, and about one tenth said they had the CA-125 test. 

These findings support the need for additional provider education. Educational efforts should include lack of evidence for, as well as the potential harms of, screening for ovarian cancer with CA-125.

full free access: How Research Influences Policy Makers: Still Hazy After All These Years — J. Natl. Cancer Inst. Steven Lewis (author)

"Libraries have been written about the theory and practice of public policy making. Yet, this enormous scholarship has proved insufficient to lift the veil of mystery and idiosyncrasy that shrouds the art of decision making. The heady ambition to turn both clinical practice and health policy into evidence-based bastions of rationalist decision making has been downgraded; the vocabulary is now “evidence-informed,” and the realm of admissible evidence has been greatly expanded to include preferences, political contingencies, and psychology (1). This newfound conceptual modesty and nuance does not suggest that we should abandon efforts to understand decision-making processes and to enhance the role of research-based evidence in policy. It merely confirms the complexity, contingency, and messiness of the terrain............This leads to a second issue: the definition of “use.” The questionnaires simply asked whether the respondents intended to use the brief. We do not know what “use” means.." cont'd

free full access: WHO/PLoS Collection “No Health Without Research”

"It seems astonishing that in the 21st century decisions on health care can still be made without a solid grounding in research evidence. This is true even in clinical research, whether for simple or complex interventions [1], where systematic reviews time and time again conclude that the evidence base is inadequate [2]. It is even more true in the areas of health policy and health systems, where quality research is hampered further by a lack of shared definitions, a lack of consensus on guiding principles, poor capacity (especially in low-resource regions), and methodological challenges [3],[4].
The World Health Report (WHR) for 2012 will be on the theme of “No Health without Research”. This flagship report from WHO will, for the first time in its history, focus on research for better health. The primary target audience of the report will be ministers of health in the WHO member states, and the goal of the report is to provide new ideas, innovative thinking, and pragmatic advice for member states on how to strengthen their own health research systems. The report will have the three following aims.

1. To show that research is important for meeting health needs and improving health outcomes;
2. To encourage countries to therefore invest more resources in developing and strengthening their national health research systems;
3. To argue that countries should not see research as an expense or as an afterthought, but as an investment for a better, healthier future.....cont'd

Level of Scientific Evidence Underlying Recommendations Arising From the National Comprehensive Cancer Network Clinical Practice Guidelines — JCO

Conclusion: Recommendations issued in the NCCN guidelines are largely developed from lower levels of evidence but with uniform expert opinion. This underscores the urgent need and available opportunities to expand evidence base in oncology.

full free access: More stakeholder engagement is needed to improve quality of research, say US experts

Blogger's note: Agree  based on years of RCT reviews

"Researchers need to overcome the evidence paradox of 18 000 randomised trials being published each year but almost every review concluding that not enough hard evidence exists to actually inform decision making, experts have said."

"We can’t just keep putting band aids on this system," she said. "Either health care is going to be subject to scientific methods and actually become evidence based or we are just going to keep generating little bits of evidence here and there and valiantly try to assemble them into some kind of path forward."

Review: Cochrane Collaboration - Palliative surgery versus medical management for bowel obstruction in ovarian cancer

Surgery compared to non-surgical treatment to relieve symptoms of bowel obstruction in ovarian cancer

Authors' conclusions

We found only low quality evidence comparing palliative surgery and medical management for bowel obstruction in ovarian cancer. Therefore we are unable to reach definite conclusions about the relative benefits and harms of the two forms of treatment, or to identify sub-groups of women who are likely to benefit from one treatment or the other. However, there is weak evidence in support of surgical management to prolong survival.

How to Avoid a Heart Attack: Putting It All Together -Journal of the American Osteopathic Association

Note: this is not specific to treatment-related cardiovascular concerns

Conclusion
The central question posed in the letter to the editor by Juhl et al2 is whether supplements of vitamins E and C and the B vitamins have demonstrated an evidence-based reduction in patients' cardiovascular risk. Unfortunately, the authors' criticism of the perceived deficiencies of a previously published study1 does not constitute evidence to support their position; it serves only to point out those perceived flaws.

Multiple meta-analyses and reviews of published medical literature have convincingly established that there are few, if any, objective, evidence-based, well-designed trials to support the use of supplements of vitamins E or C or those in the B family to reduce risk of cardiovascular events. Furthermore, I am unaware of any study that advocates the use of these supplements to help patients or to rejuvenate our ailing medical delivery system.

If Dr Juhl and his coauthors2 seek to establish the medical value of these supplements, I would recommend that they design, participate in, and publish a study to establish their yet unproven hypothesis. Until such a goal is accomplished, my opinion (shared by researchers at the Mayo Clinic,3 the Cleveland Clinic,5 the AHRQ,12 and the American Heart Association19) is that published evidence clearly does not support the use of vitamins E, C, B6, B9, or B12 to improve patients' cardiovascular health.

EvidenceUpdates: Cochrane Collaboration review: Vaccines for preventing influenza in healthy adults including professional commentaries and warning

CONCLUSIONS: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.

WARNING: This review includes 15 out of 36 trials funded by industry (four had no funding declaration). An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.

Also: link to the Cochrane Collaboration review (The Cochrane Library):

Background
Different types of influenza vaccines are currently produced worldwide. Healthy adults are presently targeted mainly in North America.

Objectives
Identify, retrieve and assess all studies evaluating the effects of vaccines against influenza in healthy adults

Authors' conclusions
Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.

WARNING:

This review includes 15 out of 36 trials funded by industry (four had no funding declaration). An earlier systematic review of 274 influenza vaccine studies published up to 2007 found industry funded studies were published in more prestigious journals and cited more than other studies independently from methodological quality and size. Studies funded from public sources were significantly less likely to report conclusions favorable to the vaccines. The review showed that reliable evidence on influenza vaccines is thin but there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies. The content and conclusions of this review should be interpreted in light of this finding.





Plain language summary

Vaccines to prevent influenza in healthy adults
Over 200 viruses cause influenza and influenza-like illness which produce the same symptoms (fever, headache, aches and pains, cough and runny noses). Without laboratory tests, doctors cannot tell the two illnesses apart. Both last for days and rarely lead to death or serious illness. At best, vaccines might be effective against only influenza A and B, which represent about 10% of all circulating viruses. Each year, the World Health Organization recommends which viral strains should be included in vaccinations for the forthcoming season.

Authors of this review assessed all trials that compared vaccinated people with unvaccinated people. The combined results of these trials showed that under ideal conditions (vaccine completely matching circulating viral configuration) 33 healthy adults need to be vaccinated to avoid one set of influenza symptoms. In average conditions (partially matching vaccine) 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalised or working days lost but caused one case of Guillian-Barré syndrome (a major neurological condition leading to paralysis) for every one million vaccinations. Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccines trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited.

Health Affairs -- Comments on: Evidence That Consumers Are Skeptical About Evidence-Based Health Care

When Reputation Trumps Evidence-based Outcomes :: article

"It’s in the interests of public health to try our best to measure what should guide our health decisions – and to measure what actually does."

April 2010: Genomics|Genetic Testing|EGAPP Recommendations|Lynch Syndrome

EGAPP Working Group Recommendation

Genetic testing strategies in newly diagnosed individuals with colorectal cancer aimed at reducing morbidity and mortality from Lynch syndrome in relatives
Approximately 3% of people who develop colorectal cancer have an autosomal dominant inherited condition known as Lynch syndrome, sometimes referred to as Hereditary Nonpolyposis Colorectal Cancer or HNPCC. Individuals with this condition have a greatly increased chance to develop colorectal and other cancers, especially under age 50. Screening for Lynch syndrome in all patients with newly diagnosed colorectal cancer has been proposed to improve outcomes for patients and/or family members.
EGAPP Recommendation Statement: The EGAPP™ Working Group found sufficient evidence to recommend offering genetic testing for Lynch syndrome to individuals with newly diagnosed colorectal cancer (CRC) to reduce morbidity and mortality in relatives. We found insufficient evidence to recommend a specific genetic testing strategy among the several examined.

Note:  See website for access to the pdf files below (full free access):

• EGAPP Recommendation  (PDF 220KB) (Jan 2009)

• Evidence Report (May 2007)

• Supplementary Evidence Report (PDF 664KB) (Jan 2009)

• CDC Summary of Lynch Syndrome EGAPP Recommendation (Apr 2010)

Combination versus sequential cytotoxic chemotherapy in recurrent ovarian cancer: Time for an evidence-based comparison

Note: no abstract/subscriber based journal ($$)
Combination versus sequential cytotoxic chemotherapy in recurrent ovarian cancer: Time for an evidence-based comparison.
Markman M

Of Value: A Discussion of Cost, Communication, and Evidence to Improve Cancer Care -- The Oncologist

Methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material.

Authors’ conclusions There is little evidence from randomised controlled trials of the effects of consumer involvement in healthcare decisions at the population level. The trials included in this review demonstrate that randomised controlled trials are feasible for providing evidence about the effects of involving consumers in these decisions.
   Comment 1:This paper is an issue for public health policy-makers not clinicians. Consumer involvement has a great risk of being tokenistic.  Comment 2:As a community health professional, the results will serve as an evidence to involve health care consumers in the process of policy and guideline formulation.  Comment 3:
The evidence presented that face-to-face interactions with consumers is the most effective type of involvement for developing patient educational materials is helpful for clinicians.

'New' Evidence for Clinical Practice Guidelines: 'New' Evidence for Clinical Practice Guidelines: Should we Search for 'Preference Evidence'?

Abstract

Clinical practice guidelines (CPGs) are systematically developed statements to assist both patient and practitioner decisions. They link the practice of medicine more closely to the body of underlying evidence, shift the burden of evidence review from the individual practitioner to experts, and aim to improve the quality of care. CPGs do not routinely search for or include evidence related to patients' values and preferences.

We argue that they should.

We think that such evidence can tell us whether a decision is preference sensitive; how patients feel about important health outcomes, treatment goals, and decisions; and whether preferences vary in different types of patients. The likely effects of reviewing the literature are a general sensitization to the importance of preferences in decision making, the recognition that some decisions are simply all about preferences, a more considered approach to forming preferences among patients and other stakeholders, and more effective integration of preferences into decisions.

Tamoxifen for relapse of ovarian cancer. Cochrane Collaboration review (abstract)

AUTHORS' CONCLUSIONS: We are unable to make any evidence-based recommendations as we found no comparative studies assessing the effectiveness of tamoxifen in women with recurrent ovarian cancer. There is limited evidence on anti-tumour activity from phase 2 studies, but these contain no data on the effect of tamoxifen on symptom control, QOL or the prolongation of life.

Plain language summary

No evidence to suggest tamoxifen benefits patients with relapsed ovarian cancer
Ovarian cancer often spreads before symptoms show. Cytotoxic drugs are often only partly effective and cause severe side-effects. The main aims of treatment for relapsed disease are symptom control and prolongation of life. No data from RCTs or non-RCTs were found, so there was no evidence that tamoxifen was effective and safe as a treatment for relapsed ovarian cancer. Laboratory studies suggest tamoxifen may be effective as a treatment for women with ovarian cancer. Although, uncontrolled non-comparative trials on patients with relapsed ovarian cancer showed tamoxifen may shrink or stabilise tumours in a small number, there is a strong need for an RCT or good quality non-randomised comparative studies to determine the effectiveness and safety of tamoxifen in terms of overall survival, tumour response, symptom control, quality of life and adverse events.