Physicians have started to face up to an uncomfortable truth: their profession has often embraced new treatments that don’t really help patients. “When you look at the balance of benefit and harm, some therapies provide no net benefit,” says OHSU assistant professor Vinay Prasad, M.D., M.P.H., who has landed a $2 million grant to go after the problem.
Photo: Vinay Prasad (OHSU/Kristyna Wentz-Graff)The funding, awarded by the Laura and John Arnold Foundation, will support an effort to ferret out treatments and tests that are contradicted by reliable evidence. The three-year project calls for sharing the findings via a public website and developing teaching modules that can be incorporated into medical school or residency curricula. The goal is to help reduce the use of low-value care and prevent unnecessary medical spending.
Given the enormous and rising amount the U.S. spends on health care, Prasad says there’s an urgent need to prioritize where the money goes. Disproven practices are easy targets.
“This isn’t about cutting things that are simply costly,” he says. “It’s about cutting things that don’t work.” Prasad is a hematologist-oncologist in the Knight Cancer Institute and a senior scholar in the Center for Health Care Ethics at OHSU.
The project continues a line of research expounded in Ending Medical Reversal: Improving Outcomes, Saving Lives (Johns Hopkins University Press, 2015), a book Prasad co-authored with University of Chicago physician Adam Cifu. The book presents an alarmingly long list of medical “advances” that turned out to be useless or even dangerous. It explores why these so-called medical reversals are common, and offers ways to avoid them. A glowing review in The New York Times called the book “subtly subversive.”
Cancer medicine is not immune from the problem. In the 1990s, for example, some 40,000 patients with breast cancer underwent high-dose chemotherapy with autologous bone marrow transplant before the highly toxic therapy proved ineffective in randomized clinical trials.
Erythropoiesis stimulating agents for treating chemotherapy-induced anemia are another case in point. The FDA based approval on data showing improvement in hemoglobin levels and a reduced need for blood transfusions. Later trials linked the agents to a significantly increased risk of stroke and possibly worse survival. In the end, the FDA required black box warning labels on the products, and medical societies rewrote practice guidelines to limit their use.
More recently, the drug bevacizumab (Avastin) gained an accelerated approval for metastatic breast cancer based on dramatic gains in progression-free survival. But in later randomized trials the drug did not help patients live longer even as it caused a range of severe side effects, some of them life-threatening. The Food and Drug Administration withdrew its approval for breast cancer in 2011.
These examples also highlight the difficulty of withholding new and unproven drugs and procedures when companies (with profits at stake) and patients (desperate for cures) push for access without waiting for randomized clinical trials.
Prasad says he and his collaborators are more than ready to stand up to the pressure. “We haven’t been afraid to point out when things don’t work,” he says, “even if they are common and have a lot of people that adhere to them.”