Gatsky

Read the ESR1 rapid update. The methods say:

"A targeted electronic literature search was conducted to identify any additional phase III randomized controlled trials in this patient population. No additional randomized controlled trials were identified. The original guideline Expert Panels reconvened to review evidence from EMERALD and to review and approve the revised recommendations."

Where is the meta-analysis? Where is the funnel plot? What are you even arguing about? They issued an update because of one trial.

Here is another one from June 2022, a major change to how one type of breast cancer is managed, in the methods:

"A targeted electronic literature search was conducted to identify phase III clinical trials pertaining to the recommendation on immune checkpoint inhibitors in this patient population. No additional randomized trials were identified. The original Expert Panel was reconvened to review the key evidence from KEYNOTE-522 and to review and approve the revision to the recommendation."

Where is the meta-analysis? Again, what are you trying to argue? They issued an update because of one trial.

There are two updates this year, one about HER2 testing, and one about ESR1.

Sorry to hear you have suffered poor quality interactions with doctors. Being honest, if there is no trust in the relationship between patient and doctor, then nothing else matters much as the experience will be poor on both sides.

Patient can of course bring whoever they want into the circle. The problem is the intrusions that neither healthcare provider nor patient want.

Actually doctors would be universally happy to get more help and support to deliver better healthcare. That you don't talk about that is quite telling, or is that what you mean by 'regulation'?

Casting the patient doctor relationship in terms of power dynamics is a bogus sociological construct divorced from reality. The true division of power is between those who fund healthcare and those who receive it, I would start there if you think things need to be improved.

The president of Medicens sans frontieres, Rowan Gillies, gave a speech once. He had a drawing of a patient and the doctor inside a circle. His comment was 'Other people keep trying to climb into this circle. They can all fuck off.' Excuse his profanity, but I offer this response to you, who knows nothing about what I do, and understands nothing about quality healthcare.

Well you discount the most important thing in the first line. 'Cutting-edge' is a funny way of saying 'most effective', as if it were somehow irrelevant.

I didn't say most evidence is from phase III RCTs, particularly if you include everything that happens in oncology as the denominator, only that meta-analyses were not that relevant. Most of the critical patient facing interventions have the backing of good quality trials, at least where it is reasonable and possible to do a trial. Also one of your citations is seemingly casting doubt on the value of meta-analyses in oncology, so somewhat confused about your point.

That paragraph from NCCN is quite interesting. It is describing medicine in general really, and belies the fact that oncology has probably one of the strongest evidence base across all medical fields. Take for example how many stents cardiologists have inserted long after contradictory evidence was available, or how many pointless back operations have been done, or how many people have sat through fruitless psychoanalysis.

Disagree. I change practice on Monday after a single quality trial. Pick up any society guideline, only a small amount of the recommendations rely on meta-analyses. Look at immunotherapy or antibody drug conjugates, revolutionary therapies that arrived one trial at a time.

Yeah, well in my field, oncology, meta-analyses are somewhat irrelevant. As you can imagine, the bar for completing a phase 3 randomised trial in oncology is pretty high. Meta-analyses are mostly there for trainees to notch up a paper.

Another fine example of the author's point is the ivermectin in covid meta-analytic nonsense (which I cannot even bring myself to link), where a bunch of small rubbish trials are meta-analysed into a 'flawless' body of evidence while double blind randomised trials are impugned.

The biggest issue, IMHO, is that clinical trials are often unethical. This is both in theory and especially in practice. I say this as a physician and clinical trial investigator.

EBM deals with this by saying ‘there is no viable alternative’, a remarkable statement of epistemological nihilism that enables much low quality snd pointless research.

Some people aren't worth it. Some people are just miserable. Not depressed, just miserable. Some people are insecure, vindictive, manipulative, querulous, disagreeable. Having a relationship with them will be as much as 100x more difficult than another person. This is the hard lesson I learned after 4 years in a thoroughly depleting relationship where I tried everything to make it work. When I look at my friends in their 40s, some have great partners and some don't, and the ones that don't have a truly execrable life despite good health, jobs, income, cars, holidays etc. Choosing a good partner matters more than almost anything else.

Don't get me wrong - I am not advocating we put all the bad partners in a camp somewhere. They are fundamentally in a state of suffering, and benefit from help and support. But the way to deliver that support is not by being in a romantic relationship with them.

If you are good partner material, consider the following asymmetry: A good partner can be in a relationship with a poor partner, but two poor partners will almost never be in a relationship together. This means that being a good partner increases your chance of ending up with a poor partner.

Antivirals probably won’t help as most infections are silent, a vaccine is needed. Moderna is working on one.

I think this is a great comment, with much broader implications for living well. Unmooring the sense of self from external factors is one important aspect of spirituality.

There are thousands of sequenced human genomes available to access for research purposes (1000 genomes project, UK biobank etc) so one additional genome adds no marginal value.