May 14, 2010

Archives of Internal Medicine's new "Less is More" series

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Terrific idea for a new medical journal series. Excerpt:

“Less is More,” a new series in the Archives, will highlight situations in which the overuse of medical care may result in harm and in which less care is likely to result in better health. For example, a series of articles in this issue of the Archives documents serious adverse effects of proton pump inhibitors, including increased rates of fractures, Clostridium difficile infection, and recurrence of diarrhea caused by C difficile; previous reports have also documented an increased risk of pneumonia. Harm will result if these commonly used medications are prescribed for conditions for which there is no benefit, such as nonulcer dyspepsia.

Comments (4)

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Elaine Schattner, M.D.

May 14, 2010 at 2:14 pm

I agree this is a terrific idea (mammography aside), but it’s unlikely to persuade doctors who order lots of tests without reason. Few specialists, even among internists, read the Archives of Internal Medicine.

Greg Pawelski

May 15, 2010 at 8:36 am

The less is more axiom often applies in cancer medicine. I’m not claiming that low dose therapy is to be preferred, anymore than claiming that high dose therapy is to be preferred. If one has a highly effective drug or drug regimen, then this should be given at the optimum dose to achieve whatever it is supposed to achieve.
There appears to be a number of patients who have had long-term survival after high dose therapy, but there are a number of patients whose tumors are responsive to chemotherapy who have had long-term remissions from low dose therapy, as well as a number who show no difference in survival when treated with low-dose or high-dose therapy.
More emphasis should be put on matching treatment to the patient, having more respect for minimal partial response or stable disease, when it can be achieved through use of the least toxic and mutagenic drug regimens, and reserve the use of higher dose therapy or aggressive combination chemotherapy to those patients with tumor biologies most amenable to attack and destroy by these treatments.
Trying to mate a notoriously heterogeneous disease into one-size-fits-all treatments is disingenuous to all who are inflicted with it. And the criticism remains: All of the clinical trials resources have gone toward driving a square peg (one-size-fits-all chemotherapy) into a round hole (notoriously heterogeneous disease).
To beat down your individual cancer mortality, an oncologist needs to target all the many cancers that make up your individual cancer, the dozens of different pathways that cells use to proliferate and spread. That is the leading edge of research and treatment, determining how an individual’s tumor cells work and hitting those pathways with multiple drugs, simultaneously or sequentially, each chosen because it targets one of those growth, replication and angiogenesis pathways.
The hope is to match tumor type to drug. We need to make the next leap, getting the right drug to the right patient.