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Evidence based medicine: 1 year of blogging with Dr. Bishal Gyawali

First of all, thank you!

It has now been a year since the blogs "Last Month in Oncology with Dr. Bishal Gyawali" were first published. What started as a passionate rant against the lack of sense in oncology (practice, research and publications) is now 1 year old with 19 blogs and hundreds of readers worldwide. This journey would have been impossible without your support and suggestions, for which I remain very grateful.

The blogs exist for only one purpose: to tell the Emperor that he is naked when he is truly so and to praise him if he really does have good clothes on. This doesn’t sound like a lofty aim to live by, but modern oncology seems tragically crippled by senselessness and driven by hypes and fear-mongering. This is further complicated when experts consciously or subconsciously distort the picture due to their conflicts of interest. Clearly, honesty is nice but it doesn’t seem to pay people well.

Although we emphasise on evidence based medicine (EBM), the evidence we put trust in is usually unsound for various reasons as beautifully explained in this recent blog by Dr. John Mandrola. Moreover, most modern medical practice is not based on evidence, but on expert interpretation and presentation of evidence. Industry sponsored educational events where the paid expert interprets data to the sponsor’s liking has become the main mode of education for early-career oncologists. Many oncologists imbibe information from such events, take these biased opinions for granted and practice oncology based on those recommendations, which is far from the ideal of EBM. This is not meant to undermine the role of true experts, however. A true expert honestly appraises the evidence, points out the limitations in studies, provides key practical tips, and inspires the attendees to appraise the evidence by themselves. A true expert is humble, takes feedback from oncologists who have experience in the real-world, is eager to learn from his own or others’ mistakes, encourages the attendees to involve patients in deciding what’s best for them and most importantly, distributes hope but not false hype. Thus, a true educational event celebrates success with a dose of caution, emphasises pitfalls in interpretation of results, highlights limitations of studies and motivates all participants to get involved in a meaningful dialogue with the experts, having the benefit of patients at the centre of all discussions. However, such meaningful exercises are rare when there is an agenda to promote. Hence, early career oncologists like myself miss chances to be truly educated in the art of oncology that includes a dose of scepticism, a desire to look up the evidence, and a passion to be a partner in the patient’s journey with cancer. 

As lamented by Ioannidis in this essay, the tools of EBM have been hijacked. Today, the excess of evidence is a bigger problem than the lack of evidence. The use of poor quality data masquerading as EBM to support non-beneficial or even harmful treatments is a real threat to cancer care. It’s very difficult for a busy oncologist to take the time to read through the medical literature and assess for the quality of evidence. It is also difficult for early career oncologists to see through the bias and spin to make an informed interpretation of such studies. Statistics can be manipulated to one's convenience and results can be interpreted in a way to suit an agenda. Thus, the reader is always prone to manipulation. Ideally, editorials in journals should provide the reader with these insights and help reach an informed decision but more often than not, even the editorials paint a one-sided picture because many experts seem to have an axe to grind.

These blogs aim to address all these issues: To provide an unbiased and truthful summary of major studies in oncology for the busy oncologist, help distinguish hype from realistic hope, emphasise the disconnect between clinical benefit and statistical significance, praise good practice, police against badly conducted or poorly reported studies and encourage sense in oncology. In simple terms, to check beyond the layers of spin and see if the Emperor is truly naked and if he is, make him and others see that. In this era of alternative truths where blatant lies are being pronounced by people in power as facts, it is all the more difficult to see under veils of spin, bias and contortion. In this modern era where true- and pseudo- scientific advances are claimed at a rapid rate, I sometimes think that even the monthly blogs are not frequent enough to provide a truthful and unbiased commentary which clinicians and patients can rely upon. Every month, I have to leave many poor quality studies out due to space and time constraints. I am frequently asked by my friends (and future employers!) what particular clinical or research speciality I would like to focus on in future. I have never been able to answer that with ease because my interests are varied. But as I write this, it's beginning to dawn on me that maybe I would like to start a "Centre for Sense in Oncology" that exposes the nonsense in oncology that we come across every day, educates cancer doctors and patients against irrational hypes and contradictions, and focuses on projects such as a "cancer groundshot" and "wise avoidance" that can help patients globally.

Let me tell you a brief history of how these blogs started. Last year in April, the results of ROMANA trials were published in a major oncology journal. These were phase 3 studies of a drug called anamorelin aimed to combat cachexia in lung cancer patients. The study showed that patients gained less than 1 kg of lean body mass (statistically significant) with anamorelin but that didn’t improve muscle function.  I found it ridiculous that a drug which improved muscle mass by less than a kilogram but had no impact on muscle function was hailed as effective simply based on statistical significance. I then read the editorial hoping that the editorial would show the obvious flaws in the interpretation of these studies! To my utter dismay, the editorial was full of praise for the drug. Only at the end of the editorial did I realise that the editorialist had a COI with the same company that made anamorelin. That made (no) sense.

I wrote a letter to the editor (LTE) of the journal pointing out the obvious problems with the study and asking for editorials to be free from conflicts of interest at least with the same company whose product they are commenting upon! Had that letter been published, it would have been the end of it and these blogs would probably never have existed but the LTE was fortunately rejected. You can read a revised version of that LTE as a journal club article in ESMO Young Oncologist page.

I realised that there were too many studies that had some or many problems and I couldn’t be writing tens of LTEs every month and hope the editor accepted all of them. From my discussion with colleagues and others, it was also apparent that many readers take the conclusions of studies published in major journals to be sound without actually reading those papers in detail. So, inspired by Richard Lehman and his blogs, I decided to blog my thoughts on major oncology studies and news every month. Without the rejection from the journal and inspiration from Richard Lehman’s blogs, these blogs probably wouldn’t have existed. I should also thank the ever-unafraid-to-tell-the–truth Vinay Prasad, who continuously supported me since the early days of blogging. And of course, many thanks to each of you who have continuously supported and motivated me through your kind and encouraging tweets and facebook comments.

I have also been fortunate to have ecancer as the platform for the blogs. When I approached the ecancer team with the idea, they immediately embraced the concept with open arms. The entire team, Audrey and Jon in particular, have been very positive and supportive from day one, and that encouragement is an impetus to keep going every month. Truly, the growth of this blog was impossible without the extremely supportive team of ecancer led by the EIC Prof. McVie.

The journey, although short, has been very eventful. I have received a few slaps (not literal of course!) but that has been more than compensated for by hundreds of claps. Receiving “thank you” and “keep it up” emails from oncologists and patients that I have never met before makes all the hard work worthwhile. Some people get upset at what I write but when I look in more detail, I find that they usually have a conflict and then their anger makes sense to me. When someone without conflicts complains, I always pause and take a moment of introspection to check if I have been wrong about something. Most importantly, patients’ and caregivers’ opinions always matter the most. Because this journey is not about me, the experts, the societies or the industries. It has been and will always be about patients. Indeed, although I began these blogs with fellow health care professionals in mind, I have since then realised that many patients and caregivers also follow the blogs. I feel honoured and always try to write with the interests of patients in mind.  If these blogs can encourage rational drug prescribing in a couple of oncologists, motivate some of us to read between the lines, inspire the industry to work harder for better drugs, and educate an early career oncologist to treat the whole patient, then the mission will have been accomplished. It’s not easy and time is always in short supply but when I think of the tens of thousands of patients being treated by hundreds of oncologists everyday globally, I find the exercise worthwhile. And the love, support and encouragement I receive from the readers make writing the most enjoyable and grateful vocation.
Unlike ranting in blogs, putting gratitude into words doesn't seem to come easy but to all my dear readers, supporters, well-wishers, inspirers, colleagues and patients who have been on this journey together, I am truly thankful. I am because you are.

Thank you.

Bishal Gyawali, MD is a postgraduate trainee in medical oncology at the Graduate School of Medicine, Nagoya University, Japan, where he is also a PhD candidate under the Japanese government scholarship. His areas of clinical and research interests include evidence-based oncology practice, global oncology, cancer policy, cancer management in resource-limited settings, financial toxicities of cancer treatment, clinical trial methods and supportive treatment of cancer. He has no conflicts of interest to declare. Dr Gyawali tweets at @oncology_bg. Read his previous blog posts here.



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