Vinay Prasad, a practicing hematologist-oncologist and associate professor at UC San Francisco, dives deep into the challenges of oncology. He discusses medical reversals, emphasizing the disconnect between clinical practice and robust research. Prasad highlights the high costs of cancer treatments versus their benefits, and the ethical dilemmas posed by financial interests in medical decisions. He concludes with his six hallmarks of successful cancer policy, offering a roadmap for meaningful progress in the fight against cancer.
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question_answer ANECDOTE
Insufficient Progress
Vinay Prasad recalls a drug that improved median survival for a cancer from six to eleven months.
His friend, without medical training, criticized this as insufficient progress, highlighting the need for higher aspirations in oncology.
insights INSIGHT
Marginal Benefits
New cancer drugs offer modest survival benefits, averaging 2.1 months based on 71 approved drugs.
These minimal improvements raise concerns given their high costs, often exceeding $100,000 annually.
question_answer ANECDOTE
Clinical Trial vs. Real World
Clinical trials select healthier patients, leading to inflated drug efficacy results.
A real-world study of the liver cancer drug sorafenib showed median survival of only four months, half that of the placebo group in the trial.
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In 'Forgive and Remember', Charles L. Bosk explores the challenges of training surgeons and managing medical errors. The book provides insights into the social structure of surgical teams and how they handle mistakes, distinguishing between technical, judgment, normative, and quasi-normative errors. It offers a nuanced understanding of the complexities in medical decision-making and the ethical considerations involved.
Ending Medical Reversal
Adam Cifu
Vinayak K. Prasad
In 'Ending Medical Reversal', Drs. Prasad and Cifu delve into the phenomenon of medical reversals, examining why ineffective or harmful practices are adopted and later abandoned. They provide examples such as Vioxx and vertebroplasty, and propose reforms in medical education, research, and drug approval processes to ensure more effective medical practices.
Malignant
How Bad Policy and Bad Evidence Harm People with Cancer
Vinayak K. Prasad, MD, MPH
In 'Malignant', Dr. Vinayak K. Prasad critiques the current state of oncology, highlighting issues such as lax regulatory standards, financial conflicts of interest, and the overemphasis on surrogate endpoints in clinical trials. He argues for reforms to ensure that cancer drugs provide meaningful benefits at lower costs. The book offers insights into how cancer trials are conducted and how drugs are approved, proposing solutions to improve cancer medicine.
Vinay Prasad is a practicing hematologist-oncologist who doubles as a “meta-researcher,” studying the quality of medical evidence, health policy, and clinical trials. In this episode, Vinay discusses the differences in clinical treatment from the existing medical evidence, often leading to useless, or even harmful, outcomes for patients. With a focus in oncology, he takes a deep dive into the field’s structural problems, which include the disconnect between progress and funding, drug costs, and financial conflicts of interest. He concludes with his “six hallmarks of successful cancer policy” as a potential roadmap to sustained progress against cancer and a way to avoid repeating the policy and practice mistakes of the past.
We discuss:
Vinay’s background and unique perspective [3:15];
Medical reversal—the disconnect between research findings and clinical applications in medicine [10:15];
The uniquely challenging field of oncology [22:45];
The importance of bedside manner with cancer patients [30:00];
Structural problems in oncology—Problem #1: Huge costs for small improvements [37:00];
Structural problems in oncology—Problem #2: Medical reversal—when medical practices are adopted based on low levels of evidence [40:15];
Structural problems in oncology—Problem #3: Slow progress in cancer research (despite all the hype and propaganda) [45:00];
Structural problems in oncology—Problem #4: The burden of payment is not matched with those making treatment decisions [54:45];
“No-brainer” moves in oncology [1:06:45];
“Fool’s gold” treatments in oncology [1:09:30];
The six hallmarks of successful cancer policy [1:16:00];
Cancer policy hallmark #1: Independence [1:18:00];
Cancer policy hallmark #2: Evidence [1:28:15];
Cancer policy hallmark #3: Relevance [1:31:30];
Cancer policy hallmark #4: Affordability [1:32:00];
Cancer policy hallmark #5: Possibility [1:47:00];
Cancer policy hallmark #6: Agenda [1:52:00];
Tumor genome sequencing and liquid biopsies [1:54:30];
Vinay’s clinical philosophy, being skeptical without being too contrarian, and practicing medicine without perfect information [2:03:30]; and
The Peter Attia Drive 
