In a recent letter to the editor (“Spec a conspirator,” March 31), the author rails against the “corporate corruption that dominates both our political and academic landscape.” He accuses the Spectator of being a conspirator in a facade. Cry! These are very strong accusations which are based on a recent article, “The illusion of evidence-based medicine” in the British Medical Journal (BMJ) (16 March 2022). In my opinion, the letter is ill-conceived and the author misinformed.
Evidence-based medicine (EBM) refers to the use of the best available evidence to make decisions about the care of individual patients. The best available evidence is based on the highest quality research. In the 1970s and 1980s, the Department of Epidemiology and Biostatistics at McMaster University was a pioneer in advocating the principles of EBM. Here are examples of these guiding principles: “How do you determine if a treatment does more good than harm? and “How do you rate the quality of a test?” EBM provides a hierarchy of criteria for judging the quality of a study. Today, EBM is ubiquitous and embedded in everything we do in treating our patients. Before EBM, medical decision-making was based on the opinion and experience of physicians. While these are valuable, they have resulted in the use of many ineffective, harmful and expensive treatments.
The BMJ article was not original research but just opinion. It focuses on the corporate sector, which produces drugs. Many interventions commonly used in daily practice, including medications, surgery, and diagnostic tests, have been evaluated with EBM. In my own area, large randomized trials done over 50 years ago found that in women with breast cancer, lumpectomy had the same survival as mastectomy. Today in Canada, about 70% of women with breast cancer have lumpectomies. In women who undergo a lumpectomy, radiation therapy to the breast after surgery is standard. This is based on the results of clinical trials (including one conducted in Ontario), which showed that radiation reduced the risk of local recurrence. (Note that these surgery and radiotherapy trials did not involve the corporate sector).
The letter writer posits that medical research (both in academia and in the corporate sector) is only pursued if there is the inherent possibility of phenomenal profit. Balderdash and insulting! Most academics and pharmaceutical companies do research because they want to help patients and improve health. The reality today is that the pharmaceutical industry produces all drugs. They are used to fight disease, prolong life and improve quality of life. The introduction of immunotherapies for lung cancer, kidney cancer and melanoma now gives hope to patients who previously had dismal prognoses.
It costs a pharmaceutical company billions of dollars to develop a single drug. Governments cannot invest the funds needed for research and development. Therefore, it is not unreasonable for the pharmaceutical industry to recoup their investment. I am not trying to defend companies, only to explain the current reality. The design and conduct of clinical trials is a very complex subject.
I spent 40 years as an academic researcher conducting clinical trials to benefit my patients. Yes, some of the trials that have evaluated new drugs have been supported by the pharmaceutical industry. I have always been guided by EBM in my research and clinical practice. I hope my commentary has given Spectator readers a better understanding of EBM and its complex relationship to research and health care.