"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.

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

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.

But to give a concrete example, the problem with meta-analyses is well illustrated in the recent EBCTG meta-analysis published in the Lancet, a top tier journal. This involved over 100,000 patients, and explored concurrent chemotherapy regimens in breast cancer. The problem is that such regimens are not used anymore. The authors acknowledge in their own conclusion that this massive meta-analysis contradicts their own previous meta-analysis showing the superiority of sequential therapy. What exactly does one do with this? How does this help a patient get the right therapy? The treatment of various breast cancer subtypes has also evolved so much that the trials they meta-analyse are mostly obsolete. Hence my point, that meta-analyses are just not that useful in oncology, even truly massive well conducted ones published in prestigious journals. So it is not so simple as meta-analysis > RCT, that is merely lazy dogma. I find it hard to believe that anyone actually treating cancer patients would hold this view.

Of course most meta-analyses in oncology are not 100,000 patient behemoths conducted by consortia. They are much smaller studies, which usually don't bother to get patient level data, and just copy numbers from tables in the original papers while running through the Cochrane systematic review template.

And yet, here I am dubbed 'radical' at the bottom of a comment thread on Hacker News. Unfortunately the dogma around systematic reviews and EBM has exceeded its usefulness by quite some margin. The meta-analytic method was developed by psychologists trying to compile evidence about extra sensory perception of all things - an inauspicious beginning if there ever was one for the supposed cornerstone of medicine.

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.

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.

Some recent examples of problems with clinical trials:

1. Using a harmful or deliberately inadequate placebo. https://academic.oup.com/jnci/article/104/4/273/979399 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.0... https://pubmed.ncbi.nlm.nih.gov/34688044/

2. Starting a bunch of clinical trials using a biomarker which turned out to be invalid. https://www.nejm.org/doi/10.1056/NEJMoa1214271

3. Endless 'me-too' trials driven by pharma, with a low chance of success. https://www.statnews.com/2019/09/04/me-too-drugs-cancer-clin...

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.

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.

> For this thesis, an atmospheric propagation code named ANCHOR (Atmospheric NPS Code for High Energy Laser Optical pRopagation) was developed and utilized to study the propagation of high energy lasers in various atmospheric conditions and for numerous laser configurations. The ANCHOR code accesses existing industry databases to obtain relevant optical properties for various atmospheres and then uses scaling laws to simulate laser propagation through the defined environments. ANCHOR accounts for the effects of atmospheric diffraction, turbulence, platform jitter and thermal blooming on the laser beam, and outputs on-target irradiance and power-in-the-bucket profiles for a wide range of laser wavelengths. Several known physical trends associated with laser propagation will be reproduced, and the results will be compared to the industry accepted propagation code Wavetrain. The results of ANCHOR studies will indicate that the 100 kW-class high energy laser can effectively engage slow-moving targets at ranges greater than five kilometers in clear weather by delivering enough energy to melt 0.1 liters of one millimeter-thick aluminum aircraft skin in five seconds. For hazy, turbulent, and rainy conditions, the laser can effectively engage targets from ranges closer than three kilometers, but reasonable dwell times are only achieved for ranges closer than two kilometers.

[1] https://core.ac.uk/download/pdf/36734846.pdf

Interpreting the results is a more manual process. Really depends on what you are interested in.

1. Expensive - probably at least 2 - 3 thousand dollars.

2. Require you to do your own analysis.

Obviously you can't be 100% sure they will delete your genomic data, but they have no incentive to keep it.

> From there I believe viewers will be given the ability to be digitally scanned themselves, and pay extra to have themselves inserted in these custom films. You'll also start to see licensing deals made with studios, so that viewers can order up older films like "Star Wars" and put their face on Luke Skywalker's body, and their ex-wife's face on Darth Vader's body, and so on.

This is pretty far from what most people want, I think. How are you going to chat about your AI generated custom personal vendetta movie around the watercooler?