Still, the surgery—like some others meant for narrower uses—is common even for patients who don't need it. And patients themselves are part of the problem. According to interviews with surgeons, many patients they see want, or even demand, to be operated upon and will simply shop around until they find a willing doctor. Christoforetti recalls one patient who traveled a long way to see him but was "absolutely not a candidate for an operation." Despite the financial incentive to operate, he explained to the patient and her husband that the surgery would not help. "She left with a smile on her face," Christoforetti says, "but literally as they're checking out, we got a ding that someone had rated us [on a website], and it's her husband. He's been typing on his phone during the visit, and it's a one-star rating that I'm this insensitive guy he wouldn't let operate on his dog. They'd been online, and they firmly believed she needed this one operation and I was the guy to do it."
So, what do surgeons do? "Most of my colleagues," Christoforetti says, "will say: ‘Look, save yourself the headache, just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account's not going to be upset with you for doing the surgery. Just do the surgery.'"
Randomized, placebo-controlled trials are the gold standard of medical evidence. But not all RCTs, as they are known, are created equal. Even within the gold standard, well-intentioned practices can muddle a study. That is particularly true with "crossover" trials, which have become popular for cancer-drug investigations.
In cancer research, a crossover trial often means that patients in the control group, who start on a placebo, are actually given the experimental drug during the study if their disease progresses. Thus, they are no longer a true control group. The benefit of a crossover trial is that it allows more people with severe disease to try an experimental drug; the disadvantage is the possibility that the study is altered in a manner that obscures the efficacy of the drug being tested.
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