[Gatsky]

Well you discount the most important thing in the first line. 'Cutting-edge' is a funny way of saying 'most effective', as if it were somehow irrelevant.

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.

[haldujai]

> Well you discount the most important thing in the first line. 'Cutting-edge' is a funny way of saying 'most effective', as if it were somehow irrelevant.

I'm discounting it for this discussion because your argument is:

"meta-analyses are somewhat irrelevant" and "Meta-analyses are mostly there for trainees to notch up a paper." which is completely false.

Note a single clinical trial is still only considered "good quality" while multiple trials or meta-analyses are considered "high quality".

To address this new point you raised, when something has very promising early results we start using it in treatment (e.g. 3rd gen TKIs in adjuvant NSCLC) but until this weekend we had no 5 year OS survival for adjuvant use.

It's entirely possible something one thinks is "most effective" is later proven to not be (gen 1-2 TKIs, HIPEC, etc).

> 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.

I'm not sure what point you are trying to make by addressing other specialties.

The National Comprehensive Cancer Network, comprised of multidisciplinary experts from 33 of the leading cancer centers in the country, is unequivocally the authority in oncology and is incredibly well respected. I'm going to defer to their opinion on the quality of evidence available and the hierarchy of evidence.

> Also one of your citations is seemingly casting doubt on the value of meta-analyses in oncology, so somewhat confused about your point.

The JAMA article states that the methodology in many studies does not meet NCCN/PRISMA criteria which is a well known, this says nothing about the relative value of good-quality meta-analyses (which are far more common now with the PRISMA update).

I'm really not sure why you think systematic reviews are irrelevant, this is a very radical viewpoint that I've seen no evidence of. Good meta-analysis > good RCT. The reality is that good quality studies of both types are uncommon in medicine, but the goal is still to use good SRs.

[Gatsky]

I don't think it is false. I can only speak of my experience as an oncology healthcare provider. I spend many hours each week digesting the literature, and <5% of that involves meta-analyses. In the multidisciplinary meetings I chair, we rarely discuss evidence from meta-analyses, but we are always talking about clinical trials. The NCCN guidelines were useful when I was a trainee, but otherwise they are too US-centric, and they are always out of date due to the frequency they are updated. This is why ASCO keeps issuing rapid updates in breast cancer for example (https://old-prod.asco.org/practice-patients/guidelines/breas...). There are 2 such updates this year already. If the primacy of meta-analyses were so great, why would they bother to issue rapid updates of what you class as low quality evidence?

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.