Author: Art Diamond

For Some Cancers, Less Aggressive Therapies Can Be Equally Effective, With Fewer Damaging Side-Effects

(p. A1) Doctors are coalescing around the ironic idea that for some cancer treatment, less can be better.

Some patients with cervical and pancreatic cancer can do as well with less invasive surgery, according to research presented at the American Society of Clinical Oncology conference in Chicago over the weekend. Other studies at the annual meeting showed some patients with rectal cancer or Hodgkin lymphoma can safely get less radiation.

The findings expand a body of evidence doctors are using to design treatment plans that aim to reduce side effects and costs. They call the strategy de-escalation: cutting back on some therapies to improve a patient’s quality of life without hurting their odds of survival.

Newer treatments and tests are extending patients’ lives and moving cancer care away from a blunt, one-size-fits-all approach. On the strength of studies like those presented in Chicago, doctors are getting better at determining who needs the most aggressive care and who can get away with less treatment and less collateral damage.

. . .

(p. A7) In another study presented at the conference of some 1,200 patients with rectal cancer that had spread to nearby tissue or lymph nodes, about half got standard chemotherapy and radiation before surgery. The others got more aggressive chemotherapy but no radiation, unless their tumors failed to shrink by at least 20%. About 10% of those patients needed the radiation, according to the study, which was published in the New England Journal of Medicine and the Journal of Clinical Oncology.

At five years, results from the protocols were similar, suggesting that many rectal cancer patients can safely skip radiation that increases risks of pelvic fractures, bowel and sexual dysfunction and infertility, researchers said.

“We can spare select patients,” said Dr. Pamela Kunz, director of the Center for Gastrointestinal Cancers at Yale Cancer Center. “This trial is really less is more.”

The patients who avoided radiation by undergoing more aggressive chemotherapy experienced more, different shorter-term side effects including appetite loss, fatigue and nervous-system damage. Some patients might still opt to get the radiation, researchers said.

. . .

The Food and Drug Administration this year released draft guidance to cancer-drug developers on how to determine the best dose for new therapies. Doses were traditionally set at the highest tolerable amount, since the drugs were less precise and patients needed them quickly.

For the full story, see:

Brianna Abbott. “Cancer Doctors Rethink Aggressive Treatments.” The Wall Street Journal (Tuesday, June 6, 2023): A1 & A7.

(Note: ellipses added.)

(Note: the online version of the story was updated June 5, 2023, and has the same title as the print version. The wording in the last sentence quoted above follows the more nuanced online version of the sentence.)

Small-Brained Early Humans Buried Their Dead and Used Symbols

(p. A16) Discoveries from a subterranean cave system in South Africa are prompting paleoanthropologists to rethink what makes us human. New findings reveal a small-brained human relative known as Homo naledi buried its dead and carved symbols on walls inside the system. Both these behaviors were previously associated with our species or the big-brained Neanderthals with which we interbred.

“We’re looking at cultural behavior that is very human in a species that has a brain a third the size of ours,” said John Hawks, a University of Wisconsin-Madison paleoanthropologist and co-author of the research released Monday [June 5, 2023], which will soon be published in the journal eLife as reviewed preprints. “It is going against the idea that brain size is what made us human.”

. . .

“We’ve never had a creature that manifested the complexity of us that wasn’t us,” said Lee Berger, a paleoanthropologist and an explorer in residence at National Geographic who co-authored the new research. Homo naledi, he added, is “threatening to the very clearly defined narrative of the rise of human exceptionalism.”

For the full story, see:

Aylin Woodward. “Ape-Size-Brained Relative Upends Theories.” The Wall Street Journal (Tuesday, June 6, 2023): A16.

(Note: ellipsis, and bracketed date, added.)

(Note: the online version of the story was updated June 5, 2023, and has the title “New Homo Naledi Cave Discoveries Upend What We Know About Being Human.”)

The reference to the journal preprint mentioned above is:

Agustin, Fuentes, Kissel Marc, Spikins Penny, Molopyane Keneiloe, Hawks John, and R. Berger Lee. “Burials and Engravings in a Small-Brained Hominin, Homo Naledi, from the Late Pleistocene: Contexts and Evolutionary Implications.” bioRxiv (2023): 2023.06.01.543135.

The Enemies of Horatio Alger “Are Out to Get the American Dream”

(p. A13) Of all the institutions for investigative journalists to put under the microscope, the Horatio Alger Association of Distinguished Americans sure is a strange target.

The charity says it has awarded more than $245 million in college scholarships to 35,000 students since 1984. Its 300 or so members cross the political, cultural and business-success spectrum and include Michael Bloomberg and Oprah Winfrey.

So what explains the recent onslaught of critical press coverage? The New York Times has put eight reporters on the case and devoted two 4,000-word Sunday front-page pieces in the past two months to the Horatio Alger Association and its members. ProPublica, which styles itself “an independent, nonprofit newsroom that produces investigative journalism with moral force,” produced a 5,000-word article that credited four reporters.

The journalists and the advocates they quote say it’s a matter of judicial ethics, highlighting Justice Clarence Thomas’s role as an honorary board member of the Horatio Alger Association and his friendships with the association’s members, some of whom are prosperous.

. . .

The venom directed at the Horatio Alger Association, though, isn’t only about Justice Thomas and the court. The association’s critics are out to get the American dream.

The association’s website explains that its mission is to “educate all youth about the limitless possibilities that are available through the American free-enterprise system.” The group was founded to dispel the myth “that the American dream was no longer attainable.” Its members are “role models whose experiences exemplify that opportunities for a successful life are available to all individuals who are dedicated to the principles of integrity, hard work, perseverance and compassion for others.”

For the full commentary, see:

Ira Stoll. “Why the Left Hates Horatio Alger.” The Wall Street Journal (Saturday, Aug. 12, 2023): A13.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date August 11, 2023, and has the same title as the print version.)

With Repetitions Surgeons Gain Informal Knowledge, Such as “Muscle Memory”

(p. C6) Imagine you’ve been admitted to the hospital and you’re meeting the physician taking care of you for the first time. Who are you hoping walks through that door? Would you rather they be in their 50s with a good amount of gray hair, or in their 30s, just a few years out of residency?

In a study published in 2017, one of us (Dr. Jena) and colleagues set out to shed some light on the role of age when it came to internists who treat patients in hospitals. These physicians, called hospitalists, provide the majority of care for elderly patients hospitalized in the U.S. with some of the most common acute illnesses, such as serious infections, organ failure and cardiac problems.

. . .

. . ., the results suggested if the over-60 doctors took care of 1,000 patients, 13 patients who died in their care would have survived had they been cared for by the under-40 doctors. We repeated the analysis using 60- and 90-day mortality rates, in case longer term outcomes might have been different, but again, the pattern persisted: Younger doctors had better outcomes than their more experienced peers.

. . .

Younger doctors possess clinical knowledge that is more current. If older doctors haven’t kept up with the latest advances in research and technology, or if they aren’t following the latest guidelines, their care may not be as good as that of their younger peers.

. . .

. . ., a separate study by Dr. Jena and colleagues looked at about 900,000 Medicare patients who underwent common non-elective major surgeries (for example, emergency hip fracture repair or gall bladder surgery) performed by about 46,000 surgeons of varying age.

. . .

The results showed that unlike hospitalists, surgeons got better with age. Their patient mortality rates had modest but significant declines as they got older: mortality was 6.6% for surgeons under 40, 6.5% for surgeons age 40-49, 6.4% for surgeons age 50-59, and 6.3% for surgeons over age 60.

Clearly something different was happening here. It may be that for hospitalists, the benefit of steadily increasing experience starts to be outweighed by their waning knowledge of the most up-to-date care. It’s different for surgeons, though, who hone many of their skills in the OR. Surgeons build muscle memory through repetition, working in confined spaces with complex anatomy. They learn to anticipate technical problems before they happen and plan around them based on prior experience. Over time, they build greater technical skills across a wider variety of scenarios, learn how to best avoid complications, and choose better surgical strategies.

What does this mean for all of us as patients when we meet a new doctor? Taking studies of hospitalists and surgeons together, it’s clear that a doctor’s age isn’t something that can be dismissed out of hand—age does matter—but nor can it be considered in isolation. If we’re concerned about the quality of care we’re receiving, the questions worth asking aren’t “How old are you?” or even “How many years of experience do you have?” but rather “Do you have a lot of experience caring for patients in my situation?” or “What do you do to stay current with the research?”

For the full essay, see:

Anupam B. Jena and Christopher Worsham. “Do Younger or Older Doctors Get Better Results?” The Wall Street Journal (Saturday, July 8, 2023): C6.

(Note: ellipses added.)

(Note: the online version of the essay was updated July 8, 2023, and has the same title as the print version.)

The essay quoted above is adapted from the book:

Jena, Anupam B., and Christopher M. Worsham. Random Acts of Medicine: The Hidden Forces That Sway Doctors, Impact Patients, and Shape Our Health. New York: Doubleday, 2023.

Plastic in Oceans Is Only One-Sixteenth of Previously Publicized Estimate

(p. A7) There’s less plastic pollution flowing into the ocean from land than scientists previously thought, according to a study published Monday in the journal Nature Geoscience.

The researchers estimated that about 500,000 metric tons of plastic end up in the ocean each year, with about half from land. The other half comes from the fishing industry in the form of nets, ropes, buoys and other equipment.

An earlier, widely publicized study in 2015 estimated that about eight million metric tons of plastic were entering the ocean each year from rivers alone.

. . .

The 2015 study was one of the first comprehensive research efforts to tally up how much plastic ends up in the ocean. But there was a large discrepancy between its estimate of eight million metric tons and the amount of plastic observed in the ocean. Newer studies have tried to address this gap.

The paper published on Monday [Aug. 7, 2023] combined data from many earlier studies that sampled smaller plastics in the ocean using net trawls or observed larger plastics from ships and from shore. The researchers fed this data into a computer model of how objects move around the ocean in order to estimate both how much plastic is entering the ocean each year and how much total plastic pollution there is floating on the sea surface.

For the full story, see:

Delger Erdenesanaa. “Previous Study Overestimated Level of Plastic In the Oceans.” The New York Times (Tuesday, August 8, 2023): A7.

(Note: ellipsis, and bracketed date, added.)

(Note: the online version of the story has the date Aug. 7, 2023, and has the title “There Might Be Less Plastic in the Sea Than We Thought. But Read On.”)

The academic article summarized above is:

Kaandorp, Mikael L. A., Delphine Lobelle, Christian Kehl, Henk A. Dijkstra, and Erik van Sebille. “Global Mass of Buoyant Marine Plastics Dominated by Large Long-Lived Debris.” Nature Geoscience 16, no. 8 (Aug. 2023): 689-94.

Socialist Alexandria Ocasio-Cortez (AOC) Rallied with Poor Hispanic Entrepreneurs Who Were Shut Down by Government Regulators

(p. A21) Until last week, Corona Plaza in Queens was bustling: taqueros flipping fresh tortillas and vendors hawking Central American crafts over a soundtrack of cumbia and train traffic. There were produce stands, live bands and surging crowds, all in a public square that was named one of the 100 best places to eat in the city.

But last Thursday [Aug. 3, 2023] and Friday [Aug. 4, 2023], sanitation workers swept through the plaza, removing several stalls and threatening to penalize vendors who did not have a city permit to operate — nearly all of the more than 80 who regularly work there. In the days since, the grilled-meat stands and jugs of agua fresca have been replaced with protest signs.

It was the latest escalation in the city’s tense relationship with the plaza merchants — most of them immigrant women, many of them undocumented — who have helped revive one of the New York neighborhoods hit hardest by the coronavirus pandemic.

. . .

The City Council passed a law in 2021 mandating the release of another 445 food vendor permits every year for a decade, but the rollout has been slow.

There are 10,195 food vendors on the waiting list, according to a spokeswoman for the Department of Health and Mental Hygiene, which manages the applications. The agency has issued just 104 of the new licenses so far, and only four of the recipients have completed all the steps needed to sell food legally.

Ms. Calle is one of the few vendors at the plaza who has a permit — but only because she rents it from a third party for $16,000 a year, a prohibited but widespread practice.

Even so, Ms. Calle decided to close her stall this week, in solidarity with her neighbors.

“I know how hard it is” for new vendors, she said in Spanish, recounting how she had been arrested four times in 23 years for various permitting violations.

While few merchants at the plaza own the hard-to-obtain permits, most of them, including Ms. Calle, pay taxes on sales, and hold a license that certifies they have taken a food safety course.

At the rally at the plaza on Wednesday [Aug. 2, 2023], the dispersed merchants were joined by elected officials including Representative Alexandria Ocasio-Cortez and Donovan Richards, the Queens borough president, . . .

. . .

Nearly 4,000 people, most of them locals, have signed a petition in support of the vendors.

The plaza, once an underused service road near 103rd Street and Roosevelt Avenue, was redesigned in 2012 as a public square.

When the pandemic hit the surrounding neighborhood of Corona — harder than almost anywhere else in the United States — the plaza became an economic and cultural hub for recovering workers, said Carina Kaufman-Gutierrez, the deputy director of the Street Vendor Project.

For the full story, see:

Stefanos Chen and Raúl Vilchis. “Their Food Is Hailed; They Want the Right to Sell It.” The New York Times, First Section (Sunday, August 6, 2023): A21.

(Note: ellipses, and bracketed dates, added.)

(Note: the online version of the story has the date Aug. 5, 2023, and has the title “They Make Some of New York’s Best Food. They Want the Right to Sell It.” Where there are minor differences in wording between the print and online versions, the passages quoted above make use of the online wording.)

The “Deliciously Guilty Pleasure” and “Disorienting Joy” of California Skiing in August

(p. A20) This weekend, . . . hordes of Californians are smearing pink and yellow zinc oxide on noses, shoving feet into hard plastic ski boots and gliding over to the lifts at Mammoth Mountain for yet another day on the slopes. A reminder: It’s August.

. . .

Unpredictable change is the new status quo.  . . . it can also, in a rare instance like the chance to ski in the dog days of summer, bring a disorienting joy.

. . .

In mid-July [2023], well after all the hot dogs and fireworks, I headed up to the Sierra and ran into so much lingering snow that the road through Yosemite National Park hadn’t yet opened for the season. I took an alternate route, 108 over Sonora Pass, and saw people parking in turnouts, carrying skis up dirt trails through trees, stepping onto sunny snow slopes and linking turns back down to ice chests full of cold drinks before, you know, maybe going for a swim. When I finally got to Kelly’s place, the creek on her high desert property frothed in a fabulous white and clear torrent through sage lands sparkling with superblooming yellow mule’s ear, red paintbrush and white phlox. The big peaks, meanwhile — in the dead heat of a California summer — remained so heavily blanketed in snow that I felt I was seeing them the way Indigenous people must have during the Little Ice Age, 500 years ago.

The premise of California’s secular faith in nature is that water plus sunshine equals enlightenment. In high school I was transfixed by a description on the jacket of Bank Wright’s classic “Surfing California” of “skiing Mount Baldy in the morning and surfing Hermosa Beach in the afternoon.” That struck the teenage me as the absolute perfect way of snatching healthy peace and giddy fun from the predictable maw of adult misery.

. . .

. . . when I drove to Mammoth, put on my favorite cowboy hat against the sun and sipped iced coffee while watching tiny black figures ski down blinding white slopes, the experience was perhaps best likened to the queasy adrenalized thrill of an oncoming manic episode after a long and dark depression — worrisome, yes, bound for nowhere good but, as long as we’re just talking here and now, a deliciously guilty pleasure.

For the full commentary, see:

Daniel Duane. “The Upside of Climate Chaos? Skiing in August.” The New York Times (Monday, August 7, 2023): A20.

(Note: ellipses, and bracketed year, added.)

(Note: the online version of the commentary has the date Aug. 6, 2023, and has the title “It’s August. Californians Are Still Skiing. Don’t Ask.”)

Bullshit Is Worse Than a Lie

(p. A17) Professor Frankfurt became best known for a single, irreverent paper largely unrelated to his life’s main work.

The paper, written in the mid-1980s under the same title as his eventual book, discussed what to his mind was a pervasive but underanalyzed feature of our culture: a form of dishonesty akin to lying but even less considerate of reality. Whereas the liar is at least mindful of the truth (if only to avoid it), the “bullshitter,” Professor Frankfurt wrote, is distinguished by his complete indifference to how things are.

Whether its purveyor is an advertiser, a political spin doctor or a cocktail-party blowhard, he argued, this form of dishonesty is rooted in a desire to make an impression on the listener, with no real interest in the underlying facts. “By virtue of this,” Professor Frankfurt concluded, “bullshit is the greater enemy of truth than lies are.”

. . .

For all this sang-froid, Professor Frankfurt was heartfelt in his philosophical pursuits. Throughout his career, he was drawn to lines of inquiry — about freedom, love, selfhood and purpose — that he said appealed to him not only as an academic but also “as a human being trying to cope in a modestly systematic manner with the ordinary difficulties of a thoughtful life.”

For the full obituary, see:

James Ryerson. “Harry G. Frankfurt, a Philosopher Eager to Cut the Bull, Dies at 94.” The New York Times (Tuesday, July 18, 2023): A17.

(Note: ellipsis added.)

(Note: the online version of the obituary has the date July 17, 2023, and has the title “Harry G. Frankfurt, Philosopher With a Surprise Best Seller, Dies at 94.”)

Frankfurt’s best-known book is:

Frankfurt, Harry G. On Bullshit. Princeton, NJ: Princeton University Press, 2005.

Hybrids Appeal to Consumers with Short-Term E.V. “Range Anxiety”

(p. A19) . . . there’s a good argument to be made that the government, and automakers, are leaning too hard into all-electric and neglecting the virtues of hybrid technology. When I first heard this counterintuitive argument from Toyota, I dismissed it as heel-dragging by a company that lags in electrics, but I’ve come around to the idea that hybrids — at least for now — do have a lot of advantages over all-electric vehicles.

. . .

(p. A6) “Toyota’s claim is accurate. We’ve crunched the numbers on this,” Ashley Nunes told me. He is a senior research associate at Harvard Law School and the director for federal policy, climate and energy at the Breakthrough Institute, a think tank. He testified on the topic in April [2023] before the House Subcommittee on Environment, Manufacturing and Critical Materials.

. . . electric vehicles consume huge quantities of lithium and other materials because they have huge batteries. And they have huge batteries because customers suffer from “range anxiety” and won’t buy an E.V. unless it can go for hundreds of miles without charging — even though the vast majority of trips are short.

. . .

Some people will keep driving old ICE-mobiles (cars with internal combustion engines) because they can’t afford an E.V. And those ICE-mobiles will continue to be major emitters of greenhouse gases.

The production of electric vehicles produces more greenhouse gases than the production of cars with combustion engines. So E.V.s have to travel between 28,000 and 68,000 miles before they have an emissions advantage over similarly sized and equipped ICE-mobiles, according to Nunes. That may take 10 years or more if the E.V. isn’t driven much.

For the full commentary, see:

Peter Coy. “We May Not Be Ready for an All-E.V. World.” The New York Times (Monday, July 17, 2023): A19.

(Note: ellipses added.)

(Note: the online version of the commentary has the date July 14, 2023, and has the title “A Climate Hawk’s Issues With Electric Vehicles.”)

“Proud Symbol of Britain’s Welfare State” in “Deepest Crisis of Its History”

(p. A1) As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either (p. A6) joining strikes or leaving for jobs abroad.

Interviews over three months with doctors, nurses, patients, hospital administrators and medical analysts depict a system so profoundly troubled that some experts warn that the health service is at risk of collapse.

. . .

(p. A6) More than 7.4 million people in England are waiting for medical procedures, everything from hip replacements to cancer surgery. That is up from 4.1 million before the coronavirus pandemic began in 2020.

Mortality data, exacerbated by long wait times, paints a bleak picture. In 2022, the number of excess deaths rose to one of the highest levels in the last 50 years, and those numbers have kept rising, even as the pandemic has ebbed.

In the first quarter of 2023, more than half of excess deaths — that is, deaths above the five-year average mortality rate, before the pandemic — were caused by something other than Covid-19. Cardiovascular-related fatalities, which can be linked to delays in treatment, were up particularly sharply, according to Stuart McDonald, an expert on mortality data at LCP, a London-based pension and investment advisory firm.

For the full story, see:

Mark Landler. “After 75 Years, Health Service In U.K. Teeters.” The New York Times (Monday, July 17, 2023): A1 & A6-A7.

(Note: ellipsis added.)

(Note: the online version of the story has the date July 16, 2023, and has the title “A National Treasure, Tarnished: Can Britain Fix Its Health Service?”)

Perverse Medicare Pricing Incentives Drive Hospital Consolidation Inefficiency

(p. A17) Currently, Medicare pays hospital-owned facilities two to three times as much as independent physician offices for the same service, according to the Alliance for Site Neutral Payment Reform. This creates an enormous incentive for large hospital chains to acquire outpatient practices. Consolidation creates a vicious circle in which larger hospital systems can demand ever higher rates from insurers and also have the capital to buy up physician practices. Removing this perverse incentive will ensure that patients have access to trusted doctors and appropriate care at the same price regardless of treatment location and remove artificial pressure to consolidate.

These bipartisan reforms would deliver hundreds of billions in savings for families. Site-neutral payments would save taxpayers more than $153 billion in Medicare spending over the next decade and also substantially reduce premiums and cost-sharing for Medicare beneficiaries by $94 billion, according to CRFB. In total, these changes could save patients and taxpayers between $346 billion and $672 billion over the next decade.

Large hospital systems have exploited our nation’s outdated billing systems to foist gigantic bills on Americans. Bringing much-needed transparency in hospital billing will deliver more affordable care and put patients back in control.

For the full commentary, see:

Bobby Jindal and Charlie Katebi. “Doctor’s Office Care at Hospital Prices.” The Wall Street Journal (Thursday, July 27, 2023): A17.

(Note: the online version of the commentary has the date July 26, 2023, and has the same title as the print version.)