- Email: [email protected]
Alberto Costa
LIFELINE Alberto Costa Alberto Costa has been the director of the European School of Oncology in Milan, Italy, since 1982, and is a breast surgeon at the European Institute of Oncology. His clinical work has focused mainly on breast-cancer surgery, and his research work on cancer chemoprevention with retinoids and tamoxifen. He has a keen interest in medical education and scientific communication. Who was your most influential teacher? Umberto Veronesi, who pioneered Italian cancer research, and who developed conservative surgery for breast cancer, taught me that if you think something is important you must do it. Which research paper has had most effect on your work? Michael Sporn’s paper defining cancer chemoprevention for the first time proposed the concept of interfering with the process of carcinogenesis rather than merely treating the established disease. What would be your advice to a newly qualified doctor? Listen to patients, and control the need to make clinical decisions too quickly. How do you relax? Horse riding, listening to classical music, and reading newspapers and books. What is your favourite journey, and why? The journey to Connemara, on the west coast of Ireland, because I know at the end I will find peace of mind and complete tranquillity. What is your greatest fear? A severe and terminal illness in one of my children. What are you currently reading? Coelho’s The Alchemist. What is your worst habit? Fussing. What is your greatest regret? Not to have spent enough time with my father. Who is the greatest love of your life? Kathy Redmond, who brought happiness and joy into my life, and for all she has done for cancer nursing in Europe. How would you like to die? Not suddenly, but without pain or breathlessness, feeling very tired and falling asleep.
602
The weight of evidence as medicine an enjoyable profession in the dark ages when all sorts of evidence did not illuminate our path? I confess that I still enjoy seeing patients, but the feeling is short lived and turns into anguish when I have to advise them. Consider, for example, my first patient this morning, a man in his mid-40s, married, and for a long time happy with his married life, which included a good sex life. His diagnostic work-up clearly shows that he has essential hypertension, and the weight of the evidence forces me to insist on my previous prescription of diuretics and b-blockers (one or the other of them alone has not been enough) despite his assertion that my treatment has ruined his sex life and my fear that he will soon become noncompliant. Will my anguish overcome the evidence? The next patient adds a further few beats per minute to my heart. Ms B, a newcomer to my surgery, has been taking dihydrogenated ergot alkaloids for years, and when she came to see me a month ago it was for a minor contusion. Otherwise she was happy and in good spirits. Of course, my devotion for evidence forced me to withdraw the ergot derivative, and she now complains of depression, insomnia, and other subjective troubles. When confronted with the rulings of evidence she was not convinced at all and even used a word quite unsuitable for a lady of her otherwise exquisite manners. Will I, in my anguish, prescribe a low-dose neurolepic, which evidently is able to calm some patients, or will my agony be further increased by the fear of serious side-effects? When she leaves I am nursing a headache on top (never a better word) of my worries. I even start to pray that my next patient is straightforward, whatever the diagnosis or severity of the disease. I crave a direct application of the evidence that has been so painfully collected and digested by others.
W
No chance! It is true that the next patient has a treatable disease and that the treatment is supported by three major clinical trials, but my shortness of breath returns when I realise that his age, race, and constellation of syndromes and symptoms add up to at least three or four (depending on the trial) exclusion criteria. He is simply not in the evidence! It will probably not come as a surprise to you if I mention that although another patient this morning has a condition whose treatment has been evaluated in two important clinical trials, and who has complied with the inclusion criteria in both of them, I am not happy: I am paralysed by their statistically significant but quite opposite results. This is definitely not a good morning. After that patient leaves, I have to administer a vaccine to a young man who has to travel to an exotic area and needs the vaccination certificate to obtain a visa. Am I right? The efficacy of this vaccination procedure, which nobody disputes, has never been validated in a proper clinical trial. Which authority shall I honour? Well, if you do not regard this as a problem, think about the next patient. His liver is not in the best condition, and I know that he continues to drink. I will reiterate my warnings, but where are the double-blind randomised clinical trials showing that alcohol is deleterious in chronic liver disease? Where is the evidence to guide my hand? What shall I do? Am I evidenceresistant, or am I perhaps in the midst of an eclipse of evidence? My friends believe that I am becoming paranoid, and it must be so, because the last patient to walk into my surgery is an old lady who has been on calciumchannel blockers for more than 18 years. She must be statistically dead and I am seeing ghosts. So much for evidence! Sergio Erill
THE LANCET • Vol 353 • February 13, 1999
602
The weight of evidence as medicine an enjoyable profession in the dark ages when all sorts of evidence did not illuminate our path? I confess that I still enjoy seeing patients, but the feeling is short lived and turns into anguish when I have to advise them. Consider, for example, my first patient this morning, a man in his mid-40s, married, and for a long time happy with his married life, which included a good sex life. His diagnostic work-up clearly shows that he has essential hypertension, and the weight of the evidence forces me to insist on my previous prescription of diuretics and b-blockers (one or the other of them alone has not been enough) despite his assertion that my treatment has ruined his sex life and my fear that he will soon become noncompliant. Will my anguish overcome the evidence? The next patient adds a further few beats per minute to my heart. Ms B, a newcomer to my surgery, has been taking dihydrogenated ergot alkaloids for years, and when she came to see me a month ago it was for a minor contusion. Otherwise she was happy and in good spirits. Of course, my devotion for evidence forced me to withdraw the ergot derivative, and she now complains of depression, insomnia, and other subjective troubles. When confronted with the rulings of evidence she was not convinced at all and even used a word quite unsuitable for a lady of her otherwise exquisite manners. Will I, in my anguish, prescribe a low-dose neurolepic, which evidently is able to calm some patients, or will my agony be further increased by the fear of serious side-effects? When she leaves I am nursing a headache on top (never a better word) of my worries. I even start to pray that my next patient is straightforward, whatever the diagnosis or severity of the disease. I crave a direct application of the evidence that has been so painfully collected and digested by others.
W
No chance! It is true that the next patient has a treatable disease and that the treatment is supported by three major clinical trials, but my shortness of breath returns when I realise that his age, race, and constellation of syndromes and symptoms add up to at least three or four (depending on the trial) exclusion criteria. He is simply not in the evidence! It will probably not come as a surprise to you if I mention that although another patient this morning has a condition whose treatment has been evaluated in two important clinical trials, and who has complied with the inclusion criteria in both of them, I am not happy: I am paralysed by their statistically significant but quite opposite results. This is definitely not a good morning. After that patient leaves, I have to administer a vaccine to a young man who has to travel to an exotic area and needs the vaccination certificate to obtain a visa. Am I right? The efficacy of this vaccination procedure, which nobody disputes, has never been validated in a proper clinical trial. Which authority shall I honour? Well, if you do not regard this as a problem, think about the next patient. His liver is not in the best condition, and I know that he continues to drink. I will reiterate my warnings, but where are the double-blind randomised clinical trials showing that alcohol is deleterious in chronic liver disease? Where is the evidence to guide my hand? What shall I do? Am I evidenceresistant, or am I perhaps in the midst of an eclipse of evidence? My friends believe that I am becoming paranoid, and it must be so, because the last patient to walk into my surgery is an old lady who has been on calciumchannel blockers for more than 18 years. She must be statistically dead and I am seeing ghosts. So much for evidence! Sergio Erill
THE LANCET • Vol 353 • February 13, 1999