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THE WAR ON CANCER – 2010. THE CURRENT STATE PREVENTION STRATEGIES HEALTH DISPARITIES. D.E. KENADY M.D. Otis W. Brawley, M.D. Chief Medical Officer Executive Vice President American Cancer Society. Professor of Hematology, Oncology, Medicine and Epidemiology Emory University.

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slide1
THE WAR ON CANCER – 2010
  • THE CURRENT STATE
  • PREVENTION STRATEGIES
  • HEALTH DISPARITIES

D.E. KENADY M.D.

otis w brawley m d chief medical officer executive vice president american cancer society

Otis W. Brawley, M.D.Chief Medical OfficerExecutive Vice PresidentAmerican Cancer Society

Professor of Hematology, Oncology, Medicine and Epidemiology

Emory University

2009 estimated us cancer deaths
2009 Estimated US Cancer Deaths*

Men292,540

Women269,800

Lung & bronchus 30%

Prostate 9%

Colon & rectum 9%

Pancreas 6%

Leukemia 4%

Liver & intrahepatic 4%bile duct

Esophagus 4%

Urinary bladder 3%

Non-Hodgkin 3% lymphoma

Kidney & renal pelvis 3%

All other sites 25%

26% Lung & bronchus

15% Breast

9% Colon & rectum

6% Pancreas

5% Ovary

4% Non-Hodgkin lymphoma

3% Leukemia

3% Uterine corpus

2% Liver & intrahepatic bile duct

2% Brain/ONS

25% All other sites

ONS=Other nervous system.

Source: American Cancer Society, 2009.

us mortality 2006
US Mortality, 2006

No. of deaths

% of all deaths

Rank

  • 1. Heart Diseases 631,636 26.0
  • 2. Cancer559,888 23.1
  • 3. Cerebrovascular diseases 137,119 5.7
  • 4. Chronic lower respiratory diseases 124,583 5.1
  • 5. Accidents (unintentional injuries) 121,599 5.0
  • 6. Diabetes mellitus 72,449 3.0
  • 7. Alzheimer disease 72,432 3.0
  • 8. Influenza & pneumonia 56,326 2.3
  • Nephritis* 45,344 1.9
  • 10. Septicemia 34,234 1.4

Cause of Death

*Includes nephrotic syndrome and nephrosis.

Source: US Mortality Data 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.

change in us death rates from 1991 to 2006
Change in US Death Rates* from 1991 to 2006

Rate Per 100,000

1991

2006

* Age-adjusted to 2000 US standard population.

Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.

2006 Mortality Data: US Mortality Data 2006, NCHS, Centers for Disease Control and Prevention, 2009.

cancer death rates by sex us 1975 2005
Cancer Death Rates* by Sex, US, 1975-2005

Rate Per 100,000

Men

Both Sexes

Women

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

cancer death rates among men us 1930 2005
Cancer Death Rates* Among Men, US,1930-2005

Rate Per 100,000

Lung & bronchus

Stomach

Prostate

Colon & rectum

Pancreas

Leukemia

Liver

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,

National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

cancer death rates among women us 1930 2005
Cancer Death Rates* Among Women, US,1930-2005

Rate Per 100,000

Lung & bronchus

Uterus

Breast

Colon & rectum

Stomach

Ovary

Pancreas

*Age-adjusted to the 2000 US standard population.

Source: US Mortality Data 1960-2005, US Mortality Volumes 1930-1959,

National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

2009 estimated us cancer cases
2009 Estimated US Cancer Cases*

Men766,130

Women713,220

27% Breast

14% Lung & bronchus

10% Colon & rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanoma of skin

4% Thyroid

3% Kidney & renal pelvis

3% Ovary

3% Pancreas

22% All Other Sites

Prostate 25%

Lung & bronchus 15%

Colon & rectum 10%

Urinary bladder 7%

Melanoma of skin 5%

Non-Hodgkin 5% lymphoma

Kidney & renal pelvis 5%

Leukemia 3%

Oral cavity 3%

Pancreas 3%

All Other Sites 19%

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.

Source: American Cancer Society, 2009.

cancer incidence rates by sex us 1975 2005
Cancer Incidence Rates* by Sex, US, 1975-2005

Rate Per 100,000

Men

Both Sexes

Women

*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.

Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:

SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

cancer incidence rates among men us 1975 2005
Cancer Incidence Rates* Among Men, US, 1975-2005

Rate Per 100,000

Prostate

Lung & bronchus

Colon and rectum

Urinary bladder

Non-Hodgkin lymphoma

Melanoma of the skin

*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.

Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:

SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

cancer incidence rates among women us 1975 2005
Cancer Incidence Rates* Among Women, US, 1975-2005

Rate Per 100,000

Breast

Colon and rectum

Lung & bronchus

Uterine Corpus

Ovary

Non-Hodgkin lymphoma

*Age-adjusted to the 2000 US standard population and adjusted for delays in reporting.

Source: Surveillance, Epidemiology, and End Results Program, Delay-adjusted Incidence database:

SEER Incidence Delay-adjusted Rates, 9 Registries, 1975-2005, National Cancer Institute, 2008.

cancer incidence death rates in children 0 14 years 1975 2005
Cancer Incidence & Death Rates* in Children 0-14 Years, 1975-2005

Rate Per 100,000

Incidence

Mortality

*Age-adjusted to the 2000 Standard population.

Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

cancer incidence rates in children 0 14 years by sex 2001 2005
Cancer Incidence Rates* in Children 0-14 Years by Sex, 2001-2005

Site Male Female Total

All sites 16.1 14.1 15.1

Leukemia 5.4 4.5 5.0

Acute Lymphocytic 4.3 3.6 3.9

Brain/ONS 3.4 3.1 3.2

Soft tissue 1.1 1.0 1.1

Non-Hodgkin lymphoma 1.2 0.6 0.9

Kidney and renal pelvis 0.8 0.8 0.8

Bone and Joint 0.7 0.7 0.7

Hodgkin lymphoma 0.7 0.4 0.5

*Per 100,000, age-adjusted to the 2000 US standard population.

ONS = Other nervous system

Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

cancer death rates in children 0 14 years by sex us 2001 2005
Cancer Death Rates* in Children 0-14 Years by Sex, US, 2001-2005

Site Male Female Total

All sites 2.7 2.3 2.5

Leukemia 0.8 0.7 0.8

Acute Lymphocytic 0.4 0.3 0.4

Brain/ONS 0.8 0.7 0.7

Non-Hodgkin lymphoma 0.1 0.1 0.1

Soft tissue 0.1 0.1 0.1

Bone and Joint 0.1 0.1 0.1

Kidney and Renal pelvis 0.1 0.1 0.1

*Per 100,000, age-adjusted to the 2000 US standard population.

ONS = Other nervous system

Source: Surveillance, Epidemiology, and End Results Program, 1975-2005, Division of Cancer Control and Population Sciences, National Cancer Institute, 2008.

tobacco use in the us 1900 2005
Tobacco Use in the US, 1900-2005

Per capita cigarette consumption

Male lung cancer death rate

Female lung cancer death rate

*Age-adjusted to 2000 US standard population.

Source: Death rates: US Mortality Data, 1960-2005, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-2007.

trends in cigarette smoking prevalence by sex adults 18 and older us 1965 2007
Trends in Cigarette Smoking Prevalence* (%), by Sex, Adults 18 and Older, US, 1965-2007

Men

Women

*Redesign of survey in 1997 may affect trends.

Source: National Health Interview Survey, 1965-2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

slide19
Current* Cigarette Smoking Prevalence (%) Among High School Students by Sex and Race/Ethnicity, US, 1991-2007

*Smoked cigarettes on one or more of the 30 days preceding the survey.Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for

Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

slide20
Trends in Consumption of Five or More Recommended Vegetable and Fruit Servings for Cancer Prevention, Adults 18 and Older, US, 1994-2007

Note: Data from participating states and the District of Columbia were aggregated to represent the United States.

Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2003, 2005, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2004, 2006, 2008.

slide21
Trends in Prevalence (%) of No Leisure-Time Physical Activity, by Educational Attainment, Adults 18 and Older, US, 1992-2007

Adults with less than a high school education

All adults

Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for adults 25 and older.

Source: Behavioral Risk Factor Surveillance System CD-ROM (1984-1995, 1996, 1998) and Public Use Data Tape (2000, 2002, 2004, 2005, 2006, 2007), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2001, 2003, 2005, 2006, 2007, 2008.

trends in obesity prevalence children and adolescents by age group us 1971 2006
Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-2006

*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category.

Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.

trends in obesity prevalence by gender adults aged 20 to 74 us 1960 2006
Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, 1960-2006†

*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population.Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

slide24
Mammogram Prevalence (%), by Educational Attainment and Health Insurance Status, Women 40 and Older, US, 1991-2006

All women 40 and older

Women with less than a high school education

Women with no health insurance

*A mammogram within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States.

Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.

slide26
Adjusted Breast Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB
breast cancer
Breast Cancer
  • It is estimated that 57,000 breast cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment.
  • Breast cancer screening rates have actually gone down during the period 2000 to 2005
breast cancer28
Breast Cancer
  • Imagine a world in which
    • Mammography rates were greater than 80%
    • All women with an abnormal screen got it evaluated
    • All women with breast cancer got optimal therapy
slide29
Trends in Recent* Pap Test Prevalence (%), by Educational Attainment and Health Insurance Status, Women 18 and Older, US, 1992-2006

All women 18 and older

Women with no health insurance

Women with less than a high school education

* A Pap test within the past three years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States. Educational attainment is for women 25 and older.

Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data Tape (2000, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.

slide30
Screening Guidelines for the Early Detection of Colorectal Cancer and Adenomas, American Cancer Society 2008
  • Beginning at age 50, men and women should follow one of the following examination schedules:
  • A flexible sigmoidoscopy (FSIG) every five years
  • A colonoscopy every ten years
  • A double-contrast barium enema every five years
  • A Computerized Tomographic (CT) colonography every five years
  • A guaiac-based fecal occult blood test (FOBT) or a fecal immunochemical test (FIT) every year
  • A stool DNA test (interval uncertain)
        • Tests that detect adenomatous polyps and cancer
        • Tests that primarily detect cancer

People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule

slide31
Trends in Recent* Fecal Occult Blood Test Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2006

*A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were aggregated to represent the United States.

Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.

slide32
Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy Prevalence (%), by Educational Attainment and Health Insurance Status, Adults 50 Years and Older, US, 1997-2006

*A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the District of Columbia were aggregated to represent the United States.

Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.

slide34
Adjusted Colorectal Cancer Survival by Stages and Insurance Status, among Patients Diagnosed in 1999-2000 and Reported to the NCDB
colorectal cancer
Colorectal Cancer
  • It is estimated that 77,000 colorectal cancer deaths were averted between 1990 and 2005 due to screening, early detection, and aggressive treatment.
  • Colorectal cancer screening rates have actually gone down during the period 2000 to 2005
colorectal cancer36
Colorectal Cancer
  • Imagine a world in which
    • Colorectal cancer screening rates were greater than 80%
    • All men and women with an abnormal screen got it evaluated
    • All with colorectal cancer got optimal therapy
sunburn prevalence in the past year adults 18 and older us 2004
Sunburn* Prevalence (%) in the Past Year, Adults 18 and Older, US, 2004

*Reddening of any part of the skin for more than 12 hours. Note: The overall prevalence of sunburn among adult males is 46.4% and among females is 36.3%.

Source: Behavioral Risk Factor Surveillance System Public Use Data Tape, 2004. National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2005.

ultraviolet radiation exposure behaviors prevalence adults 18 and older us 2005
Ultraviolet Radiation Exposure Behaviors* Prevalence (%), Adults 18 and Older, US, 2005

*Proportion of respondents reporting always or often practicing the particular sun protection behavior on any warm sunny day. †Used an indoor tanning device, including a sunbed, sunlamp, or tanning booth at least once, in the past 12 months.

Source: National Health Interview Survey Public Use Data File 2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

slide42

How can we provide adequate high quality care (to include preventive care) to a population that has so often not received it?

quality of care
Quality of Care
  • There are more than two dozen patterns of care studies to show racial disparities in care received by Blacks and/or the poor have:
    • Delayed treatment
    • No adjuvant chemotherapy
    • Dose reductions of chemotherapy
    • No hormonal therapy
    • No surgery
    • No radiation when it was appropriate
quality of care matters
Quality of Care Matters
  • CMF post mastectomy adjuvant chemotherapy
  • CMF useful when > 85% of planned dose given for 12 cycles
  • 5 year Relapse Free Survival
    • > 85% of planned dose 77%
    • No Chemotherapy 45% p=0.0001
    • Subgroup getting < 65% of planned dose 48%
      • Bonadonna et al NEJM 1981
      • Bonadonna et al NEJM 1995
quality of care45
Quality of Care
  • Receipt of “minimum expect care” in SEER-Medicare data 1992-1999
  • Blacks less likely OR 0.67 95% CI (.59-.76)
  • Hispanics less likely OR 0.77 95% CI (.66-.90)
      • Haggstrom, Cancer 2005
quality of care46
Quality of Care
  • In a prospective study of 764 women getting chemotherapy for breast cancer, the following were associated with intentional reduction of chemotherapy dose in univariate analysis
    • Education Attainment
    • Zip Code Correlated SES Measures
    • BMI
    • Geographic region
      • Griggs et al JCO 2007
quality of care47
Quality of Care
  • In a multivariate analysis, factors independently associated with a decrease in chemotherapy dose

OR 95% CI

    • Obesity 2.47 (1.36 to 4.51)
    • Severe obesity 3.04 (1.46 to 11.19)
        • Griggs et al, JCO 2007
quality of care48
Quality of Care
  • In a study of women breast cancer patients aged 20 to 54, a higher proportion of Blacks had a greater than three month delay in treatment from initial consultation.
    • 22.4% of Blacks
    • 14.3% of Whites
      • Gwyn et al, Cancer 2004
quality of care49
Quality of Care
  • In a SEER Study of more than 870 Blacks and 2430 Whites treated in 2000 to 2001
    • Blacks were 4 to 5 fold more likely to get definitive treatment more than 60 days after initial consultation
    • Of patients treated with lumpectomy 61% of Blacks and 72% of whites completed radiation
    • In one SEER registry 7.5% of Blacks with clinically localized disease got no surgical therapy vs 2% of whites
      • Lund et al Breast Ca Res Treat, 2007
quality of care50
Quality of Care
  • In a SEER Study of more than 870 Blacks and 2430 Whites treated in 2000 to 2001

7.5% of Black women with clinically localized disease got no surgical therapy vs 2% of whites

Note: These women had enough access to get diagnosed

      • Lund et al, Breast Ca Res Treat, 2007
equal treatment yields equal outcome
Equal Treatment Yields Equal Outcome?
  • No racial differences in survival HR 1.08 95% CI (0.97-1.2) after adjusting for
    • Mammography screening
    • Tumor characteristics
    • Biologic markers
    • Treatment
    • Comorbidity
    • Demographics
      • Curtis et al, Cancer 2008
equal treatment yields equal outcome53
Equal Treatment Yields Equal Outcome?
  • In NSABP studies of 543 Blacks and 7582 Whites with node negative breast cancer
    • Black/White DFS 1.06 95% CI (0.92-1.23)
    • Black/White Mortality 1.21 95% CI (1.01 to 1.46)
      • Modestly greater and attributed to non-cancer causes of death (co-morbidities?)
      • Excluding non-cancer deaths 1.08 95% CI (.88 to 1.33)
        • Dignam et al, JNCI Monographs 2001
equal treatment yields equal outcome54
Equal Treatment Yields Equal Outcome?
  • In NSABP studies of 548 Blacks and 4986 Whites with node positive breast cancer
    • Black/White DFS 1.04 95% CI (0.95-1.17)
    • Black/White Mortality 1.18 95% CI (1.03 to 1.34)
      • Modestly greater and attributed to non-cancer causes of death (co-morbidities?)
      • Excluding non-cancer deaths 1.09 95% CI (.96 to 1.25)
        • Dignam et al, JNCI Monographs 2001
equal treatment yields equal outcome there is not equal treatment
Equal Treatment Yields Equal OutcomeThere is not Equal Treatment
  • Studies suggest that disparities in treatment may be due to:
    • Cultural differences in acceptance of therapy leading to good therapy being refused.
    • Disparities in comorbid diseases making aggressive therapy inappropriate.
    • Lack of convenient access to therapy making good therapy hard to accept.
    • Racism and SES discrimination leading to good therapy not being offered.
the meaning of race in science and medicine
The Meaning of Race in Science and Medicine
  • Differences in patterns of care by race documented in:
    • Prostate Cancer
    • Colon Cancer
    • Breast Cancer
    • Lung Cancer
  • The full reasons for the differences have yet to be explained
the bottom line
The Bottom Line
  • There are some differences in pathologies among populations.
  • Simply getting good care (a logistical issue) to Blacks and the poor will improve overall American breast cancer statistics.
higher per capita spending in the u s does not translate into longer life expectancy
The Cost of a Long Life

Average Life Expectancy (years)

United States

Higher Per Capita Spending in the U.S. does notTranslate into Longer Life Expectancy

Per Capita Spending in USD

Life Expectancy – Per Capita Spending

2006 CIA FACTBOOK

the economics of healthcare
The Economics of Healthcare
  • Healthcare is 17% of the nation’s Gross Domestic Product and growing
  • The country with the second greatest is Israel with 9.5% of its GDP devoted to healthcare
  • The U.S. spends more on healthcare than it spends on food and clothing
the economics of healthcare60
The Economics of Healthcare
  • The average cost to Medicare per beneficiary in 2006 was $8304
  • New York City $9564
  • Honolulu $5311
  • Miami $16,351
  • San Francisco $8331
  • NY Times June 11, 2009
disparities in health
Disparities in Health
  • Some consume too much
    • (Unnecessary care given)
  • Some consume too little
    • (Necessary care not given)
  • We could decrease the waste and improve overall health!!!!
disparities in health62
Disparities in Health
  • There are dramatic geographical differences in use of a number of expensive screening technologies and therapies without evidence of difference in outcomes.
    • Prostate cancer screening and treatment
    • Lung cancer screening
    • Third and fourth line chemotherapy of metastatic disease
    • Intensity Modulated Radiation Therapy in some cancers
    • Overuse of radiologic imaging
    • Possibly colonoscopy versus stool blood testing
faith based versus evidence based medicine
Faith Based versus Evidence Based Medicine
  • We in medicine have a tendency to adopt things before fully accessing their benefit or harm.
  • We also criticize those who question the benefit and some even praise/worship advocates with a monetary interest.
    • Bone marrow transplant for breast cancer
    • Lung cancer screening with Chest Xray
    • Neuroblastoma Screening with urine VMA
    • The Halsted Mastectomy
    • Postmenopausal hormone replacement
    • Prostate cancer screening
disparities in health64
Disparities in Health
  • A call for the use of “Evidence Based Care”
  • That is:
    • the rational use of medicine
    • not the rationing of medicine
ad