The Best Science from The New England Journal of Medicine

This is the Science-Based Medicine blog, but all too often we talk about things that are not science-based medicine. Examining what is not science-based medicine is a good way to better understand what science-based medicine is or should be. But let’s not forget to celebrate the successes of good science-based medicine.

The New England Journal of Medicine is one of the most prestigious medical journals with the most rigorous standards for publication. Jeffrey Drazen has been its editor-in-chief for 19 years, and as he prepares to retire, he has selected Drazen’s Dozen, twelve articles published during his tenure that stand out to him as the most important and useful articles that physicians could act on immediately to improve patient care.

1. Exposure to peanuts is safer for infants than avoidance. (“Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy“.) Standard advice for infants at high risk of developing peanut allergies was to avoid peanuts in the early years of life. This study found that the standard practice increased the risk of peanut allergy, and that sustained peanut consumption in the first 11 months of life was associated with an 86% reduction in peanut allergy at 60 months of age.
2. A better way to prevent strokes. (“Apixaban versus Warfarin in Patients with Atrial Fibrillation“.) Patients with atrial fibrillation were treated with warfarin to prevent strokes. Dosage was hard to adjust and required frequent blood tests; interactions with other drugs were common. Apixaban, a pill that doesn’t require blood tests, was shown to be superior to warfarin in preventing stroke or systemic embolism; it caused fewer bleeding complications and even reduced the risk of death from any cause by 11%.
3. Lifestyle intervention, not drugs, is the best way to prevent Type 2 diabetes. (“Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin“.) Lifestyle changes (weight loss and exercise) were superior to the prescription drug Metformin: the number needed to treat to prevent one case of diabetes during a period of 3 years was 6.9 for lifestyle changes and 13.9 for Metformin.
4. Colonoscopy screening saves lives. (“Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths“.) Colonoscopy screening has long been recommended, but we had no direct evidence that it prevented deaths. Now we do. This study showed that after a mean period of nearly 16 years, mortality from colorectal cancer in study subjects was 53% lower among those who had undergone colonoscopy and had adenomas removed than in a reference group.
5. A cure for chronic HCV infections. (“Sofosbuvir and Velpatasvir for HCV Genotype 1, 2, 4, 5, and 6 Infection“.) Chronic hepatitis C virus (HCV) infections cause liver cancers and deaths. 3 million Americans are infected, and as many as half of them don’t know it. Curing the infection reduces the risk of liver cancer by 76% and of death from any cause by 50%. Previous treatments caused side effects and were not very effective. A new treatment is much better. Clinical trials showed excellent safety and efficacy of once-daily use of a combination of two new drugs for 12 weeks.
6. New hope for patients with chronic myelogenous leukemia (CML). (“Hematologic and Cytogenetic Responses to Imatinib Mesylate in Chronic Myelogenous Leukemia“.) CML is potentially curable with allogeneic stem-cell transplantation, but fewer than 30% of patients have suitably matched donors. The standard drug treatment, interferon alfa, is toxic and not very effective. In this study, patients who had failed interferon treatment were given imatinib mesylate (Gleevec). It was effective and well-tolerated. The progression-free survival rate was 89 percent.
7. The cause of SARS was rapidly identified. (“A Novel Coronavirus Associated with Severe Acute Respiratory Syndrome“.) An outbreak of severe acute respiratory syndrome (SARS) started in China in 2002 and spread to other countries. A global collaborative effort led to the identification of its cause: a new coronavirus that may have originated in animals. The authors said, “The investigation of the SARS outbreak serves as a positive template for laboratory and epidemiologic response to possible future infectious-disease pandemics.”
8. A new vaccine to prevent cancer. (“Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions“.) Human papillomavirus (HPV) infections cause many types of cancer, especially cervical cancers in women. This new vaccine was the first explicitly designed to prevent cancer induced by a virus. In a randomized, double-blind placebo-controlled trial, the quadrivalent vaccine was 98% effective for the viral strains covered.
9. Functional outcomes from strokes can be improved. (“A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke“.) Initial treatment for a stroke is an intravenous drug to break up clots, but intraarterial treatments (retrievable stents, clot dissolution, clot retrieval) are often needed for revascularization. Intraarterial treatment in patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation was effective and safe when administered within 6 hours after stroke onset. There was a clinically significant increase in functional independence in daily life by 3 months, with no increase in mortality. Questions remain, but the accompanying editorial calls this study the first step in the right direction.
10. Prostate surgery reduces prostate cancer deaths but not overall mortality. (“A Randomized Trial Comparing Radical Prostatectomy with Watchful Waiting in Early Prostate Cancer“.) Prostate surgery carries a significant risk of impotence and incontinence. It reduces the rate of death from prostate cancer but does not increase overall survival compared to the option of watchful waiting. An accompanying editorial asks if all patients should get radical prostatectomy and if no one should be followed with watchful waiting; it answers both questions with a categorical “no”. This is a complicated subject with evolving criteria and ongoing trials, and it would be best to fully inform patients about their options and support their choices.
11. Radical mastectomy is obsolete. (“Twenty-Year Follow-up of a Randomized Study Comparing Breast-Conserving Surgery with Radical Mastectomy for Early Breast Cancer“.) This long-term study demonstrated that the survival rate with breast-conserving surgery is as good as with radical mastectomy. Breast-conserving surgery is now the treatment of choice for relatively small breast cancers.
12. Inducing labor can benefit mothers without harming babies. (“Labor induction versus Expectant Management in Low-Risk Nulliparous Women”.) A randomized trial found that inducing labor at 39 weeks in low-risk women decreased the C-section rate and did not increase adverse perinatal outcomes for babies compared to expectant management.

Conclusion: Science rules!

Note that these are all large, well-designed, rigorous, high quality studies that answer important questions for clinical practice. The authors’ conclusions don’t go beyond the data. They don’t indulge in fanciful speculations. They acknowledge remaining uncertainties and the need for more research.

Now look at some of the best studies you can find from the world of alternative medicine. There is no comparison. I once reviewed what a chiropractic website called the “top 10 chiropractic studies of 2013”. The quality of those studies was abysmal. You can read my analysis here.

You may not agree with Drazen’s selection of the top dozen, but I think you will agree that the NEJM is an excellent source of good scientific studies and has so far been resistant to quackademic medicine (as opposed to many other sources I could name). It is important to criticize poor science, pseudoscience, and CAM silliness, but it’s also important to celebrate the undeniable achievements of science-based medicine. As Bill Nye the Science Guy says, “Science Rules!”