Cancer Forums and News by PhD's


News | Forums Register

Go Back   Cancer Forums and News by PhD's > Breast Cancer Forum

Reply
 
Thread Tools Display Modes
  #1  
Old 09-30-2010, 09:19 AM
Dross Dross is offline
Moderator
 
Join Date: Nov 2006
Posts: 883
Default Age 50 as mammography screening threshold proven unfounded

The landmark breast cancer screening study of women 40-49, published online in Cancer, has proven that annual mammography screening of women in their 40s reduces the breast cancer death rate in these women by nearly 30 percent. The results of this largest study ever conducted on women in this age group confirm that the use of the age of 50 as a threshold for breast cancer screening is scientifically unfounded. Women should begin getting annual mammograms at age 40.

"This study, which looked at the performance of screening mammography as it is actually used, rather than relying on mathematical modeling, shows without a doubt that mammography decreases deaths from breast cancer in women aged 40-49 by nearly one third. There is no excuse not to recommend that average risk women begin annual screening mammography at age 40," said Carol H. Lee, MD, Chair of the American College of Radiology Breast Imaging Commission.

In Nov. of 2009, the United States Preventive Services Task Force (USPSTF) ignored published data showing a similar death rate reduction to this landmark trial, and withdrew support for screening women 40-49. This real world study is far more robust, based on real world numbers, and proves that the benefit is nearly twice that of the USPSTF estimate of 15 percent.

"This study shows that annual mammograms for women 40 and over result in a tremendously significant reduction in the breast cancer death rate for women 40-49. The age of 50 is an artificial threshold that has no basis in scientific fact. The debate is now over. Women should no longer be confused about the importance of annual breast cancer screening. Mammography saves lives. If you are a woman age 40 or over, one of them could be yours," said Phil Evans, MD, President of the Society of Breast Imaging (SBI).

The Swedish trial followed more than 600,000 women for 16 years. The number of breast cancer deaths among the women in the study who did not receive mammograms was twice as high as those who underwent screening. Breast cancer is the most common cancer in women worldwide. It kills around 465,000 people globally each year. Mammography can catch cancer early, when it is most treatable. While not a perfect test, at present, there is no other screening tool to replace it.

"It is now time to stop confusing women with conflicting information. Mammography is a lifesaver for women in their 40s. What providers need to do now is uniformly confirm for women that they need to start getting annual mammograms beginning at age 40 and work to build on the ability of mammography to detect cancer early, when it is most treatable. Mammography saves a significant number of lives in all women 40 and over. Let's all move forward from there," said Gail Lebovic, MD, breast surgeon and President of the American Society of Breast Disease (ASBD).

Last edited by gdpawel : 12-12-2012 at 11:32 AM. Reason: posted full article
Reply With Quote
  #2  
Old 10-02-2010, 08:01 AM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default

Dr. Peter C. Gotzsche of the Nordic Cochrane Center in Copenhagen, a nonprofit group that reviews health care research, has said in response to this study out of Sweden is that the investigators counted the number of women who received a diagnosis of breast cancer and also died of it. They did not compare the broader breast cancer death rates in the counties.

He said it is an important distinction because screening finds many cancers that do not need to be treated or found early. With more harmless cancers being found in the screened group, it will look like the chance of surviving breast cancer is greater in that group. “The analysis is flawed,” he said.

And Donald Berry, a statistician at MD Anderson Cancer Center, responded that the overdiagnosis problem was a serious one. "We are finding cancers that would never be found if we didn't look," he was quoted for the media. "Small wonder people think screening is great - some of the cancers it finds were not lethal in the first place."

It seems like the new Swedish study (not a randomized trial) would be far from convincing and probably wouldn't meet the USPSTF test for high-grade evidence. The authors made no adjustment for any risk factors.

The absolute risk revealed was quite small, about two-tenths of one percent. There were a total of 1,824 breast cancer deaths in the entire cohort, or roughly one of every 550 women. According to the authors of the study, 1,250 women in their 40's would have to be routinely given mammograms to prevent one breast cancer death.

As a result, a much larger proportion of those women would get false cancer signals, leading to unnecessary biopsies and other treatments. It was even suggested by the American Society of Clinical Oncology (ASCO) that women under 50 discuss with their doctors their own situation and the risks and benefits before going forward with routine mammograms.
__________________
Gregory D. Pawelski
Reply With Quote
  #3  
Old 10-03-2010, 03:56 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default

In a book written by Dr. H. Gilbert - Should I Be Tested for Cancer? - professor at the Dartmouth Medical School and co-director of the V.A. Outcomes Group in the Department of Veterans Affairs in White River Junction, Vt., admits that many doctors understand that early detection is a double-edged sword.

In fact, most learn about these problems in medical school. But once they are out of school all the forces are lined up to encourage them to test: whether it is making screening a measure of health-care quality (where the doctor who screens 100 percent is best), fear of legal liability from failure to diagnose (ever heard of a doctor sued for diagnosing cancer unnecessarily?) or financial pressure (it's quicker to order a test than to talk about why it might not be in your best interest).

For some common cancers, it is not clear that early detection and treatment actually prolong patients' lives. Early detection may just mean patients spend a longer time knowing they have cancer, and yet die at the same time they would have died anyway if the tumor had been diagnosed later. A decision to forgo cancer screening can be a reasonable option (Arch Intern Med. 2008;168(21):2300, 2302-2303, 2311-2316).
__________________
Gregory D. Pawelski
Reply With Quote
Sponsored Links
Advertisement
  #4  
Old 10-04-2010, 05:16 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Swedish mammography study

Effectiveness of population-based service screening with mammography for ages 40 to 49 years

Authors

Barbro Numan Hellquist, Stephen W. Duffy, Shahin Abdsaleh, Lena Björneld, Pál Bordás, László Tabár, Bedrich Viták, Sophia Zackrisson, Lennarth Nyström, Hĺkan Jonsson

Abstract

BACKGROUND:

The effectiveness of mammography screening for women ages 40 to 49 years still is questioned, and few studies of the effectiveness of service screening for this age group have been conducted.

METHODS:

Breast cancer mortality was compared between women who were invited to service screening at ages 40 to 49 years (study group) and women in the same age group who were not invited during 1986 to 2005 (control group). Together, these women comprise the Mammography Screening of Young Women (SCRY) cohort, which includes all Swedish counties. A prescreening period was defined to facilitate a comparison of mortality in the absence of screening. The outcome measure was refined mortality, ie, breast cancer death for women who were diagnosed during follow‐up at ages 40 to 49 years. Relative risks (RRs) with 95% confidence intervals (CIs) were estimated.

RESULTS:

There was no significant difference in breast cancer mortality during the prescreening period. During the study period, there were 803 breast cancer deaths in the study group (7.3 million person‐years) and 1238 breast cancer deaths in the control group (8.8 million person‐years). The average follow‐up was 16 years. The estimated RR for women who were invited to screening was 0.74 (95% CI, 0.66‐0.83), and the RR for women who attended screening was 0.71 (95% CI, 0.62‐0.80).

CONCLUSIONS:

In this comprehensive study, mammography screening for women ages 40 to 49 years was efficient for reducing breast cancer mortality.

journal Cancer 2010 10.1002/cncr.25650
__________________
Gregory D. Pawelski
Reply With Quote
  #5  
Old 10-04-2010, 05:18 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Effect of Screening Mammography on Breast-Cancer Mortality in Norway

Effect of Screening Mammography on Breast-Cancer Mortality in Norway

Mette Kalager, M.D., Marvin Zelen, Ph.D., Frřydis Langmark, M.D., and Hans-Olov Adami, M.D., Ph.D.

N Engl J Med 2010; 363:1203-1210September 23, 2010

Background

A challenge in quantifying the effect of screening mammography on breast-cancer mortality is to provide valid comparison groups. The use of historical control subjects does not take into account chronologic trends associated with advances in breast-cancer awareness and treatment.

Methods

The Norwegian breast-cancer screening program was started in 1996 and expanded geographically during the subsequent 9 years. Women between the ages of 50 and 69 years were offered screening mammography every 2 years. We compared the incidence-based rates of death from breast cancer in four groups: two groups of women who from 1996 through 2005 were living in counties with screening (screening group) or without screening (nonscreening group); and two historical-comparison groups that from 1986 through 1995 mirrored the current groups.

Results

We analyzed data from 40,075 women with breast cancer. The rate of death was reduced by 7.2 deaths per 100,000 person-years in the screening group as compared with the historical screening group (rate ratio, 0.72; 95% confidence interval [CI], 0.63 to 0.81) and by 4.8 deaths per 100,000 person-years in the nonscreening group as compared with the historical nonscreening group (rate ratio, 0.82; 95% CI, 0.71 to 0.93; P<0.001 for both comparisons), for a relative reduction in mortality of 10% in the screening group (P=0.13). Thus, the difference in the reduction in mortality between the current and historical groups that could be attributed to screening alone was 2.4 deaths per 100,000 person-years, or a third of the total reduction of 7.2 deaths.

Conclusions

The availability of screening mammography was associated with a reduction in the rate of death from breast cancer, but the screening itself accounted for only about a third of the total reduction. (Funded by the Cancer Registry of Norway and the Research Council of Norway.)

Source Information

From the Cancer Registry of Norway, Oslo (M.K., F.L., H.-O.A.); the Departments of Epidemiology (M.K., H.-O.A.) and Biostatistics (M.Z.), Harvard School of Public Health; and the Dana–Farber Cancer Institute and Harvard Medical School (M.Z., H.-O.A.) — all in Boston; and the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (H.-O.A.).
__________________
Gregory D. Pawelski
Reply With Quote
Sponsored Links
Advertisement
  #6  
Old 10-04-2010, 05:27 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Dr. Russ Harris on the new mammography screening

An email from Dr. Russel Harris, Professor and Director of the Health Care & Prevention Concentration of the University of North Carolina School of Public Health, and former US Preventive Services Task Force member, and a recognized thought leader on issues of prevention and especially of screening tests, to Gary Schwitzer of the HealthNewsReview.org, giving analysis of the study. Read this carefully. You'll learn a great deal from his analysis.

"First, the authors say that their primary purpose is showing that there is a reduction in breast cancer mortality due to screening for women ages 40-49. It is worthwhile to point out that the US Preventive Services Task Force (USPSTF) agrees that there is a reduction in mortality in this group. Recall that the systematic review by Nelson et al found a relative risk reduction of 16% for this group, with a number needed to screen (NNS) for 10 years (with NNS you always have to give a length of time for the intervention) of about 2,000. The Swedish study found a relative risk reduction of 26%, with a NNS of 1252. The key issue is not whether there is a benefit, but rather how large the benefit is. In addition, this study says nothing about the harms of screening, while the USPSTF spent much time and energy trying to get a handle on the magnitude of the harms. The decision about screening (whether a policy decision or an individual patient decision) should hinge on the balance between the magnitude of benefits and the magnitude of the harms. So, we can discuss the difference in magnitude of benefit between this study and the USPSTF, but this study won't help us at all with the issue of the magnitude of the harms (including the experience of women with false positive results and the effects of overdiagnosis).

Now, to look at the Swedish study, it is also worthwhile to note that these investigators have an obvious point of view from the start. Their previous papers (especially Tabar and Duffy) have all come to the same conclusion - that screening is a good idea. The Swedish data, and the Norwegian data, are rich datasets and should be explored. However, in both cases it might make more sense for the investigators exploring these data to be clearly disinterested investigators who are not out to prove something. This becomes even more important as we get into the analysis required from such a dataset.

The research design of the Swedish study is a non-randomized trial, with primarily ecologic data (i.e., the data comes from large national databases of breast cancer diagnoses and deaths). When contrasting breast cancer mortality in large groups, two critical issues are (1) making sure the groups are comparable in all factors that might determine the outcome (breast cancer mortality). You want the groups, as much as possible, to differ only in that one group receives screening while the other does not. The other critical issue (#2) is that we could outcomes (breast cancer deaths) equally in both groups. If we count deaths unequally, we bias the results either in favor of or against screening.

In terms of the comparability of the groups, there are several problems:

• The areas that screened starting at 40 are better off than counties that started at 50, meaning that there are likely many other factors (such as treatment) that also are different in these groups. In terms of treatment, for example, the study period (1986-2005) witnessed an impressive improvement in breast cancer treatment. If these improvements in treatment occurred more in the study than the control areas, this could easily explain all of the difference between USPSTF and this study's estimates of the relative risk reduction for women 40-49.

• Some areas switched approaches during the study period - sometimes starting at 40 and sometimes at 50 (and one even at 45). This required statistical "adjustments". The best way to do these adjustments are not clear, and some might do them one way while others might do them another. The Norwegian study tried to take treatment into account - imperfectly, I am sure, but they probably got it at least partly right. The problem of how best to do these adjustments is a special problem for investigators who begin with a point of view. It would be very easy to adjust in a way favorable to their point of view and then justify themselves later.

In terms of which breast cancer deaths to count, this also is probematic:

• They (correctly) focused on deaths in the study group of women diagnosed during their 40s, whether they died then or years later. The issue with screening, after all, is whether diagnosis at an earlier time (in this case, during their 40s) ends up with better health outcomes than diagnosis later, after the women or physician finds a breast lump. The problem comes in which breast cancer deaths in the control group should be counted. To be comparable, you really want to count all of the deaths of women who would have been diagnosed had they been screened. But some of these control group women will, in the absence of screening, now be diagnosed in their 50s rather than 40s. But not all women diagnosed with breast cancer in their 50s in the control group would have been diagnosed by screening in their 40s. So which ones should we count and which ones not? In an RCT, one can determine this by waiting for a time after screening stops in both groups and then, when breast cancer cases in the control group "catch up" with cases in the screen group, you have comparability. But in the Swedish type of study design, there is no way to do that. What this means, then, is that further statistical "adjustments" must be done. The Swedish investigators added or subtracted (they don't tell us how they did this) person-years from the denominator of the study group to adjust. But, as noted above, it is very easy to make those adjustments in a way that favors your point of view.

The end result is that it is really difficult to have confidence in the analyses of this group, and the results of this study. There are just too many ways that the adjustments could bias the final result into the desired direction.

So I think this study points out the many problems of this study design, and the potential for bias in the analysis. Again, I would call for an independent group without a preformed point of view to analyze such data. (Something similar happened with prostate cancer screening in the Tyrol study.)"
__________________
Gregory D. Pawelski

Last edited by gdpawel : 12-12-2012 at 11:31 AM. Reason: spelling error
Reply With Quote
  #7  
Old 10-06-2010, 08:58 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default The efficacy of screening for breast cancer

The efficacy of screening for breast cancer depends not only upon test accuracy, but upon the "efficacy" of proceeding with definitive diagnosis and therapy versus the "efficacy" of doing nothing at all. This is the problem with mammography for breast cancer. There is no doubt that screening mammography can identify cancer at an earlier stage than in the absence of screening.

Biologically, it appears that many cancers diagnosed at an earlier stage with screening are so aggressive that, even at the time of the time of earliest possible detection, there are already micrometastases, meaning that earlier extirpation of the primary tumor does not influence ultimate outcomes in a meaningful way.

More commonly, tumors are so indolent that metastases would not have occurred, even had diagnosis been delayed by one, two, or several years (i.e. until the lesion became palpable and was diagnosed in the former, pre-screening manner).

The use of radiographic tests to screen for the presence of previously undiagnosed cancer is an odious comparison, for a number of reasons.

If one has a test which is less than 100% sensitive and specific, the accuracy of the test depends profoundly on the pre-test probability that whatever is being tested for actually exists.

In the case of mammography, let us say that it is one in 100. We know in advance that 99 women really don't have breast cancer.

If we have 10 suspicious mammograms in these women, requiring follow-up, we are generating expense and possible harm (from unnecessary radiation exposure and complications of biopsy procedures and even from unnecessary extirpative surgery) in 9 women for each woman whom we ultimately help.

So the only patients helped by screening are those who (1) are accurately detected by the screening exam and (2) which have a "Goldilocks" biology -- not too aggressive/not too indolent. Balanced against this is the harm caused by screening, with respect to the false positives and the underlying morbidity of the screening procedure (e.g. radiation exposure).
__________________
Gregory D. Pawelski
Reply With Quote
  #8  
Old 02-22-2011, 05:14 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Blood Test for Early Cancer Detection?

The realm of cancer early detection is just in the image scanning realm. Dr. Robert Nagourney of Rational Therapeutics, described a novel application of the cell search technology developed by Veridex, LLC (a subsidiary of Johnson & Johnson) that may provide an extemely sensitive tool for the early detection of cancer. Four major cancer centers in the United States are conducting an analysis to determine the accuracy of this method for early diagnosis.

Over recent years, it has been recognized that cancer patients circulate small numbers of tumor cells in their blood. Using microbead technology, these tumor cells can be isolated from the blood stream and characterized. The original application of the technology was a prognostic marker by which patients with breast, colorectal or prostate cancers and high levels of circulating tumor cells, fell in the “high-risk” groups. This provides a new opportunity for early diagnosis.

As we speculate on the ramifications of this discovery, certain questions are raised. The most immediate being: What to do with the data? It has previously been suggested that many cancers arise 20 or 30 years before they are clinically detected. Malignant populations measuring in the hundreds of thousands, millions or even hundreds of millions, may still lie below the radar screen of modern diagnostic tools.

If we have the capacity to identify patients 10 or 20 years before their cancers can be clinically detected, would we then begin therapy decades before clinical disease arises? If so, what treatments will we administer? Will the early detection of cancer cells be associated with the further characterization of tumors, such that targeted agents can be utilized to eliminate these clones at their earliest inception?

It will be interesting to see how we answer the questions that arise.
__________________
Gregory D. Pawelski
Reply With Quote
  #9  
Old 07-24-2012, 12:37 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Swedish Mammography Research Finds No Survival Benefit

Mammography Screening and Breast Cancer Mortality in Sweden

P. Autier, A. Koechlin, M. Smans, L. Vatten and M. Boniol

International Prevention Research Institute (iPRI), Lyon, France (PA, AK, MS, MB); Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway (LV)

Correspondence to: Philippe Autier, MD, International Prevention Research Institute (iPRI), 95 Cours Lafayette, 69006 Lyon, France

Abstract

Background:

Swedish women aged 40–69 years were gradually offered regular mammography screening since 1974, and nationwide coverage was achieved in 1997. We hypothesized that this gradual implementation of breast cancer screening would be reflected in county-specific mortality patterns during the last 20 years.

Methods:

Using data from the Swedish Board of Health and Welfare from 1960 to 2009, we used joinpoint regression to analyze breast cancer mortality trends in women aged 40 years and older (1286 000 women in 1995–1996). Poisson regression models were used to compare observed mortality trends with expected trends if screening had resulted in breast cancer mortality reductions of 10%, 20%, or 30% among women screened during 18 years of follow-up after the introduction of screening. All statistical tests were two-sided.

Results:

From 1972 to 2009, breast cancer mortality rates in Swedish women aged 40 years and older declined by 0.98% annually, from 68.4 to 42.8 per 100 000, and it continuously declined in 14 of the 21 Swedish counties. In three counties, breast cancer mortality declined sharply during or soon after the implementation of screening; in two counties, a steep decline started at least 5 years after screening was introduced; and in two counties, breast cancer mortality increased after screening started. In counties in which screening started in 1974–1978, mortality trends during the next 18 years were similar to those before screening started, and in counties in which screening started in 1986–1987, mortality increased by approximately 12% (P = .007) after the introduction of screening compared with previous trends. In counties in which screening started in 1987–1988 and in 1989–1990, mortality declined by approximately 5% (P = .001) and 8% (P < .001), respectively, after the introduction of screening.

Conclusion:

County-specific mortality statistics in Sweden are consistent with studies that have reported limited or no impact of screening on mortality from breast cancer.

JNCI J Natl Cancer Inst (2012) doi: 10.1093/jnci/djs272

[url]http://jnci.oxfordjournals.org/content/early/2012/07/12/jnci.djs272.abstract
__________________
Gregory D. Pawelski
Reply With Quote
  #10  
Old 12-30-2012, 02:31 PM
gdpawel gdpawel is offline
Moderator
 
Join Date: Feb 2007
Location: Pennsylvania
Posts: 4,345
Default Value of Screening - Mammography Questioned

Silvana Martino, M.D.
Director of Breast Cancer Research and Education
The Angeles Clinic Foundation
Santa Monica, California

The New England Journal of Medicine published an article in the November 22, 2012 issue with the conclusion that “Despite substantial increases in the number of cases of early-stage breast cancer detected, screening mammography has only marginally reduced the rate at which women present with advanced cancer. Although it is not certain which women have been affected, the imbalance suggests that there has been substantial over diagnosis, accounting for nearly a third of all newly diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate of death from breast cancer.” This is not a new accusation against screening mammography, it is simply the latest. Is it completely unfounded? I think the answer is no.

The basic principle that underlies screening for any cancer is the assumption that cancers behave in a predictable manner starting from the time of their initial inception. We presume that they begin as small, not invasive lesions, and that with time they become invasive and larger. At some point in the invasive process they spread to the surrounding lymph nodes; and either at the same time or latter, they spread to other parts of the body. If this is always true, than the earlier we identify them, the less likely they are to spread. Theoretically, all breast cancers could be found early enough that none would have the opportunity to spread. With this logic, if all cancers could be found when they are noninvasive, all cancers could be cured simply and require only local therapy.

The present report is based on data compiled from the Surveillance, Epidemiology, and End Results (SEER) program. Breast cancer trends from 1976 through 2008 were used. These data suggest that the introduction of screening mammography over this period has been associated with a doubling of the number of early breast cancers (DCIS and node negative) diagnosed each year. At the same time, the number of advanced (node positive and metastatic) cancers has decreased by only 8%. Further, this small decrease has been primarily in node positive disease with almost no decrease in women presenting with metastatic disease. This suggests several things: (1) We are not preventing metastatic disease by this process, (2) We are modestly reducing node positive disease to node negative or DCIS, (3) We are probably identifying a number of women with DCIS and node negative disease that if not diagnosed might never develop symptoms of breast cancer at all. Presumably some of these women would be better off never knowing that they have an early breast cancer, avoiding treatment, anxiety and cost. This article further states that the improvement in survival that has been seen in breast cancer over the past decades is mostly due to improvement in systemic therapy and not from screening. Improvement in therapy makes screening increasingly less valuable.

So where are we going with all of this? Clearly one of the goals is reducing the cost of medical care in the U.S. Screening the general population is not an inexpensive proposition. This controversy was preceded in 2009 by a report from the U.S. Preventive Services Task Force (USPSTF) recommending that screening mammography begin at age 50 and not at 40, and that mammograms be performed every other year rather than yearly. Since then, there has been a decrease in mammograms in women under 50 in spite of considerable public opposition to the recommendations. The present article serves to further discourage screening mammography.

Other than a need to reduce medical expenditure, is there any other value to the present article? Truthfully, I am not certain. That we have not decreased the number of women who present with more advanced disease is disappointing. It may be that some breast cancers become metastatic so early in their course that we simply cannot find them “early enough.” One could argue that, perhaps, we are not screening often enough or we need to realize that mammography is simply not a “good enough” tool.

That we are diagnosing a lot of women with DCIS and early invasive breast cancer can be seen as both good and bad. Some women absolutely benefit by
being diagnosed at an earlier stage than would happen otherwise. However, I do believe that there are women with early disease that if not diagnosed would be better off. These are women who would never go on to have any symptoms of breast cancer in their lifetime. Both the personal and financial cost could be avoided. If only we could identify these women, we could leave them alone. Is the key a better tool?

In summary, though many of us are deeply wedded to the concept of screening mammography, and I am suspicious that this issue is primarily about cost
containment, we must be fair and critically analyze data that suggest that we have overestimated its biological value.
__________________
Gregory D. Pawelski
Reply With Quote
Sponsored Links
Advertisement
Reply


Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

vB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Forum Jump


All times are GMT -5. The time now is 05:46 AM.