While we wait for our shot(s); an opinionated take on NEJM highlights for January 2021

Incremental progress in the fight to treat heart failure

After a decade or more of relative quiescence in the 2000s, a volley of new therapies have come to the forefront in the pages of the NEJM: sacubitril valsartan (2014 – Novartis’ Entresto), various SGLT2 inhibitors such as dapagliflozin (2019, AstraZeneca’s Farxiga), vericiguat (2020 – Merck’s Verquvo), and now a 2021 entry from Amgen in the form of the cardiac myosin activator omecamtiv mecarbil. None of those are a panacea, and of the four listed, omecamtiv has the lowest efficacy profile in the trial. But for each of these, there are going to be patients who respond better and worse, and one can envision real future value in figuring out predictive biomarkers as well as biomarkers of response that allow the optimal choice. Cardiac Myosin Activation with Omecamtiv Mecarbil in Systolic Heart Failure; Stimulation of Contractility in Systolic Heart Failure


On the whacking of moles

Invasive melanoma is without a doubt a serious cancer, and increasing awareness over the last decades has led to a much greater rate of annual screenings and biopsies of skin lesions. In a thoughtfully argued piece, a dermatologist, a pathologist, and public health specialist, argue that this has gone way too far. To support their perspective, they show how the rate of diagnosis of “melanoma in situ” has increased completely out of proportion of what might be expected even with a worst-case scenario of sunburn and tanning salon exposure, and that there is little associated health benefit. It’s a system run amok: awareness begets screenings which beget more biopsies which are assessed with lower and lower threshold for diagnosis of a malignant process which then increases the case rate and finally then again increases awareness. And in a fee-for-service regime, with dermatopathology services frequently offered under the same roof, financial incentives are not helping. This is not an isolated story, see for instance this recent critique of the over-aggressive evaluation of incidentally detected lung nodules. Getting this right is probably the thorniest and most central problem of value for money in healthcare. The Rapid Rise in Cutaneous Melanoma Diagnoses


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.