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Selected news articles which highlight important policy issues.

News: Weekly Archives

News for the week of 05-28-2007

Doctors' list puts a price on care
Los Angeles Times, 5-28-07

Editor's Notes:

The L.A. Times writes that "California's largest private physician practice", with over a half million patients, has posted prices for many routine medical procedures on its Web site, following the example set by convenient care clinics like RediClinic and MinuteClinic.

The move by Torrance–based HealthCare Partners Medical Group, which serves more than 500,000 patients, puts a significant crack in the ages–old reluctance by doctors and other medical providers to let consumers comparison shop for services such as chest X–rays, baby vaccinations and Pap smears.

HealthCare Partners quietly posted on its website last week prices for 58 common procedures.

Patients can go on the group's website and find that a chest X–ray runs $61 and that a physical examination for a middle–aged patient ranges from $140 to $160. Flu vaccinations are listed at $15, although HealthCare Partners notes that it adds a $31 administrative fee for the first vaccination and $18 for each additional shot on the same visit.

HealthCare Partners' effort could prompt other physician groups to follow suit, given the competitive nature of Southern California's healthcare market, some experts said.

...

The move was motivated in part by the rapid advance of walk–in medical clinics at drugstore chains and discount retailers, such as CVS Caremark Corp. and Wal–Mart Stores Inc., where the prices of blood pressure checks and flu shots are as easy to spot as those for rubbing alcohol and cat food.

HealthCare Partners' price list also answers calls from President Bush and others to give consumers the information to make better healthcare choices. Proponents believe that shifting medical costs to patients, along with price tags, will blunt the nation's runaway medical bill by curbing unnecessary care and infusing price competition into the marketplace.

There are two criticisms of price posting: First that "providers don't want to compete on price because they think it cheapens the medical field." With all due respect to physicians, if a provider doesn't want a consumer to know how much their services cost, they must not be very confident that the patient would think that the price reflects fair value. This is not, however, a good reason to not do it.

The second objection is that "the biggest cost drivers are the chronically ill, who are often unable to comparison shop and quickly reach even the highest deductibles every year." This is a serious objection, but it has more to do with our third–party health insurance system. If consumers had a direct tax credit or tax deduction for health insurance, as President Bush has proposed, they could shop for specialized health insurance vehicles that would bundle chronic care services for a single affordable price. (For more on how this would work, see Regina Herzlinger's new book, Who Killed Health Care? America's $2 Trillion Medical Problem and the Consumer Driven Cure)

The real kicker in the L.A. Times story, however, is this revelation: "almost a third of physician groups' overhead is the cost of submitting and collecting bills to insurers and government programs." If consumers purchased more of their own health care directly, those administrative costs would fall overnight.

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Facing cancer without insurance
Cleveland Plain Dealer, 5-28-07

Editor's Notes:

Although liberal and conservative policy experts may disagree on the exact solution to our health care woes, one thing we can all agree on is that the current tax preference for employer–provided health insurance does a grave disservice to the uninsured, particularly those with chronic illnesses.

No illness is easy for an uninsured patient, but one is particularly onerous.

Cancer, the nation's No. 2 killer, has bankrupted families and strained hospital charity funds in Northeast Ohio. And although insurance does not guarantee a positive outcome, experts agree that it influences how quickly cancers are detected and how aggressively they get treated.

As politicians nationwide debate health insurance, here are the stories of four patients who bring the issue to life.

Jacqueline Pineda

One morning as Pineda awoke, the weeks of swelling and pain in her breast erupted. What the uninsured mother from Canton had dismissed as a cyst was actually a cancerous tumor. It burst through the skin as a brownish discharge, and the disease had spread to her lymph nodes.

Pineda had never seen a doctor about the swelling; she couldn't afford to. She was already in debt when she first noticed the knifing pain building in her right breast. She was climbing out of personal bankruptcy and focusing most of her energies on her teenage son.

Since her illness, Pineda has relied on family, friends, churches and private charities to pay her monthly household expenses and car payment. Her son lives with his father in Georgia.

Eventually, Pineda got government assistance. Her first disability check arrived in May, and Medicaid is paying most of her $100,000 in unpaid medical bills. She said she hopes to return to work once her radiation is completed. But Pineda still reels from the financial headaches.

We must do more to make routine health care more accessible and affordable for patients like Ms. Pineda, and the best way to start is by creating a tax credit or deduction for health insurance that would help the uninsured purchase health insurance, whether or not they were employed.

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GlaxoSmithKline shares fall after report shows U.S. doctors shunning Avandia drug
Associated Press, 5-29-07

Editor's Notes:

The AP reports that U.S. physicians are "shunning" Avandia in the wake of a report in the New England Journal of Medicine showing that patients taking the drug may have an increased risk of heart attack.

GlaxoSmithKline PLC shares dropped Tuesday after a report showing that doctors in the United States have shunned its diabetes drug Avandia since a study was published last week showing that people taking the drug are at greater risk of having a heart attack.

Market intelligence group Impact RX said that Avandia's share of the market for newly prescribed oral anti–diabetics fell to around zero from around 10 percent in the two days after the article was published in The New England Journal of Medicine on May 21.

At the same time, the rate of patients switching from one drug to another was three times the usual level. Takeda Pharmaceutical Co. Ltd.'s rival drug Actos' share of the new prescription market increased from 10 percent to 22 percent.

"This reaction is far worse than we had anticipated and suggests that there could be as much as 22 percent downside risk to GSK's near–term earnings, suggesting that there is still further downside to GSK's share price," Deutsche Bank analysts said in a note.

Glaxo shares fell 2.1 percent to 1,306 pence (US$25.87; €19.20) on the London Stock Exchange.

The journal, citing a number of combined studies on the drug, reported last week that people using Avandia have a 43 percent greater risk of heart attack than patients using other diabetes drugs, or no medication.

Glaxo said its own reviews showed the drug increased the risk of heart attack by 30 percent, and said it told the Food and Drug Administration about that last year. The British drugmaker added that it disagreed with the article's conclusions and questioned its methodology.

Is Actos, whose market share doubled, a safer drug than Avandia? Will patients who were stable on Avandia have worse outcomes after switching to another treatment? What are the long term outcomes of the switch from Avandia? These are important questions, but it's not clear that anyone is trying to answer them in the media feeding frenzy around the drug.

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Why Health Care No Longer Makes Politicians Leery
Wall Street Journal, 5-30-07

Editor's Notes:

This article tries to make the case that the American electorate is finally willing to "think big" about health care and sanction a larger role for the government in this area. And politicians from both parties are following the political head winds:

This shift reflects rising and inflation–topping out–of–pocket costs for health care and insurance premiums, co–payments and deductibles. Also, the number of uninsured has spiked to about 45 million, from 37 million when Mr. Clinton was president. Business leaders increasingly are seeking a government–imposed solution, saying employee health costs put them at a disadvantage with foreign competitors.

Those forces, in turn, have combined to embolden politicians in both parties to once again propose universal health care that inevitably would mean a big role for government—and possibly upend the powerful insurance, medical and pharmaceutical industries.

Mr. Obama's speech unveiling his initiative in Iowa, the state with the first nominating contest, comes a week after Sen. Hillary Clinton of New York proposed health–cost savings as an integral part of a later plan specifically aimed at covering uninsured Americans. The third candidate in Democrats' top tier of White House contenders, former North Carolina Sen. John Edwards, beat both to the punch with a detailed universal–coverage plan in early February.

In Congress, Democratic Sen. Ron Wyden of Oregon and Republican Bob Bennett of Utah have drafted a bill to overhaul the nation's health system. It isn't expected to get off the ground during the current Congress and the remainder of George Bush's presidency, though, given the president's belief in market forces and opposition to government regulation. Moreover, he and the Democrat–led Congress are locked in battle over Iraq. The public likewise is preoccupied with war, polls show, but health care has re–emerged as voters' top domestic concern.

Indeed, the political center on the issue seems to have shifted so much that the health–insurance industry, which undermined the Clinton plan with commercials featuring middle–class couple "Harry and Louise" ridiculing the big bureaucracy it would create, openly supports a federal role in universal coverage. The industry strategy is to shape the result rather than to fight it.

Mohit Ghose, a spokesman for America's Health Insurance Plans, the successor group to the one that fought the Clintons, yesterday said, "The most important thing for us is that there are plans out there." The group's own proposal for universal health care, unveiled after Democrats won control of Congress, focuses on increasing federal subsidies for insurance, and avoids new mandates or regulations.

The Republican Party also is adjusting to voters' openness to a government role in making health-care more affordable and accessible, with the goal of putting its imprint on any changes.

"Republicans have an opportunity to lead on health care by promoting broad-based reform consistent with our principles: consumer choice, market incentives, technology," said former Republican Party Chairman Ken Mehlman.

Some things have changed, but some things remain the same. The number of uninsured, for instance, has increased, but not spiked: the percentage of uninsured in the U.S. has been the same for about the last decade, around 15%. Numbers are up, but only because the U.S. population has grown. There is also recognition that the "45 million" is a largely inflated statistic.

Also, opinion surveys supporting universal health care show about the same levels of support as in 1994, when HillaryCare was in full swing. What has changed, however, are health care costs, and the fact that employers are shifting more of those costs directly to employees.

Whether this translates into wholesale reform is too hard to say yet. Most likely, incremental reforms will continue to be the order of the day, no matter which party takes the Presidency in 2008.

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Bush AIDS Plan Gets Bipartisan Praise
Washington Post, 5-31-07

Editor's Notes:

This week, President Bush proposed doubling the funding (from $15 billion to $30 billion) for the President's Emergency Plan for AIDS Relief (PEPFAR), which has received high marks for bringing antiretroviral AIDS drugs to millions of patients in Africa, Guyana, Haiti, and Vietnam.

President Bush's call for a doubling of the U.S. commitment to battling the global AIDS crisis was met yesterday with broad support uncommon in Washington. International aid organizations, advocacy groups and members of Congress from both parties offered praise for the proposal—even if some argued that the proposed increase is insufficient.

Speaking in the Rose Garden yesterday, Bush called on Congress to increase the funding for the President's Emergency Plan for AIDS Relief (PEPFAR) to $30 billion over five years, beginning in October 2008. In his State of the Union address in 2003, the president promised $15 billion to fight AIDS over the five years ending in September 2008—hen the largest financial commitment by a nation to battling a disease.

The increased commitment Bush is asking for would pay for AIDS treatment for 2.5 million people in 15 countries—more than double the 1.1 million who now receive treatment through the program.

"This is a promising start, but yet without further action the legislation that funded this emergency plan is set to expire in 2008," Bush said in calling for expanding and extending the program...

Bush's statement was immediately applauded by members of Congress, as well as by representatives of international aid organizations and other advocacy groups.

"With the energy and resources provided by PEPFAR and other programs, there has been impressive progress in the fight against HIV and AIDS worldwide, but the battle is far from won," said Sen. Russell Feingold (D–Wis.), who chairs the Foreign Relations Committee's Africa subcommittee. "Right now, only a small percentage of those who need lifesaving drugs are receiving them, while millions more are contracting this preventable virus every year."

PEPFAR and similar initiatives from organizations like the Bill and Melinda Gates Foundation are saving lives and should be applauded. But the West's preoccupation with buying expensive, high tech treatments (like AIDS drugs) ignores the sad fact that the disease's prevalence is rapidly outstripping treatment efforts in many countries, and will continue to do so as long as prevention takes a back seat to treatment.

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FDA Remains Unsettled in Wake of New Questions
The New York Times, 5-31-07

Editor's Notes:

The New York Times habitually portrays the FDA as an agency in "crisis", unable or unwilling to grapple with safety questions surrounding new drug approvals. This article offers the same narrative regarding questions about the safety of the diabetes drug Avandia, which may (the data is uncertain at this point) be linked to a small but significant increase in heart disease in some patients.

The FDA is adopting a "wait and see" approach as it reviews evolving data, while the media seems to have already decided that the FDA has blundered.

When Dr. Andrew C. von Eschenbach took over the Food and Drug Administration in 2005, the agency had a crisis over drug approvals that had missed or ignored dangerous side effects in Vioxx, antidepressants and other prominent medications.

Dr. von Eschenbach promised improvements, and agency officials said they would no longer be caught flatfooted on drug safety.

But this month, The New England Journal of Medicine published a study suggesting that a major diabetes pill, Avandia, might increase the risk of heart attacks.

Concerns over that drug and others have led Republicans and Democrats in the House and the Senate to call for investigations. A House hearing is planned for June 6.

Dr. von Eschenbach said in a briefing on Wednesday that his agency needed to collaborate more closely with drug companies. "The point is that we need to look at the role of the F.D.A. in being a bridge to the future, not a barrier to the future," he said at his office here.

Responding to a suggestion that promoting collaborations with drug makers, including an effort to modernize human testing and find genetic markers to predict suffering from side effects, may not be politic, Dr. von Eschenbach said the agency was not working solely with pharmaceutical companies.

"It's with everyone," including government agencies and independent scientists, he said.

He defended the agency in the Avandia case, saying, "I believe we did it right with regard to Avandia."

Hints of the heart risks from Avandia were, however, present from the beginning. The original trials, overseen by GlaxoSmithKline, the drug's maker, showed that patients taking the drug had more than twice the rate of ischemic heart disease as recipients of placebos.

The article goes on to note that there is dissension at the FDA between safety reviewers and officials who oversee new drug approvals. This debate, however, goes to a larger public policy question: Should new drugs have to prove that they are reasonably safe and effective before they are marketed, or should companies have to resolve and adjudicate all potential safety questions before a drug is cleared for marketing?

At least some safety reviewers, like David Graham, think the latter standard, not the former, should apply. Others hew to the more flexible, "reasonable", test for drug safety.

In fact, the FDA didn't "miss or ignore" questions "over drug approvals" for Vioxx and antidepressants, because some safety issues simply won't emerge until medicines are used by millions of patients in a post market environment. Even in those cases, the safety signals can often be contradictory or muddled—as is the current case with Avandia.

In other words, the studies required for FDA approval don't—and in some sense can't—pick up every safety issue that can conceivably emerge in larger patient populations. While the FDA should receive new funds and power to monitor drugs after they are on the market, this will not somehow make drugs "safe," it will just improve how we use them—a critical improvement, but not a cure–all.

Asking drug manufacturers to meet a precautionary standard for drug safety would, however, bring drug development to a grinding halt because it is impossible to only approve "safe" drugs, something which the media and Congress seem unable to grasp. For some reason, the potential risks associated with drugs seem to overshadow the far more serious and routine dangers of diseases like diabetes and depression.

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Will you get cancer?
Forbes, 5-31-07

Editor's Notes:

Forbes offers an overview on how rapidly genetic testing is evolving, and suggests that in the next 5-10 years there will be a wave of new genetic tests coming to market.

If the only thing you know about genetic testing comes from Ethan Hawke's travails in the movie Gattaca you probably think that genetic testing will lead to a nightmare of mass discrimination and Orwellian–style surveillance.

Misuse is always a danger (particularly in despotic regimes like North Korea) but these predictions are unlikely to pan out in free societies—at least not if the market has anything to say about it. After all, as we unravel the genetic roots of disease, companies are going to find new ways to treat and cure those same diseases more effectively and cheaply than ever before.

For most of her adult life Kim I. Wolfe lived in constant fear of breast cancer. Her mother had survived the disease at age 37. By the time she turned 32, Kim was undergoing breast exams every three months. In 2003 her mother tested positive for a gene that dramatically raises the risk of breast and ovarian cancer. In 2005 Kim herself took the test, six months after the birth of the younger of her two sons.

And then she knew: She had the breast cancer gene, too. Yet she says she felt "relieved" and "empowered" by the verdict. In an eight–hour operation at Memorial Sloan–Kettering Cancer Center in New York, she had her breasts and ovaries removed. Her reconstructed breasts "look real," she says, and she has had no second thoughts. "I feel a hundred bricks have been lifted off of me," she says. "The genetic testing is the most wonderful thing. You can look into a crystal ball and almost see your future... and then do something about it."

The breast cancer gene test generates sales of $100 million a year for Myriad Genetics, which has sold it to 150,000 women. Sales are growing 40% a year; the first tv ads are planned for the fall. It is among the first hit products in a wave of hundreds of new DNA diagnostic tests that will overrun medicine in the next five to ten years. Able to foretell higher risks for cancer, heart disease, diabetes, schizophrenia and more, these gene screens will form a new multibillion-dollar business, promising a new kind of preemptive care and posing new ethical questions of what patients should know and when they should know it.

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Good, bad news on breast cancer; drug curbs relapses, but eligibility tests raise major doubts
Chicago Tribune, 6-5-07

Editor's Notes:

While we are bullish on the future of genetic screening for disease, and the ability of gene tests to help develop better, more targeted medical treatments, the reliability of some current genetic tests leaves much to be desired, as the Tribune reports in this article:

Cancer researchers meeting in Chicago had good and bad news Monday for breast-cancer patients who are eligible for treatment with the new-generation drug Herceptin—at least 40,000 a year in the U.S. alone.

The good news is that Herceptin continues to prevent relapses years after patients stop taking it. The bad news is that the laboratory tests used to determine eligibility appear to be highly inaccurate. That means some women who could benefit from Herceptin don't get it, while others are subjected to the side–effects and high cost of the drug with no hope of a benefit.

"It is a very big deal," said Dr. Larry Norton, head of breast-cancer programs at Memorial Sloan–Kettering Cancer Center in New York.

About one–quarter of breast–cancer patients carry extra copies of a gene called HER2, which makes their tumors more aggressive but also makes them respond to Herceptin, a synthetic antibody that targets the HER2 protein. Herceptin, one of the first in a new generation of targeted cancer drugs, has been shown to reduce the risk of recurrence by about 50 percent. That is a huge benefit, because breast cancer doesn't become life–threatening unless it recurs and spreads to other parts of the body.

On Monday Dr. Edith Perez of the Mayo Clinic location in Jacksonville, Fla., presented trial results showing that, four years after treatment, the women who got Herceptin in addition to chemotherapy were 35 percent more likely to be alive and 52 percent more likely to be relapse–free.

"This is good news for patients," she said.

But one of the slides Perez screened at the annual meeting of the American Society of Clinical Oncology showed that some patients who were classified as HER2–negative got the same benefit as those who tested positive. Perez's data contained too few patients to be statistically significant, but another researcher was scheduled to present similar findings Tuesday in a bigger set of patients...

Dr. Kathy Albain, director of breast research at Loyola University Health System in Maywood, predicted the data would cause "mass confusion," adding, "It will give me pause to remeasure someone who is initially HER2—negative."

Perez also suggested it might make sense to retest anyone whose first test was negative, just in case it's a false result. "I'm worried about excluding patients who might benefit," she said.

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Antipsychotics may bear fatal risks
The Globe and Mail, 6-5-07

Editor's Notes:

While Congress and the media are in a tizzy over who-knew-what–where–when over the FDA and Avandia, this article may help put some of these questions into perspective by reminding readers that while initial studies on the risks of newer drugs may make them appear more dangerous than older medicines, additional studies may wind up contradicting those findings.

The problem is that generic companies have no incentives to study older, off–patent medicines, and they receive much less critical media attention than companies making newer treatments. The result may be a bias that older drugs are safer than newer ones, which is certainly not always the case.

Antipsychotic drugs commonly prescribed to calm nursing–home residents who suffer from dementia appear to increase the risk of death, according to new Canadian research.

A study published in today's edition of the Annals of Internal Medicine also shows, surprisingly, that tried–and–true antipsychotic medications appear to be even more risky than the newer versions, which have come under much scrutiny.

"Warnings have been applied specifically to new drugs, but we should consider putting warnings on older drugs too," said Sudeep Gill, an adjunct scientist at the Institute for Clinical Evaluative Sciences and lead author of the study, in an interview.

He also expressed concern that there has been a "troubling shift back to conventional agents that might be potentially harmful."

Still, Dr. Gill, who is also a geriatrician at St. Mary's of the Lake Hospital in Kingston, Ont., stressed that there can be real benefits to using antipsychotics to treat patients with dementia who are quite agitated.

"On balance, this may be something a patient needs," he said. "So I would be very cautious about the message."

Dr. Gill's admonition about being "very cautious about the message" when delivering data on drug risks is very well taken—but does not seem to be much heeded.

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Giuliani Health Proposal Seeks Individual Coverage; Candidate to Unveil Market Based Plan Easier on Employers
Wall Street Journal, 6-6-07

Former New York Mayor Rudy Giuliani, one of the leading candidates for the Republican presidential nomination, has begun to flesh out his plans for health care reform. Giuliani's plan is market friendly, and is based on giving individuals more control and responsibility for their own health care:

Mr. Giuliani, currently leading opinion polls for the 2008 Republican nomination, wants to move tens of millions of people from employer–based health insurance to the individual market as a way of giving people more coverage choices. It is an idea he alluded to in Tuesday's Republican debate in Manchester, N.H., and later expanded on in an interview...

The plan, which Mr. Giuliani said he hopes to unveil in detail this summer, launches the health–care debate among Republican candidates and provides a contrast to the push for universal coverage aided by government subsidies emerging from the Democratic field.

The principles Mr. Giuliani identified for health care mirror President Bush's call for an "ownership society" in which the power of the free market could eventually shore up health and retirement security programs alike. That concept proved a political failure when Mr. Bush used it in 2005 to argue for partial privatization of Social Security. But in the campaign to woo Republican primary voters, it could provide Mr. Giuliani with an issue to appeal to economic conservatives at a time when some social conservatives have misgivings about his support for abortion rights and gun control.

In Mr. Giuliani's view, the U.S. health–care system's major problem is a lack of consumer choice. "It's your health; you should own your own insurance," he said in Tuesday's debate. "The reality is that we need a free market."

He envisions a system where neither state regulations nor federal tax law push people into expensive plans rich in benefits. Rather, health insurance should be more like car insurance, he said, where people pay out of pocket for minor repairs and maintenance.

In its initial outlines, Giuliani's proposal seems promising and mirrors suggestions for health care reform made by our colleagues David Gratzer and Regina Herzlinger.

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Cancer Catch-22; Researchers want to know if a pill can prevent breast cancer, but U.S. calls study too risky for healthy volunteers who won’t get disease.
Chicago Sun-Times, 6-6-07

Editor's Notes:

The National Cancer Institute has put on indefinite hold a study looking at how two cancer drugs might actually prevent breast cancer from taking root in the body:

Can taking a pill drastically reduce a woman's risk of getting breast cancer?

For 15 years, the government has been funding big, expensive studies on this idea, called "chemoprevention."

The latest study was to be a head–to–head comparison of the promising chemoprevention drugs Evista and Femara, to be given to 12,800 women at high risk for breast cancer.

But just before the $100 million trial was to begin, the director of the National Cancer Institute abruptly put the study on hold.

The move has infuriated researchers. "It is not acceptable to withhold funding for a study that represents a vital opportunity to dramatically reduce the toll of breast cancer," said Dr. Seema Khan of Northwestern University medical school, one of several Chicago centers planning to participate in the trial.

But some breast cancer advocates consider chemoprevention misguided. Why, they ask, should a woman who probably will never get breast cancer take a pill that could cause serious and potentially fatal side effects?

"Over 95 percent of the healthy volunteers to be accrued to the trial will not develop breast cancer if they took a sugar pill, and still they will be exposed to potent drugs," said Carolina Hinestrosa of the National Breast Cancer Coalition Fund.

More than 1 million women are at high risk of breast cancer, meaning they face a greater than 1.7 percent chance of getting breast cancer in the next five years. Many women face a lifetime risk of at least 20 percent. Factors that increase the risk include family history (mother, sister or daughter), multiple breast biopsies, carrying the BRCA breast cancer mutation, etc. (To calculate your risk, visit www.breastcancerprevention.org).

While details are relatively sketchy in the article, it seems strange to put a trial on hold if rules on informed consent have been met, and the relative risks and benefits of the procedure have been adequately explained to trial volunteers.

The trial should also be targeted at the patients who are at highest risk for breast cancer, and thus have the highest likelihood of benefiting from the treatment.

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Project FDA.

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