statistical significance tests

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John Park, MD
Radiation Oncologist
Kansas City VA Medical Center

Poisoned Priors: Will You Drink from This Well?

As an oncologist, specializing in the field of radiation oncology, “The Statistics Wars and Intellectual Conflicts of Interest”, as Prof. Mayo’s recent editorial is titled, is one of practical importance to me and my patients (Mayo, 2021). Some are flirting with Bayesian statistics to move on from statistical significance testing and the use of P-values. In fact, what many consider the world’s preeminent cancer center, MD Anderson, has a strong Bayesian group that completed 2 early phase Bayesian studies in radiation oncology that have been published in the most prestigious cancer journal —The Journal of Clinical Oncology (Liao et al., 2018 and Lin et al, 2020). This brings about the hotly contested issue of subjective priors and much ado has been written about the ability to overcome this problem. Specifically in medicine, one thinks about Spiegelhalter’s classic 1994 paper mentioning reference, clinical, skeptical, or enthusiastic priors who also uses an example from radiation oncology (Spiegelhalter et al., 1994) to make his case. This is nice and all in theory, but what if there is ample evidence that the subject matter experts have major conflicts of interests (COIs) and biases so that their priors cannot be trusted?  A debate raging in oncology, is whether non-invasive radiation therapy is as good as invasive surgery for early stage lung cancer patients. This is a not a trivial question as postoperative morbidity from surgery can range from 19-50% and 90-day mortality anywhere from 0–5% (Chang et al., 2021). Radiation therapy is highly attractive as there are numerous reports hinting at equal efficacy with far less morbidity. Unfortunately, 4 major clinical trials were unable to accrue patients for this important question. Why could they not enroll patients you ask? Long story short, if a patient is referred to radiation oncology and treated with radiation, the surgeon loses out on the revenue, and vice versa. Dr. David Jones, a surgeon at Memorial Sloan Kettering, notes there was no “equipoise among enrolling investigators and medical specialties… Although the reasons are multiple… I believe the primary reason is financial” (Jones, 2015). I am not skirting responsibility for my field’s biases. Dr. Hanbo Chen, a radiation oncologist, notes in his meta-analysis of multiple publications looking at surgery vs radiation that overall survival was associated with the specialty of the first author who published the article (Chen et al, 2018). Perhaps the pen is mightier than the scalpel! Continue reading →