NEJM: Competing Visions for U.S. Health Policy, Evolocumab for Pediatric Familial Hypercholesterolemia, and the Cervical Cancer Vaccine

A recent commentary (M Fiedler. NEJM 2020; 383: 1197-99. Competing Visions for the Future of Health Policy) describes two competing approaches to U.S. healthcare policy.

  • The current administration has supported legislation which would repeal or sharply curtail many of the Affordable Care Act’s (ACA’s) coverage provisions and is “asking the U.S. Supreme Court to strike down the entire ACA.”  Their approach views “existing federal coverage programs, particularly those serving lower-income people, [as] too expansive.”
  • The main alternative approach aims for expanded insurance coverage and deep subsidies to cover low- and moderate-income individuals.
  • Areas of potential agreement include encouraging competition to lower costs as well as making prices more transparent to encourage patients to seek out lower-priced alternatives.

My take: Overall, I favor more expansive health care coverage.


RD Santos et al. NEJM 2020; 383: 1317-1327. Evolocumab in Pediatric Heterozygous Familial Hypercholesterolemia

Methods: In this 24-week, randomized, double-blind, placebo-controlled trial with pediatric patients (n=157) with heterozygous familial hypercholesterolemia, patients 10 to 17 years of age were treated with evolocumab.  All had been receiving lipid-lowering treatment before screening and had LDL cholesterol level of 130 mg/dL.

Key finding: At week 24, the mean percent change from baseline in LDL cholesterol level was −44.5% in the evolocumab group and −6.2% in the placebo group.

My take: Long-term data are needed.  However, in high risk patients who have not responded to other intensive treatment, evolocumab may be worthwhile.


J Lei et al. NEJM 2020; 383: 1340-1348. HPV Vaccination and the Risk of Invasive Cervical Cancer

Methods: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017.

Key findings:

  • After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.

My take: HPV vaccine (aka ‘Cervical Cancer Vaccine’) may lower the risk of cancer by 88% in those vaccinated before the age of 17 years.

From The Onion

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