The Lake Wobegon Effect: Why Most Patients Are at Below-Average Risk
Authors: Andrew J. Vickers, David M. Kent
Journal: Annals of Internal Medicine (2015)

Ideas and Opinions16 June 2015The Lake Wobegon Effect: Why Most Patients Are at Below-Average RiskAndrew J. Vickers, DPhil and David M. Kent, MD, CM, MScAndrew J. Vickers, DPhilFrom Memorial Sloan Kettering Cancer Center, New York, New York, and Tufts Medical Center, Boston, Massachusetts. and David M. Kent, MD, CM, MScFrom Memorial Sloan Kettering Cancer Center, New York, New York, and Tufts Medical Center, Boston, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-2767 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In Garrison Keillor's fictional Midwestern town of Lake Wobegon featured in A Prairie Home Companion, "all the women are strong, all the men are good-looking, and all the children are above average." It might also seem deliberately paradoxical to say that "most patients are at below average risk" or that "most patients within a trial experience less than the average level of benefit from a drug." But these statements are true more often than not (1).To start with a simple example, the lifetime risk that an American will develop lung cancer is about 7.5%. But because smoking strongly increases ...References1. Kent DM, Hayward RA. Limitations of applying summary results of clinical trials to individual patients: the need for risk stratification. JAMA. 2007;298:1209-12. [PMID: 17848656] CrossrefMedlineGoogle Scholar2. Bach PB, Gould MK. When the average applies to no one: personalized decision making about potential benefits of lung cancer screening. Ann Intern Med. 2012;157:571-3. [PMID: 22893040] doi:10.7326/0003-4819-157-8-201210160-00524 LinkGoogle Scholar3. Kent DM, Hayward RA, Griffith JL, Vijan S, Beshansky JR, Califf RM, et al. An independently derived and validated predictive model for selecting patients with myocardial infarction who are likely to benefit from tissue plasminogen activator compared with streptokinase. Am J Med. 2002;113:104-11. [PMID: 12133748] CrossrefMedlineGoogle Scholar4. Kent DM, Schmid CH, Lau J, Selker HP. Is primary angioplasty for some as good as primary angioplasty for all? J Gen Intern Med. 2002;17:887-94. [PMID: 12472924] CrossrefMedlineGoogle Scholar5. Thune JJ, Hoefsten DE, Lindholm MG, Mortensen LS, Andersen HR, Nielsen TT, et al; Danish Multicenter Randomized Study on Fibrinolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI)-2 Investigators. Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty. Circulation. 2005;112:2017-21. [PMID: 16186438] CrossrefMedlineGoogle Scholar6. Vickers AJ, Cronin AM, Björk T, Manjer J, Nilsson PM, Dahlin A, et al. Prostate specific antigen concentration at age 60 and death or metastasis from prostate cancer: case-control study. BMJ. 2010;341:c4521. [PMID: 20843935] doi:10.1136/bmj.c4521 CrossrefMedlineGoogle Scholar7. Carlsson S, Assel M, Sjoberg D, Ulmert D, Hugosson J, Lilja H, et al. Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population based cohort study. BMJ. 2014;348:g2296. [PMID: 24682399] doi:10.1136/bmj.g2296 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Memorial Sloan Kettering Cancer Center, New York, New York, and Tufts Medical Center, Boston, Massachusetts.Grant Support: In part by funds from David H. Koch provided through the Prostate Cancer Foundation, the Sidney Kimmel Center for Prostate and Urologic Cancers, and the National Cancer Institute (P50-CA92629 [Specialized Programs of Research Excellence grant] and P30-CA008748 [to Memorial Sloan Kettering Cancer Center]). Additional support was provided by the National Institutes of Health (grant U01 NS086294), the Patient-Centered Outcomes Research Institute (grant 1IP2PI000722), and a Clinical & Translational Science Awards U-award (UL1 TR001064).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2767.Corresponding Author: Andrew J. Vickers, DPhil, Memorial Sloan Kettering Cancer Center, 307 East 63rd Street, 2nd Floor, New York, NY 10065; e-mail, [email protected]org.Current Author Addresses:Dr. Vickers: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY 10017.Dr. Kent: Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA 02111.This article was published online first at www.annals.org on 14 April 2015. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited By'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary careRisk Framing in Cardiovascular Medicine IIFear of Coronavirus Disease 2019—An Emerging Cardiac RiskThe Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement: Explanation and ElaborationDavid M. Kent, MD, MS, David van Klaveren, PhD, Jessica K. 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