REVERSAL OF ESTABLISHED MEDICAL PRACTICES

Evidence to Abandon Ship?

Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new treatments outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not. In these cases, it becomes apparent that clinicians, encouraged by professional societies and guidelines, have been using medications, procedures, or preventive measures in vain.

For example, percutaneous coronary intervention performed for stable coronary artery disease and hormone therapy prescribed for postmenopausal women cost billions of dollars and supported the existence of entire specialties for many years. Stable coronary artery disease accounted for 85% of all stenting in the United States at the time of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. 1 Large, well-designed randomized trials that tested whether these practices improved major patient outcomes revealed that patients were not being helped. Defenders of these therapies and interventions wrote rebuttals and editorials and fought for their specialties, but the reality was that the best that could be done was to abandon ship. Often, what is a standard of practice involves the livelihood of countless specialists. How many are willing to abandon an ineffective status quo if their lifestyle is dependent upon maintaining it?

How many established standards of medical care are wrong? It is not known. Medical practice has evolved out of centuries of theorizing, personal experiences, bits of evidence, expert consensus, and diverse conflicts and biases. Rigorous questioning of long-established practices is difficult for most to undertake due to the risk of being ostracized and ridiculed by your peers, as well as being blackballed by pharmaceutical and device manufacturer research funding. There are thousands of clinical trials, but most deal with trivialities or efforts to increase the sales of specific products. The overwhelming majority of these trials are designed, controlled, and conducted by companies who stand to benefit from “positive” results.

Given this conundrum, it is likely that some entire medical subspecialties are based on very little evidence. Their disappearance probably would not harm patients and might help salvage derailed health budgets. However, it is unlikely that specialists would support trials testing practices that constitute their main source of income. Instead, the research community performs studies of minimal value without even knowing whether the basic standards of care are appropriate.

Rarely, some investigators find the courage to test established “truths” with large, rigorous randomized trials. When this happens, empirical evidence suggests that “medical reversals” can be quite common. In an evaluation of 35 trials that were published in a major clinical journal in 2009 and that tested an established clinical practice, 16 (46%) reported results consistent with current beneficial practice, 16 (46%) reported evidence that contradicted current practice and constituted a reversal, and another 3 (9%) were inconclusive. 2 Perhaps high-profile general medical journals are more prone to publish unusual results and less inclined to defend a clinical practice or specialized turf than specialty journals. However, it is unlikely that the selection filter in favor of reversal publications is stronger than the selection filter favoring the validation of standard of care.

The mere testing of a standard of care generates interest because many standards of care are never tested. In another evaluation of trials published in 3 major general medical journals or high–impact factor specialty journals, 3 of the 39 most cited randomized trials published in 1990-2003 that found a significant benefit of a clinical intervention, 9 (23%) found effects stronger than those found in subsequent studies and 19 (49%) found results replicated in subsequent studies, but 11 (28%) remained largely unchallenged, with no large trial conducted on the same question. 3

Many medical reversals involve conditions for which the standard of care has been promoted over the years based primarily on pathophysiological considerations. Often one or more trials exist, but they have not tested clinically relevant outcomes or have been biased. For example, vertebroplasty—the injection of polymethylmethacrylate cement into fractured bone—gained popularity in the early 2000s for the treatment of osteoporotic fractures. Initial studies addressed the pathophysiology of this therapy, delineated the technical skills required to optimally perform the procedure, and furthered the discussion about the benefits of vertebroplasty. Claims of benefit were strongly contradicted in 2 randomized trials 4,5 that included a sham (placebo) procedure, which alone might have been responsible for pain relief. Trials without sham (placebo) control might continue to show benefit, but it is difficult to justify performing invasive, expensive operations simply to obtain placebo effects.

Despite the evidence, many specialists will not abandon the procedure. A study of vertebroplasty utilization at one in- stitution showed little reduction in referrals after publication of studies contradicting current practice and in fact even showed that increasing percentages of referred patients were offered the procedure.6 Similarly, the results of COURAGE have done little to improve optimal medical management of stable coronary artery disease prior to invasive intervention. Stenting may not improve mortality, but the procedure apparently diminishes angina. 7 However, more than 50 years ago, Cobb et al 8 demonstrated that large improvements in pain with internal mammary artery ligation were comparable to results obtained with a sham (placebo) procedure. As is the case with vertebroplasty, stenting performed in patients with stable disease is probably widely used as an expensive placebo for pain control.

The increasing use of surrogate end points and short-term outcomes has also affected the credibility of clinical trial results. Reversal of important research findings is more common when pragmatic clinical outcomes are not used for initial approval and licensing of interventions. For instance, bevacizumab exploited an accelerated approval process for treatment of metastatic breast cancer. Approval was granted based on preliminary data on disease progression, an end point that may not necessarily translate into improved life expectancy or quality of life for patients. After accrual of further data, on November 18, 2011, the US Food and Drug Administration revoked its prior approval for this indication. Yet it only took weak data for approval! In other words, patients paid to be guinea pigs

Because medicine is in part a statistically driven science, a certain amount of reversal of standards of care is inevitable. However, what is currently tolerated is far greater than the uncertainty of statistics. Reversal of established practices implies at least 3 grave consequences besides unjustified cost. First, patients who undergo the therapy during the years it is in favor receive all the risk of treatment and, ultimately, no real benefit. Second, contradicting studies do not immediately force a change in practice; the contradicted practice continues for years. 9 Third, contradiction of mainstream practices undermines trust in the medical system, and shows the cracks in the foundation of “modern medicine”. The implications of reversal are significant. Reversal implies error or harm to patients who underwent the practice in question, during the years it was considered effective, opening the doors for catastrophic litigation.

Given the slow rate of abandonment of ineffective medical practices, the standards governing drug and device approval must be strengthened. This means that newly proposed innovations should be evaluated in sufficiently large unbiased randomized trials that demonstrate improvement in important clinical end points before being widely disseminated.

Such an insistence on well-designed, large studies may be seen as overly costly during times of financial hardship. However, the costs of permitting increasing widespread use of ineffective interventions like chemotherapy are much greater.

In the case of vertebroplasty, a few million dollars used to conduct a proper clinical trial before regulatory approval might have saved nearly a billion dollars a year over the course of a decade. 10 For unnecessary hormone therapy and coronary stenting, the cost has been even greater. Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.

Realistically though, asking corporate sponsors to perform critical trials on their own products is like asking a painter to judge their own painting so as to receive an award. If a manufacturer can be allowed to manipulate the system to create a blockbuster product from an ineffective drug, the temptation is hard to resist.

Besides the need for better evidence for new interventions, medical reversals also suggest that reality checks should be encouraged for established practices that constitute the core of medical care. Priority should be given to testing practices having limited or no prior randomized evidence for their use, reassessing old evidence that may no longer be relevant for current clinical settings, and evaluating therapies and interventions that are most expensive.

Sometimes the beliefs of Doctors can have similar psychological characteristics as the nonscientific beliefs observed in other areas of society. The wish bias of individuals, irrespective of topic, can be large and may also influence the interpretation of scientific results and lead to the precribing of ineffective protocols due to ego and “wishful thinking”. Such bias has been discussed and demonstrated in the past for several other societal and scientific efforts. 11-16

Wish bias does not necessarily mean that the defended beliefs are wrong. Moreover, it can be difficult to discern whether perpetuated beliefs are based on careful consideration of all evidence and differential interpretation, inappropriate entrenchment of old information, lack of dissemination of newer data, or purposeful silencing of their existence. Regardless of the reasons, better communication between research specialists and evidence-based clinical science 17 may improve this situation and may lead to more rational and concerted translational efforts in basic, preclinical, and clinical research.

REFERENCES

1. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.
2. Prasad V, Gall V, Cifu A. The frequency of medical reversal. Arch Intern Med. 2011;171(18):1675-1676.
3. Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA . 2005;294(2):218-228.
4. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361 (6):557-568.
5. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361(6):569-579.
6. Luetmer MT, Kallmes DF. Have referral patterns for vertebroplasty changed since publication of the placebo-controlled trials? AJNR Am J Neuroradiol. 2011; 32(4):647-648.
7. Weintraub WS, Spertus JA, Kolm P, et al; COURAGE Trial Research Group. Effect of PCI on quality of life in patients with stable coronary disease. N Engl J Med. 2008;359(7):677-687.
8. Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation of internal-mammary-artery ligation by a double-blind technic. N Engl J Med. 1959; 260(22):1115-1118.
9. Tatsioni A, Bonitsis NG, Ioannidis JPA. Persistence of contradicted claims in the literature. JAMA. 2007;298(21):2517-2526.
10. Elshaug AG, Garber AM. How CER could pay for itself—insights from vertebral fracture treatments. N Engl J Med. 2011;364(15):1390-1393.
11. Markovits H, Nantel G. The belief-bias effect in the production and evaluation of logical conclusions. Mem Cognit. 1989;17(1):11-17.
12. Kaptchuk TJ. Effect of interpretive bias on research evidence. BMJ. 2003;326(7404):1453-1455.
13. Koehler JJ. The influence of prior beliefs on scientific judgements of evidence quality. Organ Behav Hum Decis Process. 1993;56:28-55.
14. Resch KI, Ernst E, Garrow J. A randomized controlled study of reviewer bias against an unconventional therapy. J R Soc Med. 2000;93(4):164-167.
15. MacCoun RJ. Biases in the interpretation and use of research results. Annu Rev Psychol. 1998;49:259-287.
16. Bazerman MH, Loewenstein G, Moore DA. Why good accountants do bad audits. Harv Bus Rev. 2002; 80(11):97-102.
17. Ioannidis JP. Evolution and translation of research findings: from bench to where? PLoS Clin Trials. 2006;1(7):e36.

mammograms-and-nejm-big-studyMammography exposed in the NEJM

mammograms-cause-breast-cancer-dr-ben-johnsonMammograms cause Breast Cancer

mammograms-do-not-save-lives-cnnMammograms do not save lives CNN

mammograms-get-some-women-unnecessary-treatmentMammograms get many women unnecessary treatment

mammograms-save-lives-debunked-nbc-newsMammograms Save Lives? Debunked on NBC News

mammogram-study_test-doesnt-save-lives-of-women-40-59Mammogram study: Test doesn’t save lives of women 40-59

mammogram-the-history-and-the-shamMammogram: the history and the sham

mammography-is-ineffective-ctv-national-newsMammography is ineffective, CTV National News

mammography-the-truth-about-itMammography: the truth about it

Facebook
Google+
Twitter
YouTube
Instagram
 

To access the drfarrahcancercenter.com site, you must agree to the following;

Terms of Use

OVERVIEW

Please read these Terms of Use carefully before accessing or using our website. By accessing or using any part of the site, you agree to be bound by these Terms of Use. If you do not agree to all the terms and conditions of this agreement, then you may not access the website or use any services.

This website is operated by private parties in the Republic of Panama. Throughout the site, the terms “we”, “us” and “our” refer to drfarrahcancercenter.com, which offers this website, including all information, tools and services available from this site to you, the user, conditioned upon your acceptance of all terms, conditions, policies and notices stated here.

You understand and agree that you are accessing a website registered, owned, and hosted in the Republic of Panama. Therefore, all issues of a legal nature fall under the jurisdiction of the Republic of Panama legal system.

You understand and agree that as an authorized user you may only access information to which you have the legal authority to view and use. drfarrahcancercenter.com will monitor and record activity on this system to protect the system and its information and may use that monitoring information for official administrative or legal purposes. You understand and agree that you are not permitted to record, screenshot, or disseminate any information contained on the drfarrahcancercenter.com website to any party for any purpose whatsoever, and as such, you agree not to engage in such banned activities.

You understand and agree that unauthorized use of the system such as gaining unauthorized access to data, changing data, causing harm to the system or its data, or misuse of components is prohibited and may result in criminal, civil, or administrative penalties.

You also understand that drfarrahcancercenter.com can suspend or stop your use of this system if drfarrahcancercenter.com suspects any unauthorized use of the system attributable to you has occurred.

Your access to and use of the drfarrahcancercenter.com site is conditioned on your acceptance of and compliance with these Terms. These terms apply to all visitors, users and others who access or use the drfarrahcancercenter.com site. By accessing or using the drfarrahcancercenter.com site, you agree to be bound by these Terms. If you disagree with any part of the following Terms of Use, then you may not access the drfarrahcancercenter.com site.

By visiting our site and/ or purchasing anything from us, you engage in our “Service” and agree to be bound by the following terms and conditions (“Terms of Use”, “Terms”), including those additional terms and conditions and policies referenced herein and/or available by hyperlink. These Terms of Use apply to all users of the site, including without limitation users who are browsers, vendors, customers, merchants, and/ or contributors of content.

Any new features or tools which are added to the current website shall also be subject to the Terms of Use. You can review the most current version of the Terms of Use at any time on this page. We reserve the right to update, change or replace any part of these Terms of Use by posting updates and/or changes to our website. It is your responsibility to check this page periodically for changes. Your continued use of or access to the website following the posting of any changes constitutes acceptance of those changes.

 

SECTION 1 – ONLINE WEBSITE TERMS

By agreeing to these Terms of Use, you represent that you are at least the age of majority in your state, province, country or city of residence, or that you are the age of majority in your state, province, country or city of residence and you have given us your consent to allow any of your minor dependents to use this site.

You may not use any of our website for any illegal or unauthorized purpose nor may you, in the use of the Service, violate any laws in your jurisdiction (including but not limited to copyright laws).

You must not transmit any worms or viruses or any code of a destructive nature.

A breach or violation of any of the Terms will result in an immediate termination of your Services.

 

SECTION 2 – GENERAL CONDITIONS

We reserve the right to refuse service to anyone for any reason at any time.

You agree not to reproduce, duplicate, copy, sell, resell or exploit any portion of the Service, use of the Service, or access to the Service or any contact on the website through which the service is provided, without express written permission by us.

The headings used in this agreement are included for convenience only and will not limit or otherwise affect these Terms.

You understand and agree that this website is for information purposes only, and that by providing the information contained herein, we are not diagnosing, treating, curing, mitigating, or preventing any type of disease or medical condition. You understand and agree that before beginning any type of natural, integrative or conventional treatment regimen, it is advisable to seek the advice of a licensed healthcare professional.

You understand and agree that the information on the site is presented for the sole purpose of disseminating health information for general educational purposes only. You understand and agree that if you think you may have a medical emergency, you should call your doctor or 911. You understand and agree that the information on this site is not intended or implied to be medical advice, and you understand and agree that the information does not constitute the provision or practice of medical, nursing, or professional health care advice or services. You understand and agree that you will not use the information on this site as a substitute for professional medical advice, diagnosis, or treatment. You understand and agree that you should always seek the advice of your physician or other qualified health care provider prior to starting any treatment or with any questions you may have regarding a medical condition.

You understand and agree that nothing contained on this site is intended to be or will be used by you for medical diagnosis or treatment. You understand and agree that you should never disregard professional medical advice or delay in seeking treatment based on the information contained on this site. You understand and agree that the service and any content or information contained on the site is provided on an ‘as is’ basis. You understand and agree that while efforts have been made to assure the accuracy of the information on this site, there is no guarantee that such information is accurate or up-to-date. You understand and agree that, except for information, products, or services clearly identified as being supplied by the site, the site does not operate, control, or endorse any information, products, or services on the internet, in any way.

In addition, access to this site constitutes acceptance and understanding of the following,

By accessing this system, you hereby acknowledge, consent, and agree to all listed provisions and consent to monitoring.

You understand and agree that any copyright laws pertaining to the ownership and reproduction of all data fall exclusively under Panamanian legal jurisdiction for drfarrahcancercenter.com

If you are a copyright holder, or a director, officer, owner, employee, agent, supplier, licensor, contributor, service provider, website hosting company, trade partner, heir or assign of a copyright holder and feel that you or anyone you are engaged in any form of relationship whatsoever may have rights to data as part of this site or related sites, your agreement with the terms of use constitutes the following agreement, which is mandatory in order to access the data contained on this site.

I do hereby declare, understand, agree and warrant that I am a copyright owner, or an authorized representative of a copyright owner of film, print, slide, movie, video, artwork, digital image, negatives or any other material in any format whatsoever (hereafter referred to as “COPYRIGHTED DATA”) which I believe to be, known to be, or suspect to be contained on the drfarrahcancercenter.com website.

I hereby freely grant a non-exclusive license to drfarrahcancercenter.com and its agents to reproduce these COPYRIGHT DATA in perpetuity, and I represent and warrant that I have the legal right and authority to grant such a license. I may at my discretion ask to be credited for my contribution or the contributor I represent to the drfarrahcancercenter.com site as a contributor whether this occurred with or without my knowledge, but even if I or the contributor I represent remains uncredited, this agreement shall survive since participation in the free flowing of information for the public at large is a paramount responsibility we all should share. Therefore, in the best interest of free-flowing information for the public at large, I am freely undertaking this agreement, and clearly warrant that I have the authority to do so. I agree to indemnify and hold harmless drfarrahcancercenter.com and any of its directors, officers, owners, employees, agents, suppliers, licensors, contributors, service providers, website hosting companies, trade partners, heirs and assigns from any and all liability, damages, and expenses (including reasonable actual attorney’s fees) that may incur as a result of use and publication of said material, including any claims brought by any person claiming an interest in the COPYRIGHTED DATA or their subject matter. I agree and warrant that anyone containing any format of data from drfarrahcancercenter.com contained in any medium outside of the drfarrahcancercenter.com website itself, is bound by this agreement, since acceptance of this agreement is the only way to legally access such data. In addition, I understand and agree that accessing or storing any format of data contained in any medium outside of the drfarrahcancercenter.com website where it is hosted, constitutes a violation of the copyright laws of Panama against the offending party. I understand and agree that if I copy, contain, possess, or transmit any such data from the drfarrahcancercenter.com site in any format outside of the website itself, that my possession of such materials is a violation of Panamanian laws, and I agree to destroy such data forthwith.

 

SECTION 3 – ACCURACY, COMPLETENESS AND TIMELINESS OF INFORMATION

We are not responsible if information made available on this site is not accurate, complete or current. The material on this site is provided for general information only and should not be relied upon or used as the sole basis for making decisions without consulting primary, more accurate, more complete or more timely sources of information. Any reliance on the material on this site is at your own risk.

This site may contain certain historical information. Historical information, necessarily, is not current and is provided for your reference only. We reserve the right to modify the contents of this site at any time, but we have no obligation to update any information on our site. You agree that it is your responsibility to monitor changes to our site.

 

SECTION 4 – MODIFICATIONS TO THE SERVICE

We reserve the right at any time to modify or discontinue the Service (or any part or content thereof) without notice at any time.

We shall not be liable to you or to any third-party for any modification, change, suspension or discontinuance of the Service.

 

SECTION 5 – OPTIONAL TOOLS

Any use by you of optional tools offered through the site is entirely at your own risk and discretion and you should ensure that you are familiar with and approve of the terms on which tools are provided by the relevant third-party provider(s).

We may also, in the future, offer new services and/or features through the website (including, the release of new tools and resources). Such new features and/or services shall also be subject to these Terms of Use.

 

SECTION 6 – THIRD-PARTY LINKS

Certain content, products and services available via our Service may include materials from third-parties.

Third-party links on this site may direct you to third-party websites that are not affiliated with us. We are not responsible for examining or evaluating the content or accuracy and we do not warrant and will not have any liability or responsibility for any third-party materials or websites, or for any other materials, products, or services of third-parties.

We are not liable for any harm or damages related to the purchase or use of goods, services, resources, content, or any other transactions made in connection with any third-party websites. Please review carefully the third-party’s policies and practices and make sure you understand them before you engage in any transaction. Complaints, claims, concerns, or questions regarding third-party products should be directed to the third-party.

 

SECTION 7 – USER COMMENTS, FEEDBACK AND OTHER SUBMISSIONS

If, at our request, you send certain specific submissions (for example contest entries) or without a request from us you send creative ideas, suggestions, proposals, plans, or other materials, whether online, by email, by postal mail, or otherwise (collectively, ‘comments’), you agree that we may, at any time, without restriction, edit, copy, publish, distribute, translate and otherwise use in any medium any comments that you forward to us. We are and shall be under no obligation (1) to maintain any comments in confidence; (2) to pay compensation for any comments; or (3) to respond to any comments.

We may, but have no obligation to, monitor, edit or remove content that we determine in our sole discretion are unlawful, offensive, threatening, libelous, defamatory, pornographic, obscene or otherwise objectionable or violates any party’s intellectual property or these Terms of Use.

You agree that your comments will not violate any right of any third-party, including copyright, trademark, privacy, personality or other personal or proprietary right. You further agree that your comments will not contain libelous or otherwise unlawful, abusive or obscene material, or contain any computer virus or other malware that could in any way affect the operation of the Service or any related website. You may not use a false e-mail address, pretend to be someone other than yourself, or otherwise mislead us or third-parties as to the origin of any comments. You are solely responsible for any comments you make and their accuracy. We take no responsibility and assume no liability for any comments posted by you or any third-party.

 

SECTION 8 – ERRORS, INACCURACIES AND OMISSIONS

Occasionally there may be information on our site or in the Service that contains typographical errors, inaccuracies or omissions that may relate to product descriptions, pricing, promotions, offers, product shipping charges, transit times and availability. We reserve the right to correct any errors, inaccuracies or omissions, and to change or update information or cancel orders if any information in the Service or on any related website is inaccurate at any time without prior notice (including after you have submitted your order).

We undertake no obligation to update, amend or clarify information in the Service or on any related website, including without limitation, pricing information, except as required by law. No specified update or refresh date applied in the Service or on any related website, should be taken to indicate that all information in the Service or on any related website has been modified or updated.

 

SECTION 9 – PROHIBITED USES

In addition to other prohibitions as set forth in the Terms of Use, you are prohibited from using the site or its content: (a) for any unlawful purpose; (b) to solicit others to perform or participate in any unlawful acts; (c) to violate any international, federal, provincial or state regulations, rules, laws, or local ordinances; (d) to infringe upon or violate our intellectual property rights or the intellectual property rights of others; (e) to harass, abuse, insult, harm, defame, slander, disparage, intimidate, or discriminate based on gender, sexual orientation, religion, ethnicity, race, age, national origin, or disability; (f) to submit false or misleading information; (g) to upload or transmit viruses or any other type of malicious code that will or may be used in any way that will affect the functionality or operation of the Service or of any related website, other websites, or the Internet; (h) to collect or track the personal information of others; (i) to spam, phish, pharm, pretext, spider, crawl, or scrape; (j) for any obscene or immoral purpose; or (k) to interfere with or circumvent the security features of the Service or any related website, other websites, or the Internet. We reserve the right to terminate your use of the Service or any related website for violating any of the prohibited uses.

 

SECTION 10 – DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY

We do not guarantee, represent or warrant that your use of our service will be uninterrupted, timely, secure or error-free.

We do not warrant that the results that may be obtained from the use of the service will be accurate or reliable.

You agree that from time to time we may remove the service for indefinite periods of time or cancel the service at any time, without notice to you.

You expressly agree that your use of, or inability to use, the service is at your sole risk. The service and all products and services delivered to you through the service are (except as expressly stated by us) provided ‘as is’ and ‘as available’ for your use, without any representation, warranties or conditions of any kind, either express or implied, including all implied warranties or conditions of merchantability, merchantable quality, fitness for a particular purpose, durability, title, and non-infringement.

In no case shall anyone affiliated with drfarrahcancercenter.com including our directors, officers, employees, affiliates, agents, contractors, interns, suppliers, service providers or licensors be liable for any injury, loss, claim, or any direct, indirect, incidental, punitive, special, or consequential damages of any kind, including, without limitation lost profits, lost revenue, lost savings, loss of data, replacement costs, or any similar damages, whether based in contract, tort (including negligence), strict liability or otherwise, arising from your use of any of the service or any products procured using the service, or for any other claim related in any way to your use of the service or any product, including, but not limited to, any errors or omissions in any content, or any loss or damage of any kind incurred as a result of the use of the service or any content (or product) posted, transmitted, or otherwise made available via the service, even if advised of their possibility. Because some states or jurisdictions do not allow the exclusion or the limitation of liability for consequential or incidental damages, in such states or jurisdictions, our liability shall be limited to the maximum extent permitted by law.

You understand and agree that no singular individual, group of individuals or entity in any form whatsoever is responsible or liable in any manner for any content generated on, for, or as a result of the existence of this site, since this is a community generated site. You understand and agree that as this is a community generated site, and as a result of this, there is no good way to control what users and contributors post on or through the sites and drfarrahcancercenter.com cannot be responsible for any offensive, inappropriate, obscene, unlawful, infringing or otherwise objectionable or even illegal user generated content you may encounter on the sites or, in connection with your use of the sites.

You understand and agree with the following statement made on behalf of drfarrahcancercenter.com, “We, on behalf of our directors, officers, employees, agents, suppliers, licensors, contributors and service providers, exclude and disclaim liability for any losses and expenses of whatever nature and howsoever arising including, without limitation, any direct, indirect, general, special, punitive, incidental or consequential damages; loss of use: loss of data; loss caused by a virus: loss of income or profit: loss of or damage to property: loss of life: claims of third parties: or other losses of any kind or character, or the inability to use, the site or the content even if we have been advised of the possibility of such damages or losses, arising out of or in connection with the use of this site or any web site with which it is linked.”

 

SECTION 11 – INDEMNIFICATION

You agree to indemnify, defend and hold harmless drfarrahcancercenter.com and our parent, subsidiaries, affiliates, partners, officers, directors, agents, contractors, licensors, service providers, subcontractors, suppliers, interns and employees, harmless from any claim or demand, including reasonable attorneys’ fees, made by any third-party due to or arising out of your breach of these Terms of Use or the documents they incorporate by reference, or your violation of any law or the rights of a third-party.

 

SECTION 12 – SEVERABILITY

In the event that any provision of these Terms of Use is determined to be unlawful, void or unenforceable, such provision shall nonetheless be enforceable to the fullest extent permitted by applicable law, and the unenforceable portion shall be deemed to be severed from these Terms of Use, such determination shall not affect the validity and enforceability of any other remaining provisions.

 

SECTION 13 – TERMINATION

The obligations and liabilities of the parties incurred prior to the termination date shall survive the termination of this agreement for all purposes.

These Terms of Use are effective unless and until terminated by us. You may terminate use of the drfarrahcancercenter.com site, but this Terms of Use shall survive in perpetuity.

If in our sole judgment you fail, or we suspect that you have failed, to comply with any term or provision of these Terms of Use, we also may terminate this agreement at any time without notice and you will remain liable for all amounts due up to and including the date of termination; and/or accordingly may deny you access to our Services (or any part thereof).

 

SECTION 14 – INDEMNIFICATION

The information supplied through this website, or by any representative or agent of Dr. Farrah, whether by telephone, in person verbal, email, letter, image, text, facsimile or any other conceivable form of communication, is for informational purposes only and does not constitute medical, legal or other professional advice. Health-related information provided through this website is not a substitute for medical advice and should not be used to diagnose or treat health problems or to prescribe any medical devices or other remedies. The receipt of any questions or feedback that you submit in any form to any Dr. Farrah medium does not create a professional relationship and does not create any privacy interests.
You agree to indemnify, defend and hold harmless drfarrahcancercenter.com and our parent, subsidiaries, affiliates, partners, officers, directors, agents, contractors, licensors, service providers, subcontractors, suppliers, interns and employees, harmless from any claim or demand, including reasonable attorneys’ fees, made by any third-party due to or arising out of your breach of these Terms of Service or the documents they incorporate by reference, or your violation of any law or the rights of a third-party.

 

SECTION 15 – GOVERNING LAW

These Terms of Use and any separate agreements whereby we provide you Services shall be governed by and construed in accordance with the laws of the Republic of Panama.

 

SECTION 16 – CHANGES TO TERMS OF USE

You can review the most current version of the Terms of Use at any time at this page.

We reserve the right, at our sole discretion, to update, change or replace any part of these Terms of Use by posting updates and changes to our website. It is your responsibility to check our website periodically for changes. Your continued use of or access to our website or the Service following the posting of any changes to these Terms of Use constitutes acceptance of those changes.

 

SECTION 17 – CONTACT INFORMATION

Questions about the Terms of Use should be sent to us at staff@drfarrahcancercenter.com

Upon agreeing to these terms and conditions, you gain access to the drfarrahcancercenter.com website and assume total responsibility for any and all actions undertaken by you as a result of your access to the drfarrahcancercenter.com website. You agree and understand that the terms of this agreement shall be binding upon you, your respective heirs, successors, assigns and legal representatives. You understand and agree that all provisions of this Terms of Use agreement that by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity, licensing in perpetuity and limitations of liability.