Tag Archives: cancer

Cancer Research and Care Embrace Technology

Oncology is about to take a huge step toward changing the way that cancer is understood and treated with the development of a breast cancer-specific prototype for a rapid learning system in cancer care. This system takes advantage of health IT advances (such as EHRs) in order to connect oncology practices, measure quality and performance, and provide physicians with decision support in real time.

The prototype is part of the American Society of Clinical Oncology’s (ASCO’s) vision for CancerLinQ  a “system that assembles and analyzes millions of unconnected medical records in a central knowledge base, which will grow ‘smarter’ over time,” according to the organization.

Illustration courtesy of the American Society of Clinical Oncology

As part of ASCO’s focus on quality improvement, the protoype will use clinical practice guidelines and measures of the Quality Oncology Practice Initiative to build quality measurement and clinical decision tools. Next, breast cancer patient records and data (stripped of identifying information) imported from the electronic health records (EHRs) of academic centers and oncology practices will be added.

As a proof of concept, ASCO says that the prototype will:

  • provide the foundational information and lessons learned to allow ASCO to move into a full-scale implementation;
  • provide real-time, standardized, clinical decision support integration within a demonstration EHR;
  • demonstrate a set of value-added tools; including a physician’s ability to measure their performance against a sub-set of QOPI measures in real-time;
  • demonstrate the ability to capture data from a variety of sources and aggregate the data using novel methodologies;
  • and create a demonstration which will allow exploration of data in unprecedented ways and generate hypotheses related to breast cancer.

Once the full technology platform is completed, CancerLinQ ultimately is expected to improve personalized treatment decisions by capturing patient information in real time at the point of care; provide decision support to cancer teams to adapt treatment plans to each patient and his or her cancer; and report on quality of care, compared with clinical guidelines and the outcomes of other patients. It’s also hoped that the system will help to “educate and empower patients by linking them to their cancer care teams and providing personalized treatment information at their fingertips.” Lastly, the system stands to be a powerful new data source for analysis of real-world quality and comparative effectiveness, as well as to generate new ideas for clinical research. It’s hoped that in time, this approach can be adapted to all types of cancer.

Kerri Wachter

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More Docs Are Asking Patients to Exercise

Physicians are getting better at advising adults to exercise.

Photo courtesy National Cancer Institute/Bill Branson

In 2010, 32.4% of adults in the United States who had seen a physician or other health care professional in the past year had received a recommendation to begin or continue to do exercise or physical activity, up from 22.6% in 2000. At each time point, women were more likely than men to have been advised to exercise.

The findings, published this month as a National Center for Health Statistics Data Brief, come from the National Health Interview Surveys conducted in 2000, 2005, and 2010.

Between 2000 and 2010 the percentage of patients aged 85 and older who received a “get fit” recommendation from a physician nearly doubled from 15.3% to 28.9%. The percentage of patients aged 18-24 years receiving such a recommendation also increased during the same time period, but to a lesser extent (from 10.4% to 16.1%).

The report also found that the percentage of adults with hypertension, cardiovascular disease, cancer, and diabetes who received exercise advice from a physician increased between 2000 and 2010.

“Trends over the past 10 years suggest that the medical community is increasing its efforts to recommend participation in exercise and other physical activity that research has shown to be associated with substantial health benefits,” the report states. “Still, the prevalence of receiving this advice remains well below one-half of U.S. adults and varies substantially across population subgroups.” 

 — Doug Brunk (on Twitter@dougbrunk)

Photo courtesy National Cancer Institute Visuals Online

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Should Physicians Prescribe Positivity?

Scott Jordan Harris  is a U.K.-based blogger, editor, book author, movie critic, and sports writer. Remarkable, considering that he spends most of his time in bed. His primary diagnosis is myalgic encephalomyelitis (ME), also known as chronic fatigue syndrome.

In a piece he wrote last week for the BBC’s website, Mr. Harris said that keeping a diary in which he focuses on the positive aspects of his life — at the suggestion of a doctor – keeps him “sane.”

©froglegs/Fotolia.com

“My depression told me my existence was filthy and barren…. After a few months of storing up the previously unrecorded richness of my life, my diary simply disproved that. I knew from re-reading the pages I’d written that I was doing interesting things — and I began to ensure I kept doing them simply to have something to write about. The diary was better than therapy; it pushed me forward through mental pain that had been holding me back.”

He added, “Doctors unaware of the realities of the lives of the chronically ill often suggest we waste what little energy we have noting down exactly how unwell we feel each day, how much we sleep and how little we do, so that they may study the results. These doctors are to be smiled at, and nodded to, and instantly ignored.”

So should physicians advise patients with chronic conditions to keep positive diaries?  I asked two experts.  Dr. Daniel Clauw, a rheumatologist who directs the University of Michigan’s Chronic Pain and Fatigue Research Center, referred me to his associate, Afton Hassett, Psy.D.

“That was a compelling story in the BBC and it actually does reflect my clinical and research experience as a pain psychologist,” Dr. Hassett told me.

Negative and positive affect (emotions) have been well-studied  in health in general and chronic and acute pain states in particular. There are numerous studies suggesting that positive affect plays an important role in pain outcomes. While few formal studies have evaluated the effectiveness of the exact intervention Mr. Harris described, there are studies   supporting the efficacy of similar positive psychology interventions for depression, Dr. Hassett said.

“Enhancing positive affect is likely a good thing for one’s mental and physical health. Sometimes just keeping a gratitude journal like the BBC article writer noted is all it takes. I always tell people to write down three different things each day for which you are grateful. After the first week or so you really start looking for the small wonders in your life: a great cup of coffee, a kind gesture from a complete stranger, the first tiny yellow flowers of spring.”

Courtesy Wikimedia Commons/4028mdk09/Creative Commons License

But Dr. David Spiegel, a psychiatrist who heads the Stanford University Center on Stress and Health, urges caution regarding positive psychology.   “I think the drumbeat for upbeat can be a little overwhelming… I agree with [Mr. Harris] that just focusing on how bad you feel you can dig yourself into a pit, but at the same time you can’t deny your feelings. The worst thing you can do to a depressed person is to tell them to cheer up.”

However, Dr. Spiegel, who works with breast cancer patients, noted that “you can help them by saying let’s give dimension to what’s bothering you, but also put that in perspective, and see other things that are good, that are positive. So it’s not one or the other…Happiness is not the absence of sadness.”

Dr. Spiegel said that advising patients with chronic conditions to keep a diary in general is an “interesting idea,” and that there is a literature base  for the medical benefits of journaling.

He advised that physicians suggest to their patients, “See if it helps you to have a daily journal of your journey through this illness, what your problems were and what your little victories were, and what you did that helped you deal with it and get beyond it.”

—Miriam E. Tucker (@MiriamETucker on Twitter)

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Feds Fund Two Cancer Information Apps

It sounds cute and perky, but Ask Dory! is actually an informative app that helps patients find information about clinical trials for cancer and other diseases.

©YANKIN CHAUVIN/fotolia.com

Along with another app, My Cancer Genome, the two recently won $20,000 each from the federal government.

Ask Dory! integrates data from www.clinicaltrials.gov. My Cancer Genome provides “therapeutic options based on the individual patient’s tumor gene mutations, making use of  National Cancer Institute’s physician data query clinical trial registry data set and information on genes being evaluated in therapeutic clinical trials,” according to a statement.

The two apps are part of the rapidly growing field of mHealth — or use of mobile devices for health purposes. Some are calling it an “mHealth bubble,” as thousands of groups large and small are rushing to develop the next great app for diabetes, cancer, infectious diseases, weight management,  addictions, and more.

Seeing the potential benefit for patients and providers, federal officials are providing incentives, and funding initiatives as simple as free text messaging reminders for pregnant women and new moms, to apps like Ask Dory!

“What makes these health IT challenges so powerful is their ability to catalyze the expertise and creativity of innovators both in and out of health care,” said Wil Yu, special assistant for innovation at the  Office for the National Coordinator for Health Information Technology (ONC), which awarded the prizes.

In collaboration with the National Cancer Institute, ONC launched the “Using Public Data for Cancer Prevention and Control: From Innovation to Impact” challenge in summer 2011. The two winners were among four semifinalists who submitted their products to the ONC challenge in November 2011.

—Naseem S. Miller (@NaseemSMiller on Twitter)

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Moving Beyond the Hospital

Recently, officials at Hoag Memorial Hospital Presbyterian, a regional health care system in Orange County, Calif., decided to rebrand their 60-year-old institution. The not-for-profit health care system is now known simply as Hoag. They weren’t just going for brevity. They specifically wanted to drop the word “hospital.”

Dr. Richard Afable, Hoag’s president and CEO, recently spoke to a small meeting of hospitalists in Las Vegas and explained that the name change reflects a shift toward providing more services outside of the hospital. Hoag’s hospitals do a great job treating the acutely ill, he said, but the leadership wanted to reach out to people in the community before they got sick enough to make it to the hospital.

Dr. Richard Afable. Photo by Mary Ellen Schneider/ Elsevier Global Medical News.

So officials at Hoag have been working to offer more services related to conditions that either slightly touch the hospital or don’t touch it at all, Dr. Afable said. For example, the system has beefed up its offerings around diabetes care and now provides counseling on how to manage the disease and prevent complications. In the old days, they would have waited for someone to have a heart attack or lose a limb before taking care of them, Dr. Afable said. They also are developing community-based programs for breast cancer, a condition that today is treated primarily outside of the hospital.

And Dr. Afable advised hospitalists to consider following Hoag’s lead and look how they can be involved in care outside of the hospital. He noted the example of CareMore, a medical group and health plan based in California, which is being acquired by the health insurer Wellpoint, Inc. Under CareMore’s model, hospitalists not only care for patients while they are in the hospital, but also after they leave. Once a patient is stable, they are sent back to receive the rest of their care from their primary care physician. Since CareMore uses a capitation payment model, there aren’t concerns about which physician gets the payment for the post-discharge care. The model is food for thought for hospitalists as care becomes increasingly less hospital centric, Dr. Afable said.

— Mary Ellen Schneider

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Nobel Finally Does Right by Marie Curie

In 1903 the word on the street was that Pierre and Marie Curie were the front-runners for the Nobel Prize in Physics for their work on radioactivity — inherent in which was the hypothesis that the atom was not the most basic particle but could emit subatomic particles. Some were affronted by the idea that a woman could have played any significant part in this work, and they argued for awarding the prize to Pierre and French physicist Henri Becquerel, but not Marie.

Courtesy Wikimedia Commons/Witkacy/Creative Commons License

When Pierre caught wind of this, he argued vehemently on his wife’s behalf. When the award was finally presented to both Curies and Becquerel, Marie was lauded at the presentation as a “help meet” to Pierre. Thus, Marie Curie became the first woman to win a Nobel Prize. The insulting irony was that Pierre had given up his work on crystals and magnetism to literally help his wife blaze a new trail in chemistry and physics with her work on radioactivity.

Courtesy Wikimedia Commons/Author Unknown/Public Domain

This year marks the 100th anniversary of Marie Sklodowska Curie’s second Nobel Prize — this time in chemistry for the discovery of polonium and radium. The first woman to win a Nobel became the first person to win two. But the second award was not without controversy. After Pierre’s death in 1906, Marie was rumored to have begun an affair with French physicist Paul Langevin. The scandal broke around the same time as her second award.  She refused to let the slander mar her scientific work. She wrote to a critic that “I believe there is no connection between my scientific work and the facts of private life.”

One hundred years later, Madame Curie stars in an exhibit at the Nobel museum in Stockholm — giving her the credit that she was denied by many during her lifetime. Marie died in 1934 of aplastic anemia most likely due to her lifelong exposure to radiation. A year later, her daughter Irene Joliot-Curie and her husband Frederic Joliot won the Nobel Prize for Chemistry for their work on the synthesis of radioactive elements. Irene died in 1956 of leukemia, also likely due to her exposure to radioactive materials.

The opening of the exhibit coincided with the European Multidisciplinary Cancer Congress. Madame Curie’s discovery of radiation proved to be a double-edged sword. Exposure to ionizing radiation is associated with several cancers — lung, skin, thyroid, multiple myeloma, breast, and stomach. However, the physics of radiation underlie many imaging techniques that allow physicians to noninvasively identify and follow tumors in the body. Radiation also turns out to be an effective treatment of certain cancers. Her pioneering investigation provided the groundwork for cancer research that greatly increased the odds of survival for many cancer patients.

Kerri Wachter

Solvay Conference 1927, Courtesy of Wikimedia Commons/Benjamin Couprie, Institut International de Physique de Solvay/Public Domain

The Solvay Conferences in Brussels were initiated to have the brightest minds of the age work on preeminent open problems in both physics and chemistry. The most famous meeting was held in 1927 and is noted for the presence of so many scientific luminaries addressing the newly proposed quantum theory. Seventeen of the 29 members were Nobel winners or would become winners. In the photo, Marie Curie — with two Nobel prizes to her name — takes her place alongside Albert Einstein, Niels Bohr, Erwin Schrodinger, and Werner Heisenberg, among others.

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Geriatric Oncology: The Elephant in the Empty Room

Kerri Wachter/Elsevier Global Medical News

It’s easy to tell which oncology topics are hot and which are not here at the Multidisciplinary Cancer Congress in Stockholm. Metastatic breast cancer? Thousands of people pushing their way into the cavernous meeting hall.  Advanced non-small cell lung cancer? I practically had to bribe the doorman to let me in.  Geriatric oncology? (crickets chirping)  It was kind of lonely in the geriatric oncology meeting room, one that was a tiny fraction of the size of the main hall.

Yes, it’s difficult to study cancer therapies in elderly patients.  They may have  comorbidities and poor performance status.  They may have impaired cognition or be unsuitable candidates for surgery. They may be frail. Then again, they may be none of those things. In fact, they may be in better health than younger patients. As one oncologic surgeon put it, “chronologic age should not be a primary factor in the decision-making process” for cancer treatment in elderly patients.

Courtesy Flickr/User TBOARD/Creative Commons License

What is clear is that we’re going to need lots of interest and research in geriatric oncology, now that the baby boomers are approaching old age. So far we have no good tools for separating the elderly patients who can handle more aggressive treatment from those who can’t.  We have little data on the effects of cancer treatments on elderly patients because they are typically excluded from trials. We don’t even have a clear definition of “elderly.”

The fact that we’re ill prepared to care for the growing population of elderly cancer patients  is the elephant in the room. Sadly, it’s a small room that’s pretty empty.

—Kerri Wachter (@knwachter on Twitter)

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Conflicts of Interest at the UN Noncommunicable Disease Summit? Bingo.

Just in advance of the United Nations High Level Meeting on the Prevention and Control of Non-communicable Disease, a coalition comprising more than 140 nongovernmental and public health organizations has called on the UN to restructure the way in which the food and beverage industry has been involved in the policy negotiations.   

Photo by Christian Cable / Wikimedia Commons

The Conflicts of Interest Coalition (COIC) describes itself as a group of “civil society organizations united by the common objective of safeguarding public health policy-making against commercial conflicts of interest through the development of a Code of Conduct and Ethical Framework for interactions with the private sector.” 

The COIC sent a Statement of Concern to the President of the United Nations General Assembly and the UN summit’s facilitators, decrying the lack of clarity regarding the role of the private sector in public policy-making in relation to the prevention and control of non-communicable diseases (NCDs).  

“Since the major causes of preventable death are driven by diseases related to tobacco, unhealthy diet, physical inactivity and alcohol drinking, we are concerned that many of the proposals to address NCDs call for ‘partnerships’ in these areas with no clarification of what this actually means. Public-private partnerships in these areas can counteract efforts to regulate harmful marketing practices,” the COIC wrote.

Calling industries “both part of the NCD problem and the solution,” the COIC believes industry should be involved in the implementation of policy but not its development. To that end, the group’s Statement offered two proposals:

First, a change in the nomenclature of nongovernmental organizations (NGOs) to distinguish between those that are industry-supported and those that are strictly civil society: “Business-interest-not-for profit organizations (BINGOs) and public interest nongovernmental organizations (PINGOs).

Second, a “code of conduct” that sets out a clear framework for interaction with the food and beverage industry and managing conflicts of interest, differentiating between policy development and implementation. 

“We ask for the UN to consider our comments and take them into account for the UN High Level Meeting in September,” the COIC wrote in the Statement, a version of which was published Sept. 16 online in The Lancet.  

Indeed, food industry lobbying is believed to have played a role in the removal of specific targets and indicators for reductions in salts, sugars, and saturated fats from earlier versions of the Political Declaration that will be voted on at the UN High-Level meeting, but it is probably too late to change that document since the vote is expected to take place Monday morning, according to Ann Keeling, chair of the Noncommunicable Disease Alliance (NCDA), the leading NGO that pushed for the Summit.

Ann Keeling photo courtesy of the International Diabetes Federation

However, she told me in an email, there will be time to address the conflict of interest issue in 2012, when the UN will be making decisions on both the establishment of partnerships as well as targets and indicators.

“The view of the NCDA is that the private sector, subject to ethical frameworks on conflict of interest, must be part of the solution, especially in implementation. We believe there should be a ‘triple partnership’ going forward – public/private/people with NGOs being the people and with far greater involvement from global to community level of people with NCDs.”

–Miriam E. Tucker (@MiriamETucker on Twitter)

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Noncommunicable Disease Alliance Fights to Retain Goals

The international noncommunicable disease movement has hit a snag. Negotiations have been delayed in drafting the official Political Declaration for the United Nations High-Level Meeting on the Prevention and Control of NCDs, scheduled for Sept. 19-20. The main issue, according to the NCD Alliance, a lobbying coalition of global NCD-related organizations, is that the United States, Canada, and the European Union are blocking proposals for the inclusion of the specific goal of cutting by 25% all preventable deaths from cancer, cardiovascular disease, diabetes, and chronic respiratory disease by 2025.

Arnaldo Pomodoro's "Sphere within Sphere" sculpture at UN Headquarters in New York/ Photo by Miriam E. Tucker

In a statement, the alliance said “The situation is urgent. Yet, it is reported that sound proposals for the draft Declaration to include time-bound commitments and targets are being systematically deleted, diluted and downgraded.” The alliance has sent a letter to UN Secretary-General Ban Ki-moon to express “grave concern at the current state of preparations” for the high-meeting, which is to be only the second-ever such UN meeting focusing on a global health issue. The first one, on HIV/AIDS in 2001, is credited with spurring global political, social, and financial action to address that problem.

According to the alliance, language about “action-oriented outcomes” is being replaced with “vague intentions” to “consider” and “work towards” NCD reduction goals, moves they deem “simply unacceptable.” Along with the 2025 goal, the letter reiterates previous demands that UN member states must develop a set of specific, evidence-based targets and global indicators, a clear time line for tackling the epidemic of the four major NCDs, and “a high-level collaborative initiative of government and UN agencies with civil society to stimulate and assess progress.”

In an interview with Reuters, NCD chair Ann Keeling said that money was the main sticking point, with wealthier nations reluctant to commit to paying for chronic disease care in poor countries at a time when even “rich” economies are in a downturn. Indeed, the sum is considerable, as NCDs now account for 63% of all deaths worldwide and half of all global disability, posing a serious threat to development in many lower-income nations. “The reason we called for a UN summit in the first place was to move toward a global action plan…The world is essentially sleepwalking into a sick future,” said Ms. Keeling, who is also chief executive officer of the International Diabetes Federation.

Negotiations on the Political Declaration are set to resume Sept. 1. In the meantime, the IDF has recently launched a postcard campaign urging President Obama to attend the high-level meeting, which is expected to draw heads of state from many UN member nations. The IDF has also organized a rally – with the support of several U.S.-based diabetes organizations and bloggers and other international NCD-related groups – to be held in New York City’s Central Park on Sunday, Sept. 18 to raise public awareness about the worldwide impact of NCDs.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Palliative Care in the Comfort of Home

Meet the Health Buddy, a telehealth technology intervention that significantly improved the symptoms and quality of life for head and neck cancer patients in a randomized trial by delivering symptom management in the comfort of the patient’s home, computer not required.

courtesy of wikimedia commons user Arglos/collected via GNU Free Documentation License

Cynthia Ellis Keeney, RN, MSN, couldn’t contain her excitement as she presented her group’s study findings in a poster session at a palliative care summit in Bethesda, Md. The meeting was sponsored by the National Institute of Nursing Research and partner organizations.

Head and neck cancer patients suffer terribly from a range of symptoms, and they often find it difficult to talk and uncomfortable to leave the house, said Ms. Keeney.

She and her colleagues randomized 80 newly diagnosed head and neck cancer patients to an intervention with a telehealth device or usual care. The telehealth device was connected to a landline phone and featured a small screen with large buttons.

The device allowed patients with limited computer savvy and no internet access to benefit from the convenience of the telehealth intervention, Ms. Keeney emphasized.

Each day, a green light on the Health Buddy would blink, prompting patients to respond to questions about how they were feeling that day. Based on their answers, the system would recommend an intervention, such as asking the doctor for a drug to treat a particular symptom (for example, constipation). Symptom control algorithms had been used to generate questions based on symptoms that are most likely to occur during the active phase of cancer treatment. The phone number of the patient’s doctor had been programmed into the system for immediate access.

After the active phase of their cancer treatments, patients in the Health Buddy group reported significantly higher physical well being than did controls.

Although the doctors and patients weren’t connected visually in real time, the patients felt that being able to define their symptoms through the Health Buddy and receive suggestions for symptom management allowed them to have better conversations with their doctors, Ms. Keeney said. As a result, “the patients in the intervention group thought they got better care,” than if they had not used the Health Buddy, she added.

–Heidi Splete (on twitter @hsplete)

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