Tumor Board: Is There Value in Multidisciplinary Case Consideration?

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digital health, evidence based medicine, health, innovation, oncology, participatory medicine, tumor board

By Gregg A. Masters, MPH

When the American College of Surgeons Commission on Cancer picked up the accreditation football and in the spirit of the then Joint Commission on Accreditation of Hospitals ‘Joint Commission‘ began the promulgation of specific standards for the accreditation of aspiring ‘cancer programs’, at the center of this consideration was the multidisciplinary cancer conference also known as ‘tumor board.’

Via these standards there were both structural and certain process considerations to meet, but the underlying assumption or zeitgeist of the value proposition – better cancer care – was that ‘multidisciplinary’ engagement of cancer specialists in the diagnosis and treatment of cancer patients would produce superior outcomes.

Then in October of 2012 Keating et al published a study titled: ‘Tumor Boards and the Quality of Cancer Care’. While somewhat dated (interval 2001-2004), and not generally representative of community oncology practices per se (the sample was sourced in the Veteran’s Health System), the conclusions are none-the-less a compelling call to objectively demonstrate long held assumptions of the benefits of tumor board ‘collaboration’.

The background context for the study was noted as follows:

Despite the widespread use of tumor boards, few data on their effects on cancer care exist. We assessed whether the presence of a tumor board, either general or cancer specific, was associated with recommended cancer care, outcomes, or use in the Veterans Affairs (VA) health system.

While Keating et al concluded as follows:

We observed little association of multidisciplinary tumor boards with measures of use, quality, or survival. This may reflect no effect or an effect that varies by structural and functional components and participants’ expertise.

Following publication a series of pieces appeared in the professional press with eye catching headlines such as:

‘Tumor Boards May Not Really Impact Cancer Care‘, and ‘Little association of multidisciplinary tumor boards with effects on cancer care‘, but the title that grabbed our attention was an opinion piece in response to the Keating study offered by Douglas W. Blayney, MD, Stanford Cancer Institute, Stanford School of Medicine, titled: ‘Tumor Boards (team Huddles) Aren’t Enough to Reach the Goal‘.

Blayney details his reasoning and observation while cautioning against the potential ‘knee jerk’ over reaction by some to the Keating conclusions and ‘market aftermath’ as follows:

Tumor boards have too long a history for them to be easily
abandoned. Much like the “hurry-up” offense changed the conduct of huddles in football, tumor boards should also adapt to the changing times and technology. In the system studied by Keating et al. (1), there are only huddles and no feedback loop. Their measurement work provides a reason to change tumor board conduct.

On ‘This Week in Oncology‘, May 22nd, 2013 at 2PM Pacific/5PM Eastern Dr. Blayney is our very special guest. We’ll dive deeper into his thought process, rationale and recommendations to tweak the tumor board formula via technology and other process adds, to perhaps better align this important multi-disciplinary experience with improved patient outcomes.

‘You Don’t Know Jack’ by Morgan Spurlock

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cancer, clinical trials, digital media, evidence based medicine, health, innovation, Intel Science Fair, jack andraka, oncology, participatory medicine

By Gregg A. Masters, MPH

But you should! Get to know him here:

Earlier today we just finished chatting with Jack Andraka on This Week In Oncology. One of my favorite lines from the conversation is quoted below, Jack refers to the high school biology class as the:

absolute stifler of innovation

From which he none-the-less associates inspiration for his scientific inquiry. Suffice it to say, Jack was neither encouraged nor challenged by the curriculum, and found other ways to engage his mind and curiousity.

@IBMwatson and the Future of Oncology Care

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cancer, digital health, FutureMed, genomics, health, IBM Watson, Marty Kohn MD, oncology, wellness

By Gregg A. Masters, MPH

Another of the highlights of FutureMed 2013 was the track on ‘the future of oncology’. In addition to the promise of favorably impacting both the early diagnosis and thus treatment outcomes for pancreatic cancer via the discovery of Jack Andraka, Ronald Levy, MD of Stanford wove a beautiful narrative of hope and promise that might best be represented by the following quote:

My dream is to get rid of chemotherapy and do it with the immune system..

Dr. Levy’s concluding slide outlined the visioned future for oncology:

Meanwhile one could not be but immensely inspired by the clinical decision support and powerful AI platform demonstration detailed by Marty Cohn, MD. Witness ‘IBM Watson Demo: Oncology Diagnosis and Treatment’ developed in conjunction with Memorial Sloan-Kettering Cancer Center:

Meet Jack Andraka: Mathematician, Scientist, Cancer Researcher

By Gregg A. Masters, MPH

Last week FutureMed at Singularity University on the campus of NASA Ames in Mountain View, California ran it’s week long intensive for 2013. This year It’s executive director and principal organizer, Daniel Kraft, MD gave the cyberspace crowd a full day’s taste of the program on Tuesday, February, 5th. For the agenda including links to faculty, click here.

Of the many powerful and stimulating presentations one in particular stands out as offered by 16 year old scientist, and winner of the 2012 Intel National Science Fair Jack Andraka. For a taste of Jack’s entusiasm, passion and intellect check out the video below:

We are thrilled that Jack will be joining us on ‘This Week In Oncology‘ on February 20, 2013 to learn more about this remarkable young man and discuss his journey into science and making a difference. We’ll post the details and program description shortly.

For additional insight on Jack, see a recent BBC interview below, where he explains his process and determined journey in the face of a serious amount of mainstream academia skepticism:

 

 

Biometric Monitoring Systems: A Role for Monitoring & Managing Cancer?

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bimetric scoring systems, ces 2013, digital health, health, michaeal singer, Quantified Self, vitality analyzer, wellness

By Gregg A. Masters, MPH

There is considerable (and growing) attention focused on the emerging role of ‘quantified self’ tools to improve our overall health status, enhance access, improve outcomes while also lowering the total cost of health care. At the recently concluded CES 2013 Conference and Exposition a Forbes article posed the following question:

CES 2013: The Year of The Quantified Self?

If you’ve not heard of the ‘Quantified Self‘ movement you will. Their website is chock full of information and health apps for the curious and motivated. The recent blog post: Future Normal: Quantified Self Tools at the Apple Store hints at the new normal now in sight. Or as overheard several times on the Silicon Valley circuit for at least the last three years and oft credited to William Gibson:

The future is already here. It’s just not evenly distributed yet

So in this entrepreneurial frenzy and resultant sea of digital health apps all chasing the holy grail to define and manifest a healthier America, much attention has rightfully focused on the capture, reporting and sharing of meaningful biometric data to maintain health, improve health literacy, better inform doctor/patient communications and ultimately support improved health outcomes.

Against this background, now ponder the following xPrize-esque(?) question:

Imagine if you could have a conversation with your body on a cellular level. What if you asked your cells, how am I really doing? Am I healthy? Is my treatment working? Is there anything I could be doing better?

And consider the following reply:

‘The Vitality Analyzer, an FDA approved Class II over-the-counter medical device that electrically measures your health, is a simple tool that helps you answer those questions. Based on well established technology, the Vitality Analyzer measures your health collecting information about your body’s cells and then translates it to a numeric score; your Vitality Index a global health indicator.’

Sound interesting, if not a bit of an over the top claim to make? it did to me. So on the Wednesday, January 30th 2013 broadcast of ‘This Week in Oncology‘ we’ll chat with the inventor Michaeal Singer and dive deeper into the peer reviewed science supporting the ‘well established technology’ cited above.

To state the obvious, at least from the point of view of cancer patients wondering what is happening at the cellular level minimally in between those routine or non-routine follow-up visits to the oncologist, if this metric can reliability report on the underlying state of health or to the contrary tumor pathogenesis, this is the kind of ‘biomarker’ information most cancer patients would want to have.

A Conversation with Jeff Hall, PhD, Vice President of GenOptix

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biomarkers, cancer, genomics, GenOptix, medicine, novartis, oncology, pharma, social media

By Gregg A. Masters, MPH

On Wednesday’s broadcast of This Week in Oncology our guest Dr. Jeff Hall makes his second appearance on the show. The topic was ‘Biomarkers: their emerging clinical significance in the diagnosis and treatment of cancer’.

Dr. Hall has over 20 years of experience in the life sciences industry, and is currently the Vice President of Clinical Education at GenOptix. He holds a BA in Biology and Chemistry from UC Santa Cruz and a PhD in Biochemistry from UC Berkeley. Dr Hall was the first author on the landmark 1990 Science paper describing the location of BRCA I on chromosome 17q.

GenOptix is division of Novartis. For broader context see webcast by Novartis CEO Joseph Jimenez to the JP Morgan Healthcare conference, and for the deck click here.

To listen to archived replay of broadcast, click here.

Is It Safe?

Tags

cancer, digital media, ehr, emr, innovation, internet security, mat honan, oncology, social media

By Richard Just, MD

When I read William Goldman’s book “The Marathon Man” years ago, I recall the evil Nazi dentist with drill in hand (played by Sir Laurence Olivier in the subsequent movie) hovering over the un-anesthetized Dustin Hoffman strapped to a chair asking the question: “Is it safe?” Of course, Hoffman didn’t know. So when Olivier turned on the drill and Hoffman started screaming, everyone in the theater identified with his pain. I still get chills when thinking about it.

In previous blog post here, I’ve described the pain I experienced when we transitioned from paper charts to electronic medical records. Certainly not as intense as having dental work without anesthesia, but agony just the same. Well guess what! Now we’re transitioning to a new EMR. In many ways, our pain level has increased from 6/10 to 9/10.

I interviewed Casey Quinlan, of Might Casey Media, a very astute commentator on healthcare in general and cancer care specifically, on This Week in Oncology last Wednesday. The “Mighty Casey” made several cogent observations on EMR’s, but, we  really didn’t address the question of security. In the December 15-16, 2012 issue of the Wall Street Journal, Ellen E. Schultz  wrote an article entitled: “How Safe Are Your Medical Records?” Two pieces of legislation are cited:

The first is the Health Insurance Portability and Accountability Act (HIPAA) which “allows health-care providers to disclose medical records without a patient’s consent when the information used is for treatment, payment and ‘health-care operations.’ Providers are supposed to exchange only relevant information, but they commonly transfer a patient’s entire file, which is easier than separating the pertinent records.” In the same manner, protection can be lost for psychotherapy records if they are co mingled with other medical records.

Second is the American Recovery and Reinvestment Act of 2009 which “prohibits the unauthorized sale of medical records, requires that data be encrypted and mandates that individuals be notified of security breaches. It is too soon to say how effective these rules will be.”

Drilling down to the core problem is Mat Honan’s original article “How Apple and Amazon Security Flaws Led to My Epic Hacking” and follow-up video entitled “Mat Honan Hacked and Digitally Destroyed” he describes an “epic hack” that destroyed his entire digital life in 1 hour. Having been the victim of a phishing expedition, a minor nuisance compared to his experience, I know how it feels to have your identity stolen.  After researching how and why hacking has become more problematical, Honan concludes: “The age of the password has come to an end; we just haven’t realized it yet. And no one has figured out what will take its place.” He continues: “The ultimate problem with the password is that it’s a single point of failure, open to many avenues of attack. Two factors should be a bare minimum.” This creates the dilemma that if the password is too simple and obvious, it’s a no-brainer to crack; if it’s too complex and obscure, the password is hard to remember. And, we are advised never to write passwords down. Why am I not surprised that the most common password used is, in fact, “password”, and second is “123456”?

Honan provides a helpful Dos and Don’ts list to survive the “password apocalypse”:

“DON’T:

1. REUSE PASSWORDS. If you do, a hacker who gets just one of your accounts will own them all.
2. USE A DICTIONARY WORD AS YOUR PASSWORD. If you must, then string several together into a pass phrase.
3. USE STANDARD NUMBER SUBSTITUTIONS. Think P455wOrd is a good password? NOp3! Cracking tools now have those built in.
4. USE A SHORT PASSWORD-no matter how weird. Today’s processing speeds mean that even passwords like “h6!r$q” are quickly crackable. Your best defense is the longest possible password.

DO:

1. ENABLE TWO-FACTOR AUTHENTICATION WHEN OFFERED. When you log in from a strange location, a system like this will send you a text message with a code to confirm. Yes, that can be cracked, but it’s better than nothing.
2. GIVE BOGUS ANSWERS TO SECURITY QUESTIONS. Think of them as a secondary password. Just keep your answers memorable. My first car? Why, it was a “Camper Van Beethoven Freaking Rules.”
3. SCRUB YOUR ONLINE PRESENCE: One of the easiest ways to hack into an account is through your e-mail and billing address information. Sites like Spokeo and WhitePages.com offer opt-out mechanisms to get your information removed from their databases.
4. USE A UNIQUE, SECURE EMAIL ADDRESS FOR PASSWORD RECOVERIES. If a hacker knows where your password reset goes, that’s a line of attack. So create a special account you never use for communications. And make sure to choose a username that isn’t tied to your name-like m****n@wired.com so it can’t be easily guessed.”

So, the answer to the question: “Is it safe?” is an emphatic NO. Honan concludes that online identity verification will not be a password-based system in the future, any more than our system of personal identification will be based on photo-ID’s. But, passwords may still be involved as just one part of a multifaceted process.

Clinical Cancer Advances 2012 via @ASCO

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cancer, evidence based medicine, innovation, medical education, oncology, participatory medicine, physician, social media, twitter

Now in its eighth year, Clinical Cancer Advances 2012 was developed under the guidance of an 21-person editorial board of leading oncologists, overseen by Executive Editors Nicholas J. Vogelzang, MD and Bruce J. Roth, MD.
Each year, the American Society of Clinical Oncology conducts an independent review of advances in clinical cancer research that have the greatest potential impact on patients’ lives.

This year’s report, Clinical Cancer Advances 2012: ASCO’s Annual Report on Progress Against Cancer, features 87 studies, 17 of which were designated as “major” advances by the report’s 21-person editorial board.

The large number of advances featured in this year’s Report affirms the remarkable payoff of national investments in clinical research on cancer prevention, screening, treatment and quality of life for patients with cancer.

For complete report, click here.

The ‘Oncology ACO’: Does it Have a Future?

Tags

accountable care, aco, affordable care act, cancer, FloridaBlue, health reform, innovation, obamacare, oncology ACO, US Oncology

By Gregg A. Masters, MPH

The best business model for oncology care is not yet obvious to me. But it is crystal clear that innovative new models are being hatched before our eyes.. via Oncology Times

Since CMS (via HHS) issued the final rule addressing ACO provisions and specifically ‘excluded’ oncologists from participating as ACO organizers, instead relegating their involvement in at least via the Medicare Shared Savings Program to ‘participants’, there has been rumbling underneath the surface of ‘ACO-dom’.

Perhaps as best evidenced by the April announcement of a tripartite venture between FlordiaBlue, Advanced Medical Specialties (a former US Oncology Affiliate now part of the McKesson fold), and Baptist Health System, the competitive positioning in the oncology market is not sitting idly by as other medical specialties, including primary care, carve out their niche and actively experiment with their version and local vision for accountable care aka ‘the triple aim.’

In the broader conversation on ACOs or their derivatives including medical homes or accountable care collaborations, etc, there has been much discussion from very smart and accomplished wonks including periodic banter, i.e., Goldsmith v. De Marco] as to the significance and forward [reasonably expected] benefits from duly organized [or in the latter case - arranged] ACOs. Bottom-line,  there is a fair amount of credible disagreement over whether these entities as variably configured actually make a difference?

Meanwhile, in the oncology domain, much of the action seems relegated to a few forward thinking players who have taken the initiative regardless of CMS’ decision to limit their participation (at least to this point in time) to contracted participant suppliers of specialty services.

For a deeper dive into the question: ‘Who Is Taking the Lead in Incorporating Oncology into ACO Thinking?’ see: The Rapidly Evolving ACO World, we have the following observation and summary data:

There are several examples of organizations that have stepped up and have taken the lead in exploring payment re-design in oncology, some within an ACO shared savings context and some outside the ACO context.

The vanguard includes:

• Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home®, Drexel Hill, PA
• United Healthcare (5 episode payment pilot sites)
• Texas Oncology/Innovent Oncology and Aetna
• Oncology Physician Resource (OPR) and Michigan Blue Cross
• Wilshire Oncology and Wellpoint, Southern California
• CareFirst Blue Cross pathways and medical home initiative, Maryland
• Priority Health oncology medical home initiative, Michigan
• Florida Blue, Baptist Health South Florida and Advanced Medical Specialties Oncology ACO, Miami
• Harvard Pilgrim Health Plan with oncology medical home demonstration pilot, Massachusetts;
• Innovative Oncology Business Solutions with CMMI Innovation Challenge grant to demonstrate value proposition of community oncology medical home (COME HOME) at 7 community oncology practices nationwide.

And certainly there will be more organizations joining the vanguard in the near future.

We are working on getting Ronald Barkley, CCBD Group, and Linda Bosserman, MD, President and CEO of Wilshire Oncology respectively to share their thoughts on ‘This Week in Oncology’. We’ll keep you posted when we’re able to lock them down.

Meanwhile, with the elections now behind us, the future is rather clear at least for those who want to manifest the spirit and intent of the Affordable Care Act, so ‘warp drive Mr. Zulu’ as the ACO movement shifts into overdrive.

Can ‘Social Media’ Bridge the Gap Between Payers and Oncologists?

Tags

@tumorboard, cancer, digital media, health, innovation, managed care, medical education, participatory medicine, social media, twitter

By Gregg A. Masters, MPH

The continued penetration of social media tools, platforms and derivatives into medicine in general and oncology in particular continues to make steady if not uneven headway into the workflow of medical groups, physician networks if not individual practices.

Still somewhat of a ‘show me the money’ value proposition, social media leverages widely accessible web-based and mobile technologies to create and share user-generated content in a collaborative and more often than not near real time social context. The ultimate promise is, that it’s effective uptake will enable new opportunities for physicians, other healthcare professionals and even certain ‘calcified institutions’ i.e., hospitals, to interact with patients in new and different ways.

In cancer care social media can serve as a platform for patient education (see: @Chemotopia) if not as an authoritative health messaging resource, where oncologists fulfill their role as trusted publishers if not de-facto ‘search nodes on the web’. Additionally many believe these emerging technologies can add to professional development, see @TumorBoard, knowledge sharing, and even where appropriate direct patient interaction, if key legal and privacy concerns can be addressed prospectively.

In the professional development department, the video below was shot on November 16 2012 at American Journal of Managed Care’s (AJMC) ‘Translating Evidence-Based Research Into Value-Based Decisions in Oncology’.

Featuring Dennis Scanlon, PhD, who addresses the ‘Importance of Payer/Provider Relationships’. Dr. Scanlon is Professor of Health Policy and Administration, The Pennsylvania State University, stresses: ‘it is very important to bridge the gap between providers and payers in oncology management’ as ‘there is a lot of variation in the cost and quality of care in oncology. The goal is to identify the appropriate payments for quality care.’