In Absentia

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cancer, digital media, integrated medicine, integrative oncology, Just Oncology, oncology, richard just md, social media

By Gregg A. Masters, MPH

When I first approached Dr. Just on his potential interest in the emergence of social media in healthcare in general and medicine in particular, we engaged in conversations that generally tethered to a contribution to a ‘legacy’ theme.

Reflecting on a now 40 year career in community based medical oncology he was thinking about winding down his participation in a full time practice while passing on the deep wisdom and insights developed over the decades.

Considering the explosion of digital media platforms and capabilities, and the low hurdle rate to participate via this medium this consideration was rather timely.

The first order of business was to brand that voice and craft a social media ‘presence’.

As I reflected on his last name ‘Just’, and saw a double entendre opportunity to conflate ‘just’ with ‘oncology’ – I thought how perfect! Lets brand you as ‘JustOncology.com’. Since in this context ‘just‘ could mean ‘Dr Just’, or solely focused on oncology, or even just in the sense of ‘equity’ or fairness in oncology care. In all cases, the branding expression and focus was clean and consistent with his interest to write, speak and counsel others on the journey.

So we created the blog JustOncology and twitter handle @JustOncology (though he principally tweets via @chemosabe1) and shortly thereafter launched the radio show ‘this week in oncology’.

As noted in the masthead above Dr. Just writings would reflect on ‘health, illness & evidence based medicine’. An intentionally broad brush tapestry that included everything from his personal health encounter with heart surgery, the move into value based pricing for oncology services, oncology ACOs, seemingly interminable encounters with EHRs that actually work for the practice, practice mergers, partner relations and the most recent shift into ‘integrative oncology’ which has literally taken him offline for almost a year – at least as a principal contributor to this blog.

So as his partner, de-facto editor and co-contributor, let this post call attention to two projects that fit squarely into the ‘legacy’ theme and Dr. Just’s valuation of and advocacy for truly ‘patient centered care’.

Meet @TumorBoard aka TumorBoard (dot) com and CancerCenter (dot) TV – both projects in the incubator of ideas in search of funding support.

A little history on @TumorBoard includes the following introduction from our concept paper.

Context

A centerpiece of the American College of Surgeons’ Commission on Cancer (COC) standards to accredit hospital based cancer programs is a multidisciplinary conference (aka ‘tumor board’) of doctors and other cancer specialists, who meet on a regular basis to collaborate in the diagnosis and recommend treatment options for cancer patients. An active and vibrant tumor board is an essential consideration in the accreditation process. For further context see the Commission on Cancer’s ‘Cancer Program Standards 2012, Version 1.1: Ensuring Patient-Centered Care.’

As defined by the National Cancer Institute (NCI), a ‘tumor board’ is:

A treatment planning approach in which a number of doctors who are experts in different specialties (disciplines) review and discuss the medical condition and treatment options of a patient. In cancer treatment, a tumor board review may include that of a medical oncologist (who provides cancer treatment with drugs), a surgical oncologist (who provides cancer treatment with surgery), and a radiation oncologist (who provides cancer treatment with radiation). Also called multidisciplinary opinion.

Once a popular collegial if not ‘social’ venue to network and learn from one’s peers, periodically present or consult on cases, possibly earn CME credit, if not grab an occasional meal, tumor board has unfortunately lost some of its attraction and ‘gravitas’.

Increased practice complexity, misaligned financial incentives, declining reimbursement and growing demands on physician time, are some of the obstacles resulting in declining physician participation in traditional hospital based tumor boards. Yet few other comparable multidisciplinary, peer based clinical forums outside of mature integrated delivery systems or academic medical centers have the potential to enable the integrated practice of collaborative, coordinated and evidence based community cancer care.

Realizing the Promise of Multidisciplinary Cancer Care

Many assume multidisciplinary care is better care, since it engages multiple minds in the care process, yet in ‘The Need for Assessment and Reassessment of the Hospital Cancer Conference‘, in the Annals of Surgical Oncology, October 2009, Frederick L. Greene, MD, identifies the traditional weakness of many hospital based tumor boards:

most of these [tumor board] conferences…are based on a “show and tell” mentality rather than serving as treatment-planning conferences utilizing the expertise of the participating multidisciplinary experts….

In other words, traditional hospital based tumor boards have not yet fulfilled the promise of better care or improved outcomes as a result of the assumed value add of multidisciplinary engagement in cancer diagnosis and treatment. Apparently, business as usual ‘silo-ed’ medicine remains embedded in the care process even in the midst of what appears to be multidisciplinary consideration.

Why @TumorBoard?

@TumorBoard intends to uniquely address the convergence of several macro trends:

• The high cost of cancer treatment and parallel shift of a greater share of the total cost burden on to a resource constrained and often health literacy challenged patient.
• A heightened awareness of the need for increased clinical integration and care coordination across an otherwise silo-ed and discontinuous portfolio of specialties.
• Formal recognition that the upside of the multi-disciplinary engagement of cancer specialists (i.e., tumor board), has neither realized nor fulfilled its collaborative promise (see: Tumor Boards (Team Huddles) Aren’t Enough to Reach the Goal).
• Emergence of an informed and engaged ‘e-patient’ (witness the launch of SmartPatients).
• A nascent yet growing pool of technology savvy, patient-centric cancer specialists who value peer based collaborative multidisciplinary care with active engagement of the patients under their care (See e-patients and the Society for Participatory Medicine).

For more information, download the TumorBoard concept paper via tumorboard_description_v1.5.

 

 

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The Advent of Cancer Immunotherapy: Addressing Unmet Needs Part 1

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cancer, evidence based medicine, health, immunotherapy, innovation, integrative oncology, managed care, medical education, wellness

By Gregg A. Masters, MPH

The following is provided via the video series at the American Journal of Managed Care on ‘The Advent of Cancer Immunotherapy’, part 1 of a 3 part series:

 

In a discussion moderated by Dr. Peter Salgo, Drs. Jeffrey Weber, Michael Kolodziej, and Daniel J. George share their insights and perspectives on the rise of cancer immunotherapy, and its significance during a time in which cancer is recognized as the “new global pandemic” that has killed more than 600,000 US persons in 2012 alone.

 

For original source link, click here.

Crowds Care for Cancer Challenge: Supporting Survivors the Finalists

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accountable care, cancer, coordinated care, crowds care for cancer, digital media, health, innovation, integrative oncology, medicine, survivorship

By Gregg A. Masters, MPH

Last month in a continuing commitment to advance the art and science of patient engagement in health the Office of the National Coordinator for Health Information Technology (ONC) teamed up with the National Cancer Institute (NCI) partnering with Health 2.0 Challenge and the Medstartr crowd funding platforms to field an innovative challenge on creating applications for the estimated 14 million cancer survivors in the United States.

For complete program details on the the ‘Crowds Care for Cancer: Supporting Survivors‘ challenge click here, and for the finalists now in the crowd funding optimization stage see the Medstartr finalists feature page here.

On This Week in Oncology, we chat with each of the three finalists in the competition, beginning with Journey Forward: My Care Plan, a project by Tiffany Devitt.

On Thursday, June 27th, 2013 at 1:30PM Pacific/4:30PM Eastern to join us live (or for an archived replay) with Patti Ganz, MD of the Journey Forward: My Care Plan team, click here.

Both remaining Crowds Care for Cancer: Supporting Survivors Challenge finalists are scheduled as follows:

PatientWithPower: A project by PatientsWithPower | 11AM Pacific/2PM Eastern Friday, June 28th, 2013. For live or archived replay, click here.

Together: A project by Michelle Longmire | 11AM Pacific/2PM Eastern Tuesday, July 2nd 2013. For live or archived replay, click here. 

Please review each of the candidates in this important challenge and show your support accordingly. The leader board to date is as follows: PatientsWithPower, Journey Forward: My Care Plan followed by Together.

 

Get to Know ‘Chemotopia’

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cancer, chemotherapy, chemotopia, evidence based medicine, integrative oncology, Just Oncology, medical education, oncology, social media, startUp health, twitter

By Gregg A. Masters, MPH

On the Wednesday, November 7th 2012 broadcast of
‘This Week in Oncology‘ we chatted with medical oncologist, integrative cancer care specialist, and ‘serial entrepreneur’ Steven Eisenberg, D.O., co-founder of StartUp Health Academy’s transformer entry ‘chemotopia‘aka @chemotopia on Twitter.

Disclosure: Dr. Eisenberg is a partner with Dr. Just in Cancer Care Associates for Research and Education (CCARE).

We spoke with Dr. Eisenberg about his most recent entrepreneurial interest known as ‘chemotopia’, where the tagline is:

getting through chemotherapy, together

To listen to the broadcast, click on the show logo below:

Western Meets Eastern Medicine: Or Ying Meets Yang?

Tags

cancer, clinical trials, CME, digital media, epatients, evidence based medicine, innovation, integrative oncology, medicine, pharma, physician, research, Traditional Chinese medicine

By Richard Just, MD

In today’s China, both eastern and western medical philosophies and practices exist relatively harmoniously.  Patients with minor, usually self limited problems are treated initially with a seven day course of seven liquid herbal preparations taken each day.  If symptoms subside, usually treatment is discontinued.  If improved but not resolved, formula may be modified.  If worse, regimen can be changed and/or referral to specialists arranged.  There are hospitals that practice purely eastern or only western medicine.  But it is becoming more frequent to find hospitals that integrate both disciplines.  Chronic conditions, like cancer, tend to be treated with western techniques, with Traditional Chinese Medicine (TCM) used in a supportive or complementary role.

I was somewhat surprised to hear that the 2 largest cancer problems are breast cancer and liver cancer (mainly the former but not the latter).  Before I left, one of my patients had brought an article to my attention about a low incidence of breast cancer in China  compared to the West.  This may not be the case.  Primary liver cancer, hepatocellular carcinoma), has long been the number one cancer in frequency in the world due to a high incidence of hepatitis, especially in Asia.  This results in chronic active hepatitis, cirrhosis and, finally, cancer.  Even though we stayed at 5 star hotels, we didn’t brush our teeth or rinse our toothbrushes with tap water, and avoided ice.  Sanitation, or lack of it, is an issue.

Everywhere in China, especially big cities, there are forests of skyscrapers.  Private homes are essentially nonexistent as the government owns all the land.  New construction is ubiquitous, so cranes are numerous.  Many of these apartment spaces are empty due to high prices, and those that are bought or rented are shared by several families.  Same with kitchens and bathrooms.  Public bathrooms may lack toilets and simply be holes in the ground.  In some buildings, one bathroom per floor exists.  We saw the interiors of 3 residences.  First, the home of one of four of the farmers that first discovered the terra-cotta warriors outside Xi’an.  Clean.  Very little furniture as you buy empty spaces which you have to furnish yourselves.  But several generations of the family lives there.  Second, a more modest quarters of a woman in the old section of Beijing.  Bathrooms were down the road apiece.  The last was a tiny, single room in what used to be the French Concession section of Shanghai.  Five people slept on one cot.  No mystery why hepatitis and liver cancers are still issues.

Another surprise is lack of mention of lung cancer.  Cars everywhere.  Their gridlock is continuous and called “rush days”.  Mist or fog (mostly pollution) gives a surreal appearance to the landscape of high rises.  Seemingly everyone coughs.  Lots of spitting.  A perfect setup for respiratory problems including lung cancer.  There are several hospitals in major cities devoted to respiratory diseases, however.

An excellent article appeared in the Wall Street Journal, Tuesday, April 3, 2012, pg D4, entitled “Chinese Medicine Goes Under the Microscope” by Shirley S. Wang.  The main topic is a clinical trial studying a four herb combination, called huang qin tang in China and PHY906 in this trial, in combination with chemotherapy to see if effective in reducing side effects of chemo (nausea, vomiting, and diarrhea).  If so, patients might be able to tolerate higher doses of chemo with better results.  Trial design and quality control are issues when doing studies such as these:

One challenge with using herbal medicines is that the ratio of the chemicals they contain isn’t consistent when plants are grown under different conditions.  After testing various suppliers, Dr. (Yung-Chi) Cheng ended up creating a biotechnology company sponsored by Yale called PhytoCeutica to carefully monitor growing conditions to ensure plants from different batches were pharmacologically consistent and to continue clinical development of the compound.

Finally, an article that appeared in the China Daily entitled “There’s More to Life Than Money” by Cai Hong, a senior writer for the paper, cites the first World Happiness Report   released by the Earth Institute last month.  Not surprisingly, the top 4 rated are northern European welfare states:  Denmark, Finland, Norway and the Netherlands.  China doesn’t make the top 100.  One of the benchmarks evaluated is health:

……Increased insurance coverage has not yet been effective in reducing patients’ financial risks, as both health expenditure and out-of-pocket payments continue to rise rapidly.  And there are many reports of disgruntled patients and their relatives attacking the medical staff in hospitals.  Reform of public hospitals is essential to control health expenditure because such institutes deliver more than 90% of the country’s health services.  But Health Minister Chen Zhu said the cost of improving care remains an obstacle, and China is looking to other nations for cost-effective solutions.

While this notice appeared in the WSJ this last weekend:

U.S.-China Pharma: Some big pharmaceutical firms are partnering with Chinese companies in trying to discover the next blockbuster drug.  This Philadelphia conference will include venture capitalists and such Western firms as Novartis and Abbott Labs. Wednesday-Thursday, Hub Cira Centre.  Regular admission:  $1,799.00.

I find it interesting that both the U.S. and Chinese governments are investigating hospitals for price gouging in the sale of drugs. Further, given the emerging cost and access pressures they’re witnessing, might mainland China by eying the health system reform experiment underway in Taiwan?

China: A report from the journey

Tags

cancer, digital media, evidence based medicine, integrative oncology, medical education, oncology, participatory medicine, physician, social media, Traditional Chinese medicine, wellness

By Richard Just, MD

China is nothing like I imagined! The evolution of healthcare mirrors major events in Chinese history.  Traditional Chinese Medicine (TCM) dates back 5,000 years when the first documentation appears.  What is currently called TCM goes back 3,000 years, and was essentially passed from one generation to the next.  Another factor that resulted in fragmentation of medical practices was that China was a feudal society whose states were constantly at war with each other.  The emergence of the Qin state resulted in a single state system with a single script and standardized weights and measures.  But their reign was so oppressive it lasted only 15 years, overthrown by the Han Dynasty in 210 BC.  During this time fragments of the Great Wall were fused into one continuous structure, and the underground mausoleum of the terra-cotta warriors was constructed near modern day Xi’an which was China’s capitol at that time.

In my mind, China was still a monolithic society under a Communist regime and TCM was available to the masses while western medicine was for the ruling class.  Well that’s not exactly the case.  Prior to 1949, there had been a widening chasm between those who had access to healthcare and most everyone else who didn’t.  When the Party came to power, most workers were employed by the government and had access to healthcare.  All through the Cold War era, the only major leader who never left his country was Mao.  He was mainly concerned with unification of the country and building a strong infrastructure.  Many lesser officials did interface with the West, and when they returned with different ideas, the Cultural Revolution (1966-1976) ensued.

We all know that intellectuals, including doctors, suffered.  But Mao realized he needed some physicians to treat the population.  He also realized that TCM needed to be standardized so it could be disseminated to as many doctors as possible.  In this process, much of the practice of TCM was changed in China, but it continued as it had been practiced for 3,000 years in Japan.  In 1980, with the end of the Cultural Revolution, two policies were instituted that have resulted in major changes in society:

1. One child per family rule:  There are certain exceptions to this rule.  But, in general, if a family has more than one child they are fined, heavily.  And, if the practice continues, a sterilization procedure results.
2. Opening up China to western ideas and businesses:  One of the first businesses allowed into China was health insurance.  Hard  to believe but true.  What has resulted is a system resembling ours.  Government employees and  officials  have  government insurance, which is essentially free.  They have access to everything necessary for their care, and it is funded by taxing the entire population.  Non-governmental employees buy private health insurance which generally covers 70% of  costs, leaving 30% out-of-pocket.  These policies consume a  good  chunk of income, and are renewed for 25 years after which all costs are covered by Social Security and the government.  Again these funds derive from taxes.  Parents pay for healthcare of their children, and rural farmers who can’t afford insurance are eligible for something like Medicaid/MediCal with “bare-bones” coverage.  This latter situation is also not free.  Obviously, most young people prefer a government job.  These are hard to come by unless you know someone, and contribute to his “Red Pack.”  This is the local phrase for payola or bribe.

Does this sound familiar?  I found no one who felt the system was fair.  But I didn’t speak with a government official.

Meanwhile, my wife and I had a personal experience with TCM.  Prior to our trip, Dee Dee fractured two metatarsals in her left foot.  This was healing when we left.  But, I’ve dubbed China as the country of stairs.  Lots of walking and climbing.  This time both feet and ankles were extremely painful and swollen when we boarded the Yangtze River cruise.  Fortunately, there was a doctor on board who saw her the next day.  Her treatment consisted of acupuncture, acupressure, placement of antifungal patches on the tops of her feet and cupping.  Not what I learned in training.  It was recommended that she soak her feet and legs up to mid-calf level each night in very warm to hot water for 20-30 minutes.  The whole process lasted one hour and cost 550 yuan, equating to roughly 90 USD.  She was much improved by the following morning.  That afternoon, Dee Dee had a second treatment.  Both treatments were very painful, especially when the needles were inserted.  It turns out Chinese needles have a much larger bore than those used in the U.S.

We listened to a lecture on TCM given by the same doctor.  TCM involves not only acupuncture, acupressure and cupping, but also herbal medicine, Qigong, and Tai chi.  He discussed the use of TCM modalities in treatment of migraine and other headaches, motion sickness and back pain.  Every morning, the same Dr. John Lee gave Tai chi lessons on board, which we both attended.  The only excursion Dee Dee has missed was to the temples at Fengdu which involved over 500 stairs and inclined walkways.

Now for the big question:  “Is there any role for TCM in the treatment of cancer?”  He said that TCM is of little benefit in treating or preventing cancer, but may have some benefit as an adjunct to surgery or other conventional treatments.  More on this when we reach Shanghai.

China Bound: An Appeal to the China Clinical Trials Consortium (CCTC), et al

Tags

cancer, china clinical trials consortium, clinical trials, clinicaltrials, evidence based medicine, integrative oncology, medical education, medicine, oncology, research, Traditional Chinese medicine

By Gregg A. Masters, MPH

Dr. Just will be heading to China this week and has an interest in connecting with clinicians associated with the China Clinical Trials Consortium, other academic or established medical group practices’ specializing ‘integrative oncology’, or solely traditional Chinese medicine for the care of cancer patients.

For a brief personal invitation please watch the video above. Dr. Just’s Twitter handle is @chemosabe1, if you are available during the timeline below and interested in meeting with an American colleague please follow @chemosabe1 on Twitter, he will follow you back and enable direct message sharing. Otherwise an @reply will work as well.

Travel dates and cities are: arriving Beijing, Thursday, May 3rd, and departing Shanghai on Friday, May 18th, 2012.