In Absentia

Tags

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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Big Data, Government and Cancer Research: A Benefit for Patients?

Tags

big data, cancer, clinicaltrials, dan munro, evidence based medicine, genomics, innovation, medicine, oncology, social media

By Gregg A. Masters, MPH

On the Wednesday, July 24th, 2013 broadcast of This Week in Oncology at 2PM Pacific/5PM Eastern our special guest is entrepreneur, social media thought leader and Forbes Contributor Dan Munro aka @danmunro.

Dan recently penned a piece for Forbes titled: ‘Big Government Opens Big Database For Cancer Research‘

This catchy headline caught my attention since part of our mission at This Week In Oncology is to eliminate the esoterica from ‘oncology-speak’ and to present the significance of the discoveries, trends and developments in the cancer care and dignostics in plain english for more general consumption.

Much progress has been realized in medica oncology of late with a fair amount of the promisesd upside of ‘personalized [or individualized] medicine’ often pointing to better outcomes via more targeted treatment of specific tumors based on their unique genetic signature.

So called ‘big data’ is in the news as ubiquitous technology, connectivity, the declining costs of massive data dragnets and disease specific mashups affords insights previously inaccessible to reseachers, clinicians and others interested in the diagnosis and/or treatment of oncology.

We’ll get Dan’s takes on his piece and see how he sees the confluence of these trends coming together for the benefits of patients.

To listen live or via archived replay, click here.

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

Tags

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

Tags

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.

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.’

Get to Know ‘Chemotopia’

Tags

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:

The Shell Answer Man

Tags

cancer, clinical trials, clinicaltrials, CME, digital media, evidence based medicine, health, Just Oncology, oncology, participatory medicine, social media, twitter

By Richard Just, MD

Over the past 37 years in practice, I’ve received thousands of requests from patients, family and friends to interpret results of clinical trials.  These requests have increased dramatically with the advent of the Internet.   Many of these reports involve poor trial design or are inappropriate for the patient under consideration.  Sometimes I’ve mumbled to myself “I feel like the Shell Answer Man”.  For those too young to remember, I’m referring to a Shell Oil Co. ad beginning in the 1960’s in which the ‘Shell Answer Man”, replete in his Shell gas station uniform, answered common questions about driving and the uses of gas and oil. He just memorized a script; sometimes I wish I had one.   

Over Labor Day weekend, while in Chicago for a family event, we turned on TV to catch up on the day’s news. As fate would have it, we stumbled upon a healthcare segment on the NBC affiliate.  The reporter was listing items individuals should consider in evaluating results of clinical trials.  It seemed to me that knowledge of these items would be very helpful to people who are not healthcare professionals; people who need some way to filter trials worth pursuing with their physicians.  The following are those questions:

1. Are the patients in the trial separated into groups, with one receiving the drug or regimen being tested (“Experimental Group”) while the other is treated with the agent(s) considered standard treatment (“Controls”)?  These groups are many times labeled “arms.”  The Control Arm may be a placebo if there is no known standard treatment.  This does not mean the patient receives no treatment at all.  These types of studies are considered the “gold standard” of clinical trials in that they involve large numbers of patients who are followed for long periods of time.  This increases the likelihood that resultant findings are valid.  The downside is they take a long time to complete and are very expensive (about $1 billion from start to finish).
2. What is the total number of patients entered into the trial?  As alluded to above, the more the better.  If one study includes 50 patients while another 350 (all other factors being equal), place more trust in the larger trial.
3. What is the length of the study? In other words, how long are the patients followed? Again, the longer the better.
4. Were the patients included in the trial representative of the proposed population to be studied?  For example, if the population to be studied involves pediatric patients, someone over 18 years of age should not be entered into the trial.
5. Who is funding the study? Pay attention here. If the study is paid for by the company who developed the experimental agent, how likely are they to give a completely unbiased report? Of course we want to assume that they will, but unfortunately, some won’t.  A government supported trial is more likely to report balanced findings than an industry funded one. The reporter added that patients should note what the authors say about their study, i.e., do they make overly optimistic claims for their treatments?  Most investigators add some type of cautionary note, like “the proposed treatment looks promising pending further studies.”  This disclaimer recognizes that no study is perfect.  In fact, there has been a marked increase in the number of studies initially reporting positive results that were retracted when similarly designed trials were subsequently negative.  The end result has been a delay in patients receiving appropriate treatments and a horrible waste of money.
6. I’m adding this one on my own. I’ve noticed that one of the most common mistakes people make is to search for clinical trials involving the wrong cancer, not realizing that we identify cancers by their organ-of-origin, not the organ where they spread (metastasize).  An example would be to collect articles about liver cancer instead of colon cancer that metastasized to liver.

As chairman of our hospital’s Investigational Review Committee, I and our members are in charge of reviewing proposed clinical trials conducted in our hospital district.  The above factors, as well as many others, are considered before studies are approved, denied or amendments recommended.  Consideration of the items discussed above could save everyone a lot of wasted time, and even lead to the retirement of the Shell Answer Man.

CDC Cancer TweetChat

Tags

cancer, CDC, epatients, medicine, oncology, social media, survivorship, Tweetchat, twitter

By Gregg A. Masters, MPH

On Tuesday June 19th, 2012 from 2:00 to 3:00 PM Eastern the Center for Disease Control’s (CDC), aka @CDCgov, Division of Cancer Prevention and Control aka @CDC_Cancer  hosted a ‘Tweetchat’ on cancer survivorship. Subject matter experts including Blythe Ryerson, MPH and Dr. Elizabeth Rohan moderated the session and answered questions posted via the Twitter hashtag #CDCcancerChat.

The stats tracked represent Tweets posted to #CDCcancerChat hashtag in the 24 hours before and during the actual Tweetchat and certainly represent an impressive potential reach of the message!

The ‘Cancer Survivorship’ Tweetchat began with the following Tweets:

Below are  the influencers:

 

 

 

 

 

 

The last series of ‘long tail’ Tweets are represented below:

Clearly we are early in the application of social and/or digital media to influence, shape if not resolve many lingering chronic healthcare financing, delivery and public health concerns. Kudos to the CDC!

For recent timely topical reflections from @chemosabe1 aka Dr Just, click on ‘Cancer Survivorship.’

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.