August 21, 2015
It has been said that with knowledge comes understanding.
A research paper and editorial published in this week's issue of JAMA Oncology may have brought knowledge, but if you read various media reports I am not so certain it has clarified understanding. And the distinction is important, because when a woman is confronted with the diagnosis of a "Stage O" breast cancer (aka ductal carcinoma in situ or DCIS), the decisions she makes about treatment can have far-reaching and long lasting impact for her and those who care about her. More...
August 10, 2015
(The following blog was originally posted on MedpageToday on August 3, 2015. It is reprinted here with permission.)
Genomics and its impact on clinical medicine appear to be the topics du jour. The science is rapidly advancing, but our ability to understand and apply that science may not be keeping pace. The question is whether expectations will meet the promise, and are we wise enough to navigate the maelstrom and bring true benefit to our patients and consumers in general?
Three recent research reports highlight how fast some of this discovery is moving. Two reports focused on the use of cell-free DNA fragments extracted from the blood and saliva to identify cancer related markers in patients with pancreatic and head and neck cancer. The other reported discordance in DNA from mothers and their fetuses discovered when prenatal blood tests were done, again using cell-free DNA. In short, the researchers reported on situations where a prenatal screen showed abnormal DNA, the fetus was tested and showed normal DNA which then led to the discovery of cancer in the mother.
To be certain, there are many similar research reports. But they all point in the direction that we are soon going to be facing the challenge of determining how to apply this technology to the everyday practice of medicine, and cancer care specifically. The reality -- as emphasized in the reports -- is that this is early stage science, and not ready for prime time. But the question remains: will others try to exploit these findings and make claims beyond what the science will support?
The question is not so far-fetched. It is happening already.More...
July 29, 2015
It's no secret that genomics is cutting edge science. It is exciting, it is changing the way we think about ourselves and the medical care we receive. But with all the "gee whiz" aspects of what we are discovering every day about our genetic code, it may be surprising to learn that one of the most important parts of our new tool kit may be sitting right there in front of us gathering more dust than attention.
This revelation came while attending a conference this past week sponsored by a group called HL7. HL7 develops standards for the exchange, integration, sharing, and retrieval of electronic health information in the healthcare setting. They convened this particular meeting to better understand how we can more effectively integrate genomic data into health care delivery and research so we can full advantage of the information from genomic-derived science that is coming at us like a tsunami.
What stood out amidst all of the topics discussed-and what achieved the greatest consensus among the conferees-was the role that the tried-and-true basic family history can play in helping us understand how the information provided by genomics fits together with real life. That's correct: the old fashioned family history that you occasionally fill out in the doctor's office that neither you nor your health professional usually pay much attention to.
Perhaps that needs to change.More...
June 10, 2015
Fate can work in mysterious ways.
A couple of months ago I was invited to participate in a symposium conducted by the National Cancer Policy Board at the Institute of Medicine in Washington DC. The topic was cancer in dogs, and how we might find ways to benefit dogs, their owners and science to better inform the treatment of cancer in humans through what is called "comparative oncology". It was an unusual topic in my experience and that of my colleagues, so I eagerly anticipated learning about something I hadn't given much consideration to in the past.
Little did I know at the time how personal this journey was going to be for me and my family.
Shortly after I accepted the invitation, we received sad news: our Golden Retriever Lily-who has been a member of our family for 11 years-developed swelling in her face. Our vet saw her the next day and told us she had lymphoma. The outlook without treatment wasn't good, and with treatment wasn't much better.
Tears flowed in our home that evening.
A week later we found a mass on Lily's back leg. Another trip to the vet, another needle biopsy, and another cancer, this time a sarcoma. The prognosis was even worse. Lily likely had weeks to live.
Lily fortunately didn't suffer, and died peacefully last week. Our local vet and my newly acquainted veterinary oncologists from Purdue (who were part of the conference faculty) became our trusted guides through a journey about which we knew precious little.
And now I found myself offering a presentation as the last speaker at the symposium, discussing our journey and what I have learned from the conference. Getting past the tears of our loss wasn't easy. More...
June 02, 2015
When it comes to personalized/precision medicine we should never forget it's all about the people, particularly the cancer survivors whose very lives depend on us getting it done quickly and getting it right.
That was the message from a discussion I had the privilege to moderate on Monday evening with cancer survivors and representatives of advocacy organizations, professional associations, government agencies, and industry at a session held in conjunction with the annual meeting of the American Society of Clinical Oncology (ASCO), now wrapping up in Chicago.
There has been an incredible amount of big science presented at this meeting that relates very directly to the care we provide cancer patients. Some of that science has immediate application to cancer care. On several occasions, acknowledged experts opined in front of thousands of physicians, other scientists, and health professionals that new treatments-particularly immunotherapy-were new standards of care in the management of patients with certain cancers.
Running in parallel to the development of new approaches to the treatment of cancer is the science that is helping to define and personalize which patients would benefit most from which treatments. As an example, for the new immunotherapy drugs there are biomarkers that may eventually predict who is going to respond better to which medicine. And frequently during the research presentations there was evidence that the more a cancer cell had mutated the more likely it was to respond to these new drugs.
But it was the survivors who touched my heart, my thoughts and my hopes.More...
May 29, 2015
(This blog was originally published on Medpage Today and is presented here with permission)
Disruptive innovation is a relatively new term that refers to dynamic changes in how we live our lives. Think of your smartphone and you have a good example of disruptive technology; one that replaces old tools. Who even takes pictures with a point and shoot camera any more, or uses a map to find their way? But the rise of disruptive technologies in medicine to me raises some difficult questions.
The recent announcement by a company called Color Genomics which will provide a 19 gene assay to help women assess their risk of breast and ovarian cancer could be called a disruptive innovation. For $249, a woman can have this panel of tests done at her request so long as she has a health professional order it.
And if she doesn't have a health professional readily available, the company will be glad to provide one.
Oh, and by the way: they don't accept insurance. They reason: the company says the cost is so low that insurance companies shouldn't come between women and the test. And if you want genetic counseling, they will provide that too but only after the test is done -- which clearly contravenes the recommendations of a number of professional and voluntary health organizations.
Another example of disruption in the laboratory world is the anticipated onslaught of direct consumer availability of laboratory studies based on minimal amounts of blood, possibly at a pharmacy near you. It is not clear for now whether a health professional will be an intermediary, but the end goal is pretty clear that patients will have the opportunity to order their own labs when they want to get them. More...
May 20, 2015
It's that time of year again, those months we all look forward to when life (sometimes) gets a little bit slower, the days a bit longer, and many of us take (yes!!!!!) a vacation. It's also time for Don't Fry Day, which is the Friday before Memorial Day. That's the day when organizations including the American Cancer Society and led by the National Council on Skin Cancer Prevention remind you to be sun safe, and know what to do to protect the skin you are in.
From an American Cancer Society perspective, the rules are pretty straight forward and easy to remember:
- Slip! (on a shirt)
- Slop! (on the sunscreen)
- Slap! (on a wide brimmed hat), and
- Wrap! (on a pair of UV protective sunglasses)
I could go through a long list of what you should do and how you should do it to protect your skin, but it's easier to go to our website or to the National Council on Skin Cancer Prevention website for that information. You should take the information to heart. Skin damage isn't a walk in the park (or on the beach, for that matter)-either now while you may be on vacation, or years later when you deal with the delayed effects such as skin aging, wrinkles, and-yes-skin cancer.
You can't be expected not to enjoy the outdoors. That's part of a healthy lifestyle. Staying inside day in and day out just isn't fun. Unless there is a reason you can't go out of doors, you should spend time outside. It's how you spend that time that can make all the difference. More...
May 14, 2015
Dealing with a diagnosis of cancer remains a very scary, emotionally charged experience. That experience is not helped by the addition of conflicting advice, especially advice based on opinion and not evidence. And once in a while, that's what happens when a celebrity is the source of the information, as has now occurred with Sandra Lee. But this time reporters are stepping up to address the issue on the record.
Many of you are familiar with the now widely available interview Ms. Lee gave with ABC's Good Morning America anchor Robin Roberts, herself a cancer survivor who has openly shared her journey with the public. Ms. Lee told the nation that she has breast cancer, that a lumpectomy had positive margins, and that her doctors recommended a double mastectomy since she was a "ticking time bomb" in her words.
What the nation also knows is that Ms. Lee at the age of 48 was critical of guidelines that-in her words-tell women to wait until they are 50 to get a screening mammogram. She also recommended that women of all ages, even in their 20s and 30s, call their health professional now and get a mammogram. In short, all women "need to know" whether or not they have breast cancer.
A diagnosis of breast cancer is traumatic. A positive mammogram that turns out not to be cancer--what doctors call a "false positive"--is also traumatic, especially if a women has to endure the uncertainty of follow-up tests including additional x-rays and biopsies, which are certainly uncomfortable at the least and disfiguring at the worst. Younger women have a greater number of false positive mammograms, in part because their breast tissue is more dense making the reading of a mammogram more difficult.
People are entitled to their opinions. But when personal thoughts turn into public pronouncements it can create a sense of fear and a sense of panic that may not be warranted. Often, listening to what the science tells us can help us confront some of that fear. In this case what the science tells us is that screening women in their 20s and 30s who are at average risk of breast cancer would cause a great deal of harm and not much benefit. More...
April 21, 2015
Years ago when I first started this blog I wrote about the democratization of information, and how people would come to an era where they had ready access to information yet reserved the right to determine whether that information was valid or not.
Fast forward to today, and a company called Color Genomics announced a new genomic based profile to measure breast cancer risk. They are clearly headed into the democratization of health care, since they are pricing the test at $249 and have tried to reduce the barriers for women and men to get the test.
Inevitably, this announcement is going to fan the flames of how far we should be going to allow people to get whatever laboratory tests they would like, whenever they want them. Although a health professional must order the test, in reality doctors will be available to meet your need if you decide to bypass your personal physician. And although most professional organizations active in this field recommend genetic counseling from a qualified professional be done before such tests are done, the company says they will provide such counseling-after the test results are known. More...
January 30, 2015
This blog was originally published on the Medpage Today website on January 22, 2015. It is reposted here with permission.
Are we prepared for the genomics revolution?
The President's proposed Precision Medicine Initiative as mentioned in his recent State of the Union address suggests it's probably time to get ready for some changes in our daily routines as health professionals.
I'm not talking about the incredible information that has already been produced by researchers examining the human genome. Nor am I referring to the work that is going on in major cancer centers and elsewhere exploring how to better match patients with genomic analyses of their cancers, for example.
And I am not talking about the advances in targeted therapies associated with diagnostic tests that can help guide the treatment of patients with a variety of cancers including but not limited to lung and breast cancers as examples.
No, I am asking whether we are prepared to usher in the new era of medical practice where genomic analyses in one form or another will be a part of our everyday medical practice. It's not just about cancer, my friends. It will be coming to a primary care practice near you probably sooner than you realize -- but it is coming. More...