http://connection.asco.org RSS feeds for ASCO Connection – professional networking for ASCO’s worldwide oncology community 60 http://connection.asco.org/Commentary/Article/ID/3544/Consulting-for-Family-Friends-How-Do-You-Do-It.aspx#Comments 0 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3544 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3544&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3544/Consulting-for-Family-Friends-How-Do-You-Do-It.aspx I often am asked for opinions about hematology/oncology cases from colleagues around the country. Additionally, whenever a family friend or relative is diagnosed with cancer, I also often am asked for an opinion. How do you handle these unofficial second opinions? One option is to say, “See your own doctor. I can’t comment.” I don’t have numerators and denominators, but it seems that this is an unlikely response. These are not uncommon requests, and, in many cases, we can help by reassuring or finding problems with the workup or treatment. It could be the guy at a party asking about his prostate biopsy or a relative of a friend with a metastatic cancer. You could provide general advice and stay away from specifics. Or, get “all” of the details (how?). How to intervene, especially if you are unsure of the local expertise, or you just want to really help and counsel the person? There are many options for continuing medical education (CME) as well as for discussing general or specific (usually de-identified) clinical cases including on the forums: Best Doctors, Doximity, HealthTap, LinkedIn, QuantiMD, Sermo, and even Twitter and Facebook. Those formats all have their own platform-specific utilities, as well as potentially negative aspects. Many health systems including well-regarded cancer centers have e-opinion/tele-oncology services varying from chart reviews to formal reviews of imaging and pathology. Some are system specific and some are global opinion mechanisms. I’ve commented before on “Does Telemonitoring Have a Place in Oncology?”. I have also used the ASCO Membership Directory (for referrals) and ASH “Consult a Colleague” online tools. However, what do you do when you want to review a case and be able to provide some input, but don’t’ necessarily want a fully public forum. Often emailing a single or small group of colleagues can work. In one case someone listed me as his physician so I was cc’d on official medical transcripts. This also came up when someone wanted me to review a series of radiology images for his cancer. He had the digital image burned to a CD and then delivered to me by mail. I took the CD down the street to my friendly neighborhood interventional radiologist to review on his laptop. It struck me as bizarre that in this digital age we couldn’t look it up online and avoid the potential time delay and CD software incompatibilities that sometimes crop up. I remembered a beta demonstration of a patient-focused imaging upload tool (image_32 – previously known as ImagingCloud in an early beta version). At the time the image_32 patient portal wasn’t fully ready, so we couldn’t use it in a timely manner. Now that it is publicly available it likely would have helped with reviewing images. Other potential issues include tracking longitudinal patient information without an EMR. Questions Have you been asked for the Thanksgiving table “curbside” consult?What are your thoughts on it?What tools have you used to facilitate care for friends and family? (e.g., online tools, Skype, FaceTime, websites, etc.)? Note: Dr. Thompson is a member of the above mentioned online and social media forums. Dr. Thompson is on the medical advisory boards for Doximity and image_32.  Michael A. Thompson, MD, PhD Fri, 31 May 2013 20:59:18 GMT f1397696-738c-4295-afcd-943feb885714:3544 http://connection.asco.org/Commentary/Article/ID/3543/Social-Media-Is-a-Form-of-Media.aspx#Comments 6 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3543 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3543&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3543/Social-Media-Is-a-Form-of-Media.aspx It may sound obvious, but social media is a form of media, which can be defined as “tools used to store and deliver information or data.” Social media is “media disseminated through social interaction.” The use of media has evolved—most recently, from radio to TV, and then from TV to the Internet. We have been in the process of moving from passive/static Internet sites to social networks (Web 2.0, 3.0, 4.0—in other words, “interactive” sites). Social media is an iteration of this ongoing evolution of media. The uptake has been fast, global, and spanning demographics. Likely, in the future, we will not differentiate "social" media from media at all. However, for now, it is still new to many people, including those in the oncology community. What are the differences in social media versus traditional media? fasterpermanent (archived)interactive amplifies / impact beyond initial "broadcast" audiencesearchable There may be (and are) criticisms of individual social media platforms; however, you can't wait for the optimal platform or you will be waiting forever. Before, at, and after the ASCO Annual Meeting, discussions will be identified on the microblogging social media site, Twitter, using the hashtag #ASCO13. And we will be discussing the use of social media at the ASCO Tweetup on June 1st, 2013, in room N226 of the McCormick Place  (#ASCO13Tweetup Tweetvite RSVP). I hope to see you connect and interact with ASCO members and content. Below are some resources that might be of help. Sampling of people and organizations “followed” by the ASCO Twitter account: @ASCO @ASCOPost @iConquerCancer @CancerDotNet @CliffordHudis—Dr. Cliff Hudis, ASCO’s Incoming President @YupOnc—Dr. Peter Yu—ASCO’s Incoming President-elect @RSchilsky – ASCO’s Chief Medical Officer @DrAnasYounes—Chief of MSKCC Lymphoma service and early social media adopter @DrDonSDizon—Editor of the #ASCO13 Educational Book @FischMD—Palliative care, general oncology, and @SWOG social media proponent @rsm2800—Editor-in-Chief of ASCO’s Cancer.Net Helpful social media and oncology links--ASCO Social Media site--ASCO Connection--ASCO Ten Tips for Use of Social Media--Trends in Twitter Use by Physicians at the American Society of Clinical Oncology Annual Meeting, 2010 and 2011—Chaudhry et al. JOP--Putting Twitter to Use Among Oncologists: Shared Note-Taking at National Meetings and Other Stuff—by  Mike Fisch (@FischMD) on ASCOconnection.org--Symplur #ASCO13 analytics--Practical Guidance: The Use of Social Media in Oncology Practice—Dizon et al. JOP 2012--To Friend or Not to Friend: The Use of Social Media in Clinical Oncology—Wiener et al. JOP 2012--Using Social Media in Oncology for Education and Patient Engagement—Thompson et al. Oncology 2012--Online Medical Professionalism: Patient and Public Relationships: Policy Statement from the American College of Physicians and the Federation of State Medical Boards —Farnan et al. Ann Int Med 2013--Tao of Twitter by Mark Schaefer (@markwschaefer) Apps to help interact with ASCO: --iDirectory --JCO --JOP --Cancer.Net --Conquer Cancer Foundation --AM iPlanner --iLibrary—This free app has all of ASCO’s publications and media in one place; this content is accessible to ASCO members using an ASCO username and password. It also has a publicly available portal to oncology-related apps called Oncology App Central. Oncology App Central provides access to ASCO apps, as well as featured sponsored oncology apps. Oncology App Central is included within the iLibrary app and is accessible even when not logged in. To read more about these ASCO apps and find links for downloads, visit: asco.org/mobile-applications. Michael A. Thompson, MD, PhD Wed, 29 May 2013 20:49:37 GMT f1397696-738c-4295-afcd-943feb885714:3543 http://connection.asco.org/Commentary/Article/ID/3473/CPR-in-Advanced-Cancer.aspx#Comments 7 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3473 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3473&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3473/CPR-in-Advanced-Cancer.aspx I recently saw a new patient with advanced cancer in the intensive care unit (ICU). She had been treated with multiple lines of therapy at other cancer centers. While she already had an oncologist, I was called in to help the ICU team with any oncologic issues. There were no acute cancer problems to solve, but I noted the patient was “full code.” I thought that clarifying code status might be helpful. In our discussion, it seemed that (at least from the patient’s perspective) no one had deeply dived into this topic. I quoted cardiopulmonary resuscitation (CPR) statistics in cancer, and after a long discussion, she changed her code status to “do not resuscitate, do not intubate (DNR/I).” That was the right decision.  Later, I self-analyzed that discussion and realized I was reciting information from my fellowship training. I did not know the primary data supporting what I said. As I researched the literature, it turns out that I was indeed accurate. I did what any physician would do these days -- I Googled the question. I found a good reference, but then used my enriched “micro-crowd sourcing” to ask for any references from a friend and palliative-care expert. He shared some PDF files, including a meta-analysis, which I will discuss below. My conclusions are distilled down to this: Conclusions: 1)    The chance of survival after CPR for advanced cancer patients is low (~ 5-8%) 2)    Survival may be increasing over time. We need data on survivor quality of life (QOL). 3)    Poor Px Fx (%survival): ICU (<=2%), Heme/BMT (1.5%) or anticipated code (0%) 4)    Informed (via 3 min video) patients are 3.5 times more likely to choose DNR/I 2001: MDACC (n=243) Inpatients with Cancer In 2001, a group at MD Anderson Cancer Center published “Characteristics of Cardiac Arrest in Cancer Patients as a Predictor of Survival after Cardiopulmonary Resuscitation.” (Ewer et al. Cancer 2001;92:1905–12). From 1993-1997, cases for 243 inpatients who experienced cardiac arrest and received CPR were reviewed, and their course observed until hospital discharge or death. 16/73 patients (22%) who had sudden, unanticipated cardiac arrests survived to be discharged from the hospital. 0/171 of patients who experienced an anticipated cardiac arrest survived (P < 0.001). They analyzed by subgroup (Table 2 from study, below) and used logistic regression (Table 3 from study, below). They also suggested an algorithm for anticipated codes that might “avoid painful and costly interventions that are futile with the present techniques of cardiopulmonary resuscitation.”  2006: Meta-analysis (N=1707) In 2006, Reisfield and colleagues at the University of Florida Health Science Center published “Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis” (Resuscitation 2006 Nov;71(2):152-60). In their meta-analysis, they found 42 studies from 1966-2005, including 1707 adult cancer patients undergoing in-hospital CPR. The overall survival to discharge was: all adult cancer patients (6.2%), localized disease (9.5%), metastatic (5.6%). When analyzed for data since 1990, this gap seemed to decrease, with survival: localized disease (9.1%) and metastatic (7.8%). Survival for patients on general floors was 10.1% and was 2.2% for the ICU. The authors concluded that improved outcomes more recently may be due to more selective use of CPR in advanced cancer patients. 2012/2013: Better Information = Better Decisions Dr. Volandes and colleagues published online (2012) and in print (2013) on a “Randomized Controlled Trial of a Video Decision Support Tool for Cardiopulmonary Resuscitation Decision Making in Advanced Cancer” (J Clin Oncol 2013 vol. 31(3):380-386; JCO podcast-Thomas Smith). In 150 patients with advanced cancer they randomized patients to: 1) a verbal narrative (control) describing CPR and the chance of CPR success versus 2) a 3 minute video (experimental intervention). The video showed a patient on a ventilator and CPR on a simulated patient. Most patients were comfortable watching the video, had better CPR knowledge compared with the control group, and were more likely to choose DNR/I (see Table below, unadjusted odds ratio, 3.5; 95% CI, 1.7 to 7.2; P < 0.001). These studies suggested to me that patients with advanced cancer rarely survive in-hospital CPR. Often those who do survive have a poor quality of life and short survival after (I haven’t seen those data explicitly depicted). We are likely getting better at selecting patients for CPR, but not in a systematic fashion. Patients who are anticipated to have a code should not receive CPR. We now have randomized data showing that a short, non-threatening intervention such as a short video can improve patient knowledge and potentially avoid costly futile interventions. I would love to see a downloadable video available (e.g., iTunes or JCO online appendix) to use for all cancer patient admissions that is viewable on a computer or tablet (e.g., iPad) to help facilitate these discussions and appropriate decision making.    What are your thoughts and experiences with CPR in patients with advanced cancer? Michael A. Thompson, MD, PhD Fri, 01 Mar 2013 15:25:23 GMT f1397696-738c-4295-afcd-943feb885714:3473 http://connection.asco.org/Commentary/Article/ID/3287/Twheel-and-Information-Overload.aspx#Comments 0 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3287 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3287&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3287/Twheel-and-Information-Overload.aspx Check out twheel, a new iPhone/iPad app for visualizing Twitter feeds released just yesterday, August 7, by Fluid Interaction. It uses cognitive science and circles to display and interact with complex data sets. According to EContent magazine, "Finland-based company Fluid Interaction announced the release of a new app called twheel. With this app, iPhone users will be able to change the interface to be visualized as a rotating wheel, offering a game-like interface for Twitter. The app will display the most relevant data with visual pop-outs such as colors and form deviations. “The company believes that by using twheel, it will make using Twitter much faster than relying on list-based interfaces. Twheel can be downloaded from the iPhone app store and is currently available in Europe, North and South America, India, and Australia, with plans to expand further at a later time." In a Wired news article, titled "Twheel reimagines Twitter with cognitive science and circles," they noted that: "‘Twheel is designed to help our brains process information,’ says Fluid Interaction's chairman, Kristian Lukander. ‘Twheel does not curate or filter information, but reshapes the way data is displayed based on our understanding of human cognition.’" Can you think of any uses in oncology? Even if you aren't on Twitter, check it out and think about a similar mindset applied to basic cancer science data analysis, as well as potential applications in patient communication interactions. The twheel mindset as noted in their blog is "to provide better tools for discovery" without putting you in a pre-determined "filter bubble." For instance, using a visual weighting methodology, this might be useful to patients who need to sift through all of the "noise" offered by the Internet or other sources to find the "signal" they need for the situation they are in. Imagine if the 70 points of possible adverse events were visualized separately by severity as well as frequency. Other uses could include visualizing symptom scales in oncology and/or palliative care. As noted: "It's an approach that neatly addresses the concept of information overload . . . "  Given that physicians and patients have information overload, this might be one strategy—cognitive science/gaming strategy—to address that. Fellow ASCO Connection columnist Mike Fisch, MD, also explored this in his recent post, “Bringing Gamification to the Serious World of Cancer Care.” Michael A. Thompson, MD, PhD Wed, 08 Aug 2012 15:05:56 GMT f1397696-738c-4295-afcd-943feb885714:3287 http://connection.asco.org/Commentary/Article/ID/3240/Pinterest-for-Medicine-Oncology-An-Opportunity.aspx#Comments 5 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3240 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3240&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3240/Pinterest-for-Medicine-Oncology-An-Opportunity.aspx Women are on the social media platform Pinterest. Women are the primary decision makers about health care in most households (~80% according to the U.S. Department of Labor). Get it? Let's delve in. I was never interested in Facebook or Twitter—and at one point thought they were jokes—but I ended up joining them and seeing their utility. Likewise, I thought Pinterest was a joke. I registered on the site, but still hadn't really seen the utility—at least for me. I saw a tweet from @BrianSMcGowan—"'Like' This: The Most Effective Uses of Social Media in Healthcare" bit.ly/MV2YB1 #hcsm #overview #socialQi,” which directed me to the referenced article. There were a number of interesting points in the article, but I was intrigued by comments from Lee Aase, director of Mayo Clinic's Center for Social Media. He noted social media platforms that are currently underutilized by health care organizations include Pinterest and YouTube. Pinterest started in 2010, but has rapidly been growing in popularity, particularly among women. Notably 97% of the fans of Pinterest's Facebook page are women. And women tend to be the primary decision-maker about health care in most households, as noted above. "That’s where people are. That’s the bottom line," said Ed Bennett, who tracks the use of social media in health care as Director of Web Strategy for the University of Maryland Medical Center. Social media and mobile health expert Jennifer Shine Dyer, MD, MPH (@Endogoddess) noted in her blog in March (bold added): "I LOVE pinterest. It is so very very beautiful. I am also using it now as my main index to organize my shopping and cooking interest. Sometimes I like to just look at my boards and sort of wander around in the prettiness of the things I love . . . it's like a visual dreamland. Regarding health, seems the best way to use pinterest would be to distribute health information related to facts that people would like to 'collect' . . . this is the way users like me are looking at the pins on the main feed (i.e., what do I like and want to collect and add to my boards?). Hope that helps! If not, follow me on pinterest for a few days and I think you'll get the hang of it. :)" From a return on investment (ROI) perspective, apparently Pinterest is driving more online sales than any other network and "brands are growing faster than on Twitter," according to SocialMouths.com. "If 2012 is going to go down the history books as the Facebook year, then it would also be remembered as the year of Pinterest," notes blogger Prasant Naidu (@LHInsights) on SocialMediaToday.com. So, are you on Pinterest? Is your health care organization? Even heard of it? Whatever group (e.g., ASCO) gets to Pinterest first will gain a foothold in the digital mind of the primary health care decision makers for families. "That’s where people are. That’s the bottom line." Michael A. Thompson, MD, PhD Fri, 15 Jun 2012 15:16:44 GMT f1397696-738c-4295-afcd-943feb885714:3240 http://connection.asco.org/Commentary/Article/ID/3229/What-Matters.aspx#Comments 0 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3229 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3229&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3229/What-Matters.aspx I was preparing some thoughts for the #ASCO12 Tweetup today and received an email. John was emailing me about his father, who is my dad's best friend from college. He thanked me for referring him to colleagues at M. D. Anderson Cancer Center (MDACC) for metastatic cholangiocarcinoma. Everyone was aware of the bad prognosis, but they were thankful for my small bit of help and guidance I provided. His dad was doing better and in fact had driven himself from Louisiana to Nebraska and then played a guitar for four hours at a family reunion. My parents had both traveled to meet him in Nebraska. This reminded me in the midst of signal transduction pathways, Bayesian statistics, quality metrics, and stock quotes what really matters in the world we occupy. I love the science and biology of oncology, but will always try to remember the human with an extended network of family and friends that are affected by cancer. Thanks to my GI colleagues Mike & Scott at MDACC for helping this family out. Michael A. Thompson, MD, PhD Sat, 02 Jun 2012 20:16:37 GMT f1397696-738c-4295-afcd-943feb885714:3229 http://connection.asco.org/Commentary/Article/ID/3211/Does-Telemonitoring-Have-a-Place-in-Oncology.aspx#Comments 12 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3211 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3211&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3211/Does-Telemonitoring-Have-a-Place-in-Oncology.aspx Does telemonitoring (remote monitoring of patient vitals or other biometric data) have a role in oncology? TelemedicineTelemonitoring is a specific form of "telemedicine," which is the use of telecommunication to provide health care at a distance. That can include sending images, video (e.g., for dermatology consults in rural areas), or person-to-person discussions such as via Skype. Remote monitoring devices and companies are proliferating rapidly since many individuals have sophisticated computers with Bluetooth and WiFi capabilities with them all the time—i.e., smartphones. These may be linked with biologic monitors such as watches with HR monitors, dedicated blood pressure monitors, or even biologically integrated sensors in the skin or deeper tissue to transmit information. Oncology I imagined the ability to monitor for biologic parameters such as heart rate and temperature in high-risk patients after chemotherapy to improve neutropenic fever care. This might be helpful after outpatient stem cell transplants. Also, remote monitors could evaluate adherence to oral medications on or off study. Other applications might be monitoring well-being, pain control, nausea, or other patient-centered outcomes to improve the continuum of care. Mayo Telemedicine Study = no drop in readmissions, ED visitsI was alerted to an interesting study on telemonitoring by the following tweet (HT @medskep): RT @jessiegruman: Telemonitored pnts: no drop in readmissions, ED visits. Time to re-think breathless marketing? [study. Arch Int Med]: bit.ly/Io30wQ In the study by Takahashi and colleagues, "A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits," published in the Archives of Internal Medicine (online April 16, 2012), the authors found that "Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits."   The manuscript noted that, "Efficiently caring for frail older adults will become an increasingly important part of health care reform; telemonitoring within homes may be an answer to improve outcomes." The study was a randomized controlled trial in patients older than 60 years at high risk for rehospitalization. The 205 study participants were randomized to telemonitoring or usual care. Telemonitoring was accomplished by daily biometrics, symptom reporting, and video conference.    As noted in the AMA Medical News: “‘We’re trying to change our care model for sick and older people, and we know this technology’s been out there, and the question is: Will it help?’ said Paul Y. Takahashi, MD, MPH, lead author of the study. ‘We went into it with the thought that this would provide some assistance. . . . It didn’t help at all.’” The study was performed by a great team with a leader (Paul Y. Takahashi, MD, MPH, was my attending when I was a resident at Mayo) who understands the potential to merge medicine and technology. The study was performed at a well-recognized center that is engaged in innovation. What went wrong? I don't think this study "kills" the concept of telemonitoring. However, it is cautionary that technological innovation cannot solve all problems in human medicine. Just as anti-VEGF therapy didn't cure all cancer, new technology has great potential, but may need additional effort or fine tuning of population, etc. I think this and future prospective studies will provide more real data as opposed to the theoretical speculation of how this remote monitoring might help. What are your thoughts? Michael A. Thompson, MD, PhD Thu, 03 May 2012 16:15:39 GMT f1397696-738c-4295-afcd-943feb885714:3211 http://connection.asco.org/Commentary/Article/ID/3123/Favorite-Hematology-Oncology-Apps.aspx#Comments 13 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3123 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3123&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3123/Favorite-Hematology-Oncology-Apps.aspx Please share your favorite iPhone (or other OS) hematology / oncology mobile applications (“Apps”). A few of mine: iPhone (iOs): ASH Guides Cancer.Net (ASCO) CCF (ASCO)  CTCAE v4.0 Dropbox ePocrates Expensify – for trips Evernote FRAX Heme Calc iPlanner ASCO Molecules NCCN Guidelines PubMed Tap Qx Calculate RCC Prognosis RL Classic Rx-Bayes UpToDate VocreVisit the ASCO App's page for more information on other great apps from ASCO, including the iDirectory Social Media (General) Facebook Google+ LinkedIn TweetPic Twitter Social Media (Medicine-focused) Doximity HealthTap MDiPad only: TransFuse by Mayo Clinic Michael A. Thompson, MD, PhD Mon, 09 Jan 2012 18:22:04 GMT f1397696-738c-4295-afcd-943feb885714:3123 http://connection.asco.org/Commentary/Article/ID/3075/Breast-Cancer-Diet-Exercise-and-Treatment-Cost.aspx#Comments 12 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3075 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3075&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3075/Breast-Cancer-Diet-Exercise-and-Treatment-Cost.aspx    Access a PDF of this commentary and share it with patients and colleagues.   After the ASCO Integrated Media and Technology Committee meeting I was delayed at Reagan National Airport with poor Wi-Fi access. I resorted to reading a physical (yes, paper!) journal (Oncology. Oct 2011, Volume 25, Number 11). I was struck by two seemingly unrelated manuscripts (and commentary). Goals and Costs of Cancer Therapy The first article was by fellow ASCO member and blogger L. Michael Glodé, MD: “Oncology Perspectives: Is Cancer the Answer?” Some of his main points were that humans are not immortal, cancer care is expensive, early palliative care appears to have a survival benefit (at least in some cancers), and we should consider all treatment options including non-pharmacological interventions. Obesity, Diet, Exercise, and Breast Cancer The other article was “Obesity and Breast Cancer” by Jennifer Ligibel, MD. Commentary articles followed that manuscript. I was aware of data suggesting that obesity and related medications or biomarkers such as metformin, insulin level, metabolic syndrome, diabetes, etc., were related to breast cancer risk or recurrence. However, I admit I was unaware of the depth and number of studies evaluating this. I was also unaware of some holes in our information, i.e. “…no studies examining the impact of purposeful weight loss on breast cancer prognosis.” Please read the full manuscript and accompanying commentaries. I was struck by the consistency of hazard ratio (HR) risk reduction from various interventions including diet and exercise (often intensive and individualized, not just an offhanded statement to eat more veggies; see article's Table 1) as well as the risks with high insulin, metabolic syndrome or other biomarkers (see article's Table 3). Sparano and Strickler in “Breast Cancer Patients Who Are Obese at Diagnosis: Alea Iacta Est? or "Is the Die Cast?" pointed out the concept of the “healthy obese” patient exists that may not have the same risk of recurrence (a hypothesis) as other “morbid obese” (where morbid is unhealthy, not BMI) and that we may need to risk stratify obese patients based on biomarkers. The juxtaposition of the Glodé and “Obesity and Breast Cancer” articles resonated with me. Given the data (and not just a vague warm and fuzzy sentiment for a healthier lifestyle), why isn’t there an algorithm in the NCCN (or other) guidelines for dietary interventions as adjuvant therapy? To be fair, NCCN does mention diet and exercise (p. 26/148 - BINV-16 and p. 99/148 – MS-35 in version 2.2011): “Evidence suggests that active lifestyle, achieving and maintaining an ideal body weight (20-25 BMI) may lead to optimal breast cancer outcomes.” So, maybe this should be mentioned more prominently in the upfront algorithm, rather than after other adjuvant therapies? Clinical trials (as mentioned in the Ligibel article) are evaluating various interventions. One currently accruing study is the MA.32 trial "Phase III Trial of Metformin versus Placebo in Early-Stage Breast Cancer" by the National Cancer Institute of Canada (NCIC) Clinical Trials Group and the U.S. NCI. QUESTIONS I suspect that some of these interventions may have a higher magnitude of benefit than chemotherapy. Can the effects of diet and exercise as adjuvant therapy be incorporated into Adjuvant! Online to help better personalize treatment planning? Would an adequately informed patient choose chemo over a POTENTIALLY (based on individual patient/tumor characteristics) larger risk reduction with diet/exercise? In an Accountable Care Organization (ACO) world with limited resources isn’t this highly important for a potential way to contain costs? Should we be hiring more registered dieticians, physical therapists, personal trainers, and paying for gym memberships rather than chemo? Can we save money, improve health, and spare toxicities (in selected patients)? I am still trying to decide how to implement these interventions, but I will certainly refer more quickly to diet and exercise programs in the future. What do you think?ADDENDUM:Other Links:NCI Cancer Bulletin (11/15/11) - "The Emerging Evidence about the Role of Obesity in Cancer" - http://ht.ly/7vlLLNature Medicine (10/30/11 online) - "Adipocytes promote ovarian cancer metastasis and provide energy for rapid tumor growth" - http://www.nature.com/nm/journal/v17/n11/full/nm.2492.htmlamednews (11/16/11) - AMA helping physicians broach the subject of obesity - http://www.ama-assn.org/amednews/2011/11/14/prsf1116.htmMetformin and thiazolidinediones are associated with improved breast cancer-specific survival of diabetic women with HER2+ breast cancerHe et al. Ann Oncol (2011) - http://annonc.oxfordjournals.org/content/early/2011/11/09/annonc.mdr534.short?rss=1 Conclusions: Thiazolidinediones and metformin users are associated with better clinical outcomes than nonusers in diabetics with stage ≥2 HER2+ breast cancer. The choice of antidiabetic pharmacotherapy may influence prognosis of this group.12/2011Obesity linked to worse survival in #BreastCancer adjuvant therapy - Dr. Sao Jiralerspong @bcmhouston http://ow.ly/aDzaa & @ASCO YIA 2007 http://ow.ly/aDzovFasting Might Boost Chemo's Cancer-Busting Properties: Scientific American -- http://bit.ly/zPzm9WFrom NPR 4/26/12 -- Evidence Mounts That Diet, Exercise Help Survivors Cut Cancer Riskhttp://www.npr.org/blogs/health/2012/04/25/151387672/evidence-mounts-that-diet-exercise-help-survivors-cut-cancer-risk?ft=1&f=1128&sc=twEffects of a Caloric Restriction Weight Loss Diet and Exercise onInflammatory Biomarkers in Overweight/Obese Postmenopausal Women: ARandomized Controlled TrialIkuyo Imayama, Cornelia M. Ulrich, Catherine M. Alfano, Chiachi Wang, LirenXiao, Mark H. Wener, Kristin L. Campbell, Catherine Duggan, Karen E.Foster-Schubert, Angela Kong, Caitlin E. Mason, Ching-Yun Wang, George L.Blackburn, Carolyn E. Bain, Henry J. Thompson, and Anne McTiernanCancer Res 2012;72 2314-2326http://cancerres.aacrjournals.org/cgi/content/abstract/72/9/2314?etocFindings suggest that weight loss with or without exercise may reduce riskof breast cancer, possibly due to a reduction in systemic inflammation thatmay support tumor development or progression. Michael A. Thompson, MD, PhD Mon, 14 Nov 2011 14:30:34 GMT f1397696-738c-4295-afcd-943feb885714:3075 http://connection.asco.org/Commentary/Article/ID/3062/Participatory-Medicine-in-Oncology.aspx#Comments 8 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/RssComments.aspx?TabID=117&ModuleID=478&ArticleID=3062 http://connection.asco.org/DesktopModules/DnnForge%20-%20NewsArticles/Tracking/Trackback.aspx?ArticleID=3062&PortalID=0&TabID=117 http://connection.asco.org/Commentary/Article/ID/3062/Participatory-Medicine-in-Oncology.aspx What does a healthy medicine and oncology “ecosystem” look like? I attended the 3rd Annual Health Care Social Media Summit hosted by the Mayo Clinic Center for Social Media in collaboration with Ragan Communications (link). Multiple speakers at that conference discussed the changes in health care. It was noted that we have evolved from a Web 1.0 to 4.0 (or Health/Medicine 1.0 to 4.0, Nash, Lasseter): 1.0   Content — Web: original Internet — Med: passive reading about medical information 2.0   Communities — Web: interactive sites — Med: downloading articles and interacting with medical professionals 3.0   Commerce and data-driven applications — Web/Med: mobile health technologies (mHealth) 4.0   Coherent — Web: social networks — Med: patient-interactive, patient-driven comprehensive social networks It has been noted that it wasn’t until Web 2.0 that the Web “began to harness the intelligence of its users” (Tim O’Reilly). At the Mayo Social Media conference this week, @ePatientDave (Dave deBronkart, who helped establish the Society for Participatory Medicine link) presented on participatory medicine and the concept of the e-patient. In that scenario the e-patient is Empowered, Engaged, Equipped, and Enabled. Wikipedia defines participatory medicine as: “…a model of medical care in which the active role of the patient is emphasized. Participatory Medicine has been used at least as early as 2000 to mean one or more of four interrelated ideas: A group of people who suffer from a chronic disease form a community (often an online community, a support group) to share information and mutually support each other. Members of a patient community (or members of a community disproportionately affected by a disease) play important roles in community health decision-making. [1] Patients play a role as part of collaborative 'treatment teams' addressing their diseases. [2] A patient is 'mindfully' involved in treatment, by making behavioral changes, meditating, or similar acts. [3]" The Society for Participatory Medicine's definition is: “Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.” Patient questions may be answered by sites such as Avvo, HealthTap, or others. It is not entirely clear that this will solve individual oncology practice communication issues. It is possible that some integrated electronic medical (or health) records (EMR/EHR) implementations could provide one iterative approach to interactivity. Patient online forums may be powerful ways to disseminate information (e.g., The SCAD Ladies - Where Patient Empowerment Meets Rare Diseases) but can be full of erroneous and potentially dangerous advice. Additionally, despite some specific success stories, not all “average” individuals may be maximally benefiting from Med 4.0 type patient or patient-physician social media networks. Patients such as “@ePatientDave” may be more on the directed/autonomous end of the patient continuum compared to the other end with the patient asking for paternalistic physician guidance. Some limitations of physician interaction in such Med 4.0 social media networks may include: Time — MD mainly, but also patient Regulatory barriers HIPAA Billing Scheduling (when to interact in a busy schedule?) Will an accountable care organization (ACO) health care model fix this? Insurance driven solutions? Patient advocacy? Online patient forums? What do you think? Michael A. Thompson, MD, PhD Tue, 25 Oct 2011 06:02:28 GMT f1397696-738c-4295-afcd-943feb885714:3062