Precision oncology: lessons learned and challenges for the future

The decreasing cost of and increasing capacity of DNA sequencing has led to vastly increased opportunities for population-level genomic studies to discover novel genomic alterations associated with both Mendelian and complex phenotypes. To translate genomic findings clinically, a number of health care institutions have worked collaboratively or individually to initiate precision medicine programs. These precision medicine programs involve designing patient enrollment systems, tracking electronic health records, building biobank repositories, and returning results with actionable matched therapies. As cancer is a paradigm for genetic diseases and new therapies are increasingly tailored to attack genetic susceptibilities in tumors, these precision medicine programs are largely driven by the urgent need to perform genetic profiling on cancer patients in real time. Here, we review the current landscape of precision oncology and highlight challenges to be overcome and examples of benefits to patients. Furthermore, we make suggestions to optimize future precision oncology programs based upon the lessons learned from these “first generation” early adopters.

The full article can be downloaded below.  

Virtual Visits: Telehealth and Older Adults

Telehealth allows patients to have visits with health care providers remotely using video technology. Such visits are increasingly available and have the potential to make health care more accessible and convenient for patients. In May 2019, the University of Michigan National Poll on Healthy Aging asked a national sample of adults age 50–80 about their experiences with and opinions of telehealth.

The full report can be downloaded below.  

Getting Beyond Hype Vs Hope in Precision Medicine and AI: The Life Cycle Of Technology Revolutions

Powerful new technologies have the potential to radically transform both science and society. In science, as Douglas Robertson describes in Phase Change (2003), a new technology like the microscope, the telescope, and the calculus can profoundly alter the questions we ask, and advance our ability to better understand nature. Society, visibly, can also be transformed by technology, as we’ve seen with examples ranging from the steam engine and the telegraph to automation and the internet.

The catch is, this transformation doesn’t occur overnight – far from it.  The remarkable and often maddening aspect of innovation (as I’ve discussed here, here) is the exceptionally long time it takes between the time a technology is originally invented and the time when people figure out how to use it most effectively.

In this three-part piece, I will first present a framework, developed by economist Carlota Perez, describing the life cycle of transformative technologies, and outline relevant refinements, introduced by columnist Daniel Gross. I’ll then locate our contemporary debate around the utility (or not) of precision medicine – and particularly, precision oncology – in the context of this framework; this section is richly informed by the perspective shared by key physician and physician-scientist thought leaders in this space. Finally, I’ll suggest that AI (as a proxy for the emerging excitement – and skepticism — around digital and data in health) seems to be entering the earliest stages of the technology diffusion trajectory, which may help explain both the frenzy and the confusion.

The full Forbes article can be viewed at this link.  

Explainable AI In Health Care: Gaining Context Behind A Diagnosis

Most of the available health care diagnostics that use artificial intelligence (AI) function as black boxes—meaning that results do not include any explanation of why the machine thinks a patient has a certain disease or disorder. While AI technologies are extraordinarily powerful, adoption of these algorithms in health care has been slow because doctors and regulators cannot verify their results. However, a new type of algorithm called “explainable AI” (XAI) can be easily understood by humans. As a result, all signs point to XAI being rapidly adopted across health care, making it likely that providers will actually use the associated diagnostics.

The full Forbes article can be viewed at this link.  

Healthcare executives look to bring the joy back to medicine

As health systems survey candidates for executive roles, experience, academic achievements and other measures of scholarship typically top the priority list.

Leadership qualities, “coachability” and emotional intelligence are often overlooked, particularly at academic institutions. That represents a fundamental flaw in the hiring process and the medical education system, which hardwires doctors to be self-interested and autonomous, said Dr. Peter Pisters, president of the University of Texas MD Anderson Cancer Center.

“Our search committees have been anchored in a series of biases that include an overemphasis on scholarship and an underemphasis on leadership capabilities, especially emotional intelligence,” Pisters told the audience during Modern Healthcare’s Workplace of the Future conference last month. “That has created real challenges.”

MD Anderson has brought in psychologists specializing in emotional intelligence and incorporated that metric into the selection process. It mandates implicit bias training to ensure objectivity. Like many systems, the academic medical center has also pushed for more diverse leaders and has cast a wider net to attract more applicants.

The full Modern Healthcare article can be viewed at this link.  

Precision Medicine Versus Evidence-Based Medicine

A 1986 Cleveland Clinic observational study showed that coronary artery bypass grafting with the left internal thoracic artery anastomosed to the left anterior descending artery provided better 10-year survival and graft patency than saphenous vein bypass grafts. Subsequently, it was demonstrated that use of both left and right internal thoracic arteries further improved survival. However, when Taggart and colleagues conducted a 28-site phase III randomized trial of using a single internal thoracic artery graft versus both internal thoracic arteries (ART [Arterial Revascularization Trial]), no survival difference was evident even at 10 years! The surprised investigators then searched for and found a subset of patients who appeared to benefit: those receiving 2 or more arterial grafts, including the radial artery. Although one can challenge a post hoc analysis of a negative trial, is it not worthwhile for any treatment to ask the questions, Who benefits? Who doesn’t? Who is harmed? At some level, we believe in “the right treatment for the right patient at the right time.” The right treatment involves discovering an individual patient treatment effect, the essence of precision medicine, not an average treatment effect as from a randomized trial, the gold standard for evidence-based medicine.

The full article can be downloaded below.  

Precision Medicine For Pediatric Patients Gets A Boost From Congress

Of the approximately 7,000 rare diseases 80% are genetic. And, more than half of rare diseases affect children.

For patients and their caregivers, one of the more frustrating aspects of rare diseases is the length of time from symptom onset to an accurate diagnosis, which averages 4.8 years.

Last month, together with several colleagues in the House, Representative Eric Swalwell of California reintroduced a bipartisan bill called Advancing Access to Precision Medicine Act. The legislation had originally been proposed in January 2018, and is aimed at promoting the use of genetic and genomic testing to improve healthcare delivery. Specifically, the bill is designed to improve patient access to genetic and genomic testing to help shorten the time to diagnosis, easing the diagnostic odyssey for pediatric patients suffering from rare diseases.

The full Forbes article can be viewed at this link.  

Don't Force Patients Off Opioids Abruptly, New Guidelines Say, Warning Of Severe Risks

There's no doubt that opioids have been massively overprescribed in U.S. In the haste to address the epidemic, there's been pressure on doctors to reduce prescriptions of these drugs — and in fact prescriptions are declining. But along the way, some chronic pain patients have been forced to rapidly taper or discontinue the drugs altogether.

Now, the U.S. Department of Health and Human Services has a new message for doctors: Abrupt changes to a patient's opioid prescription could harm them.

On Thursday, the agency issued new guidelines for physicians on how best to manage opioid prescriptions. They recommend a deliberate approach to lowering doses for chronic pain patients who have been on long-term opioid therapy.

"It must be done slowly and carefully," says Adm. Brett P. Giroir, MD, assistant secretary for health for HHS. "If opioids are going to be reduced in a chronic patient it really needs to be done in a patient-centered, compassionate, guided way."

The full NPR article can be viewed at this link.  

Doctors turn to thumbs for diagnosis and treatment by text

Dr. Anna Nguyen spoke with none of the five patients she treated on a recent weekday morning. She didn’t even leave her dining room.

The emergency physician nevertheless helped a pregnant Ohio woman handle hip pain, examined a Michigan man’s sore throat and texted a mom whose son became sick during a family trip to Mexico.

Welcome to the latest wrinkle in health care convenience: the chat diagnosis.

The full article from the Associated Press can be viewed at this link. 

Missed Appointments, Missed Opportunities: Tackling The Patient No-Show Problem

I was asked last week at a healthcare industry roundtable about the single-biggest problem I’m trying to solve in my organization. My answer was surprisingly mundane, but relatable to anyone who has worked in a medical office: helping to address the ever-patient vexing problem of predicting and addressing patient no-shows.

Much has been made about the economic effects of patient “no-shows” on the health care system. One study found that no-shows cost the U.S. health care system more than $150 billion a year and individual physicians an average of $200 per unused time slot. After all, whether or not patients show up, healthcare organizations and medical practices still have to pay their staffs and cover expenses like rent and the cost of equipment.

But above and beyond the economic implications, no-shows have a direct impact on individuals’ health. When patients miss appointments, continuity of care is interrupted. Medication efficacy can’t be monitored regularly. Preventive services and screenings can’t be delivered in a timely manner. Acute illnesses are more likely to go untreated and become chronic conditions with complications. In short, missing an appointment can be severely detrimental to one’s health.

The full Forbes article can be viewed at this link.