Getting Healthcare Social. Time is ready, doctors are not.

by Gianmarco Contino

Healthcare is a unique kind of "market". Doctors determine demand, doctors deliver offer. Of course they are not totally free: in the best care scenario they have their professional ethics, knowledge, and compassion. However it would be unfair not to acknowledge the role of national budgets, healthcare policies, big and small pharmas, medical device companies, and insurances. Patients are always at the bottom of this complex network, unfortunately not as real players. Drug and healthcare advertisement don't make a patient free to choose about his own health. Considering the relevance of healthcare choices, advertisement is not able to improve patient's awareness, and in a way it distracts patient-doctor relationship from its trustworthy nature. At the same time, entirely delegating choice to the patient by providing tons of information, doesn't help patient's awareness, it just makes him feel alone with his medical condition.

I have no doubt, time has come for a change. Doctors have been bound to the Hippocratic Oath "to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according to medical law, but to no one else." Thus, medicine has been immune by a true "democratization" process, and doctors need to help this process go in the right direction.

Shared decision making is what we need. Embracing this change will save and strengthen the value of patient-doctor relationship, and minimize most of the deviated influences I wouldn't have liked to list above. Shared decision making means essentially shared medical knowledge, and shared personal and institutional healthcare information.

Medical knowledge has been increasingly spread by some high quality governative and private channels, although bad quality healthcare is what make the most of internet and other media. We need a quality ranking system to help people choose where to learn.

Shared personal and institutional information is the most complex part of the problem. The first issue is privacy. Once this is solved a new issue, we can hardly see at the moment, will be what to make of those information in order to help patients to choose and doctors to deliver better care. At the moment both patients and doctors do not see the enormous potential of embracing this challenge. As a result, investment and commitment of government and academia is poor.



I want to give you a taste of what is the potential of medicine getting social the right way. Doctors know every patient is unique, but rely on the largest studies possible to deliver evidence based medicine, which is the best care for the average patient. This medicine is not up to date with the potential of personalized medicine, and old school trials are getting obsolete. Shared medical information has potential to retrieve new kind of data on best personalized treatment, taking in account actual compliance to the treatment, past medical history, geographic area and in close future genetic determinants. Doctors working in underserved or poor areas, will be able to compare treatment with similar areas around the world. Medicine try to set up the best standard of care by implementing new therapies or devices, which constantly increase prices. Not all the world lives in Massachusetts. It will be able to create communities able to negotiate the price of specific drugs such Herceptin for breast cancer, whose cost are extremely variable depending on insurances and public health/government institutions, but most of the time not accessible to poor areas of the worlds. Examples can extend to infinite. But one thing should be enough to convince you this effort is worth. Shared decision making will build up a medicine that requires doctors to listen to patients and vice versa, and doctors and patients listening among them. This is more relevant to the Hippocratic Oath than it is restricting access to knowledge.


I found some inspiration in:
Dave deBronkart, known as e-patient Dave http://www.youtube.com/watch?v=2vejkD0Rl3o
and Information needs of cancer patients and their organisations

RAS Mutations in Cutaneous Squamous-Cell Carcinomas in Patients Treated with BRAF Inhibitors — NEJM

RAS Mutations in Cutaneous Squamous-Cell Carcinomas in Patients Treated with BRAF Inhibitors — NEJM

BRAF inhibitors are gaining increasing attention for treatment of BRAF mutated cancers. A proportion of patients develop squamous cell carcinoma. A possible mechanism is identified here: RAS mutation can account for this in a substantial proportion of those patients.

Doctor and Patient: Why Doctors Can't Predict Life Expectancy - NYTimes.com

why we shouldn't predict prognosis...

Doctor and Patient: Why Doctors Can't Predict Life Expectancy - NYTimes.com: "
January 19, 2012, 12:01 AM
Why Doctors Can’t Predict How Long a Patient Will Live

Processed meat and Pancreatic cancer are linked, one more reason to go veggie.

Find more on http://www.nature.com/bjc/journal/vaop/ncurrent/full/bjc2011585a.html

British Journal of Cancer advance online publication 12 January 2012; doi: 10.1038/bjc.2011.585

Red and processed meat consumption and risk of pancreatic cancer: meta-analysis of prospective studies

S C Larsson and A Wolk

background:

  

Whether red and processed meat consumption is a risk factor for pancreatic cancer remains unclear. We conducted a meta-analysis to summarise the evidence from prospective studies of red and processed meat consumption and pancreatic cancer risk.

methods:

  

Relevant studies were identified by searching PubMed and EMBASE databases through November 2011. Study-specific results were pooled using a random-effects model.

results:

  

Eleven prospective studies, with 6643 pancreatic cancer cases, were included in the meta-analysis. An increase in red meat consumption of 120 g per day was associated with an overall relative risk (RR) of 1.13 (95% confidence interval (CI)=0.93–1.39; P_{heterogeneity}<0.001). Red meat consumption was positively associated with pancreatic cancer risk in men (RR=1.29; 95% CI=1.08–1.53; P_{heterogeneity}=0.28; five studies), but not in women (RR=0.93; 95% CI=0.74–1.16;P_{heterogeneity}=0.21; six studies). The RR of pancreatic cancer for a 50 g per day increase in processed meat consumption was 1.19 (95% CI=1.04–1.36; P_{heterogeneity}=0.46).

conclusion:

  

Findings from this meta-analysis indicate that processed meat consumption is positively associated with pancreatic cancer risk. Red meat consumption was associated with an increased risk of pancreatic cancer in men. Further prospective studies are needed to confirm these findings.

1) Introduzione al Tumore del Colon-retto

Primo episodio del videolog sul tumore del colon retto. Gli argomenti trattati sono l'epidemiologia, i fattori di rischio, la prevenzione e cenni di terapia. Questo video e' adeguato al pubblico generale e non sostituisce il parere del medico curante cui e' sempre necessario rivolgersi. Spero sia utile a chi vuole o ha bisogno di capire qualcosa in piu' su questa malattia. a presto Gm

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Microsatellite instability and a defective Heat Shock protein are linked in Colorectal Cancer

A review of the recent Nature paper: 

Expression of a mutant HSP110 sensitizes colorectal cancer cells to chemotherapy and improves disease prognosis.

Dorard C, de Thonel A, Collura A, Marisa L, Svrcek M, Lagrange A, ..., Parc Y, Tiret E, Fléjou JF, Gaub MP, Garrido C, Duval A  Nat Med. 2011 Oct; 17(10):1283-9

Microsatellite instability (MSI) is a well-known feature of a subset of colorectal cancer (CRC) that harbors a defective DNA mismatch system. MSI CRC is characterised by an improved prognosis and may not benefit from adjuvant fluorouracil (5FU) therapy in particular stages. Interestingly, this paper provides a possible MSI-related mechanism with possible implications for treatment and stratification.

The authors found that MSI CRCs can be associated to an aberrant splicing of the heat shock protein HSP111, producing an aberrant isoform, namely HSP110DeltaE9. The overexpression of this isoform in CRC cells affects the function of the naïve protein and increases the sensitivity to 5FU. So, if those cells are more sensitive to 5FU, why clinical trials show that MSI may not respond to this drug? The authors say that subjects with MSI-HSP110DeltaE9 (high) represent only a small fraction of the total MSI CRC cases and clinical heterogeneity is present in this group with respect to 5FU response. Interestingly, this aberrant molecule could be considered a natural inhibitor of HSP110, which has been found overexpressed in CRC and other tumors and associated with poor prognosis and metastases.