Two Distinct States of Mind

As a young medical student, I saw a person dying. Fluid was filling his lungs as a heart valve had ruptured from a massive heart attack a few days earlier. I did not have the ability to save his life where I was working — no immediate ICU or surgical care was available. It struck me later that I had the choice of disclosure. Should I have told him and his wife that he was dying? Would there have been a few minutes of “I love yous” and goodbyes? Or, would ensuing panic be all that remained etched as the last few memories?

Working in the developing world, non-disclosure to the patient, and their right to not know all about their healthcare is the default. Patients entrust decision making and autonomy to their family members, and many times, they are implicitly aware that they are not fully in the loop. Families also do not want diagnoses of terminal illness disclosed to patients. The enduring belief is that this will shorten their life and remove potential for happiness. In cultures accustomed to death at any age, dying is seldom discussed. It often happens, at home, with family, silently, without much accompanying discussion.

It has always struck a chord with me that the dying are aware that they are passing away. The ebb of the body’s energy is not mistaken at the end of times for something else. Spoken or not, it is implicit in every interaction.

In cultures accustomed to death at any age, dying is seldom discussed.

Yet, friends often describe a loved one’s passing from cancer as “sudden” or “unexpected”. “He was doing fine”- in the house in bed, or in the hospital ward, until he fell sick and passed in a matter of days. Despite a terminal diagnosis of advanced refractory cancer, the story that is told is one of death arriving without a warning.

I believe that there are two distinct states of mind— one of caregiving, and the other of grieving. These cannot coexist easily. The caregiver, even the self, nurtures the past and hopes for the future, since the present is intolerable. The grieved, instead lives solely in the past, and rewrites history to make sense of the powerlessness to change the future.

Physicians struggle with this. As a patient transitions from curative to comfort driven measures, they raise the specter of disclosure, of poor prognosis and impending death, as a way to absolve themselves of any guilt, any way to impact the future. Rarely, this is needed in the developing world. As a gross generalization, bucket lists are the privilege of the healthy and wealthy. Otherwise, many families are already together, at home, with their loved ones, in the non-medicalized ritual of dying that is as ancient as our cultures.

What is forgotten is that no one knows the future. We play with probabilities and pretend that they are certainties. The removal of hope for families and self leaves very little to get through the everyday with. Much has been written about living a pain free day, the taste of something special, or watching a grandchild at play. But there is also the balm of improbable hope, balanced with measured, comfort providing interventions, that allow family and patient to weather the present.

There will always be time for grieving. I am now beginning to see the wisdom of not starting that process while our loved ones are still with us.

-Dr. Naresh Ramarajan

 

Online Expert Opinion: www.Navya.Care

Tata Trusts: www.tatatrusts.org

Tata Memorial Center: www.tmc.gov.in

Navya: www.NavyaNetwork.com

La Médecine C’est Guérir Parfois, Sulager Souvent, Consoler Toujours

A friend approached me today. His mom is ebbing away with one of the most primal challenges — losing her ability to breathe. A tumor grows around her vocal cords, constricting her ability to eat, or swallow her saliva, or breathe – while her mind works and shuts down internally into depression and despair.

‘’La médecine c’est guérir parfois, soulager souvent, consoler toujours’

This medieval French admonition to doctors is to ‘Cure occasionally, relieve often, comfort always’

Much of my experience with patients is one where they are more terrified of what doctors will do to them in pursuit of an often elusive cure. We have invented many novel methods of torture in the pursuit of life – and apply them indiscriminately in response to fears, anxiety, guilt and shame; both ours and the families’.

Over some time, we uncovered that his mom doesn’t want treatments. She wants to feel more comfortable. Lessening the tidal wave of fear of choking was the only comfort that made sense to offer.

I tinkered around with some solutions — cool humidified mist, thickened fluids, a touch of benzodiazepines to allay anxiety. We also talked about music, prayer, family, and food for taste or comfort rather than nourishment.

Where is our calling and ability to minister to those dying from our incurable maladies?

Palliative and supportive care medicine is just now reaching some recognition in most of the world. The Indian Supreme Court ruled recently that a person’s right to dignity and privacy included a natural death in a course of their choosing.

As the technology to cure improves, so must our resolve to releave and comfort those beyond our means.

I am eager to expand Navya’s palliative recommendations, especially in settings where we die suffering without any help or comfort. The full spectrum of care must include the ability to recognize a patient’s dignity and preferences, and to comfort – always.

-Dr. Naresh Ramarajan

 

Online Expert Opinion: navyanetwork.com/tmh

Tata Trusts: tatatrusts.org

Tata Memorial Center: tmc.gov.in

Navya: www.navya.care

Navya Scales Access to Rare Cancer Care Expertise and Tailors Evidence-based Treatment Plans to Individuals Based on Affordability and Access to Therapies

Navya Press Release img1

Navya Presents Joint Study with National Comprehensive Cancer Network at San Antonio Breast Cancer Symposium, December 5-9, 2017

CAMBRIDGE, Mass. and SAN ANTONIO, Texas – Dec. 8, 2017 – “TMC NCG Navya Online” (Navya) has scaled access to rare cancer care expertise, tailoring evidence based treatment plans to individuals based on affordability and access to therapies. Navya, a clinical informatics system and online expert opinion service, provides evidence based multidisciplinary expert opinions within 24 hours to thousands of cancer patients around the world. Navya learns from evidence, prior tumor board decisions and quick review from expert oncologists to recommend tailored treatment plans to patients at all levels of affordability.

A joint study presented at San Antonio Breast Cancer Symposium on December 8, 2017 by National Comprehensive Cancer Network (NCCN) and Navya demonstrated that 88.3 percent of Navya’s treatment decisions mapped to NCCN’s Resource Stratified Framework (NCCN-RSF) for Lower Middle Income Countries (LMIC).

Navya is sensitive to the needs of resource constrained patients.  Expert oncologists from Tata Memorial Centre (TMC) – one of Asia’s largest tertiary cancer centers, and National Cancer Grid (NCG) – a consortium of 108 cancer centers and specialty centers in India, provide online opinions to patients via Navya.

In most of the world, the cancer burden is disproportionately greater than the scarce access to tumor board expertise.  Patients often do not receive evidence based treatment plans. Further, patients are resource constrained and are unable to afford or access therapies that are optimal per global guidelines like NCCN.

Since its creation in 2015, over 17,000 patients from 22 LMIC’s have reached out to TMC NCG Navya Online to receive an online expert opinion.

Dr. Ben Andersonvice chair of the NCCN Breast Panel and chair of the NCCN International Program Committee and the senior author of the study said, “While there is significant drug discovery and treatment  research happening worldwide to combat cancer, the therapies are often unviable to LMIC. Tailoring treatment plans to patient constraints is critical and Navya’s online expert opinion service does that in a scalable manner.”

Dr. Rajendra Badwe, Director of Tata Memorial Centre, stated, “In India and low and middle income countries, patients are challenged to receive evidence based therapies within available resources. NCCN-Resource Stratified Guidelines is an attempt by a globally reputable standard of care organization to determine treatment pathways based on resources.  This study shows that only 8.6 percent of parent NCCN guidelines could be mapped directly to patient care in India.  Additionally, 79.7 percent required tailoring for resource constraints, and even so 11.7 percent of guidelines did not map.  There are several expert practices in India that are not yet included in the global guidelines.  For instance, unlike TMC’s clinical practice, NCCN-RSF does not recommend shorter courses of expensive targeted therapies like Trastuzumab for patients who cannot afford year-long therapy.  Our informatics system captures and disperses such expertise to resource constrained patients nationwide.  NCCN can scale adoption and learning of resource constrained treatment guidelines by leveraging on the ground systems.”

Dr. Naresh Ramarajan, Founder of Navya and Chief Medical Officer further stated, “Navya’s vision is to transform delivery of cancer expertise to impact cancer care at a global level. This study shows that the informatics based system and online service is scalable and individualized to each patient’s condition and constraints. Expanding the reach of this service across the developing world can maximize outcomes for financially underprivileged patients.”

National Cancer Grid (NCG), tmc.gov.in/ncg Tata Memorial Centre (TMC) tmc.gov.in

The NCG is a consortium of 108 cancer centers, with a mandate to standardize cancer care, nationally. NCG is the largest global network of cancer centers collaborating to use technology and training to bring cancer expertise to every oncologist and cancer patient in India. TMC is Asia’s largest leading tertiary care expert cancer center, seeing over 67,000 cancer patients every year. Its strength necessitates a responsibility to make its expertise available to patients across India and developing countries, especially those who reside in locations where there are no expert cancer care centers.

Navya www.navya.info

Navya is a clinical informatics and patient services organization with a unique understanding of cancer patients and oncologists and a core commitment to cancer care. With a proven track record of successfully implementing innovative solutions that are low cost and effective, Navya is the first to develop technology systems specific to Indian cancer data for use by cancer patients and oncologists in India.

Twitter: https://twitter.com/NavyaCare
Facebook: https://www.facebook.com/NavyaNetwork/
LinkedIn: https://www.linkedin.com/company/15236089

Contact:  Gitika Srivastava | gitika@post.harvard.edu

Empowering Cancer Patients with Expert Opinion: Navya

Ms. Khan had been living in South Korea for years. Recently, her skin had started to get a jaundiced look. The gastroenterologists at South Koreas premier hospital unfortunately diagnosed her with a periampullary mass in the duodenum, and the surgeons promptly completed a Whipple procedure. Her surgery was a success! The tumor was completely removed. But three nodes near the duodenum were positive. Mr. Khan wanted to ensure that the cancer didn’t come back or spread.

The Ampulla of Vater sounds like something straight out of Hogwarts. Digestive juices from the bile ducts and the pancreas pool together in the ampulla to meet the food coming into the small intestine (duodenum) from the stomach in this action-packed area of the GI tract. Naturally, even small tumors in and around the ampulla cause major problems. Blocking bile ducts causes a quick yellowing of the skin and eyes. When the ampulla is blocked and the juices do not flow freely, the pancreas, the liver and the stomach all start to back up.

Mr. Khan reached out to Navya for a review of his wife’s case. Navya is an evidence and experience-based expert decision system. We were focused on an expert opinion, a single consensus opinion that combined relevant and applicable knowledge from clinical trials, international guidelines, outcomes of similar patients, and true experts from only the handful of true expert centers. That reconciled opinion – the expert opinion – would remove all complexity of what treatment to undertake (preventive surgery or just sit tight… surgery first or chemotherapy… benefits of radiation versus risk of incontinence or infertility… chemotherapy or new targeted therapy or both… reinduction protocol or maintenance protocol or wait and watch…). Navya’s patented system uses clinical informatics, predictive analytics and machine learning technologies. It combines several clinical information sources as inputs – and outputs a treatment decision most applicable to a unique patient.

Promptly, the Navya Expert System, Vyas matched her case with similar patients seen before. Confronted with a duodenal periampullary cancer, Vyas looked up data related to duodenal/intestinal malignancies and recommended fluorouracil based therapies. The structured summary was quickly compiled and sent to an Indian medical expert in London affiliated with Tata Memorial Center for review. The expert quickly responded, correcting Vyas. Treating the tumor as periampullary rather than as dudodenal/intestinal made more sense, said the expert. The treatment recommended was a two-drug regimen recently shown to increase survival in pancreatic cancer at ASCO 2016.

The patient report reached South Korea within 13 hours of Mr. Khan reaching out to Navya. Needless to say, Mr. Khan’s family was grateful and impressed. Vyas learned something new from the case. The experts quick review and feedback pointed Vyas to emphasize periampullary origin over intestinal origin of cancers while looking for treatment options. Vyas integrated the knowledge it already had about the ESPAC4 trial from ASCO’s conference in 2016 for pancreatic cancers in a new manner into its experience engine for ampullary tumors.

Navya is committed to holding the hand of every cancer patient and lifting them to the same pedestal as everyone else in the world:  expert cancer care for all. Navya is the only clinically validated end-to-end decision system in cancer treatment decision making.You, your family, your friend, will always have us no matter the cancer to conquer or access to technology and data. Access is always enabled through us, and our system, service, and experts empower for real, in a format that you can consume from home.

Online Expert Opinion: http://www.navya.care

Navya – Making Cancer Expertise Accessible and Affordable

Navya is committed to holding the hand of every cancer patient and lifting them to the same pedestal as everyone else in the world: expert cancer care for all. Navya is the only clinically validated end-to-end decision system in cancer treatment decision  making.You, your family, your friend, will always have us no matter the cancer to conquer or access to technology and data.  Access is always enabled through us, and our system, service, and experts empower for real, in a format that you can consume from home.

Navya is an evidence and experience-based expert decision system. We were focused on an expert opinion, a single consensus opinion that combined relevant and applicable knowledge from clinical trials, international guidelines, outcomes of similar patients, and true experts from only the handful of true expert centers. That reconciled opinion – the expert opinion – would remove all complexity of what treatment to undertake (preventive surgery or just sit tight… surgery first or chemotherapy… benefits of radiation versus risk of incontinence or infertility… chemotherapy or new targeted therapy or both… reinduction protocol or maintenance protocol or wait and watch…). Navya’s patented system uses clinical informatics, predictive analytics and machine learning technologies. It combines several clinical information sources as inputs – and outputs a treatment decision most applicable to a unique patient.

The Ampulla of Vater sounds like something straight out of Hogwarts. Digestive juices from the bile ducts and the pancreas pool together in the ampulla to meet the food coming into the small intestine (duodenum) from the stomach in this action-packed area of the GI tract. Naturally, even small tumors in and around the ampulla cause major problems. Blocking bile ducts causes a quick yellowing of the skin and eyes. When the ampulla is blocked and the juices do not flow freely, the pancreas, the liver and the stomach all start to back up.

Ms. Khan had been living in South Korea for years. Recently, her skin had started to get a jaundiced look. The gastroenterologists at South Koreas premier hospital unfortunately diagnosed her with a periampullary mass in the duodenum, and the surgeons promptly completed a Whipple procedure. Her surgery was a success! The tumor was completely removed. But three nodes near the duodenum were positive. Mr. Khan wanted to ensure that the cancer didn’t come back or spread.

Mr. Khan reached out to Navya for a review of his wife’s case. Promptly, the Navya Expert System, Vyas matched her case with similar patients seen before. Confronted with a duodenal periampullary cancer, Vyas looked up data related to duodenal/intestinal malignancies and recommended fluorouracil based therapies. The structured summary was quickly compiled and sent to an Indian medical expert in London affiliated with Tata Memorial Center for review. The expert quickly responded, correcting Vyas. Treating the tumor as periampullary rather than as dudodenal/intestinal made more sense, said the expert. The treatment recommended was a two-drug regimen recently shown to increase survival in pancreatic cancer at ASCO 2016.

The patient report reached South Korea within 13 hours of Mr. Khan reaching out to Navya. Needless to say, Mr. Khan’s family was grateful and impressed. Vyas learned something new from the case. The experts quick review and feedback pointed Vyas to emphasize periampullary origin over intestinal origin of cancers while looking for treatment options. Vyas integrated the knowledge it already had about the ESPAC4 trial from ASCO’s conference in 2016 for pancreatic cancers in a new manner into its experience engine for ampullary tumors.

Online Expert Opinion: http://www.navya.care

An Expert Opinion makes the difference to Cancer Patients – not another 2nd opinion

The Ampulla of Vater sounds like something straight out of Hogwarts. Digestive juices from the bile ducts and the pancreas pool together in the ampulla to meet the food coming into the small intestine (duodenum) from the stomach in this action-packed area of the GI tract. Naturally, even small tumors in and around the ampulla cause major problems. Blocking bile ducts causes a quick yellowing of the skin and eyes. When the ampulla is blocked and the juices do not flow freely, the pancreas, the liver and the stomach all start to back up.

Ms. Khan had been living in South Korea for years. Recently, her skin had started to get a jaundiced look. The gastroenterologists at South Koreas premier hospital unfortunately diagnosed her with a periampullary mass in the duodenum, and the surgeons promptly completed a Whipple procedure. Her surgery was a success! The tumor was completely removed. But three nodes near the duodenum were positive. Mr. Khan wanted to ensure that the cancer didn’t come back or spread.

Mr. Khan reached out to Navya for a review of his wife’s case. Promptly, the Navya Expert System, Vyas matched her case with similar patients seen before. Confronted with a duodenal periampullary cancer, Vyas looked up data related to duodenal/intestinal malignancies and recommended fluorouracil based therapies. The structured summary was quickly compiled and sent to an Indian medical expert in London affiliated with Tata Memorial Center for review. The expert quickly responded, correcting Vyas. Treating the tumor as periampullary rather than as dudodenal/intestinal made more sense, said the expert. The treatment recommended was a two-drug regimen recently shown to increase survival in pancreatic cancer at ASCO 2016.

The patient report reached South Korea within 13 hours of Mr. Khan reaching out to Navya. Needless to say, Mr. Khan’s family was grateful and impressed. Vyas learned something new from the case. The experts quick review and feedback pointed Vyas to emphasize periampullary origin over intestinal origin of cancers while looking for treatment options. Vyas integrated the knowledge it already had about the ESPAC4 trial from ASCO’s conference in 2016 for pancreatic cancers in a new manner into its experience engine for ampullary tumors.

Navya is an evidence and experience-based expert decision system. We were focused on an expert opinion, a single consensus opinion that combined relevant and applicable knowledge from clinical trials, international guidelines, outcomes of similar patients, and true experts from only the handful of true expert centers. That reconciled opinion – the expert opinion – would remove all complexity of what treatment to undertake (preventive surgery or just sit tight… surgery first or chemotherapy… benefits of radiation versus risk of incontinence or infertility… chemotherapy or new targeted therapy or both… reinduction protocol or maintenance protocol or wait and watch…). Navya’s patented system uses clinical informatics, predictive analytics and machine learning technologies. It combines several clinical information sources as inputs – and outputs a treatment decision most applicable to a unique patient.

Navya is committed to holding the hand of every cancer patient and lifting them to the same pedestal as everyone else in the world:  expert cancer care for all. Navya is the only clinically validated end-to-end decision system in cancer treatment decision making. You, your family, your friend, will always have us no matter the cancer to conquer or access to technology and data.  Access is always enabled through us, and our system, service, and experts empower for real, in a format that you can consume from home.

Online Expert Opinion: http://www.navya.care

Confronted With Complex Cancer Treatment Decisions? Get Consensus Opinion of an Expert Panel of Multidisciplinary Oncologists with Navya

Navya is an evidence and experience-based expert decision system. We were focused on an expert opinion, a single consensus opinion that combined relevant and applicable knowledge from clinical trials, international guidelines, outcomes of similar patients, and true experts from only the handful of true expert centers. That reconciled opinion – the expert opinion – would remove all complexity of what treatment to undertake (preventive surgery or just sit tight… surgery first or chemotherapy… benefits of radiation versus risk of incontinence or infertility… chemotherapy or new targeted therapy or both… reinduction protocol or maintenance protocol or wait and watch…). Navya’s patented system uses clinical informatics, predictive analytics and machine learning technologies. It combines several clinical information sources as inputs – and outputs a treatment decision most applicable to a unique patient.

The Ampulla of Vater sounds like something straight out of Hogwarts. Digestive juices from the bile ducts and the pancreas pool together in the ampulla to meet the food coming into the small intestine (duodenum) from the stomach in this action-packed area of the GI tract. Naturally, even small tumors in and around the ampulla cause major problems. Blocking bile ducts causes a quick yellowing of the skin and eyes. When the ampulla is blocked and the juices do not flow freely, the pancreas, the liver and the stomach all start to back up.

Ms. Khan had been living in South Korea for years. Recently, her skin had started to get a jaundiced look. The gastroenterologists at South Koreas premier hospital unfortunately diagnosed her with a periampullary mass in the duodenum, and the surgeons promptly completed a Whipple procedure. Her surgery was a success! The tumor was completely removed. But three nodes near the duodenum were positive. Mr. Khan wanted to ensure that the cancer didn’t come back or spread.

Mr. Khan reached out to Navya for a review of his wife’s case. Promptly, the Navya Expert System, Vyas matched her case with similar patients seen before. Confronted with a duodenal periampullary cancer, Vyas looked up data related to duodenal/intestinal malignancies and recommended fluorouracil based therapies. The structured summary was quickly compiled and sent to an Indian medical expert in London affiliated with Tata Memorial Center for review. The expert quickly responded, correcting Vyas. Treating the tumor as periampullary rather than as dudodenal/intestinal made more sense, said the expert. The treatment recommended was a two-drug regimen recently shown to increase survival in pancreatic cancer at ASCO 2016.

The patient report reached South Korea within 13 hours of Mr. Khan reaching out to Navya. Needless to say, Mr. Khan’s family was grateful and impressed. Vyas learned something new from the case. The experts quick review and feedback pointed Vyas to emphasize periampullary origin over intestinal origin of cancers while looking for treatment options. Vyas integrated the knowledge it already had about the ESPAC4 trial from ASCO’s conference in 2016 for pancreatic cancers in a new manner into its experience engine for ampullary tumors.

Navya is committed to holding the hand of every cancer patient and lifting them to the same pedestal as everyone else in the world:  expert cancer care for all. Navya is the only clinically validated end-to-end decision system in cancer treatment decision  making.You, your family, your friend, will always have us no matter the cancer to conquer or access to technology and data.  Access is always enabled through us, and our system, service, and experts empower for real, in a format that you can consume from home.

Online Expert Opinion: http://www.navya.care