Making Complex Decisions When Confronted With Conflicting Opinions

Dr. Ramesh, a dermatologist from Tirupathi, traveled to Chennai with his father-in-law, Mr. Subramaniam, who had been diagnosed with prostate cancer. It had been diagnosed at an early stage and there was a good chance that the right treatment could lead to a complete cure. Mr. Subramaniam was a fit 61-year-old who went for walks in the morning and was in great physical shape. He looked forward to beating the disease. Owing to the contacts of Dr. Ramesh, they were able to get appointments with two oncologists at a top private hospital in Chennai. They felt enthused that this trip would be successful and that they would get clarity on the path forward. After they met with the two specialists, the family seemed more confused than ever. The surgical oncologist recommended immediate surgery and the radiation oncologist opined that radiation followed by chemotherapy would be the recommended course of action. Even though both of these specialists were practicing in the same hospital, the patient needed to take separate appointments and the treatment advice was contradictory with neither consulting the other.

Cancer decisions are complex as they require multidisciplinary opinions.  Treatment plans need to be decided by a group of doctors who discuss and weigh the pros and cons of the various treatment paths. In a tertiary care center like Tata Memorial Center or Stanford Medical Center, a case like this would involve a decision being made by a tumor board. A tumor board typically consists of a diagnostic radiologist, pathologist, surgeon, medical oncologist and a radiation oncologist getting together in the same room to discuss the case. A decision is first taken on the diagnosis and staging of the disease where the pathologist and diagnostic radiologist weigh in. Once this is completed, the surgeon, medical oncologist and radiation oncologist decide on the treatment path. The intent is to recommend a path that will provide a complete cure or extend years of cancer free survival or improve quality of life. This can be possible through surgery if the disease is localized and operable. Sometimes the surgeon will suggest that the tumor be shrunk through chemotherapy or radiation and then the patient get operated. Having all relevant specialists weigh in and review the case is the ideal scenario but this is unfortunately not the modus operandi in most hospitals.

Given the contradictory paths presented to them, Dr. Ramesh decided to approach Tata Memorial Center. They became aware of the online opinion service available and registered on www.navya.care. He uploaded all of his father-in-law’s reports following which a Navya clinical analyst reached out to him to not only understand the medical history but also all questions they needed answered. “We believed that we had gone to one of the best hospitals in South India and had met with two reputed oncologists. Even though I am a doctor myself, we were in a quandary as we were given contradictory opinions. Given this situation, we wanted to know from Tata Memorial Center how we should proceed in this case. Navya expedited our request and within 24 hours, we got a report that included the consensus of opinions from three experts including a surgical oncologist, a medical oncologist, and a radiation oncologist. The report was detailed and mentioned all of the treatment options and the reasons for recommended path. A clinical trial was also considered which gave us the peace of mind that no stone was left unturned.” The treatment recommended was to follow chemotherapy at this time and then consider definitive or curative therapy which could either be surgery or targeted radiation. The path was clear and the patient underwent a cycle of chemotherapy and the family heaved a collective sigh of relief.

Gaining access to even one oncologist can be challenging. Consulting more than one is often not possible, and even when it is, it takes up significant time. Given the criticality of timely treatment, the process of consulting several oncologists can be physically and emotionally draining and can lead to contradictory opinions which lead to confusion. To ensure that the treatment plan is comprehensive and is arrived at after considering all options, Navya processes cases by incorporating opinions of several experts from renowned cancer centers such as Tata Memorial Centre or expert centers such part of National Cancer Grid. Using Navya’s ExpertApp, case details and possible treatment options are sent to multiple experts who discuss the case online and build a multidisciplinary consensus opinion.

Says Dr. Abhishek Mahajan, a diagnostic radiologist at Tata Memorial Centre:”I am able to look at DICOM (Digital Imaging and Communications in Medicine) images to confirm the diagnosis and staging of the cancer. In some cases, there can be a question of the origin of the cancer. In one case, the treating oncologist needed to know whether it was a case of liver cancer or if it was a cancer that had spread to the liver.” The therapies recommended for each of these cases could be very different.

“Treatment decision making in oncology is essentially a joint discussion between all care givers, aiming towards the best course forward for the patient. At times, only surgery and radiation may suffice without chemotherapy, or chemotherapy and radiation can make surgery easier, and at times single modalities of treatment like chemotherapy or radiation may be all that the patient requires. What matters most is the optimal timing and selection of right modality of treatment. Navya, through the online ExpertApp, brings together a nuanced consensus from opinions of all the experts, in a language and manner understandable to all stakeholders, thus the best possible care for the patient” says Dr. Tushar Vora, medical oncologist at Tata Memorial Center.

Urging family members of cancer patients, Gitika Srivastava, Founder of Navya, shares her personal viewpoint:  “Most people who have had any experience with cancer are aware of TMC and that it is one of the largest tertiary care centers in the world. However, not everyone from far flung areas can come to Mumbai or is aware of the significance of a proper choice in treatment to a change in outcomes. Given the cases we have seen, we would urge everyone to get an expert opinion online at http://www.navya.care.  You can be assured that the opinion rests on the experience of world renowned cancer experts and follows evidence based protocols best suited to your loved one’s specific case.”

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

The NCG is a consortium of 104 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 http://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.  Contact:  Gitika Srivastava | gitika@post.harvard.edu

Twitter: https://twitter.com/NavyaCare

Facebook: https://www.facebook.com/NavyaNetwork/

LinkedIn: https://www.linkedin.com/company/15236089

PRESS RELEASE 06/05/2017

CS Pramesh
Dr CS Pramesh – Coordinator National Cancer Grid

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Expert Oncologists from Tata Memorial Centre (TMC) and National Cancer Grid (NCG) Use Navya to Provide Rapid Online Opinions to Patients across 22 Developing Countries

The results of a prospective study presented at the 2017 American Society of Clinical Oncology (ASCO) meeting demonstrates the global impact of an informatics-based scalable and low cost online service to maximize outcomes for patients in areas without ready access to expertise

CAMBRIDGE, Mass., MUMBAI, India and Chicago, Ill. – June 5, 2017: “TMC NCG Navya Online” provides multidisciplinary evidence based expert opinions within 24 hours to thousands of cancer patients in urban and non urban areas in the developing world.  A prospective study assessing the real world impact of this service concluded that patients shared the expert opinions with their treating providers and received evidence-based treatment. Expanding the service to non urban USA and the western world, can maximize cancer care outcomes, globally.

There is a scarcity of expert oncologists in the world. Patients in non urban areas have poor access to evidence-based treatment decisions and worse outcomes. In India, there are circa 1600 oncologists for 1.8 million patients and the lack of expertise translates to suboptimal and expensive treatment decisions. Navya’s informatics based expert opinion service, scalably provides multidisciplinary evidence based treatment opinions on-time, empowering every patient.

Since its creation in 2014, 10,779 patients from 22 developing countries have registered with TMC NCG Navya Online. The technology based operation with a median turnaround time of 24 hours, consists of clinical analysts who collect patient data and an informatics system that generates patient-specific evidence-based treatment options.  Experts take into account  patient preferences and rapidly review and vet the options within 1-2 minutes on the mobile ExpertApp.  The system generates a consensus multidisciplinary treatment decision and analysts create an expert opinion report in simple layman language which is sent to the patient online.

“The online expert opinion service is a game changer for regions where the demand for cancer expertise far outstrips supply, by democratizing access. This has enabled proliferation of standardized evidence based treatment recommendations for patients who lack the access to tertiary care centers and thereby expertise” said Dr Pramesh, Coordinator National Cancer Grid, the world’s largest consortium of 108 cancer centers in India. Dr Pramesh made an oral presentation of this abstract at ASCO on the 5th of June, 2017.

The study included 914 patients who registered with the service between July 2016 and March 2017 and were asked via phone follow up: 1. If report was shared with treating provider, 2. Final treatments received. Of the 90% of patients who responded (n=824), 72.3% [CI 3.05%] of patients shared the Expert Opinion Reports with their treating oncologists. 78% [CI 2.95%] of patients received treatments recommended by TMC NCG Navya.  Common reasons why patients received different treatments included decline in performance status after receiving the online opinion and not testing for biomarkers (Estrogen Receptor/Progesterone Receptor, etc.), likely due to lack of access to resources.

“The finding that a high proportion of the patients are sharing the reports with their treating oncologist and most proceed treatments that TMC and NCG experts would recommend,  demonstrates that the online service has wide approval both among patients as well as local physicians and oncologists” said Dr Rajendra Badwe, Director of Tata Memorial Centre, one of Asia’s largest leading tertiary care cancer centers.

Says Gitika Srivastava, Founder of Navya: “Navya’s vision is to meaningfully move the needle in the way cancer care is delivered. This study shows that the informatics based system and service is scaleable and has positively impacted patients from all over the developing world. Expanding the reach of this service can maximize outcomes for patients, especially those in non urban areas, across the world.”

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 http://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 an end to end expert decision system for use by cancer patients and oncologists globally.  Navya’s online expert opinion service is also the first of its kind to offer evidence based opinions from world leading experts at low cost, answering every single question of the patient, within 24 hours.

Twitter: https://twitter.com/NavyaNetwork

Facebook: https://www.facebook.com/NavyaNetwork/

LinkedIn: https://www.linkedin.com/company/15236089

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

PRESS RELEASE

 

 

Confronted With Complex Cancer Treatment Decisions – Navya Empowers Patients With the Consensus Opinion of an Expert Panel of Multidisciplinary Oncologists

 

Navya in partnership with Tata Memorial Center (TMC) and National Cancer Grid (NCG) enables cancer patients to have their cases reviewed by a multidisciplinary panel of experts, to arrive at the best possible treatment plan. This is critically important as cancer decisions are complex and often involve several organs and types of treatments.

A woman with advanced breast cancer may need surgical removal of the breast, radiation therapy to the brain, and multiple lines of chemotherapy with side effects impacting the heart and the liver.  Therefore, it is critical that experts in each of the specialties collaborate to determine the treatment plan; from radiologists reading mammograms and brain scans to breast oncology surgeons, neuro oncology radiation experts, and medical oncology experts.

While leading medical institutes across the world consider multidisciplinary treatment planning to be the standard of care, extreme shortage of cancer experts in India means that this is not the norm. A medical oncologist may treat breast cancer (solid tumor) and Leukemia (liquid tumor), and determine the radiation dosage for treatment.

Further, choices such as chemotherapy versus surgery, aggressive therapy versus supportive care, or Hail Mary attempts with expensive targeted therapies or enrolling in clinical trials, require evidence based knowledge and experience treating thousands of complex cases.  Such nuanced decision making weighing pros and cons of each treatment path is only possible when experts collaborate on a multidisciplinary tumor board.

At world renowned cancer centers such as TMC in Mumbai or Dana Farber Cancer Institute at Harvard, all cases are reviewed by a tumor board of cancer experts who jointly arrive at a treatment decision.  By leveraging its patented technology and collaboration with the best cancer experts in the country, Navya replicates this gold standard in cancer treatment planning.

“TMC and Navya have collaborated since 2011 to develop an expert decision system that uses clinical informatics, predictive analytics and machine learning to recommend evidence and experience-based expert treatment decisions, similar to decisions made by expert tumor boards,” said Dr. Rajendra A. Badwe, Director of Tata Memorial Centre.

At multidisciplinary tumor board meetings, a pathologist, radiologist, surgeon, medical oncologist, and radiation oncologist get together in the same room to discuss each case.  Sometimes the surgeon will suggest that the tumor be shrunk through chemotherapy or radiation and then the patient get operated. At other times the radiation oncologist may determine that the tumor site is not safe to radiate. If the radiologist determines spread of cancer across organs, the medical oncologist may recommend chemotherapy alone.  Having all relevant specialists weigh in and review the case is the ideal scenario but this is unfortunately not the modus operandi in most hospitals.  This is where Navya comes in.

Mr. Shah’s father in Rajkot was diagnosed with a form of lung cancer following a routine checkup. Several tests followed and there was confusion as it could have been metastatic mesothelioma that may or may not be operable and therefore whether to proceed with surgery and radiation therapy or chemotherapy alone was unclear. They consulted oncologists in Ahmedabad, Mumbai, and also reached out to oncologist friends in the US.  The conflicting opinions meant that even though they had access to reputed oncologists, each was making a decision in a silo. In their relentless search for credible advice, they were made aware of http://www.navya.care and the fact that it offered multidisciplinary opinions. While the previous three weeks were chaotic with several view-points and a plethora of tests being recommended, the next 24 hours served to create order where there was chaos. Mr. Shah’s case was looked at by a team of experts that included the top thoracic surgeon in the country collaborating with a senior medical oncologist and radiation oncologist. The treatment path was clear and precise and helped the family move forward with confidence.

Says Mr Shah, “By the grace of God, we are not constrained by a lack of resources, and I was able to connect with several oncologists across India and the US. However, it was tough for us to assimilate the opinions and determine the one clear path to follow. We found that only Navya was able to do this and we are grateful for the clarity and thoroughness.”

To ensure that the treatment plan is comprehensive, Navya processes cases by incorporating opinions of several experts from Tata Memorial Centre and National Cancer Grid, a consortium of expert centers in India.

“Patients at small or remote centers will now have access to the world class expertise of cancer experts in India,” said Dr. C.S. Pramesh, Coordinator of the National Cancer Grid. “Treating oncologists can consult with multidisciplinary experts online in a simulated tumor board that results in expert treatment decisions for patients everywhere.”

www.navya.care leverages the power of the internet to make access to expert treatment decisions convenient, cost effective, and ubiquitous so every cancer patient receives a multidisciplinary opinion.  Patients simply upload their medical reports and decision questions and receive an expert opinion report within 24 hours.

Gitika Srivastava, Founder of Navya, says: “Most people who have had any experience with cancer know it’s not always possible to gain access to cancer experts.   Tata Memorial Centre, National Cancer Grid, and Navya are working to change this.  Every cancer patient has the right to an expert opinion.  We urge you to leverage  www.navya.care for an online opinion. You can be assured that the opinion rests on the multidisciplinary experience of world renowned cancer experts collaborating to deliver the best possible treatment plan uniquely suited to your case.”

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

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.  The NCG is a consortium of 104 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.\

Navya http://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.  Contact:  Gitika Srivastava | gitika@post.harvard.edu

Twitter: https://twitter.com/NavyaCare

Facebook: https://www.facebook.com/NavyaNetwork/

LinkedIn: https://www.linkedin.com/company/15236089