Category: Cancer care

The Clarity of an Expert Opinion Prevents Unnecessary Chemotherapy

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Reshma Singh, a 22 year old, working with a multinational in Pune received a call from her father. Her mother, Mamta, 50, who lived in Sehore, a small town midway between Indore and Bhopal was diagnosed with Resectable Ovarian Cancer following severe abdominal pain and was advised immediate surgery. There was a mass detected in the uterus which meant that a complete hysterectomy was deemed necessary. The family had to travel to Indore where, in consultation with a Laparoscopic surgeon at a private hospital, she underwent a successful procedure where the tumor was removed.

This was supposed to be the end of the ordeal but things turned out very differently. “That one week in the hospital post surgery was a stressful time for us where each doctor visit would cost us several thousand rupees” said Reshma. After a biopsy, the surgeon recommended that she go through a chemotherapy regimen of 7 cycles. “The doctor told us that this was a precautionary measure to ensure the cancer does not recur. This came as a shock to all of us. I also felt that the surgeon was pressuring us into starting an expensive and possibly unnecessary treatment.” A heated debate ensued within the family with some members feeling that the doctors word must be trusted and Reshma insisting that such a big step should not be taken without getting another unbiased opinion from an expert.

Reshma wanted to get an opinion from Tata Memorial Center in Mumbai but her mother was in no shape to travel. She reached out to TMC NCG Online, Navya Expert Opinion Service to get the advice of world renowned experts. She uploaded all her mother’s reports following which a patient advocate reached out to her to understand the medical history and to know what the family wanted to ask the experts. A clarification was sought about the marginal status of the surgery as well as the planned treatment.

The case was compiled and sent to an expert at the Gynecology disease management group and his opinion was sought. The response was that as per the globally accepted guidelines for the treatment of cancers, surveillance was the recommended course of option. This would require the patient to undergo a physical examination and a battery of recommended tests every 3 months for the next two years. Chemotherapy was not a recommended course of treatment at this time. The report was shared with Reshma who shared it with the elders in the family. “When my father saw that the Tata Cancer hospital doctors had given this opinion, there was a sense of relief.”

There is scarcity of cancer experts in India, located mostly in metropolitan cities, but the number of cancer patients in need of an expert opinion is in the millions. Traveling to consult an expert at each of the many treatment decision points is costly, logistically complex, and delays the onset of treatment. In this case, reaching out to TMC NCG Online -Navya Expert Opinion Service, meant that the patient was not administered Chemotherapy which would have been against globally accepted guidelines for that particular situation.

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 centres 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 through TMC NCG Online. 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 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/organization/15236089/

Data Driven Doc: Staying Informed on the Diagnosis (Part 2 of 2)

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(Continued from previous post here)

We struggled with how to let my dad know about this upstaging. I intensely felt the need to protect him from bad news and at the same time the need for disclosure to move ahead. But I couldn’t move past the diagnosis and into treatment planning until he knew. We waited for his appointment that evening and then broke the news to him.

Perhaps overwhelmed by this unforeseen information, I dropped my guard. The urologist recommended surveillance to see if the cancer cells at the positive margins would grow. We did not start any anti cancer therapies. We were not even referred to see a radiation oncologist.

For a high-grade tumor that was outside the capsule of the prostate already, this approach should not have passed the smell test. But all the energy I had put into researching my options were now focused on helping dad recover from the surgery. We simply took the urologist at his word and waited. I didn’t even lookup my online medical references.

No surprise to anyone but us, the tumor markers quickly started inching up and doubling. Imaging showed that the recurrence was not spread in the body, and was still local. Alarmed, I went back to my information-first mode, and read every study on local salvage therapies. I was surprised to find out that early salvage radiation and hormones immediately after surgery were already becoming standard.

I discovered that in most other locally advanced tumors with a high grade, positive margins aren’t simply ignored, rather are treated with repeat surgery or adjuvant therapies!

Although reeling for lost time, I was also exceptionally thorough this time. We went through every possible radiation and hormone therapy option – to radiate the pelvic nodes or not, use protons or photons, what dose, to use short course or long course hormones or no hormones.

I read every study and guideline that was applicable. I spoke with every expert in the area I knew at UCLA, Stanford and nationally. I wanted to be certain that I was making a decision with the best information at hand.

After extensive discussions with my father on his preferences, and discussions with his radiation oncologist, we embarked on round two of beating his prostate tumor. My dad was fully aware of his diagnosis, his options, and his choice of therapy. The clarity of that knowledge and reassurance that we were doing everything possible gave us so much strength. Instead of being victims to the process and the disease, and have something to hide from and be protected from, we were open, clear, calm and as much in control as we could be.

That was almost 5 years ago. Luckily, my dad continues to have his 3 month check-ups that are coming back clear. He is not out of the window of recurrence just yet, but it is safe to say we are getting there.

Not all stories have happy endings. Despite being treated at the best cancer center in America, my aunt succumbed to inflammatory breast cancer in 2009. She was diagnosed the same year as my father, and we went through the same exhaustive search for therapies and options that we did with my father. When she went on hospice, she knew she had exhausted every option medical science could offer us at the time. I still carry that little piece of reassurance inside me today.

While my physicians have my best interests in mind, they are limited in ferocity as this is not their battle to fight. It is mine.

I see a diagnosis of cancer for what it is now. Without knowing the name of my enemy, I cede power of fighting to others. While my physicians have my best interests in mind, they are limited in ferocity as this is not their battle to fight. It is mine. Staying informed on the diagnosis, science behind the options, and the experience of true experts in the field is the only reassurance I can have that the best possible decision has been made.

-Dr. Naresh Ramarajan

Online Expert Opinion: www.Navya.Care
Tata Trusts: tatatrusts.org LinkedIn Facebook  Twitter
Tata Memorial Center: tmc.gov.in  Facebook
Navya: navyanetwork.com  LinkedIn  Facebook  Twitter

Data Driven Doc: Staying Informed on the Diagnosis (Part 1 of 2)

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I’ve been told the events of the first time so many times, that I have a vivid memory of it now. My fathers mother, Bhuma, succumbed to a recurrent brain tumor that kept growing in the small confinement of her skull. When she was first admitted to a small hospital in Massachusetts, confused after a fall, my father was not at her side. My aunt had driven her to the hospital, and first received the news of impending brain surgery. But without my father around, my aunt couldn’t let my grandmother know. Bhuma was a woman who was in exquisite control of her world and those around her. To know that she was losing that control in a strange land would unravel her deeply, thought my aunt. Could she undergo surgery without knowing why?

Although common in South Asia and other parts of the world, this idea of keeping a diagnosis secret from the patient, especially one who needed a surgery, was foreign to the surgeon. As the story goes, my aunt stood between the surgeon and my grandma, and refused to translate a word of his English into her Tamil. The standoff continued until my father got there the next day.

Once my father arrived, my aunt gave up her shield to him. The energy of my family was spent in understanding the prognosis and explaining it to my grandmother. It did not occur to them to explore what treatments to do and in which sequence. It was 1989, and the trust in the surgeon was much higher than the trust in the patient.

After much reassurance from the surgeon, and not much understanding, my family consented to neurosurgery. The tumor was incompletely removed, and treated almost too conservatively. It came back again and again until there was no radiation or surgery that would stay it’s course.

I often wonder what Bhuma thought of all the medical decisions she relegated to her surgeon alone, and what sense of acceptance and calm allowed her to continue through the storm of medical care that pursued her the rest of her life. For a woman who consistently went out of her way to ensure that even her neighbors had their lives in order, the loss of autonomy and empowerment might have been frightening.

I often wonder what Bhuma thought of all the medical decisions she relegated to her surgeon alone.

Many years later, cancer found my family again. Freshly graduated from Stanford Medical School and an intern at UCLA, I felt ready to assume decision making for my father. When we were initially debating surgery vs radiation for early prostate cancer, I did exhaustive searches of the published research and expert reviews. I understood the side effects and the tradeoffs extremely well. My father became integral to the decision making. We made a calculated choice to go for surgery. My father strongly preferred to have the cancer out, and to have radiation available as a salvage option. The evidence and guidelines supported either choice, although each expert still had their preference in the matter. We were confident we had made the right choice.

So when my mother called me with her early online access to dad’s pathology report – I was saddened and grateful at the same time. The tumor was more aggressive than we thought, a Gleason score 9 instead of a 6, was not early and limited to the prostate but had invaded the surrounding tissues, and the margins were positive. There was still some of that cancer left behind.

We certainly would not have known this information without a surgery. My dad was in the small percentage of patients where the preoperative imaging and biopsies had not picked up the full extent of the disease. It was a lucky alignment of our decision and hindsight.

-Dr. Naresh Ramarajan

Online Expert Opinion: www.Navya.Care
Tata Trusts: tatatrusts.org LinkedIn Facebook  Twitter
Tata Memorial Center: tmc.gov.in  Facebook
Navya: navyanetwork.com  LinkedIn  Facebook  Twitter

Major Digital Health/Healthtech/Health 2.0 Trends for 2017 (Part 3)

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First, I will define digital health/healthtech/health 2.0 as products and services that rely on using the Internet and digital data (versus paper or physical contact/in-person consultations), to better the overall physical or mental health of an individual. This does not include medical devices or pharmaceutical.

The major trends for 2017 include using information technology and Internet, of which mobile is a significant component, to do the tasks that patients and physicians or other service providers would ordinarily do, but at a faster, cheaper, and larger scale i.e. to reach a global network without incurring added costs of time and money. Unlike in other industries, healthcare does not allow immediate and ground-breaking leaps in the use of information technology to do new and powerful things that were otherwise not already possible, for example, offering a treatment or diagnosing using the Internet.

Offering a treatment or diagnosing using the Internet.

A few years ago, as an early stage startup investor in Boston, I came across technologies that proposed to use video games to treat Attention Deficit Disorder, or rely on patterns in mobile phone usage to diagnose and manage depression, or leverage the iPhone camera to send images to ophthalmologists to diagnose eye infections in rural India, or attach monitors to cell phones as an electrocardiogram device.

These innovations tread on diagnosing and treating, and must be tempered by regulation and clinical trial validations before adopted use. This is beyond what digital health/healthtech/health 2.0 can reasonably promise to deliver, as the intricacies of the healthcare and legal landscape intervene.

The success of such innovations, measured by adoption and use in the clinical world, is yet to be seen.

However, leveraging technology to improve performance of products and services that already exist, and that improve healthcare delivery as it exists today, is a fair game for digital health/healthtech/health 2.0. This can be boiled down to some key trends.

Trend #3 – Keeping track with the mobile phone

A lot of physical barriers of time and place are broken by the mobile phone today. The mobile phone basically goes wherever you go, no matter where the data or the person who matter to you, resides.

The mobile allows workflow optimizations, such as scheduling and reminders for doctor’s visits, prescription pickup, taking medications, or accessing your health records when you’re on the go.

Secure access to data on the cloud, and on-the-go use of the mobile phone will dominate how patients manage their health matters on a day to day basis. Most likely, there will be more free services and mobile apps that enable such conveniences for patients, and make the experience of interaction with doctors and providers more pleasant and convenient.

Monetization of such conveniences has traditionally been done by collection and sale of data, which in healthcare is valuable (for pharmaceutical companies) but protected by privacy laws (as it should be).

However, when service providers such as a doctor’s office allows you the convenience to complete the medical form on your mobile while you’re waiting in the lobby, driving to the doctor’s office in your cab, collects feedback via a quick alert to your phone on your way out, or allows scheduling to happen via a chat message versus waiting on the phone listening to Muzak for many minutes, there is significant arbitrage of time and money for convenience and pleasantness of experience.

Mobile apps will enable such experiences and enrich the patient, physician, and service providers with time and workflow optimizations. Mobile apps offering several small conveniences in the logistics of healthcare delivery and consumption, will be an enabling trend in the coming years.

– Gitika Srivastava

Online Expert Opinion: Navya.Care

Tata Trusts: tatatrusts.org LinkedIn Facebook  Twitter

Tata Memorial Center: tmc.gov.in  Facebook

Navya: navyanetwork.com  LinkedIn  Facebook  Twitter

Major Digital Health/Healthtech/Health 2.0 Trends for 2017 (Part 2)

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First, I will define digital health/healthtech/health 2.0 as products and services that rely on using the Internet and digital data (versus paper or physical contact/in-person consultations), to better the overall physical or mental health of an individual. This does not include medical devices or pharmaceutical.

The major trends for 2017 include using information technology and Internet, of which mobile is a significant component, to do the tasks that patients and physicians or other service providers would ordinarily do, but at a faster, cheaper, and larger scale i.e. to reach a global network without incurring added costs of time and money. Unlike in other industries, healthcare does not allow immediate and ground-breaking leaps in the use of information technology to do new and powerful things that were otherwise not already possible, for example, offering a treatment or diagnosing using the Internet.

A few years ago, as an early stage startup investor in Boston, I came across technologies that proposed to use video games to treat Attention Deficit Disorder, or rely on patterns in mobile phone usage to diagnose and manage depression, or leverage the iPhone camera to send images to ophthalmologists to diagnose eye infections in rural India, or attach monitors to cell phones as an electrocardiogram device.

These innovations tread on diagnosing and treating, and must be tempered by regulation and clinical trial validations before adopted use. This is beyond what digital health/healthtech/health 2.0 can reasonably promise to deliver, as the intricacies of the healthcare and legal landscape intervene.

The success of such innovations, measured by adoption and use in the clinical world, is yet to be seen.

To better the overall physical or mental health of an individual.

However, leveraging technology to improve performance of products and services that already exist, and that improve healthcare delivery as it exists today, is a fair game for digital health/healthtech/health 2.0. This can be boiled down to some key trends.

Trend #2 – Leveling information disparity

Access to medical information including evidence (i.e. published clinical trial data) and outcomes of patients at expert centers, unlocks the ability for any physician to make expert grade treatment decisions for their patients.

The Internet and mobile apps allow for such information to be easily disbursed to physicians, and machine learning on data allows for intelligence to be computed and disseminated to everyone, and not just the specialists at referral centers. This allows physicians in small and remote centers and in the developing world, to have access to the same high quality information that experts at academic centers have usually been equipped to access and use.

Such leveling of information disparity can be seen in every facet of the clinical landscape, where intelligent targeted search engines can make information consumable and ubiquitous around the world. Insurance companies can rely on high quality evidence and experience data to make good decisions about treatments.

Machine learning, clinical informatics, and predictive analytics of medical and patient data will dominate the way clinical decisions are made and executed henceforth.

The next post will conclude my discussion of these trends.

– Gitika Srivastava

Online Expert Opinion: Navya.Care

Tata Trusts: tatatrusts.org LinkedIn Facebook  Twitter

Tata Memorial Center: tmc.gov.in  Facebook

Navya: navyanetwork.com  LinkedIn  Facebook  Twitter

Data Driven Doc: Denial & Detachment

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In Berkeley, Calif., Hope Friedman, a 62-year-old retired nurse, said she was also stunned by the result…As she described her reaction to Mr. Trump’s victory, she wept.

“It kind of felt like being punched in the stomach,” she said. “It feels like when you get a cancer diagnosis and you are sick to your stomach and you can’t believe it and your mind is spinning” (NYT November 11, 2016)

Denial is a powerful emotion. Recently, Navya processed the case of a 28 year old with cancer matting his lymph nodes even after surgery. Navya had to write, heartbreakingly, in response to every one of his questions. “Do I still have cancer?” (Yes, you do.) “Will I survive?” (Let us recognize the inability to predict the future of an individual and just try and focus on onward treatment, knowing that data shows most patients in your situation do not outlive their disease for 5 years.) “Is the CT scan truly confirmatory of recurrence” (Yes, unfortunately, it is.)

 Hope is the ultimate enemy of cancers

Imaging, evidence and experience review had certainly helped this young man. We had identified immunotherapy and radiotherapy as an option for him. But it didn’t feel like a victory. For a 28 year old, it was cold comfort. An extension of life through the misery of treatment. Something about life itself was unfair and wrong.

Trump’s victory feels the same to many in the country. A diagnosis sunders reality apart, and fear sets in. While things may turn out all right, the chances that they would are much lower than ever before the diagnosis of President Trump. Now all one can do is be watchful, and be ready to do battle at every sign of encroachment and assault.

I’m thankful for denial. When reality makes me sick to the stomach, denial and detachment allow me to function. It allows me to plan, to research and to execute. It maintains hope. And hope is the ultimate enemy of cancers – of the physical body and of the body politic.

-Dr. Naresh Ramarajan

Online Expert Opinion: navyanetwork.com/tmh
Tata Trusts: tatatrusts.org
Tata Memorial Center: tmc.gov.in
Navya: navyanetwork.com

Data Driven Doc: A Clear Way Forward

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Navya’s new technology platform to review images is helping us clinch staging and diagnosis accurately to guide treatment opinions for patients with even more precision than before.

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Just a couple of weeks ago, we had the heart crushing situation of a 20-year-old woman who had undergone surgery for an aggressive advanced cancer in the abdomen. After surgery, her PET-CT was still lighting up with growths along some of her blood vessels. The patient wasn’t sure if this meant that she had residual cancer, especially since a biopsy of the nodules was nondiagnostic.

Navya was able to immediately provide an evidence based, expert opinion.

Prior to our imaging review platform, we would have requested the patient to come in person to reconcile the images with the biopsy. Now, with Navya’s review of the clinical details, and our online surgical expert’s review of the images confirmed the sad news that indeed, the patient’s surgery had not been curative. However, Navya was able to immediately provide an evidence based, expert opinion recommending specific additional chemotherapy, surgery, and radiation to affect a cure.

We were also approached by a patient in Chennai with back pain and difficulty walking, with an undiagnosed growth in his spinal cord. Our expert radiologists and neurosurgeons in Mumbai were able to confirm that a patient’s spinal cord tumor appeared benign. Navya’s evidence and experience review pointed clearly towards an immediate surgical resection of the lesion, and our experts agreed. The patient had a clear way forward with a reassurance that the images had been scoured by expert neuroradiologists and neurosurgeons, and incorporated into Navya’s evidence based expert opinion.

-Dr. Naresh Ramarajan

Online Expert Opinion: navyanetwork.com/tmh
Tata Trusts: tatatrusts.org
Tata Memorial Center: tmc.gov.in
Navya: navyanetwork.com