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

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

Major Digital Health/Healthtech/Health 2.0 Trends for 2017 (Part 1)

photo-effect-359981_1280

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.

Healthcare does not allow immediate and ground-breaking leaps in the use of information technology.

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.

Let’s look at the first one:

Trend #1 – Increasing access to expertise

There are only a few hundred or few thousand experts in any given clinical indication/disease. These experts are limited to a few expert centers usually in large cities in the developed world. Using digital transcription of clinical information and medical reports, and the Internet via email and mobile application, these experts can provide their opinions to patients around the world.

My company, Navya, provides one such avenue for cancer patients to receive online expert opinions on the next best step in the management of their care. So far patients from 42 countries, including 20 developing countries in Asia and Africa, have availed the service.

Technology systems and online service enable the bridging of access to world leading experts who today provide opinions locally but can now also provide opinions to patients in Fiji, Mozambique, Russia, China, and in any corner of the world.

I will discuss another trend in the next post.

– 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

Tata Memorial Centre and Navya Create Experience Engine (XE) that “Thinks” like Expert Oncologists

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Press Release

Tata Memorial Centre and Navya Create Experience Engine (XE) that “Thinks” like Expert Oncologists  

System Mines Knowledge of World Leading Experts for Cancer Treatment; Promising Results Presented at San Antonio Breast Cancer Symposium (SABCS) – December 6-10, 2016 – San Antonio, TX  

CAMBRIDGE, Mass., MUMBAI, India and SAN ANTONIO, Texas Dec. 7, 2016 – Tata Memorial Centre (TMC), seeing over 50,000 new cancer patients a year, and Navya, a clinical informatics and patient services organization focused on complex decision making, announced Experience Engine (XE), a machine learning solution to structure experiential knowledge relevant for treatment decision making. The learning solution derives a similarity metric for patients who have received similar treatments and predicts treatment decisions that experts are likely to recommend. XE goes beyond evidence, solving patient cases that clinical trial data does not.

Promising results from the first trial of organized learning from past tumor board decisions at TMC and UCLA-OVMC to predict treatment decisions that oncologists would make for a new set of patients are being presented at SABCS 2016. The abstract titled, “Building an Experience Engine to Make Cancer Treatment Decisions Using Machine Learning,” is being presented on Wednesday, December 7, 2016.

Dr. Rajendra A. Badwe, Director, TMC said, “The Experience Engine captures the way experts think and outputs treatment options for each patient in line with what they would recommend. This is how we can scale access to expertise. The resulting database of opinions is also an excellent companion for online training.”

Being a tertiary care referral center, TMC’s experts treat highly complex, nuanced and rare cases from across the Indian subcontinent, Asia and Africa. Multidisciplinary tumor board decisions at TMC represent an unparalleled wealth of intelligence and experience, currently trapped in the minds of experts and electronic medical records.

Dr. Naresh Ramarajan, graduate of Harvard College and Stanford School of Medicine, and Founder and Chief Medical Officer at Navya said, “Tata Memorial Centre and Navya create a new source of knowledge. The Experience Engine has implications for training oncologists, standardizing cancer care across the world and driving accurate decisions for complex patients not addressed by the evidence.”

Navya’s Engines synthesize evidence specific to a patient and learn from relevant tumor board decisions to make treatment decisions. The Navya Evidence Engine (EE) was validated in three clinical trials at Tata Memorial Centre and UCLA-OVMC. Results showing 98 percent concordance between the EE decisions and TMC and UCLA-OVMC tumor board decisions were published at the SABCS in 2014 and American Society of Clinical Oncology (ASCO) in 2016.

Tumor boards at tertiary centers like TMC and UCLA-OVMC provide solutions to complex cases not addressed by high quality evidence. Experts intuitively retrieve patterns from years of experience to make treatment decisions. Short of personal consultations, there is no way to access this vast “experience database.”

Richness of Navya’s ontology represents each patient with 690 individual features. XE uses relevance learning to identify the core set of highly informative features for decision making.

Multiple similarity distance metrics were systematically evaluated for each decision point. When a new patient was presented to XE, the learned similarity metric was used to identify similar patients. XE then predicts a decision based on the treatment received by these similar patients.

XE’s predicted decision was compared with the expert’s actual decision. The primary endpoint of comparison was accuracy (defined as AUC – Area Under Curve). In addition, state of the art multiclass classification algorithms were also evaluated. Winning XE algorithms were chosen specific to each decision point. The algorithms were used on a completely new prospective group of patients who were seeking an online opinion from tumor board experts of Tata Memorial Centre.

Accuracy of prediction for each decision point was significantly (~40 percent) more accurate than baseline of weighted random guessing. When XE predicted whether a patient needed standard evidence based therapy or a non-standard experience based therapy, it was highly accurate (70 percent to 99 percent based on the decision point).

The XE is a truly novel source of knowledge, containing learning from patients with significant comorbidities, multiple lines of prior treatments and poor performance status for whom standard evidence-based treatments from randomized control trials are not applicable. The analysis of hundreds of similar patients to these complex patients uncovers new insights into possible treatments.

Further, XE enables oncologists to evaluate why similar patients may receive different treatments. Variations in practice patterns, treatment centers, expert preferences, affordability of patients and patient preferences, are features that influence decision making. These are considered by XE, but not possible to consider by medical evidence guided by randomized clinical trials.

About Tata Memorial Centre
Tata Memorial Centre, founded in 1941, leads the Indian subcontinent in cancer care by evidence based practice of oncology, and research and services which are affordable, innovative, and relevant to the needs of the country.   Every year nearly 50,000 new patients visit TMC from all over India and developing countries in Asia, Africa. Approximately, 70 percent of these patients are treated almost free of charge.   Visit: https://tmc.gov.in.

About Navya
In 2009, Navya was founded in Cambridge, MA by graduates of Harvard, MIT Sloan, and Stanford.  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.  For the first time, quick and affordable access to evidence and experience based expert treatment decisions is available to every cancer patient. Navya’s Online Expert Opinion Service has been used by 8000 patients in 42 countries. Visit: www.navyanetwork.com.

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

Media Contact:
Tracy Wemett
+1-617-868-5031
tracy@broadpr.com

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The Doctor’s Thoughts: A Medical Perspective

medical-563427_1280Evidence and Experience Overcomes Corruption

Narendra Modi, prime minister of India, announced a surgical strike against corruption in India today (November 8th 2016).  In one fell swoop, he declared all 500 (~8$) and 1000 Rs (~15$) cash notes illegal tender today. While this causes some hardship for people with small amounts of cash in hand, the implications for the formerly black money & cash rich in India are stunning. The mountains of undeclared untaxed cash are reduced to paper overnight.

The panic of the black money rich and the joy of the common man in India tonight reinforces Navya’s core values. Stay unbiased, stay independent, stay clear of cutbacks, commissions and conflicts of interest. Steer away from the murky transactions in the business of medicine.

The practice of medicine worldwide and in India both, has been mired in conflicts of interest. Pharma companies develop drugs that make you bleed uncontrollably – and aggressively market them to cancer patients until it replaces older and safer drugs. The same companies then sell antidotes to the same drug for those cursed with a major bleeding episode, profiting on both ends of the spectrum!

In India, I have had the personal shock of calling an MRI center to get a study priced – only to be rudely told that the price of the study depends on the doctor who ordered it. The charged price adds in the cutback to the ordering physician. Conflict of interest in America is more subtle but even more prevalent in dollar figures. Incentives to undertreat or overtreat patients are cooked legally into the medical system we practice in. Professional society guidelines, endorsed widely, reflect the financial incentives of medical groups rather than evidence based facts like true gains in efficacy of a treatment.

Navya, since its inception, has been evidence and experience based. We build measures of conflict of interest in our models. We do not engage in partnerships with diagnostic centers to reach their patients in exchange for referral fees.  Similarly, we do not recommend hospitals or clinical services to our patients.  We spread our word organically, from person to person, patient to patient, and physician to physician, in partnership with government mandated organizations like National Cancer Grid, and we work with true experts at Tata Memorial Centre who volunteer selfless opinions to patients. The choice of a medical treatment should be based on clinical efficacy, cost effectiveness, affordability, logistics of travel to a treatment center and patients’ tolerance of side effects – nothing else.

Our commitment to offer an unbiased, evidence and experience based expert opinion is a bedrock principle at Navya that Gitika, the experts at Tata Memorial Center and I share. To this end, the eradication of large cash transactions in India, properly implemented, could be a boost to all of us marching towards a corruption free world.

-Dr. Naresh Ramarajan

Online Expert Opinion: navyanetwork.com/tmh

Tata Memorial Center: tmc.gov.in

Tata Trusts: tatatrusts.org

Navya: navyanetwork.com