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

Tata Memorial Centre (TMC) National Cancer Grid (NCG) Online – Navya Expert Opinion Service improves access to specialized expertise in pediatric oncology to patients nationwide

Since 2015, the service has recommended evidence and experience based treatment protocols for children that can give them the best possible outcomes.

MUMBAI, India – Feb. 15, 2017: In keeping with their efforts of democratising access to their significant expertise for patients across the country, Tata Memorial Centre (TMC) reviewed the impact of their online service in helping pediatric patients on the occasion of International Childhood Cancer day. TMC NCG Online – Navya Expert Opinion Service (available at www.navya.care) provides critical treatment opinions to parents and caregivers of children with cancer. The expert opinion helps them validate or discuss an evidence based change in treatment plan with their treating oncologists. For pediatric patients, choosing the right therapy vetted by an expert, can be the difference between cure and failed treatment.

“If a child is diagnosed early and treated appropriately, 80% of cases should lead to cure. However we are seeing many cases where parents are bringing children to us as a last resort after expensive and failed treatments” said Dr Shripad Banavali, Head of Department, Medical Oncology at Tata Memorial Hospital, Mumbai. “If they had reached out to us online through TMC NCG Navya and followed our opinion, the situation could have been better. We are also finding cases where aggressive chemotherapies are being prescribed that are not suitable for children. This is partially because of the absence of pediatric oncology expertise.”

Pediatric patients are treated differently with doses and regimens than adults, and there are only a limited number of cancer experts who specialize in pediatrics.  TMC NCG Online makes it possible for patients to get the advice of specialized pediatric experts at TMC while often continuing the treatment locally. In cases where expertise or treatments that are not available locally are required, patients are advised to visit accessible expert care centres, such as those in the National Cancer Grid (NCG).

“We have been able to provide appropriate treatment recommendation to many patients in small towns where access to specialized oncology centers is sparse” continued Dr Banavali.“ A lot of these families would either have to travel significant distances or worse still proceed with suboptimal treatments leading to a reduced probability of cure.”

Pediatric oncology is a specialized expertise and often unavailable everywhere. This leads to parents approaching oncologists and physicians who lack the experience and expertise needed in treating children. In many such cases, treatment plans are followed that are not beneficial and in some cases harmful to the patient.

TMC NCG Online has also received cases where parents are reaching out to validate the need for expensive therapies. In one such case of a three month old baby boy, a reputed private hospital had recommended an expensive robotic surgery. The experts at TMC clarified that conventional surgery would be sufficient and would avoid wait time and expense of robotic surgery.

Says Dr Tushar Vora, a nationally acclaimed pediatric solid tumor expert at TMC: “Pediatric malignancies have a very high cure rate but the best chance of cure is the first chance. Many a times, given the emotional state of diagnosis, families are financially exploited and given inappropriate treatment in the name of emergency, which significantly affects the ultimate cure rates. In such circumstances TMC NCG Online – Navya Expert Opinion Service can give the families the means to evidence based recommendations quickly and prevent the above.”

Continues Dr Vora; “also in circumstances when heroic efforts, again with financial and emotional appeal, are counterintuitive, the expert opinions can give realistic hopes and expectations and means for the best possible course.”

On the positive side, TMC NCG Navya has been able to empower families with expert opinions that have enabled them to change treatment plans leading to improved outcomes. A child from Delhi was being treated for Turberculosis without improvement. TMC experts suspected cancer and recommended a surgical biopsy which proved Lymphoma.  The child is currently under life saving treatment for the same.

Urging parents of pediatric 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 in the Indian subcontinent or developing countries in Asia and Africa 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. As parents, you can be assured that the opinion rests on the experience of world renowned pediatric cancer experts and follows evidence based protocols best suited to your child’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/NavyaNetwork

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

LinkedIn: https://www.linkedin.com/company/navya-network

Data Driven Doc: As Easy As ‘Tak, tak, tak’

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Early on in creating Navya- Gitika and I met with the CEO of a private hospital in Mumbai exploring interest in Navya’s expert opinion services. He dismissed us offhand- saying he could email his friends ‘tak, tak, tak’ (Indian/Desi colloquialism for ‘instantly’) and get a response from them on any questions he had. Funnily enough – he was a radiologist who didn’t see the power of asynchronous and instantaneous collaboration on medical information. Today teleradiology is one of the largest medical services online.

A few years later, I’m impressed with how many ‘tak, tak, tak’ connections Navya has created for our patients across the world. We had 20 requests for consultations today, and we were able to get instantaneous reviews of many of the cases by international experts.  Where one expert’s response wasn’t confident enough, we got two or three to confirm! Back to the patient in a day!

A well-connected CEO of a hospital may get his medical questions answered by specialists in a jiffy, but the true value of Navya on democratizing expert information across the world, instantaneously, is beautiful. It’s truly as easy as ‘tak, tak, tak’.

-Dr. Naresh Ramarajan

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

TMC Platinum Jubilee – Jan. 28, 2017

TMC Platinum Jubilee – Jan. 28, 2017

Dr. Pramesh – head of the national cancer grid, a consortium of 96 cancer centers around the country, said “Navya is our own solution for Watson”.

Navya is our own solution for Watson.

Navya’s evidence and experience based expert opinion system was presented at the 75th year Platinum Jubilee celebrations of Tata Memorial Centre.  TMC convenes the National Cancer Grid, a consortium of 96 cancer centred in India.  Navya was developed with experts at TMC and is now used by experts at NCG to provide online expert opinions to patients with cancer. Go to www.Navya.care  to be empowered with the best treatment decisions in cancer.