Three Recommendations for President Obama’s Precision Medicine Initiative

Attribution:  Spencer Nam

One of the pleasantly surprising announcements President Obama made during his 2015 State of the Union address was “a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes.” 



Although the term ‘Personalized Medicine’ is also used to convey this meaning, that term is sometimes misinterpreted as implying that unique treatments can be designed for each individual.^[1]

Given precision medicine’s potential to solve many outstanding health care issues and lower costs without compromising clinical quality and performance, the President’s proposal is a welcome initiative. Many of the challenges we face practicing symptom-focused intuitive medicine could be overcome by turning toward precision medicine, a process of precisely diagnosing and targeting disease.

However, announcing the initiative is one thing. As with all policy discussions, the devil is in the details – and there are three details specifically that could make the difference between political rhetoric and a policy that truly improves the health of American citizens.

1.  Focus on the entire process of the disease – starting with prevention. Because most chronic diseases show few symptoms until the disease has significantly progressed, treatments for cancer and diabetes patients are primarily at the disease management phase. However, we are acutely aware that the best way to “cure” cancer or diabetes is prevention, and prevention requires better early diagnosis. Unfortunately, we still lack convenient and accurate ways to diagnose for various cancers and diabetes. Given the high costs of treating advanced-stage chronic diseases, precision diagnosis of risk factors or disease progression will materially lower the costs of health care.

For example, currently the only place we can check hemoglobin A1c (HbA1c), or blood glucose levels, is at physicians’ offices. With nearly 30 million Americans with type-2 diabetes and another 30 million pre-diabetic, it is time to develop a more convenient and affordable way to check for HbA1c so more regular testing can be done, particularly for those with risk factors. Cancer diagnostics is also confusing and difficult, with imaging modalities (CT, PET, MRI, X-ray) as the only reliable diagnostics methods. We need to develop more reliable and accepted diagnostics to identify and monitor cancers in their early stages.

2.    Strategically target diseases. Particularly in cancer and type-2 diabetes, two of the fastest growing disease segments in the United States, there is a significant opportunity for precision medicine to improve early diagnosis and treatment, and lower the costs of care. Remember, we tackled HIV and AIDS issues over the past thirty years with a precise target (HIV) and with research focused on quickly translating basic science to clinically effective and safe drugs. Because cancer and diabetes are systemic diseases, affecting multiple aspects of a human body, focusing on translational science based on specific types of cancer or specific aspects of diabetes may in fact accelerate not only the understanding of the diseases but also improve the treatment methods at each stage.

While our understanding of cancer and diabetes has substantially grown over recent decades, we’ve also found the core issues of these diseases to be much more complex and involved than previously understood. As PresidentKennedy set a national goal of “landing a man on the moon and returning him safely to the earth,” by setting their sights on one or two of the nation’s most critical diseases, President Obama and his team of experts could provide a strategic framework for marshalling resources to make real progress toward their cure.

3.      Set standard definitions and metrics. One of the major challenges in migrating toward precision medicine is lack of a common clinical language and metrics that help us to refine our interpretations and focus our messages to physicians and patients. Because cancer and diabetes are still treated in the realm of intuitive medicine, different physicians can provide different opinions on these diseases. Although we need to appreciate individuals’ genetic and biological uniqueness in discussing chronic diseases, precision medicine cannot establish deep roots without more commonly accepted definitions and associated metrics.  

Gaining more precise understanding of cancer and diabetes and developing precise diagnostics and treatments to be administered at the right time will reduce inefficiency and waste –delivering substantial dividends. However, let’s not forget that a detailed education plan as well as appropriate reimbursement schedule will be integral for the initiative to truly go beyond the drawing board. By providing strategic focus and direction to lead the Precision Medicine Initiative forward,President Obama has an opportunity make a real impact.

Often, though not necessarily, PM involves the application of panomic analysis and systems biology to analyze the cause of an individual patient's disease at the molecular level and then to utilize targeted treatments (possibly in combination) to address that individual patient's disease process. The patient's response is then tracked as closely as possible, often using surrogate measures such as tumor load (v. true outcomes, such as 5 year survival rate), and the treatment finely adapted to the patient's response.^[2] The branch of precision medicine that addresses cancer is referred to as "precision oncology".^[3]

Inter-personal difference of molecular pathology is diverse, so as inter-personal difference in the exposome, which influence disease processes through the interactome within the tissue microenvironment, differentially from person to person. As the theoretical basis of precision medicine, the "unique disease principle"^[4] emerged to embrace the ubiquitous phenomenon ofheterogeneity of disease etiology and pathogenesis. The unique disease principle was first described in neoplastic diseases as the unique tumor principle.^[5] As the exposome is a common concept of epidemiology, precision medicine is intertwined with molecular pathological epidemiology (MPE). MPE research is capable of identifying potential biomarkers for precision medicine.^[6]

Precision Medicine is and will be in a state of evolution as markers are defined and testing becomes cost-effective. Moving Precision Medicine into the clinic, from research will usher in a new age of medicine.

Spencer Nam is a senior research fellow at the Clayton Christensen Institute for Disruptive Innovation, where his work focuses on disruptive innovations in the health care industry.

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Chart: New measles cases skyrocketed in January

by Christopher Ingraham as reported in the Washington Post

(editor-Gary M. Levin M.D.)

How important is vaccination ? The viruses for measles, smallpox, polio and others are still out there, waiting patiently for the uninformed to drop their guard.

The recent outbreak of measles underscores this truth:

Data released Monday from the Centers for Disease Control shows 102 confirmed new measles cases in the month of January this year. That's far and away a monthly record for the years since 2000, when the disease was officially declared eradicated. The majority of cases stem from an outbreak at Disneyland in California.

To put it another way, we've had about twice as many new measles cases in the past 31 days as we did in all of 2012.

Last year was a record year for measles, with 644 new cases confirmed in 2014 -- the highest in decades. If the California outbreak continues to spread, this year's totals could end up much higher.

From a public health standpoint, policymakers are in something of a bind. The impulse is to urge parents to vaccinate their children, as President Obama recently did. But when politicians get involved, the danger is that a public health issue becomes a political one. On Monday morning, New Jersey Gov. Chris Christie tried to set himself apart from Obama's position by calling for "balance" on the vaccine debate, only to hastily walk back his statements hours later.

It's nigh impossible to change hearts and minds on vaccines; a recent study found that presenting vaccine skeptics with facts only reinforced their views. Over at The Upshot, political scientist Brendan Nyhan warns that "news articles focusing on an extreme and unrepresentative group of anti-vaccine parents and celebrities may cause others to wrongly infer that their views are mainstream." In reality, their numbers are small -- in California, for instance, only about 2.5 percent of kindergartners hold "personal belief exemptions" that allow them to opt out of state vaccine requirements.

Large outbreaks and big infection numbers, like what we're seeing in California, may scare some skeptical parents into holding their nose and getting their kids the required shots. Reporting out of California from my colleague Todd Frankel suggests this may already be happening.

Christopher Ingraham writes about politics, drug policy and all things data. He previously worked at the Brookings Institution and the Pew Research Center.

What to Ask Your Surgeon Before an Operation

Surgery is often a major, life-changing event.

If you ask your surgeon, "do you guarrantee a good result?"  and he says yes, turn and run away as fast as you can. No competent surgeon will ever do that, but they will give you a list of possible complications and the risk of each one.

Patients can be overwhelmed by the experience and sometimes do not ask their surgeons the best questions to understand the operation and to make sure they have good outcomes.

DOYOU NEED SURGERY?

Before having an operation, you must understand what disease you have and if there are ways of treating the disease without an operation. You should find out if the problem you have is common and if there is anything unusual about your condition.

ARE THE SURGEON AND HOSPITAL WHERE THE SURGERY WILL BE PERFORMED RIGHT FOR YOU?

Ask your surgeon about his or her training for doing your operation. Where did they learn how to do the operation and how extensive was their training? Physicians must have a license to practice medicine in the state where they practice. They do not have to be board certified or belong to professional organizations, but it is generally better if they have these credentials. Ask if the surgeon is board certified and, if not, why not. Ask if the surgeon takes care of patients with your problem very often. How many times have they performed the operation they propose to perform on you as the surgeon in charge (attending surgeon)? Who are the other doctors the surgeon will work with to provide your care? Depending on your condition, it is often better to have a team of health care professionals involved with your care rather than a single doctor.

If a special type of operation or technology (such as laser or robotic surgery) will be used, ask about why it is better than conventional approaches to your problem. Ask the surgeon how much training and experience he or she has had with the usual approaches for your problem and with the newer techniques being proposed. Surgeons learning newer techniques may have learned them during a very brief course—ask about this.

Ask if the hospital has a special area and staff trained to take care of your specific medical problem. How many patients do they take care of with a problem like yours? You should discuss the various options for anesthesia care with your anesthesiologist prior to surgery.

WHAT CAN YOU DO BEFORE SURGERY TO ENSURE THAT YOU GET THE BEST POSSIBLE RESULT?

Ask your surgeon about things you can do before surgery to improve the likelihood of having a good result. Should you exercise? Stop smoking? Go on a diet? Achieve better control of your diabetes? Should you stop taking any of your regular medications? Your surgeon may want you to bathe yourself the day before surgery with special cleansers to minimize the risk of infection. He or she may also ask you cleanse your bowels before surgery.

WHAT WILL HAPPEN TO YOU AFTER THE SURGERY?

Ask your surgeon about how much pain you should expect and how it can best be managed. Surgery is often associated with short-term limitations in activity and/or diet restrictions. The amount varies with the type of operation and level of activity you have. Ask how long you will be unable to work and make sure the surgeon knows what type of work you do. Will you need help after the surgery? Who can provide the help? Are there resources for you to get help if needed after the surgery?

If you have a problem after leaving the hospital, who should you call or where should you go for help? Will the surgeons themselves be available at all times of the day, night, or weekend to provide care if needed? If not, who will provide emergency care and how experienced are they at taking care of patients like you?

Are there printed or online materials available so that you can learn more about your disease and surgical treatment?

For More Information

• American College of Surgeons
  www.facs.org/education/patient-education

To find this and previous JAMA Patient Pages, go to the Patient Page link on JAMA’s website atjama.com. Many are available in English and Spanish. A Patient Page on health care professionals and qualifications was published in the December 5, 2012, issue.

ARTICLE INFORMATION

The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, call 312/464-0776.

Source: Unpublished survey of selected academic surgeons attending the 2015 Academic Surgical Congress

Where People go to look for Medical Information on the WWW

Everyone is doing it. Patients do it, physicians do it, and family members do it.



For the current generation (Millenials, Gen-X) the use of the internet and familiarity with search is a sine-qua-non. They have used it in school, most likely beginning in elementary school. It has become an educational staple, much like learning your ABC and/or multiplication tables.

One of the key ingredients is to  know where to search for what. A simple Google search will result in thousands of results, which is not much help in the long run. Google's search engine optimization is not built for research. It is a marketing tool based on several algorithms to  analyze who watches what, and if they return.

The PEW Internet Project evaluated internet usage in depth, by illnesss, chronic disability, age, other demographics

Health Fact Sheet

Highlights of the Pew Internet Project’s research related to health and health care.

A key ingredient is the ease of access to this information:

90% of U.S. adults own a cell phone; 58% of U.S. adults own a smartphone (January 2014 survey). For more, see: Mobile Technology Fact Sheet

87% of U.S. adults use the internet (January 2014 survey). For more, see: Internet User Demographics

Online health information:

72% of internet users say they looked online for health information within the past year.

• This is based on a September 2012 survey, the first time we asked people to think only about their online health activities in the past 12 months. For historical perspective, see: Health Topics and Who Doesn’t Gather Health Information Online?

77% of online health seekers say they began their last session at a search engine such as Google, Bing, or Yahoo. Another 13% say they began at a site that specializes in health information, like WebMD. Just 2% say they started their research at a more general site like Wikipedia and an additional 1% say they started at a social network site like Facebook.

The most commonly-researched topics are specific diseases or conditions; treatments or procedures; and doctors or other health professionals.

Half of online health information research is on behalf of someone else – information access by proxy.

26% of online health seekers say they have been asked to pay for access to something they wanted to see online (just 2% say they did so).

Clinicians remain a central resource:

When asked to think about the last time they had a serious health issue and to whom they turned for help, either online or offline:

• 70% of U.S. adults got information, care, or support from a doctor or other health care professional.
• 60% of adults got information or support from friends and family.
• 24% of adults got information or support from others who have the same health condition.

People turn to different sources for different kinds of information:

When people have technical questions related to a health issue, professionals hold sway. When a situation involves more personal issues of how to cope with a health issue or get quick relief, then non-professionals are preferred:

Technology Revolution

Three major technology revolutions have occurred during the period the Pew Research Center has been studying digital technology – and yet more are on the horizon.

Broadband

First, the rise of the internet changed the way that people got information and shared it with each other, affecting everything from users’ basic social relationships to the way that they work, learn, and take care of themselves. The speed of internet connectivity picked up considerably with the rise of broadband connections. As people adopted those higher-speed, always-on connections, they became different internet users: They spent more time online, performed more activities, watched more video, and themselves become content creators.

Second, mobile connectivity through cell phones, 

and, smartphones and tablet computers, made any time-anywhere access to information a reality for the vast majority of Americans. Mobile devices have changed the way people think about how and when they can communicate and gather information by making just-in-time and real-time encounters possible. They have also affected the way people allocate their time and attention.

                                                               Social

Third, the rise of social media and social networking has affected the way that people think about their friends, acquaintances, and even strangers. People have always have social networks of family and friends that helped them. The new reality is that as people create social networks in technology spaces, those networks are often bigger and more diverse than in the past. Social media allow people to plug into those networks more readily and more broadly – making them persistent and pervasive in ways that were unimaginable in the past. One of the major impacts was that the traditional boundaries between private and public, between home and work, between being a consumer of information and producer of it were blurred.

Health Care Social Media is a in social media. The use of hashtags allows anyone to search on twitter for specific diseases, treatments, and more including twitter postings from scientific meetings, ie #AMA2015, or #AAFP2015. This allows any twitter user to receive tweets from the specific meeting, filtered out from the twitter stream.

This last category  has potential to be the most important. Facebook pages, Google plus pages offer a visible and easily accessed methodology to 'llke" "follow" or + topics of interest. Many of these sites come directly from a hospital and/or clinic. 

Static web pages are fixed in content. A web page coupled with an active daily or weekly social media posting using hashtags as a search modality gives both user and patient an active inter-action.

These formidable changes have not been limited to healthcare. Health professionals were lagging in interest possibly due to the issues of privacy and confidentiality.  HIPAA clearly defines the limits of information in regard to personal identification placed in a public space, accessible to anyone. 

Access to these high speed resoures remains limited however in many rural and some suburban areas due to the unavailability of modern broadband resources. The development of high speed 4G, and LTE cellular networks is also lacking in some areas. Profitability and a business model for those regions remains a paramount barrier.

Who is not using modern technology to access health information?