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Tag: Oncology

A Health Tech’s Secret Weapon: The People Under The Hood

The recently-announced acquisition of the oncology data company Flatiron Health by Roche for $2.1B represents a robust validation of the much-discussed but infrequently-realized hypothesis that technology entrepreneurs who can turn health data into actionable insights can capture significant value for this accomplishment.

Four questions underlying this deal (a transaction first reported, as usual, by Chrissy Farr) are: (1) What is the Flatiron business model? (2) What makes Flatiron different from other health data companies? (3) Why did Roche pay so much for this asset? (4) What are the lessons other health tech companies might learn?

The Flatiron Business Model

To a first approximation, Flatiron has a model that can be seen as similar to tech platforms like Google and Facebook – delight (or at least offer a useful service to) front-end users, and then sell the data generated to other businesses. For Flatiron, the front-end users are oncologists (mostly community, some academic), and the data customers are pharma companies. In contrast to Google (and also in contrast to the less successful Practice Fusion, recently acquired at a loss), Flatiron doesn’t sell access to front-end users themselves (e.g. through targeted ads), but rather access to de-identified, aggregated clinical information.

Success of this model requires that the Flatiron platform is attractive to oncology practices, who must feel that they’re getting distinct value from it and believe that it helps them fulfill their primary mission of taking care of cancer patients. If this is true, then the Flatiron platform will enjoy continued traction from its current base, and may more easily win over new users (including practices that use a different EMR system, like Epic, but still want access to the Flatiron network and analytics).

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It’s Time to Truly Share the Chemo Decision With Cancer Patients

You (or a loved one) has cancer, but the latest round of chemotherapy has unfortunately had only a modest impact. While you’re acutely aware of the “wretchedness of life that becomes worn to the nub by [ chemotherapy’s] adverse effects” you’re also a fighter.

How do you decide whether to continue with chemo?

The answer to that question is both intimately personal and inextricably tied to health policy. Cancer is the leading cause of death among those aged 60 to 79, and it is the second leading cause of death for all Americans. With expenditures on cancer care expected to top $158 billion (in 2010 dollars) by 2020, the financial and emotional stakes are both high.

How do you decide whether to continue with chemo?

The answer to that question is both intimately personal and inextricably tied to health policy. Cancer is the leading cause of death among those aged 60 to 79, and it is the second leading cause of death for all Americans. With expenditures on cancer care expected to top $158 billion (in 2010 dollars) by 2020, the financial and emotional stakes are both high.

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New “kid” on specialty ACO block –Chuck Saunders, Integra Connect

One of the more surprising announcements at HIMSS17 (or anywhere so far this year) was that a company led by some well known health tech veterans has both invested a ton of money and been off the ground for some time, while being very quiet about it. Integra Connect is the company and it’s a tech and services company providing ACO/APM/MACRA/ MIPS-type services for high cost specialty care (think cancer). CEO Chuck Saunders was at Aetna’s Healthagen group (and before that Broadlane/WebMD/EDS and some others I forget) and the Chairman (and source of most funding) is Raj Mantena who built several companies in the specialty pharmacy space (inc ION and Oncoscripts). Integra Connect already over 1,000 employees and several large physician groups as customers and I spoke with Chuck about the (high cost and pretty large) niche they’re in and how they’re working.

An Ad Page In the NEJM and the Future of Cancer Care

I am not sure how many docs still do this, but I still read the actual hard copy of my New England Journal of Medicine, and that means I flip past ad pages with smiling grandfathers playing with grandchildren thanks to supercalifragilistic products on my way to scholarly papers with tables and figures. But this time, I stopped in puzzlement when I came across an ad from Intermountain.

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Intermountain is a health system based in Utah, highly respected for its sound approach to quality and cost control[1], but not broadly well known for cancer care in the way of centers like Dana Farber or Sloan Kettering. Digging further by going to the website uncovers the actual offering which is a streamlined 5 step process:

  1. Send tumor sample
  2. Deep sequencing of 96 key cancer genes
  3. Genomic data analysis
  4. Tumor board makes a treatment recommendation
  5. Facilitated procurement of the relevant cancer drugs

Turn-around time is about two weeks, fast enough to wait for the information before starting a regimen.

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The Right to Die: The Suicide Checklist

flying cadeuciiPhysician–Assisted–Suicide; the collaboration of two through a professional relationship, to cause the death of one.

Ever since Socrates took hemlock, suicide has been part of society, sometimes supported, often condemned.  Today, many argue that we have a right-to-die, sort of an infinite extension of free speech or thought.   Regardless, to actively involve doctors is a unique distortion of the medical arts, as if stopping a beating heart can somehow mend disease.  For a healer to take life is bizarre and threatens the physician-patient relationship.  If individuals really want and require assistance to die perhaps there is another solution.

A long trail of vital documents marks our lives. These include birth certificate, diplomas, driver’s and marriage license, advanced directives, wills and most recently the POLST. Perhaps we should create a new personal document.  Its purpose would be to give each person not only permission to kill themselves, but access to the means.  A permit controlled by the patient and only their responsibility.  A passport for dying.  A Suicide Certificate.

The Suicide Certificate would be a kind of application.  A legal checklist, which once complete would allow the individual to die by their own hand, but in a controlled and definite manner.

What would go on this form?  First, basic demographics; name, birth-date, address, social security number, etc.  It is important to confirm that the right person is filling out the form.  A photograph might be a good idea.

Next, statements regarding right-to-die laws.  This could include a review of the sanctioned methods available, as well as the legal indications and limits for committing suicide.  It might remind the applicant that a terminal disease is required, what is and is not a qualifying medical condition, and that suicide pacts are discouraged and therefore forbids sharing the lethal prescription. The whole form might start on-line and as part of the process an instructional video must be viewed and review answers given correctly, before it can be printed.  Alternatively, an app could be developed.

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What Twitter Tells Us about the War on Cancer

asco 2014 entranceThe American Society of Clinical Oncology recently made public nearly all of the abstracts — more than 5,000 pieces of research — that were selected for the ASCO annual meeting, which kicked off in Chicago on the last day of May.

Sifting through those 5,000 abstracts would be an almost inhuman task: each abstract contains 2,000 characters. That’s 10 million characters of information about oncology created by experts that’s now available for the public to parse.

But as remarkable as the ASCO abstract drop is, that research is not the only overwhelming trove of communication on cancer created by doctors. One ASCO abstract (based on research by me and W2O colleagues Greg Matthews and Kayla Rodriguez) tells story of how, over the course of 2013, U.S. doctors tweeted about cancer 82,383 times. At 140 characters a tweet, that’s nearly 12 million characters.

We know there were 82,383 tweets because we counted them. Using our MDigitalLife database, which matches Twitter handles with verified profiles from the government’s physician database, we scanned all tweets by doctors for mentions of dozens of keywords associated with cancer over the course of calendar year 2013.

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The Gift of Cancer

flying cadeuciiAfter my last post about “the gift of cancer” I must say that CLL has felt much less like a gift this month.

Joining the ranks of those with “a diagnosis” has given me a some insight into what our patients face all the time.

Recently, I received my second dose of humility.  I capped off a truly exhausting week in the hospital with a routine lab follow-up.

The last day of my 85-hour week I had my CBC checked, and my platelets dropped from the 100s to the 30s.

My first reaction was denial.  Lab error.

Unfortunately, they dropped further the next day and I realized that the little red bumps on my legs weren’t some skin reaction, but petechiae.  Bummer.  Turns out that in addition to the 2% of people diagnosed with CLL under age 40, I also joined the 20% who develop idiopathic thrombocytopenic purpura (ITP).

The treatment of choice for ITP is prednisone 1mg/kg.  So after a visit with my oncologist, I started 80mg of prednisone.

I realized with more than a little chagrin that I have a double standard about therapeutics. I was surprised at how much I despise being on prednisone.

I had never taken it before, and I would guess that I prescribe it every week, if not every day, that I work in the hospital. I have always felt that prednisone is fine for my patients to take.

Steroids work to help clear up that asthma flare, quickly improve that gout pain, or even help with a burst of energy in the last days or weeks of life for a terminal patient.

But for me? No thank you.

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Whose Cancer Is It, Anyway?

flying cadeuciiI recently read a blog by Dr. Danielle Ofri in the New York Times “Well” blog about how as a physician she learned to respect the patient’s wishes even when they contradict her professional inclinations. It’s called Doctor Priorities vs Patient Priorities.”

She writes that the patient is looking through a “wide-angle lens” that takes in the whole of his life while the doctor’s lens is “narrowly focused on the disease that pose[s] the gravest and most immediate risk”. She saw her challenge as entering into dialogue with her patient in order better to understand the wider perspective of his whole life and to work with him to find the most acceptable way to deal with his disease.

If only Dr. Ofri were an oncologist. If only she were my oncologist. My last appointment with my onco, Dr. G, was a disaster. Not only have I not been back to her, I have not gone to any oncologist since then. Part of that is because I don’t want any treatment at this time; that’s still true.

But if I am going to be very honest, and I try to be that always, it is also because of that disastrous appointment with Dr. G.

First of all, she would not respect my decision not to have any more chemo and refused to order any scans unless I would a priori agree to chemo if she decided it was indicated. She also mocked me. It took a long time for me to tell that second bit. In fact, from that day in August 2013 until just recently—seven months!—I only told one or two other people about what happened.

The evening of that last appointment, Dr. G called me at home to continue the argument. I found myself apologizing for causing her distress. Yes, I know that’s ridiculous, but that is how I react to being bullied. Borrowing the words of a friend who really gets it, I apologize to others for their hurtful behavior and then I internalize it. I haven’t talked about Dr. G mocking me because I feel ashamed.

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The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act

What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common?  They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.

Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity?  Look into our subconscious to explain everyday behavior?  Give basic healthcare to everyone?  Ludicrous.  That is why we named these advances after these men.

As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA).  The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:

-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.

-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.

-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.

-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.

-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.

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Prostate Cancer: Not a Good Week

The general practice of oncology seems to come in waves of disease.  One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU.  This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.

First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing.  We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”).  What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery.  More than having cancer, Allen is hurt by the feeling it should have been him.

Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland.  Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal.  Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating.  What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike.  He has recurrence of prostate cancer, previously treated with surgery.  Now Mike needs RT.  Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
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