The doctor is in… cyberspace

Getting health care — whatever happens with the health care bill — is no longer just a matter of getting to the doctor. Issues of comfort, efficiency and cost control increasingly point to the use of telemedicine, which is coming, ready or not. And one recent report suggested the medical profession isn’t ready. Pauline Chen, M.D. , writing recently in the New York Times, cited resistance by doctors and nurses alike to what some consider long-distance health care.

Telemedicine has the potential to improve quality of care by allowing clinicians in one “control center” to monitor, consult and even care for and perform procedures on patients in multiple locations. A rural primary care practitioner who sees a patient with a rare skin lesion, for example, can get expert consultation from a dermatologist at a center hundreds of miles away. A hospital unable to staff its intensive care unit with a single critical care specialist can have several experts monitoring their patients remotely 24 hours a day.

But despite its promise, telemedicine has failed to take hold in the same way that other, newer, technologies have. Not because of technical challenges, expense or insufficient need. On the contrary, the most daunting obstacle to date has been a deeply entrenched resistance on the part of providers.

Tech industry writer/elder care advocate Laurie Orlov thinks those concerns are a thing of the past. Since data was gathered for the study Dr. Chen cited, Orlov points out in her Aging in Place Technology blog, doctors, patients and technology have come a long way. “Forget the JAMA study”, Orlov says, “here come the virtual visits.”

Medical practices, hospitals, clinics are well aware of a much-changed world and consumer health care costs that can be breathtaking. American Well’s virtual visit platform use is growing, as are other virtual platforms discussed in our 2009 Calibrated Care report. They have read about transformation of self-care and virtual visits in Denmark. Given the geographic distribution of people — and the distance required to get to doctors in some states and rural areas, given the availability of technology that was barely known or completely unknown in 2006, these are going to happen, reimbursement has begun, criteria for the use has emerged, and the JAMA study (and its much-syndicated press coverage) is already irrelevant.

On a technologically lower level is the use of PC programs long in place for Kaiser patients. They haven’t asked for a testimonial, but here’s one, with enthusiasm. The e-mail your doctor program allows doctor-patient communication at the convenience of each (my primary care doc, oncologist and other specialists almost all answer queries within 24 hours or less); test results are posted immediately and can be viewed via charts or graphs to show how you’re doing; drug information or other Q&A’s are immediately accessible through personal accounts. All of the above save time, money and patient angst.

Doctors in cyberspace could be good medicine indeed for U.S. health care.

Leaving Cancer Alone

We don’t talk a lot about not treating cancer. But as mentioned recently in this space, leaving it the heck alone is an option that merits consideration, particularly in the case of breast and prostate cancers detected very early on.  Now comes further news, reported by New York Times health writer Gina Kolata, of studies showing that some other cancers might also go away by themselves.

Call it the arrow of cancer. Like the arrow of time, it was supposed to point in one direction. Cancers grew and worsened.

But as a paper in The Journal of the American Medical Association noted last week, data from more than two decades of screening for breast and prostate cancer call that view into question. Besides finding tumors that would be lethal if left untreated, screening appears to be finding many small tumors that would not be a problem if they were left alone, undiscovered by screening. They were destined to stop growing on their own or shrink, or even, at least in the case of some breast cancers, disappear.

The Times article cites studies of testicular, cervical, kidney and other cancers that suggest some, left untreated, might simply go away; the trick now is to begin identifying which these would be.

I don’t know anyone who would opt out of treatment when it is likely to offer restored health. But especially for older populations, the choice of not treating a small cancer could be more frequently and seriously discussed.

Cancer cells and precancerous cells are so common that nearly everyone by middle age or old age is riddled with them, said Thea Tlsty, a professor of pathology at the University of California, San Francisco. That was discovered in autopsy studies of people who died of other causes, with no idea that they had cancer cells or precancerous cells. They did not have large tumors or symptoms of cancer. “The really interesting question,” Dr. Tlsty said, “is not so much why do we get cancer as why don’t we get cancer?”The earlier a cell is in its path toward an aggressive cancer, researchers say, the more likely it is to reverse course. So, for example, cells that are early precursors of cervical cancer are likely to revert. One study found that 60 percent of precancerous cervical cells, found with Pap tests, revert to normal within a year; 90 percent revert within three years.

And the dynamic process of cancer development appears to be the reason that screening for breast cancer or prostate cancer finds huge numbers of early cancers without a corresponding decline in late stage cancers.

If every one of those early cancers were destined to turn into an advanced cancer, then the total number of cancers should be the same after screening is introduced, but the increase in early cancers should be balanced by a decrease in advanced cancers.

That has not happened with screening for breast and prostate cancer. So the hypothesis is that many early cancers go nowhere. And, with breast cancer, there is indirect evidence that some actually disappear.

A sister who is six years older than I was diagnosed with breast cancer at 72, had a mastectomy and is cancer free. Six years later I was diagnosed with breast cancer, had a mastectomy and am cancer free. Last week I visited a college classmate who had been diagnosed two weeks ago with breast cancer; she had a mastectomy and is cancer free. Cancer free is good. But what if — just what if — one of those cancers might have disappeared without major surgery?

Disappearing tumors are well known in testicular cancer. Dr. Jonathan Epstein at Johns Hopkins says it does not happen often, but it happens.

It is harder to document disappearing prostate cancers; researchers say they doubt it happens. Instead, they say, it seems as if many cancers start to grow then stop or grow very slowly, as has been shown in studies like one now being done at Johns Hopkins. When men have small tumors with cells that do not look terribly deranged, doctors at Johns Hopkins offer them an option of “active surveillance.” They can forgo having their prostates removed or destroyed and be followed with biopsies. If their cancer progresses, they can then have their prostates removed.

Almost no one agrees to such a plan. “Most men want it out,” Dr. Epstein said. But, still, the researchers have found about 450 men in the past four or five years who chose active surveillance. By contrast, 1,000 a year have their prostates removed at Johns Hopkins. From following those men who chose not to be treated, the investigators discovered that only about 20 percent to 30 percent of those small tumors progressed. And many that did progress still did not look particularly dangerous, although once the cancers started to grow the men had their prostates removed.

In Canada, researchers are doing a similar study with small kidney cancers, among the few cancers that are reported to regress occasionally, even when far advanced.

One of the things we post-mastectomy women were talking about last week was how we might handle a recurrence. The reality is, as we have all already proved: you live long enough, you get stuff. Maybe someone at Johns Hopkins (or elsewhere; Kaiser San Francisco would suit me fine) will undertake a study in which older women with small breast cancers can opt for “active surveillance” rather than major surgery. Should I qualify, I would enroll. To this admittedly untrained and unscientific survivor it seems a study whose time has come.

Cancers Can Vanish Without Treatment, but How? – NYTimes.com.