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Harold J. Burstein

A recent article in The New England Journal of Medicine (N Engl J Med 2010;362:948–952) centered on the pros and cons of board recertification for United States clinicians. A clinical vignette described a middle-aged internist and endocrinologist “grandfathered” by his initial board certifications and asked whether he should register to recertify. The article contained well-crafted arguments for and against recertification. In favor of recertification are the arguments that maintaining clinical skills is valuable and leads to better care; that the recertification process and content differs from other CME programs; and that the requirements are not unduly burdensome or expensive. The contrary opinion suggests that data proving the worth of recertification as a way to maintain or improve clinical outcomes are lacking; that standardized testing is a weak surrogate for clinical skills or judgment; and that the American Board of Internal Medicine has a functional monopoly on testing programs, feathering the nest of its own foundation by charging clinicians lots of money for the privilege of maintaining a paper (or online) certification. The journal invited readers to reply, and more than 2000 did. By a 2:1 majority, readers from the United States, United Kingdom, and Australia recommended that the clinician not recertify. In Canada, the vote was 50:50. However, even that tepid endorsement for recertification if grandfathered was vastly in excess of actual practice. American Board of Internal Medicine (ABIM) data suggest that fewer than 1% of clinicians who are grandfathered bother to participate in maintenance of certification. I have been...
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Harold J. Burstein

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Harold J. Burstein

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Harold J. Burstein

One of the treasures of oncology practice is a vast and accessible clinical literature to draw on to guide clinical treatment. Truly, oncology is a field dominated by science and evidence. Some great resources in oncology are comprehensive treatment guidelines, such as those from NCCN, that review, interpret and instill the literature, and infuse it with clinical expertise to create a road map for effective treatment. Given my thoughts on these, it was sobering to read a recent paper that investigated the levels of evidence underlying NCCN recommendations for 10 common cancers.1 The authors reviewed NCCN Guidelines levels of evidence and consensus (1, high evidence, uniform consensus; 2A, lower evidence, uniform consensus; 2B, lower evidence without uniform consensus but no major disagreement; 3, any level of evidence but major disagreement), identified all treatment recommendations in the Guidelines, and tallied the level of evidence behind those recommendations. The major findings were that only 6% of recommendations were level 1; the vast majority (83%) were level 2A—consensus, but less evidence. Among diagnostic workup and cancer surveillance, 0% of recommendations were level 1, and in many major cancer types (lung, prostate, colorectal, melanoma, pancreas, lymphoma, bladder, uterus), fewer than 10% of all recommendations were level 1. The most level 1 recommendations were in initial therapy; beyond that, the rate drops substantially. These observations point to a large gap in evidence for many oncology practices, and though these observations are not necessarily new, it is time for all of us in oncology to mind...
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Harold J. Burstein

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Harold J. Burstein

A unique hallmark of comprehensive cancer care is treatment delivered in well-organized teams. Most comprehensive cancer centers organize care around multidisciplinary provider teams that center on the disease rather than the training or professional background of the providers. Most oncology patients can identify multiple clinicians who are part of their cancer care team. Most guidelines in oncology, and certainly the NCCN Clinical Practice Guidelines in Oncology, invariably describe integrated, multidisciplinary management. The number of sub-specialists involved in caring for a single patient can be legion: surgical, radiation, and medical oncologists; radiologists; pathologists; pain or palliative care specialists; geneticists; psychologists, social workers, and counselors; oncology-specialized treatment and symptom-control nurses, nurse practitioners, and physician assistants. A patient with newly diagnosed cancer who is embarking on a multidisciplinary treatment program might encounter literally dozens of health care providers—each with his or her own business card, email address, and pager number—who will weigh in on the treatment plan and goals. Further, all these clinicians must communicate with each other and work together to deliver the type of seamless care that patients deserve. Sometimes the entire cancer care team works in the same building at a single institution; other times, the members may be joined in a loose confederation or work at entirely different cancer clinics. This brings up many questions. How are teams created and sustained? How is com-munication facilitated and enhanced? Although easily recognized as an important goal incancer care, the fully integrated team of cancer specialists is not an easy creation. Medical...
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Harold J. Burstein

“Personalized medicine” has rapidly evolved from connoting cutting-edge thinking about medical care based on individualized need to something of a cliché; everyone wants to focus on personalized medicine these days. At its core, the concept suggests that treatments could be tailored to the health needs of a given person, based on extensive and detailed understanding of the underlying biology of their disease, their intrinsic body function, and the dynamics of whatever intervention is planned. In oncology, the concept is most often linked to 2 particular aspects of personalization: use of gene expression arrays to define which cancer subset most closely describes the tumor, and use of the patient's gene profile to understand either why this cancer developed or how best to treat it.Breast cancer serves as a model disease for those seeking to develop personalized medicine in oncology. The use of biomarkers and gene expression profiling has yielded important insights into the heterogeneity of breast cancers. We now speak not of “breast cancer” as one monolithic tumor type, but of important, recognizable, definable subsets such as “HER2-positive” breast cancer, “triple-negative” breast cancer, or “ER-positive breast cancer.” Further personalization emerges in treatment algorithms. In particular, the ER-positive tumor types are being splintered into subgroups with different treatment needs.Tumor-based gene expression analyses, such as the OncotypeDX recurrence score, are used to gauge which patients with ER-positive breast cancer should have chemotherapy and which should not. Finally, breast cancer treatment holds the one instance of pharmacogenomic significance in all of cancer...
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Harold J. Burstein

A hallmark of oncology practice is the need to share bad news with patients. Too often cancer is a devastating disease, and oncologists must by necessity discuss heart-breaking and frightening clinical results with patients and their families. Training in oncology often focuses on technical performance of care delivery—the right type of surgery, how to arrange radiation treatment fields, chemotherapy dosing, and side effect management. Oncology training usually does not concentrate on a different kind of professional performance: the communication of medical information. The resulting inexperience may be compounded by the stress of bad news, for both the clinician and the patient. Seasoned clinicians may develop successful ways to talk with patients, but that often occurs through years of experiences, both good and bad. Fortunately, the literature on how to better manage these moments with patients, families, and medical providers is growing, yielding better communication and a more satisfying emotional experience. In this issue of JNCCN, we feature an article by Jacobsen and Jackson that outlines a communication approach for oncologists when discussing some of the most challenging topics in cancer care: “bad news” and care at the end of life. These are some of the most demanding moments in the lives of cancer providers, and suggestions that enhance our ability to communicate with our patients are most welcome. Guidance for such important clinical moments is clearly needed, and SPIKES is an acronym that is worth remembering in this context: S, setting up the interview; P, perceptions of the patient; I,...