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Harold J. Burstein

An October op-ed piece in The New York Times (http://www.nytimes.com/2009/10/10/opinion/10DeVries.html?_r=1&scp=1&sq=mammologist&st=cse) introduced a new term into the medical lexicon: Mammologist. This title refers to a multidisciplinary breast cancer specialist who would serve as a facilitator specifically for patients with newly diagnosed breast cancer. The concept proposed was timely, with October marking Breast Cancer Awareness Month, although the goal of a mammologist—to ease patients through the steps of cancer care by being involved in every step of their treatment—is very similar to that of patient navigators. The idea of a patient navigator is gaining currency at cancer centers around the country. Its rationale is based on recognition of the complicated layers cancer patients must negotiate from diagnosis through treatment and follow-up. Consider a “typical” woman with newly diagnosed breast cancer. She may already be under the care of a primary care physician and a gynecologist. She is sent for routine screening mammography and is told by the radiologist that she needs a biopsy based on the findings. Based on the biopsy results, she is referred to a breast surgeon and may also need to see a plastic surgeon, radiation oncologist, and medical oncologist. That's 7 doctors before even she gets to a second opinion! Anyone who has tried to negotiate the current health care system knows how vexing it can be. Care at a comprehensive center—where radiology, surgery, and oncology specialists all reside under one roof and may even work through one scheduling office—can minimize some of the hurdles. But many patients...
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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

“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,...
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Harold J. Burstein

NCCN guidelines are notable for their comprehensive, maybe even exhaustive, nature. The goal of the guidelines is to create a template for most conceivable common clinical circumstances. Some nodal points in the guidelines are supported by high-quality evidence from randomized clinical trials. Others are supported by lesser data, expert opinion, or, in certain instances, the best guess of clinical experts. A great strength of the guidelines is that they patch together these decision points; those reinforced by strong ropes of data and those held by more tenuous lines of judgment. Such thoroughness is very useful in clinical practice, both in high-volume clinical situations in which clinicians are often quite experienced, and arguably even more so in low-volume clinical circumstances, that are often unfamiliar to practicing oncologists, who refer to guidelines for real guidance. This thoroughness creates somewhat of an illusion, however, that NCCN guidelines panel members always know the right thing to do next, that little uncertainty exists, or that things couldn't be done better. This is rarely the case in oncology, of course, which is why clinical trials are needed. NCCN guidelines always recommend consideration of clinical trials. In fact, the introduction to all the disease-based guidelines states: The NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Although these sentiments are widely accepted throughout the NCCN and larger oncology community, participation rates in clinical trials remain dismal. In the United States, fewer than 5% of...
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Harold J. Burstein

The most important recent publication on health care in the United States can be found in the June 1 The New Yorker magazine, in an article by Dr. Atul Gawande of Brigham & Women's Hospital (available at: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrail). Dr. Gawande spoke with locals about health care in McAllen, Texas—a town notable for spending more per capita on health care than the average resident earns in a year. He made a quick diagnosis: health care costs are high in McAllen because of the most expensive piece of medical equipment—the doctor's pen! That is, expenses are high because clinicians order and deliver a lot of health care services, many of which may not be needed. The result is not necessarily better health but simply higher costs. The White House is reportedly paying close attention to Dr. Gawande's article as the administration embarks on health care reform. Doctors may have several reasons for over-ordering medical services, including insecurity in medical judgment, misunderstanding proper care algorithms, patient demand, the desire to “do right” by patients, excess supply of available medical services, and personal financial gain. In light of this article, data in the paper by Foster et al. in this issue of JNCCN (page 712) are illuminating. The authors created a series of hypothetical case management questions and asked oncologists to state the next treatment or evaluation. The study reports that oncologists often made guideline-consistent choices but also suggests that these same oncologists frequently order unnecessary tests (such as staging PET, chest imaging, and...
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Harold J. Burstein

If you read articles about hereditary cancer syndromes, biological markers that predict risk and benefit from targeted therapies, optimizing adjuvant chemotherapy regimens, risk stratification based on tumor biology and stage considerations, emerging molecular diagnostic tests, and quality of life in cancer survivors, you would be forgiven for thinking that they are about breast cancer. So welcome to the new breast cancer: colon cancer. This issue of the Journal of the National Comprehensive Cancer Network highlights many of the new trends in colorectal cancer management. These trends epitomize the kind of changes that have redefined care in breast cancer and that are now being extended into other major tumor types. Heterogeneity that is a familiar part of the treatment dialogue in lymphoma and breast cancer is now also seen in colon cancer, promising a new wave of refinements in pathology, treatment selection, and tailored therapies. These are welcome changes. Colorectal cancer accounts for the second largest toll of cancer deaths in the United States, after lung cancer and before breast and prostate cancers. Recent years have shown real progress with the availability of new chemotherapy agents and biologically targeted drugs that seem to improve outcomes in both advanced and early stage disease. Insights into molecular subtypes of colon cancer may determine both risk and treatment. What can experts in colon cancer learn from breast cancer? First, guidelines may need to be restructured to accommodate various colon cancer subsets and provide recommendations for each tumor type, first in the metastatic, and eventually...
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Harold J. Burstein