Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Using Data Analytics to Make an Impact in Brain Cancer

Lisandra West-Odell, PhD, Scientist and Product Manager, Cancer Commons, Los Altos, CA;

Q: Reflecting the current reality of a brain cancer diagnosis, how can Cancer Commonspositively impact the treatment and outcome of each patient diagnosed with brain cancer?

A: Just over two and a half years ago the March 30, 2015 issue of Time magazine arrived in my mailbox. The cover story “Closing the Cancer Gap” featured two women: “Both of these women have brain tumors…One of them is beating the odds”. In essence, the article compared two women diagnosed with glioblastoma and evaluated the impact of tumor genetic testing in their treatments and outcomes. The first was treated with standard of care chemotherapy. The second received the BRAF inhibitor vemurafenib in a basket trial after genetic testing identified a rare BRAF mutation in her cancer. Treatment with vemurafenib lead to unprecedented tumor regression with few side effects allowing her to beat the odds typical of glioblastoma – the most aggressive form of brain cancer.
I was gripped by this story because as a scientist (working at the time for CollabRx on the content and curation team mining treatment rationales for individual variants) it was apparent to me that treatment selection based on identification of predictive biomarkers has the potential to make a significant difference in outcomes for patients. But I saw the other side of the argument too. Comprehensive sequencing is expensive, identification of driving alterations is rare, and most often more questions are raised than answered. In my current position, scientist and product manager atCancer Commons (CC), I’d like to say a bit more about how a non-profit organization such as CC can move the needle in a landscape as bleak as brain cancer.
We must start collecting patient journeys before we understand how dozens of genetic abnormalities (or more, and their infinite combinations) propel growth, drive tumor evolution, and contribute to therapy response or evasion. I am reminded of the old adage: “Lessons come from the journey, not the destination.” Where one patient’s story can only exist as an anecdote, many stories can be organized into larger buckets or cohorts elevating them to a higher level of evidence. For this purpose, Cancer Commons is building an interactive Patient Registry that can accommodate both prospective and retrospective patient data. We are capturing a specific and limited set of data necessary to understand each patient’s diagnosis and treatment and match them to relevant treatment insights and clinical trials. We follow the patients over time to capture outcomes data so that we can inform future patients what worked and what didn’t.
Importantly, as a companion to the Patient Registry, we are building a case analytics exploratory tool. The case exploration tool allows us to display aggregate data in the registry in the form of graphs and statistics. We can thus visualize the distribution of treatments, the frequency of treatments given, and the outcomes associated with each. We can ask questions such as: Which treatments have been the most efficacious with the highest quality of life? Are any investigational drugs in trials performing well within a patient cohort? Do exceptional responders share any genetic features? What is the next best treatment option for this unique patient right now? All of this is being piloted in brain cancer as a proof of concept. But the approach of knowledge collection, analysis, and sharing will be extended to every cancer type.
I would like to invite YOU to get involved with the Cancer Commons – we are taking all comers. If you are an advocacy group, foundation, or health care organization, join our platform – we can white label our tools and services to support your patients. Share your de-identified data if you have it – the more data we have in our repository, the more powerful our analytics tool becomes. Physicians, key opinion leaders and researchers, contribute your treatment rationales and insights to collaborate on difficult cases, and help us understand how we can improve our data collection methods and interpret our findings. And finally, if you are the patient, all of this was built for you. No matter your cancer type or stage, or location or financial situation, our expert network can help you tap into the world’s collective cancer knowledge. There is a better way forward. Please come help us forge it.
Lisandra West’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Life After Oncology

Professor Michael Baum, Professor Emeritus of Surgery & Visiting Professor of Medical Humanities, University College, London, UK;

Q: You have recently decided to “withdraw from the field” after a distinguished multi-decade career in Surgical Oncology. Many of our readers will confront a similar choice. How do you see your life evolving from here on?

A: I qualified as a doctor in 1960 and was appointed to my first chair of surgery, at Kings College London 20 years later. In 1981, I established the first clinical trials center for cancer in the UK in my department. To succeed in that field, I needed to become cognizant of the latest teachings in moral and scientific philosophy. Ten years later I was headhunted for the chair of surgery at the Royal Marsden Hospital, the center for our National Institute of Cancer Research. Finally, I was tempted to take up an offer of a professorship at University College London in 1997, during which time I helped develop a course in “Medical Humanities”. In the UK, you are not encouraged to continue operating after the age of 70, so I relinquished my clinical chair but was kept on as visiting professor of Medical Humanities.
I continued my role in running RCTs for the treatment of solid tumors but had time to teach my students on the role of moral and scientific philosophy, history, literature, theatre and fine art, in the practice of medicine. I was also editor-in-chief of the International Journal of Surgery. I honed my skills in creative writing through the medium of my monthly editorials.
All my life I’ve loved drawing and painting, so I filled up the remainder of my time by studying painting in art schools. My ambition was to become a full-time author and artist when I eventually retired. Trouble was that the older I got, the more I became interested in the study of oncology! I then tried to combine my enthusiasm for science, art, and literature by writing provocative papers such as “Does breast cancer exist in a state of chaos?” [1] and “Why does the weeping willow weep?” [2] Eventually, as I was approaching my 80th birthday my family ganged up on me to abandon all my academic activities and long-haul trips to conferences, encouraging me to fully retire to write books and paint “great works of art”! My last trip was to deliver a talk on intraoperative radiotherapy in Las Vegas in early May and I’m happy to say that I survived that experience to celebrate my 80th on May 31st. Since then one of my art works has appeared on the cover of the Red J [3] and my second novel, “Aaron’s Rod” [4] (linked to my interests in Biblical archaeology) was published this month.
I consider myself lucky to have survived the rigors of a life in surgical oncology long enough to relaunch myself in a new career or two. I strongly recommend all oncologists to plan for their retirement, not only in financial terms, but also to maintain the health of their brain.
Professor Baum’s contact info is included in the author affiliations at the top of this page.

  1. Baum M, Chaplain M, Anderson A, Douek M, Vaidya JS. Does breast cancer exist in a state of chaos? Eur J Cancer 1999; 35: 886–91.
  2. Baum.M, Why Does the Weeping Willow Weep? Reconceptualizing Oncogenesis in Breast Cancer. N Engl J Med 373;13, September 24, 2015

Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Huge Progress in Palliative Care

Diane E. Meier, MD, FACP, Director, Center to Advance Palliative Care; Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; New York, NY;

Q: You wrote in MedGenMed in 2007 that palliative care was the job of all hospitals(MedGenMed 2007; 9(3) 6. July 7. PMCID:PMC2100088). In October 2017 you were honored at the National Academy of Medicine for your achievements in this field. How fully has your charge to hospitals in 2007 been realized?

A: Palliative care is a fairly new medical specialty devoted to reducing suffering and improving quality of life for people living with serious illness-whether the disease is curable, chronic, or life threatening and progressive. Palliative care teams work alongside disease treatment specialists to provide an added layer of support in service of pain and symptom management, family support, attention to the social determinants of health, and skilled communication about what to expect and what matters most to the patient in the context of the reality of the illness. Multiple studies demonstrate palliative care’s contribution to achievement of the triple aim: better experience of care, better care outcomes (including survival in several studies), and as an epiphenomenon of better care, much lower unnecessary utilization of 911 calls, ED visits, and hospitalization.
Until recently, palliative care was only available through hospice, a Medicare funded benefit limited by statute to people with a short (< 6 month) prognosis who agree to give up insurance coverage for treatment of their terminal illness. Not surprisingly, most people choose not to give up coverage for treatment and, as a result, the median length of stay in hospice is only 17 days with more than 30% of hospice patients receiving such care for less than a week. Hospitals are filled with patients pursuing disease treatment for one or more serious illness who are either not hospice eligible or not willing to give up treatment. The evidence of suffering- physical symptom distress, depression, anxiety, confusion about what to expect, family caregiver exhaustion- was growing in the medical literature and clinicians working in hospitals developed hospital palliative care teams to try to respond to this need. But by the year 2000, fewer than 20% of US hospitals reported any palliative care capacity. Today that number exceeds 80%- four out of five US hospitals now report a palliative care team, and among those hospitals with more than 300 beds (the tertiary and quaternary care settings that serve the sickest and most complex Americans), over 90% now have a palliative care team.
While growth in prevalence of hospital programs improves patient access (now 80% of all hospitalized patients in the US receive care in an organization with a palliative care team), access is not the same as quality. Only 39% of hospital palliative care programs meet guidelines for staffing levels and disciplines and fewer than 10% of 1,800 U.S. hospital palliative care teams have achieved the optional Joint Commission advanced certification in hospital palliative care, a marker of consistent guideline adherence and quality.
But there are challenges that go beyond the need for greater accountability for quality and standardization among hospital palliative care teams. The greatest current challenge in the field is the recognition that the great majority of people living with serious illness are neither dying (and are therefore ineligible for hospice) nor hospitalized- hence the real gap in access is in community settings including patient’s homes, nursing facilities, cancer centers, dialysis units, and office practices. The next 10 years of our organization’s work will be committed to both ensuring quality and standardization incentives and requirements for palliative care programs regardless of setting and in markedly improving access in American communities nationwide.
Diane E. Meier’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

How I Survive Cancer

Erin Maloney, Intrepid explorer, Amateur photographer, Aspiring leader; Toronto, ON;

Q: You have recently disclosed that you have had a diagnosis of cancer and described your experience in some detail on Medium. What does it mean to you to be a “Cancer Survivor”?

A: Calling myself a survivor sometimes feels like an exaggeration. In 2016, I was diagnosed with Stage 1A2 squamous cell carcinoma of the cervix. It began with a routine pap smear and led to a robotic laparoscopic radical trachelectomy seven months later. Every procedure was challenging, and surgery was particularly arduous. However, I did not have to endure radiation, brachytherapy, or chemotherapy. I got to keep my hair, didn’t have to cope with nausea or worry about the lifelong maintenance required after radiation. So, in many ways, calling myself a survivor feels fraudulent. I have it too easy.
The physical recovery was relatively smooth but there is no preparation available for the mental toll of the Big C diagnosis. After the gynecologist shared the news, everything moved quickly. Within 10 days I had an MRI and was in consultation at Princess Margaret Cancer Hospital. It did not leave much room for preparation. In a very brief timeframe, I went from being a healthy 32-year old with no plans to have children to being a 33-year old who might not have a say in the matter.
People expect others to react in a binary way to that kind of news. There is a belief that one can choose to be optimistic or pessimistic, but that is a false dichotomy. Some days optimism abounds; most days, the fear brews below the surface unacknowledged. I mentally created a list of unanswerable questions (Would a hysterectomy be better? Would I feel like less of a woman? What if it comes back? How do I cope with this forever? Is this what kills me?). I researched and armed myself with information – a coping mechanism that allowed me to ignore my own terror.
I am not the same person I was a year ago. Prior to this, I was entrenched in the pitfalls of my Type A personality: a planner and organizer, domineering and determined, opinionated and unwilling to compromise. I had big ambitions and undaunted confidence. But our best-laid plans can be laid waste by a simple two-word sentence: “It’s cancer.” I wished I believed that this was part of some larger plan but it wasn’t. Instead, what it meant for me was that I had to change. My attitude needed to be different if I was going to come out the other side not completely broken.
Cancer took away my control. I could think of little else. Administrative inefficiencies rendered me powerless. I couldn’t get the answers I was seeking faster than they were willing to give them. For example, making decisions for myself was challenging when I needed answers from a busy surgeon. If I tried to use the same approach as I normally would, I would probably have ended up insane. So, I made the decision to adapt. I had to learn patience, to be more open to spontaneity, flexibility, and work on being able to ‘go with the flow.’ I try to allow humour and positivity to flow into impossible situations. I practice kindness and thoughtfulness as often as I can. I strive to think of others and notice their needs. Above all else, I try to treat people the way I want to be treated; to be more open and to deliver honesty without being cruel or callous.
There are many days when I fail at most of those things. Self-improvement is never easy. Imposed self-improvement as a survival mechanism is even more difficult. Finding and maintaining true positivity in the face of overwhelming terror has been the hardest task of all.
The depression that surfaced during recovery was different; it was borne out of a deep desire to live and the constant fear that I might not. I still don’t have certainty. The fear that surrounds each appointment will never abate. In a strange way, that has been inspiring. I want to live. I want a full, vibrant life that is technicolour. It doesn’t mean every day, and it doesn’t mean I get to tick off all those dreams immediately. Ultimately it means that I want to live better and that’s what makes me a survivor.
Erin Maloney’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Who Owns Patient Data in Clinical Research?

Charlotte J. Haug, MD, PhD, MSc, International Correspondent, New England Journal of Medicine; Senior Scientist, SINTEF Techology and Society; Adjunct Affiliate, Stanford Health Policy; Oslo, Norway;

Q: Many people are coming to believe that active patient participation will be a key to more rapid movement forward in cancer research. Data sharing can help. But who owns the data? And what rights and responsibilities are thus conferred? Your recent NEJM article provides helpful background. Can you help us better understand?

A: Exchange of data between patients and doctors is essential for the practice of medicine – and patient data are essential for medical research and progress.
Traditionally, doctors collected patients’ health information (typically the medical history, laboratory tests, drugs prescribed, outcome of treatment, etc.) and sometimes shared that information, in confidence, with colleagues to seek advice and advance science. The medical record was the physician’s property, and still is in many countries and legislations. But do physicians own the patient data?
In clinical research, patient data from many sources must be collected and analyzed. Researchers must have explicit and informed consent from participating patients to do this, but when they have such consent they are free to use the trial data any way they wish. This is true even for commercial purposes – the norm for drug trials. But do researchers own the patient data?
Until quite recently the question of who owns patient data collected in clinical practice and clinical trials has not been discussed very much, mostly because it hasn’t been very important. Medical records and research results were analyzed and archived on paper. It was difficult, if not impossible, to reuse those data for anything else. Claiming ownership had no real value.
Internet, digitalization of medical records and datasets, and the vast increase in data-storage and data-processing power (especially over the last decade) has changed that. Since it is now possible to combine and reanalyze huge datasets quickly in totally new ways to create useful information about diseases and treatments, it is important to clarify who owns the data in order to clarify who can give permission to share and use data in ways beyond the original intent.
So far, the discussion about data sharing and data ownership has largely taken place between clinical trialists (who spend years collecting, curating, and analyzing data from clinical trials) and data scientists (who would like to add value to those data by reanalyzing and reusing them in novel ways). Both sides claim to have the patient’s and the public’s best interests at heart. But not many have asked patients what those interests are.
At a NEJM conference earlier this year, patients were asked this question. It turns out most of them want to share their data and to share them quickly, especially to ensure that other patients know about possible side effects. But they also want some control over how the data are shared. For example, they would be more hesitant to participate if commercial or other interests were involved. Which is unfortunately the case in most clinical trials. Something many of the patients didn’t seem to be aware of.
But the new “digital patients” also don’t want to be passive observers and sources of research data. They want to use the power of the Internet to engage in their own care, interact with clinicians and fellow patients, create new knowledge, and suggest new ways of delivering health care. They believe in sharing data and experiences to help themselves and fellow patients.
Patients want their data used responsibly and to take part in generating and curating the data. So perhaps the question needs to be rephrased: Who should control how data are distributed and used by others? The patients themselves? Doctors and researchers? Research institutions or governments?
Laws vary from country to country. In the United States, for example, absent specific language to the contrary in informed consent documents, research participants don’t have to give specific permission for their deidentified data to be used by other researchers. Europe is moving in the opposite direction — requiring explicit consent for reuse of data or data sharing and allowing patients to withdraw their consent at any time.
Perhaps the solution to the data-sharing and privacy struggle lies in shifting data ownership and control to individual patients everywhere.
Charlotte Haug’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Nicotine Addiction: Harm Reduction by E-cigarettes and Snus

Joel L. Nitzkin, MD, Public Health Physician, New Orleans, LA

Q: Tobacco smoking remains the most preventable primary form of cancer causation in Americans. A recent Medscape column urged that harm reduction for confirmed nicotine addicts is the kindest and most effective strategy. How can products like “snus” be helpful?

A: As noted by Dr. Michael Russell in 1976, people smoke for the nicotine, but die from the tar. According to CDC, about half of long-term smokers will die of a smoking-related disease. They estimate that about 480,000 Americans die from cigarette smoking each year, including about 50,000 from the environmental tobacco smoke. According to our best current estimates, snus and the other smokeless products used by American men pose little or no risk of cancer of the mouth or any other cancer. E-cigarettes, having no combustion and no tobacco, are likely similarly low in risk.
Snus, e-cigarettes, and other smokeless nicotine delivery products offer an interesting and unusual approach to reducing the deadly toll of addition to cigarette smoke. Rather than present themselves as drugs to treat a deadly disease, these products offer recreational substitutes for cigarettes that already enable large numbers of smokers to satisfy their urge to smoke while reducing the risk of potentially fatal cigarette-related cancer and other diseases by more than 95% (likely more than 99%). This is a public health benefit that can be secured for many more smokers, (at no cost to the taxpayer) by simply advising them of this difference in risk. Sweden, where most men use snus rather than cigarettes to satisfy their urge for nicotine, has the lowest rate of lung cancer among men in the Western world. There is even one small study that shows that e-cigarettes can get smokers not interested in quitting to quit by switching to this much lower risk product. All it takes is informing them of this difference in risk.
American public health authorities recognize that snus and e-cigarettes are much lower in risk than cigarettes. Their objection to allowing manufacturers to claim lower risk, however, is based on a very different concern. They object on the basis that advertising these products as lower in risk might attract teens and other non-smokers to tobacco-related products; and from there to cigarettes. Research published this last decade provides substantial evidence that such advertising would not be likely to attract teens to these lower-risk products who otherwise would not have taken up smoking.
For many years, the goal of public anti-smoking programming has been “a tobacco-free society.”This goal has been based on the premise that all non-pharmaceutical nicotine products are so addictive and so hazardous that none should be tolerated. This goal has also been interpreted as ruling out any consideration of any non-pharmaceutical nicotine product in any public health initiative. Now that we know that we can communicate reduced risk without attracting teens who otherwise would not have taken up smoking, the time has come to use this knowledge to further reduce the burden of addiction, illness, and death that cigarettes have imposed both in the USA and worldwide.
Joel Nitzkin’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Pharmacogenomics for Clinical Use of Cannabis

Saeed K. Alzghari, M.S., M.B.A. (HOM), Pharm.D., BCPS, Director of Clinical Pharmacy, Gulfstream Genomics, LLC., Dallas, TX;

Q: Proper use of Pharmacogenomics can inform better patient care in many potential ways. Pain relief by use of Cannabis instead of opioids shows substantial promise. How do you think pharmacogenomic study could guide intelligent clinical use of Cannabis?

A: Over the past decade, pharmacogenomics (the study of how genes affects a person’s response to drugs) has gained much ground. More than 160 drugs currently have pharmacogenomic labeling by the Food & Drug Administration (FDA) and the list is growing. The excitement that surrounds pharmacogenomics and the applications associated with this technology are endless.
In order to understand the role of cannabis for pain pharmacogenomics, one must understand how pain is treated. In my experience as an oncology pharmacist, I have seen first-hand the unbelievable amounts of opioids a cancer patient may take just to gain some relief. Pain is treated according to the World Health Organization’s (WHO) Pain Relief Ladder where pain is treated in steps based on severity (Figure 1). Steps 2 and 3 of the pain ladder begin to include opioids as part of the treatment course since, when used properly, opioids offer the best chance at reducing pain.

An important consideration that is often forgotten is the use of adjuvant agents to help reduce the amount of opioids used when treating pain in general or to help with different types of pain such as neuropathic pain. In regards to cancer, the first clinical trial to show that an adjuvant therapy can help with chemotherapy-induced peripheral neuropathy was duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), typically indicated for depression.
The role of cannabis in pain management, in my opinion, will most likely be as an adjuvant. I do not see cannabis completely eliminating the need for opioids in patients with moderate-to-severe pain, but I believe cannabis can reduce the amount of opioids a patient may take. The main pharmacogenomic focus for cannabis is related to two primary cannabinoid receptors (CB1-R and CBR-2) that marijuana acts upon. Cannabinoid receptors are of great interest to researchers since our own body produces endocannabinoids that play a role in pain. Research associated with genetic polymorphisms in the cannabinoid receptor CNR1 and CNR2 genes are in preliminary stages; however, these genes hold promise to optimize and individualize therapies that act on the cannabinoid receptor. Other pharmacogenetic markers and their role in patients taking cannabis are also being investigated.
The largest barrier to research related to cannabis is that marijuana is classified as a Schedule I controlled substance by the U.S. Drug Enforcement Administration. Researchers are restricted on how marijuana is studied and is a deterrent to those wanting to perform trials in U.S.-respected organizations, such as the American Cancer Society, that have taken the position in supporting the need for more scientific research associated with cannabis to provide better patient care. If marijuana is rescheduled in the U.S., then its barriers to research will be lifted and more studies involving the pharmacogenomics of cannabis can be performed to improve patient care.
Saeed Alzghari’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Public Health Personalized Medicine

Gualberto Ruaño, MD, PhD, President, Genomas Inc.; Medical Director, Laboratory of Personalized Health; Hartford, CT;

Q: Public participation by contributing specimens to assess personal genomic information is rapidly increasing. How might this expansion of testing become actually useful for the health of the public?

A: The fields of public health and medicine share a common objective of maintaining the well- being of people, but with very different modes of operation. Medicine has historically focused on interventions to treat illness and restore health, while public health seeks to prevent disease. Hence, medicine generally focuses on the needs of the individual, while public health focuses on the population. Because of this division, policies that serve the common good are limited by the individuals who do not realize the intended benefit. Could prevention become personalized with genomic information so that public health is synonymous with personal health?
The two perspectives can be illustrated by the approaches for dealing with nutrition. Various food pyramids purporting to guide the amount of milk products, fruits and vegetables, grains and legumes, meat, and water have been proposed amid controversy. A school system that adopts a public health approach to the problem might implement a food pyramid based menu, thus increasing its compliance but at the risk of variable responses among its students. Some individuals may have a gene or a lifestyle that makes them benefit from one kind of nutrient while others may have undesired weight gain. If it were possible to identify those individuals who would benefit most from a particular nutrient, then it may be possible to optimize the program as a whole, by avoiding side effects and increasing efficiency. In effect, this effort would bring together aspects of the medical and the public health perspectives by personalizing the public health strategies, thus providing a method by which individuals can optimize their own health, and in the process, benefit the population at large.
I believe the current consumer genomic products offer a path to personal health. Many citizens are purchasing these services and depositing their genomes with companies that will offer various interpretations of the genomic data, as the consumer requires. So far, the leading interest has been ancestry, but business models are evolving to offer consumers a variety of windows on their genome to guide diet and exercise and even expose disease susceptibility (information that can be “opened” by purchasing different products and applications). The genome is sequenced or genotyped once, the information is stored and queried repeatedly depending on the need or interest.
In this scenario, most of the algorithms leading to an interpretation will not be results of causative inference. Knowledge that a particular genetic polymorphism will produce a given effect on the outcome is really limited to genetic diseases, some pharmacokinetic polymorphisms and various cancers. A practical standard would be to determine whether ensembles of particular polymorphisms are associated with the outcome, a relationship that most likely is not causative.
We must be alert to this developing model. This is not science, which has the ultimate goal of understanding mechanisms of pathophysiology. This is modeling for predicting outcomes based on associations that exist between individual genomic characteristics and the outcome of interest. This would allow us to improve our prediction of the response by incorporating information that is related to the outcome, but when we cannot be certain that the associations are causal, we must maintain a level of caution in using the predictions.
There are various technical and medical problems with this model. The first is the quality of the genomic data. In the laboratory profession we strive to maintain a given level of quality and reproducibility so the test results are clinical grade and support medical interventions. But in the genome storage model, there is likely none because the algorithms are sampling multiple polymorphisms, and some redundant ones because of linkage disequilibrium may become the actual quality control. The second limitation is the relative contribution of phenotypic characteristics versus genetic markers to a prediction. It may be that for some predictions, the bulk of the prediction is carried by the phenotype, and the genotype is a small percentage of the predictive power. But will this matter to the consumer?
I believe the genie is out of the bottle concerning consumer genomics, and that an antagonistic view of the field by the medical profession is not in the best interest of the consumer or our profession. In the evolving genome storage model, a number of vendors could provide the initial sampling of the personal genome, and yet other vendors could support a marketplace of algorithms to interpret the genome and provide guidance. Competing algorithms will probably exist so that the consumer can select or compare for the same prediction. The models become fluid and there will be various versions released to the market, each claiming to be more precise. If a vendor persuades the consumer to give feedback information on individual response, the models could become self-improving. I predict that this world of genome data obtained once coupled to a diversity of algorithms for querying will allow public health to become personalized. I further suspect that the interest in ancestry will propel much demand for algorithms related to longevity, wellness, nutrition and fitness. These are indeed the historically desired outcomes of sound public health policy, but enabled by the interpretations of the personal genome of each individual.


Gualberto Ruaño’s contact info is included in the author affiliations at the top of this page.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Psychiatric Drug Use by Medical Students and Residents

Pamela Wible, MD, Founder of the Ideal Medical Care movement; Author of Physician Suicide Letters—Answered; Family medicine practitioner in Oregon;

Q: Medical students and residents are among the most important human resources in the United States. Yet we lose many during training due to suicide. Have you information you can share with our readers about the mental health and psychiatric drug use of medical students?

A: I asked 220 doctors: “Have you ever been depressed as a physician?” Ninety percent stated yes. Yet few seek professional help. Here’s what depressed doctors do (when nobody’s looking). Some drink alcohol, exercise obsessively, even steal psychiatric meds. Still more shocking—I discovered that 75% of med students (and new doctors) are now on psychiatric medications.
“I was told by the psychologist at my med school’s campus assistance program, that 75% of the class of 175 people were on antidepressants,” shares psychiatrist Dr. Jaya V. Nair. “He wasn’t joking. How broken is the system, that doctors have to be pushed into illness in order to be trained to do their job?”
How many docs do we lose per year to suicide? The equivalent of one medical school full of students wiped out annually. In my 2016 TEDMED talk, I explain why doctors kill themselves. Personally, I lost both doctors I dated in med school to suicide and 8 physicians in my small town. In 2012 I decided to run a suicide hotline for doctors. I’ve heard from so many suicidal doctors that I published a book of their suicide letters.
In 1990, even I was severely depressed as a first-year med student. So my mom (a psychiatrist) mailed me a bottle of Trazodone. I thought I was the only one. Turns out occupationally-induced depression is rampant in medical training. Now schools dole out antidepressants like candy. Stimulants are used by med students like steroids in athletes. So where do we go from here? Should med schools distribute samples of Zoloft and Adderall during orientation?
The problem is physicians must answer mental health questions (right next to questions on felonies and DUIs) to secure a medical license, hospital privileges, and participate with insurance plans. Check the YES box and be forced to disclose your “confidential” medical history and defend yourself—again and again–for your entire career. You get treated like a criminal for taking meds to cope with the torment of medical training (and practice).
Maybe that’s why so many future (and current) physicians sneak drugs and go off-the-grid for mental health care.
“I’ve been in practice 20 years and have been on antidepressants and anxiolytics for all of that time,” says Jason. “I drive 300 miles to seek care and always pay in cash. I am forced to lie on my state relicensing every year. There is no way in hell I would ever disclose this to the medical board—they are not our friends.”
What if we stop the mental health witch hunt on our doctors? Why not replace threats and punishment with safe confidential care? What if we address the root of the problem—the great sickness in medical education—rather than shifting blame to 75% of medical students for not having enough serotonin or dopamine or norepinephrine in their brains?
As scientists, we can’t continue to approach medical education reform as a neurotransmitter deficiency in medical students. Can we?

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Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

The Worst Phony Cancer Cures

Stephen Barrett, MD, Retired Psychiatrist; Medical Editor for and 24 other consumer-protection Web sites; Publisher for Consumer Health Digest; Chapel Hill, NC;

Q: Who tops your list as the most brazen promoters of phony cancer cures in the past 25 years?

A: Three people come to mind: Gregory Caplinger, Hulda Clark, and Dr. Lorraine Day.
Gregory Earl Caplinger died in 2009 while serving a 12-year prison sentence for fraud. For many years he claimed to be a distinguished and widely published medical doctor, professor, and researcher. However, he did not have a bona fide medical degree and accumulated more questionable “credentials” than any other impostor I have ever investigated or heard of. His bio listed more than 75 of them. A habitual con man, he got into legal trouble at least six times for defrauding people. During the mid-1990s, he began operating a clinic in the Dominican Republic that offered treatment to desperate cancer patients. In 2000, after a six-day trial, a North Carolina jury convicted him of wire fraud and money laundering related to “investments” in his phony remedy “ImmuStim.” In 2001, he was sentenced to federal prison and ordered to pay more than $1 million restitution to several victims.
Hulda Regehr Clark (1928-2009) falsely claimed to cure cancer, AIDS, and many other serious diseases with herbs and low-voltage electrical devices. She earned an accredited Ph.D. in zoology but practiced “naturopathy” based on a correspondence course obtained from a non-accredited correspondence school. She was best known for her book, Cure for All Cancers, which claimed that all cancers and many other diseases are caused by “parasites, toxins, and pollutants” and can be cured by killing the parasites and ridding the body of environmental chemicals. Clark used and promoted two medically worthless galvanometric devices. Her “Synchometer” allegedly identified diseased organs and detected toxic substances by noting whether the device made various sounds when “test substances” were placed on a plate. Her “Zapper” allegedly killed microorganisms with electrical energy without harming human tissue. Its use was based on the notion that all living things broadcast characteristic radio frequencies and that the device would issue counter-frequencies that killed unwanted organisms. Clark said she could tell when cancer and AIDS patients were cured within days or even a few hours after her treatment was begun. She died of complications of multiple myeloma under circumstances which suggest that her life was shortened by failure to seek timely medical care.
Lorraine Jeanette Day, M.D. (1937- ), would like people to believe that personal experiences have enabled her to discover the answer to cancer. Unlike Caplinger and Clark, Day has excellent credentials (as an orthopedic surgeon), but in 1989, she suddenly withdrew from medical practice. A few years later, she underwent diagnostic and incisional biopsies for breast cancer. About 20 years ago, she began marketing educational videotapes which claim that her cancer ultimately caused her to become deathly ill and bedridden for many months, but cured herself with a combination of diet and prayer. However, portions of medical records suggest that she had an early-stage intraductal carcinoma that was completely removed during her second biopsy. (She could easily address this issue but has refused repeated requests for the relevant medical records.) Day advises people not to trust the medical profession and claims that standard cancer treatment has never cured anyone. Instead, she recommends strengthening the immune system by dietary means and other methods recommended in her educational materials. Day’s medical credentials and apparent sincerity make her particularly dangerous. A few people have told me about relatives with treatable cancers who shortened their life by relying on Day’s advice instead of standard care.

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