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© 2011, 2012 Health Futures Digest
Death from cancer has declined for two straight years in the US. Whether the trend continues may depend on finding cures or preventives for prostate cancer, which could go through the roof as the baby-boomers age, but a glance through this issue of the Digest reveals a raft of genetic and pharmaceutical advances in the War on Cancer, including a finding that existing cancer drugs can prevent prostate cancer metastasis in mice. These advances and higher spending on pharmaceutical R&D notwithstaning, the number of new drugs being developed is in decline. Drug companies, it seems, are less innovative than before.
The US National Institutes of Health (NIH) hopes to stimulate innovation in medicine by spending up to five percent of its $30 billion budget for cross-disciplinary, “trans-NIH” research projects. With molecular and other exotic forms of medicine increasingly crossing traditional boundaries, this was a necessary and inevitable change that will keep the NIH relevant and better able to guide and promote advances in postmodern medicine.
Doctors and medical educators, too, must keep abreast of accelerating innovation or risk delaying advances of great potential benefit to patients. One tool of medical education that is receiving a makeover is the Grand Rounds, though it appears to need work.
A tool that we think ought to be taught in medical schools is the cell phone. By the end of this year nearly half the world’s population will have one. The simple ability to communicate on such a vast human scale is revolutionary in and of itself, but within the next year or two cell phones will become essentially PCs, and may incorporate sophisticated clinical monitoring, measuring, decision, and communication features. The implications of the ubiquitous presence of these devices — for healthcare access, disparities reduction, disease management, research, medical education, and more — should be assessed now.
Cancer Deaths Decline Continues
In 2003-4, the latest years for which figures are available, the number of cancer deaths in the United States dropped for the second straight year. Much of the decrease was due to smoking cessation and improved detection and treatment of colorectal, breast, and prostate cancers, writes Denise Grady in the New York Times . By far the greatest decreases in mortality have been in colorectal cancer — 1,110 fewer deaths in men, 1,094 fewer in women, partly as a result of more screening and partly because of “a revolution in treatment between 1998 and 2000, and revolution is a mild word,” as one expert put it. “We went from having one drug to having six or seven good drugs. The cure and survival rates have increased dramatically as a result. The cost of care has also gone up, but you get what you pay for.” But another cancer – prostate – is likely “to absolutely go through the roof in the next decade or two” as the population ages, another expert told Grady.
The US Government Accountability Office reported in December that while annual research and development spending by the pharmaceutical industry increased 147 percent between 1993 and 2004, the number of new drug applications grew by only 38 percent, and has “generally declined since 1999.” “What is more,” wrote Christopher Lee in the Washington Post , “about two-thirds of the new applications were for drugs that simply represent modifications to existing medicines.”
Reasons include:
- A growing difficulty in translating basic research into effective medicines;
- A shortage of physician-scientists who have both medical and research expertise;
- A focus on “blockbuster” drugs, which has reduced the numbers and types of new drugs; and
- A focus on treatments for complex diseases such as cancer, which have higher failure rates.
Transdisciplinarity at the NIH
In January, President Bush signed legislation giving the director of the National Institutes of Health more central authority over the research budgets of its 27 semiautonomous institutes and centers by allowing the director to skim some five percent of the agencies’ combined $30 billion budget into a “common fund” that wil be used for cross-disciplinary, “trans-NIH” research projects.
But with NIH budgets already tight and likely to remain so for some time to come, NIH director Elias Zerhouni said it will take “multiple years” for the fund to grow to five percent of the overall budget. Wall Street Journal reporter Bernard Wysocki Jr. noted that the NIH Roadmap – “a pilot project for the common fund” – and other trans-NIH programs account for about one percent of the NIH budget. However, he noted, “Patient-advocacy groups worry that individual NIH agencies’ programs might be squeezed by contributions to the fund.”
Zerhouni cited research into obesity and nanotechnology as two high-priority targets for the new money.
Future of Medicine from the NY Times
“As a reporter for The New York Times for 37 years,” wrote Lawrence K. Altman, MD, in one of two retrospectives on progress in healthcare published in the paper, “… it is clear that technology has accounted for the greatest changes in medicine.”
While noting that “Few people appreciate that medicine has advanced more since World War II than in all of earlier history,” his first article illustrates how doctors themselves are sometimes a barrier to its advance (though this was by no means the focus of his article.) Here are excerpts from various parts of the article:
- “Although doctors had measured blood pressure, few believed until the 1960s that lowering high blood pressure would prevent complications like strokes, heart attacks, loss of vision and kidney disease.”
- “… in the late 1960s … [a] patient needed scores of blood transfusions because of intermittent rectal bleeding. Standard techniques failed to detect the source of the bleeding in the bowel. An attending physician told us to stop the transfusions and let the patient die because he was depleting the blood supply. In desperation, we asked a radiologist to use new angiographic techniques to pinpoint the bleeding and stop it. The effort saved the man’s life.”
- “For breast cancer, radical mastectomy was virtually the only choice of surgery. We read studies from doctors in Canada and Europe who since 1939 had reported benefits from radiation and simpler operations for breast cancer. But our professors, virtually all men, made disparaging remarks about the quality of the work, and held dogmatically to a thesis that the more tissue removed, the better the outcome.”
- “In 1984, two Australian doctors, Barry J. Marshall and J. Robin Warren, reported scientific evidence that the H. pylori bacterium, not stress, caused most stomach ulcers. Many doctors dismissed the finding as nonsense, and criticized me for reporting what they knew could not be true. Soon antibiotic treatment for ulcers made a rarity of the common ulcer treatment: surgical removal of parts of the stomach. In 2005, Dr. Marshall and Dr. Warren shared a Nobel Prize.”
- “During my training, most professors said that all diseases were known. That hubris left doctors unprepared when AIDS came along in 1981.”
- “As malaria and many other so-called tropical diseases disappeared from the United States, most doctors did not understand their continued importance in the era of jet travel, which allowed someone to become infected in one part of the world and return home before falling ill.”
- “Though doctors have long stressed the importance of prevention and public health, they and society have been slow to take strong action. Our medical school class was lucky to have a good course in preventive medicine because epidemiology was not widely taught elsewhere. … At the time, anyone who went into preventive medicine and public health was assumed to have graduated at the bottom of the class. A shingle on Park Avenue was the measure of success, not saving lives in poor countries. Now students are eager to study global health.
“[I]magine,” he writes, “the laughter in 2056 as people look back at the brand of medicine and public health that we consider so sophisticated today. For all that doctors have learned in the last half-century, we are ignorant about far more.”
In his second article, “Grand rounds are not so grand anymore,” he points to one potential barrier to advances: Grand Rounds, where “For at least a century at many teaching and community hospitals, properly dressed doctors in ties and white coats have assembled each week, usually in an auditorium, for a master class in the art and science of medicine from the best clinicians. Before us was often a patient who sat in a chair or rested on a gurney and two doctors, one in training and the other a professor or senior doctor at the hospital. In a Socratic dialogue, they often led the audience in a step-by-step deciphering of the ailment.“ But in recent years, grand rounds have become didactic lectures focusing on technical aspects of the latest research. Patients have disappeared. If a case history is presented, it is usually as a brief synopsis and the discussant rarely makes even a passing reference to it.
Now grand rounds are often led by visiting professors, who is sometimes paid by drug companies and device makers, and the Socratic dialogue has given way to PowerPoint. These rounds are often useful, but certainly not grand. In short, “Grand rounds were showcases featuring the best clinicians, and the practice thrived in an era when doctors knew little more than what they observed at the bedside,” but that format “may no longer be enough to teach doctors what they need to know about proper care.” Nevertheless, they “remain important in continuing medical education, despite crtics who say that “the switch to lectures is a sign of the time pressures that have contributed to erosions in the patient-doctor relationship and to the dehumanization of medicine.” However, there is little published data documenting the effectiveness of grand rounds as a teaching forum.
“In an era of proliferating subspecialties, a chief aim of grand rounds is to emphasize a core body of knowledge that all physicians need to share and to keep abreast of…. Yet attendance at grand rounds has reportedly declined in recent years.… As medical educators seek ways to increase the appeal of grand rounds, they might look at being more imaginative and restoring a sense of humor.”
In the mid-1980s, the cell phone industry predicted that by the year 2000 there would be a market for about 900,000 cell phones worldwide, reports Jonathan Fildes for the BBC News. In fact, by 2000 that many phones were being sold every 19 hours. The latest prediction is that by the end of 2007 there will be more than three billion billion cell phone subscribers globally – almost half of the world’s population.
Demand for basic cell phones remains huge in the developing world, while phones replete with MP3 player, high resolution camera, games, GPS-based services (such as finding a nearby restaurant) and other capabilities will become the norm in the developed world as hardware continues to shrink, memory grows cheaper, software grows smarter, resulting on what one pundit says will be “the first true convergence of features.”
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