Tuesday, July 08, 2014
With ELIZABETH SMITH, PHD, Professor in Social & Behavioral Sciences in the School of Nursing, University of California, San Francisco
Tobacco use by military personnel is harmful to individuals, it’s harmful to the institution, and there’s no reason to continue supporting or even allowing it — was the argument Elizabeth Smith, PhD, and six co-authors made in a recent Perspective article in the New England Journal of Medicine (DOI: 10.1056/NEJMp1405976).
“People in the military are trying to implement these policies. And it’s really important that they get support from people involved in public health — doctors, nurses, and advocates, including people concerned about cancer,” Smith explained in an interview with OT. Here’s more on why she’s focusing her attention on this issue now…
1. The health risks associated with tobacco are well-known — why is NOW the right time to restrict tobacco use in the military?
“It’s been a good time for a long time. And the military has tried to do a lot of things over the past 20 years, but often Congress has prevented them from implementing strong tobacco control. For example, the Secretary of the Navy Ray Mabus wants to end tobacco sales on navy installations, but the House Armed Services Committee has put an amendment into the defense authorization bill that would prevent him from doing that.
“And that’s where the problem has been for a long time — in Congress, where the tobacco industry has a lot of influence. So public health advocates really need to step up and support the military’s effort to improve the health of the personnel.
“Right now is a good time [to enact this policy] partly because the support from the higher leadership does seem to be there — not only from the Secretary of the Navy, but also from the Secretary of Defense — and also because we’re having a drawdown of our military as forces pull out of combat. Personnel are going to be reduced, so now is a good time to tighten rules and restrict membership.”
2. Is there a precedent to restrict tobacco use in the military? What are the arguments AGAINST restricting its use by the military?
“Yes. Most fire departments do not allow their personnel to smoke because of the health consequences, which is a precedent for restricting tobacco use. It’s never been declared a right.
“It’s never been determined to be a right by any court and smokers are not a protected class. And, many of the rights of military personnel are curtailed in the name of good discipline or good health. Using tobacco is certainly not a benefit — we’re talking about selling members of the military an addictive and deadly product. It’s hard to see how that’s really a benefit, but that argument does get made.”
3. The NEJM Perspective article emphasizes that public health advocates need to support this initiative… Why? What are the implications for larger tobacco-cessation and cancer prevention efforts?
“Having a tobacco-free military sets a great example. It means that for young people who want to join the military, they’re much less likely to start smoking if they know they won’t be able to continue once they join. And once personnel leave the military, we won’t have that pool of people at a higher risk of smoking rejoining civilian life and increasing smoking rates in general. It would be a significant victory.”
Friday, May 23, 2014
With JEFFREY S. WEBER, MD, PHD, of Moffitt Cancer Center
Immunotherapy — particularly for the treatment of melanoma — played a break-out role at last year’s American Society of Clinical Oncology Annual Meeting with pivotal findings for the anti-PD-L1 antibody MPDL3280A and for the ipilimumab-nivolumab combination regimen being reported. Current ASCO President Clifford A. Hudis, MD, deemed it “the beginning of an exciting new chapter of cancer” (OT 6/25/13 issue).
Will the trend continue at this year’s 2014 Annual Meeting?
Yes, said Jeffrey S. Weber, MD, PhD, Director of the Donald A. Adam Comprehensive Melanoma Research Center at Moffitt Cancer Center — who will be moderating the Oral Abstract Session at ASCO this year on Melanoma and Skin Cancers (Mon., 6/2, 3-6 pm). “But it’s going to have to meet a pretty high bar.”
In an interview, Weber previews what to expect — and what not to miss…
1. Last year was a break-out year for immunotherapy — how will this year top it?
“Last year we saw significant clinical impact with high response rates, long duration of responses, and intimation that you had clearly prolonged survival in patients [with melanoma] who had failed on all other therapies, but then got PD-1 blockade. Everyone realized that these drugs were going to get approved — and it was obvious that they were going to provide significant patient benefit. And it was not just one drug, but three different drugs. Everyone felt the PD-1 blockade had arrived.
“This year, for the first time, we’re going beyond melanoma. You’re going to see some of this in solid tumors. There’s going to be data on the PD-1 antibody in lung cancer. There are studies on tumor infiltrating lymphocytes in cervical cancer and adoptive therapy.”
2. What would you say was the impetus to move immunotherapy beyond melanoma?
“Melanoma is the immunogenic tumor — if an immunotherapy is going to work, you’re going to have to test it in melanoma. But, people realized that when they started to reach across a broad range of cancers in the first Phase I trial of nivolumab, it looked like there was some activity in lung cancer and maybe colon cancer — that was the impetus, and it was a good thing.
“I call it the Rodney Dangerfield effect. His punch line was: ‘I don’t get no respect.’ With immunotherapy, for years people thought it would only work in melanoma, the immunogenic tumor. Now it works really well in melanoma with long survival, and now it’s starting to work in renal cell cancer, non-small cell lung cancer, and maybe other cancers. Now there’s some respect in the field. It’s all about the non-melanoma data.”
3. What about in melanoma — what’s going to be the big immunotherapy news this year?
“You’re going to see expanded data on what came out last year — follow up data and long-term survival data. Antoni Ribas, MD, PhD, will be talking about MK-3475. Michael Atkins, MD, will be talking about pidilizumab, another PD-1 antibody. Stephen Hodi, MD, will be talking about long-term survival for nivolumab. And, Mario Sznol, MD, will be talking about ipilimumab with nivolumab.
“Then you’ll have Howard Kaufman, MD, talking about T-VEC [talimogene laherparepvec], and Alexander Eggermont, MD, PhD, presenting the final definitive Phase III relapse-free survival data from the ipilimumab versus placebo EORTC 18071 trial (the CTL4 antibody).
“Those are all pretty serious.”
Friday, May 16, 2014
With SAMUEL WAXMAN, MD, Founder & CEO of the Samuel Waxman Cancer Research Foundation
NEW YORK — Dozens of cancer researchers convened for two days earlier this week at the Leon and Norma Hess Center for Science and Medicine at Mount Sinai Hospital to discuss the results from their work in brain cancer, blood malignancies, cancer stem cells, lung cancer, breast cancer, and more—and how their findings translate across laboratories and across tumor sites. Their willingness to collaborate is why this group of researchers was chosen to receive funding from the Samuel Waxman Research Foundation.
“To get a grant past the first year, the researchers have to collaborate with other researchers funded,” explained Samuel Waxman, MD, founder and CEO of the Foundation. The idea, he continued, is that including researchers with a diversity of thought offers the best hope of translating progress in cancer treatment across cancer types and research efforts.
That was the lesson of Waxman’s well-known successes in acute promyelocytic leukemia: “That idea is now being translated to other forms of blood malignancies and cancers,” he said.
In an interview at the symposium, Waxman elaborated on the potential of such collaborations.
1. The researchers funded by the Foundation are working on all different types of cancer research — could you explain how that is connected and how the researchers can collaborate?
“We have created a brain trust on understanding what is wrong with the abnormal gene expressions in cancer. It goes across the entire spectrum of cancer. By having that reach, we can understand why a cancer cell doesn’t function properly and what makes it go on to die; why cancer cells have the ability to become resistant to treatment; and why some cancer cells remain dormant but are still able to survive many many years in the patient.
“The Foundation was built on the idea that in order to make progress in curing and finding treatments for cancer, you have to understand what the problem is in the cancer cell. You need really good discovery research. And, that can be done only by highly qualified scientists, and can be done more rapidly by teams collaborating.
“It may be that foundations do better in terms of fundraising if they focus on one kind of cancer — and we discussed this at great length [at the symposium over the past two days]. And, it was the overwhelming opinion of the researchers funded by the foundation that the diversity of thought — having the right brain trust — is what makes this foundation unique.”
2. So how do you select researchers to receive funding and be part of the Foundation?
“We’re looking for real experts — scientists of proven performance. And they have to respond to our mission — that is, to be interested in abnormal function of the gene or pathway that results in cancer cell development — in any form of cancer. We often call this the epigenetic part of cancer control.”
3. Which updates at the symposium were you most excited about?
“There is a form of leukemia that has a problem with a particular gene in the biochemistry of these cells. There is a metabolite building up because of a mutation. But, if you use an inhibitor against it—you can actually get remissions in this form of acute myeloid leukemia (AML). That’s the same idea as what we did in acute promyelocytic leukemia — the cells actually differentiate to stop looking leukemic, they become n-stage leukemic cells, and people go into remission.
“And in colon cancer, there is new research on the effect of diet and inflammation — what particular genes are responding in a way that causes cancer in response to fat, diet, and inflammation, like Crohn’s disease.
“We also heard about some really interesting genes that make proteins that could be drugs, and we heard a lot about cancer stem cells in leukemia and in breast cancer.”
Thursday, May 08, 2014
With ALEC STONE, MA, MPA, Health Policy Director for the Oncology Nursing Society
ANAHEIM, Calif.—The “fixes” to today’s health care (and more specifically cancer care) dilemmas will require more coordination of care, and more individuals to act as navigators to help guide patients through the maze of care regulation, insurance red tape, hospital care, and specialty care — so explained the Oncology Nursing Society’s Health Policy Director, Alec Stone, MA, during a session on health policy issues here at the ONS Annual Congress.
“Almost all successful models of care coordination have incorporated patient-based communication,” he said. “You as nurses — you have the central role here.”
During the session Stone talked about H.R. 1661, legislation that would amend title XVIII of the Social Security Act to provide (paid) comprehensive cancer patient treatment education under the Medicare program. In an interview after the session, Stone reiterated these key points about what the proposed law would change, and how oncology nurses can play a role in getting the bill passed.
1. How would The Improving Cancer Treatment Education Act actually improve cancer treatment education if passed?
“The legislation calls for one hour of one-on-one reimbursed time [$83/hour] to educate cancer patients in an outpatient practice about their symptom management. And that hour of education would be reimbursed by Medicare.
“The idea is that that one hour of education gives the patient an understanding of what their disease is and what the symptoms are, so they can take better care of themselves — and would diminish hospital readmissions — and diminish the need for patients to run to use the emergency room as a primary care physician. An ounce of prevention saves millions of dollars down the road.”
2. And the idea is that once Medicare does it, private insurers will follow suit?
“It’s not immediate — it takes time. But people come to demand it.
“It’s already happening in diabetes. Diabetes educators get $45 for 30 minutes of patient education [reimbursed by Medicare] to teach the patient about how to manage blood sugar levels and how to use insulin, and appropriate nutrition and exercise programs.
“And insurance companies now are not suggesting that diabetics get this education, they are demanding that they get it — because when a patient’s disease is out of whack, it costs more. Now they’re saying it’s much cheaper for us, as the insurance company, to pay the $45 [for that hour of education], than for the patient to come in once a month or once a year [with complications].
”That’s what we’re saying for cancer as well — at the beginning, educate the patient, and later on you don’t have to pay for these other complications.”
3. What’s the next step to get the bill passed?
“Send letters and emails to your elected officials — members of Congress, your representatives and your senators. Educate your legislators. Here’s our bill, 1661. Either, ‘You’re not signed onto it, please sign onto it. I’m an oncology nurse and here’s what I think.’ Or, ‘You are signed onto this. Here’s what I just heard about this. Thank you very much.’
“If a U.S. Representative gets ten emails from ten oncology nurses, someone in that office is going to see that as a red flag. It’s not just one. Ten oncology nurses from one congressional district emailed us. Something is going on. We need to find out what that is.
“Oncology nurses are very powerful advocates and they have very powerful stories — about children with leukemia, about a wife with breast cancer, about a father with colon cancer. These are stories that resonate. They can really move audiences.
“It’s an uphill climb, though. We have 41 bipartisan cosponsors in the House, but we don’t have a companion bill in the Senate. So we’re working to energize our members to reach out to their senators to try to get a bill introduced.”
Get more info on H.R. 1661: www2.ons.org/LAC/WhatONSisDoing/EducationBill or www.govtrack.us/congress/bills/113/hr1661.
Tuesday, May 06, 2014
With ANNE IRELAND, MSN, RN, AOCN, CENP, of City of Hope
ANNE IRELAND, MSN, RN, AOCN, CENP, serves as Clinical Director of the Solid Tumor Program at City of Hope National Medical Center, and also previously served as the Clinical Architect for electronic health record implementation for Fletcher Allen Health Care in Burlington, Vermont
Even if you can look up a patient’s electronic medical health record from another unit, should you? What happens if you accidentally pull up the wrong patient’s EHR? What happens if you accidentally divulge information from that EHR?
There can be serious consequences for not using technology wisely and not thinking. That was the takeaway message of a session this week at the 2014 Oncology Nursing Society Annual Congress on Health Information Technology and Ethics in Oncology, here in Anaheim, California. With the implementation of electronic medical health records systems still underway, and the rules of social media changing all the time, sessions like this one tended to raise as many questions as answers.
The promise of a fully recognized EHR system comes with new challenges to protect patients’ privacy, confidentiality, and data, plus puts new ethical burdens on care providers to use the tools responsibly, Ireland and the other session moderators explained. In an interview afterward, Ireland summed up these key points.
1. What new challenges does health IT pose regarding the protection of patients’ privacy?
“All information is fully accessible — it’s really easy now. But by the code of ethics it is obligatory to protect the health information of the people that we care for. Other people around them don’t have a right to know any of that information, unless the patient has explicitly given me permission to share that. It’s hard now though, because the information is just there.
“We talked about that in the conversation. When we asked the nurses: ‘If you work in one unit, are you able to look at a patient’s chart in another unit? Everybody said yes. But, is it OK that you can just click and go read?’”
2. What information is considered protected, private?
“Anything that could speak to the patient’s health condition or the treatment of that health condition. Anything that would make it clear, explicitly, what was going on with that particular patient. Frankly, even just knowing that somebody’s coming to a facility for care can be a breach. In my case, I work at City of Hope. If you’re a patient at City of Hope, people now know you have cancer. So, I’m very sensitive to that.
“That gentleman I was just talking about [During the session Ireland had related an incident of running into a patient who asked her where he knew her from, while both were at a baseball game] — I said I work in ‘health care.’ … I didn’t want to say I work at City of Hope, because by virtue of saying that — I didn’t know whether the people that were with him knew he had a cancer diagnosis.
“These issues have existed in health care for a long time. Because now you can see what people are doing and where people are looking — every click is recorded — in a way, health IT has just shined a light on all of it.”
3. The onus then seems to be on the provider then to be aware of whether or not they are breaching a patient’s privacy? What is your advice for providers?
“Choose those words very carefully — what you say in public, especially what you say in public places where other people are around. You have to assume that the person doesn’t want anyone to know [information about their health]. That’s the safe place to start from.
“Before we share anything — unless the patient has explicitly said, ‘please share this information with this person because I want them to understand and help’ — we have to assume that they don’t want that person to know anything. And it’s incumbent upon us, professionally to protect their request.”