COMMENTARY

Dealing With Data Overload in Oncology

H. Jack West, MD; Hossein Borghaei, DO

Disclosures

May 30, 2018

H. Jack West, MD: Hello. I am Jack West, medical director of the thoracic oncology program at Swedish Cancer Institute, in Seattle. Welcome to Medscape Oncology Insights. Joining me today is Hossein Borghaei, chief of thoracic medical oncology at Fox Chase Cancer Center in Philadelphia. Welcome, Hoss.

Hossein Borghaei, DO: Thank you.

West: We're going to talk about something that is applicable to just about all of oncology and probably the broader range of medicine: the explosion in the rate of new information and the implications of that. It's been great for medicine and great for patient care to have more options, but I think it's really changed how we need to process information.[1,2] This is especially true if you are more of a generalist, seeing 10 or 15 kinds of cancer or multiple aspects of medicine. That and the fact that information is just more transparently available—not just to doctors anymore, but to patients and caregivers, and covered on the news.[3] It has changed the equation of how patients and physicians interact.[4] Previously, doctors had a very finite amount of knowledge that they needed to carry in their head and deliver to patients. We'd say, "Here's what you need to do," and the patient nodded and did it or did not do it. Now, the new developments are just coming out of a firehose to everybody. It's really very challenging for doctors to keep up with what's happening.

It's really very challenging for doctors to keep up with what's happening.

We're in the wake of the American Association for Cancer Research meeting. Historically, this meeting highlighted preclinical data and very early clinical data, but this year, researchers presented information from randomized phase 3 studies that have clinical implications.[5] It's a reflection of how temporally decentralized things have become, that every few weeks we're getting new press releases and having to think about how to incorporate not the actual data, but the data in the press release that gets picked up on the news. And when data are presented, they're no longer just presented at one big major meeting but at multiple meetings peppered throughout the year. It never stops, and it's coming at a faster and faster pace. Patients and their caregivers are increasingly coming to us with information. I think it has huge implications. I wonder if we're at a point where docs can't even pretend or shouldn't agonize over keeping up with everything, and you now just have to accept that you're going to need to find it on demand when you need it, rather than carry it in your head. What are your thoughts about the ability to keep up with all of this information?

Borghaei: I only do lung cancer and I sometimes wonder how I can keep track of everything that's being reported. I wish to God that they would get rid of these press releases, because they're more frustrating than anything else. It's impossible. I feel really bad for my colleagues who are in private practice, as they have to know the data for breast cancer, for renal cancer, for bladder cancer, for lung cancer. Again, it's difficult. In our business, we might call, text, or email a friend and say, "You're an EGFR expert; what would you do in this scenario?" It is difficult to keep up-to-date, and knowing all of the numbers off the top of your head has become quite a challenge for most medical oncologists. That's a good thing, because it suggests that we have many more options for patients. It's a bad thing, in that you are not as confident remembering overall survival data from one regimen versus the other. [Your knowledge is] a little bit diminished, because there are so many options.

What do I do? In a standard clinical practice, I would go to guidelines. We have ASCO guidelines.[6,7,8] We have NCCN guidelines that are updated so frequently with the data, and that is a wonderful resource.[9]

West: That brings up a couple of things, the first of which is the need to have reliable, credible sources such as the NCCN guidelines, UpToDate, and Medscape, that clinicians can turn to for the latest information. Go to these credible sources, and use that for what is current as of today.

You mentioned the guidelines, but I think we need to move to more algorithm-based medicine. You and I might be specialized enough to keep up with our corner of it, but I also treat some other cancers and, of course, there are many other docs who are treating 10 or 15 kinds of cancers in a day or other aspects of medicine. It has become so complex that you need to rely on algorithms to keep up-to-date and [informed] on the best treatment for your patients.

Borghaei: Yes. I think we're going to see more and more of that, because, again, it is difficult to keep up with all of the data in all of the areas. I have a feeling we're going to see a lot of these algorithms flourishing and guidelines from different groups coming out, and then physician groups actually following the specific guidelines and algorithms, because that's the way you know you're getting the best care to your patients.

West: I think that this concept of pathways and algorithms is a double-edged sword. Some people feel constrained by that, and yes, you don't want to be imprisoned by that to the point that there is no role for personal judgment. However, in a world where things are changing so quickly, it's helpful to just know the current expectation.

Borghaei: Right. I would look at [the guidelines] as suggestions, not necessarily a dictum of the way you have to do it. But it gives you an idea. If you were doing primarily lung cancer, but then you see a breast cancer patient, it would be good to know the recommended first- or second line for a specific patient population. Again, you're allowed to interpret the data, but the guidelines and the algorithms will provide you with at least a starting place of what most people would probably consider.[6,7,8,9]

A second opinion is not a rejection of the doctor.

West: Today we see more [advanced practice clinicians (APCs)], mid-levels as they are sometimes referred, and other nonphysicians delivering more care at the bedside, but they are well trained.[10] I think that is going to lead to more doctors covering a broad range of patients, maybe even at different centers with telemedicine, and I hope it leads to an increasing use of more specialized docs just more intermittently.[11,12,13]You and I see a lot of second opinions. It's important to highlight that a second opinion is not a rejection of the doctor. It's helpful to have someone on the team who eats, sleeps, lives, and breathes one subspecialized cancer and who can offer some thoughts that can be executed close to home by the local physician and their team that may include an APC.[10,14]

Borghaei: I think that would be a great resource for everybody.

West: We don't want to have people fighting traffic to get into the city when they could get the exact same chemo that could be administered close to home.

Borghaei: Right. I agree with that.

West: We will see how that happens. I'm starting to see telemedicine begin to get executed and, obviously, we have the technology.[11,12,13] We have to overcome the regulatory hurdles and get used to integrating it; telemedicine has the potential to enable patients to receive the care they need closer to home without having to take half a day off from work to come in and get this or that skin lesion looked at.

Borghaei: I have evolved my ideas about telemedicine over the years because, as you just heard, it doesn't make a lot of sense to see somebody who drives an hour and half to two hours when they could have received therapy closer to home. For patients like that, telemedicine makes perfect sense. You are just across from a camera, and you deliver the same kind of idea instead of a patient having to come two hours away.

West: What would be great is having patients be able to stay close to home and get their care by the person who is most accessible. It may be most efficient to have an APC at the top of the license, and then overseen by and working with an oncologist who may be a general oncologist. Then, you can have a telemedicine-based specialist or an occasional visit to a subspecialist who can offer their honing thoughts on [treatment] that can be executed close to home. The patient can avoid traveling and paying $25 to park for the same treatment.

Borghaei: We don't charge patients for parking, but I can understand.

The fact that your patient may know a lot about something, maybe more than you, doesn't make you a bad doctor.

West: We do. It's interesting. The other aspect that has really changed is having patients become more aware of their own diseases and how that changes the dynamic. We now have an increase in patient online groups, particularly for subgroups with narrow populations—say a ROS1 rearrangement[15] or the Life Raft group for GI stromal tumors. [Life Raft] was among the first [patient groups] for what was seen as a rare cancer to get mobilized. And they became a force to be reckoned with.[15,16] This group highlighted several things, first of which was that these patients can disseminate great information across a broad geography, often about a topic that many doctors do not see a lot of and don't have as much knowledge about. As doctors, you need to understand that the fact that your patient may know a lot about something, maybe more than you, doesn't make you a bad doctor. It's that they can focus hours every day on a topic and you can't.

Borghaei: For years, we wanted our patients to be their own advocates. We wanted them to be more involved in their care so they know what's going on. That's what we're seeing now. It might mean that you're spending a little bit more time with the patient who comes in and wants a therapy that you might not agree with, but overall, having this patient awareness and the families actually looking into things has been good for medicine.

West: Increasingly, what I perceived as the firewall between the patient side and the physician side is eroding. There are doctors working more closely with patient groups, sharing/providing information and vetting it. Ideally, what is being shared among the patients, very efficiently, and virally sometimes, is high-quality information. It's not undermining the messages we want to get out there. Rather, it may get a message to hard-to-reach [doctors] who only see one ROS1 patient a year.

Increasingly, online groups are starting to partner with investigators and companies to say, "Hey, we're a group of people who are really eager to have access to this drug that you might want to develop. We can guarantee that we will get the trial enrolled for your novel agent." This changes the equation. If a company knows that a 1% or 2% population is not an insurmountable barrier [to development] and that they could enroll a phase 2 trial of this rare subgroup in a matter of months, it makes it increasingly possible to complete the research faster.

Borghaei: Absolutely. Then again, having a patient advocate, when you're doing clinical trials design and talking about all of this, is important. It's important to get the patient's perspective as to what they really think about increased toxicities and how much clinical benefit is worth the additional toxicity, etc.[7,8,9] Those kinds of discussions never used to take place, but now, more and more, they've become commonplace. I think all of that has been good.

West: Yes, it's obviously going to continue to evolve. It's all a byproduct of having so many options that we're tripping over them. It's good for the field. We just need to change our practices from the time when we collected our information by reading textbooks and hardback, because if it's in print, it's practically out of date right now.

Borghaei: I agree.

West: Thank you for joining us today for this discussion.

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