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Cancer, Patient Care, Stanford News, Videos

How a new Stanford program is helping transform cancer care

How a new Stanford program is helping transform cancer care

Earlier this week my colleague wrote about a new program where experienced nurses help newly diagnosed cancer patients navigate their medical care. The video above talks more about the program (“We want to take the fear away from our patients and their family,” explains oncologist Oliver Dorigo, MD, PhD) and how it fits into Stanford’s efforts to transform cancer care.

Previously: Pioneering cancer nurses guide patients through maze of care, Ironman of Stanford Women’s Cancer Center and Director of the Stanford Cancer Institute discusses advances in cancer care and research

Cancer, Events, Genetics, Imaging, Stanford News, Surgery, Women's Health

Don’t hide from breast cancer – facing it early is key

Don't hide from breast cancer - facing it early is key

cat_hiding-pgMy cat suffers from acute anxiety. Although she and I have lived together for more than 12 years, and the worst thing I’ve ever done to her was cut her nails, she’s terrified of me. (She’s also very smart – she runs from the sound of my car, but not my husband’s). During trips to vet, Bibs hides her eyes in the crook of my elbow.

It’s a strategy that’s only minimally effective. After all, what I can’t see, or don’t recognize, can still hurt me.

Take breast cancer. It terrifies most women. And if you don’t look for it, you won’t find it. But if you do look, and find it early, you might save your life and your breast, says Amanda Wheeler, MD, a Stanford breast surgeon. She joined other Stanford breast cancer experts at a recent public program sponsored by the Stanford Women’s Cancer Center called “The Latest Advancements in Screening and Treatment for Breast Cancer.”

“One of our biggest challenge is women are scared of breast cancer, but[we have to get] the word out that we have such great advances, we’ve just got to catch it early,” Wheeler said.

She pointed to a tiny dot on a screen. At that size, Wheeler said, breast cancer is almost 100 percent curable. She performs a small lumpectomy. If it’s a little bigger, she can still probably save the nipple.

And if the entire breast must be removed, surgeons like Rahim Nazerali, MD, come in. Nazarali explained the importance of choosing a reconstruction surgeon carefully: The doctor should be accredited by the American Society of Plastic Surgeons and have experience with microsurgery, preferably on the breast. There are different ways to remold a breast and doctors can use either a synthetic implant or a patient’s own tissue, from their abdomen, hips or thighs, Nazerali explained.

All of Wheeler and Nazerali’s artistry depends on expert imaging performed by specialists like Jafi Lipson, MD, whose message at the event was simple and encouraging.

Thanks to many new developments, mammography isn’t the only way to detect nascent breast cancers, Lipson said. Her team can employ 3-D mammography, or tomosynthesis, to reveal a layered look at a breast. And genetic screening, particularly for those with a history of breast cancer in the family, can provide the earliest warning signal of all, the breast cancer team said.

Women no longer need to hide their eyes from the risk, the experts emphasized. Women should take a peek – there’s help coping with what they may find.

Previously: Screening could slash number of breast cancer cases, The squeeze: Compression during mammography important for accurate breast cancer detection, Despite genetic advances, detection still key in breast cancer, NIH Director highlights Stanford research on breast cancer surgery choices, Breast cancer awareness: Beneath the pink packaging and Using 3-D technology to screen for breast cancer
Photo by Notigatos

Cancer, Events, In the News, Patient Care, Stanford News

A neurosurgeon’s journey from doctor to cancer patient

A neurosurgeon's journey from doctor to cancer patient

image.img.320.highEarlier this week, I had the chance to hear Stanford neurosurgeon Paul Kalanithi, MD, discuss living with advanced-stage lung cancer in a conversation with palliative care specialist Timothy Quill, MD. The idea for the night’s event, which was held on the Stanford medical school campus, was to provide a good example of how the doctor-patient relationship can help improve quality of life for the very sick. On stage before a packed audience, Kalanithi, prodded by Quill’s gentle but pointed questions, told the story of how serious illness changed his life. As I wrote in an online story posted yesterday:

“Are there things in particular that you worry about now?,” asked Quill… a professor of psychiatry and medical humanities at the University of Rochester School of Medicine and an expert in end-of-life decision making. “Not really,” [Kalanithi] said. “I am sad at not seeing my daughter grow up, at probably not being here long enough for her to have a memory of me. I try to worry about things that are actually changeable. I worry about getting my book finished. I’d like to have that done for my daughter to know me.”

What surprised Kalanithi most about his life after being diagnosed with lung cancer was just how hard it was dealing with those “existential” questions, he told Quill:

“Having to deal with questions like, ‘What am I going to do with my life?’ was exceedingly difficult. After realizing I wasn’t going to die in weeks or months, figuring out what I was going to do with that time was a struggle.”

Kalanithi has reorganized his priorities since his diagnosis in May 2013, setting new priorities for a much shorter lifespan than he once expected – planning for years instead of decades. He and his wife got their finances in order, they had their first child July 4. Kalanithi said he has found solace in his love of poetry, and through his writing. Kick-starting a writing career that he had planned to start in 20 years was one of those changes.

In January, he wrote an op-ed piece for the New York Times about his cross over from physician to patient titled: “How long have I got left?” He told the audience how surprised he was at the overwhelmingly positive response he received to the story. “My own thoughts on something very personal, really resonated with people. I still get an email every other day in response to the New York Times piece. It’s a great inspiration to me to remember why writing is important.” [Editor's note: Kalanithi's recent Q&A here on Scope has also drawn massive attention; it's already one of our most popular posts of the year.]

Kalanithi’s final message, particularly to those young physicians and medical students in the audience, was to listen to your patients. Take time to get to know them. Remember why it is that you went to medical school. When asked if he treats his own patients differently since his diagnosis, he was characteristically thoughtful. “I think I felt a depth that I didn’t before… But I had excellent role models. I was trained you don’t just go over what are the risks and benefits. You really try to convey as much as you can about what it’s going to feel like.” He told his favorite example of a pediatric oncologist who he observed talking to parents whose daughter had just been diagnosed with a brain tumor. The doctor’s advice: “You need to support each other. You have to prepare your patients as much as you can for that larger emotional experiential landscape. You have to get enough sleep.”

Previously: “Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness and No one wants to talk about dying but we all need to.
Photo by Norbert von der Groeben

Cancer, Genetics, Medicine and Society, Research, Stanford News, Women's Health

Screening could slash number of breast cancer cases

Screening could slash number of breast cancer cases

dna-163466_1280Should every newborn baby girl be genetically screened to prevent breast cancer? Obviously, that isn’t cost-effective — yet. But if it were, would it be worthwhile?

A previous study said no. But research published today in Cancer Epidemiology, Biomarkers & Prevention by Stanford researchers suggests otherwise.

Led by senior author Alice Whittemore, PhD, the team examined 86 gene variants known to increase the chances of breast cancer. They created a model that accounted for the prevalence of each variant and the associated risk of breast cancer. Each possible genome was then ranked by the likelihood of developing breast cancer within a woman’s lifetime.

“It was quite a computational feat,” Whittemore told me.

Working with Weiva Sieh, MD, PhD; Joseph Rothstein, PhD; and Valerie McGuire, PhD, the team found that women whose genomes ranked within the top 25 percent of risk include 50 percent of all future breast cancers. Those women would then have the opportunity to get regular mammograms, watch their diets and make childbearing and breast-feeding decisions with the awareness of their higher risk. Some women might even select, as Angelina Jolie did quite publicly, to have their breasts removed.

“The main takeaway message is we can be more optimistic than previously predicted about the value of genomic sequencing,” Whittemore said. “But we still have a way to go in preventing the disease.”

“Our ability to predict the probability of disease based on genetics is the starting point,” Sieh said. “If a girl knew, from birth, what her inborn risk was, she could then make more informed choices to alter her future risk by altering her lifestyle factors. We also need better screening methods and preventative interventions with fewer side effects.”

“We want to focus on those at the highest risk,” Whittemore said.

Previously: Despite genetic advances, detection still key in breast cancer, NIH Director highlights Stanford research on breast cancer surgery choices  and Breast cancer awareness: Beneath the pink packaging 
Photo by PublicDomainPictures

Biomed Bites, Genetics, Research, Stanford News, Videos

DNA architecture fascinates Stanford researcher – and dictates biological outcomes

DNA architecture fascinates Stanford researcher - and dictates biological outcomes

It’s time for the next edition of Biomed Bites, a weekly feature that highlights some of Stanford’s most innovative research and introduces Scope readers to groundbreaking researchers in a variety of disciplines. 

It’s a puzzle that would delight puzzle master Will Shortz: How do you pack 2 meters of DNA into a container (the nucleus) only .000005 meters wide? Precisely, and according to plan, it seems. Stanford biophysicist Will Greenleaf, PhD, studies the architecture of the genome, building on the knowledge that DNA’s shape effects how a gene is expressed.

In the video above, Greenleaf, now an assistant professor of genetics, explains: “The genes have to be unpacked to be expressed. The mechanics of that are really fascinating.”

Greenleaf is a physics guy, earning a PhD in applied physics at Stanford to build on his undergraduate Harvard physics degree. He has also studied computer science and chemistry, bringing all of this knowledge to bear on demystifying the structure of DNA, and its RNA offshoots. Greenleaf and his team also develop new instruments needed to measure, see and manipulate DNA structure.

This is important for many reasons, but most directly to treat chromatinopathies, or diseases caused by the improper folding or structure of DNA and its associated proteins.

Learn more about Stanford Medicine’s Biomedical Innovation Initiative and about other faculty leaders who are driving forward biomedical innovation here.

Previously: Caught in the act! Fast, cheap, high-resolution, easy way to tell which genes a cell is using, “Housekeeping” protein complex mutated in about 1/5 of all human cancers, say Stanford researchers and Mob science: Video game, EteRNA, lets amateurs advance RNA research

Cardiovascular Medicine, Chronic Disease, In the News, Research, Science, Stanford News

How best to treat dialysis patients with heart disease

How best to treat dialysis patients with heart disease

523392_4923732760_zKidney failure patients on dialysis often have other chronic diseases – heart disease topping the list. They’re prescribed an average of 12 pills a day by physicians, according to Stanford nephrologist Tara Chang, MD, and they spend three-to-four hours at a treatment center three times a week connected to an artificial kidney machine.

For Chang, this makes it all the more important that any medication she prescribes for a patient on dialysis is both essential and effective.

The problem is, particularly in the case of treating kidney patients with heart disease, evidence-based treatment guidelines just aren’t available. Kidney doctors are left making best guesses based on guidelines written for the general population.

“Our patients might be different from patients not on dialysis,” said Chang. “Dialysis patients have a lot of heart disease, yet rarely does a cardiology study enroll patients on dialysis, so we just don’t know.”

This was part of the motivation behind Chang’s most recent study examining the use of anti-platelet drugs such as clopidogrel, one of the most commonly prescribed drugs for kidney patients. The researchers looked at the use of anti-platelet medications such as clopidogrel as treatment following stenting procedures to unclog arteries in the heart in 8,458 dialysis patients between 2007 and 2010. The data suggests that longer-duration of drug use may be of benefit to patients on dialysis who get drug-eluding stents but not those who get bare metal stents. Chang told me:

We found that for those who got drug-eluting stents who took the drug for 12 months compared to those who had stopped the drug at some earlier time point, there was a non-statistically significant trend towards lower risks of death and heart attacks. So for this group, following the same guidelines as for the general population may be appropriate. However, we found no indication of benefit with longer duration of anti-platelet drug use for patients on dialysis who got bare metal stents.

About half of the 400,000 patients in the U.S. on dialysis also have coronary artery disease, as referenced in the study. The number of those getting stents inserted to unclog arteries also has increased 50 percent in the past decade, the study states. The results of the study, while not definitive as to exactly how long doctors should prescribe the drug, does stress the need for more clinical research on patients with kidney failure to provide guidance on treatment strategies for heart disease.

“Because our study was not a randomized trial,” said Chang, “we tried to be very measured in how we interpreted the results. What it does point to is the fact that we can’t assume that what works in non-dialysis patients works in dialysis patients. Hopefully our study will help convince researchers to include our dialysis patients in their studies.”

The paper was published this week in the Journal of the American Heart Association.

Previously: Keeping kidney failure patients out of the hospitalStudy shows higher rates of untreated kidney disease among older adults and Study shows daily dialysis may boost patients’ heart function, physical health.
Photo by newslighter

Autoimmune Disease, Chronic Disease, Immunology, Stanford News, Videos

Unbroken: A chronic fatigue patient’s long road to recovery

Unbroken: A chronic fatigue patient’s long road to recovery

“Fatigue is what we experience, but it is what a match is to an atomic bomb,” said Laura Hillenbrand, the author of Unbroken, about how it feels to live with chronic fatigue syndrome.

I recently finished a Stanford Medicine story and video (above) about another CFS patient, “Erin,” who asked that her real name not be used. After an acute illness in rural Mexico, Erin went from being an elite soccer player to one of the 17 million people worldwide who suffer from the condition.

Most people who acquire hit-and-run infections go back to their normal lives after a few days. But these patients don’t. They become virtual shut-ins, prisoners of a never-ending cycle of flu-like symptoms, many of them bedridden for years. CFS, also called myalgic encephalomyelitis or ME/CFS, has no known cause or cure, frustrating both patients and physicians.

What makes Erin’s CFS story somewhat rare is its happy ending. With the help of Stanford infectious disease expert José Montoya, MD, and cardiac electrophysiologist Karen Friday, MD, Erin is back to working fulltime and playing soccer.

“Dr. Montoya and doctors like him are heroes for taking up an unpopular disease and patients that most doctors shun,” said Lori Chapo-Kroger, a registered nurse and CEO of the patient charity, PANDORA Org. “He combines his medical expertise and a creative approach with a truly caring heart for suffering patients.”

Dr. Montoya is also collaborating with immunologist Mark Davis, PhD, on the Stanford Initiative on Infection-Associated Chronic Diseases, a research project using cutting-edge technologies to identify the biomarkers and root causes of ME/CFS. Working at the Human Immune Monitoring Center, team members are searching 600 blood samples for infectious microbes, inflammation-related molecules and genetic flaws. In addition, they’re conducting brain scans and physical exams to look for physical abnormalities among these patients.

Early results are promising — the team has discovered a number of measurable biological markers that indicate that ME/CFS patients may be suffering from out-of-control inflammation.

The team’s goal: To find out what is wrong with the immune systems of patients with infection-triggered diseases such ME/CFS and Lyme disease, then figure out how to help them get better.

Previously: Deciphering the puzzle of chronic fatigue syndrome

The HIMC is partially funded by Spectrum, Stanford’s NIH Clinical and Translational Science Award.

Health Costs, Health Policy, Medicine and Society, Public Health, Research, Stanford News

Competition keeps health-care costs low, Stanford study finds

Competition keeps health-care costs low, Stanford study finds

The term market competition usually sparks a mental image of business suits and ties, not white coats and stethoscopes. Yet even the health-care system plays by the rules of the economic market place.

A new study, conducted by Stanford researchers Laurence Baker, PhD; M. Kate Bundorf, PhD; and colleagues, provides important evidence that less competitive health-care markets are more likely to charge higher prices for office visits. The article was published today in The Journal of the American Medical Association.

There’s a push through the private sector and through Medicare to encourage the formation of larger practices, which could improve the efficiency of the health-care system, said Bundorf.  The researchers sought to understand what effect these larger practices have on health-care spending.

To make the comparisons, the researchers used a database to establish the prices paid by PPOs for the most commonly billed office visits within 10 physician specialties. Next, they adapted a standard economic competition measure to calculate physician practice competition for different U.S. regions.

As I wrote in a release today:

Studying a measure that averaged prices across multiple types of office visits, in their most conservative model, being in the top 10 percent of areas with the least competition was associated with 3.5 to 5.4 percent higher mean price. The researchers point out that in 2011, privately insured individuals in the United States spent nearly $250 billion on physician services. In that context, these small percentage increases could translate to tens of billions of dollars in extra spending.

The study’s findings show the importance of developing policies that will encourage a balance between the quality of care and health-care spending. As Baker explained, “Sometimes it can be tempting to say our goals for the health care system should be only about taking care of patients and doing it as well as possible – we don’t want to worry about the economics. But the truth is we do have to worry about the prices because the bill does come even if you wish it wouldn’t.”

Previously: What’s the going rate? Examining variations in private payments to physicians

NIH, Research, Science Policy, Stanford News

Shake up research rewards to improve accuracy, says Stanford’s John Ioannidis

Shake up research rewards to improve accuracy, says Stanford's John Ioannidis

currencyLab animals such as mice and rats can be trained to press a particular lever or to exhibit a certain behavior to get a coveted food treat. Ironically the research scientists who carefully record the animals’ behavior really aren’t all that different. Like mice in a maze, researchers in this country are rewarded for specific achievements, such as authoring highly cited papers in big name journals or overseeing large labs pursuing multiple projects. These rewards come in the form of promotions, government grants and prestige among a researcher’s peers.

Unfortunately, the achievements do little to ensure that the resulting research findings are accurate. Stanford study-design expert John Ioannidis, MD, DSci, has repeatedly pointed out serious flaws in much published research (in 2005 he published what was to be one of the most highly-accessed and most highly-cited papers ever in the biomedical field “Why most published research findings are false”).”

Today, Ioannidis published another paper in PLoS Medicine titled “How to make more published research true.” He explores many topics that could be addressed to improve the reproducibility and accuracy of research. But the section that I found most interesting was one in which he argues for innovative, perhaps even disruptive changes to the scientific reward system. He writes:

 The current system does not reward replication—it often even penalizes people who want to rigorously replicate previous work, and it pushes investigators to claim that their work is highly novel and significant. Sharing (data, protocols, analysis codes, etc.) is not incentivized or requested, with some notable exceptions. With lack of supportive resources and with competition (‘‘competitors will steal my data, my ideas, and eventually my funding”) sharing becomes even disincentivized. Other aspects of scientific citizenship, such as high-quality peer review, are not valued.

Instead he proposes a system in which simply publishing a paper has no merit unless the study’s findings are subsequently replicated by other groups. If the results of the paper are successfully translated into clinical applications that benefit patients, additional “currency” units would be awarded. (In the example of the mice in the maze, the currency would be given in the form of yummy food pellets. For researchers, it would be the tangible and intangible benefits accrued by those considered to be successful researchers). In contrast, the publication of a paper that was subsequently refuted or retracted would result in a reduction of currency units for the authors. Peer review and contributions to the training and education of others would also be rewarded.

The concept is really intriguing, and some ideas would really turn the research enterprise in this country on its head. What if a researcher were penalized (fewer pellets for you!) for achieving an administrative position of power… UNLESS he or she also increased the flow of reliable, reproducible research? As described in the manuscript:

[In this case] obtaining grants, awards, or other powers are considered negatively unless one delivers more good-quality science in proportion. Resources and power are seen as opportunities, and researchers need to match their output to the opportunities that they have been offered—the more opportunities, the more the expected (replicated and, hopefully, even translated) output. Academic ranks have no value in this model and may even be eliminated: researchers simply have to maintain a non-negative balance of output versus opportunities. In this deliberately provocative scenario, investigators would be loath to obtain grants or become powerful (in the current sense), because this would be seen as a burden. The potential side effects might be to discourage ambitious grant applications and leadership.

Ioannidis, who co-directs with Steven Goodman, MD, MHS, PhD, the new  Meta-Research Innovation Center at Stanford, or METRICS, is quick to acknowledge that these types of changes would take time, and that the side effects of at least some of them would likely make them impractical or even harmful to the research process. But, he argues, this type of radical thinking might be just what’s needed to shake up the status quo and allow new, useful ideas to rise to the surface.

Previously: Scientists preferentially cite successful studies, new research shows, Re-analyses of clinical trial results rare, but necessary, say Stanford researchers  and John Ioannidis discusses the popularity of his paper examining the reliability of scientific research
Photo by Images Money

Behavioral Science, Mental Health, Public Health, Stanford News

“Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention

in-a-lonely-place-fa873a88-0c57-4b11-8f84-58c09aab94acMost people shy away from talking about suicide. Me too – I have some personal ties to the topic that still stab every time the s-word comes up. Yet after the initial reluctance wears off, that pain from grief and anger and fear turns into a motivational jab. Let’s talk about suicide nonstop. Let’s talk to make it stop.

Laura Roberts, MD, who leads Stanford’s psychiatry department, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. And she took it – partnering with the Wisconsin-based Charles E. Kubly Foundation to produce a special package of articles to inform clinicians about the latest efforts to prevent suicide.

Roberts and I spoke recently about the special issue and about suicide prevention:

Why did you want to publish this issue?

Suicide is such an under-recognized phenomenon, and it is an urgent threat to public health. Mental illness affects one in five people. Each year, more than 36,000 people commit suicide in the U.S. That is one person every fifteen minutes. In rough numbers, that’s twice the number of people who die from a violent injury in this country. Really, every life is touched by suicide.

Despite their serious public-health impact and life-threatening nature, illnesses and conditions associated with suicide have received little attention in society. These conditions are poorly understood and so greatly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education — we really wanted to emphasize these topics in this special collection.

New evidence-based models for prevention of suicide are emerging and inspire optimism. Integrating these new models is an exciting challenge for medical educators. Papers in this collection also document the impact of suicide and suicidal behavior among medical students and graduate students. About 350 physicians commit suicide each year in the U.S., and recently two interns in New York City ended their lives shortly after entering residency training. This is devastating.

In our special issue, a systematic review highlights the observation that psychiatry residents commonly experience the death of a patient by suicide, and three articles address coping with suicide professionally. Several articles focus on the development of educational programs that help strengthen suicide prevention, including screening skills and suicide awareness and management. Two articles address the resources and experience of from the Department of Veterans Affairs.

The journal special issue underscores there is much we can do in medical education to foster understanding and strengthen our responses to the phenomenon of suicide. Taken together, the papers also show how important it is that academic leaders better educate other about the prevention and impact of suicide.

What have we learned about preventing suicide?

We have learned a great deal about the prevention of suicide. Population data have shown that certain subgroups are especially vulnerable to suicide, including, for example, older white men who are ill and live alone, Native American youth as they make the transition to adulthood, and people living with serious illnesses that cause great physical and emotional pain. Understanding these larger population patterns has done a lot to help raise awareness of suicide and has allowed for creative interventions to address this problem.

Recently, researchers have been pursuing neurobiological markers that may signal when an individual is most at-risk for attempting suicide. Other studies are connecting other aspects of health — such as healthy sleep and exercise — to protective factors that may help diminish the likelihood of suicide. Such innovative work is very much needed because it will help us understand when a person with latent risk factors for suicide may act on this impulse, or, alternatively, how we can better support and intervene.

Other recent work has focused on psychological and situational factors that may contribute to suicidality among young veterans, and again, this line of inquiry may give us greater understanding on how best to reduce suicide deaths. As you may know, the number of veteran deaths due to suicide have been devastating. The VA has shown immense concern for members of the military and young veterans returning from conflicts around the world. In the course of studying suicide in this population, we have begun to have greater insight into when and whether an individual will act on an impulse to end his life. Three factors appear to be in play: first, a predisposition or vulnerability, for example, the presence of depression or anxiety that increases the general risk of suicide; second, access to a way to end one’s life, such as a gun; and, third an experience or set of experiences that make the individual feel like he is out of place, isn’t part of things, and doesn’t belong — what’s referred to as “thwarted belongingness.”

We are getting parts of the problem figured out, but so much more scientific investigation is needed. Ironically, suicide has been understudied because of concerns that the population is too vulnerable to be included in human research studies and because of the stigma associated with suicide. There have been so many barriers to these studies, and it strikes me as doubly tragic that suicide takes so many lives and yet has been relatively neglected by society and by science. In the Department of Psychiatry and Behavioral Sciences at Stanford, we are working to turn this around.

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