OncologyLive® is the flagship publication of OncLive®. Each issue delivers expert insights and clinical oncology news and updates, which impact the day-to-day clinical practice of oncology professionals who work tirelessly to help improve patient outcomes.

Combining a modified version of a commonly used chemotherapy medication with Positron Emission Tomography (PET), researchers at UCLA have achieved a breakthrough in immune system modeling and treatment response monitoring.

In the past, oncologists have been forced to wait weeks and often months to determine whether a patient is responding to a therapy. Currently, physicians use conventional imaging methods such as CT and MRI to scan tumors before and during treatment to measure tumor size and determine how it is responding to treatment. However, because of the time lag involved, patients who don’t respond to treatment are exposed to toxic therapies for longer than necessary, and precious time is wasted during which another, more effective therapy could have been administered. That may change soon.

 (JCCC) have modified a common chemotherapy drug to create a new probe for Positron Emission Tomography (PET), an advance that will allow them to model and measure the immune system in action and monitor response to new therapies. The probe can monitor immune and treatment response much more quickly than conventional imaging techniques—within a week or two&mdash;thereby sparing patients from prolonged exposure to therapies that aren’t working. The results of the study, published online June 8 in the peer-reviewed journal 

, reveal how this new development will enable scientists to monitor the immune system three-dimensionally as it tries to fi ght some cancers, or when it goes awry, as it does in autoimmune diseases.

Researchers created the small molecule, called FAC, by slightly altering the molecular structure of gemcitabine. They then added a radiolabel so the cells that take in the probe can be seen during PET scanning. Because the probe is labeled with positron-emitting particles, cells that take it in glow “hot” under PET scanning. Th e probe is based on a fundamental cell biochemical pathway called the DNA Salvage Pathway, which acts as a recycling mechanism that helps with DNA replication and repair. The pathway is activated at very high levels in lymphocytes and macrophages, causing the probe to accumulate at high levels in those cells.

“This will help us to more eff ectively model and measure the immune system,” said Dr. Owen Witte, a researcher at UCLA’s Jonsson Comprehensive Cancer Center and senior author of the study. “Monitoring immune function using molecular imaging could significantly impact the diagnosis and treatment evaluation of immunological disorders, as well as evaluating whether certain therapies are effective.” The work, done in animal models, will be further evaluated in subsequent studies. Eventually, Witte said, researchers hope to monitor the immune systems of patients with FAC and other PET probes.

Understanding the role of immune response in fighting or, in some cases, possibly stimulating tumor growth is a dilemma faced by many cancer researchers, says Kevin Shannon, MD, the Auerback Distinguished Professor of Molecular Oncology at the University of California, San Francisco. “Dynamic probes like the one developed by UCLA scientists will allow researchers to learn more about the role of the immune response in cancer, how current treatments aff ect immune cells, and will allow them to quantitatively monitor responses to new modalities such as tumor vaccines,” says Shannon. “Probes of this type may also help oncologists more rapidly identify tumors that will respond to certain drugs so treatments can be made more patient-specific.” In previous studies, UCLA researchers were able to track the immune system as it recognized and responded to cancer. But in those studies, the cells had to be modifi ed with “reporter” genes that sequestered a specifi cally designed PET probe that allowed scientists to monitor them.  The new probe doesn’t require modifi ed cells, making it easier and less expensive to use and giving it far broader applications than existing probes. In addition to modeling and measuring the immune system, those applications include stratifying diff erent types of cancers and their response to therapy, defi ning the level of immune response and helping to determine whether new drugs prompt an immune response to cancer and other diseases. “This probe will tell us things about the immune system that existing probes can’t,” says Caius Radu, a Jonsson Cancer Center researcher and the first author of the study.

Kim Irwin is director of media relations for the Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research at UCLA’s Jonsson Comprehensive Cancer Center.

Articles

Molecular Imaging: A New Twist on PET May Enable More Efficient Monitoring of Cancer Treatment

Because the delivery of oncology care involves many high-cost assets and ever-narrowing margins, the judicious application of health IT solutions has the potential to transform care by reducing costs, increasing efficiency, and improving quality. However, despite the enormous potential of electronic health records (EHRs) and other health IT applications, very few providers have adopted them.

	Most physician offices already use information technology (billing and scheduling programs, etc) to manage the business side of practice, so many of them already have the hardware necessary to operate a full-featured EHR. However, implementing a comprehensive clinical system is a major challenge. It involves more than just making an often substantial financial commitment; it also requires a commitment to major organizational changes in nearly every aspect of practice. To realize the full benefits of an EHR, physicians must devote considerable time to personalizing the system, to training office staff, and to adapting their work processes to incorporate the new technology into the daily workflow.

	Choosing the product that best suits their practice’s unique needs from among the dozens of EHR vendors is a daunting challenge for providers. With so many choices and rapidly developing technologies, many providers are concerned about buying the wrong system for their practice. Many oncologists also remain skeptical that EHRs will enable them to improve the quality of healthcare they deliver. However, EHRs have been shown to:

		Improve safety in the use of toxic chemotherapeutic agents

		Identify harmful drug interactions/allergic reactions

		Help oncologists manage complex patients with clearly accessible information flow sheets

		Identify patients who are eligible for clinical research protocols

	Allow timely communication of progress to other specialists involved in multimodality care EHRs also enable oncology providers to run their practices more effi ciently by eliminating the use of medical transcription and the need to physically pull medical charts. EHRs reduce practice variation by promoting adherence to formularies and internal limited protocols and allow physicians to defi ne protocol-driven care for use by extenders. However, potential EHR users must keep in mind that not every practice will realize all of these benefi ts. For example, eliminating chart pulls reduces costs but only for larger offices. Because the staff at smaller offices often perform multiple functions, these practices are less able to reduce staff to cut costs.

	Estimating the total cost of implementing EHR systems in offi cebased oncology practices is complicated by the sheer number and variety of systems available. Implementing an EHR involves not only direct costs (for hardware, software, licensing fees, installation, and training), but also indirect costs (eg, practitioners’ reduced productivity during the early stages of adoption).  Total cost for an offi ce-based EHR can be as much as $45,000 per physician. Estimates of annual costs for operating and maintaining the system (including software licensing fees, technical support, and updating and replacing used equipment) range from 12%—20% of initial costs. Fortunately, the prices of health IT products appear to be falling. In particular, Internet-based applications are becoming available and may limit costs to an annual subscription fee as low as $2,000 per physician.

	Several studies have shown that practice productivity can decrease by at least 10% for several months following EHR implementation. In some non-oncology studies, the average drop in revenue from that loss of productivity was about $7,500 per physician. These issues are discussed in great detail in a recently released 

 report on the costs and benefi ts of health IT. The report reinforces the need for answers to some of the core questions raised in 

: How will we demonstrate value to our patients and even payers? How good is the cancer care we are providing? How do we compare to providers elsewhere? What are the tools we will use to engage our patients? Adopting clinical IT systems will enable us to collect critical information as a byproduct of workfl ow, answer these questions, and improve the health outcomes that are the ultimate measure of performance.

Jivesh Sharma, MD, is CEO of Texas Cancer Associates, a midsize oncology practice based in Dallas/Fort Worth, TX. He is also CEO of HealthIT, an Internet services company that supports the patient/ provider network with technology solutions, and founder of NextGen Oncology, which works to provide next-generation solutions for the diagnosis, management, and treatment of cancer. E-mail Dr. Sharma at 

Despite the enormous potential of electronic health records (EHRs) and other health IT applications, very few providers have adopted them.


The Costs and Benefits of Health IT in Cancer Care

The Internet can be an amazingly useful educational resource for patients who have been diagnosed with cancer. It can also be the source of potentially dangerous misinformation. Luckily, that’s often the exception to the rule, as demonstrated by reliable and useful sites like 

 that provide convenient access to essential information that supplements the guidance patients receive from their physicians.

, 80% of American Internet users have searched for information for at least one of 17 health topics. In addition, 53% said that the information they found from the most recent search affected how they took care of themselves or cared for someone else, and 54% reported that the information led them to ask a doctor new questions or receive a second opinion from another doctor.

	Judging by these numbers, it is likely that your patients are going online to fi nd information about cancer. What are some advantages of patients accessing cancer information online? First, this allows patients and their family and friends to learn more about the disease at their own pace and review this information thoroughly. Often, patients report difficulty comprehending all of the information they receive from their doctor, especially after a new diagnosis. In addition to teaching about the basics of cancer, a good website can help patients learn about diagnostic tests they will need and help them evaluate treatment options. Patients can also go online to find support and connect with others who have a similar diagnosis. Finally, the Internet provides

	the growing population of cancer survivors with up-to-date information about post-treatment concerns and follow-up care.

	However, the Internet is not without its drawbacks and dangers. Not all websites have timely, accurate, and relevant information. Some sites promote expensive and unproven or unsafe treatments to vulnerable people at the expense of curative therapy. Because of the wide disparity in the quality of online information, many healthcare professionals remain wary of

Cancer.Net: The voice of the cancer physician

	To address the need for accurate, understandable, patient-centered, online cancer information, 

 brings the expertise and resources of the American Society of Clinical Oncology (ASCO), the voice of the world’s cancer physicians, to people living with cancer and those who care for and care about them. Cancer.Net provides timely, oncologist-approved information to

	help patients and families make informed healthcare decisions. All information on Cancer.Net is developed through a peer-review process by the Cancer.Net editorial board, which comprises more than 150 medical, surgical, radiation, and pediatric oncologists; oncology nurses; social workers; and patient advocates. The content is reviewed annually

	or as needed for both accuracy and readability.

	Although the primary audience is people with cancer and their families and friends, ASCO members, nurses, other healthcare providers, and patient advocates play a key role in sharing this resource with patients.

Key content on Cancer.Net: Guides to Cancer

 for more than 120 types of cancer and cancer-related syndromes. These guides provide comprehensive disease information, covering statistics, risk factors, prevention strategies, symptoms, tests used to make a diagnosis, an explanation of cancer staging and how it affects treatment and prognosis, clinical trials, treatment options,

	follow-up care, questions to ask the doctor, and current research for each type of cancer. In addition, Guides to Cancer for 25 of the most common cancers affecting Hispanics and Latinos in the United States are now available in Spanish.

	The “ASCO Cancer Education Slides” provide reliable, oncologist-approved cancer information in a turn-key Microsoft PowerPoint presentation. Based on the Guides to Cancer, the slides are intended for oncologists, oncology nurses, and other healthcare professionals who give patient and community group lectures. More than 20 titles are available 

	Based on the ASCO Clinical Practice Guidelines for physicians, patient guides are available in both text and .PDF versions 

. They cover treatment options and tests for specific forms of cancer and include background information, summaries of the recommendations of the ASCO expert panels that designed the treatment guidelines and what they mean for patients, questions to ask the doctor, and additional resources for further research. Several of the patient guides have been translated into Spanish.

	More than 35 podcasts on cancer-related topics are available for patients 

. Many podcasts involve interviews with ASCO members about timely topics in cancer, including PET scans, targeted cancer treatments, and advances in cancer screening.

 provides commentary from ASCO experts on prominent news stories and can be found in the “News and Events section on Cancer.Net.”

	People can learn what ASCO experts are saying about a variety of cancer topics at the “

.” These short interviews address a specifi =c area of cancer care or research. Topics include young adults with cancer, the role of a tumor board in cancer treatment, and the attributes of quality clinical trial sites.

	Patients can fi nd an oncologist near their home or search by practice specialty by accessing a database of ASCO members who have made their contact information public 

	Other popular content on Cancer.Net includes information on managing side effects; cancer survivorship; cancer prevention; a library of medical and staging illustrations; weekly feature articles that offer practical, timely information on a variety of cancer topics; links to additional patient information resources; and an extensive section on coping with cancer, designed for both patients and caregivers.

Finding credible online health information

	With more patients using the Internet to find cancer information, how do you steer them to the best resources? The first discussion you have with your patients may need to address the idea that there is bad information on the Internet. In the 2006 Pew report, 75% of health seekers did not regularly check the source and date of the health information they found online.

	There is a tendency for people to assume that all information on the Internet is true, instead of being critical about the information. Because Internet content is not regulated, patients need to become knowledgeable consumers of online health information. Taking a proactive approach to review information with your patients may prevent them from feeling as if they can’t discuss what they have found on the Internet with you. Share the following tips with your patients:

		Find out who manages the website. The person or organization that operates the website should be identified throughout the website so users know the source and purpose of the information (such as education or selling a product). Use the “About Us” section to learn more about who operates the site.

		Learn who is responsible for the content and how often it is updated. Reliable websites tell you who edits and approves the content (such as an editorial board) and how to contact the organization that operates the website. Look for a date at the beginning or end of an article, so you know when the article was last posted or reviewed. Be cautious when reading information posted on discussion groups, bulletin boards, and blogs because these sections may not be regularly reviewed or updated.

		Learn the source of the information on the website. Trustworthy cancer information is based on scientific evidence and not personal feelings or experiences. When learning about treatment options, look for links or references to research studies. If some material is based on an opinion, it should be clearly labeled. Be cautious about scientific-sounding material that has no data to support the information.

		Find out who funds the website, because this may aff ect how information is presented. High-quality websites make it easy to tell the difference between advertisements and medical information. Patients should avoid websites that promote a specific medication or treatment over another.

		Learn how the website maintains privacy. If the website requires you to give confidential information—such as your name, address, e-mail address, or diagnosis&mdash;there should be a separate security or privacy policy statement telling you how this information will be used.

		Check that the website has a linking policy. Links take the user to another website. Be aware that the new website may not have the same standards as the one you left. Some sites have a policy of only linking to websites that meet specific criteria, whereas other sites may include links to any website.

		Avoid websites that make claims that seem too good to be true.

		Do not start new medications, stop taking current medications, or otherwise change any health behaviors based on information found online without consulting your doctor.

Helping patients understand research findings

	Of course, much cancer information on the Internet is not easily interpreted, especially by patients. With the explosion of online

	healthcare information, patients can easily find journal studies, abstracts, posters, and other forms of scientific communication. You can play an important role by putting the cancer information into context for your patient. It is helpful to review whether a study pertains to the patient’s specific type and subtype of cancer; how the study may or may not mimic actual clinical practice; any limitations of the study, such as study length, sample size, and health of the participants; and the availability of the treatment mentioned in the study (often, investigational drugs are only available through a clinical trial, and some patients may not realize this).

	On Cancer.Net, summaries of key information from ASCO meetings and symposia are summarized in the Cancer Advances publication, a series of consumer information resources found 

. Included in each study is a section titled “What Th is Means for Patients” that places the study information into the appropriate context for patients. The same feature is also found in the 

, which are easy-to-read-summaries for patients based on the ASCO Clinical Practice Guidelines.

	By recommending credible online health resources such as Cancer.Net, it is possible to help your patients and their friends and family learn more about cancer. High-quality information can help them make the best possible decisions, which ultimately strengthens the relationship between you and your patients.

Diane Blum, MSW, is Editor in Chief of Cancer.Net and Executive Director of CancerCare.

The Internet can be an amazingly useful educational resource for patients who have been diagnosed with cancer. It can also be the source of potentially dangerous misinformation.

Way Too Much Info

Rafael Fonseca, MD, is a professor of medicine at Mayo Clinic and a consultant in the Division of Hematology/Oncology. He also serves as deputy director for the Mayo Clinic Cancer Center. In addition, Dr. Fonseca has an adjunct appointment at the 

Translational Genomics Research Institute

, where he works in collaboration with Drs. John Carpten and Jeffrey Trent. Dr. Fonseca concentrates on the genomic nature of late B-cell neoplasms, particularly focused on multiple myeloma. He is interested in the clinical implications for prognosis and treatment selection of specifi c molecular markers in the myeloma cells. Dr. Fonseca worked for 10 years at the Mayo Clinic in Rochester and transferred his research program to the Mayo Clinic in Scottsdale in January 2004.

1 What is your primary focus at the Translational Genomics Research Institute?

I have a joint appointment at TGen with a goal of participating in joint projects relating to the genetics and genomics of multiple myeloma. In partnership with Dr. John Carpten, we have been successful in establishing a large number of genomic studies that have already resulted in joint grant applications as well as high-profile publications. Mayo brings research expertise at the laboratory level, as well as the clinical expertise for understanding the implications of new findings. Working with scientists such as Dr. Carpten, we were able to leverage some of the great power of TGen genomic tools, such as the array-based comparative genomic hybridization (aCGH). Together, we have tried to tackle one of the challenges in genomics research—how to integrate all of the information related to the sample quality, clinical features associated with the samples, data associated from the DNA copy number, gene expression profiling, etc. In one example, our team found that NF-kappa B was constitutively activated in up to 50% of myeloma patients.

2 What have been some of your successes over the last four years since joining the team?

Since I came to Mayo in 2004, I was fortunate to have worked with two great friends and colleagues, Drs. Leif Bergsagel and Keith Stewart. We had long talked about the possibility of joining forces and working together toward applying genetics and early drug development for the treatment of myeloma. We were successful in recruiting Dr. Bergsagel nine months after my arrival in Arizona and Dr. Stewart the year following that. I consider the formation of this team one of my biggest successes. We now have a laboratory meeting that encompasses up to 20 individuals, including postdoctoral fellows, research technologists, and principal investigators. These individuals come from all over the world, including Singapore, New Zealand, Argentina, Brazil, Canada, and Mexico. This is a highly collegial team, but nevertheless competitive, and in a short period, we have been able to produce a large stream of publications. However, our greatest success is our ability to translate some of these findings and research to the clinic. Since coming to Arizona, we have had a very significant growth in the number of myeloma patients that we can care for in the clinic and with whom we can work in clinical trials and on basic research projects. We are clearly honored to have this partnership with those individuals who entrust us with their healthcare.

3 What clinical trials are you and your colleagues currently involved with?

We have an ample portfolio of phase I and phase II clinical trials. We have been involved in the development of a third generation of immunomodulatory drug, related to thalidomide and lenalidomide, CC 4047. Currently at Mayo, we are running a clinical trial with CC 4047, which we are hoping to ultimately bring to the clinic. We have also been engaged, primarily through the leadership of Dr. Stewart, in the development of novel proteasome inhibitors, such as carfilzomib. We have participated in the early development of this drug and are currently involved in phase II and phase III clinical trial design. Our team, in conjunction with the Multiple Myeloma Research Consortium, was also the first to lead a clinical trial targeting a specific genetic marker in myeloma. We had a small molecule inhibitor of the oncogene FGFR3 in myeloma patients.

This clinical trial was the first ever attempt to target such genetic lesions in multiple myeloma. Our hearts were really close to the development of that trial because of our close participation in the concept development. Dr. Bergsagel, and his wife Dr. Marta

Chesi, discovered the translocation almost 10 years ago. My laboratory uncovered the clinical implications for this genetic abnormality, and ultimately, the preclinical development of the compound was lead by Dr. Stewart.

4 How has patients’ expanded access to medical information affected clinical care and research?

We clearly live in the age of information. In an era with patients who are much better informed than in the past, access to healthcare information becomes of paramount importance to the treating physician. It is a huge challenge to practice general oncology today (because of the amount of information generated daily), and I can see a future in which there will be multiple subspecialties within oncology. We use electronic tools for accessing the latest research and most up-to-date publications about the multiple clinical trials for myeloma. Our patients likewise present to our clinical offices with copies of the most recent papers, wanting to understand the relevance to their particular situation and whether treatments proposed there are appropriate. Patients often come with some basic or translational research papers, and they question us about the implications of several genetic markers or other findings in the analysis of the bone marrow! Oncologists can no longer provide superficial answers to very complex questions, and patients can quickly discern who is not up-to-date on the latest information.

Patients also find information regarding ongoing clinical trials on the Internet. We value participation in clinical research as one of the basic tenants of our clinical practice. It is often through these clinical trials that we can provide patients access to cutting-edge drugs, or those that are not available otherwise but have already shown activity against disease. There needs to

be a seamless integration between our clinical research activities and our clinical practice. Needless to say, participation in clinical trials is always voluntary, but we value such opportunities as ways that can improve our patients’ well-being.

5 What are your thoughts on patients who use the Internet to find information and connect with support groups and

I frequently hear about people who complain about patients accessing the Internet and how it may create confusion at the time of the appointment. I could not be in greater disagreement. I think my patients are much better informed now as a consequence of the information available on the Internet. People in general have become more savvy consumers, capable of discerning the

more important fi ndings from the “fluff .” I think the well-educated patient and caregiver provide a much better context for the overall care and management of a patient with multiple myeloma. Not only that, but patients and families with this information frequently ask additional questions that undoubtedly help improve the quality of the care provided.

I am a great advocate for patients working with grass roots organizations and other Internet-based information sources. Many of our patients work with the 

 to find information about the diagnostic implications for their condition, as well as the many treatment options and available clinical trials. It would be nearly impossible for a physician’s office or practice to try to provide all of this information that is available to patients. It is true that this amount of information poses an extra burden to patients, and that sometimes it can be confusing as they try to make decisions, but in the end, their decisions are more informed, and patients and their families are empowered by working jointly with their healthcare providers.

Rafael Fonseca, MD, is a professor of medicine at Mayo Clinic and a consultant in the Division of Hematology/Oncology.

5 Questions... with Rafael Fonseca, MD

Dr. Adil Daud is a clinical physician and medical researcher, certified by the 

in both oncology and hematology. He serves as associate professor and director of Melanoma Clinical Research at the University of California, San Francisco, and is a member of the National Comprehensive Cancer Network’s Melanoma Panel Committee, the American Society of Clinical Oncology, and the American Association for Cancer Research.

How does Leukine work to extend the lives of patients with high-risk melanoma? How effective is it when used in combination therapy?

The study findings published in the July 1 issue of the 

 may offer clinical benefi ts in high-risk melanoma patients by increasing and diff erentiating dendritic cells, which are special antigenpresenting cells that help the immune system recognize cancer cells and are the most eff ective antigen-presenting cells known. These study results indicate that an increase in dendritic cell counts may correlate with delayed recurrence of disease in highrisk melanoma patients.

In addition to these data published in the Journal of Clinical Oncology, further findings regarding Leukine in melanoma were released at the 44th Annual Meeting of the American Society of Clinical Oncology (ASCO). According to these data, adjuvant therapy with Leukine and a synergistic cytokine, IL-2, was generally well tolerated in patients with highrisk melanoma following potentially curative surgery. Each patient received two years of adjuvant therapy—year one with Leukine and IL-2 and year two with only Leukine. Results showed that 60% of the 45 high-risk patients enrolled in the trial experienced disease-free survival at 21 months, with an overall survival rate of 64%.

What is the median overall survival time in patients? How long has the study been conducted, what patients were tested, and when do you anticipate moving into a phase III trial?

Data from the phase II trial of 42 high-risk melanoma patients published in the 

 showed that Leukine demonstrated a median overall survival of 65 months (95%, CI 43—67 months) and a median recurrence-free survival of 5.6 months (95%, CI 3.7–11 months).

Patients were treated with Leukine at 125mg/m2/day for 14 consecutive days followed by 14 days of no treatment. This regimen was repeated for 13 cycles, or a total of one year, unless patients had unacceptable toxicity or showed evidence of disease recurrence. Patients had no evidence of the disease at the start of the trial as measured by imaging. Patients underwent restaging every four months.

Additionally, 11 patients who relapsed within three months of starting Leukine had lower dendritic cell counts at two weeks compared to those who relapsed after three months and those who remained in remission throughout the course of the study.  However, the ability of Leukine to induce mature dendritic cells appeared to be confi ned to those patients who had low dendritic cell count before treatment.

In regards to a phase III trial, there is currently an ongoing fully accrued cooperative group trial, E4697, that randomizes patients to one of six arms depending on whether they are HLA A2+ or not and includes vaccine in some arms. Results from this trial are expected next year. A concern about this trial is that splitting a relatively small number of patients into multiple arms could reduce the power to tell us if GM-CSF truly was better or not. As of now, I don’t know of any other ongoing or planned phase III trials in high-risk melanoma.

Are any other treatment options available to patients with melanoma that demonstrate comparable results?

This is currently a very difficult area for patients. We know melanoma recurrence is highly associated with death from this disease, yet there aren’t many options. The most commonly used agent that is FDA approved for this indication is interferon alpha-2b. However, it is much more toxic. It has been shown in randomized trials to reduce the risk of melanoma recurrence and its effect on overall survival is of borderline statistical significance in a metanalysis looking at all randomized interferon clinical trials done to date. So Interferon is an option for young, healthy patients.  Vaccines have been tested for more than three decades and to date no study has shown a benefi t in terms of survival or diseasefree survival. Some studies presented at the ASCO 2008 and 2007 meetings have even shown that they may reduce survival so we have to carefully evaluate them in the future. Chemotherapy has been tested and found to not help and probably should not be considered an option here.

Dr. Adil Daud is a clinical physician and medical researcher, certified by the American Board of Internal Medicinein both oncology and hematology. 

Eye on Innovation: Chemotherapy

Does the word “free” grab your attention? It sure gets mine. In the universe of computing, free software has always been fairly commonplace. There are many reasons for this, starting with the fact that software doesn’t cost much to produce, except for intellectual eff ort, which some people choose to give away for free. While some programmers and vendors are motivated by altruism, others simply want to show off their programming skills, and others ultimately want to sell you a product. Whatever the reason vendors have for giving it away, you can benefi t from downloading and using freeware and shareware.

reeware is software that is available for use at no cost.  Freeware is usually made available in a proprietary form that cannot be modifi ed, copied, or redistributed to somebody else. You can find freeware programs for virtually every computer platform, including Windows, Mac, UNIX, and DOS. Common examples of freeware include games, graphics (such as fonts and screensavers), offi ce productivity tools, and systems utilities.

Another form of “free” software is known as shareware. This “try-before-you-buy” software is a marketing method that allows the user to try out the software free of charge before purchasing it. Sometimes the trial version is the full version of the software; other times it off ers only a few of the product’s features.  Google the word “freeware,” and you will retrieve many sites that offer a wide variety of programs for download. These sites generally allow users to review and comment on the software, so you can see what’s popular and highly rated by peers. To protect your data, make sure to stick with legitimate sites that are secure and free of viruses and spyware. 

 is well organized and has a nice, clean interface.

 is an excellent example of a new form of freeware: the Web 2.0 application that exists only online. Intended to compete with the Microsoft Office suite, these free programs let you create and save documents, spreadsheets, and presentations online. I briefl y tested the word processing program and found it adequate for most basic writing tasks. It is missing a few high-end features, such as automatic spellchecking and an unlimited number of fonts, but it should cover most users’ needs. It even lets you insert tables and comments. The stripped-down presentation program is also basic but is a great alternative to purchasing Microsoft PowerPoint if you create just one or two presentations per year.

Th ere are many freeware programs specifi cally written for medical professionals. 

, for example, offers a free mobile drug and formulary reference. Two good sites for fi nding medically relevant freeware programs are 

. You can even find free versions of fairly sophisticated software, such as 

. It is a free, open source replacement for medical applications like Medical Manager, Health Pro, and Misys. One caveat: if knowing how to sync your PDA is basically the extent of your technical know-how, then this Linux program probably isn’t for you.  As I mentioned, shareware is more of a sales technique than a way for you to get free software; however, it does deliver real value because it lets you “test drive” an application before you buy it. Many well-known companies (including Microsoft, Adobe, and many others) let users try versions of their products for free. In my own EHR business, I have always allowed potential customers to try Amazing Charts in their own practice for three months before being asked to pay for it, and I am consistently told that this is a major factor in their decision to eventually purchase the system.

Personally, before I purchase any software, I search for free alternatives (usually on Google). If I don’t fi nd a free product that fi ts my needs, I try to fi nd a shareware version of the software and run it through its paces before paying a penny.

Dr. Bertman is Physician Editor-in-Chief of MDNG: Primary Care/ Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.  com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Does the word "free" grab your attention? It sure gets mine. 

Get Your Software on the Cheap

Cell phone applications, interactive video tutorials, online symptom navigators, and other high-tech tools are changing the way physicians approach patient education and are opening up new possibilities for patients seeking to learn more about their conditions and take control of their health.

In baseball, bats, balls, and gloves are commonly referred to as the “tools of the trade”—the equipment used by players to participate in and determine the outcome of the game. In medicine, tools of the trade have traditionally included a stethoscope and a sphygmomanometer by which physicians obtain information that can help them positively impact a patient’s health outcome. Those tools haven’t gone away, but healthcare providers have begun embracing new tools&mdash;technology tools, including cell phones, video, and the Internet&mdash;to help educate patients so they can make more informed decisions regarding their own health.

“When I was in training, the focus of medical care was in the hospital,” recalls Alan Greene, MD, chief medical officer at 

., a leading provider of high-quality, technology-driven health information solutions. “Th en it was in the outpatient setting. More and more, it’s moving to where people are in their daily lives; the places where they’re making their healthcare decisions.” Enabling that decision-making is the technology that is putting information in healthcare consumers’ hands whenever they need it, wherever they might be.

Peter Waegemann is chief executive officer of the 

Center for Cell Phone Applications in Healthcare

. An international leader in medical informatics, Waegemann believes that in the next 10 years, the cell phone will have the greatest impact on health information and technology. His vision is that in fi ve years time, “a large percentage of people, maybe even 100 million in this country, will have their basic health information on their cell phone.”

Waegemann says the cell phone can serve as the platform for consumer health-related

software, such as wellness-related programs and disease management programs. By off ering consumers health-related Internet access, cell phones can allow patients to quickly and easily look up information about medications or symptoms related to their health status.

Imagine a patient using her cell phone to look up a specifi c medication after it has been prescribed at a clinic visit, noting it interacts with another of her medications that she forgot to mention during the visit, and alerting her physician via the cell phone before the prescription is filled. “And it won’t only be for checking medications,” says Waegemann. “It will be for making decisions. When a consumer has a pain, they may not go to their doctor. Instead, they may look for advice on the Internet using their cell phone.”

Waegemann’s vision is already taking shape. The A.D.A.M. Symptom Navigator for the iPhone and new 

 is a free application introduced last month that is designed to help consumers match medical symptoms with relevant assessments and appropriate treatments. Adapted from A.D.A.M.’s standard edition of the Symptom Navigator, which is the backbone of many medical websites, including the National Library of Medicine, the tool addresses possible causes of symptoms and medical conditions, how to self-treat, when you should call a doctor, and how to prevent it in the future.

Symptom Navigator resides on the Web. A button on the iPhone’s screen quickly brings up an image of the human body. By touching the part of the body of interest, users are presented with a menu of related symptoms and walked through the possible causes, home care, and when to consult their doctor. “As a physician, it’s wonderful for me to know my patients have access to

this kind of quality data,” says Greene. “It makes patient discussions with physicians richer, deeper, and more efficient.”

Patricia Raymond, MD, FACP, FACG, a board-certified physician in gastroenterology and internal medicine in Chesapeake, VA, performs many colonoscopies as direct access, meaning that patients do not actually meet her prior to the procedure. As a result, she needed a way to educate her patients while also promoting some degree of bonding and familiarity. “If you’re going to come in and have me drop a sixfoot-long tube in your bottom, it better feel at least like you know me a little,” Raymond says.  She put up a 

, from which patients could view videos of her answering questions about colonoscopy.

Developing the script/answers to the questions was easy, says Raymond. She’d always been asked the same questions by patients over and over, so she wrote them down and divided them into pieces, or video clips, that were informative yet short enough that they wouldn’t lock up a patient’s computer during download. Total time for all the video components combined is

between 15 and 18 minutes, says Raymond, and patients “feel like they’ve gotten 15 minutes with me before I’ve even entered the room.”

Why video? Raymond says it’s important to use a level of technology that your patients are most comfortable with. Her patients are age 50 and older, so they’re not going to listen to podcasts. But, they’re savvy enough to use the Internet. And according to Raymond, studies have indicated that if patients are shown a video of the physician explaining something they’ll perceive a much longer contact time with the doctor than if they were limited to a standard office visit.

“[Th e video] is me saying the same thing over and over,” Raymond explains. “If I can have that same conversation with patients at their demand, at their convenience, then maybe they’ll feel more comfortable coming in for a colonoscopy, because they feel like they’ve already met me.”

, Inc. (IDI), based in Bethesda, MD, has taken the video-based exchange of information one step further. The company has developed a voiceactivated, interactive educational method it calls “virtual dialogue.” Individuals are able to conduct a virtual conversation with a real person, in this case a healthcare expert, whose images are pre-stored on the computer. Using a microphone, the user asks questions, and the expert responds. An intelligent scrolling prompt provides relevant questions for the user to ask, or the user may ask questions on their own.

IDI has conducted extensive scientifi c research to measure the eff ectiveness of the virtual conversation from two perspectives: transfer of knowledge from the expert to the user and the feeling of actually being in the presence of the expert. Testing was conducted both prior to and following users’ conversations. Knowledge gain, says president and CEO William Harless, PhD—who developed the virtual conversation method&mdash;has been exceptional.

“We engaged 70 women, 35 of whom were breast cancer patients and 35 of whom were women concerned about breast cancer,” Harless explains. “They each took a pre-test to determine how much they knew about breast cancer, had a virtual dialogue with the oncologists for about an hour, and then took a post-test. Th e average pre-test score was 65, and the average posttest score was 93. That has real implications for medical education.”

Anne Moessner, MSN, RN, CCRN, a clinical nurse specialist with Mayo Clinic in Rochester, MN, has been piloting IDI’s virtual dialogue for several years. She says that she and the families that she has run through the program’s traumatic brain injury series have been amazed by the life-like features of the technology. “[Th e families] feel like they’ve spoken to a person as opposed to passively watching a videotape,” says Moessner.  “I think it’s something about the technology that is very engaging.”

To facilitate the conversations, IDI researches and prepares a list of 75—125 questions that patients frequently ask about a particular topic, such as breast or prostate cancer. The questions are reviewed by the healthcare expert, who then answers the questions in front of a camera without a prepared script. Doing so, says Harless, makes the conversation spontaneous, as though the expert were answering the question live. Do individuals ever ask a question for which no answer has been prepared? Quite frequently, it turns out. But IDI executive vice president Marcia Zier says that’s good.

“Ninety-fi ve percent of everything they ask gets a reasonable answer,” she explains. “But if the basic information we provide is triggering new questions or more in-depth questions, we’re delighted, because now their real concerns are starting to surface. And when they talk with their physician, they’re going to have a more substantive conversation. It takes the patient to a diff erent level.”

From hospital and healthcare system hallways to physician offi ce waiting rooms, digital signage is becoming a popular method for personalizing medical information that not only gains patients’ attention, but educates them as well.  For example, at Lancaster General Hospital, in Lancaster, PA, sets of eight, 46-inch, NEC LCD panels form two separate one-by-four matrices that display everything from information on health awareness programs to photo collages showing various hospital departments at work.  Th e information is made available, but in a nonintrusive manner.

“With some other technologies, you have to go to a website and pull information; you have to ask for specific information,” explains Jeff Collard, president of Toronto-based 

, a developer of software for digital signage networks and electronic displays. “Digital signage is very much a visual communication medium where we push information. People don’t come in and ask for it; we make it available to them whether they ask for it or not. But it needs to be supportive of what the patient needs to know, and invite them to get involved.”

In that respect, digital signage is very much an interactive medium, not merely flashing static information. Consider the case of a hospitalized child. The parents inform the hospital that the child’s favorite toy is a stuffed dinosaur. That information is imbedded in the medical bracelet around the child’s wrist. When the child approaches a screen in a common area or the children’s play room, the screen will show a story about a dinosaur. “The bracelet triggers it, so the screen knows who’s in front of it,” says Collard. “Then it goes into this database and pulls out something that relates to that child.”

Collard says the thing to remember about digital signage is that it’s a visual communication medium, and people, he adds, pick up visual cues much better than actual words. And the messages that are communicated are unique and tailored to a specifi c audience. “If I have 20 screens in a hospital, I don’t send the same message to all of them,” he says. “Every location should be a unique message, because where you are in your head and what’s going on in your life in radiology is completely diff erent than in the maternity ward. We’re delivering specifi c messages to specifi c people at specifi c times and places to make them feel more comfortable and help them facilitate a decision.”

Digital signage can also gather information about patients and healthcare consumers when they make choices through a touch screen. That information, says Collard, goes back to the hospital or the doctor’s offi ce and enables the facility to learn how to provide even more effi cient information to the patient. “It’s all data driven,” says Collard, “and that’s where the value is.”

What do patients do in a physician office waiting room? They wait, of course. So, how about putting that waiting time to good use? Patricia Neafsey, RD, PhD, a nursing professor at the University of Connecticut School of Nursing, has developed software that helps counsel patients with their self-medication management through the use of computer touch-screens available to them in the waiting room. With the assistance of a $1 million grant from the National Institutes of Health, Neafsey’s Personal Education Program — Next Generation (often referred to as PEP-NG) is helping older adults with hypertension reduce dangerous self-medication practices.

While patients wait to see their doctor, they can work at a computer screen and respond to various prompts asking what medications they are on—what medication they take for their blood pressure, as well as medication they may take for common health problems, such as pain or stomach ailments. The computer program counsels them, showing them the possible drawbacks of taking multiple medications, and what medications may interact negatively with one another. Upon completion, patients receive a printout they can take with them when they meet with their doctor, allowing for further discussion and maximizing the time available for the appointment.

“Everything is written for a lower health literacy level,” explains Neafsey. “That’s extremely important. And every screen, every word, the size of the buttons, every color, and the speed of the animation has been tested in very structured usability studies, so we know that they are readable and engaging.”

They’re also effective. An initial test of the software showed that 82% of patients with high blood pressure were able to lower their blood pressure using the system over a four-month period. A second, larger study is currently underway with 264 patients at 11 primary care practices in Connecticut.

“These are teachable moments,” explains Neafsey of the time patients spend in physician waiting rooms. “We thought, let’s use the time people spend waiting to gather information, analyze it in real time, and deliver a personal education program that supports the whole regimen for treating hypertension.”

Using technology tools of the trade, A.D.A.M.’s Greene expects healthcare providers to capitalize on those teachable moments going forward. “Th is is really the beginning of a new era,” says Greene. “It’s a new era of tools for patients to be able to track their own health, monitor it, and make changes. It’s an exciting time in medicine. Th ere are some real positive changes happening.”

Ed Rabinowitz is a veteran healthcare journalist based in Bangor, PA.

Cell phone applications and other high-tech tools are changing the way physicians approach patient education.

Beyond Brochures: Using Tech to Teach Patients

Health literacy requires more than just knowing how to read. It involves 

, including listening, analyzing, and decisionmaking. Patients are called on to demonstrate health literacy skills in a variety of situations when interacting with the healthcare system, including deciphering appointment slips; comprehending written and verbal instructions for prescription and OTC medications and supplements; understanding information in health brochures and other instructional and educational materials; comprehending and acting on instructions from healthcare professionals; filling out consent forms; and maneuvering through the often-complex modern healthcare system.

Literacy problems are not rare, nor are they trivial. The 

2003 National Assessment of Adult Literacy

 found that 43% of adults read at basic or below basic levels, which can translate into poor health outcomes. The 

Agency for Healthcare Research and Quality

 (AHRQ) found that for a number of health and healthcare topics, patients with low literacy had a worse prognosis than those with 

. Populations with sizeable percentages of people who have poor health literacy include the elderly, minorities, immigrants, low-income groups, and people with chronic mental and/ or physical health problems. 

 include lack of higher education, learning disability, cognitive decline among the elderly, and lack of regular reading resulting in diminishing ability over time.

It can be challenging to identify people with low health literacy, as these individuals will not necessarily volunteer their limitations.  Th ey often can be ashamed of their limitations and are very protective of them. Th ere is no particular “look” for someone with low health literacy; these individuals can be well-groomed, articulate, and appear quite intelligent (http:// caonline.amcancersoc.org/cgi/content/ abstract/52/3/134).

Formal tests of health literacy include the 

Rapid Estimate of Adult Literacy in Medicine

Test of Functional Health Literacy in Adults

 (TOFHLA). However, these are not one-size-fi ts-all tools—the lead author of the article on the REALM test only recommends using these formal instruments in clinical practice if the physician is willing to take the time to tailor the communication to the particular patient to be assessed with the formal test.

Physicians and other healthcare professionals must always be on the alert for patients with low health literacy. Beyond merely assuming that patients who are of older age or have limited formal education are at risk, there are several signs that may indicate a patient has low health literacy: claiming they forgot their glasses and therefore cannot read brochures or other print pieces received from your staff , always bringing family members with them to explain instructions and other information, and failing to properly or accurately complete patient intake forms or research surveys.

INTERNET-BASED COMMUNICATION With so many patients relying on the Internet as their main source of healthcare information, the diffi culty of the language used to present medical information can pose a major challenge. 

 found that 100% of the English-language websites evaluated off ered health information at the ninth-grade reading level or higher. Even the language used by physicians in written and oral communications with their patients may be confusing or unfamiliar. 

 offer a number of practical suggestions for clinicians to promote effective communication with patients.

When you are recommending websites to patients or printing pages from websites to distribute to patients, consider whether they are written for people with low health literacy. If you are not aware of specifi c websites that meet this criterion, then recommend those with lower grade reading levels. The typical website is often written at a 

National Work Group on Cancer and Literacy

 recommends that essential written communication for patients should be written at a fifth-grade reading level or lower.

How can you determine if a particular webpage is written at a lower grade reading level? One way is to copy and paste the text into Microsoft Word and calculate the 

. To do this, click “Tools” and select “Options” from the drop-down list (a), click the “Spelling and Grammar” tab (b), and then click the “Show Readability Statistics” checkbox ©.  Then click “Tools” again and select “Spelling and Grammar” from the drop-down menu (d). Word will highlight all spelling and grammar mistakes, off ering you the chance to correct or ignore them, and then display the readability statistics, including the Flesch-Kincaid grade level (e).

 recognizes every occurrence of a period as a sentence. Thus it will count abbreviations such as “Dr.,” numerical expressions with decimal points, and bulleted lists as very short sentences, which may lower the reading grade level. If necessary, edit those parts from the document to allow for a more accurate readability estimate.  When creating a page on a practice website, consider the grade level of the information and other content you plan to include.

 have been shown to be effective means of communicating with patients with low literacy levels. Research has also shown that 

 increases comprehension among patients with low health literacy.

Some physicians embrace e-mail as a way to communicate with their patients. It may be helpful to determine the two or three 

 of clinical importance you wish to convey and include only those in e-mails to patients; anything more than that may be too much content and potentially overwhelm patients with poor health literacy skills. It is also important to use 

, or “living room” language, when possible. Keep in mind that the patient may not be the one opening and reading the e-mail—a friend, family member, or caregiver may be opening and printing the content for the patient to read at a later time.

In addition to the e-mail recommendations, there are several 

 you can employ to promote understanding if you are communicating with your patient via instant message. Avoid asking, “Do you understand?” as many patients will respond “yes” regardless of whether they truly understand. Instead, use a “teach back” approach, in which you ask patients to state in their own words the information and instructions you have communicated to them.

Poor reading comprehension and defi ciencies in other health literacy skills are common and often diffi cult to detect in patients.  Failure to accommodate the needs of patients with low health literacy can result in poor communication, leading patients to misunderstand or ignore your instructions to the detriment of their health. By following the suggestions outlined above, you can help your patients understand and retain the information they need to make better decisions and experience better outcomes.

Dr. Fogel is an Oncology Net Guide editorial board member and an assistant professor in the department of economics at Brooklyn College of the City University of New York. He can be reached at 

Health literacy requires more than just knowing how to read. It involves a number of additional skills, including listening, analyzing, and decisionmaking. 

August 2008 | Oncology Live®