My (informal) social media policy

I use social media - mostly Twitter and this blog - to share content (journal articles, news stories, blogs, tweets, pictures, videos, etc.) that I find interesting and worthy of dissemination. For Twitter, I often make the decision as to its worthiness at the moment I am reading it, so it is usually unfiltered and spontaneous. However:

• Sharing it does not mean I endorse it, agree with it, or necessarily believe it represents a balanced or carefully researched viewpoint.
• RT in Twitter does not mean I endorse the tweet or the link contained in the tweet. It just means I think it is something my followers should see.
• "Favoriting" a tweet does not mean I approve it; usually it just means I intend to read it later. Sometimes I RT or marked a tweet as a favorite only for note-taking purposes.
• If I share it, I usually will have read the linked article completely enough to understand the main points and general concepts the author(s) intend to convey. However, there are exceptions - I may RT something that looks particularly interesting or provocative without reading it in detail, but usually only if I am familiar with the source.
• Since tweets are only 140 characters, it is often difficult to convey nuance or detail, and read out of context are by definition prone to misinterpretation.

My audience is both a professional audience (other physicians or healthcare/IT specialists) and a lay audience (patients). Whenever I tweet or write a blog post, I do not intentionally create the content exclusively for one audience or the other. I recognize there is a lot of overlap in interests, and I believe that is a good thing.

Sometimes I will link to articles that require a personal or institutional subscription to view the full text, or as some call it, articles that are behind a "paywall." I do regret that all of my readers will then not have full access to what I am sharing, but that is the reality of publication today. I'm not going to wade into that discussion here, but I will say that I recognize current business models mean that many journals can't stay afloat financially without advertising directed at paid subscribers. Sorry folks. 

I will not share any patient-specific information, and certainly not anything that would run afoul of HIPAA. Patient privacy is a sacred trust for physicians, and protecting that is my highest priority.

Moreover, while I may share some perspectives and experiences surrounding patients I have encountered, I will do so in a general way, and individual patients should not be able to identify themselves. I realize that it is still possible to reveal enough information in a scenario or vignette to violate privacy without including a patient-specific identifier, so I won't do that.

If I do share a vignette or patient story, it will be a conglomeration of multiple patients or it will be otherwise fictionalized so that an individual won't be able to identify him- or herself. The exception would be if I chose to share a specific patient story with the explicit permission of that patient.

Tweets or blog posts do not represent medical advice. Any interactions I may have with individuals on this blog or Twitter are of a general nature about the health condition but not your health condition. These interactions do not constitute a doctor-patient relationship. You should always consult with your personal physician for questions about your health.

My blog posts and tweets are my opinion only and not that of any other person or organization. They do not represent the opinion of the Johns Hopkins University School of Medicine (my employer) or the American Society of Clinical Oncology (where I volunteer). I am not speaking on behalf of Hopkins or ASCO. I do attempt to honor the social media policies of both organizations, however.

While some have advocated that physicians and other professionals have completely separate social media accounts for their personal and professional uses, I don't totally agree with that (who has the time). I have one blog (this one) and one main Twitter account (@rsm2800). I do use LinkedIn for professional contacts and Facebook on occasion for keeping in touch with friends. However, on LinkedIn I generally only accept connections from people with whom I have a prior or existing business relationship, and I only accept friend requests on Facebook from personal friends.

I am honored to have my patients read my blog or follow me on Twitter, but I do not practice medicine using social media. If you are a patient and you need to contact me about a specific health concern, please DO NOT do so on those channels since I cannot guarantee your privacy or assure you a timely enough response. (At the time of your visit, we will discuss the best way of reaching me or my office - a phone call is always the safest and most direct.) Also for reasons of privacy - yours and mine - I do not accept LinkedIn connection requests or Facebook friend requests from existing or past patients. 

I enjoy being visible on social media and interacting with Twitter followers and readers of this blog, but that doesn't mean I am available 24/7. I have a demanding job and like everyone else I need to tune out at times, not think about work, not read email etc. Some of those times I may still be on social media, so you may see me there even if I am not in the clinic, answering email, etc. If I have any email unavailability longer than an overnight or a weekend, I will use my Out of Office message so you can know when that is. For my Hopkins patients, there is always an oncologist on call 24/7, who can be reached by calling my office number day or night, so if I am not around, someone else covering for me will be.

And finally…

Remember that the strength of social media is its immediacy and accessibility, and the content shared is often spontaneous and unpolished. The ideas may be further developed by sharing and interaction (RT's, blog comments, etc.), and that means that the tone and conclusions may evolve. Pediatrician and social media expert Dr. Bryan Vartabedian calls this "public thinking," and I would agree with his premise that physicians are starting to have an obligation to connect and spread ideas in this very transparent and public space. But by definition, that makes social media a much different communication channel for me as a physician than traditional ones - interacting one on one with a patient in the exam room, publishing in the scientific literature, or speaking at a conference. So while I will always endeavor to make the content I share publicly on social media accurate, timely, and relevant, readers of this blog and my Twitter stream must appreciate the differences between the traditional and social channels. And it is important to do both well!

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[UPDATE 1/2/2015]

On 12/3/2014 I became a full-time employee of the American Society of Clinical Oncology (ASCO), meaning that my previous employment at Johns Hopkins has ended. My position at ASCO is Senior Director, Quality and Guidelines and Medical Director, CancerLinQ. From time to time, I will continue to update this blog, Perspicacity. I remain active on Twitter at @rsm2800. The views I express on any and all of my social media channels are personal views and do not necessarily represent the views of ASCO. I am not speaking on behalf of ASCO. As noted above, "retweeting" or "favoriting" on Twitter does not mean I endorse the content of the tweet. "Following" another user on Twitter does not mean I agree with the positions or policies of that person or organization. And tweets/blog posts never represent medical advice.

Electronic Health Records Infographic

The blogs that I read regularly are full of posts from physicians bemoaning the shortcomings of electronic health records, from poor usability to exorbitant costs to the impact on face-to-face (or at least eye-to-eye) contact with patients. As someone heavily involved in the design and implementation of the Epic system at Johns Hopkins, I know most of these comments represent an accurate depiction of a technology that is a long way from achieving its stated goals of increasing interoperability, enhancing patient safety, and ultimately improving patient outcomes. But this great infographic from the Office of the National Coordinator for Health Information Technology (ONC) reminds us that despite all of their faults, EHR's are able to connect patients and doctors much more effectively than paper records ever could, and there is no turning back if medicine wants to thrive in the 21st century.

Engage With Grace

Thanks to Matthew Holt (@boltyboy on Twitter), founder and publisher of The Health Care Blog, for allowing this to be shared. A more important conversation cannot be had with family and loved ones this Thanksgiving. --Bob Miller

By Alexandra Drane

Once again we're hosting the annual Engage with Grace blogrally. Engage with Grace aims to get people talking about their wishes for end of life and advanced care. If you want to host this on your blog please do and feel free to get the html for this post here --Matthew Holt

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’ We love it for three reasons: 1) It reminds all of us that living with intention is one of the most important things we can do. 2) It reminds all of us that one day will be our last. 3) It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much. And maybe that doesn't bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else. But it’s someone that we love. And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has. Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values. And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter. Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony. So let’s take that off the table right now, this weekend. Know what you want at the end of your life; know the preferences of your loved ones. Print out this one slide with just these five questions on it.

Have the conversation with your family. Now. Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW. Have it this Thanksgiving when you are gathered together as a family, with your loved ones. Why? Because now is when it matters. This is the conversation to have when you don’t need to have it. And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating. We find sharing almost everything else about ourselves fascinating – why not this, too? And then, one day, when the real stuff happens? You’ll be ready.

Doing end of life better is important for all of us. And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama. Others had before. Why was this day different? Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too. Know the answers to just these five questions for yourself, and for your loved ones. Commit to advocating for each other. Then pass it on. Let’s start a revolution.

Engage with Grace.

Alexandra Drane is the Founder of Engage with Grace

ASCO guidelines for breast cancer follow-up: Solid science & rational skepticism

The American Society of Clinical Oncology (ASCO), the primary professional society representing doctors who care for people with cancer, periodically publishes guidelines for common clinical situations encountered by oncologists. The ASCO guidelines are a summary of best practices based on the latest and most thorough analysis of the scientific evidence currently available. ASCO creates its guidelines using a very rigorous and time-consuming workflow by first identifying and analyzing relevant research findings, crafting them into a format that is practical and accessible for patient care, and then submitting them for multiple layers of editorial review. By comparison, guidelines from the National Comprehensive Cancer Network (NCCN), an alliance of 21 different leading cancer centers, including my own institution Johns Hopkins, are created by panels of disease experts based on their consensus opinion. Both processes have a lot of value and are widely used, and to some extent they complement each other. The NCCN guidelines are much more numerous than ASCO's, and they not only address the treatment of different cancers by primary site but also cancer detection, prevention, risk reduction, and supportive care. NCCN also provides a version of their guidelines for patients. The ASCO guidelines are fewer in number than NCCN and deal with more selective situations, and in part this is due to the different methods used for their creation.

Why are there guidelines for the management of cancer in the first place? The most important reason is that it's a way of standardizing clinical care for common tumors, and since the guidelines are created by recognized experts from respected organizations like ASCO and NCCN, there is usually little controversy that they represent best practices based on the most current knowledge. Here's a good description from an article by Drs. Irwin and Peppercorn in the November 2012 Journal of Oncology Practice entitled "Promise and Perils of Guidelines in Quality Cancer Care:"

Such guidelines are currently used to encourage high-quality, evidence-based management that will increase the use of proven interventions while curtailing use of those that lack evidence or are known to be ineffective.

As the authors point out, some evidence exists that adherence to guidelines improves patient outcomes, although that is harder to prove than you might expect. No doubt, guidelines can serve as a deterrent to inappropriate and/or costly, unnecessary care, and they potentially offer physicians protection against medicolegal risks. The authors also cite some theoretical risks of standardized treatment guidelines, which you can read in the full text of the article.

ASCO recently updated their guidelines for the follow-up care of patients with breast cancer who have completed their primary therapy, whether that is surgery, radiation, chemotherapy, or hormonal treatment, or some combination of these. Basically, the population addressed is the very large number of women (and a few men) who have completed the active phase of treatment and who have no evidence of disease, "NED" in oncologist-speak. Generally these are patients who are treated with "curative intent," meaning that their therapy was delivered with the reasonable  expectation that it would result in complete eradication of the cancer. Unfortunately, we know that does not always happen, and recurrence after primary treatment, sometimes many years later, is an unfortunate and feared event. Given how prevalent breast cancer is and how the majority of patients do end up going through one of these life-altering treatments, it is critically important to have some guidance as to the most appropriate follow-up care. These guidelines address such things as how often a patient who has completed all treatment should be seen by her doctors, what lab tests and imaging studies are recommended, and what advice patients should be given. ASCO first created these guidelines in 1997 and updated them in 1999 and 2006; this is the 2012 update. Here are the relevant links:

• The abstract of the early release article from the Journal of Clinical Oncology published online 11/5/12 (shout out to the 3 Johns Hopkins co-authors, Dr. Antonio Wolff, Dr. Tom Smith, and Elissa Bantug, herself a young breast cancer survivor who coordinates our breast cancer survivorship program)
• The full text of the JCO article 
• A summary slide set
• A surveillance flowsheet in Excel format (also available as a PDF)
• Links to Cancer.Net's patient guide on the topic

Let me try to summarize the most important recommendations. The key point is that this 2012 guideline is identical to the 2006 version, which is to say that the ASCO panel, after looking at all of the published literature between 2006 and 2012, did not identify any research findings that warranted a change in their recommendations from 2006. The foundation of follow-up for patients with early stage breast cancer treated with curative intent should be periodic clinical evaluations (i.e., doctors' visits) and mammography. The frequency of recommended follow-up visits decreases as time goes on, from every 3-6 months for the first three years, to once or twice a year for years 4-5, and annually thereafter. The follow-up care should be provided by practitioners experienced in the surveillance of breast cancer (i.e., knowledgeable about the manifestations of cancer recurrence and late effects of the treatment) and comfortable with the physical exam of the breasts, especially the irradiated breast. Note that it doesn't say this has to be an oncologist necessarily, although hand-offs between oncologists and PCP's are discussed, and the practitioner is not required to be a physician, as mid-level providers working with physicians are often quite expert in this role. The guideline gives some recommendations about the frequency of mammograms which you can read at the links above. The importance of educating patients in the signs and symptoms of cancer recurrence is mentioned, as is the importance of regular gynecology follow-up.

As was the case for the identical 2006 version, the part that this 2012 guideline addresses that I think will generate the most interest is what is NOT recommended, which is basically all blood tests (including CBCs, chemistry panels, and tumor markers such as CA 27.29) and all imaging except breast imaging. So specifically all chest xrays, bone scans, CT scans, PET scans, and ultrasounds are not advised. To be clear, the recommendation against performing this type of testing applies to the patient that is in surveillance mode, who is coming in for a regular follow-up visit and who by definition does not have any specific symptoms. ASCO is not suggesting that doctors should forgo this type of testing as a way of evaluating a specific concern like a new symptom (say, back pain) or physical finding (such as an enlarged liver detected by the physician). Good medical practice would dictate just the opposite.

This is not a surprise, and the research supporting this has been around since the mid 1990s. And let me say as a breast cancer oncologist, I support this and have generally been practicing this way for many years. Those studies from the past basically showed that an intensive surveillance strategy of regular imaging studies and labs, when compared with a more conservative approach of periodic physical exams and mammograms alone, did not show any real advantages. The vast majority of recurrences were identified not by imaging tests, but by a symptom the woman herself notes or a physical finding the physician identifies on physical exam. Survival rates were the same between the patients followed more aggressively and those followed more conservatively, and quality of life was not any better. Yes, intensive surveillance and testing did identify more recurrences earlier, usually by no more than a few months, but it did not translate into higher cure rates or even fewer complications. Since metastatic breast cancer is incurable, all the early testing did was identify metastases a few months or so before they declared themselves either by a symptom or a physical finding.

And to take this a step further, this idea of not doing surveillance testing on patients with early stage breast cancer in the follow-up phase made it onto ASCO's Top Five list for the American Board of Internal Medicine Foundation's Choosing Wisely campaign - five commonly used practices that can and should be questioned since they are costly and lack medical justification. I cover this in a blog post from a couple of months ago.

But if there ever is an issue that I find problematic in my clinical practice, and one that raises delicate issues of patient empowerment and autonomy, physician authority and adherence to evidence-based medicine, and doctor-patient communication, it is this one. This issue about not performing certain tests is one that causes understandable tension with many of my patients, since at face value it seems illogical and inappropriate. Why wouldn't you want to detect cancer earlier? How could it be that would not improve outcome? And even if there was some uncertainty about that, why should ordering a simple blood test be an issue since the harm is perceived as minimal and potential gain great? Let me run through a few aspects of this issue that contribute to making it so challenging:

1. Oncologists used to do this for breast cancer patients. Yes, that is very true. When I was doing my fellowship in the late 80s I think some of the regular testing was starting to wind down, but I do recall that getting annual bone scans and liver ultrasounds - and certainly "routine labs" like chem panels - was accepted without much question.
2. Oncologists do this these days for patients with other cancers. Yes, very true as well. For example, there is very good evidence that monitoring patients with colon cancer who have had primary surgery +/- chemo with CEA blood tests and periodic liver CT scans, improves outcomes by identifying liver metastases early, thereby permitting potentially curative resection of the liver lesions.
3. Some oncologists do this these days for breast cancer patients. Also very true. I see a fair number of patients who receive their care outside of Johns Hopkins, and it is not at all rare when I review their records that I can tell their doctors are ordering CA 27.29 blood tests every few months for monitoring. In fact, a rising tumor marker in the absence of any other positive findings is a common reason for referral to an academic medical center like Hopkins. When I try to diplomatically explain that this was a test that we probably wouldn't have ordered here, the patient is often confused and conflicted, particularly since that fact is irrelevant as far as they are concerned if it suggests that there is a potential problem (which I totally get).
4. The downstream consequences of false positives and enhanced anxiety are not trivial. What is not always easy to appreciate is how a relatively lousy screening test like the CA 27.29, with less than optimal specificity and sensitivity, may open up a whole range of problematic issues - over-interpretation of trivial xray findings, misattribution of physical symptoms better explained in another way to "the cancer," and the endless cycle of repeating scan after scan to follow up on an equivocal abnormality. 
5. Even though patients may intellectually understand #4, many still want these tests done for whatever assurance they can provide, and they are willing to risk the false positives. Again, I am quite sympathetic to this viewpoint which many of my patients articulate to me. But I see how it can go either way - the test can be "negative" which is reassuring for everyone, including me as the oncologist who usually is the one who ordered it, or it can be abnormal or equivocal, leading to more testing. And when the patient now finds herself on the receiving end of the latter, it's much harder to deal with that scenario than it is in the abstract.
6. Patients just want some reassurance that they are ok. The doctor asking you questions and doing regular physical exams, in this modern era of sophisticated imaging and labs, isn't very reassuring. At the completion of adjuvant chemo and radiation, virtually every patient asks me, "How do you know it worked?" In other words, how do you know I am ok? How will I be monitored to know that I remain ok? It's so disconcerting when I have to say that we only really know if chemo didn't work, and we have no way of proving that it accomplished what we wanted it to do. It's very understandable that patients want some objective evidence that they are cancer-free. That's why they are naturally inclined to expect that some type of testing - not the word of the oncologist, even when the trust factor is very high - will offer them that reassurance.
7. A negative test means that based on the performance characteristics of that test there is no evidence of cancer at that time. So a relatively insensitive test (e.g., a chest xray) offers a small degree of reassurance that everything is ok, at least in the lungs, but it is only as good as its ability to discriminate a lesion large enough for it to detect. So a chest xray is likely to miss a 4 mm lung nodule, something that is much easier to see on a CT scan but at the price of a much higher exposure to radiation. But even a CT or a PET scan or whatever the latest imaging test to come will be has a shelf life - a negative PET scan in January does little to reassure anyone in October.
8. It is increasingly being recognized that radiation from diagnostic imaging is not good for you, and it probably increases your risk of cancer a small amount. While this is true, it does seem a little incongruous when an oncologist uses this line in someone that has just gone through 20 weeks of chemo and 6 weeks of radiation which themselves can, ahem, cause cancer. I'm not trivializing the risk, but I understand some patients find this "justification" for not ordering a screening test a bit of an odd juxtaposition.
9. It is possible that a physician ordering a blood test or especially a more expensive study like a PET scan may have a financial stake in the matter, which could theoretically cloud his/her judgment. Doctors who are part owners of facilities that do PET scans or labs that run chemistry panels may benefit financially from these tests, to a greater extent than an employed physician like me, who gets $0 for any test I order. But let me say that having spent the first 17 years of my career in a private practice with an in-office lab, it is hard to believe that even subconsciously that would have influenced my decision to order a chem panel, and of course, if I really followed the guidelines, I would be going against my own financial interest. However, when this potential conflict of interest exists, it does raise the question as to why there are such variances of practice.
10. Where do cost and the ethical principle of justice fit in here? Talk about a thorny issue! When I advise a patient not to undergo a PET scan for the primary purpose of reassuring them that they are ok post-treatment, I am not doing it primarily to save dollars. In fact, that is the furthest thing from my mind in the exam room. In essentially no cases right now (and this will change with ACO's - accountable care organizations) is an insurance company telling me not to do it. At least if they deny coverage, it is transparent and the patient knows right away. But where do you draw the line? It's incredibly easy for me to order a lab test because a patient or family insists, even if I am not convinced it is medically justified. While I have a responsibility to act in good faith, for a cancer patient I can almost always "justify" a lab test for the payer. But should I? If I order a test on every patient who insists on having it done, costs paid by someone will escalate. And if thousands of my colleagues do this all over the country, it will easily be hundreds of millions of healthcare dollars spent. Should those limited dollars be spent on testing that does not improve patient outcomes, like PET scans that identify an incurable lung metastasis 4 months before it declares itself, even though it would not affect treatment decisions one bit? Or should they be spent on something better, like co-pay assistance so people don't go bankrupt paying for potentially curative treatments like Herceptin?
11. Am I really sure of the data? I started this by saying that the ASCO guidelines represented best practice. But evidence-based medicine is hardly static. It changes all the time. While no study to my knowledge has ever shown that periodic measurement of serum markers like CA 27.29 or the Circulating Tumor Cell assay used in some places affect outcome, I am pretty sure these specific issues have not all been addressed in randomized controlled trials in systematic fashion. I noted that none of the 14 manuscripts the ASCO panel looked at to update these guidelines between 2006 and 2012 specifically address these tests as a primary variable. Is it possible that some combination of lab or imaging tests may someday reveal better quality of life or even greater longevity for more heavily screened patients, especially as our treatments improve? Hardly implausible.
12. And finally, doesn't this focus on guidelines impair the trust between the doctor and patient by making the care less individualized? Doesn't the physician's judgment enter in at some point? Do guidelines always have to be followed? My answers are - yes it certainly can and does; absolutely; and absolutely not. No physician should be worshipping at the altar of "guidelines" without a thoughtful examination of their strengths, their flaws, and the needs of the patient in front of you. Medicine and certainly oncology will never be a cookbook science, and the imprecision and variability of some of these issues is as maddening to doctors and patients alike as it is inevitable.

My bottom line - I think the ASCO guidelines being discussed here are rational, reasonable, solid, and as good a blueprint as we can hope for in 2012 for this specific clinical issue. They are also as flawed and incomplete as virtually everything else in clinical medicine. I have used them as a starting point for discussion and education with my patients. Usually that goes well, but it is a process not without its tensions at times. I have tried not to draw a line in the sand, but I can think of a few occasions where there was an impasse that we could not bridge. There are few absolutes here. It's not always as straightforward as simply doing whatever test or procedure the patient wants. That's not patient-centered care. Just as I've failed if my reasoning is dogmatic and opaque to my patient, I've also failed if I do something that my training and judgment tells me is incorrect or improper. I hope and pray I can continue to grow in wisdom to make the best decisions. I need input not just from expert ASCO panelists that create these guidelines, but from the real people - my own patients - who are living with breast cancer and trying to make some sense of the madness. And if any of you have read this far, I would love to hear your comments on this blog post. Your insights are always welcome and instructive.

USA Today article on #bcsm weekly tweetchat

Kudos and thanks to Liz Szabo (@LizSzabo on Twitter) from USA Today for her 10/23/12 article "Breast cancer survivor group is a social movement" about the weekly breast cancer social media (hashtag #bcsm on Twitter) tweetchat and online support group.  Co-founded by two breast cancer survivors/bloggers Jody Schoger (@jodyms) and Alicia Staley (@stales) a little over a year ago, the group has blossomed into a vibrant community of support for breast cancer patients and their families, caregivers, friends, and many other interested folks. If you're unfamiliar with the lingo, a tweetchat is a virtual meet-up on Twitter at a specified time, often repeated weekly or at some other interval, around a predetermined hashtag, which is a type of metadata. The conversation is often organized around questions or topics posted by the moderator, although tweetchats are by definition unstructured and free-flowing. Here's a more detailed explanation. 

The USA Today story emphasizes the power of the community that has arisen out of this online gathering. While it seems improbable that meaningful interaction could really occur over the exchange of 140-character tweets, that is exactly what happens, and the online conversation is deeply-nuanced and powerful. I have been honored to be a guest expert on #bcsm, and I frequently join in the conversation, which occurs most Monday evenings at 9:00 pm Eastern time.

I appreciate Liz Szabo allowing me to be quoted for the article and more importantly for publicizing the existence of the group and the good that it is doing. This is another example of how social media provide opportunities for connection and community that transcends geographical, institutional, and socioeconomic boundaries.

Help me show a group of physicians the power of social media

I'm going to be giving Grand Rounds for the Department of Medicine at University of California, Irvine School of Medicine on Tuesday, October 16, 2012 at noon PDT, as I mentioned in an earlier blog post. The title of my talk is "Social Media and the Digital Physician - #UCIMedGrandRounds." Since it would probably be a wee bit too challenging to try to livetweet my talk while actually giving my talk (I'm good, but not THAT good), I decided to pre-schedule a series of tweets using HootSuite with the #UCIMedGrandRounds" hashtag, to be posted during the talk, roughly correlated to the topics I am covering at the time. I fully plagiarized this idea from @colleen_young, who pulled this off in spectacular fashion I am told at the 2012 #Med2 conference in Boston - props to you!

So I am hoping that my Twitter community will join in the fun next Tuesday 10/16 at noon Pacific time. Please follow the #UCIMedGrandRounds hashtag that day, and "wave" to the audience by introducing yourselves to them via Twitter. I'll send out a few reminders at the start of the talk. While I don't know how social media savvy my physician audience will be, since it's an academic medical center I suspect that penetration of Twitter may be fairly minimal. I am hoping we can generate a little buzz by showing them the power of connection and interaction that we find in social media. Maybe we will get a few converts! Thanks.

Breast cancer links page

This blog post will be a work in progress, and I'll probably keep updating it. I was motivated to do this to try to put together a list of online references for my own breast cancer patients. I do regret I haven't really done this in quite a few years. I frequently refer patients to the Hopkins Breast Center web site or Cancer.Net, but obviously there are many other choices. I will generally only list institutional, non-profit, or governmental sites, and usually only those with which I am reasonably familiar. While there is much good content on commercial sites and social media sites, it is not my intent to focus on those here.

Curation of online content - in my humble opinion - is an important role for the 21st century physician. In a perfect world, I would spend part of every visit, or at least every new patient visit, pointing my patients to online references that complement what we covered during the visit and help them further understand their diagnosis, prognosis, and treatment options. The truth is, it is very challenging to find the time to do that. That is not likely to change until we have our EHR fully implemented at Hopkins next spring, with the patient portal in place and automated after-visit summary generated with each visit. I am optimistic that the technology will facilitate this type of educational offering.

I welcome recommendations of other web sites that my readers have found helpful. As mentioned, I intend to focus largely on reputable institutional sites, but I will read every suggestion. Please leave me a comment below or suggest a site to me on Twitter (@rsm2800).

And now the obligatory disclaimer stuff...

The links that I list below are from organizations that are reputable and have a history of producing high quality , credible patient-education information. If I approve a blog comment mentioning other sites/resources, I am sharing it but not necessarily endorsing it. Obviously, all of these sites are from third parties, and I do not control their content. And as I say in the disclaimer on my home page, this blog is not medical advice. Always consult your physician for specific medical questions about your condition.

General Breast Cancer Information

Cancer.Net - Cancer Types>>Breast Cancer

NCCN Guidelines for Patients - Breast Cancer

National Cancer Institute - Breast Cancer Home Page

American Cancer Society - Breast Cancer Overview

Johns Hopkins Kimmel Cancer Center - Breast Cancer Program Home Page

Drug Information

Drug Index - British Columbia Cancer Agency

American Cancer Society - Guide to Cancer Drugs

National Cancer Institute - Cancer Drug Information

WebMD - Drug and Medication List

Clinical Trials

National Cancer Institute - Clinical Trials Search

ClinicalTrials.gov

American Cancer Society Clinical Trials Matching Service

Johns Hopkins Kimmel Cancer Center Breast Cancer Program - Clinical Trials Page

Breast Cancer/General Oncology News

Breastcancer.org Research News

MedPage Today - Oncology/Hematology Information Center

Oncolink - Cancer News

Coping/Supportive Care

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Whose opinion matters in medical decision-making?

Caring for patients involves the formation of multiple opinions. Traditionally, the patient's physician generates the first opinion, with other clinicians offering second opinions. However, an opinion at least as important must also be recognized in this traditional rubric—that of the patient and family members. Just as the conscientious health care practitioner is constantly reformulating his or her opinion based on many factors, so too is the patient.

 --Recognizing an Opinion: Findings From the IOM Evidence Communication Innovation Collaborative JAMA. 2012;():1-2. doi:10.1001/jama.2012.13369

How important is the opinion of the patient and/or family in medical decision-making? And how can these opinions and preferences be better integrated into clinical care? A discussion paper published this month from the Institute of Medicine (IOM) entitled Communicating with Patients on Health Care Evidence attempts to tackle these questions and other issues related to improving the quality of medical decisions. The impressive list of authors, who are all thought leaders in areas as diverse as academic medicine, public policy, and consumer empowerment, were participants in the "Evidence Communication Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care." (Now, there's a title.) Props to the IOM for releasing the full text of the paper as a freely available PDF and to JAMA for posting the Viewpoint summary article from Novelli et al also with free access to full text. 

A few key takeaways from the report:

• 8 in 10 people want their provider to listen to them.
• 8 in 10 people want to hear the full truth about their diagnosis.
• 7 in 10 people want to understand the risks of treatments.

BUT:

• 8 in 10 people want their health care provider to listen to them, but just 6 in 10 say it actually happens.
• Less than half of people say their provider asks about their goals and concerns for their health and health care.
• 9 in 10 people want their providers to work together as a team, but just 4 in 10 say it actually happens.

The report defines the three components of informed medical decisions as medical evidence, clinician expertise, and the patient's goals and concerns. In Figure 4, survey data are shown demonstrating that patients place nearly equal weight on each of these, with a slight edge to medical evidence as the leading component. Interestingly, women were somewhat more likely than men to say that their personal goals and concerns were "very important" (64% vs. 50%).

In addition, the following language was deemed in patient interviews and focus groups to "resonate best" in regards to medical evidence:

Making sure you get the best possible care starts with you and your doctor making the best decision for you. Your doctor can help you understand what types of care work best for your condition, based on medical evidence. Because there are always new treatments, doctors use this evidence to keep up with which work best. Your doctor's experience helps him or her evaluate and apply the evidence to your situation. The doctor also needs to listen to you so he or she understands your values, preferences, and goals. This is important because every patient is different, and when there are options, it is important for the doctor to know what is important to you.

In the conclusion, the authors call for the following actions:

1. Cultural changes - providers should recognize existing gaps and adopt decision aids when available and other tools, including mobile technologies, to facilitate the presentation of knowledge and care coordination
2. Incentive alignment and infrastructure support - patient-centered medical homes and EHR's that promote "meaningful choice" are singled out
3. Quality standards and accountability - including a suggestion for professional licensing/accreditation bodies to incorporate criteria encompassing patient-centered medical decision-making

So is there anything new here? And what are the lessons for oncologists in particular? As a busy clinician in a breast cancer practice at an academic medical center who every day tries to guide patients through difficult decisions - whether or not to receive adjuvant chemotherapy for an ER positive cancer, whether to enter a Phase I trial when conventional options are exhausted for refractory disease, whether to be hospitalized for IV hydration or pursue a purely palliative approach at home with hospice - my first reaction, and admittedly not my best reaction, is to go into Defensive Mode. Of course, I always consider patient preferences. Of course, I always give people the full truth about diagnosis and prognosis. Of course, I explain risks adequately. And so on. But based on this paper and numerous other examples, it doesn't take much self-reflection to acknowledge that my colleagues and I probably aren't hitting the mark nearly as often as we would like to give ourselves credit. The one concept from this paper that resonated the most with me was the emphasis on the idea that patients want to know all of their options for a given decision, not just the ones that I as the provider favor. Using the example of trying to decide whether to administer adjuvant chemotherapy for an ER positive, node negative breast cancer (let's make it more complicated and say the Recurrence Score is 22, and there's no trial avaiable), what options might I present to a patient, who is otherwise fit for chemotherapy and willing to receive it? Well of course I tell them that tamoxifen or an AI alone may very well be sufficient treatment. And then after trying to put the use of adjuvant chemotherapy into an historical perspective, I discuss with them the option of a standard regimen like TC x 4. I do usually tell them that no systemic treatment is also an option, although not one I advise. And within the limits of our knowledge and predictive ability, I try to estimate the risk of recurrence and the potential benefit of the intervention in numerical terms, trying to emphasize absolute benefits instead of relative. (I confess, I have been known to start the conversation by saying that an AI will "cut the risk of recurrence by half." I'm not immune to sound bites.) But along this vein, do I give them the option of TAC x 6, even if in my opinion the potential benefit is not high enough to justify the greater toxicity of a 3rd generation regimen? Not often. Do I mention regimens that I just don't use, like CMF or M->F, knowing that there are a few places that still do use them, and there is some evidence to support their use? No, I don't. Or do I regularly discuss a possible role for adjuvant bisphosphonates, recognizing they are not FDA approved for this indication, and I am personally not convinced that we have enough data, even in postmenopausal women, to demonstrate a net benefit? No, not usually, unless asked.

Why don't I do these things? I suppose I partially justify it by saying that I simply can't recommend and discuss as a viable option a treatment that I don't feel passes my own evidence test - not necessarily my own experience. And, being realistic here, time constraints do play a role. In a perfect world, a new consultation would last 2 hours, 3 hours, or however long was needed to convey all of this information, or would extend over multiple visits. But if I did that with everyone, my new patient slots would dry up, and it would take weeks and weeks to get an appointment with me, which means the next patient needing consultation would be kept waiting in frustration. Furthermore, no matter how skillful a presentation of options is in a clinical encounter, a recitation of treatment choices rendered without context or hierarchy is frequently meaningless and confusing to even highly sophisticated patients. So does this mea culpa make me a non-patient-centered oncologist, and guilty of the failings described in the IOM report? Like most of us I would hope, I have an infinite capacity for self-criticism and second guessing, so I suppose the answer is that, yes, at times I indeed need to be more mindful of the alternative approaches and considerations illustrated in this piece. But I offer this reflection to illustrate how complex and nuanced the physician perspective is in the spectrum of informed decision-making. 

Lest my comments be interpreted as critical of IOM or suggesting this discussion paper is some ivory tower assessment devoid of the realities of practice in the modern era, far from it. I salute the IOM for focusing on this issue with the right combination of balanced analysis and practical suggestions. I will try to reflect on the recommendations they put forth in all of my patient encounters this week and put the principles of patient engagement front and center. I challenge all of my clinician colleagues reading this blog to do the same. And to our patients in the difficult situation of being on the receiving end of these discussions, I salute you and recognize you are the ones thrust into this situation unwillingly and often with little time to prepare for such weighty decision-making. Help us your caregivers help you. Tell us what you need and when we have failed to include you.

I'm on BlogTalkRadio 9/26/12 5PM EDT with Dr. Richard Just

I'm honored to be asked to appear on Internet radio with San Diego area oncologist and social media triple threat Dr. Richard Just, Wednesday 9/26/12 5:00 pm EDT for a 30 minute chat ranging from social media for oncologists to breast cancer. You can listen in live here. And be sure to check out Dr. Just's lively Twitter stream with the handle @chemosabe1 (wish I'd thought of that one) and blog JustOncology.com.

The Virtual Choir

[This weekend, while trying to work on my Department of Medicine Ground Rounds talk at UC Irvine for next month ("#UCIMedGrandRounds – Social Media and the Digital Physician"), I've been listening to some soothing Eric Whitacre pieces with hopes that it would inspire me to get most of my slides done. Not sure that is working yet, but it inspired me to share a blog I did for ASCO Connection earlier this year about artistic vision, collaboration, and illness.]

In a previous life I used to be a church musician. I started piano in the 1st grade, and since I attended a pretty traditional parochial elementary school, it was natural to gravitate in this direction. Over the years I’ve been involved in church and school choirs as a pianist, organist, singer, arranger, composer, and conductor, and I did this in high school, college, med school, and beyond, as recently as about four years ago. Lest you confuse me with someone with real talent, let me say I was never classically trained and I would probably embarrass myself pretty badly today if I tried to perform anything complicated. But I’ve long maintained my love for classical choral music, both sacred and secular, and I’ve always greatly enjoyed listening to choral works on my iPod.

A few years ago, while browsing the iTunes store, I discovered a composer and conductor named Eric Whitacre, who has had a somewhat meteoric rise to fame and international acclaim in this genre. He has an interesting personal story. He grew up in rural Nevada in the ‘70s-‘80s and attended UNLV, not exactly known as a powerhouse for classical music. As he tells it, even though he could sing, he couldn’t read music when he started college. On a whim, he joined a college choir and almost immediately had a transformative experience with the music and the blending of voices that led to a BA in music, then a Masters at the Juilliard School, and over the next 20 years lavish praise, fame, and multiple awards as a prolific composer and conductor of choral and symphonic music. I’m sure it doesn’t hurt that, now at 42, he is described as “boyishly handsome” and is an articulate and passionate speaker. His music is known for its dense harmonies, dissonance, and unusual rhythms. I find it very beautiful and challenging. But what I really found fascinating was an experiment he started in 2009 with something called the Virtual Choir. It’s probably easier to watch this 11-minute “TED Talks” video, which went insanely viral last year, than read my summary, but I will try to be brief. It seems that a young girl sent him a fan video on YouTube of her singing the soprano part to one of his pieces called Sleep. He was struck by the tribute, and he recognized the purity and sweetness of her artistry. He then had an inspiration about how to harness the creativity of multiple other would-be performers who might be singing to their video cameras and uploading to YouTube, hoping to create something beautiful that would make them famous. So what he did was to put out a call, using social media, encouraging singers all over the world to video themselves singing one of the parts of his work Lux Arumque. He ended up receiving almost 200 hundred videos from a dozen countries. Then with a collaborator, he assembled his Virtual Choir into a single video, with himself conducting these virtual voices, and the results are, well, astounding. He went on to produce Virtual Choir 2.0, with over 2,000 separate singers from dozens of countries, and then just this week released the video of Virtual Choir 3.0, with 3,746 singers from 73 countries performing his work Water Night. I know you are busy people, but take 30 minutes out of your evening to view all three of these videos. Even if you are not a fanboy like me, the artistry is remarkable, and the music sublime and exhilarating.

So what in the world does this have to do with medicine, oncology, or ASCO Connection? As I followed this story, it struck me how there are some parallels with health care and the experience of illness. In the Virtual Choirs, Whitacre and thousands of others with the common interest of choral music were coming together to share an artistic vision and create a larger work. While each singer was recording an individual vocal track in the privacy of his or her own bedroom, there was an undeniable social connection. The need to connect with other people who share our interests and experiences is one of the strongest forces of our humanity. And I see this every day in the practice of oncology. Yes, this is the era of personalized medicine, but so many of our patients have a fundamental need to connect with other patients and families that are going through the same thing they are, a need that we as health professionals can’t possibly fill. People need to learn from each other in a social and collaborative fashion, and the wonders of the Internet and the explosion of so many social media channels today have enabled this to a degree never before possible. Much research has confirmed this, and while patients will usually come to their physicians for the authoritative voice we have, they still need to process this knowledge through the filter of other people. As oncologists, we would be foolish to deny this reality, and I would maintain that a much greater good could come from our efforts to facilitate it, if not harness it for a larger purpose.

But for us as physicians, it’s more than simply allowing patients to share their war stories and their tips on dealing with treatment, with some type of blind but vaguely disapproving eye. I think this social urge is a greatly underutilized resource for discovery. Think of the whole concept of patient-reported outcomes. As physicians, we know or should know that we generally do a lousy job in assessing the patient experience of illness. In our field this very pointedly is the patient experience of treatment toxicity, fear of the disease process, and loss of control. The data are so much better when we let patients tell their stories directly. And think how easy it would be to enable this with all of the simple and widely accessible technologies available today, like YouTube and cell phone texting. As investigators, we could create our own Virtual Choir of our patients, individually and collectively, contributing content that we can amass and analyze for trends and causality. Think how simply elegant an experimental design could be. Say we wanted to know the temporal trend of patient-rated bone pain following a Neulasta injection. Sure, we think we know this from existing clinical trial data, but mostly it’s what we’ve asked our patients to tell us. What if we told every breast cancer patient getting dose-dense AC starting on day 2 of each cycle to text an integer value from 1-10 corresponding to their level of bone pain to 11435? And what if the data were displayed real time on a website that refreshed every ten seconds with all other participants’ results, so that people feeling lousy in their homes that night could see other peoples' scores and know they weren’t alone? I would predict that this collaborative content creation would enhance study compliance like no $25 Starbucks gift card ever could. And if instead of a Virtual Choir of 2,000 or 4,000, we had tens of thousands of patients doing the same thing? Talk about Big Data! Yes, our current broken clinical trial system can’t support something like this. But I believe we can figure out a better way to harness the power of social media, collaborative data creation, and the patient voice to overcome these barriers and transcend our current maddening limitations.

Whitacre had a vision of musical creation that transcended a single concert hall or venue, and the results were breathtaking. In our field, I believe we are no less creative and passionate. What are the provocative questions we can answer by being as visionary and bold?

The evolution of the inpatient attending physician: JAMA Viewpoint

I enjoyed this recent perspective article in JAMA by Dr. Bob Wachter of UCSF and Dr. Abraham Verghese of Stanford about the role of the inpatient ward attending in the "modern era" of hospital medicine, with the rise of the hospitalist movement and housestaff duty hours restrictions. Full text is available here. Again, I am sorry this is only available to JAMA subscribers or institutional members. However, you can listen to a very nice audio summary interview by JAMA editor Howard Bauchner and the two authors free of charge (scroll down to the 9/11/12 podcast).

When I was an internal medicine intern and resident at UCSF in the late 1980's - and coincidentally Bob Wachter was one of my chief residents at the time - the ward attending was a senior physician who was supposed to be in charge of our team of residents (usually 2-3 interns and 1 second-year resident) and would "supervise" us. But the reality was that we had tremendous autonomy in those days, and it seemed as if most if not all of the medical decisions on the patients on our service were made by us, the housestaff, all of whom had been out of medical school 2-3 years at the most, and not by the senior guy. His/her job was to spend a little time teaching, often about topics related to his/her subspecialty, whether relevant to the patients at hand or not, to write the daily attending progress note, and then to get out of the way and go back to the lab or office. The non-physicians reading this will no doubt find that level of (non)-supervision deplorable, and now with the perspective of almost 30 years behind me, I would have to agree with you. We did have too much autonomy, and it was not an ideal situation from a patient safety or quality of care standpoint. I'm glad it is so different now. However, lest you think it was unconscionably reckless and bordering on malpractice, we usually did a very good job taking care of our patients, and we learned to be responsible, obsessively detail-oriented, and independent in our medical reasoning and decision-making. And there was no doubt that the patients viewed us as their real doctors during that hospital stay, not the semi-anonymous old guy in the long white coat that came in 5 times a week parading in the room with a huge team of unknown people wearing scrubs and short white coats, all the while not saying much and deferring to the sleep-deprived young 'uns with the clipboards and pockets jammed with papers.

I like this perspective article because it was balanced and was not one of those "days of the giants" pieces romanticizing the old way of practicing medicine. In the modern era, attendings are usually young physicians themselves, often hospitalists physicians, who are not that many years out of training, but are typically much more involved in the day-to-day activities than 1980's attending. They are personally responsible for every major medical decision, as it should be. The hospital team structure these days is much more matrixed and redundant, and in my opinion much better for patient safety and continuity. Still, in the olden days before EHR's and discharge planners, the bedside teaching we received from the senior physicians, with a greater emphasis on interacting with the patient, listening to the patient story, and doing the physical exam, had plenty of merit, even in its brevity. Hope you enjoy the piece.

Duration of adjuvant chemotherapy: How much is enough?

(I've been away this week at the Epic Users's Group meeting in WI as part of my IT role at Hopkins, so I haven't been able to contribute to my blog. Here's another post continuing my series on recently published literature about breast cancer that patients and physicians might find relevant.)

How many cycles of chemo do you need? As a breast cancer oncologist, this question comes up in clinic a lot, particularly since I see a large number of women with early-stage disease who are being referred for my recommendations about adjuvant chemotherapy following lumpectomy or mastectomy. Since many of these patients are going to be cured even without chemo (especially if the cancer is estrogen receptor positive, meaning they will be receiving tamoxifen or an AI drug), minimizing the number of cycles of a toxic treatment like chemotherapy is critically important to achieve the optimal balance between benefits of therapy and side effects and risks. Unfortunately, we rarely have solid scientific evidence about how much is "enough," and I can appreciate how patients must think oncologists are incredibly arbitrary and vague when we advise six cycles of treatment not four, 20 weeks of therapy not 18, etc. And why do the recommendations always seem to be expressed as even numbers? Why not ever 3 or 7 cycles? (Don't ask me to try to answer that one…)

A recent trial published as an Early Release article in the Journal of Clinical Oncology came out online several weeks ago. This was a report of CALGB study 40101, entitled "Six Cycles of Doxorubicin and Cyclophosphamide or Paclitaxel Are Not Superior to Four Cycles As Adjuvant Chemotherapy for Breast Cancer in Women With Zero to Three Positive Axillary Nodes." If you are a JCO subscriber you can read the full article online. Also, there is a good summary article about the trial in the ASCO Post last week. I won't try to describe the study in detail except to say that early stage breast cancer patients who were either node-negative or had three or fewer positive nodes were randomly assigned to receive chemo with four cycles or six cycles of AC (Adriamycin/Cytoxan, a very widely used adjuvant regimen) or four cycles or six cycles of Taxol. The bottom line is that four-year relapse-free survival and overall survival was virtually identical when comparing the patients who received four cycles of either AC or Taxol with those who received six cycles of the same. Whether Taxol was superior or inferior to the AC was not reported yet, as further follow-up will be required before an answer can be determined. Having said that, the AC combination is a widely-used standard, and in very few situations would Taxol be given by itself as adjutant treatment. But clearly 6 cycles is almost always going to be more toxic than 4 cycles; now we know that it's not better, so in this population of patients (i.e., not necessarily applicable to all breast cancer patients), six cycles should NOT be used routinely.

So why can't we answer the question about duration of chemotherapy for all types of breast cancer patients and in other cancers as well?  Why is it so hard to get this information? Well, it just is, and that is very disappointing for oncologists and patients alike. These studies are very difficult to do, since they require large numbers of patients willing to be randomized and many years of follow-up. Remember that no more then 3-4% of all adult patients in the U.S. participate in cancer clinical trials. This trial enrolled 3171 women over a 6-year period of time, and it was performed in multiple institutions. That means that many thousands more treated in those same institutions either were offered the trial and declined it or were not eligible in the first place. And it took 10 years to get the results. That's because there was only a 1% difference in survival at 4 years for women treated with 6 cycles of chemo vs. 4 cycles - not statistically significant and practically not enough of a difference to justify the misery of increasing the length of the chemo by an additional 4-6 weeks. In a disease like early-stage breast cancer, where most patients do well - overall survival was > 95% - you only see differences in treatments when there is an "event," like a relapse, a death due to breast cancer or another cause, or a side effect so severe that it requires the patient to drop out of the study. In other words, only when something bad happens to a patient in the study do you really learn whether there are differences in treatment. And I should also say that it is not intuitive that four cycles of breast cancer chemo of this type are equivalent to six. It could have gone either way, and there are many other examples in oncology where shorter durations of treatment are definitely inferior to longer. So it requires a clinical trial of this magnitude to answer a question of this type.

Or does it? Maybe I'll save this discussion for another blog post, but researchers have been realizing that the days of these mega-trials, with thousands of patients randomized to different treatments that themselves represent only tiny variations in therapy, are numbered. In this era where more and more of our cancer treatments are becoming more personalized to the individual patient, taking into account the genomic make-up of their cancer and other individual variables, designing more trials like CALGB 40101 will not serve our patients well or give us the important answers we need. Furthermore, the cost of doing such mega-trials is already prohibitive, and our clinical cancer research infrastructure can barely support trials that are much more modest in scope as it is. Unfortunately, we still have few "personalized" treatments for early stage breast cancer, so adjuvant chemotherapy will continue to be used, but stay tuned. I'm confident that in a few years, I will have options to offer my early stage breast cancer patients much more attractive than AC X 4. At least it's not 6.