2 Physician Leaders Discuss Their Work in Advancing Medical Research: An HCE Original Report

by webadmin on May 6, 2016

H!X LogoAmidst the torrent of politically oriented healthcare news and process-focused initiatives, it’s easy to overlook the numerous medical breakthroughs that are being made every day. Recently, HCE spoke with two physician leaders about their efforts in advancing medical research, one in the area of pediatric brain tumors and one in robotic surgery.

If your focus as a leader is on what the future of healthcare should be, then the vision these two gentlemen describe will give you a clear picture of the exciting possibilities that are being developed in the present.

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Mark Kieran, MD, PhD, clinical director, Brain Tumor Center, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center in Boston, Mass.

Within pediatrics, brain tumors continue to be the most malignant and complex tumors to treat, and even though they are not the most common tumors, they are the number-one cause of death among children.

Mark Kieran, MD, PhD, serves as clinical director of the Brain Tumor Center at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center in Boston, Mass. The Center’s Pediatric Brain Tumor Program was established in the early 1990s, Kieran said, and from the beginning, it has had a multidisciplinary approach with neurosurgeons, radiation oncologists, neurologists, and myriad other specialists working next to each other.

When Kieran took over the brain tumor program in 1998, he wanted to expand the Center’s multidisciplinary model.

“The problem with radiation therapy is that although it’s curative in many circumstances, it cognitively devastates many of the kids,” he said. “We began to recognize early on that with brain tumors, cure doesn’t tell the whole story. Even if a child is alive, they may be unable to go to school, to get a job, to have a relationship, to get married, to have kids. Basically, they become an adult who is stuck in a rocking chair back and forth all day because they are so severely neurologically handicapped by their treatment.

“To call that case a success solely because the child didn’t die underestimates what I think most people see as what they really want as the optimal outcome for their kids.”

Kieran’s first step in revising the program’s definition of success was to introduce a variety of strategies for reducing the need, amount, and volume of toxic chemotherapies and radiation.

Second, he and his researchers, in conjunction with the Adult Brain Tumor Program at Dana-Farber, intensified their efforts to integrate the latest biological research and treatments into the program.

“Brain tumors are a little complicated in the sense that the brain is a location,” Kieran said. “It’s not a single thing. When someone says you have breast cancer, you have cancer of the breast, but you’ve got multiple different parts of the brain, and therefore, there are some 300 different types and grades of pediatric brain tumors.”

Along the way, Kieran and his team became intrigued with the idea of personalized or individualized medicine.

What appealed to them the most about personalized medicine, Kieran said, is “you don’t consider all kids with a brain tumor to be the same. Each tumor and its mutations are considered individually, and the most optimal therapy for that particular child and that particular mutation are kind of developed together to optimize the cure, which means both survivability and functionability after treatment, while minimizing the damage done to get you there.”

Third, they began to integrate all specialists related to the treatment of pediatric brain tumors under the same roof.

His team asked the question, “How can we put all services together to ensure that every stage of pediatric cancer treatment is handled in a way that children will still be able to live a high quality of life?”

This question, however, could not be answered without addressing the Center’s fourth dilemma: funding issues.

“We recognized very early on that the amount of funding, particularly for pediatric cancer, but even for adult brain cancer, grossly underfunds the severity of the disease,” Kieran said. “We talk about how important our minds our, and yet it’s an area that’s not funded. Pediatric and adult brain tumors aren’t in the main four categories for funding: prostate, breast, lung, and colon.”

Instead of complaining about the lack of funding, Kieran began to approach corporations, philanthropists, and foundations about the Center’s work. Dana-Farber/ Boston Children’s Cancer and Blood Disorders Center also formed a partnership with Stop and Shop, a large supermarket chain in Boston.

From the seed money donors provided, the program was able to support endocrinologists, ophthalmologists, audiologists, and specialists who could deal with the psychosocial issues confronting children afflicted with brain tumors, such as returning to school.

All of this was designed to augment the work begun by the Center’s original team of neurosurgeons, radiation oncologists, and neurologists.

Part of the multidisciplinary approach has also involved reaching out to educators through a program designed to teach them about the impact brain tumors can have on children in their classrooms and how to identify those problems. Kieran and his team have worked closely with school systems to develop mechanisms of education that will allow children to learn in spite of the aftereffects of a tumor.

“It’s only when we balance all of the specialties that we’ll reach optimal care,” Kieran said. “And that’s basically what the multidisciplinary clinic has done. It’s brought all of those people together into one large platform funded by the program to ensure that all of this happens in real-time.”

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Dr. Kemp Kernstine, a professor of cardiothoracic surgery and chief of thoracic surgery at UT Southwestern Medical Center in Dallas, Texas

Dr. Kemp Kernstine, a professor of cardiothoracic surgery and chief of thoracic surgery at UT Southwestern Medical Center in Dallas, Texas, has been working closely with the tech industry in developing robotic surgery since the early 2000s when such companies as Intuitive Surgical were first formed. Over the course of the ensuing decade, many other companies have seen the potential profit in robotic surgery and joined the fray.

It’s important, Kernstine said, that people understand, first and foremost, that robotic surgery does not involve a robot taking the place of a human being.

“It is a computer-assisted surgical system. There’s always a surgeon who is operating it. There’s no automation or artificial intelligence that is involved in it. It’s somewhat of a misnomer of what a robot is. It doesn’t autocallibrate. For the parts of the surgical procedure, it doesn’t have anything that is automation.”

Second, robotic surgery is able to enhance the precision of such intricate procedures as laparoscopic surgery and thoracoscopic surgery, in which the operation involves inserting a minuscule pole through a small incision straight against a surface that is perpendicular to where a surgeon is operating.

In other words, robotic surgery is able to do a great deal of movement in a small space.

“If there are issues, they are usually user issues and not due to the robot,” Kernstine said.

As of late, he has become passionate and increasingly vocal about the need for providing specialists with proper training in robotic surgery. The question, he said, is, Who is responsible for this training? Most healthcare entities seem to think it is the company producing the technology. But Kernstine argues that’s not how it works in other industries.

McDonnell Douglas, for example, isn’t responsible for training the Air Force every time it unveils a new jet. Why should a company like Intuitive, which is essentially a small business with limited resources, be responsible for training every surgeon who is going to use their equipment? Kernstine asked.

He believes the future of robotic surgery depends on establishing an oversight group, particularly one based in the federal government. Kernstine recognizes the resistance among specialists to government involvement, but he pointed out that the government did this with heart programs, which is how the certificate of need evolved.

Efforts to better train surgeons in robotic surgery should harness the skill and knowledge of the video-gaming industry, he added. A recent study found it took 1600 cases before a specialist was good at a prostatectomy, a number at which very few surgeons in the country have arrived.

But what if a gaming company could create a simulator for this procedure or numerous other procedures? The repetition, levels, and challenges that would come with a simulator would aid in the training of surgeons and in the continued refinement of their skills, Kernstine said. Suddenly, attaining 1600 cases is possible.

“There needs to be some way of incentivizing the video-gaming industry to get involved with this, and I think if they were involved it would go much faster, just blazingly faster,” he said.

Finally, it’s important to realize that not everybody should have robotic surgery, nor should every surgeon be trained on the technology.

“It’s not possible to train everyone the same,” he said. “It’s too expensive and it’s extraordinarily inefficient.”

For example, Kernstine said, a small hospital in a rural area doesn’t need robotic surgery.

“I’m just not so sure that that’s a good investment,” he explained. “I don’t know that they would have the volume generated to make their surgeon good or to make their hospital system efficient with that. Our society has gotten away from having centers of excellence where people do a large volume.”

Apart from recent news stories casting a negative light on robotic surgery and apart from the fact that some countries have grown distrustful of the technology, it is time to pay attention to how this technology is going to develop going forward, Kernstine said, because of the mind-boggling possibilities implied by robotic surgery.

Whether it’s ending the use of chemotherapy and anesthesia on patients or enhancing the safety of delicate procedures, robotic surgery has many different uses for virtually every specialty. Technology companies should be willing to collaborate even as they compete, Kernstine said. The stakes are too high, and too much potential could be lost if this technology is abused.

“With everybody wanting to do a good job, we just need to know which steps there are to get a surgeon to a level of being safe. There really needs to be some overarching thinking about this.”

-by Pete Fernbaugh

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