Beauty Health for Life

Disease Management Care Blog readers saw it here first.

Months ago, the DMCB presciently argued that cancer patients appetite for high expense and low yield treatments was based on more than desperation.  It said it was also based on doctors and patients quite rational realization that these treatments could rarely result in meaningful life prolongation.  In other words, while an "average" life expectancy from a particular treatment might be reported to be "only" six months, knowing that some persons make it to 12 or more months while others died immediately (zero months) could prompt a reasonable cancer patient to choose a shot at getting the twelve months.

The prestigious medical journal Health Affairs has finally caught up the the DMCB.  In the latest issue, Darius Lakdawalla and colleagues surveyed 150 persons with either breast cancer (N=47, 20 of whom had advanced disease), melanoma (N=20) or other types of cancer (N=83). 

There were two surveys dealing with breast cancer and melanoma that presented two nominally equal chemotherapy treatment scenarios.  One used a "hypothetical" survival outcome based on the usual kind of "average survival" statistics.  The other presented a "hopeful" survival outcome that reported a "spread" of survival statistics that included the small number of persons with shortened as well as prolonged lifespans.  The surveys were conducted face-to-face using interviews on representative patients drawn from multiple cancer treatment centers nationwide.

According to the authors, the survey was designed to test the appetite for risk among cancer patients. Behavioral economists have long known that persons generally per the "sure bets" ($100 now) over equivalently valued "hopeful gambles" (a coin flip to win $200 or lose it all).

Its also known that persons who are not well-off have a greater appetite for the hopeful gamble.  Betting a relatively small amount with a large upside explains the luster of low odds state lotteries for socioeconomically disadvantaged persons. It could also account for the willingness of very sick cancer patients - who have little to lose - to demand long shot treatments, even if theyre toxic and experimental. 

The results showed that 77% of the survey participants perred the hopeful gamble scenario. 71% of the patients with the melanoma scenario were prepared to "bet" two years of life in return for a 20% chance of living 4½ years. Among the patients with the breast cancer scenario, 83% were willing to bet 1½ years for a 10% chance of living 4 years. 

These perences were also accompanied by a willingness to spend a lot of money to access the bet. On average, the melanoma patients were willing to pay at least $45,000, while the breast cancer scenario patients were willing to pay at least $90,000.  Persons with higher income levels were willing to pay even more.

While the authors correctly note that more research is needed, the DMCB suspects this could explain the decision-making thats leading many cancer patients to demand insurance coverage of experimental, high cost and low yield treatments.  Not only does it make intuitive sense, but popular media extolls the intrepid hero who prevails and gets the girl, wins the talent show or defeats the aliens despite little chance of winning.  Were a culture inculcated with high stakes gambles,especially if there is little to lose.

The DMCB recalls one of its middle aged patients with colon cancer that had spread to his liver.  After multiple rounds of surgery (half his liver was removed), chemo and radiation, he was swollen, sickly, tired, gaunt and moribund.  He agreed the treatments were pretty bad - until he considered the alternative.

Assuming IPAB survives, do we really think their pronouncements based on the usual approaches to comparative outcomes will really convince cancer patients to not seek hope?  Will they really determine that hope is not medically necessary?

A chemical found in red wine remains effective at fighting cancer even after the bodys metabolism has converted it into other compounds.

This is an important finding in a new paper published in the journal Science Translational Medicine by Cancer Research UK-funded researchers at the University of Leicesters Department of Cancer Studies and Molecular Medicine.

The paper reveals that resveratrol – a compound extracted from the skins of red grapes – is not rendered ineffective once it is metabolised by the body.

This is an important development, as resveratrol is metabolised very quickly – and it had previously been thought that levels of the extracted chemical drop too quickly to make it usable in clinical trials.

The new research shows that the chemical can still be taken into cells after it has been metabolised into resveratrol sulfates.

Enzymes within cells are then able to break it down into resveratrol again – meaning that levels of resveratrol in the cells are higher than was previously thought.

In fact, the results appear to show resveratrol may be more effective once it has been generated from resveratrol sulfate than it is if it has never been metabolised because the concentrations achieved are higher.

The team, led by University of Leicester translational cancer research expert Professor Karen Brown, administered resveratrol sulfate to mice models.

They were subsequently able to detect free resveratrol in plasma and a variety of tissues in the mice.

This is the first direct sign that resveratrol can be formed from resveratrol sulfate in live animals, and the researchers think it may help to show how resveratrol is able to have beneficial effects in animals.

The study also showed that resveratrol generated from resveratrol sulfate is able to slow the growth of cancer cells by causing them to digest their own internal constituents and stopping them from dividing.

Professor Karen Brown said: "There is a lot of strong evidence from laboratory models that resveratrol can do a whole host of beneficial things – from protecting against a variety of cancers and heart disease to extending lifespan.

"It has been known for many years that resveratrol is rapidly converted to sulfate and glucuronide metabolites in humans and animals – meaning the plasma concentrations of resveratrol itself quickly become very low after administration.

"It has always been difficult to understand how resveratrol is able to have activity in animal models when the concentrations present are so low, and it has made some people skeptical about whether it might have any effects in humans.

"Researchers have hypothesized for a long time that resveratrol might be regenerated from its major metabolites in whole animals but it has never been proven.

"Our study was the first to show that resveratrol can be regenerated from sulfate metabolites in cells and that this resveratrol can then have biological activity that could be useful in a wide variety of diseases in humans.

"Importantly, we did all our work with clinically achievable concentrations so we are hopeful that our findings will translate to humans.

"Overall, I think our findings are very encouraging for all types of medical research on resveratrol. They help to justify future clinical trials where, previously, it may have been difficult to argue that resveratrol can be useful in humans because of the low detectable concentrations.

"There is considerable commercial interest in developing new forms of resveratrol that can resist or overcome the issue of rapid metabolism. Our results suggest such products may not actually be necessary to deliver biologically active doses of resveratrol to people."

HOW much for the PCMH?!*

According to Drs. Gill and Bagley, writing in the Annals of Family Medicine, the costs of transforming a primary care practice to a Patient Centered Medical Home should be generously borne by "payers."

While wishful thinking about payers deep pockets is not new, the article has some eye-opening data (with Disease Management Care Blog provided links) on just how much some or all of the elements of a PCMH cost:

a) $1850 per month per practice or $17,000 per physician,

b) $5,600 start-up then $2,200 per year related to the costs of reporting outcomes,

c) $117,000 per physician per year, and

d) up to approximately $15,000 per practice per year for a management facilitator. 

No wonder the DMCBs friends in academia want someone else to pay for it.

In the meantime, companies like this continue to offer a different business model. Instead of rebuilding and equipping an entire primary care practice for a croup-to-guts "transformation," population health (definition here) service providers focus on those patients who are at highest risk and provide a modular combination of in as well as outsourced services. While there is no head-to-head cost comparison of PH vs. PCMH, it would appear that the per patient approach of PH has a competitive pricing advantage.

Stocking up for allergy season

And speaking of outsourced services, the DMCB joins its other colleagues in looking forward to EHRs "meaningful use" criteria go from being meaningless to being truly meaningful.

For an under-recognized example of just how meaningful things will become, check out this interesting blog posting that describes the use of cloud-based EHR-data to follow U.S. allergy statistics.

While the information is interesting on its own merits, think how these data could be used by savvy providers to match allergy "market demand" by "stocking" a "just-in-time" "inventory" of allergy-care services such as patient reminder campaigns (for those with allergy-provoked asthma, "be sure to use your peak flow meter!") extra condition-specific appointments ("your provider with allergy expertise can see you this morning!"), treatments slots (nebulizers and immunotherapy ready to go) and medications (OTCs and prescription meds for the in-house pharmacy).


*Image from Wikipedia