June/July 2016

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

CANCER

FRONTIERS Immunotherapy Screening Controversies

Integrative Medicine End-of-Life Choices

Cannabis and Cancer

Opportunities for Prevention

Patient Perspectives . . . and more!

We moved offices! See inside for details.

VOL.89 NO.5 June/July 2016

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

June/July 2016 Volume 89, Number 5

Cancer: Frontiers in Treatment, Screening, Prevention, and More FEATURE ARTICLES

MONTHLY COLUMNS

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4

Membership Matters

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President’s Message Richard Podolin, MD

Integrative Cancer Care: An Overview of Its Evolution Michael Lerner, PhD

12 The Ecology of Breast Cancer: Opportunities for Prevention

Ted Schettler, MD, MPH 14 Breast Cancer Screening: A Modern Approach

Laura Esserman, MD, MBA

16 Prostate Cancer Screening: Where We Are and Where

We Should Go

Matthew R. Cooperberg, MD, MPH, FACS

17 Cancer Immunotherapy: Exploring a Growing Frontier

Miles Thomas 20 Life Over Cancer: Achieving a Survivor’s Edge

Keith I. Block, MD

22 No Stone Unturned: Advocating for Patients Facing Cancer

and Life-threatening Illnesses

Mark Renneker, MD 24 The Civics of Dying Well

BJ Miller, MD

26 California End of Life Options Act: Cancer and Some

Ultimate Choices

Catherine Dodd, PhD, RN, FAAN 28 Cannabis and Cancer: Decoding the Connection

Donald I. Abrams, MD

30 One Patient’s Perspective: Improving Patient Care and

Staff Well-Being

Neil Gendel, JD

32 Healing Circles: Supporting Patients through a Community

of Volunteers

Diana Lindsay and Kelly Lindsay 34 As Close as Breathing: The Life-Giving Nature of Poetry

John Fox, CPT

40 Medical Community News 42 Upcoming Events 42 Classified Ads

OF INTEREST 37 Clinical Skills Examinations: A Necessary Tool for

Physician Evaluation or a Poor Investment?

Alexandra Rojek 39 Advocacy Report: Physician Leaders Converge

on Capitol for CMA’s 42nd Annual Lobby Day

Note from the Editors This double-issue on Cancer comes at a time when both progress and controversies are expanding, not to mention a new federal “moon shot” to “cure” cancer. Some leading physicians and others write herein of treatment, screening, prevention, integrative approaches, palliative care, even poetry. Many of the papers come from the Symington Foundation Conference on New Dimensions in Integrative Cancer Care, held at Commonweal in Marin in January. We hope and think readers will find much here to be stimulating, even inspiring. We welcome your feedback.

- Gordon Fung, MD and Steve Heilig, MPH

Announcement: We moved!

Please note that the SFMS office and mailing address has changed to 2720 Taylor St, Ste 450, San Francisco, CA 94133.

Editorial and Advertising Offices: 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Reminder: CURES 2.0 Deadline is July 1, 2016 All California physicians with DEA certificates must submit an application to register for the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016.

CMA has a number of resources for practices, including tips on how to register for CURES 2.0 and an on-demand webinar that walks users through the process. These resources are available at www.cmanet.org/cures.

SFDPH Health Advisory: Benzathine Penicillin G Shortage

The manufacturer has announced a temporary shortage of Bicillin® L-A (penicillin G benzathine suspension) affecting three formulations: Bicillin L-A 600,000U Pediatric Injection, Bicillin L-A 1,200,000U/2mL, and Bicillin L-A 2,400,000U/4mL. The shortage is expected to resolve by July 2016. Bicillin L-A is the only acceptable treatment for pregnant women infected with or exposed to syphilis. Among non-pregnant adults, doxycycline 100 mg PO BID x 14 days is an acceptable alternative for those with primary, secondary, or early latent syphilis, and for those who have been exposed to a patient with infectious syphilis. Doxycycline 100 mg PO BID x 28 days is an acceptable alternative for those with late latent syphilis. Other formulations of penicillin (e.g. Bicillin® C-R) are not acceptable alternatives for the treatment of syphilis. For updates about the shortage, visit the SF City Clinic website at www.sfcityclinic.org.

Zika Virus Updates and Resources

There has been a minor change in testing recommendations for patients reporting symptoms consistent with Zika virus (fever, rash, arthralgia, conjunctivitis) who have been potentially exposed to Zika virus. Urine testing is now recommended along with serum testing, and in fact may be the preferred sample type for detection of Zika by PCR testing. Testing guidance for asymptomatic pregnant women with potential Zika exposure has not changed. California Department of Public Health (CDPH) is accepting urine specimens collected up to 21 days after symptom onset when accompanied by a serum specimen. If you are requesting Zika testing for a symptomatic patient, please contact the SFDPH Communicable Disease Control Unit at (415) 554-2830 for guidance.

Prepare your Practice for MACRA

The AMA has prepared a “Medicare Access and CHIP Reauthorization (MACRA) Action Kit”, available at www.ama-assn.org/ go/medicarepayment. There are several resources available that explain MACRA and provide details on the proposed rule. Several sessions on MACRA are planned for the AMA’s upcoming Annual Meeting.

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New Online Medi-Cal Provider Enrollment Portal to Launch Soon The California Department of Health Care Services (DHCS) recently announced that its new Medi-Cal provider enrollment system is expected to go live this summer. The new system, called the Provider Application and Validation for Enrollment (PAVE), will transform provider enrollment from a manual paper-based process to a web-based portal that providers can use to complete and submit their applications and verifications and to report changes. The portal will also be accessible on mobile devices. The new system should significantly improve the provider enrollment experience by minimizing errors in the application process and significantly reducing the time required to process provider enrollments.

Dr. Gupta Elected to SF Democratic County Central Committee

SFMS’s very own Dr. Pratima Gupta was elected to the SF Democratic County Central Committee in Assembly District 17. She was supported by the SFMS PAC and CALPAC. Our heartiest congratulations to Dr. Gupta!

CMA commends regulations to increase access to medication-assisted treatment for opioid use disorders

The Substance Abuse and Mental Health Services Administration (SAMHSA) published a proposed rule to expand access to buprenorphine, one of three medications currently approved by the Food and Drug Administration (FDA) for medication-assisted treatment of opioid use disorder. The proposed rule would increase the limit on the number of patients that qualified physicians can treat with buprenorphine. Treatment of opioid use disorder with opioid maintenance therapies has been shown to be cost effective, safe and successful when used appropriately. The California Society of Addiction Medicine offers an educational course for physicians that addresses the challenges of managing patients on buprenorphine. The workshop is designed for those with a buprenorphine waiver who are not yet fully utilizing it in their practice. CME credit is available.

Proposed rule: http://www.hhs.gov/about/ news/2016/03/29/fact-sheet-mat-opioid-use-disordersincreasing-buprenorphine-patient-limit.html.

CMA’s comments on the proposed: www.cmanet. org/files/assets/news/2016/06/cma-comments-on-samhsabup-05312016.pdf.

CSAM course for physicians: http://cme.csam-asam. org/content/x-rx-confronting-real-world-obstacles-buprenorphineprescribing.

SAN FRANCISCO MEDICINE JUNE/JULY 2016 WWW.SFMS.ORG

Free CME Course Assists Clinicians in Opioid Prescribing The Substance Abuse and Mental Health Services Administration invites you to attend a free CME training, Clinical Challenges in Opioid Prescribing: Balancing Safety and Efficacy on July 11, 2016, in Sacramento, California.

Learn to identify candidates for opioid therapy, monitor their responses, recognize problematic behaviors, and more. Seating is limited, so register today.

This course has been approved for a maximum of 7.25 AMA PRA Category 1 Credit(s)™. Visit the registration site for more information. http://www.mbc. ca.gov/Licensees/Continuing_Education/CME_Opioid_20160711.pdf.

SB1033 Defeated

SB 1033—which would require physicians whose licenses are in probationary status to disclose this status to patients—was defeated in June as it did not have enough required votes. This defeat was due to physicians and the medical societies contacting their legislators and asking them to continue to vote “no,” or abstain from voting on the legislation. This is a big victory for CMA, and once again shows the power of organized medicine.

AMA calls for a change in EHR interoperability measures

The American Medical Association (AMA) and 36 specialty medical associations urged the Obama Administration to rethink the way it measures the interoperability of electronic health records (EHR). In a letter to the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), the physician organizations said regulators should toss out measures that focus on quantity of records and instead focus on achieving interoperability and care coordination goals. The majority of EHR products exchange static documents, satisfying the minimum meaningful use requirements. Rather than using data exchange as the metric for measuring interoperability, AMA urged CMS to focus on usefulness, timeliness, correctness and completeness of data, as well as the ease and cost of information access. CMA letter: https://download.ama-assn. org/resources/doc/washington/interoperability-onc-cms-sign-on-letter03june2016.pdf.

Network of Ethnic Physician Organizations Blog

The Network of Ethnic Physician Organizations (NEPO), a cornerstone program of the CMA Foundation consisting of over 50 ethnic physician organizations across California, has launched the NEPO blog, “Finding NEPO.” The blog is available at www.thecmafoundation.org/FindingNEPO and features posts from prominent California physicians about the health issues impacting minority communities. If you are a physician interested in authoring a blog piece, please contact Kyla Aquino Irving at kariving@thecmafoundation.org.

Welcome Our New SFMS Team Member!

The SFMS is thrilled to welcome our new Associate Executive Director, Membership and Marketing, Erin Henke! Erin has a strong and impressive health care background having previously worked for VSP Vision Care, the Coalition for Compassionate Care of California as POLST Program Director, Hospice by the Bay, and the AMA. She also led the San Francisco End-of-Life Coalition for five years. Erin will be working on membership development and events, as well as marketing and communications for SFMS. In her spare time, Erin enjoys playing competitive tennis and fostering animals.

If you’d like to contact her with questions, comments, or to introduce yourself, you may reach her at ehenke@sfms.org or (415) 561-0850 x268.

WWW.SFMS.ORG

June/July 2016 Volume 89, Number 5 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

JUNE/JULY 2016 SAN FRANCISCO MEDICINE

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PRESIDENT’S MESSAGE Richard Podolin, MD

Physician-Assisted Dying: Protecting Patients—and Physicians In 1982, during my last year of residency, I visited my sister. She was forty-two years old and had metastatic colon cancer. After we’d had a few days to enjoy each other’s company, she told me that she needed my medical advice.

She went into her bedroom and returned with a plastic bag full of prescription medications that she had carefully hoarded. Her question was direct—when the time came, which ones should she take to end her life. She told me that she wanted to live and had no desire to commit suicide, but she knew her illness was terminal and she wanted a way out if living became intolerable. Her bag was filled with bowel medications and a few benzodiazepines—nothing that would have served her purpose.

The End of Life Option Act will make physician-assisted dying legal in California starting on June 9. Paradoxically, by alleviating the fear of intractable suffering, the greatest effect of the new law should be to improve quality of life for patients confronting terminal illness. But our profession must acknowledge, and vigilantly avoid, the risks of a “slippery slope.”

Like many physicians, I personally remain deeply conflicted about this new realm of physician activity. Precisely because of these conflicting values, I believe it was right for the San Francisco Medical Society to urge the CMA, repeatedly and for many years, to take a neutral position on physician-assisted dying. Finally, last year, the CMA changed its position from opposed to neutral, clearing the way for legislative action and, ultimately, signature by Governor Brown. As we heard from Assembly-member David Chiu at our last SFMS general membership meeting, the public was demanding this and it was far preferable for this to come through a legislative act that could easily be modified if problems arise, rather than through a ballot initiative that would be difficult or impossible to change. The Act contains protections for patients, physicians and health care organizations.

Protections for Patients

• The patient must have the physical and mental capacity to self-administer the aid-in-dying drug.

• The request for a prescription for an aid-in-dying drug must be made directly by the patient, and cannot be made through a power of attorney, advance directive, conservator or surrogate.

• The patient must submit two oral requests a minimum of fifteen days apart, and a written request.

• The written request must be witnessed by at least two adults, only one of whom may be related to the patient, or own, operate or be employed by a health care facility.

• The attending physician must obtain informed consent, WWW.SFMS.ORG

and in particular, the individual must be informed of the right to withdraw his or her request at any time, or to decide not to ingest the aid-in-dying drug.

• The attending physician must determine that the patient has the capacity to make an informed decision. If there is any indication of a mental disorder, the patient must be referred for a mental health specialist assessment.

• The attending physician must refer the patient to a consulting physician to confirm the diagnosis, prognosis, and the capacity to make medical decisions.

• The attending physician must confirm that the request does not arise from coercion or undue influence by asking the patient, outside the presence of other persons, if this is the case.

• The act specifically states that death from the self-administration of an aid-in-dying drug is not suicide and shall not have an effect on any life, health or annuity insurance policy.

Protections for Physicians

• The act specifies that physicians shall not be subject to censure, discipline, suspension, loss of license, loss or privileges, loss of membership or any other penalty for participating, or for refusing to participate, in physician-assisted dying.

• Physicians are not subject to any penalty for refusing to inform a patient about physician-assisted dying, or for not referring an individual to a physician that does participate.

Protection for Health Care Providers

• Health care providers may prohibit their employees, independent contractors, or other entities from participation on their premises, or while acting within the scope of employment or contract with the prohibiting health care provider, but they must provide advance notice of this policy. They cannot prohibit participation off their premises and outside the scope of their employment or contract.

The End of Life Option Act is well-crafted. Now it will be up to us to honor the spirit as well as the letter of the law.

Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff and currently serves as vicechair of the Community Board. Connect with Dr. Podolin via the SFMS LinkedIn Group or send him an email at podolin@sfms.org.

JUNE/JULY 2016 SAN FRANCISCO MEDICINE

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Cancer

INTEGRATIVE CANCER CARE An Overview of Its Evolution Michael Lerner, PhD When my father developed a life-threatening cancer in 1982, I began to explore integrative cancer therapies to see if I could help him. At that time, all com-

plementary cancer therapies were considered quackery. Friends warned my inquiry would jeopardize my career and Commonweal, the health center I had co-founded in 1976. Against their sound advice, I decided the subject was too important to ignore.

I received a MacArthur Prize Fellowship in 1983. The fellowship enabled me to visit alternative and complementary cancer centers throughout the U.S., Europe, and Mexico. Some practitioners were misguided true believers or cynical frauds.

Others were dedicated people who believed they could reduce suffering, extend life, and sometimes achieve lasting remissions or cures.

We launched the Commonweal Cancer Help Program (CCHP) in 1986. CCHP is a week-long residential psychosocial and educational support program. We do not recommend therapies. Participants are under the care of an oncologist. I lead discussions of choices in healing, medical therapies, integrative therapies, pain and suffering, and in death and dying. We have held over one hundred eighty-eight retreats over thirty years.

The Lloyd Symington Foundation was among the earliest supporters of the Cancer Help Program. Toby Symington and I launched the Lloyd Symington Foundation Conferences on New Directions in Cancer Care. The conferences brought together practitioners of integrative cancer from around the world. Many remain leaders in the field today.

I served as chief consultant to the Office of Technology Assessment (OTA) of the U.S. Congress for its groundbreaking 1990 report Unconventional Cancer Treatments. I drew on the network of colleagues from the Symington Foundation Conferences. The OTA report affirmed my approach.

I drew a distinction between (1) intrinsically health promoting modalities like diet, exercise, stress reduction and group support; (2) traditional medicines like Traditional Chinese Medicine; and (3) therapies that were not intrinsically health promoting, often expensive, sometimes based on secret formulas, and frequently had no supporting data.

I argued that intrinsically health promoting therapies help people with cancer become healthier cancer patients. Improved health meant better functional status or performance status.

Better functional status is linked in mainstream cancer research both to better quality of life and sometimes to extended survival.

This common sense analysis refuted the view that all integrative cancer therapies were quackery.

Bill Moyers released his five-part PBS series Healing and the Mind in 1993. The award-winning series and book marked a turning point in public acceptance of integrative medicine. The WWW.SFMS.ORG

final episode, Wounded Healers, was a moving depiction of the Commonweal Cancer Help Program.

My book Choices in Healing: Integrating the Best of Conventional and Complementary Approaches to Cancer came out from MIT Press in 1994. It was the first book on integrative cancer therapies to receive respectful reviews in The New Scientist, The New England Journal of Medicine, and The Journal of the American Medical Association. The SFMS’s own Steve Heilig reviewed it favorably for the San Francisco Chronicle, thus sparking a longtime collaborative relationship with the medical society.

I was invited to join the CEO Advisory Board of the American Cancer Society to help them update their position that these therapies were all quackery. In 2003, the Society for Integrative Oncology was founded. Many of our Symington Conference colleagues joined.

Substantial research has emerged on integrative cancer therapies. The evidence for the benefits of diet, exercise, stress reduction and group support for quality of life, and sometimes survival, is strong. Patients report benefits from Traditional Chinese Medicine to relieve side effects of treatment. Researchers report benefits of specific foods, herbs and spices, as well as ingredients from traditional formulas of Traditional Chinese Medicine and Ayurvedic Medicine.

Expressive arts are an important dimension in integrative cancer care. Yoga, Tai Chi, Qi Gong, and contemplative practices are frequently deployed in integrative cancer care.

Donald Abrams, MD, is the leading authority on the benefits of medical cannabis for cancer. Legalization is spreading across the country. The food writer Michael Pollan is writing a book on the rational use of psychedelic therapies in advanced cancer care.

Hospice care, once rare, is now widely available. Palliative care is a dynamic, growing specialty. Compassion in dying legislation, though ethically contested, is winning acceptance in more states.

Each of these health-medical movements represents a strand of a broader social transformation that emerged in the 1960s and has been changing American society ever since.

Mainstream cancer medicine is also changing. There is dissatisfaction with old therapies and enthusiasm for new ones.

Immunotherapies rank high among the promising new therapies. They are natural fit for many integrative therapies, since

Continued on the following page . . .

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Integrative Cancer Care Continued from page 9 . . . immunotherapies and health promotion strategies reinforce each other.

Integrative cancer treatments are now offered at most major cancer treatment centers. The offerings are typically limited.

The National Institutes of Health (NIH) has a Center for Complementary and Integrative Health. Within NIH, the National Cancer Institute (NCI) has its own Office of Cancer Complementary and Alternative Medicine. The frontiers of integrative cancer care continue to move forward, led by pioneers like Donald Abrams, MD, Keith Block, MD, Mark Renneker, MD, Dean Ornish, MD, and Dwight McKee, MD. All have been participants in the Symington Conferences at Commonweal.

Our Symington colleague Julia Rowland directs the NCI Office of Cancer Survivorship. The office was created in 1996 in response to advocacy by members of the National Coalition for Cancer Survivorship (NCCS), itself founded a decade earlier

by Fitzhugh Mullan, MD. I was among the founders of NCCS in 1986. Cancer survivors have ongoing medical and psychosocial needs that cannot be addressed by their oncologists. Their primary care providers have little training in addressing them.

Integrative post-treatment health promotion can offer significant benefit. Cancer “rehab” should join cardiac “rehab” in the medical lexicon.

Most cancer centers now offer cancer support groups.

Many independent cancer support centers have emerged over the past thirty years. A number of the residential programs— Harmony Hill in Washington, Callanish in Vancouver, BC, and Smith Center for Healing and the Arts in DC—were inspired by the Cancer Help Program.

Commonweal is working with these centers and others in a new learning network called Healing Circles. Healing Circles go far deeper than typical cancer support groups. They help participants navigate cancer and address the deepest questions of meaning in their lives. Beyond good medical care and health promoting integrative therapies, the questions of how to live with altered bodies and transformed lives are central to true healing.

One countervailing trend is the disappearance of private medical practices—and private oncology practices in particular.

Independent practitioners who have leeway to deliver integrative therapies are under crippling financial pressure.

The most neglected dimension of integrative cancer care is cancer prevention. The 2008 President’s Cancer Panel Report, Reducing Environmental Cancer Risk: What We Can Do Now, was a major contribution and has been widely disseminated. The Collaborative on Health and the Environment (CHE), a Commonweal program, was engaged in providing science for the report. CHE was founded at the SFMS and chaired by UCSF Chancellor Emeritus Philip R. Lee, MD. The issues of cancer causation are rarely simple. Ted Schettler, MD, CHE Science Director, published The Ecology of Breast Cancer in 2013. In my preface, I wrote: The Ecology of Breast Cancer is a necessary book. It is fundamentally necessary to not only understand but also embrace the complexity of the causes of this tragic epidemic disease. Ted WWW.SFMS.ORG

Schettler persuasively argues that breast cancer is ultimately a design problem. He situates the breast cancer epidemic among the other epidemic diseases of our time. He presents breast cancer as a model for understanding the epidemics of learning disabilities, autistic spectrum disorders, infertility, obesity, diabetes, Parkinson’s disease, Alzheimers, asthma, other cancers, and many other conditions.

CHE has been developing an eco-social approach to health for over a decade. The epidemic chronic diseases are multifactorial. Poor diet, lack of exercise, stress and low social support are important contributors. Income disparities are typically the most significant risk factor of all. Reducing economic, environmental, and lifestyle risks and enhancing resilience factors can have a significant effect on reducing the burden of chronic illness, including cancer.

Our bodies now carry many carcinogenic chemicals. Industry claims these carcinogens do us no harm. The evidence is otherwise. Curt DellaValle at Environmental Working Group has identified over four hundred carcinogens in biomonitoring studies. Leroy Lowe and Michael Gilbertson at the Halifax Project propose that combinations of “partial carcinogens” may collectively promote all the widely accepted hallmarks of cancer, meeting the criteria for carcinogenesis.

The Endocrine Society cautions policy makers on the health risks of endocrine disrupting chemicals, some of which are carcinogenic. Obesogens are a particular concern for cancer causation. Veterinary oncology will help define environmental contributors to cancer. Pets share our environmental exposures.

Different breeds of dogs develop different cancers.

Thirty years ago I reported that I had found no systematic cure for cancer among the integrative cancer therapies. But I found health promoting integrative therapies were improving quality of life—and might contribute to preventing recurrence and life extension.

Dean Ornish, MD, and others have now shown that systematic health promotion can stabilize some prostate cancers. This is the best evidence we have of integrative therapies altering disease progression. The potential risk reduction in breast cancer with diet and exercise holds promise. Widespread adoption of healthy lifestyles would reduce cancer incidence. But environmental factors remain major contributors to cancer.

Cancer remains the iconic illness of our time.

Reversing the epidemic will require a revolution in perspective, practice, and prevention. It is hard to be optimistic about such a change. But it is essential to remain hopeful.

Michael Lerner is president and co-founder of Commonweal. He is a graduate of Harvard and Yale Universities and is co-founder of the Commonweal Cancer Help Program, the Collaborative on Health and the Environment, The New School at Commonweal, The Cancer Prevention Initiative, and Healing Circles. He is also co-founder of Smith Center for Healing and the Arts in Washington, DC. JUNE/JULY 2016 SAN FRANCISCO MEDICINE

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Cancer

THE ECOLOGY OF BREAST CANCER Opportunities for Prevention Ted Schettler, MD, MPH Breast cancer is the most common cancer in women in the U.S. While a number of risk factors contribute to

its incidence, one or two do not stand out nearly as strongly as the impact of tobacco smoking on lung cancer risk. Rather, dynamic interactions among multi-level variables, beginning early in life, create conditions out of which breast cancer emerges.

This means that breast cancer is a systems problem requiring systems-level responses for prevention.1 Migration studies show that breast cancer risk remains relatively low in adult women who move from low- to highrisk countries but increases when they live their entire lives in a high-risk country. This illustrates the importance of early life events, but what makes a country high-risk for breast cancer?

A systems, or ecologic, framework recognizes that people are progressively nested within families, communities, ecosystems, and societies. Qualities of each of those levels interact and differ from person to person and place to place, impacting personal biology and population-wide disease risk. Although difficult to study, this framework best depicts the contextual origins of many common diseases and aligns well with integrated approaches to care.

A life-course approach to prevention is essential since the timing of environmental exposures can impact hormone levels, gene expression, the age of puberty, breast tissue dynamics and architecture—influencing cancer risk decades later. Colditz et. al. recommend beginning breast cancer prevention at age two.2 But data from laboratory animal and epidemiologic studies show that opportunities for breast cancer prevention actually begin in the womb.

Opportunities for Breast Cancer Prevention

Generally-accepted breast cancer risk factors include age, family history, genetic susceptibility, personal history of breast cancer, dense breast tissue, benign breast disease, early age of menarche, late age of first pregnancy or nulliparity, late age of menopause, chest radiation, recent oral contraceptive use, combination hormone replacement therapy, cigarette smoking, alcohol consumption, and overweight (post-menopausal breast cancer). Some of these are modifiable and can inform clinical practice. But additional risk factors are clearly involved and offer additional opportunities to prevent this disease.

Diet and nutrition: Adult diets with abundant fruits and vegetables—particularly those brightly colored with carotenoids—whole grains, fiber, more plant-based proteins, and healthy fats (e.g. olive oil, with more omega 3s) are associated with decreased breast cancer risk and improved outcomes after diagnosis and treatment.

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An even more compelling story that has emerged over the past few years highlights the importance of diets in childhood and adolescence. High intake of animal protein in childhood can result in earlier menarche, and in adolescence is associated with increased risk of both pre- and post-menopausal breast cancer.3,4 Emphasis on plant-based proteins and fats, nuts, fruits, and vegetables in childhood and adolescence is associated with even lower risk than in adults.

Childhood diets with higher amounts of whole or lightly processed soy are also more protective than high-soy diets in adults.5 This does not apply to highly processed soy or soy supplements, which have different biologic impacts. High milk intake in childhood is associated with increased risk of benign breast disease and faster peak height growth, both of which increase breast cancer risk.6,7,8 Breastfeeding not only benefits infant health but also modestly reduces maternal breast cancer risk.9

Physical activity, exercise, and weight control: Many

studies show that regular exercise not only reduces breast cancer risk but also other cancers, diabetes, and heart disease. Three to four hours per week of moderately strenuous exercise (e.g. brisk walking) reduces breast cancer risk by about twenty to twentyfive percent. Exercise levels during adolescence are most strongly associated with premenopausal breast cancer risk.

Overweight and obesity are strongly associated with increased post-menopausal breast cancer risk. Exercise can be an important part of a weight control program and add to the benefits of maintaining a healthy weight.

Vitamin D: Calcitriol, the biologically active form of vitamin D, influences gene expression in most tissues, including the breast. It regulates signaling pathways involved in cell proliferation, apoptosis, differentiation, and inflammation and downregulates aromatase. Many in vitro and laboratory animal studies support a role for vitamin D in inhibiting or delaying cancer development and progression. Most, but not all, observational studies show lower levels of vitamin D associated with increased breast cancer risk.

Vitamin D insufficiency is unfortunately quite common in the general population, and additional supplementation could have significant public health benefits.10 The Institute of Medicine acknowledges a safe upper limit of 1000-1500 International Units (IU) vitamin D daily in infants, 2500-3000 IU in children, and 4000 IU in adolescents and adults. The American Academy of Pediatrics recommends that all breastfed infants and formula-fed infants without adequate amounts of vitamin D in their formulas should receive vitamin D supplements. The American Congress of Obstetricians and Gynecologists (ACOG)

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recommends testing pregnant women at risk of low vitamin D and supplementing when necessary.

Carcinogens and endocrine disruptors: Historically,

studies of environmental chemicals and breast cancer risk focused primarily on exposures in adults. The earliest reported increased risk of breast cancer mortality in hairdressers, workers in a PVC production facility, and women exposed to a rustinhibiting chemical in a manufacturing facility. A recent review finds that nurses, firefighters and women working with chemicals in plastics, rubber, solvents, pesticides and textiles are at increased risk.11 The Institute of Medicine found strongly suggestive evidence that exposures to organic solvents including benzene, ethylene oxide, 1,3 butadiene, and polycyclic aromatic hydrocarbons increase risk. Over two hundred chemicals can cause mammary gland cancer in laboratory animals, but most have not been investigated in epidemiologic studies.

Recently, the importance of exposure to chemicals, including endocrine disruptors, during early development has gained wider attention. For example, exposure to diethylstilbestrol (DES) or higher levels of the pesticide DDT in utero or childhood is associated with increased breast cancer risk decades later.12,13,14 Studies in laboratory animals show that in utero exposures to DES and bisphenol A, among others, alter breast tissue architecture and gene expression, increasing susceptibility to breast cancer in adulthood. It will always be difficult to tease out the relationship between developmental exposures and breast cancer risk decades later. Based on what we know now, however, avoiding exposures to endocrine disrupting chemicals to the extent possible makes sense. The ACOG finds reducing those exposures to be a critical area of intervention for health care providers.15

Others: Shift work, light at night, and exposure to ionizing

radiation are also associated with increased breast cancer risk.

Studies of non-ionizing radiation from cell phones and other wireless technologies suggest a possible increased cancer risk, although the field is fraught with controversy.16 Case reports of breast cancer in young women who carried cell phones in their bras are alarming and indicate that this should be avoided.17

Conclusion

Opportunities for breast cancer prevention begin in the womb and continue throughout life. Although we have inadvertently designed higher risk into the fabric of our communities, individuals, health care providers, public health officials, community planners, businesses, governments, teachers, farmers, and others can play key re-design roles. Strategic interventions that shift complex system dynamics can help prevent this all-toocommon disease not only in individuals but in entire populations.

Ted Schettler, MD, MPH, is Science Director of the Science and Environmental Health Network. He also serves as science director of the Collaborative on Health and the Environment. He is the author of The Ecology of Breast Cancer: The Promise of Prevention and the Hope for Healing, available at http://tinyurl.com/ j3y42yv. A full list of references is available at www.sfms.org.

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Confronting a Crisis: An Open Letter to America’s Physicians on the Opioid Epidemic Steven J. Stack , MD, Emergency physician and the 170th president of the American Medical Association The medical profession must play a lead role in reversing the opioid epidemic that, far too often, has started from a prescription pad. For the past twenty years, public policies—well-intended but now known to be flawed—compelled doctors to treat pain more aggressively for the comfort of our patients. But today’s crisis plainly tells us we must be much more cautious with how we prescribe opioids. At present, nearly 2 million Americans—people across the economic spectrum, in small towns and big cities - suffer from an opioid use disorder. As a result, tens of thousands of Americans are dying every year and more still will die because of a tragic resurgence in the use of heroin.

As a profession that places patient well-being as our highest priority, we must accept responsibility to re-examine prescribing practices. We must begin by preventing our patients from becoming addicted to opioids in the first place. We must work with federal and private health insurers to enable access to multi-disciplinary treatment programs for patients with pain and expand access for medication-assisted treatment for those with opioid use disorders. We must do these things with compassion and attention to the needs of our patients despite conflicting public policies that continue to assert unreasonable expectations for pain control.

As a practicing emergency physician and AMA President, I call on all physicians to take the following steps—immediately— to reverse the nation’s opioid overdose and death epidemic: • AVOID initiating opioids for new patients with chronic non-cancer pain unless the expected benefits are anticipated to outweigh the risks. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred.

• LIMIT the amount of opioids prescribed for post-operative care and acutely-injured patients. Physicians should prescribe the lowest effective dose for the shortest possible duration for pain severe enough to require opioids, being careful not to prescribe merely for the possible convenience of prescriber or patient. Physician professional judgment and discretion is important in this determination.

• REGISTER for and USE your state Prescription Drug Monitoring Program (PDMP) to assist in the care of patients when considering the use of any controlled substances.

• REDUCE stigma to enable effective and compassionate care.

• WORK compassionately to reduce opioid exposure in patients who are already on chronic opioid therapy when risks exceed benefits.

• IDENTIFY and ASSIST patients with opioid use disorder in obtaining evidence-based treatment.

• CO-PRESCRIBE naloxone to patients who are at risk for overdose.

As physicians, we are on the front lines of an opioid epidemic that is crippling communities across the country. We must accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis. These are actions we must take as physicians individually and collectively to do our part to end this epidemic.

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Cancer

BREAST CANCER SCREENING A Modern Approach Laura Esserman, MD, MBA Even though breast cancer surveillance is considered to be a central tenant of high quality “preventive care,” there remains a great deal of controversy about the topic. It can certainly be said that mammography

is not prevention. It is, simply, early detection. After almost three decades of routine screening, what have we learned about the impact of breast cancer screening, and how do recent advances in scientific knowledge help us to understand how to optimize that impact?

Breast cancer has emerged as a complex set of diseases, and in the treatment setting, we tailor our treatments accordingly. To improve the impact screening has on mortality, we need to bring our understanding of this biological heterogeneity of the disease into the screening and prevention realms. We now have an opportunity to improve screening by increasing quality, avoiding false positives, avoiding overtreatment of more indolent disease, applying screening using a risk based approach to maximize impact, and integrating prevention along with risk assessment.

Screening and Mortality Reduction

Over the course of their lifetime, it is estimated that one in eight women will be diagnosed with breast cancer. Data show that cancers caught while still confined to the breast tend to have better outcomes (five-year survival rate of 98.1%, 83.8%, and 27.1% for localized, regionally advanced, and metastatic disease, respectively). This observation fueled the initiation of mammographic screening programs across Europe and North America over the past thirty years, as well as randomized trials, which demonstrated that screening indeed showed a reduction in mortality. However, the original trials took place prior to the advent of adjuvant systemic therapy. In the setting of modern treatment for breast cancer, the impact of that screening has on lowering mortality from breast cancer will not be as high as in the original trials. A recent study suggests that only one-third of the drop in mortality is due to screening, while two-thirds can be attributed to modern adjuvant treatment. So it is important to recognize that while screening contributes to reducing breast cancer mortality, that contribution is modest. A twenty to thirty percent reduction in the risk of dying of breast cancer translates to a much smaller number in absolute terms. For most node negative women, the chance of dying is ten to twenty percent, resulting in an absolute difference in the range of four to six percent—and that is before considering systemic therapy. No scientific article has ever claimed that because a cancer is detected by mammography, it is necessarily a life saved, but somehow this has become what the community believes, which makes it challenging to recommend strategies to improve it. However, there is opportunity to improve our approach.

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Breast cancer is very heterogeneous and varies from high grade, rapidly progressing cancers to low grade, slow growing lesions with very low risk for early recurrence, and variable risk for late recurrence. Since the start of screening, we have detected more low risk cancers, a phenomenon that happens with all types of screening. These very low risk cancers do not have the behavior that fits what we have come to think of as “cancer”.

These likely represent indolent disease. We are developing tests to identify these at diagnosis to support much more minimal treatments to avoid overtreatment. Many precancerous lesions, ductal carcinoma in situ, likely also represent over-detection and trials are in progress to learn how to do less treatment more safely. On the other extreme are the most aggressive cancers, where we still need to improve our approach to systemic therapy to avoid death from disease.

We now know much more about breast cancer risk. There are nine genes that have been implicated in predisposition to breast cancer. And small variations in inherited genes can collectively impact risk significantly. This advance in knowledge and advances in technology to enable next generation sequencing, along with the Supreme Court decision that the genome could not be patented, have made it possible to offer comprehensive genetic testing for little more than the cost of a mammogram. This makes it possible to truly find the small population of women at highest risk.

What is needed is a modern era screening trial to learn how to optimize screening. We have the opportunity to leverage what we have learned about breast cancer biology, about breast cancer risk, and update it with modern clinical trial methods.

The University of California Athena Breast Health Network has developed just such a trial that is opening this summer across California and the Midwest through the Sanford hospital network. Every woman over the age of forty can participate.

Wisdom Study: Testing A New Approach to Breast Cancer Screening

The Wisdom Study (Women Informed to Screen Depending on Measures of risk) is designed to test an approach optimizing breast cancer detection for higher-risk women while reducing the unintended consequences of current screening practices for lower-risk women. The study has been designed as a five-year, one hundred thousand-participant, preference-tolerant, randomized controlled trial of risk-based versus annual screening.

We are testing a new model for breast cancer screening based on individual risk, biology, and patient preference.

We are testing annual screening as a more individualized screening. Comprehensive risk assessment is based on a widely accepted risk model, the Breast Cancer Surveillance Consortium

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(BCSC) model, which includes endocrine exposures, family history, breast density, and genomic risk factors, including rare and uncommon major breast cancer susceptibility alleles and recently validated single nucleotide polymorphisms (SNPs). The risk will be used to assign an age to start, an age to stop, and a frequency of screening. Over the course of the trial, we will profile all tumors that arise, so that we can learn who is at risk for what kind of cancer. From this study, we should learn how to further improve and tailor our approach to screening.

Anticipated Benefits

This is a study where the results could transcend the current screening controversy and support a transition to a personalized medicine screening and prevention approach. For all stakeholders, we believe this new screening practice will increase health care value.

For patients: If the more tailored approach is successful, it

will lead to better health outcomes—fewer indolent tumors detected, fewer unnecessary biopsies and less anxiety. By making risk assessment and counseling a standard part of screening, we will necessarily increase awareness of and improve access to preventive interventions for women at high risk, thereby actually reducing the incidence and progression of disease.

For providers: A personalized approach to screening will resonate with providers’ commitment to delivering patientcentered care. For specialists, this trial will advance breast care science, enabling access to innovations that improve risk assessment and more tailored treatments. The study will provide an answer to how best to screen.

For health plans and other payers: We anticipate this program will increase value by improving outcomes and quality and decreasing cost. We anticipate the cost of personalized screening to be less that of traditional screening programs.

Health plans will be able to demonstrate commitment to their women members by way of engagement in clinical innovation.

Figure 1. Preference-Tolerant Randomized Control Trial Design

Those who agree to randomization will be randomized.

Those who do not want to be randomized and have a strong preference will pick the option they prefer and be followed in our observational cohort.

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Study Funding The program was one of the first pragmatic trials awarded funding from the Patient-Centered Outcomes Research Institute (PCORI) initiative ‘Pragmatic Clinical Studies to Evaluate Patient-Centered Outcomes’. The fourteen million dollars received from PCORI is being used for program development and the trial infrastructure. Athena is partnering with health plans to cover trial services, such as genetic testing.

About Athena

The Athena Breast Health Network (Athena) is a unique collaboration among the five University of California (UC) medical centers, the Graduate School of Public Health at UC Berkeley, the Sanford Health system based in Sioux Falls, SD, and many other public and private partners. Athena is integrating clinical care and research to revolutionize the delivery of breast care.

By standardizing the collection of data from both patients and physicians, integrating molecular profiling at the time of breast cancer diagnosis, and creating an unparalleled biospecimen repository, Athena enables personalized care informed by science and fuels continuous improvement in treatment options and outcomes. To further the integration and acceptance of personalized breast health as the standard of care, Athena has launched the PCORI-funded Wisdom Study.

Laura Esserman, MD, MBA, is Director of the Carol Franc Buck Breast Care Center at UCSF and Professor of Surgery and Radiology at UCSF.

Low-Dose Chemical Exposure and Cancer: ASCO Report Features SFMS Past-President A new report by the American Society of Clinical Oncology features SFMS past-president William Goodson, MD, Senior Scientist at California Pacific Medical Center Research Institute, reporting on the state of research into environmental contributors to breast cancer. He notes “The oncology community has little interest in environmental carcinogens, because it’s very difficult to link a cancer to low-dose exposures. However, if I had a drug that had no known side effects, and it decreased the cancer cell growth rate by 50% and increased cancer cell death from tamoxifen exposure by 50%, you’d be very interested in that drug.

That’s exactly what happens when you take cancer cells away from the chemicals we are exposed to every day. Since removing cancer cells from chemicals has this effect, taking away chemicals should be investigated thoroughly.” However, he continues, “Practicing oncologists are too busy treating their patients to get involved with this issue, and the institutions that allocate money for research, for various reasons, don’t want to fund this work.”

Read the report at: http://www.ascopost.com/issues/june-102016/low-dose-chemical-exposure-and-cancer/ ) JUNE/JULY 2016 SAN FRANCISCO MEDICINE

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Cancer

PROSTATE CANCER SCREENING Where We Are and Where We Should Go Matthew R. Cooperberg, MD, MPH, FACS For decades, prostate cancer has been the most common cancer diagnosed, and second most common cause of cancer death among American men.1 Since

early detection efforts based on prostate specific antigen (PSA) measurement began in earnest in the early 1990s, age-adjusted mortality rates have fallen over 50 percent.1 At least half of this drop is attributable to a combination of PSA-based screening and improvements in treatments relevant only to screen-detected tumors.2 Despite this remarkable public health success—rivaled in oncology only by the drop in lung cancer mortality driven by smoking cessation programs1—in 2012 the U.S. Preventive Services Task Force (USPSTF) recommended that the harms of screening outweigh the benefits and that no men should ever be offered PSA testing for early detection of prostate cancer.3 The USPSTF misinterpreted critical evidence regarding benefits. The only randomized clinical trials relevant to the question are the European Randomized Screening Study for Prostate Cancer (ERSPC)4 and the Göteborg trial,5 which showed a 21-42% relative reduction in prostate cancer mortality for screening every two to four years vs. no screening. The absolute benefits are low within the first decade of followup referred to by the USPSTF— which is why no guideline recommends screening men with less than ten-year life expectancy—but grow substantially over the lifetime of a relatively young man. The Prostate, Lung, Colon, and Ovarian (PLCO) screening trial randomized men between annual PSA testing for six years vs. “usual care.” However, the “usual care” arm was overwhelmingly contaminated by opportunistic (ad hoc) PSA testing. An updated analysis recently published indicated that nearly 90% of men in the “usual care” arm had at least one PSA test before or during the trial6; and as early as 2010 the PLCO investigators themselves concluded that the trial is informative only with respect to the question of annual vs. opportunistic screening, not screening vs. no screening.7 This statement is not controversial, and means that metaanalyses including the PLCO are invalid. The USPSTF, however, continues to cite the PLCO as evidence against the benefits of screening. Furthermore, the USPSTF guideline cherry-picked the literature to find worst-case-scenario statistics regarding the morbidity and mortality associated with prostate cancer treatment,3 again ignoring large studies and meta-analyses8 reporting far better results in contemporary practice. Given these major limitations and biases in its evidence review and methodology, the USPSTF “D” recommendation was virtually assured,9 but is in point of fact very much the wrong conclusion.

The USPSTF recommendation was issued against the backdrop of a highly suboptimal implementation of screening and treatment in practice in the U.S. In general, too few men were screened in their 50s, and too many in their 70s.10 Moreover, until 16

very recently, at diagnosis the vast majority of men with low-risk disease were treated rather than offered surveillance, and conversely many men with potentially lethal high-risk disease were undertreated with androgen deprivation treatment alone.11 The fact is that for all the thousands of men whose lives have been saved by PSA testing, thousands more have been treated unnecessarily, and too many have suffered avoidable long-term morbidity.

Without question, over-diagnosis and over-treatment of low-risk prostate cancer have been major problems, but as a solution, the USPSTF “D” recommendation is a perfect example of discarding the baby with the bathwater.

Nearly every other major guideline in the U.S.—from the National Comprehensive Cancer Network, the American Urological Association, the American Cancer Society, the American College of Physicians, and others—recommends some variation on shared decision making between physicians and patients. The USPSTF does not employ a superior methodology than these organization, nor do its members have greater expertise. In fact, not only does its membership exclude any physicians with cancer expertise or experience, but also rejects input from cancer epidemiologists and researchers, most of whom disagree to varying degrees with the their conclusions. Nonetheless, because it carries the imprimatur of the government, the USPSTF is by far the most influential guideline panel among primary care providers.12 In fact, last year the Centers for Medicare and Medicaid Services (CMS), based on the USPSTF recommendation, nearly implemented a quality measure which would penalize primary care providers for any PSA testing (http://tinyurl.com/CMS-PSA-EQM).

Even without CMS action, however, the USPSTF recommendation is exerting a substantial effect on prostate cancer epidemiology in the United States. A recent analysis demonstrated a 28% drop in prostate cancer incidence in the first year after the USPSTF recommendation.13 This decline was, predictably, irrespective of disease risk, such that the fall in over-diagnosis of lowrisk disease is occurring with a nearly parallel fall in diagnosis of high-risk disease, indicative of under-diagnosis and a virtually assured future rise in rates of metastatic disease and mortality.14 The latest data from un-contaminated cohort studies suggest that healthy men should be offered a baseline PSA test between age forty-five and fifty; the large majority of men tested will have a PSA less than 1 ng/ml and do not need repeat testing for at least five years if not more.15 For African-American men and those with strong family history or other risk factors, an earlier first screen can be considered. PSA values between 1.5 and 2.5 ng/ml in this age range identify men in the highest 10 percent of risk for prostate cancer mortality,15 and warrant referral for further evaluation. Blood and urine tests with greater specificity, such as 4K, phi,

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Cancer

CANCER IMMUNOTHERAPY Exploring a Growing Frontier Miles Thomas In 2014, I started working as a research coordinator for UCSF at a time when immunotherapy was on the forefront of cancer treatment. Having just graduated

college, I was naive to this fact, which is why I was so captivated by the first presentation that I saw on the topic. What leapt out at me was that in certain patients, immunotherapeutics were achieving such durable responses that medical oncologists were reconsidering the use of the word “cure.”

A year later, news broke that former president Jimmy Carter’s metastatic melanoma was in complete remission. Headlines had singled out pembrolizumab, an immune checkpoint inhibitor, as the key player in the former president’s treatment. This news was the serendipitous closing remark to 2015, which had already boasted eight Food and Drug Administration (FDA) approvals for immunologic agents across the settings of lung cancer, advanced melanoma, multiple myeloma and kidney cancer.1 Fast forward to April 2016, and the question “What if your immune system could kill cancer?” is emblazoned across the cover of Time magazine. Immunotherapy has become a household name and patients are seeking access to these drugs at a higher rate than ever. While oncologists witness first hand the success stories that demonstrate immunotherapy’s potential as a true game-changer, they are also faced with the reality that there are still many hurdles to overcome. UCSF’s newly launched Cancer Immunotherapy Program, led by Dr. Lawrence Fong, presents an exciting and integrated approach to addressing the challenges ahead.

As a new employee in the genitourinary oncology program, the first clinical trial that I was assigned was one using two immune based therapies to treat metastatic, castration resistant prostate cancer (mCRPC). Mr. Z was one of the first patients enrolled to this study. The trial treats patients with two drugs in succession. First with Provenge, a cell based vaccine used to treat prostate cancer, followed by ipilimumab, an anti-CTLA-4 immune checkpoint inhibitor typically used for advanced Melanoma. Currently, Mr. Z is approaching two years of follow-up since completing the ipilimumab phase of our trial. During this time, without any subsequent lines of treatment, his disease has remained radiographically stable and his prostate-specific antigen (PSA) remains suppressed to within normal limits. This is an impressive response. Patients who have progressed to the stage of mCRPC will often endure multiple lines of therapy and a diminishing quality of life, ultimately achieving a median survival of only nineteen months.

While Mr. Z’s story is, in part, one of success, it also illustrates some of the key challenges in developing effective immunotherapies. The road to remission was not an easy one for Mr. Z. In the weeks following his final infusion of ipilimumab, he beWWW.SFMS.ORG

gan experiencing fatigue, anorexia, abdominal pain and pruritic rashes. During his next evaluation, he presented in clinic with severe orthostatic hypotension and fell unconscious while having his vitals taken.

After being rushed to the emergency room, and following weeks of work-up with endocrinology, it was determined that he had developed a host of autoimmune reactions, including secondary adrenal insufficiency, Grave’s hyperthyroidism, and hypophysitis. All are serious side effects that have been reported with ipilimumab. They are caused by an immune response triggered against the body’s healthy tissue. It took almost twelve months of management with replacement hormones and steroids to get to where his side effects were finally under control.

During this time, he suffered bouts of intense fatigue, muscle loss, weight loss and abdominal pain. There is a chance that these conditions will stick with him for life, as the autoimmune side effects triggered by checkpoint inhibitors are known to be persistent. Although treatable, this is a significant price to pay for what appears to be a durable anti-cancer response.

Although the severity of reactions that Mr. Z experienced are rare, the majority of patients receiving immunotherapy will experience autoimmune reactions of some kind. Still, there are many patients who will complete courses of the field’s most toxic drugs without any side effects whatsoever. In spite of Mr. Z’s two years without disease progression, there exists the larger percentage of patients, across all cancer types, who will derive no efficacy from the immunotherapeutics that they receive. To hear a medical oncologist contextualize this for a patient in clinic is to realize that there is still a high degree of unpredictability surrounding these therapies. This speaks to only a few of the challenges surrounding immunotherapy. Currently, there is need for better predictive biomarkers, further testing across a broad range of cancers, and, for patients like Mr. Z, mitigation of toxicity in achieving efficacy. The Cancer Immunotherapy group at UCSF offers one of the greatest opportunities within the Bay Area to explore this growing frontier. Housed at UCSF’s Parnassus Campus, the group is comprised of the Cancer Immunotherapy Clinic and the Cancer Immunotherapy Laboratory, streamlining a bedside to bench analysis of tissue and blood samples from patients undergoing immunotherapy.

In chatting with the group’s leader, Dr. Fong, he makes it clear that his program has something unique to offer. “When we think about immunotherapy, an advantage that sticks out is that one drug can be effective in multiple types of cancer.” His comment follows the approval for Nivolumab as a monotherapy in non-small cell lung cancer, metastatic melanoma, and renal cell carcinoma. “We also think about the need to explore a variety

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Cancer Immunotherapy Continued from the previous page . . .

Prostate Screening Continued from page 16 . . .

of combination therapies which could spell greater efficacy than single agents alone.” Consider that in metastatic melanoma, a recent phase 3 trial combining anti-PD-1 and anti-CTLA-4 therapies demonstrated nearly sixty percent of patients responding to therapy, compared to under twenty percent with single agent treatment. “And on top of this,” says Dr. Fong, “there may be many other cancers that will prove to be highly immune responsive. More clinical testing is required to explore this.” This is exactly why the program is structured to capitalize upon this need. Notably, they are able to treat patients and conduct clinical research across a variety of malignancies by integrating oncologists from multiple specialties and implementing testing for both novel and combination therapies.

Ultimately, as Dr. Fong puts it, “we seek to provide access to novel immunotherapies that patients would not normally have access to.” Along with providing clinical benefit to patients, the hope is that this will increase our understanding of the complex biologic underpinnings behind immunotherapy. As mentioned, the group sees patients at UCSF’s Parnassus campus in San Francisco and is comprised of both outpatient and inpatient clinics.

Excitingly, they have recently begun enrolling patients to clinical trials and have a full pipeline of soon to open studies. The laboratory, an expansion of Dr. Fong’s original lab space, has long been in the process of developing better predictive biomarkers that can identify the characteristics of a responder. Down the line, this may allow physicians to increase the likelihood of a response by tailoring therapies to individual patients. In short, it is a group that is fully dedicated to understanding and improving the immune system’s role in battling cancer. We are at the dawn of a very exciting era in cancer research for which immunotherapy has lately become the poster child. As more resources are turned towards this area, we could see the next decade in immunotherapy research be even more fruitful than the last. With dedicated programs such as UCSF’s Cancer Immunotherapy Group breathing even more life into field, immunotherapy will continue to become demystified.

and PCA3, are now available as secondary screening tests for men with borderline PSAs. Most importantly, what should be stressed even before a PSA test is ordered—and certainly before a prostate biopsy is done—is that the purpose of PSA-based early detection is to find high-risk, potentially lethal prostate cancer within a window of curability. Low-risk prostate cancer, which is more commonly diagnosed, does not need treatment in the majority of cases. This message can be conveyed very concisely to most men in the primary care setting, without the need for complex decision aids.16 A common critique of screening is that we cannot distinguish indolent from aggressive cancers. This is simply false; the fact is that based on standard parameters such as PSA level, histologic grade (Gleason score) and other factors, prostate cancers can be risk-stratified with up to 80 percent accuracy,17 and emerging genomic tests and imaging in high-expertise centers are improving that accuracy further.18 Moreover, recent analyses confirm that over-treatment rates are finally improving; rates of active surveillance for low-risk disease in community practice are now up to 40 to 50 percent and rising.19,20 Over the past two decades—starting years before the USPSTF began issuing guidelines in oncology—research driven in large part by the Urology Department at UCSF has been highlighting the problem of overtreatment, the need for prostate cancer risk stratification at diagnosis, and active surveillance as the preferred option for most men with low-risk disease. These efforts are now bearing fruit nationally as well as locally. We are better able than ever before to offer rational, PSA-based early detection to men most likely to benefit; to select men for surveillance or treatment based on individualized risk assessment; and to minimize the adverse effects of treatment when required. 2016 is exactly the wrong time to abandon PSA testing wholesale. Rather, we should continue reducing overtreatment, while simultaneously striving to save men from painful, costly, and often avoidable deaths from prostate cancer.

Miles Thomas is a clinical research coordinator for the GU medical oncology group at UCSF, working on several immunotherapy clinical trials within the group. He hopes to attend medical school down the road.

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Matthew R. Cooperberg, MD, MPH, FACS, is Associate Professor in the Departments of Urology and Epidemiology & Biostatistics, and holds the Helen Diller Family Chair in Urology at the University of California, San Francisco. He maintains clinical practices focused in urologic oncology at UCSF and the San Francisco VA Medical Center. He has published over 200 papers focused primarily on prostate cancer epidemiology, risk stratification, outcomes, and biology. Dr. Cooperberg has helped develop and launch the AUA Quality (AQUA) Registry, a national registry tracking quality of care for prostate cancer and other urological diseases. In 2015 he won the prestigious AUA Gold Cystoscope Award for contributions to Urology within the first ten years of practice. The full list of references is available at www.sfms.org.

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Value

Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $300 Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $110 One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . .*$150/hour reimbursement and practice operation issues . *value hourly rate with a practice management consultant Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session Discounted registration for the Western Leadership Academy (eligible for 16 CME credits) . . . . . . . . . . . . . . . . . . . . . $300 CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $24 HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100 with other physicians at the point of care .

15% off tamper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . . . . $275 30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000 *based on average savings

Up to 25% discount on worker’s compensation insurance through Mercer Health & Benefits, as well as special . . . . . $750 pricing and/or enhanced coverage for life, disability, long term care, medical, dental and more .

Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $800 effective coding/billing strategies, and Medicare reporting compliance .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

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Cancer

LIFE OVER CANCER Achieving a Survivor’s Edge Keith I. Block, MD The Block Center for Integrative Cancer Treatment started offering integrative care before the term “integrative” even entered the medical lexicon. Our

Chicago-based program includes therapeutic nutrition with selective natural product use, biobehavioral interventions, a focus on circadian health, personalized fitness, lifestyle, and an innovative approach to mainstream treatment, including time-sensitive drug infusion, all intended to diminish toxicity, improve treatment synergy, aid detoxification, and enhance outcomes.

Much of our treatment philosophy has been laid out in the book Life Over Cancer, which provides a basis for a “no holds barred” approach, searching out whatever it takes give patients a “survivor’s edge.”1 The Life Over Cancer program is based on over three decades of clinical treatment, providing patients with a comprehensive foundation for optimal care. Our approach includes the best of mainstream therapy provided in the most innovative ways available. Underlying this therapy, however, is a strategically developed, individually tailored, and uniquely personalized integrative treatment model.

In cancer, individualization looms even larger than in other conditions. Cancer comprises not only dozens of diseases but also diverse stages and tumor grades. This diversity is modulated by metabolic, biochemical, and molecular diversity that develops among patients with different genetic, cultural, and lifestyle backgrounds. Cancer truly calls for personalized medicine, but a medicine that is personalized far beyond simply the detection of actionable mutations and therapeutic targets.

Our awareness of the need for an individualized approach led us to develop the Center with a commitment to seeking valid clinical answers wherever they can be found, along with genuine personalization of cancer treatment. Several themes guide the Center’s work. As a community-based outpatient chemotherapy unit situated in an integrative medicine center, the Center genuinely integrates conventional treatment, lifestyle, and natural product interventions based on rigorous science. Integration is done under the leadership of an integrative physician, with a staff that includes medical oncology, oncology nursing, biobehavioral counseling, physical therapy, and dietary planning by registered dietitians, along with and integrative practitioners in diverse areas of botanical medicine and manual therapy. Individualization of treatment through comprehensive assessments is another pillar of our approach. Multi-targeting, or broadspectrum, treatment of cancer is implemented through the use not only of lifestyle therapies, but also through supplement and medication suggestions based on metabolic and genomic analysis. Finally, the program is genuinely patient-centered, placing each patient as an active participant in treatment decisions regarding their own care.

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Individualizing Care through Patient Assessment Individualization through assessment is carried out at several levels. We rely on standard laboratory and radiological assessments for cancer treatment. In addition, our staff routinely uses other assessments including dietary, physical, and behavioral/psychological tests in developing plans.

A further set of advanced laboratory assessments of the patient’s biochemical, metabolic and nutritional environment, or cancer terrain, is unique to the Center. Described in detail elsewhere, the cancer terrain consists of metabolic and biochemical characteristics that support the growth of cancer and modulate patients’ responses to the challenges posed by cancer.1 Six terrain factors are assessed through standard clinical tests. These are inflammation, oxidation, glycemia, coagulation, immunity and stress chemistry. These terrain factors strongly impact five cancer challenges: tumor growth and survival, treatment response, treatment tolerance, quality of life, and life-threatening complications.

Terrain testing, developed by the Center’s director, comprises a panel that includes multiple laboratory tests for each factor. Results are presented to the patient in a specialized form that lists lifestyle/behavioral, supplementation, and medical interventions appropriate for each terrain factor. When tests for a specific factor are beyond normal ranges, patients are counseled on appropriate interventions by registered staff dietitians under the supervision of the clinic’s director.

Terrain Factors: Inflammation and Stress Chemistry

As examples of how two aspects of the terrain may impact treatment recommendations for patients, we will examine terrain factors that have been highlighted by recent advances in research. We will discuss how abnormalities in these factors impact various cancer challenges, and what types of intervention might be recommended for each.

Recent research suggests low-dose aspirin as a means to improve cancer survival.2 Inflammation’s effects on tumor growth and survival are exemplified in the rich literature on the Glasgow Prognostic Score (GPS), a score determined by levels of c-reactive protein (CRP) and albumin, both of which are elements of our testing. 3 GPS predicts survival in multiple cancer types. GPS, and CRP alone, are correlated with response to both chemotherapy and radiotherapy.4 Anti-inflammatory substances may improve treatment tolerance: the anti-inflammatory herb curcumin reduced radiation dermatitis in breast cancer patients.5 Fish oil, which also inhibits multiple inflammatory pathways, improves body composition and muscle mass in cancer cachexia, a life-threatening complication of cancer that is mediated by

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inflammatory cytokines.6 Treatment of inflammation can be enhanced with these and other supplements, along with dietary manipulations, including reductions in omega-6 fats and refined carbohydrates and increased intake of flavonoid-rich vegetables and fruits. If this is not convincing enough, breast cancer survivors with the highest inflammatory markers have a two to three times higher risk of recurrence and mortality. Correcting this is one of many essential components of integrative treatment.

Stress chemistry tests used in the terrain panel include salivary cortisol and melatonin. Both cortisol and melatonin levels show strong circadian rhythms. Cortisol peaks in the morning, whereas melatonin peaks at night, coordinated with sleep onset.

Circadian rhythms in both cortisol and melatonin are linked to rhythms of daily activity and sleep, which have long been noted to be disturbed in cancer patients. These disturbances can be quantified with actigraphy, a non-invasive system for detecting motion. Actigraphic studies reveal that cancer patients are prone to disturbed sleep, frequent lengthy napping, and inconsistent daily activity patterns. Cancer patients with disturbed circadian rhythms show approximately twenty to twenty-five percent reductions in overall survival.7 The circadian timing system is controlled by a group of “clock” genes that control the function of ten percent of the human genome. This suggests genetic and physiological origins for circadian disturbance, in addition to disturbances arising from cancer-related fatigue or restless nights due to anxiety.

Interventions to improve circadian rhythms include exercise for improvement of fatigue and sleep, biobehavioral therapies for anxiety and sleep, bright light therapy and melatonin supplementation.7 In addition, circadian or chronomodulated timing of chemotherapy, which is provided at the Block Center, has been shown to markedly diminish side effects and toxicity, improve treatment tolerance and substantially improve outcomes. For instance, a chronomodulated regimen decreased diarrhea by twenty percent in cervical cancer patients.8

Broad-Spectrum Therapy for Cancer

As co-chair of the Halifax Project, an international collaborative of one hundred eighty scientists, I recently edited a special journal issue on the topic of broad-spectrum therapies for cancer.8 Molecular target therapies are in wide use, but patients taking them are prone to relapses, due to the genetically heterogeneous nature of cancers. When a targeted therapy eliminates susceptible cells, resistant clones multiply, manifesting as recurrence. The collaborative argues that targeted and other conventional treatment should be supplemented with broad-spectrum therapies that address multiple genetic mutations. By reducing the growth rates of multiple clones simultaneously, the tendency for relapse should be reduced. Teams in the collaborative recommended agents for low-toxicity interventions that can be combined to provide broad-spectrum therapy. The interventions are chiefly phytochemicals and plant extracts, which a large body of research has shown to inhibit multiple molecular targets. The Block Center implements our broad-spectrum model through treatments based on the biochemical terrain and lifestyle, as described above. However, for patients who have genomic analysis performed on their tumors, we also are able to suggest individualized phytochemical formulas and off-label cocktails that WWW.SFMS.ORG

address the molecular targets expressed by the patient’s tumor.

Patient-Centered Integrative Care

Patient-centered care respects patients’ needs, goals, and values, and facilitates their abilities to make decisions and participate at the helm of their own care. Our philosophy has always been to place patients at the helm of their own clinical care. Many patients come to us with significant concerns about conventional cancer therapies and are initially unwilling to go through recommended medical treatments. Our systematic integration of comprehensive clinical interventions, lifestyle therapies, and metabolic and molecular-based supplementation allows many of these patients to undergo chemotherapy treatment with lower toxicity and better outcomes than they anticipated. Continuing to support and monitor patients who use alternative practitioners or enter clinical trials acknowledges their control of decision-making. Finally, educating and training patients on the Life Over Cancer model, based on the Center’s assessment system, exemplifies the empowerment of patients’ participation in their own care, since a cancer-suppressing lifestyle is the foundation of all care at the Center.

Integrative cancer care goes beyond “complementary and alternative medicine.” It is a comprehensive, strategic, and individualized system based on a specific model of disease and therapy, tailored to patients’ unique needs, health belief models, and values. It offers patients more than an improvement in quality of life: it is real medicine, tomorrow’s medicine today, and it targets and achieves superior therapeutic outcomes.

Keith Block, MD, is the Medical and Scientific Director of the Block Center for Integrative Cancer Treatment in Skokie, Illinois, Editor-in-Chief of Integrative Cancer Therapies (SAGE Publishing), and is on the Editorial Board for Physician Data Query for Cancer Integrative, Alternative, and Complementary Therapies of the National Cancer Institute. A full list of references is available at www.sfms.org.

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Cancer

NO STONE UNTURNED Advocating for Patients Facing Cancer and Life-threatening Illnesses Mark Renneker, MD It may have been due to the “Healthcare is a Right, Not a Privilege” mantra of my inner-city family medicine training program at San Francisco General Hospital, or perhaps the undue influence of television shows like “The Equalizer” (a 1980s noir drama

featuring an undercover agent battling injustice on behalf of vulnerable people), but, whatever the impetus, in October 1988 I ran a classified ad for one week in the San Francisco Chronicle that read: Trapped in a medical nightmare and need help? Call the MEDICAL EQUALIZER, a physician specializing in advocating for you, resolving unsolvable cases, and in-a-jam second opinions.

I placed this ad as a quasi-experimental attempt to measure what I had begun to observe all around me: patients, rich and poor alike, increasingly dissatisfied and struggling with the healthcare system. For whatever reason, I’d found I was good at getting such patients “unstuck” and wondered whether I might forge a practice doing just that. My supposition was that some patients’ medical problems were so complicated and their experiences with the medical system so disastrous that they had quite literally given up, and were now desperate enough to actually answer such an ad!

Calls quickly came in—a few were crank calls, but the rest were from people with truthful and compelling stories. Interestingly, some were calls from elsewhere in the state and even from out of state (who knew the Chronicle was so widely read?).

As I looked over their cases, I saw much that could still be pursued on their behalf. I tried out various strategies: seeing some patients in person, talking with others on the phone, deeply reviewing all their records (errors abounded), talking with their doctors (generally they were good), finding and analyzing relevant published literature, and calling experts around the country and world (so many wonderful, creative people out there; such geographic differences in diagnostics and therapeutics).

Some of the patients I helped considerably, others less so, but each seemed less burdened by frustration and quite grateful for my efforts. I charged them for my time, on a sliding scale (no insurance).

My position with those initial patients was (and remains) that I would not provide treatment per se, only advocacy and case-specific research, education, and guidance. I quickly learned that an entirely different clinical strength came from tying my hands as a treating physician—it was more objective, and so much easier to focus on a wider array of patient and family needs. Others things I discovered: • Most of the work was readily accomplished by phone, allowing considerable freedom of scheduling for both the patient 22

and me; plus, it was easy to conference in family members, no matter where they may be.

• Many cases required inordinate amounts of up front time: two-hour initial patient appointments, then as much as ten hours in the first week, and, until the crisis was resolved, frequent follow up appointments were needed.

• The need for advocacy services was pervasive, as suggested by an ever-increasing number of calls from elsewhere in the country (and the world); from the beginning, there have always been more patients requesting my help than I can accommodate.

• People were entirely willing to pay out-of-pocket on a time-spent basis, with reimbursement rates consistently close to one hundred percent (with some highly grateful patients paying more than billed, allowing a subsidy fund for patients with little or no money), and most patients were not expecting that insurance would cover this “extra” help.

• Patients often know better than I what needs to be done, mainly needing my strategic help and connections and encouragement to push forward.

• The most common diagnosis was false hopelessness.

I began doing this work full-time in the early 90s, and rented a house beside Ocean Beach, where I still am. I hired a part-time office manager and data/files manager, and subcontracted with someone expert in searching for medical information, and that is still what my “team” largely consists of. To avoid becoming like so many too-busy doctors, I established a “life-boat” rule: no more than one new case per week, allowing maximal, as-needed time for patients, but also to ensure my not burning out—some of these cases are emotionally difficult and spiritually profound.

With no further advertising, my practice as a medical advocate grew quickly, primarily via word-of-mouth through friends, family, colleagues, and, in particular, the patients I’d worked with. I took an all-comers approach, even if I had literally never heard of a patient’s disease. My promise to patients was not that I had great expertise with every condition, but that I had skill in finding, evaluating, and accessing experts, research, and new ideas about any disease, no matter how rare, and a commitment to follow through and help pursue every good lead. In other words, a No Stone Unturned approach.

Because I was a family physician, I felt comfortable with virtually every kind of patient—pediatric, adolescent, adult, obstetric, psychiatric, geriatric, hospice—and trusted myself in strategically handling problems from any specialty. My generalist training had taught me never to leave patients to fend for themselves with specialists, and that patients and families facing complex, life-threatening illnesses need someone to help them maintain the big picture, the ten thousand-foot view. Even so, I

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rarely found that a patient’s physician(s) needed replacing; more often their seeming rigidity or lack of interest or obstructionism could be addressed—the exception being physicians who would from the outset treat a patient like a Dead Man Walking.

The way I describe my work to puzzled fellow physicians is that I am doing little more than what they probably do for a personal family member or a very close friend. It’s all the extra things: the obtaining and rigorous checking of key records, including perhaps talking with the surgeon or pathologist or radiologist; using PubMed, but doing more than just glancing at a few abstracts, instead seeking and reading full-text articles and then calling or emailing authors of on-point papers; scouring for pre-publication information, perhaps from recent specialty meeting presentations; and, most importantly, spending time debriefing after key appointments or procedures, fielding the multitude of questions and worries that inevitably occur for patients and family members, all the while helping plot a course for the future and looking for ways to bring hope into the fray.

Then they would get what medical advocacy is.

All told, about half of my cases are cancer-related, most often dealing with high-risk, recurrent, and metastatic disease, often for unusual tumor types. Non-cancer problems are often gastrointestinal, rheumatic/immunological, endocrine, neurological and pain-related. Seventy percent of patients are from outside the Bay Area; thirty percent of patients or their spouse has a MD, PhD, or law degree (in other words, people who recognize when “standard of care” is perhaps not enough).

Two thirds have tried alternative or complementary/integrative therapies—the other third want to, often specifically seeking my help to evaluate and implement such strategies.

Now, over twenty-five years later, I have worked with several thousand patients, spanning an immense variety of medical problems and advocacy needs. Over that time, about one hundred non-physicians (mostly computer maven types) and about fifty physicians have sought me out with a serious interest in becoming either a researcher or medical/clinical advocate. They hoped to have me train them or at least shadow me in my practice, but mainly due to the exigencies of my time, and for a long time not wanting to shift to a training focus, I chose just a handful to train.

Then in 2012, I co-organized with one of my trainees, Sandee Birdwell, MD, the first national conference on clinical advocacy (we’ve used the terms “clinical” and “medical” advocacy interchangeably). We mainly invited physicians from around the country to come and present their work. Although in recent years there have come to be a number of social workers and counselors doing healthcare advocacy and patient navigation, their work often focuses on coordinating health care services, less so than deep, tailored clinical research. The conference took place up at Commonweal, with whom I have had a long affiliation (see their Website under “Healing Circles” for a more detailed recent talk/handout, dated June 5, 2015). There were about thirty-five of us at that first conference, and through our discussions one message came through loud and clear: this work needs to be taught in medical schools, and there needs to be training programs for physicians already in practice who want to shift to a more advocacy-based practice.

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In 2015, I co-initiated, with one of my other trainees, Eric Jamison, MD, an Advocacy Medicine clinical rotation for selective fourth year medical students at UCSF, through the Department of Family Medicine, and was gratified by the results: students lapped this work up, with sometimes stunning results.

That soon led to the recent initiation of a one-year pilot fellowship program to train physicians and other health professionals in medical advocacy. Again with the sponsorship of Commonweal, a volunteer planning committee/faculty of four of us who are medical advocates sought nominations for whom to invite to be trained. We eventually chose twelve individuals of varying specialties and backgrounds. In April 2016, we held an intensive inaugural five-day training/retreat at Commonweal, and are now in the process of having the fellows shadow us in our work, take on research assignments, attend every six-week salons to present and discuss cases, and we are pursuing the meat of the program: direct, on-the-phone, or in person mentoring of each fellow as they take on their own cases. The enthusiasm for this training project has been considerable.

Case Study A 27-year-old intern was diagnosed with a thymus cancer and was treated by her residency director, also an oncologist.

She’d undergone surgery to remove the tumor and part of her lung, and then received radiation and chemotherapy. She had read that these tumors often recur and consulted me to see whether she should receive additional treatment. On reviewing her case, she told me a written second opinion on the pathology had been done but she had not seen it, so I recommended we obtain a copy of it. It turned out the report had not completely concurred with the initial diagnosis, raising the possibility of it being a lymphoma. I arranged for a third, more definitive pathology review, which confirmed it was a non-Hodgkin’s lymphoma. Fortunately, that had a better prognosis, but it also meant the surgery and radiation therapy had been unnecessary, and the chemotherapy was of the wrong type. Her doctor didn’t apologize to her and opposed (unsuccessfully) her wish to receive a newer combination of chemotherapy, as recommended to her when she was seen at MD Anderson.

Mark Renneker, MD, is a graduate of and an associate clinical professor in the Department of Family and Community Medicine at the University of California San Francisco.

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Cancer

THE CIVICS OF DYING WELL BJ Miller, MD

Whose death is this anyway? If that’s a tough question to

answer vis-à-vis life, then it’s even more complicated for death.

In the 1990s, medicine’s bioethical pendulum began to swing towards autonomy. In the long, old shadow of paternalism, this was a corrective swing to be sure. The practice and systems of medicine are lumpy, and you’re still likely to find all sorts of conflicting interests, but I think it’s fair to say that, when it comes to respecting the choices and values of our patients, we have improved.

Which has brought us to a newer challenge—namely, the limits of autonomy. We know better than to offer our patients an indigestible menu of treatment options—choice for choice’s sake. We know that we individuals are social creatures who tend to make decisions with the benefit of input from people we trust, including friends and family, caregivers, and clinicians alike. Traversing the wild panoply of treatment is indeed officially and obviously a team sport.

But what about at the level of the delivery system? What about medical education? And public education?

With the ascent and acceptance of palliative care comes an opportunity to re-imagine the whole endeavor of healthcare at the rudimentary and conceptual level. Concepts like “whole-person” or “holistic” or “person-centered” care, and “quality of life” and “suffering”, all beckon to a widely integrative mode. Importantly, medicine must reconcile its traditional drive for objectivity with the insistent fact that living is a subjective and felt experience. Indeed this is radical territory for medicine and the scientific method. It is a moment to more fully develop our notions of health and improve the experience of giving and receiving care.

From funding streams, to ethos, to source material for innovation, to influence and relevance, we have the cross-disciplinary opportunity of the century.

We feel this as healthcare attempts to pivot towards a value basis in for economic policy. There is much yet to learn and to try, but it seems doubtful we’re headed back to a strict fee-for-service formula. And if political and economic imperatives aren’t enough, our epidemiological “silver tsunami” will ensure that change is seen through.

We know that aging and dying will soon happen around and to us at historical scale. The “age wave”—or “silver tsunami”—has begun. And, in our inherited medical paradigm, that means that medicine will be failing at historical scale. As part of all this, we are beginning to better appreciate—and articulate—the limits of our craft. As providers, since failing to forever forestall life’s inevitabilities is no failure, I believe this should come to us as a great relief. The truth is that our public, in general, does not want us to pretend. In fact, when conveyed to them with humility and support, patients are often relieved to hear us say what they already 24

know. There is an end, and often, the end is actually welcome.

So we feel the court of public opinion now in new ways. Let it come, as it will, and let the public help design something better.

Enter a person-centered system.

While it did not come before the electorate for a vote, per se, the passing of assisted-dying legislation is one such effort. This initiative was very much a labor of patients and families and nonmedical advocates. It’s symbolic importance is vast—a meld of grass roots and legislative action; a re-staking of personhood; and an acknowledgment of the limitations of modern medicine’s technique, as well as a call to refresh its orientation as a human service and its obligations to the public it serves. This gets all the way down to the level of the oath of our profession.

When it comes to mitigating suffering and fostering quality of life, there is tremendous potential relevancy of other fields and disciplines and constructs. We are beginning to see this cross pollination in action, with overtures to and from the design trade, the arts, philosophy, psychology, law, sociology, and anthropology, to name just a few. These are not cute efforts on the margins, but front and center now to improving the experience and appreciation of health and healthcare. Like it or not, the veil has been pierced and medicine does not have to pretend to preside over all matters of life and death.

Beyond a “Medical Event”

Which brings us back to the end. In language I learned from working at Zen Hospice Project, death is too profound to be relegated merely to a medical event. We all know this in our bones.

But where then to put it? For the purposes of study and resourcing—“ownership” at the systems level—where should Death live?

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With all the re-jiggering in the air noted above, it’s a timely question. Is it the social model or the medical model that has it most right? Or, perhaps we need to further develop a spiritual model?

Even when taken together, these three models don’t quite encapsulate the fullness of the issue, or the complexities of addressing it as a population. It should not be boring to remind ourselves that death directly affects one hundred percent of the population, no matter what stripe, across time and space, and to tremendous economic and public and private consequence. This universality kicks dying up to the transcendental or epiphenomenological level of civics. Any narrowing of its sphere of influence will leave out some people and their valuable insights. (Even civics implies just the citizenry, which I do not mean to suggest.)

Death is radically inclusive and equalizing, and therefore it has the potential to be a force for justice as well. Indeed there are a host of imperatives from which to choose: economic, political, scientific, humanitarian, cultural, ecological, moral. Take your pick—they all point to embracing the issue.

A Civic Model for Dying

What would a civic model for dying look like? To start, it means that we as a civil society should address the issue and deem it essential to our way of life, like water or public health or education or transportation or communications. Like any public utility, this entails guaranteeing accessibility, proportionate funding, and oversight.

It means that mayors’ and governors’ offices would get involved. Here in San Francisco, thanks to our Department of Public Health and Department of Aging & Adult Services, we already have a Palliative Care Committee advising the Board of Supervisors and Mayor’s Office. It means joining efforts of any civic leadership amalgam—public and private, secular and religious—and members of myriad sectors: the arts, sciences, service, education, etc. And of course, death would be the ultimate cause for sincere civic engagement. Altogether, this would immeasurably help normalize the issue, setting the tone, raising awareness, supporting innovation, and allocating money. It’s not hard to imagine some day candidates for office including ideas on the subject in their platforms. Once again, here is an increasingly loud issue that affects the entirety of any electorate.

But beyond the political and adjudication issues, I am more interested in the ethos that civics implies: that any community— cluster or tribe or town or state or country—would officially face the inevitability of death and set about creating practices and services to suit; that any banded society would come to take pride in how its members come to die, and judge itself by how well its members care for each other through to the end. This model would allow for aging as a continuously developmental arc.

With such fabric in place, taboo and denial and shame and other manners of unnecessary suffering would wither. Instead, in this new light, creativity could grow and connections—across industry and sector and discipline, and among the population— would be realized.

How wonderful it would be to include dying well—to borrow language from Ira Byock—on any list of criteria for “best places to live”. It is not everyday we can honestly assert an initiative that has the potential to benefit every single one of us. And what would happen over time to a community whose members could WWW.SFMS.ORG

rest over the full course of life, knowing their deaths will be well met and supported? Clearing that much inter- and intrapersonal angst would open massive space for all sorts of things to flourish.

In this way, with no hyperbole, a comprehensive and agile civic structure for dying would be an evolutionary step in modern human development.

I realize as I type that this is way too sensible to actually happen. Yet in some ways, as highlighted above and beyond, it is already happening, just haphazardly. Perhaps we’ve all come far enough along to finally pull off the cover. If we did, we could begin to realize the opportunity in front of us, with all the relief that comes from finally dealing with something long repressed.

BJ Miller, MD, is attending specialist in palliative care at the UCSF Cancer Center Symptom Management service, and senior director and advocate at Zen Hospice Project.

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Cancer

CALIFORNIA END OF LIFE OPTIONS ACT Cancer and Some Ultimate Choices Catherine Dodd, PhD, RN, FAAN We left mom’s tiny Oakland condo with her alert and oriented, on a stretcher in an ambulance that would take her to the Zen Hospice guesthouse, which was her “choice for dying.” Mom had been diag-

nosed with multiple myeloma seventeen years earlier, the year she retired after teaching school for thirty-one years. Her years were active—she continued to supervise student teachers right up until the last few months, and she founded the bay area multiple myeloma support group and was the “welcome” for new members. Using her tiny first generation Macintosh, she sent a Christmas letter every year, and she visited with friends inperson and by phone every day.

She had been diagnosed with lung cancer twelve months earlier (a diagnosis that was missed four months earlier on a chest x-ray result that was not followed up on), and her condition worsened quickly. We moved her care from San Francisco where she adored her physicians, even when they didn’t return her phone calls, to Berkeley where the waits were long and the physicians impersonal, with the exception of her radiation oncologist. I had finally called him because her oncologist said “bring her in” when I called and said she was vomiting up the senna pills she had taken six days earlier. I couldn’t call an ambuvan to take her to the clinic where she would wait in a wheel chair for an uncompassionate oncologist to tell her she would soon die. Her radiation oncologist looked at her pre-op chest x-ray results (taken two weeks earlier so she could have her vocal chord paralyzed, ending up with a ten-day hospital stay and a urinary tract infection), said “her lungs are like a snow storm” and that she never should have had surgery, and he offered to come to her home to tell her.

He came and knelt down before her, telling her that she had a week to a month to live. She instructed me to get the binder out of her bedroom, which had articles and information on Zen Hospice. She said, “This is where I want to die.” I had asked her primary care internist for a hospice referral six months earlier and he said, “She’s not ready yet.” I argued that she thought she was and he disagreed. I had been a primary caregiver those six months along with a host of friends who came to sit with her so she was never alone. Now she was ready, very ready. As we rode in the ambulance past Lake Merritt, she talked about the fireworks over the lake when she was a child and jogging around it as an adult. As we rode over the Bay Bridge and Treasure Island she reminisced about going to the World’s Faire there when she was eighteen.

We arrived at Zen Hospice on Page Street in San Francisco and she was carried up to a bed in a homelike room with a fireplace and a view of late afternoon sunlight shining through the trees. The staff asked her what she might want and she said “real 26

tapioca pudding” (I had been buying premade tapioca at Safeway for months). They made it, she loved it, and it was her last real food. She was taken off all her meds and put on a Bromptonlike solution for severe pain in her arm, which she had suffered from for over a year. She asked not to be given Ativan because she wanted to be alert. She was scared, and worried about falling when getting out of bed onto the commode. She had friends scheduled to be with her every two hours. On the second day, her radiation oncologist came from Berkeley to visit and she shooed everyone out so she could tell him how important he was to her.

That night the pain solution had Ativan in it, and she was never really oriented again. She slept and coughed violently for six days. In last forty-eight hours I set my watch to dose her with Roxanol every ten minutes, to keep her mouth moist (something she had written in her five wishes). She coughed and slept and slept and slept and finally took a last deep breath at 8am— “just in time for school to start”, remarked a very loving aid. She chose how and where she wanted to die. It seemed like a long time, those six months of arm pain, coughing, weakness, constipation and vomiting. Would she have chosen to die by administering a lethal dose of a medication prescribed by her oncologist or her internist? I doubt it because of her strong Catholic faith. Neither of them had the communication skills to admit to her she had no other options. Would she have had the conversation with her beloved radiation oncologist? I think yes. Would she have taken the medication? I don’t know, but I do know that she did not want me to see her continue to suffer and she often asked “for this to be over.”

How hard would it have been to arrange for her choice in method of dying had the California End of Life Options Act been in effect back in October of 2003? Her internist didn’t think she was ready for hospice and she didn’t want to challenge his decision; her oncologist never looked her in the eye but focused on her chart and barely spoke to her. Would either of them have been willing to have the critical conversation about how she wanted to die? Would she be able to say she knew that she wanted the option of a prescription to end her suffering? Would they have been able to document the conversation accurately?

Could they have made a referral to a consulting physician who would document her wishes? I don’t think so. Physician communication is so profoundly important—one couldn’t deal with his patient of over twenty years dying, and the oncologist couldn’t communicate beyond diagnosis and treatment. I believe her radiation oncologist could have had a meaningful conversation, but that was not his role, and by that time, we were out of time.

Even if they had she died within six days of learning that her days were numbered, and there is a fourteen-day waiting period from first request, confirmed by a second request.

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All this is to say: in a culture that continues to emphasize life and curative care, medicine, even oncology, lags far behind how people see their lives and deaths.

California’s new law goes into effect June 9, 2016. The law requires that physicians participate in discussions and inform patients of their rights and alternatives. There are strict rules and safe guards. In brief summary, the patient must be eighteen years of age; the medication must be self-administered; the patient must be mentally competent; two physicians must examine the patient and review all records and separately confirm the prognosis that the patient has six months or less to live; they must inform the patient of alternatives and that they can withdraw request at any time; the patient must voluntarily request the medication and reaffirm his or her request two weeks after the first request and sign a final attestation form within fortyeight hours before taking the lethal dose of medication; and final paper work must be signed after death regardless of whether the patient used the medication or died of other causes. If all processes line up the minimum time would be sixteen days, but it will likely take much longer, pointing to the need for starting these complex conversations earlier.

The medical community is appropriately hurrying to make education materials available. Public education needs to be undertaken. Oregon’s legislation had been on the ballot several times before the law finally passed, and that meant that people had talked about death and how they wanted to die for years.

Hospice is utilized in Oregon to a greater extent for that very reason. Given how poorly we have educated people about the importance of Advanced Directives over the past decade, we have much work to do to make sure people can choose how they die. We all deserve to leave this world surrounded by as much love as we were surrounded by when we entered it. It’s an informed choice to make within six months before death from a terminal illness, and it requires physicians’ assistance.

The law will sunset after a decade, making it effective until January 1, 2026. However, the state legislature could vote to extend the law, if it has been considered a success. For that to be the case, at least two broad goals need to be aggressively addressed:

Educating the public: CompassionAndChoices.org has many resources, including information on advanced directives, and consultation and education on many options, including palliative care, hospice care, and physician assisted dying. Their consultation services include support for healthcare professionals seeking information about compassionate, patient-centered, end-of-life care.

Educating providers: Physicians should review the www.

CompassionAndChoices.org material, including the “your life, your priorities” brochure. The California Academy of Family Physicians has online webinars at www.familydocs.org/eol, The California Medical Association has published guidelines which can be found through links on the www.sfms.org website, and WWW.SFMS.ORG

the American Academy of Hospice and Palliative Medicine website www.aahpm.org has many resources.

To honor mom, I did my doctoral dissertation on hospice care in California and I worked for the passage of the End of Life Options Act. Now I intend to become part of the speaker’s bureau and in my work life I am insisting that the medical groups, that the SF Health Service System contracts with, have procedures in place in June of 2016 so members can have those critical conversations and make their choices in a timely manner to avoid suffering. I love you mom.

Catherine Dodd began her nursing career on a mobile health van working with farm workers throughout California. She also worked as a high-risk perinatal nurse and as the Director of Women’s Health at San Francisco General Hospital. Author of many articles and book chapters in the nursing literature, she has been a San Francisco Health Commissioner and District Director to Congresswoman (former Speaker) Nancy Pelosi. She recently completed service on the Board of the Homeless Prenatal Program, the Board of the Breast Cancer Fund— focused on preventing breast cancer by eliminating chemical causes of cancer—and the Board of Zen Hospice Project. She is currently the Director of the San Francisco Health Service System, where she is responsible for health benefits for over one hundred six thousand covered lives, and for implementing employee wellness programming for sixty thousand employees of the County, the schools and the Community College.

RESOURCES FOR CLINICIANS ON PHYSICIANASSISTED DYING A Family Physician’s Guide to the End of Life Option Act: http://www.familydocs.org/eol/end-of-life-option-act Brief Podcasts on End of Life Care and Issues: http://www. familydocs.org/news/cafp-launches-end-of-life-podcast POLST: http://www.familydocs.org/eol/education/polst

California Medical Association guidance for End of Life Option Act: http://www.cmanet.org/news/pressdetail/?article=california-medical-association-issuesguidance

Billing for Advance Care Planning Conversations: http:// coalitionccc.org/tools-resources/advance-care-planningresources/advance-care-planning-reimbursable-undermedicare JUNE/JULY 2016 SAN FRANCISCO MEDICINE

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Cancer

CANNABIS AND CANCER Decoding the Connection Donald I. Abrams, MD It seems like just yesterday that claims were being made that cannabis caused cancer. Epidemiologic re-

ports suggested that regular cannabis use might be connected with the obvious head and neck malignancies and lung cancer, but also some that seemed more far-fetched such as cervical, prostate, and testicular. Subsequent analyses called most of these associations into question. One data set from Kaiser Northern California suggested that cannabis use might actually decrease the risk of lung cancer, a finding supported by a later case-controlled investigation from the pulmonologist at UCLA who has spent forty years studying the potential adverse effects of cannabis on the lungs. Then came the report suggesting that cannabis might decrease the risk of bladder cancer. And now, as the pendulum continues to swing, suddenly we are faced with increasing claims being made that cannabis actually cures cancer. What is the origin of such a notion?

The unearthing of the tomb of the Siberian Ice Maiden in 1993 revealed the well-preserved remains of a young woman presumed to have lived twenty-five hundred years ago. The maiden had metastatic breast cancer and was found buried with a pouch of cannabis, suggesting to the archeologists that she was using cannabis for symptom management as well as possibly a direct anti-cancer effect. Fast forward to 1974 when scientists at the National Cancer Institute published their findings that cannabinoids—delta-9-tetrahydrocannabinol (THC), delta-8-THC, and cannabidiol (CBD)—were all able to suppress the growth of Lewis lung adenocarcinoma cells in vitro and in mice. An increasing body of pre-clinical evidence from investigators predominantly in Spain and Italy supports the possibility of cannabinoids having anti-cancer effects, but to date there has only been one human study. Because the brain is enriched for the cannabinoid-1 receptor, it makes some sense that gliomas are a particularly responsive to the antineoplastic effects of cannabinoids. This led to a study conducted on patients with recurrent glioblastoma multiforme in the Canary Islands, where investigators applied topical delta-9-THC via a catheter directly into the tumors. The results were not impressive.

Certainly it cannot be the underwhelming result of that single human trial that is fanning the flames of the “Cannabis Cures Cancer” movement. A Canadian boiler maintenance worker heard of the news that cannabis may suppress tumors in 1974, two years after a cousin had died an agonizing death from cancer. Thirty years later when he was dealing with three basal cell carcinomas, he decided to treat them with a highly concentrated cannabis oil preparation. When the lesions disappeared, the highly concentrated cannabis oil took on his name and, with the impact of social media, went viral so that people all over were seeking such preparations for topical treatment of skin cancers 28

and subsequently oral ingestion for diverse malignancies. Patients posted radiographic evidence of their tumors shrinking or disappearing on the internet, and a mass movement had begun. Interestingly, a number of the most vocal advocates for the benefits of cannabis oil seem oddly amnesiac that they were also treated with chemotherapy or other conventional means.

As an oncologist in San Francisco for the past thirty-three years, I often say that I would venture to guess that the majority of the patients I have cared for have used cannabis during their treatment. Thus, if cannabis cured cancer, I would have a lot more survivors. Granted, the plasma concentration of inhaled cannabis, as most of my patients have likely used in the past, probably does not approach that which can be achieved with the highly concentrated oil preparations (no data available on this as yet), but still, oncologists maintain that the plural of anecdote is not evidence! What saddens and disturbs me the most is when I see a patient in consultation with a potentially curable malignancy who is foregoing conventional cancer therapy in hopes that cannabis oil will be a kindler, gentler treatment. The fact remains, there is no evidence at this time to support such a decision. Having completed a number of clinical trials investigating the effect of inhaled cannabis on the pharmacokinetics of protease inhibitors and sustained release opioids without seeing clinically significant perturbations of plasma concentrations of the pharmaceuticals, I hopefully extrapolate that the cannabis oil preparations will behave similarly. But again, the reality is that we have no such information. And if we were to study it, would we use a high THC oil, or a high CBD oil, or one that has one of the magic THC:CBD ratios touted by those who purvey them?

Having lived through the rise and fall of many “alternative” cancer cures during these past three-plus decades, I fear that cannabis may go the way of laetrile or shark’s cartilage, dismissed as bogus and fraudulent. The reality is that there is an increasing body of evidence that cannabinoids work against cancer cells from many angles—increasing apoptosis, decreasing angiogenesis through inhibition of vascular endothelial growth factor and thwarting invasion and metastases by matrix metalloproteinase-2. What is lacking is the demonstration that these in vitro effects translate into any benefit for people living with cancer. But there is a body of evidence that cannabis is an effective medicine for the management of symptoms arising from cancer or its treatment, so a blanket dismissal of cannabis as an invalid cancer treatment would deprive patients of a very valuable therapy.

Oncologists demand evidence before they embark on a therapeutic option. That makes sense because the diseases we treat and the interventions we employ are serious and potent, so data is essential before recommending any regimen. Similarly,

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one would hope to see data supporting the effectiveness of cannabis as an antiemetic, appetite stimulant, analgesic, sleep aid or mood elevator before feeling confident suggesting its use.

It is important to recall, however, that the only legal source of cannabis for research in the United States is the National Institute on Drug Abuse (NIDA), and that they have a mandate from Congress to only study “substances of abuse” as substances of abuse and not therapeutic interventions. So if one wants to investigate the clinical effectiveness of cannabis as medicine, the drug can be obtained from NIDA, but funding must come from elsewhere. There are numerous additional regulatory hoops that must be surmounted before such a study can be conducted.

Current data mainly involves the licensed delta-9-THC product, dronabinol, which has been the most widely studied cannabinoid medicine in the U.S. Dronabinol was licensed and approved for treatment of chemotherapy-induced nausea and vomiting in 1986, so oncologists theoretically should have the most experience using cannabis-based medicines. The fact that the single most active component of the parent plant is available supports the observation that the botanical itself is a useful antiemetic.

Many of us have patients who forego the use of prescription anti-nausea medications in favor of using cannabis alone.

In animal models, cannabinoids are effective in both treatment and prevention of peripheral neuropathy caused by each of the three main classes of chemotherapy associated with this vexing symptom—the vinca alkaloids, the platinums and the taxanes. A number of studies, including one we conducted in HIV-related peripheral neuropathy, have suggested that inhaled cannabis is effective in various neuropathic syndromes. Interestingly, all of these studies suggest that the number of patients needed to treat for one to have a benefit (NNT) is consistently between three and one-half and four, which is identical to the NNT for gabapentin, one of the more widely used interventions for painful neuropathy. As yet, only one small study of an oromucosal spray preparation of whole cannabis extract has been completed in sixteen patients with chemotherapy-induced peripheral neuropathy with results that would support conducting a larger follow-on confirmatory trial.

Often cancer patients require opioid analgesics for management of pain. A small pharmacokinetic interaction study that we conducted found no significant alteration of plasma levels of sustained-release morphine or oxycodone when vaporized cannabis was inhaled three times daily. There was, however, a signal that pain relief may have been augmented. Animal studies support the synergy between cannabinoids and opioids in analgesia. This is another potential role for cannabis medicines in cancer patients.

Many patients are now seeking CBD-enriched preparations to avoid the psychoactivity associated with delta-9-THC. Although euphoria may be considered a side effect of cannabis use, I would not consider it an adverse experience. If I have one medicine that can decrease nausea and vomiting, enhance appetite, decrease pain, improve sleep and mood, I consider that to be a valuable intervention. Instead of writing prescriptions for five or six pharmaceuticals that could all interact with each other or the chemotherapy I prescribe, I can recommend one very safe botanical. On asking cancer patients “What brings you joy?” I am impressed by the number who answer that gardenWWW.SFMS.ORG

ing does. It seems as if one is dying, or feels that a part of them has died, the ability to bring life out of the ground is a special gift. And if one can grow their own medicine, that is especially empowering.

Donald I. Abrams, MD, is chief of Hematology-Oncology at Zuckerberg San Francisco General and a Professor of Clinical Medicine at the University of California San Francisco. He provides integrative oncology consultations at the UCSF Osher Center for Integrative Medicine.

He has been conducting clinical research with medicinal cannabis since 1997.

Selected References 1. Abrams, D.I. “Integrating cannabis into clinical cancer care.” Current Oncology 2016; 23:S8-S14.

2. Abrams, D.I. and Guzman, M. “Cannabis in Cancer Care.”

Clin Pharm and Ther 2015; 97:575-586.

3. Bowles, D.W., O’Bryant, C.L., Camidge, R., Jimeno, A. “The intersection between cannabis and cancer in the United States.”

Crit Rev Oncol Hematol 2012; 83:1-10.

4. Caffarel, M.M., Andradas, C., Pérez-Gómez, E., Guzmán, M., Sánchez, C. “Cannabinoids: a new hope for breast cancer therapy?” Cancer Treat. Rev 2012; 38, 911-918.

5. Guindon, J., Hohmann, A.G. “The endocannabinoid system and cancer: therapeutic implication.” Br. J. Pharmacol. 2011; 163, 1447–1463.

6. Health Canada. “Marihuana (Marijuana, Cannabis): Dried plant for administration by ingestion or other means.” Ottawa, Canada: Health Canada, 2010. http://www.hc-sc.gc.ca/dhpmps/marihuana/med/infoprof-eng.php.

7. http://www.cancer.gov/cancertopics/pdq/cam/cannabis/healthprofessional.

8. Pisanti, S., Picardi, P., D’Alessandro, A., Laezza, C., Bifulco,

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Cancer

ONE PATIENT’S PERSPECTIVE Improving Patient Care and Staff Well-Being Neil Gendel, JD This is the story of my experiences as a recent lung cancer [non-smoking] surgery patient with a significant number of other health issues. Some experi-

ences were good, several were not. I felt the latter could have easily been avoided if staff and patients were joined together in partnerships based on mutual respect and understanding; staff was fully cross-trained to meet all the needs of individual patients; and, staff was trained to work well with each other and with patients–something they don’t learn in medical school. Try to put yourself in your patients’ shoes. See what you think.

In the Beginning

After the diagnosis, I began to prepare for the surgery and recovery periods with respect to my health and everything else: friends, finances, living situation, and more. In several ways I feel like I wasted a lot of energy, time, and effort, and wasn’t really ready for surgery. Why? Partially I feel it was because much of the written materials provided weren’t meant for me.

Some were hard to understand. The surgeon’s representations about my consequences from my surgery weren’t even close.

My recovery was more difficult and lasted much longer than described. [See Atul Gawande’s book about telling the truth to and partnering with patients.] After the surgery, I was sent home with orders to do things some of which I couldn’t possibly do on my own. Only nurses could do them. The home visiting nurse saw that and did them, for which I’m very grateful.

The Next Step

Shortly after surgery, I was told for the first time that I needed three months of chemotherapy right away and was quickly assigned to an oncologist I’d never met. I felt like I was on a conveyer belt without any control over what was happening to me. In the following months I learned much about the differing qualities of the lung cancer oncologists on staff, the importance of oncologists to patients for many years, and the chasm of knowledge between them and integrative oncologists and others on staff who are trained to help cancer patients through surgery, chemotherapy, recovery, and living with cancer in the future.

Personal experiences with the oncologist staff: The oncologist never told me about the services provided by the hospital’s integrative oncology and symptoms management staffs. When I finally learned of them and asked why I hadn’t been told anything, the oncologist replied s/he hadn’t been trained in those services and didn’t know much about them. Moreover, I’m deaf in one ear and suffer significant hearing loss in the other. I learned on my own that some chemotherapy drugs can make me deaf. The oncologist didn’t know the proper staff protocol 30

for protecting me from further hearing loss. I didn’t know that at the time. I felt that I had no choice but to refuse chemotherapy and look for help on my own. I turned to my personal otolaryngologist who I’ve known for decades to find a hearing expert on staff that agreed to help me–fortunately. All of this occurred while I was trying to recover from surgery and being pressured to submit to chemotherapy.

I also had several problems with the performance of other lung cancer oncologist staff while preparing for chemotherapy.

For example, I was given information published by the companies producing the chemotherapy chemicals that rival the tomes provided with prescribed pills at pharmacies. They weren’t easy to understand and much was not relevant to my treatment. In addition, I was given poorly written, staff-produced information about buying over the counter drugs on my own to reduce the chemotherapy’s impact. I wasn’t feeling well. I had to decipher those instructions and shop. How did the staff know I bought the right drugs, understood the instructions, and was following them properly?

I have another oncologist now who is straightforward about not being trained in integrative oncology and symptoms management services, but does tell new patients about them and makes referrals on request. S/he leaves the integrative “part” to staff in other clinics who are trained in them–e.g. diet, yoga, meditation, chi gong, exercise, supplements, acupuncture, reduced anxiety and social well-being. I had read about some of the symptoms management services, but wasn’t feeling so well at times, already had a long “to do” health maintenance list, and didn’t feel like I had meaningful access on my own to those services. Then I discovered (through Commonweal in Marin) that a separate integrative oncologist group existed on staff that could also help me reduce the chemotherapy infusions’ impact. Try as I might for several months, including getting a referral from my principal care provider in another clinic on staff, I couldn’t get help from the integrative oncologist until after my chemotherapy ended.

The Bottom Line

What can we can learn from my experiences and perspective that will help medical staff improve the well-being of their patients and themselves? Here are a few of my thoughts in a nutshell: • Personalized information provided from start to finish designed for each patient and written clearly by experienced writers • Continuous patient input and participation in choice • Thoughtfully coordinated “handoffs” to other staff as patients progress through treatment and recovery stages • Full disclosure about clinicians’ qualities and open-mindedness to complementary treatments and services

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• Full disclosure about and real and timely access to all related services, including integrative care at the time diagnosis is made • Cross-training in integrative care throughout the institution and in medical school • Good quality control throughout staff-provided treatments and services • Strong institutional support for integrative services throughout the hospital and medical school • Train staff and students about how to enjoy their work and work better together and with patients

In Conclusion

My feeling is that many of the reasons for the experiences described result from staff members trying to function as best they can in a difficult, challenging workplace, often without much needed guidance. But there is help. A number of organizations teach staffs in larger institutions how to like each other and work collaboratively, which means they get better at what they do and can work better with patients–especially if their efforts are supported at the institution’s highest level. Hire, support, and learn from them! Doing so may be the most important, single improvement in heath care you’ll ever make.

Neil Gendel, JD, a graduate of UC Berkeley’s Boalt Hall Law School, has been a California Deputy Attorney General, a cofounder of Consumer Action, a public interest attorney, a commercial law and bankruptcy attorney, and for twenty years before he retired was the Director of the Healthy Children Organizing Project, San Francisco—as well as a long-time patient of many doctors and several hospitals in San Francisco and elsewhere. He is also acquainted with a few of the training organizations briefly described above.

SFMS Vaccination Public Service Announcement Featuring Musical Icon Graham Nash “Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash and Young, graciously offers his words and classic music for this 45-second public message, “I vaccinated my kids and they’re all brilliant!” he says.

Please enjoy and share this important message. See the video here: http://goo.gl/SKFd5D.

CMA Joins SFMS in Endorsing “Screen at 23” The “Screen at 23” campaign seeks to reveal the undiagnosed cases of diabetes (more than half, according to the NIH) among Asian Americans. By screening Asian American patients using a body mass index of 23 as per the 2015 ADA recommended guideline, thousands of cases of diabetes (approximately 215,000) and even more of pre-diabetes (approximately 430,000) will be unmasked.

With the support of medical societies and physician associations, including SFMS and CMA, and over thirty health organizations, “Screen at 23” is raising awareness among physicians - the primary target audience when the campaign began last October. For more information on the campaign, visit www. screenat23.org.

The 2016 AANHPI Diabetes Coalition Conference: Reducing Disparities will be held in San Francisco on August 26 and 27, and will focus on diabetes among Asian Americans, Native Hawaiians, and Pacific Islanders. Visit https://www.eventbrite. com/e/2016-aanhpi-diabetes-coalition-conference-reducingdisparities-tickets-25062856679 to register.

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Congratulations on Your Retirement Nora!

Nora Hirschler, MD, President and CEO of the Blood Bank of the Pacific is retiring after many years of service. The Blood Bank and the SFMS have worked hand in hand for almost a century.

We wish Nora the best in her next chapter!

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Cancer

HEALING CIRCLES Supporting Patients through a Community of Volunteers Diana Lindsay and Kelly Lindsay Social networks have significant impact on our health throughout our life, impacting our weight, our

healing, our happiness, and longevity1-5 But what if your social network is weak with family far-away or frayed by divorce or death? What if you are diagnosed with cancer just months after relocating and haven’t had time to build new friendships? What if you’ve never had a strong social network?

Discussions on psychosocial care are not routinely offered to cancer patients.6 Could a community of volunteers offer social support—at no cost—in a meaningful enough way to influence healing? That is the social experiment that underpins Healing Circles Langley.

Healing Circles Langley began out of a desire to give back to the community that supported us when co-director, Diana Lindsay, was diagnosed with stage IV lung cancer in 2006 and given a prognosis of only three to twelve months to live. Ten years later, she has no evidence of disease and is radiantly healthy.

During her illness, we learned that 1) we each have an inherent ability to influence our own healing, and 2) it is much easier to access that ability when surrounded by a supportive community. If Healing Circles Langley has a cultural equivalent of DNA, those two principles would be coiled around each other in a double helix.

In January 2014, we decided to dedicate the use of two-story building in the heart of Langley, WA to a new healing center.

The next day, we serendipitously met Michael Lerner, the president of Commonweal and the co-founder of the Commonweal Cancer Help Program, the pioneer and gold standard for residential cancer retreats. The question that challenged Michael— and us—was: “Is it possible to effect the kind of profound transformations experienced at retreats in a nonresidential setting, at little or no cost to those participating?”

Healing Circles Langley opened in January 2015 with the intention to be: • A safe and nurturing place for patients and caregivers to feel supported during cancer, chronic illness, aging, and loss.

• A learning community for South Whidbey citizens to connect and collaborate in support of the wellness and well-being of the community.

The response from the community has been amazing, a reflection of the generosity and interest of those who live on South Whidbey.

A steady stream of talented volunteers has enabled us to broaden our offerings incrementally and organically.

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We launch themes at least once per month, beginning with free, public Community Conversations that often result in the formation of a new circle or class. In our first year, we held twenty of these conversations on topics such as social support, aging, health & the environment, wellness, death & dying, healing & the arts, caregiving, mindfulness meditation, and others.

Although we are a rural island and our center services a population of only fifteen thousand, we currently serve approximately five hundred visits per month and offer fifteen ongoing circles that meet weekly, bi-monthly, or monthly. Our circles reflect the range of learning styles and conditions of those who come:

Healing Circles are safe environments for those who share a

common condition and a common interest in sharing their experiences with others in order to benefit from a collective wisdom.

We now offer healing circles for those impacted by cancer, neurodegenerative disease, aging, and grief.

Discovery Circles are for those who like to process whatever they are facing through creative expression, such as poetry, writing, art, music, and even weaving.

Learning Circles are for those who share an interest in a topic or wish to develop a healing skill. We offer weekly skills-based classes in mindfulness meditation and Yi Ren Medical Qigong, and learning circles that use books or videos such as A Year to Live and Radical Remission as a starting point for deeper reflection.

Caring Circles support those who care for others, including a weekly circle for family caregivers, a drop-in circle for families, and a monthly circle for our own Circle of Hearts volunteers.

With the help of forty trained volunteers, we offer Circles of Two on a drop-in basis. For those newly diagnosed, at a turning point, or grieving, we offer of a hug, a cup of tea, and an attentive ear to whatever their day’s concern is—whether physical, emotional, mental, or spiritual. These circles are very effective in helping people find hope, assuage grief, and navigate their illnesses.

We are also partnering to offer longer retreat experiences, including Awake & Alive: Mindful Living with Cancer Retreat and Coming Full Circle: Aging with Grace, Courage, and Wisdom, based on the Circle of Trust® approach developed by Parker J. Palmer and the Center for Courage & Renewal. These retreats have drawn people across the U.S. and as far away as Europe.

Those who live locally are able to continue their healing by joining our ongoing circles.

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What People Say About Healing Circles Langley “The circle gave me the courage for truth-telling. It helped me rebuild the foundation of my life away from not-dying to living. I have recognized that I matter in my life.”

“Cancer treatment is so deconstructing of self. The biggest gift of the circle is reconstructing and nurturing my authenticity.”

“It was huge when I realized that I knew what I needed to do. I am the wise woman I’ve been seeking.”

“Without Healing Circles, I’m not sure I’d still be here.”

“This is sacred space for our community.”

Healing Circles Langley has already served as a catalyst for other South Whidbey initiatives. A Community Conversation on Aging generated so much passion that a new nonprofit based on the Village model, South Whidbey @ Home, has spun off with the mission of helping our elders stay in their homes longer.

We are particularly excited by how Healing Circles Langley has inspired others to start Healing Circles centers with programs already underway in Seattle, Houston, Washington, DC, and North Carolina.

So what’s a tiny bit of what we’ve learned so far?

• We welcome each one who walks in the door today and listen attentively to why they have come and what gift they are bringing.

• Deep listening to another—honoring and respecting their inner guidance—is enough for healing to begin.

• It’s hard to give without receiving and receive without giving, so we maintain a peer relationship as friends and neighbors.

• By offering a refuge that is a step outside of the ordinary flow of time and space, people can access their own inner guidance on how best to find their own wholeness, or healing.

We are all volunteers. Our circles are led by those with deep life experience and equal passion. We don’t require that they are trained professionals—although many are and lead workshops around the world. Our training focuses on the Heart of Healing, and we gratefully draw generously from the work of Rachel Naomi Remen and Michael Lerner of Commonweal, Christina Baldwin and Ann Linnea of The Circle Way, and Parker Palmer of the Center for Courage and Renewal.

Although Healing Circles Langley began as a desire to help cancer patients, it grew immediately to serve all who suffered from chronic illness and loss. What is life but a chronic condition? We believe the love of community can grace all our lives.

Diana and Kelly Lindsay are co-founders of Healing Circles Langley and the authors of Something More Than Hope, Something More Than Everything. They are both cancer survivors.

WWW.SFMS.ORG

“Healing Circles has brought long-desired depth, connection, support, love, and beauty into my life.”

References 1. Umberson, D., Montez, J.K. “Social relationships and health: a flashpoint for health policy.” J Health Social Behavior.

2010;51 Suppl:S54-66.

2. Nicholas A. Christakis, MD, PhD, MPH, and James H. Fowler, PhD. “The Spread of Obesity in a Large Social Network over 32 Years.” N Engl J Med 2007; 357:370-379. July 26, 2007. doi: 10.1056/NEJMsa066082.

3. Candyce H. Kroenke, Laura D. Kubzansky, Eva S. Schernhammer, Michelle D. Holmes and Ichiro Kawachi. “Social Networks, Social Support, and Survival After Breast Cancer Diagnosis.” American Society of Clinical Oncology. Vol. 24 no. 7, 1105-1111. March 1, 2006. doi: 10.1200/JCO.2005.04.2846.

4. D. Umberson. “You Make Me Sick: Marital Quality and Health Over the Life Course.” J Health Soc Behav 2006 March ; 47(1): 1–16 & Fowler, James H., Christakis, Nicholas A. “Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study.” BMJ 2008; 337 :a2338.

5. McDonald, P.G., O’Connell, M., Lutgendorf, S.K. “Psychoneuroimmunology and cancer: A decade of discovery, paradigm shifts, and methodological innovations.” Brain, behavior, and immunity. 2013;30(0):S1-S9. doi:10.1016/j.bbi.2013.01.003.

6. Laura P. Forsythe, Erin E. Kent, Kathryn E. Weaver, Natasha Buchanan, Nikki A. Hawkins, Juan L. Rodriguez, A. Blythe Ryerson, and Julia H. Rowland. “Receipt of Psychosocial Care Among Cancer Survivors in the United States.” JCO 2013: vol. 31 no. 16: 1961-1969.

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Cancer

AS CLOSE AS BREATHING The Life-Giving Nature of Poetry John Fox, CPT The Capacity of Poetry to Make a Difference After more than thirty years of professional experience with poetry-as-healer, more than knowing what it is, and how it can work successfully in all circumstances and with all people— I continue to be moved by, and I am staggered by, all that I keep discovering. As a poetry therapist, as someone who also carries a sense of the shamanic element present in this practice—I feel as if I am continually traveling into and through new landscapes.

The ever unique human element makes all the difference, that and human creativity. I am open to discovering facets of magic and mystery—the enduring and tangible capacity of poetry and poem-making to make a difference in the lives of people who open to it.

When I say more than thirty years, that can stretch all the way to forty-seven years, back to when I was thirteen and wrote my first poem about watching a girl as she skated at Thorton Park in Shaker Heights, OH. It was that same age when my mother told a group of her friends, “When my son grows up he’s going to be a poet.” I am told (I don’t actually remember this) that I turned towards my mom, saying: “I am a poet.”

Growing up, apparently I knew who I am . . . or was, already.

Consider Poetry as Real as Your Breathing

Consider poetry as real as breathing. Your in-breath, and then, your out-breath. Consider poetry and poem-making as close to you as this—not some-thing out there, not at a distance from you. As real and tangible, as close-in as breathing.

This little story was told to me twenty-three years ago by Laura Golden Bellotti, my editor at Jeremy Tarcher, Inc. I was writing my first book, Finding What You Didn’t Lose. Laura said her nephew, Ian, said to her sister, his mother, as they drove in the car: “Look, Mom, the clouds, they are like mashed potatoes!”

Simile-making was sweetly, powerfully, and let me say naturally accessible to him at that age: two and a half. Ian said to his mother, and more directly than I did, “I am a poet.” Ian hadn’t taken that important class on simile yet. He knew from direct experience when it comes to mashed potatoes . . . and then from his keen observation of life around him . . . and from his imaginative capacity to connect seemingly different things.

Once I was with a group of people in Vancouver, BC, and a man, a dentist, Doug McGinnis, plucked seemingly random words from a bowl, and then he arranged them, composing this poem: 34

Like an alphabet orphan from church I dance & dance —Doug McGinnis, age 73

Doug made his poem at the age of seventy-three. He selfreported to the circle that he couldn’t remember ever making a poem before this moment. He was claiming, as a dancing alphabet orphan, “I am a poet.” He showed us that.

Exploring the Evocative and the Expressive

Poetry and poem-making (and both little Ian and elder Doug are poem-makers) is a bridge between the evocative—the in-breath of life—where we make direct contact with experience even before words, and the expressive—the out-breath—where we voice, via our breath, and give a shape to our experience.

This shaping of experience happens not only with words but also with rhythm and pauses, with image and feeling. The writer Erica Jong would say that “. . . the image is a kind of emotional shorthand.”

The clouds are like mashed potatoes.

I am a dancing alphabet orphan.

Here is a story that leans into the evocative. It has an expressive aspect for sure, but the depth of the moment is primarily evocative. Remember my first comments to you involved mystery and the enduring capacity of poetry to make a difference?

I was sitting at bedside with Lu Melander one late evening at Lytton Gardens, a hospice in Palo Alto, CA. The year was 1992.

Lu was dying of breast cancer.

Lu was my mentor in the work I had begun to do with poetry and children. A truly remarkable, gifted capacity Lu had to meet children and their creativity!

Months before her time in hospice, she had chosen to not seek medical treatment for curing. Instead, Lu asked me to read to her guided meditations by Stephen Levine from his books, Who Dies? and Meetings at the Edge. Doing this was such an honor—in her living room, with her beloved books, Lu laying on a fairly worn out sofa. Listening. I had only known Lu about a year, but she felt comfortable asking me to do this.

That evening at Lytton, Lu was actively dying. I had brought with me poetry by Rumi. I read these poems to her. Lu was no longer speaking. Her cheeks were in-drawn, her eyes were shut, her face looked like a frail death mask about to be taken off.

The overall feeling was peaceful, quietly holy. Yet the very

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moment I spoke the very last line of one particular poem (not any of the others), I felt a clear tangible sense in myself, in the room, in Lu, and in the poem itself. My felt experience was as if, when I spoke that last line, a substantial round stone dropped into a lake in which everything was present. As the stone hit the water, nothing happened.

Only that the stone disappeared. There was not a single wave, not even a little ripple. Something dropped clear through everything. Lu, who had not acknowledged me, she had not moved or spoken, lifted her slight shoulders up, turned her riven face towards me and said, with eyes flashing: “Read that poem again!”

I did.

A dear friend of Lu’s, the artist Joyce Savre, appeared in the room just a few moments after I spoke this poem. Joyce leaned over Lu on the other side of the bed and we held hands together for a little while. I felt my time was complete and I bid Joyce and Lu goodbye. Lu, surrounded by her closest friends, in the early morning hours of the next day, died.

This particular poem, which I do not remember, for whatever very particular “reason,” had given Lu something. She breathed it in. In her dying moments, in her time of transition from this world, this particular poem went to the center of everything and she felt it.

Evocation.

So what of expression? What of your out-breath? Here is an experience that leans into the expressive.

Many years ago, I taught poetry therapy in the Graduate School of Professional Psychology at John F. Kennedy University.

A man in class, Jodie Senkyrik, shared a poem and cried as he read it. Grief was brought to the surface, or, in another way of looking, Jodie invited us down into his depths. He was not sobbing, but very strong emotions were flowing through his tears.

Someone in the class picked up a box of Kleenex and brought it towards Jodie. Jodie gently but firmly motioned the box of Kleenex away.

Jodie continued to cry while sharing his poem. At a particular point, it was appropriate to move on. I saw, very soon after his time, that Jodie started to write with great concentration.

After awhile, after a few people had shared, people who were also crying, Jodie raised his hand and asked me if he could read the poem he had just written. He said the poem spoke to why he had motioned the Kleenex away.

and reveal to you, your heart.

Let the water fall to the earth, and a tree will grow from it.

Let your tears flow from their depths and they will release the seeds of your soul.

Do not be careful Do not be contained or proper or polite.

Do not wipe your tears away.

Taste them on your lips and know that you have graced yourself, today.

—Jodie Senkyrik

This poem you have just read is a strong example of how, from a moment—knowing that he could let this crying come unimpeded—a deep and moving expression came forth.

A Closing Word

I wrote at the beginning of this essay about how, in this work with poetry-as-healer, long-time experience is constantly met by a discovery of new landscapes. I am, through this relationship with poetry and poem-making, renewed by the magic of what I do not know. I am awakened by what I haven’t yet recognized. This renewal and awakening opens the heart. Something is even thrown out beyond the heart, so that discovery remains possible. If I can listen to people in this way, in a way that has faith in what we do not know as the place something true can be revealed, healing and transformation become more possible.

John Fox is author of Poetic Medicine: The Healing Art of Poem Making and is featured in the PBS documentary Healing Words: Poetry & Medicine. He is founder of a nonprofit, The Institute for Poetic Medicine, which cultivates the healing power of poetry, especially with underserved communities.

Do Not Wipe Your Tears Away

Do not wipe your tears away.

Let them flow down your cheek.

Let them create a stream on your face to allow the healing waters to flow.

Let the waters cleanse your skin and wash your face with silk.

Let them caress you lightly WWW.SFMS.ORG

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Medical Student Perspective

CLINICAL SKILLS EXAMINATIONS A Necessary Tool for Physician Evaluation or a Poor Investment?

Alexandra Rojek There is a national movement among medical students to eliminate one of the examinations required for medical licensure by the National Board of Medical Examiners (NBME). At first glance, this may

look like students who are tired of taking too many examinations, but upon closer look, it begins to seem more than just a cursory trend to reduce the burden of exams on medical students.

The NBME incorporates clinical skills testing into the examinations for medical students in the form of one of the four required United States Medical Licensing Examinations (USMLE): Step 2 Clinical Skills (Step 2 CS). The goal is to ensure that as future physicians, we possess proper clinical skills that meet a set of expected competencies required for clinical practice, including English proficiency. However, these standardized clinical skills examinations have only existed since 2004, and passage of all four USMLE examinations is required by state medical boards.

Step 2 CS consists of twelve standardized patient encounters that are meant to assess students on history taking, physical exam skills, and written and oral communication. Students are evaluated on the basis of encounter-specific checklists by the standardized patients and observing physicians. The components are graded as pass/fail in three categories, and no written feedback is provided to students.

Debates about the usefulness of Step 2 CS fit into a larger conversation about medical licensure, and the balance between necessary regulation and that which might be wasteful or inefficient. Before the exam was implemented in 2004, groups like the American Medical Association took issue with the lack of validity for its effectiveness. The public, however, is time and again found to be in favor of additional physician licensure steps to protect patient safety.

Major sources of general oppositions to the Step 2 CS, and the basis of current student objections to it, are the inconvenience, the cost, and the lack of proven value. It is only administered at five sites nationally, costs $1275 (not accounting for travel costs), and results in an extrapolated cost of $1.13 million to identify a single student who fails the exam after a second attempt, a so-called double-failure. Its pass/fail grading also does not provide a basis for differentiation of examinees for residency programs, as other USMLE exams do.

In the past couple months, students from medical schools around the country have signed onto a petition advocating for the removal of Step 2 CS as a necessary step for medical licensure, in favor of evaluating clinical skills competencies through school-administered objective structured clinical examinations (OSCEs), which could be regularly reviewed and updated by a WWW.SFMS.ORG

body such as the Liaison Committee on Medical Education (LCME).

These OSCE exams, with standardized patients, are often already more rigorous than the Step 2 CS and are administered by the vast majority of US medical schools.

Going forward, it will be exciting to see the discussion that unfolds around not only Step 2 CS, but also around the role of medical licensure and whether it can go too far, into a land of decreasing marginal returns—a land where maybe these marginal returns may still prove valuable for patient safety, or, if they are found wasteful, Step 2 CS may be the next target of the search to eliminate waste in our ever-changing healthcare system.

Alexandra Rojek is a UCSF medical student and graduate of Harvard College.

Stanford University Seeks Cystic Fibrosis Patients Stanford University will begin enrolling adults ages 18 to 55 with a diagnosis of cystic fibrosis in a Phase 1 clinical trial starting in early July. The trial will evaluate PTI-428, an investigational oral treatment for cystic fibrosis with Fast Track designation from the FDA. Cystic fibrosis is a life-limiting, genetic disease that causes persistent lung infections and limits the ability to breathe over time. Clinical trials for cystic fibrosis are designed to add to medical knowledge related to the treatment, diagnosis, and prevention of the disease. This trial will be held at Stanford University. Area residents can get more information about participating in the trial by visiting ClinicalTrials.gov or contacting Courtney Watson at Courtney.Watson@proteostasis. com or 207-807-0211.

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As a company founded by doctors for doctors, we believe that doctors deserve more than a little gratitude for an outstanding career. That’s why we created the Tribute® Plan—to reward our members for their loyalty and commitment to superior patient care with a significant financial award at retirement. How significant?

The highest distribution to date is $138,599. This is just one example of our unwavering dedication to rewarding doctors.

Join your colleagues—become a member of The Doctors Company.

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For additional details, see www.thedoctors.com/tribute.

REWARDS

ADVOCACY REPORT Physician Leaders Converge on Capitol for CMA’s 42nd Annual Lobby Day

Over four hundred California Medical Association (CMA) member physicians, medical students and physician supporters gathered in Sacramento on April 13 to bring the voice of medicine to legislators. During CMA’s 42nd annual Legislative Advocacy Day, phy-

sicians discussed the many threats—and opportunities—facing the practice of medicine in California.

The group also headed over to the Capitol in white coats to speak to their legislators about critical legislative issues affecting the practice of medicine in California. Among the issues discussed with legislators were: expanded training opportunities for primary care physicians in California, responsible beverageservice training to reduce drunk driving, and out-of-network billing.

CMA President Steve Larson, MD, greeted attendees, saying, “You are the heart of medicine and here to talk from your hearts to legislators. Legislators will remember your face and remember the stories you tell about how bills will affect you and your patients.”

Assembly Republican Leader Chad Mayes addressed the attendees after lunch, telling them that he understood the scope of practice issues from personal experience. “When I was ten, my mother chose to not go to a doctor, but instead sought help for the birth of my brother from an alternative practitioner. We received a call after the birth to find out she was in the hospital with a uterine infection that almost killed her,” Mayes said. “I understand there is a reason you receive such extensive training. I understand you are the ones that should be giving care to patients. This is why it is so important that legislators hear your voice. If you do not lobby for your issues, someone else will lobby for something that could endanger the California (patient) population.”

With top Sacramento political consultant Jason Kinney moderating a panel of consultants for the Save Lives California Coalition, the group talked about the signature-gathering phase of the campaign. The initiative seeks to increase the state’s tobacco tax from its current $0.87 per pack—a rate that hasn’t been changed since 1998—to $2.87 per pack. That tax will also apply to other tobacco products containing nicotine. The ballot measure will save lives and reduce teen smoking, as well as generate revenue for many of the state’s underfunded health care programs.

CMA, as a member of Save Lives California coalition, is currently collecting signatures to qualify the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 for the November ballot.

Jim DeBoo, Save Lives California campaign manager, encouraged attendees to get involved in the signature gathering process. “Our goal is to get one hundred fifty thousand signatures from volunteers like you,” said campaign manager Jim DeBoo. “In this way, we get to meet voters where they are at and have WWW.SFMS.ORG

them listen to the CMA membership explain what the initiative would do.” DeBoo also led the successful “No on Proposition 46” campaign in 2014 that sent the trial lawyers’ anti-MICRA initiative to a resounding defeat.

In March, the state Legislature approved a package of groundbreaking tobacco control bills that would increase the legal smoking age from eighteen to twenty-one and regulate the manufacture and sale of electronic cigarettes for the first time.

Governor Jerry Brown is expected to sign the bills into law.

“These issues—smoking cessation and the lack of regulation of e-cigarettes—now have support with sixty percent of Californians,” DeBoo said. “We have a good chance to pass this initiative because of this support, the publicity surrounding the Legislature’s actions, and the potential for a large voter turnout for the presidential election.”

UCSF medical students and residents report:

“CMA and my local SF medical society have made lobbying to impact my patients’ health a breeze.”

“I’m proud to be a CMA member because it means advocating for important causes that affect my practice and my patients.”

“I’m proud to be part of the CMA and SF Medical Society because it gives me the opportunity to advocate for the patients that I serve and make sure their stories are heard.”

“CMA brings together colleagues for action on issues critical to us and our communities.”

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MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD, MBA

Dignity Health Saint Francis Memorial Hospital Innovative and Comprehensive Treatment Options for Bay Area Patients Orthopedics: Saint Francis recently performed the first hospital-based same-day hip replacement surgery in the Bay Area. Using the less-invasive anterior approach, Dr. Nicolas Mast, medical director of the Saint Francis Orthopedic Institute, performed the procedure from the front of the patient rather than the back as with traditional hip replacement surgery. The smaller incision can decrease complications and requires fewer restrictions after surgery. In addition to hip replacements, the Saint Francis Orthopedic Institute provides a continuum of orthopedic care for knee, shoulder, and spine and neck ailments—from orthopedic evaluation and surgery to acute rehabilitation and outpatient physical therapy.

Wound Care: The hospital also recently re-opened its Hyperbaric Oxygen Therapy (HBO) unit. The newly renovated space, conveniently located on the first floor of the hospital, has doubled the number of chambers and therefore the number of patients we can accommodate. Led by Dr. Patrick Costello— along with Dr. Jaime Bigelow, Dr. Paul Cianci, Dr. Joseph Mallon, and Dr. Andrew Wang—the unit’s team of hyperbaric specialists, nurses, and technicians provide advanced, noninvasive treatment for decompression sickness, gas gangrene, diabetic foot ulcers, radiation tissue injury, and chronic non-healing wounds.

Women’s Health: Dr. Anne Peled has joined the medical staff at Saint Francis, expanding the hospital’s breast health services.

Dr. Peled offers patients the ability to have immediate breast reconstruction surgery at the time of tumor resection. Dr. Peled received her undergraduate degree from Amherst College. She attended Harvard Medical School before completing her residency training in general surgery and plastic surgery at University of California, San Francisco (UCSF).

Dr. Peled continued her training at UCSF with a fellowship in breast surgical oncology and reconstructive microsurgery.

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St. Mary’s

Robert Weber, MD

The Spine Center at St. Mary’s Medical Center recently performed its one hundredth surgery using the Mazor Renaissance™ guidance system. This robot-assisted surgery treats patients suffering from debilitating back pain or limited range of motion caused by spinal deformities and degenerative conditions such as slipped vertebrae, scoliosis, kyphosis, and spinal nerve impingement.

This technology, which supports more accurate implant placement during lumbar and thoracic spine fusions, has proven especially beneficial for patients who require revision surgery due to previous failed spine surgeries.

Through the use of this system, patients experience fewer complications and revisions, as well as faster recovery time. St. Mary’s is the only hospital in the Bay Area to exclusively offer this state-of-the-art technology for spine surgery. Our Spine Center surgeons—James Zucherman, MD, director of the Spine Center; Jeral Glassman, DO; Masami Hattori, MD, MPH; Ken Hsu, MD; Dimitriy Kondrashov, MD; Judy Silverman, MD; and Quoc Vo, DO—also offer additional surgical treatment options such as X-Stop, I-Fuse®, artificial disc replacement, and motion preservation devices.

In other news, St. Mary’s received an “A” grade for hospital safety in the latest Hospital Safety Score from the Leapfrog Group, which rates how well hospitals protect patients from preventable medical errors, injuries, and infections. This is our third consecutive “A” grade from The Leapfrog Group—a testament to our dedicated staff who always put patient safety first. Thank you to Carl Bricca, DO, chair of our Quality Improvement Council; Russ Braun, MD, vice president of medical affairs; along with the department chairs and medical staff leadership who help make achievements like this possible. The Leapfrog Group is a national, nonprofit hospital safety watchdog. The Hospital Safety Score uses twenty-eight measures of publicly available hospital safety data to produce a single A, B, C, D, or F score, representing a hospital’s overall capacity to keep patients safe from preventable harm.

SPMF

Robert Osorio, MD, FACS

Our physicians and scientists are creating a new approach to treating cancer that is aimed at providing more personalized and effective treatments for patients. The Cancer Avatar Project was launched a year ago, and involves the skills and expertise of scientists and researchers at the California Pacific Medical Center (CPMC) Research Institute and our oncologists and surgeons.

Samples are obtained at the time of surgery or biopsy from the tumors of patients with melanoma and tumors of the breast, pancreas, colon, rectum, brain, lung, liver and ovary. Cells from the tumor are implanted into mice. Once they grow, tumor cells are harvested to create cell cultures for highthroughput drug testing, used to create more avatars, or stored for later studies. The mouse avatars, or tumors implanted in the mouse, allow researchers to test multiple drugs and drug combinations to find the one best suited to individual patients.

“The goal is to improve our understanding of the behavior of some of the most aggressive cancers, and then we can develop the most appropriate treatment for individual patients,” says Mohammed Kashani-Sabet, MD, a Sutter Pacific Medical Foundation physician and medical director for cancer programs at Sutter Health’s CPMC. Cancer treatment has improved in the last fifteen years, but treatments often benefit just a subset of patients. Project Avatar ensures a more dynamic picture of how tumors grow as DNA and RNA samples from the mouse and patient tumor are sequenced to determine the genetic mutations. “To take a quantum leap in cancer treatment, we need to take a broader view and look at the genetic underpinnings of tumors and the effect of different drugs in combination,” Dr. KashaniSabet explains. Sutter Health’s three million patients include a diverse cancer population, enhancing the project by allowing us to track outcomes from initial diagnosis to long-term follow up and improve care for patients in our communities.

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MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

To better serve our critically ill, injured, and most fragile patients, California Pacific Medical Center (CPMC) will soon introduce a dedicated fleet of air and ground ambulances co-branded with the Sutter Health name.

Launching in late June, the Sutter Health Critical Care Transportation Network will help us more quickly and efficiently transport patients needing higher levels of care. This new transport network replaces twenty-four separate ambulance contracts and will help prevent patient transportation delays. The Network will include a central transfer center with a single toll-free number—Sutter care teams needing to transfer a patient will call a central hub, which will coordinate requests with local transfer centers. Within two minutes of receiving a transfer request, the hub will dispatch the necessary air or ground ambulance.

A study by Dr. Mohammed Kashani-Sabet, California Pacific Medical Center Research Institute (CPMCRI) Senior Scientist, was one of the Journal of the National Cancer Institute’s top fifty highest-cited articles published in 2013. In the 2013 study, Dr. Kashani-Sabet and colleagues identified a new role for a gene associated with the development of melanoma, a deadly form of skin cancer. “The Role of miR-18b in MDM2-p53 Pathway Signaling and Melanoma Progression” study was the first to characterize the function of the microRNA-18b gene in controlling cancer cell growth, using melanoma as a model. The findings opened new avenues for drug development and identified novel approaches to distinguish benign versus malignant melanomas. For the first time in the U.S., a new technique being studied at CPMC will non-invasively image sentinel lymph nodes (SLN) in upwards of one hundred cancer patients receiving treatment at the hospital. The Sentinella camera is the first intraoperative device of its kind being used to identify SLNs that may be overlooked by traditional imaging techniques or in other cases where visual guidance to see SLNs was impossible. The Sentinella camera offers superior resolution and portability compared with older methods.

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Kaiser

Maria Ansari, MD

When patients receive a cancer diagnosis, it is our practice to provide them with quality multidisciplinary and comprehensive cancer care from the time they first arrive at our medical offices through survivorship.

The American College of Surgeons (ACS) Commission on Cancer (CoC) provides a framework through the establishment of strict standards that call on cancer programs to provide all patients with a full range of diagnostic, treatment, and supportive care services.

Program excellence is overseen by the Cancer Committee, whose membership includes physicians from the spectrum of cancer care delivery, as well as support from a multidisciplinary team including genetic counselors, physical therapists, social workers, and nurses.

Data is gathered through community assessments, and annually the Committee sets at least one programmatic goal and one clinical goal that align with those findings assuring that we are meeting the needs of our patient population. Ongoing quality improvement is closely monitored with the Cancer Registry providing up-to-date data and information on patient trends.

How does adherence to CoC standards benefit our patients? The patient is the center of all decision-making, and patient treatment plans are based on evidence-based guidelines.

We are also able to provide our patients access to cutting edge clinical trials. We provide patient-centric services, which include psychosocial distress screening and intervention, as well as options for genetic assessment and counseling. Additionally, palliative care services are provided for patients with advanced cancers.

Physical therapy and referrals to oncology-trained dieticians support our patients to maintain optimal physical conditioning as they receive their cancer treatment. When a patient’s active treatment concludes, they are transitioned to a survivorship care team where they are provided with a survivorship care plan.

They are given a comprehensive treatment summary that provides a blueprint for lifelong patient follow up.

SFVAMC

C. Diana Nicoll, MD, PhD, MPA

The San Francisco Veterans Affairs Health Care System provides comprehensive preventive, diagnostic, treatment, and supportive services for patients with malignancies. As a Commission on Cancer accredited Cancer Center, we receive referrals from Northern California and the western U.S. for difficult diagnostic cases including high risk neurosurgical tumors, as well as for administration of complex therapies such as hepatic chemoembolization and induction of acute leukemia.

Our five most common cancers are prostate, lung, liver, head and neck, and colorectal. Our interdisciplinary Tumor Board provides treatment recommendations for approximately two hundred patients annually and is enhanced with virtual attendance by radiation oncologists from the Hellen Diller Cancer Center at UCSF. SFVAHCS is a leader in promoting effective cancer screening. Our Radiology service pioneered the development of virtual colonoscopy; this has been complemented by our Geriatrics group’s substantial contributions to effectiveness analysis, identifying patient populations for whom the benefits of screening do not outweigh the risk. SFVAHCS is one of eight VA pilot sites performing screening CT scans for veterans at high risk for lung cancer. An interdisciplinary team from Radiology, Pulmonology, Medical Oncology, Radiation Oncology, Pathology and Thoracic Surgery has implemented a robust management forum to streamline the diagnosis and treatment of newly diagnosed patients. Preliminary results suggest a significant detection rate of early stage cancers and implementation of curative treatment strategies. We recently implemented an innovative, interprofessional, Oncology pre-clinic “daily huddle” to enhance care coordination and patient flow with Advance Practice and Infusion Nursing, Pharmacy, Palliative Care, Social Work, and Nutrition Services, in addition to treating physicians. As a team, we provide early supportive services for our vulnerable patients with advanced malignancies and psychosocial stressors. This approach has decreased the interruptions inherent in care coordination for our geographically dispersed population, improved our professional interactions, and increased patient satisfaction.

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UPCOMING EVENTS 5th Annual Asian Health Symposium August 26-27, 2016 | Laurel Heights Conference Center, 3333 California Street, San Francisco, CA | The 5th Annual Asian Health CME symposium will help bridge the knowledge and practice gaps in treating the many diseases and health issues that have significant impacts on the Asian community. The symposium will highlight specific areas for this unique community, including cancer, cardiovascular disease, integrative medicine, and infectious disease with special emphasis on the differences in Asian patients. For more information or to register online, visit cme.ucsf.edu.

SAVE THE DATE: SFMS General/All-Member Meeting

September 12, 2016, 6:00p.m. to 7:30 p.m. | Golden Gate Yacht Club | Calling all SFMS members – join us at our General Meeting on September 12, 2016. Members are welcome to stay for the board meeting immediately following the General Meeting. This is a good opportunity to meet with SFMS leadership and to learn firsthand the issues SFMS and CMA are advocating for on behalf of physicians and their patients in San Francisco and California. Details will be available soon at sfms.org and in the August issue of San Francisco Medicine. RSVP to Posi Lyon, plyon@sfms.org, (415) 561-0850 x260.

Building Healthy Communities Summit

September 16-18, 2016 | Marriott Hotel and Spa, 900 Newport Center Drive, Newport Beach, CA | The Network of Ethnic Physician Organizations (NEPO), a cornerstone program of the CMA Foundation consisting of over fifty ethnic physician organizations across California, is holding the 2016 Building Healthy Communities (BHC) Summit. The NEPO BHC Summit is a unique and exciting educational event for physicians, public health professionals, and community leaders. Featured speakers for the summit include: Dave Jones, California Insurance Commissioner; Rishi Manchanda MD, Founder of HealthBegins and author of The Upstream Doctor; Karen Smith MD, MPH, Director of the California Department of Public Health; and, George Halvorson, Chair of the First 5 Commission.

Earlybird registration ($199) ends on July 15th. https:// www.eventbrite.com/e/2016-building-healthy-communitiessummit-tickets-18979769000. In addition to keynote and breakout presentations, the Summit will also feature the presentation of the Ethnic Physician Leadership Award and the Frank E. Staggers, Sr. MD Outstanding Ethnic Physician Organization Award.

Nomination forms are due July 15th and are available at www. thecmafoundation.com/Get-Involved/Leadership-Awards.

There will also be an opportunity for medical students to present their research through the Medical Student Poster Presentations. The 2016 Call for Abstracts is open to prospective medical student presenters until July 31st.

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Classified Ads Cosmetic Surgery Practice for Sale - Fairfield, CA. Long established. Revenue $805,000 ($200k of revenue from Fillers and Botox, $100k of revenue from Obagi) Office Surgical Suite certified by AAAHC and IMQ. 2,000 sq ft with free parking. Photos available. Offered at only $205,000. Real estate also available for purchase. info@practiceconsultants.com.

800-576-6935. www.PracticeConsultants.com.

Sublet: SF Financial District Medical Office - 22 Battery St at Bush and Market. 2 exam rooms, 1 or 2 days a week. J Binstock, MD, (415) 956-8686.

Medical Office for Lease - 1000 South Eliseo Greenbrae; close to Marin General; large parking lot; 5 exam rooms; 1 consult room; 1 business office; waiting room/reception areas. ~1350 SF. $4.6/SF/month. Available 12/2016. Contact: may.tam@aasthma.com Phone: 415-751-6800.

Fall in Love with Practicing Medicine Again - For Sale: Well Established Medical Weight Loss Practice In Marin County.

Enjoy work-life balance and financial freedom. This all cash practice offers a flexible schedule and provides multiple income streams. In addition, this practice presents a significant growth opportunity. This is and will continue to be an active ongoing practice. The seller will enable a smooth transition. Email now drgail@marinweightloss.com.

Welcome New SFMS Members!

Joseph F Kerbleski, MD | Family Medicine Peter Charles Klatsky, MD | Reproductive Endocrinology/Infertility Donna Li, MD | Family Medicine Jennie Katharine Robin, MD | Emergency Medicine Dean David Schillinger, MD | Internal Medicine Genevieve Wong, MD | Family Medicine Brooke Rice | Student

SAN FRANCISCO MEDICINE JUNE/JULY 2016 WWW.SFMS.ORG

A financial safety net for you—

AND THE ONES YOU LOVE 10- AND 20-YEAR LEVEL TERM LIFE No matter where you are in life, SFMS Group Level Term Life Insurance benefits can be an affordable solution to help meet your family’s financial protection needs.

Mercer and SFMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the Voya® family of companies.

With quality life insurance benefits extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plans.

As a member, you can conveniently help protect your family’s financial future with the Group 10-Year and 20-Year Level Term Life Plan.

It features: • Benefits up to $1,000,000 • Rates that are designed to remain level for 10 or 20 full years* • Benefit amounts that never change during the level term period provided premiums are paid when due

See For Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plans, including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting www.CountyCMAMemberInsurance.com or by calling 800-842-3761.

Sponsored by:

Administered by:

Underwritten by: ReliaStar Life Insurance Company, a member of the Voya® family of companies 75553 (6/16) Copyright 2016 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Insurance License #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice.

The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

Find the best specialist for your patient with one call.

We make it easy to transfer and refer your patients to specialists at CPMC, part of the Sutter Health network. One call allows you to match your patients’ needs with the right specialist, notify admissions, get authorizations and more.

And we’re available 24/7, so you never have to wait to find the best possible care for your patients. It’s another way we plus you.

Referrals and Transfers 24/7 888-637-2762 cpmc.org