On Chemotherapy

My friend had breast cancer twenty years ago. After surgery and radiation, she has been in remission and free of health complaints. Now that she is almost 80 years old, another lump was found in the same breast. She has access to excellent medical care, and she was given the following advice:

While the lump was small, she should have a mastectomy, just in case. As she was not eligible for another round of radiation therapy, it was recommended that she go through chemotherapy, because physiologically, she was deemed to be perhaps ten years younger than her actual age.

This is typical advice to elderly adults who are in good physical shape. It is based on the assumption that adding years to your life trumps every other consideration, provided you are in good health otherwise.

At age 80, how long does the average person have to live? Two years, five years, ten years tops? With all advances in medicine, we have not managed to extend life much beyond that. We are getting more and more people to reach their eighties, but we are not living significantly longer than that.

My friend was struggling with the advice she was given, and what was presented to her as the best medical solution. She did not want to lose her breast, and she did not want to put up with the side effects of chemotherapy. So she tried hard to find second and third opinions to support the view that it was not absolutely necessary to conduct a mastectomy and chemotherapy, and that she was not carelessly jeopardizing her chances of survival by refusing these options.

As we spoke about the different considerations that come into play in these decisions, she kept saying “I will get chemotherapy if I have to, but I’d rather not”. To me, this indicated an obligation that she felt to justify her choices to her friends and family, and perhaps to her medical advisors. Nobody wants to be seen as reckless with regard to one’s own health.

However, isn’t that bizarre and plain wrong? A person’s life is a person’s life, and having a lump in your breast is just one of many things you will consider and care about. So a woman who has carried two breasts through her entire life wants her life to end with both of them in place. So a woman who may have five, six or seven more years to live, probably deteriorating progressively as she ages, does not want to ruin her sense of well-being right now with an aggressive therapy regimen. So what?

Why is she made to feel guilty or irresponsible? Why does she need to justify her course of action?

It is understandable that friends and family of a person in this situation may advocate the more aggressive therapy, as they may fear losing this person. Fair enough.

However, it is my view that medical professionals should state very clearly that the choice is entirely up to the patient, that every choice has its trade-offs and that an informed choice, whatever it is, represents a responsible and acceptable way of managing one’s health. To have this sort of back-up from the medical community would make dealing with a difficult situation easier for the patient.

The Role of Motivation in Patient Engagement

As Dave Chase @chasedave recently stated The most important medical instrument is communication, and Patient Engagement is the Blockbuster ‘drug’ of the century. The idea is that by engaging patients to become more proactively involved in the management of their own health, better outcomes can be achieved, and generally at a lower cost to the healthcare system (compared to expensive tests, procedures and medicines).

New technologies make it easier to engage patients – for example via online portals, health apps, personal electronic health records, portable monitoring devices or a clever combination of these tools within a new care model. Clearly, when the generation of texting, tweeting, vining, instagraming twenty-year olds turns fifty and start their decent into chronic illness, resistance to digital, mobile, sharable health tracking and communications technology will no longer be an issue.

Remains the issue of motivation. The people who continue to supersize their burgers and fries, do they lack awareness of the health impacts of excess weight? The schizophrenic who skips her pill because it makes her head feel fuzzy, has she not been educated on the dangers of messing with her medication regimen? Will improved communication with a healthcare provider convince my uncle to stop smoking?

Yes, there are those who suffer from inertia, who are uncertain about the right way forward or who find it hard to fit taking care of themselves into their busy days. These patients will find it helpful to be supplied with tools and supportive healthcare providers who make it easier for them to look after their own health. These patients are the low-hanging fruit for the new care models.

And then there are other people. People who will not download the app. Who will not sign up for the e-newsletter. Who do not want to be called by their pharmacy to remind them to refill their prescription. Some people will continue to do dangerous, unhealthy things because they want to. It makes them feel good, at least momentarily. Some do not want to face the realities of getting older, of their failing bodies, loss of beauty and loss of agility. Some are comfortable with the thought that this is all inevitable, and do not feel inclined to take action. Some are looking to their doctor for the quick fix, just make it go away, I don’t want to bother with it.

PtEngageUSED

Motivating people is a tricky business and tech tools are only going to do part of the work. What motivates patients to take care of themselves? Pain? The desire to live longer? A feeling of obligation? Because your mom told you to? Peer pressure? Because it is cool? Fun? Because it makes you look better?

Also, doesn’t motivation change over the course of one’s life? What motivates a twenty-five year old to track his weight loss with a health app and what motivates a seventy-year old to continue his androgen deprivation therapy would likely be very different things. Capturing the Show Me The Way segment of patients with new patient engagement tools will be easy and rewarding. Addressing the Maybe Later and the No Way segments will be much tougher, and cracking the motivation nut will be essential to make it work.

The difference between recharging and goofing off

Taking breaks from your regular activity supposedly enhances your ability to concentrate. Consequently, the clever employer should encourage those who spend their day in front of the computer screen to interrupt their activity from time to time to relax and recharge.

I have a small beach ball in my office, a promotional item left over from some conference. What if I’d throw it up into the air? Today I tried it out: very relaxing – beats walking to the washroom or getting another cup of coffee. But I felt odd.  What would my co-workers think about me? Sure looks like I’m goofing off.

In an office environment, some forms of de-stressing are more accepted that others. Getting coffee is the top accepted de-stresser, I would say. Smoking also features high on the list – need a break, have a smoke. Going for a walk – good, but may take too long in the eyes of the boss.

Many also deal with stress by talking to their fellow employees. Probably better for your health than smoking, but can cause significant disruption of the workflow, particularly if many employees go through a stressful time at once.

Spending five minutes with a beach ball (or a skipping rope? or a mini-putt?) seems like a worthwhile alternative that should be an acceptable form of recharging – and easier to monitor than other common forms of in-office relaxation, such as constantly checking your Twitter feed or Facebook updates. Then, I think, you are basically just goofing off…

Innovation, the new normal?

Companies in many sectors are facing rapid change. Following Clayton Christensen’s terminology, established businesses are being disrupted by new technology, and new business models are developed around these technologies.

Whether it is 3D printing of medical implants, crowd sourcing of clinical trial data analysis, software that supports pre-clinical studies and identifies the most promising drug candidates, ‘big data’ capturing patients’ genomic profile or personalized health records that patients can carry from physician to physician, fundamental transformations are afoot in the healthcare industry.

Consultants to the healthcare sector struggle to stay on top of all the different angles that are emerging. How much reading can you do in a day? Should you rather update your skills in data mining (i.e. working with ‘big data’) or become an expert in social media platforms and the many ways they are being used by patients and physicians or study government initiatives to incorporate new technologies in reorganizing the way healthcare is delivered to the patient?

The state of confusion is pretty typical for market changes. Initially, there is a whirlwind of new ideas and approaches. Are electric cars going to be the way of the future or ceramic fuel cells? Or will biking emerge as ‘disruptive technology’ in a reorganized urban neighbourhood? Will patients carry their own health records around on a USB stick or will they become universally accessible through a (password protected) cloud? Will pharmaceutical companies find ways to make drug development cheaper or will fewer drugs be approved or will best supportive care with the bells and whistles of comfortable retirement living ‘disrupt’ the oncology pipeline? Will iOS, android or Windows 8 emerge as the dominant ecosystem for computer / tablet / phone or do we need to learn all three to know what works how in which environment? Etc, etc.

Should we wait until the dust settles before we decide how to focus our efforts?

I am not sure that the dust will ever settle. The pace of change is accelerating, with no sign of stopping or settling down. Then where should we pitch our tent? What should we hold on to? I believe that companies and individuals will succeed who develop mechanisms, routines, practices that allow them to deal with change. Not just once, but on an ongoing basis. Those who effectively survey what is going on in the whirlwind, who systematically capture their own ideas on how to ride the storm and who devise an easy process that allows them to test, develop and implement these ideas will have a chance.

Is big data transforming healthcare marketing research?

Yesterday (June 27, 2013), SAS and GSK announced a collaboration which puts clinical trial data ‘in the cloud’ in a secure way, respecting the privacy of trial subjects, and makes it accessible to other researchers. It is believed that other big pharma companies may follow suit and create an unprecedented shared data base that could potentially speed up the analysis process, make analysis more transparent and produce significant advances in medical discovery.

While this particular example of ‘big data’ pertains to clinical trials, many other big data sets exist (or are being created) in the healthcare space, awaiting data integration and analysis. One wonders to what extent this trend will impact the need for primary healthcare marketing research. Secondary data analysis is not new – it has been part of business intelligence for a long time. What’s new is the amount of data that is being collected, the multitude of platforms and interfaces through which it is collected and the ease with which the data can be accessed and analyzed.

Traditionally, primary marketing research has been faster than secondary data sources at delivering behavioural data such as prescribing of certain drugs. This is now changing. Mobile health apps, EMR, data warehouses for adverse event reporting, point-of sales data at the pharmacy level and many more points of data collection are becoming more readily accessible. Secondary data is going ‘real time’, well almost. On the other hand, primary data collection methods can also harness the power of ‘real time’, thinking of mobile surveys etc. Who will come out on top, or rather, which mix of primary and secondary sources will deliver the best insights?

Also, primary marketing research has been practically the only way to capture attitudes and beliefs and to explore how they relate to behaviour. Arguably, communicating with your target audience is still the best way to understand their motivations. However, social listening, drawing on tens of thousands of online conversations and powerful tools for text analysis, has made some inroads into this area as well. In addition, to what extent do stated opinions really drive behaviour, and how good is primary market research, even with creative methods and advanced analytics, at uncovering these drivers?

Big data is certainly transforming the primary marketing research industry, in healthcare as well as in other sectors. The question remains which solutions will bring the most value to clients and will become the new standard for companies who survive the transformation.

Banking on our fear of death

Pharmaceutical companies have reoriented their businesses over the past several years to focus on discovery of molecules that target narrow markets, usually in oncology or in rare, but serious diseases. It is well known that revenues for ‘mass market’ products for diseases that are highly prevalent and not immediately life-threatening have been declining and few truly breakthrough discoveries have been made to replace revenue drivers that have become generic.

But why the rush into oncology and other small-but-serious markets? I believe that this has to do largely with our attitude towards death. Inevitably, we will all die of something. Before the advent of penicillin, people died of infections. As medical care has improved dramatically in the past 100 years, at least in some parts of the world, we live longer and are more likely to experience diseases which are basically a function of our body breaking down i.e. cancer.

Oncology drugs present an attempt to prevent the inevitable. In some tumour types, enormous advances have been made – breast cancer, for example, can now be regarded more as a chronic disease than as a terminal illness. For many other tumour types, however, scientific progress has been underwhelming. New agents are being trialed and approved that offer three or four more months of progression-free survival or a few months of overall survival vs. the incumbent standard of care. …and regulatory bodies such as the FDA find it difficult to turn those agents down, because they allow patients to live longer. Enormous costs to the healthcare system are perceived as justified, because they allow patients to live longer.

How much value do four extra months have when you are very sick and 80 years old? I don’t know, as I have not yet been in this situation. Who drives decisions to try another therapy, complete with side effects, at that point? Is it the physician, feeling compelled to offer a treatment when one is available? Is it the patient, clinging to life? Or is it the patient’s family, not wanting to let go?

One thing seems certain – no politician in his or her right mind will advocate spending healthcare dollars elsewhere, when there is time to be gained in the battle with death. Can you imagine the headlines? But the societal discourse may be shifting, looking at more humane ways of dealing with end-of-life, and re-evaluating our overall priorities in what kind of healthcare is being offered and funded.

Personalized, patient-centric medicine

Much has been published lately about personalized medicine. The other, similar buzzword is patient-centric.

It seems to me that in these terms, consultants and trend-spotters mesh together two very different ideas, each with associated with different strategic implications.

Personalized medicine in the sense of using biomarkers and genetic information to target therapies more specifically to patients who are more likely to respond to them is an approach that many pharmaceutical companies are embracing.

However, in this context the patient as a person has very little relevance for the R&D process and the commercialization of new products. What he or she feels, thinks, believes or does is unrelated to the peculiar genetic mutation that makes him or her a good candidate for a specific drug.

The second trend, namely focusing on the patient as a person, does not usually play a role in drug discovery. Pharmaceutical companies commonly find themselves in the situation that their compound is the third or fourth me-too agent to market with little incremental benefit. Identifying and targeting a specific patient with distinctive attitudes, behaviours and needs can be a successful marketing strategy in an undifferentiated market.

And while some companies may strive to bring both approaches closer together – understanding the patient as a person and developing new molecules that meet the patient’s specific needs – this is far more difficult to achieve in pharmaceutical product development than in the area of consumer goods.

Psychological benefits of exercising

Getting more exercise has undisputed health benefits. It is what many of us need. Experts also say that it makes you feel better. Why don’t more people get into the habit then?

In my experience, exercise does have a positive effect on mood – but not immediately. While exercising, anxiety, stress and frustration are felt even more acutely. That’s why, in my opinion, many people stay away from exercise. We don’t want to be brought face-to-face with unpleasant feelings.

However, to reap the benefits of a more relaxed mind, that’s exactly what we need to do. No pain, no gain. Good luck with the struggle!