Awareness of chronic disease technologies and remote monitoring among not only the medical community but the general population has continued to increase dramatically, as evidenced by the recent New York Times article about implantable defibrillators ability to remotely track heart failure patients. News coverage of these devices, which are poised to significantly improve quality of life for the 6 million people in the U.S. who suffer from HF, emphasizes the shift toward patient- and consumer-focused care and highlight's the public's increasing involvement in self-managing their health to a greater extent. In the Pipeline, we've covered numerous different developments in remote monitoring, which can all be found here.
For more information about remote monitoring, continue reading after the jump, or contact me at WynnP@advisory.com to discuss how Tech Insights is tracking these devices and their effect on EP and HF strategy.
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In his final post following the WCIO conference, my colleague Zach Binney discusses the relative roles of open, laparoscopic, and percutaneous approaches to tumor ablation:
Driven by broader trend toward minimally invasive surgery, percutaneous approaches growing in prominence across the ablation realm
Tumor ablation procedures -- including radiofrequency ablation (RFA), cryoablation, microwave ablation (MWA), and irreversible electroporation (IRE) -- may be performed via open surgical, laparoscopic, or percutaneous approaches. The specific approach used often depends on the type of physician performing the procedure: surgeons tend to prefer open and laparoscopic techniques given their expertise and training, while interventional radiologists (IRs) gravitate toward laparoscopic and percutaneous ablations.
In the past, a significant proportion of ablations were performed as inpatient surgical procedures. However, the approach's value proposition for patients and physicians alike -- namely, a less invasive manner for tumor destruction with fewer complications than surgery -- has led the field to shift heavily toward laparoscopic and especially percutaneous procedures in recent years.
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To continue with the previous posts following the WCIO conference, Zach Binney has weighed in below to discuss the strategies for building an effective interventional oncology (IO) program:
Building an interventional oncology program requires broad interdisciplinary cooperation
Many conversations at the conference revolved around how to best structure an interventional oncology program. Most IO procedures are shared by interventional radiologists and surgeons. In the ablation space, in particular, most open surgical procedures are handled by surgeons, while percutaneous procedures remain primarily the domain of interventional radiologists. Laparoscopic procedures may be done by either group.
Cooperation with other specialists is also critical to driving the creation and growth of an IO program. Medical oncologists coordinate the treatment of many cancer patients, and as such they -- along with surgeons -- serve as "gatekeepers" to the interventional radiologists, who report typically seeing patients only after a surgical consultation. To drive volumes, radiologists stress, both surgeons and medical oncologists must be willing to refer patients for consults with interventional radiologists.
The increasing prominence of multi-disciplinary tumor boards will likely help drive the integration necessary to strengthen IO as, potentially, a fourth leg of the chemo-surgery-radiation cancer care stool. However, this is contingent on interventional radiologists being willing to attend and actively participate in multi-disciplinary care conferences, physicians noted.
Even absent broad-based cooperative initiatives, however, programs can flourish on personal relationships. Dr. James Urbanic, a radiation oncologist at Wake Forest University Baptist Medical Center (WFUBMC), presented on how he and a radiologist colleague have collaborated on a number of cases requiring an IO and RT perspective. They regularly discuss whether RFA or radiation makes the most sense for any given patient based on the tumor's location, patient's treatment history, and other factors. They have even split patients in the past: one female patient with two lung tumors received SBRT for one and had the other ablated.
Dr. Urbanic described ideas for several clinical trials with his colleague and other physicians across WFUBMC, which he hopes will be vehicles for further collaboration.
For the third post of the series following the World Conference on Interventional Oncology, my colleague Zach Binney has provided a synopsis of the discussions and debates surrounding the relative roles of the wide array of interventional oncology (IO) therapies:
Physician preference likely to dominate modality choice for foreseeable future
One of the dominant themes of the conference was how to sort out for which patients each modality in the increasingly-crowded interventional oncology landscape is appropriate. Under the specter of healthcare reform and a broad comparative effectiveness research (CER) push, several presenters mused about the possibility of randomized controlled trials (RCTs) to help sort out the roles of individual therapies.
However, the consensus appeared to be that while in an ideal world each modality would be subjected to a rigorous series of RCTs, in reality this is not likely to happen due to a combination of factors. One is the relatively low incidence of liver cancer -- a primary site for many of these therapies -- in relation to the number of modalities that need to be tested. Combined with a general unwillingness on the part of these patients and their physicians -- the vast majority are under the auspices of medical oncologists and surgeons, not interventional radiologists -- to participate in such trials, the prospect of large-scale RCTs to sort out the issue remains weak.
Realistically, administrators should expect interventional oncology to continue to be driven by individual physician preferences for specific treatment modalities.
Many physicians at the conference expressed a strong degree of comfort with more clinically tenured modalities, such as RFA and cryoablation. In the ablation space, clinicians generally indicated an interest in continuing to use RFA for cases where it is known to be highly effective, particularly liver and lung lesions < 3 cm in diameter. Microwave ablation and other emerging modalities, meanwhile, may have a larger role to play in areas where RFA or other incumbent modalities fall short, such as larger tumors and those near blood vessels that siphon heat away before tumor cells can be killed.
My colleague Zachary Binney attended the World Conference on Interventional Oncology (WCIO) meeting last week in Philadelphia. Over the course of this week, he will be contributing a series of posts to summarize the major developments at and themes of WCIO 2010. The second post, focusing on irreversible electroporation, follows below:
Irreversible electroporation (IRE) draws some clinical interest, but remains largely relegated to research realm
IRE was also on display at WCIO 2010, with Angiodynamics promoting the NanoKnife, a new non-thermal method for tumor ablation. To perform IRE, an interventional radiologist places a single or bi-polar needle in the tumor. The needle is connected to a generator and is used to transmit a series of high-voltage, microsecond electrical bursts into the tumor cell, opening microscopic pores and ultimately causing the cancerous cells to die from damage to the cellular membrane.
However, IRE poses a couple of unique problems, as well. The high voltage applied to tissue requires administering a paralytic agent to avoid muscle spasms in addition to general anesthesia. Physicians performing IRE indicate this adds an incremental burden on the anesthesiologist; establishing standardized protocols for IRE anesthesia is critical to the smooth functioning of a program.
Additionally, early experience in the thoracic area revealed the potential for IRE to spark cardiac arrhythmias. This remains a serious issue that may restrict the modality's use in some tumor sites, though one physician described a method for gating IRE with an echocardiogram (EKG) that has allowed him to avoid the arrhythmia problem.
While a handful of physicians have begun using the NanoKnife in a clinical setting, most work with IRE remains in the research realm. Clinical work to date has been done in prostate, kidney, and primary and metastatic liver cancer, but most clinicians do not anticipate the technology will significantly impact care in the near term. IRE's non-thermal method of cell destruction, however, makes it a potentially disruptive consideration in the mid- and long-term, however, pending the release of further clinical data.
Check back tomorrow for more information on the relative roles of interventional treatment modalities.
Planning for a new MRI scanner can be a dauting task. For a system that will last at least 10 years and require millions of limited capital dollars over its life span, it is critical for hospitals to consider all MRI scanner configurations and options to safeguard against near-sighted - or inappropriate - technology decisions. A new MRI scanner serves as both a revenue generator for lucrative outpatient exams, and also an ancillary modality that supports the overall growth of hospital services. Accordingly, the capital planning process for a new MRI scanner must weigh not just costs and profitability of the system as a standalone modality, but also the near- and long-term strategies for the organization.
For the vast majority of diagnostic applications, 1.5T MRI represents the accepted clinical standard of care, and will continue to do so for the foreseeable future. It serves as the workhorse scanner for the hospitals and imaging centers, and institutions that utilize systems of less than 1.5 magnet strength will require replacement in the near future to remain competitive and provide high-quality imaging capabilities. But does that mean a hospital should invest in a 1.5T scanner? Historically, the answer has simply been, "Yes, you must acquire a 1.5T scanner to improve patient care, operations, and ability to compete in the market."
However, this more unilateral response has been complicated by the emergence of high-field MRI variants, namely, 1.5T wide-bore systems and 3T MRI (also in the wide-bore configuration). For the latter, the cost-prohibitive nature of 3T scanners and clinical benefits relegated to the advanced brain and neuroimaging space only have limited adoption to date. In this time, 1.5T wide-bore systems have gained considerable acceptance in the medical community owing to the immediate operational and marketing benefits afforded by these sytems, in that they serve a present patient need by making MRI a more "friendly" procedure for patients who are obese or experience anxiety during MR imaging.
But now, the tides are beginning to turn for 3T MRI.
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My colleague Zachary Binney attended the World Conference on Interventional Oncology (WCIO) meeting last week in Philadelphia. Over the next four days, he will be contributing a series of posts to summarize the major themes of WCIO 2010. The first post, focusing on microwave ablation, follows below:
Radiofrequency ablation (RFA) and cryoablation continued to dominate the speaker's podium and poster boards at WCIO 2010, but several other modalities - particularly RFA's cousin in heat-based tumor destruction, microwave ablation (MWA) - are encroaching on the interventional oncology (IO) terrain.
WCIO Graphic: Abstracts and Posters by Topic
Micro-wave of the future?
At WCIO 2010, the exhibitor floor was dominated by what might become the thermal ablation modality of the future: microwaves.
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On June 17th, a Silver Spring, Maryland-based Food and Drug Administration (FDA) panel will convene to consider approval of ulipristal acetate. The drug--sold in 21 European countries as ellaOne®?is an emergency contraceptive which prevents pregnancy after intercourse by delaying ovulation.
Recent studies, including a trial published in the February 2010 issue of The Lancet, suggest that ulipristal acetate is more effective at preventing pregnancy than levonorgestrel--also known as Plan B--the only emergency contraceptive approved in the US. Further, while levonorgestrel is effective up to 72 hours after intercourse, studies show ellaOne® to prevent pregnancy up to 120 hours after intercourse. Upon approval, ulipristal acetate would be accessible only by prescription, unlike Plan B, which is available over-the-counter for women over the age of 17.
The drug is also currently being tested as a treatment for uterine fibroids, benign tumors that grow within or just outside the uterine wall and affect up to 77 percent of women of childbearing age.
Read the USA Today article here.
View the Washington, DC-based Reproductive Health Technologies Project (RHTP) ulipristal acetate fact sheet here.