Wednesday, April 7, 2010

Book Review of “The Decision Tree”

“The Decision Tree” is an excellent book about personalized medicine that inspires readers to take a more active role in their health care. “The Decision Tree” is written by Thomas Goetz, who is a popular science writer and executive editor of Wired. He also has an MPH from UC Berkeley.

I’ve also found lots of videos with Thomas talking about personalized medicine (including a TED talk and a talk).  If you can’t get a hold of his book, I would recommend at least checking out some of these videos.

There is too much information in this book to relay in a single blog post. Therefore, I will only summarize the most interesting take-home messages. I’ll also provide a list of useful web-based tools that I learned about from this book.

Selected Take-Home Messages:

1) “Control over destiny” is important for your health - The Whitehall II study showed social status was strongest risk factor for heart disease. Even after adjusting for known risk factors for heart disease, people with low social status still had more than twice the risk of dying of heart disease. Thomas says that lack of control by itself can cause stress sufficient to lead to chronic illness. The need for people to take an active role in maintaining their health is emphasized throughout the book.

2) Tracking your own health statistics is valuable form of preventative medicine – Thomas discusses how self-medicating with constant number crunching can work like a self-imposed Hawthorne Effect. Some success stories include Weight Watchers and Nike+.

3) Development of a drug fact box can help patients decide which medications they wish to take – Similar to the nutrition facts label currently on food, this would allow individuals to quickly access the effectiveness and associated side-effects of a specific drug. I think this could significantly improve consumer knowledge about drug treatments, and I am glad to hear that FDA is considering a recommendation to require drug facts box on pharmaceutical labels.

4) Poor market incentives and CT scans– Although there was a relatively recent study that showed 85% of nodules discovered via CT scan were stage I lung cancer and 92% of the 375 patients with these tumors removed were still alive 10 years later, there has also been a follow-up study showed that mortality rate for those receiving CT scans does not significantly differ from those without CT scans because CT scans are primarily discovering slow growing, non-lethal tumors. This is especially important because the surgery associated with removing lung cancer has a 2-5 percent mortality rate by itself (so, you don’t want to undergo surgery unless it is really necessary). Thomas also discusses how CT scans are an anomaly in that they are a technology that does not follow Moore’s law, meaning that CT scans have actually become more expensive over time.  He attributes this market failure to lack of price transparency (can’t shop around and different companies in the same area may pay significantly different prices for CT scanners), ability to pass cost to patients and insurers (no incentives to avoid giving needless tests), and lack of automation (can’t run CT scan without trained radiologist). I think these examples all speak to the need to have a health care system that does not encourage needless testing and can correct at least some of these market failures that are driving up healthcare prices.

Health Care on the Web:

1) PatientsLikeMe – as mentioned in my previous post, PatientsLikeMe contains a database of information provided directly from patients and serves as a community for individuals to discuss symptoms and treatments associated with various diseases.

2) CureTogether – similar to PatientsLikeMe, but without "expert advice" to guide data analysis. Thomas describes advantages and disadvantages to this system.

3) Adjuvant! – also similar to PatientsLikeMe, but this is a database where physicians share information that cannot directly be accessed by patients. This database is specifically intended to help design combination treatments for cancer patients.  I think this could potentially be a useful model for assessing the effectiveness of diagnostics and treatments when more formal restrictions are required (such as FDA approval).

4) NIH Gene Test Website – provides a list of currently available genetic tests.

5) UT-San Antonio Prostate Risk Calculator - 75% of men over 80 have some form of prostate cancer, but less 5% of those will actually die from prostate cancer. Therefore, PSA test results should be weighed with other risk factors before deciding to follow an intensive treatment for prostate cancer.

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