Clinical Advances in Hematology & Oncology

September 2019 - Volume 17, Issue 9

Letter From the Editor: Counting Stars

Daniel J. George, MD

While returning home on a transatlantic flight and stuck in a middle seat, sandwiched between a movie watcher and a sleeper, I pondered the fact that we as physicians try to quantify everything. I had just spent two days at an international Delphi conference discussing and voting on quality indicators for advanced prostate cancer care. Although the cause was undoubtedly noble and important, I couldn’t help but feel exasperated at being forced to choose between the practical and the essential. What was practical to measure usually felt less than essential, and what we all felt was essential to quality care was simply impractical to measure, much like trying to count the stars in the night sky. We can all recognize a beautiful starry night, but how exactly do we measure it? Which naturally leads to the existential question, Why measure it at all?

Trained as a scientist, I believe that by quantifying an activity we can improve it; at least that is how I justified devoting my time and effort to this cause. By attempting to quantify an activity as broad as patient care for advanced prostate cancer, we inevitably emphasize the aspects that we can measure, and marginalize the otherwise immeasurable components. The irony, of course, is that the immeasurable components are the ones that actually make a difference. I thought about my own experiences with patients, and what made for a quality visit. Was it the documentation of a balanced discussion on risks and benefits, prognosis, and goals of care? Was it timely treatments with proper education and supportive care? These are all undoubtedly important and quantifiable endpoints. But what I really felt made a quality visit was the connection between me and my patient and his caregiver—my validation of the patient’s symptoms, knowledge, concerns, and expectations, coupled with their trust in me that whatever the outcome of the disease course, I would be up to the task of caring for him. 

I admit that I am a hugger, and these visits usually end with some sort of an embrace. I guess we could quantify that. Seriously, these are the aspects of patient care that artificial intelligence will not address, at least not for a while. But even if these actions are not easily quantified, they can be learned. And that is the point. Quantifying quality care should not be punitive but instructive. Likewise, the soft skills of quality care should be valued and taught. In the coming weeks, we will complete our exercise and publish our consensus quality care indicators for advanced prostate cancer. However, what we describe will undoubtedly be an incomplete picture of excellent care. How we use these measures and recognize the aspects left unmeasured may ultimately determine just how effective we are with our care. 

In the spirit of providing the highest-quality care for our patients, we kick off the issue with an interview with Dr Ruben Mesa of MD Anderson Cancer Center, who discusses the best way to manage polycythemia vera and myelofibrosis—which means achieving the best treatment outcome with the least toxicity. Next is Dr Yi-Bin Chen of Harvard Medical School, who addresses new treatment options for the management of acute graft-versus-host disease. This is important information for anyone whose patients require allogeneic hematopoietic transplant. Dr Hope Rugo of UCSF Helen Diller Family Comprehensive Cancer Center details the status of phosphoinositide 3-kinase inhibition in the treatment of hormone receptor–positive breast cancer (future issues will address the use of cyclin-dependent kinase 4/6 inhibitors in hormone receptor–positive breast cancer, and the best approach to early-stage hormone receptor–positive breast cancer). Dr Jason Luke of UPMC Hillman Cancer Center describes the newest treatments for uveal melanoma, where no standard systemic treatment has been established. 

The issue also contains three excellent review articles. First is “The Role of JAK Inhibitors in Multiple Myeloma” by Matthew Ghermezi and Drs Tanya Spektor and James Berenson of Oncotherapeutics. Second is “Measurement of Circulating Tumor DNA to Guide Management of Patients with Lymphoma” by Drs Deepika Sriram, Rahul Lakhotia, and Timothy Fenske of the Medical College of Wisconsin and the National Cancer Institute. Third is “Stereotactic Body Radiation Therapy and Immunotherapy” by Drs Mustapha Khalife, Kamran Shahid, Raetasha Dabney, and Alexandria Phan at the University of Texas Health Science Center at Tyler.

Clinical Advances in Hematology & Oncology has always focused on clinical care, and this issue is no exception. But let us remember that no matter how great our knowledge, excellent care requires a human connection. As Antoine de Saint-Exupéry wrote in The Little Prince, “What is essential is invisible to the eye.”


Daniel J. George, MD