Download If a Patient`s Cancer Is So Advanced, Who Decides Whether to

Workforce and Technology
Dr. Aron Rose, MD
By Susan Montgomery
10.1093/crival/vaw013
If a Patient’s Cancer Is So Advanced,
Who Decides Whether to
Provide Palliative Care or
Aggressively Treat It?
Aron Rose, MD, is an ophthalmologist specializing in
associate clinical professor at the Yale University Schools
cataract and glaucoma surgery. He has treated patients
of Medicine and Nursing, Dr. Rose also lectures regularly
and been invited to teach worldwide, including in China,
at the Yale Multidisciplinary Center for Bioethics.
Uzbekistan, India, Mongolia, Bhutan, Indonesia, Ghana,
Myanmar, Gambia, and Liberia, and is an expert on
He also chairs the Bioethics Steering Committee of
blindness prevention and treatment in the developing
the American Society for Clinical Pathology (ASCP)-led
world. The previous director of residency training and an
Partners for Cancer Diagnosis and Treatment in Africa,
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critical values | July 2016
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critical values | volume 9 | issue 3
a Clinton Global Initiative: Commitment to Action that
pathology and laboratory clinical multimedia, including
provides patients in underserved areas of Sub-Saharan
digital whole slide images. System workflow capabilities
Africa access to rapid cancer diagnostics and appropriate
are designed to allow pathologists to diagnose cases in
care and treatment.
real-time with multi-level security and audit tracking.
Annually, approximately 650,000 people develop can-
Dr. Rose recently took time for an interview with Critical
cer and about 510,000 cancer deaths occur in Africa
Values to talk about the initiative and the complex bioethi-
due to limited treatment and resources. More than
cal issues that the coalition is encountering.
one-third of cancer deaths in Africa are from cancers
that are easily preventable and/or treatable, if detected
Critical Values (CV): What are the key bioethical issues
early. This initiative brings together organizations with
to consider for this initiative?
the expertise necessary to diagnose cancer earlier and
Dr. Rose: The first issues we’re grappling with relate to
provide appropriate treatment, as well as establish a
informed consent for biopsies. These fall into two major
sustainable laboratory infrastructure to address these
categories: diagnostic pathology consents and consents
issues in the future.
for specimens that might also be used for future research.
There are cultural factors which are terribly important to
By leveraging leapfrog technology, and the skills and
consider here, as well as historical ones. For instance, in
experience of ASCP members, clinicians in Sub-­Saharan
some African cultures the concept of “self” is enriched by
Africa can have access to quality real-time diagnostics.
beliefs about ancestors and spirits inhabiting the body
This technology, which is already in use, provides sea-
that are completely absent in the West. Removal of por-
mless interaction, management, and secure access to
tions of the body may violate beliefs in the importance
July 2016 | critical values
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of dying fully “intact.” Specimens that might be used for
CV: Are there differing levels of awareness of bioethics
future research touch on issues of “ownership,” finan-
among healthcare providers in Sub-Saharan Africa? If
cial reward, inter-tribal dynamics, and, sadly, a history of
so, might this pose a challenge?
insensitivity to indigenous cultures for profit.
Dr. Rose: Oh yes. The level of awareness regarding
bedrock principles of bioethics ranges from great
CV: If there is a scarcity of medical resources, how do
sophistication to zero. But I might add that this is also
you determine which patient is eligible for certain kinds
the case in the industrialized world, to some extent. If
of treatment?
one [astutely] views medical communities as intellec-
Dr. Rose: This is a fascinating subject, and one central to
tual/social cultures, it’s readily apparent that attune-
bioethics even in the industrialized world where transplan-
ment and alignment to bioethical issues varies greatly
tation and other allocated services [mean that we] must
even in our country. As a physician practicing in the
constantly redefine issues surrounding “triage.” There will
States for almost three decades, I can assure you that
be a constant effort made to balance resource with need.
this is the case. Levels of interest in bioethics vary by
That equation changes based on demographics, access to
region and even by specialty. This is changing. Over the
screening and care, follow up, and even palliation.
past few decades, nearly every medical specialty society
has post­ed its own code of ethics, instituted its own
CV: Likewise, if a patient’s cancer is so far advanced,
boards of inquiry, and so forth.
how do you determine whether to provide palliative
care or attempt to aggressively treat the cancer?
CV: What have been the challenges to telepathology in
Dr. Rose: Once again, cultural factors are expected to play
the Sub-Saharan African healthcare setting?
a large role in this question. Palliative care is a new concept
Dr. Rose: Telepathology refers to implementing whole slide
in many parts of the world. Death outside of the home, or
imaging and cloud-based diagnostic systems. [Challenges
altered through medical intervention and/or drugs may be
include] addressing issues of in-country broadband
considered violations of a “natural” process. Local beliefs
capac­ity, considering power grid issues, and assessing the
vary greatly by community or tribe. Community resour-
need for generators.
ces, including traditional healers, will play roles we cannot anticipate. We’re hopeful that the services we offer
CV: How is the Partners coalition, with its expanding
will positively impact a very large population previously
network of resources, working to overcome these
unserved. But how it’s done is really the key. The most
challenges?
important attributes we can contribute to the process are
Dr. Rose: It’s a three-step process. The first is to establish
cultural humility and a willingness to offer services that
automated histopathology systems in high-population
lead with a humanitarian spirit.
centers. The location of these centers is extremely important because they must be accessible to clinicians and
CV: How does the coalition determine in which countries
their patients, as well as locally trained lab technicians,
to set up a site?
who must process and scan biopsy specimens from these
Dr. Rose: We are working closely with several govern-
sites. The next step is already in place and functioning
ments and ministers of health to determine with which
well: ASCP pathologists in the States are using cloud-
countries we initially partner, and the order in which to roll
based technology to view the processed sample(s), diag-
out our work. As you can imagine, there are many consid­
nose the patient, and upload their findings. Finally, local
erations that stretch from pre-existing infrastructure to
clinicians access the results within 24 to 72 hours and
ability to coordinate efforts. This requires stability, orga-
institute treatment protocols. I see the majority of our
nization, long-term commitment, imagination, and great
initiative’s work concentrating on expanding and improv­
vision. The framework and organizational structure con­
ing all aspects relating to screening, care, and treatment.
structed by ASCP Chief Executive Officer E. Blair Holladay
This really extends to medical training as well.
and ASCP are rock solid and fortified by enormous scope
and depth of expertise.
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critical values | July 2016
Ms. Montgomery is a Communications Writer for ASCP.