OncologyLive® is the flagship publication of OncLive®. Each issue delivers expert insights and clinical oncology news and updates, which impact the day-to-day clinical practice of oncology professionals who work tirelessly to help improve patient outcomes.

	In last month’s column, I talked about Microsoft’s newest desktop operating system, 

, and outlined several reasons why you might want to purchase it when it comes out this year. Windows 7 will include some really cool features—like multi-touch technology and usability improvements&mdash;that can benefit medical practitioners and their office staff. Because it is in Microsoft’s best interest to make the process of upgrading to Windows 7 simple and straightforward, you would think the software giant would put great effort into streamlining the experience. Unfortunately, it seems to me that Microsoft is hell-bent on driving its customers straight into the arms of its chief competitor, Apple, Inc. Microsoft engineers do this by making the software upgrade process excessively difficult for the average non-techie user.

	Even if you decide to purchase a new computer that comes with Windows 7 pre-installed, you’ll still have to select which version of Windows 7 to get. Once again, Microsoft makes this overly complicated by selling a multitude of editions. There are six flavors of Windows 7. One is for emerging-market countries, so unless you practice in Bulgaria or Uganda, that one is probably a bad choice. Another version is for people who work in large corporations, again a bad choice for most doctors. There is a stripped-down version called Starter that is available only on new machines. That version will likely be too minimal for the needs of most 

	Most tech-savvy physicians will choose either Windows 7 Home Premium, which has all the important Windows 7 features, or Professional, which adds special networking capabilities and the capacity to run some older, specialized programs. Windows 7 Professional enables you to connect remotely to a network using a system called “domain joining,” which I doubt would be used by many practices with fewer than 100 physicians. But the ability to run older programs is important for those of us who haven’t yet upgraded our legacy practice management software. One last version, called Windows 7 Ultimate, combines all the features of the other versions.

	There is one more complication. There are 32-bit and 64- bit editions of each of the three main consumer versions of Windows 7 (ie, Home Premium, Professional, and Ultimate). The 32-bit editions are for computers with standard 32-bit processors, typically found in most medical offices. The 32- bit versions cannot recognize more than three gigabytes of RAM memory, which should be more than enough for the average user. The 64-bit editions for PCs with souped-up 64-bit processors can use much more memory, making the machine run faster when multiple applications are open or when doing CPU-intensive tasks like hi-def video playback.

	For those who want to upgrade existing machines to Windows 7, there is good news and bad, depending on what operating system you use today. Vista users face a relatively easy, direct upgrade process that preserves personal files, settings, and programs, although there are some restrictions on which versions of Vista can be upgraded to which versions of Windows 7. For the most part, you can only directly upgrade comparable versions of Vista and Windows 7—Vista Home Premium to Windows 7 Home Premium, Vista Business to Windows 7 Professional, etc. There are exceptions, and you can go to Microsoft’s Website to learn more.

	For Windows XP users, the news is far worse. You will have to upgrade manually, which means that you have to reinstall and reconfigure all of your applications, settings, and personal files, assuming you kept and can fi nd the original discs, download files, and software keys. I recently read about a third-party utility from Laplink Software (

) that can handle the manual process of moving from Windows XP to Windows 7. A new version of its popular PCmover utility (

) will be able to perform automated, in-place upgrades to Windows 7 on an existing Windows XP machine and preserve existing programs. I have not used the software and cannot attest to its efficacy, but the fact that Microsoft consistently produces complicated and difficult-to-adopt software remains great news for those companies that build user-friendly utilities that are designed to remedy these headaches.

Dr Bertman is Physician Editor-in-Chief of MDNG: Primary Care/Cardiology Edition. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer Website focusing on personal medical topics. He is in private practice in Hope Valley, RI. 

Articles

In last month's column, I talked about Microsoft's newest desktop operating system, Windows 7, and outlined several reasons why you might want to purchase it when it comes out this year. Windows 7 will include some really cool features-like multi-touch technology and usability improvements-that can benefit medical practitioners and their office staff. Because it is in Microsoft's best interest to make the process of upgrading to Windows 7 simple and straightforward, you would think the software giant would put great effort into streamlining the experience.

Nothing Is Ever Simple with Windows

ONG: Can you describe the IsoFlow infusion catheter (its rationale, how it works, etc)?

 Vascular Designs has secured 510(k) marketing clearance by the US Food and Drug Administration (FDA) for its IsoFlowTM catheter device, which enables the direct delivery of medications in a highly targeted and concentrated fashion. The IsoFlow catheter enables sideways perfusion, which gives physicians the ability to push specified fluids both into side branch and angiogenicly formed vessels. With IsoFlow’s unique design, fluids can reach areas that previously could not be treated directly. IsoFlow is inserted with a guidewire and catheter for precise positioning within a patient’s body. Once in place, both of IsoFlow’s balloons are simultaneously inflated using radiopaque fluid via a single inflation lumen. Physician-specified fluid is introduced through the infusion lumen or the guidewire lumen via the one-way stopcock connection. The mixture of infusion and radiopaque agents is then delivered to the target region between the two balloons. For sideways infusion, the guidewire is retracted to allow blood to bypass the isolated target region via holes in the catheter’s exterior. Complete removal of the guidewire allows fluid delivery from the distal tip. Animation detailing this process can be found at 

ONG: What are the benefits of using the IsoFlow catheter? 

 As indicated by numerous studies, a direct delivery approach can help physicians increase drug concentrations at targeted sites, thereby reducing systemic exposure and side effects while improving efficacy patient outcomes. With the IsoFlow catheter’s unique design, fluids can be pushed into areas physicians were previously unable to treat directly. IsoFlow’s dual balloon catheter isolates a specific treatment region within the body from blood flow. It allows the infusion of fluids into the region and the perfusion of blood past the region to keep the blood flow intact during treatment.

ONG: Which cancers has the device been used for and what are its potential applications? 

 Potential applications include late-stage cancer treatment, pre-surgical treatment of cancer, direct treatment of disease, and stroke intervention. For example, one potential use is for the treatment of solid cancerous tumors with defi ned vasculature that have comprised a solid organ with vascular access. IsoFlow can provide an additional treatment option for patients who are not surgical candidates or who have already exhausted the treatment possibilities of radiofrequency ablation, chemoembolization, radiation, and systemic chemotherapy. Having recently secured 510(k) marketing clearance by the FDA, the IsoFlow device is in the early stages of introduction into the cancer treatment arsenal. To date, one T8 spinal tumor procedure has been performed by Dr Osama Zaidat at the Froedtert and Medical College of Wisconsin in Milwaukee. The IsoFlow catheter was successful in shrinking the T8 tumor, resulting in a dramatic reduction in pain for the patient as well as increased mobility.

 Robert Goldman, founder and CEO, developed the idea behind Vascular Designs and its innovative IsoFlow infusion catheter. After watching three close family members suffer from and eventually succumb to cancer, he set out to fi nd a new way to battle the disease and others like it. Motivated by a 2002 study, “Stop-flow Technique for the Loco-regional Delivery of Antiblastic Agents,”* Goldman embarked on a 7-year mission to advance the local delivery of cancer treatment. With help from collaborators at Stanford University and other institutions, he has led the development of the company’s breakthrough IsoFlow infusion catheter. 

ONG: How may oncologists have already adopted this device? 

 Vascular Designs is currently scheduling meetings with leading interventional radiologists and oncologists throughout the country. As more physicians are being introduced to the usefulness and potential applications of the IsoFlow catheter, multiple devices are either being tested or considered for immediate treatment use. Oncologists who want to request a meeting with Vascular Designs or wish to secure more information about the IsoFlow catheter can 

	* Pilati P, Mocellin S, Miotto D, et al. Stop-fl ow technique for loco-regional delivery of antiblastic agents: Literature review and personal experience. Eur J Surg Oncol. 2002;28(5):544-553. Abstract available at: 

Interview about the IsoFlow infusion catheter

Vascular Designs' IsoFlowTM Infusion Catheter: Enabling Regional Chemotherapy Delivery

	Melissa received a metastatic lung cancer diagnosis just a few weeks after celebrating her 40th birthday. Within hours of hearing her diagnosis from her primary care physician, she started searching the Internet about her disease and what to expect in terms of treatments. What she found was overwhelming. “I felt like it was a certain death sentence,” she confided, after reading many bleak statistics and horror stories about how unpleasant treatment would be. Her husband added, “it was scary, and when you go on the Internet, it gets even scarier: you can lose hope quickly.” Fortunately, within a couple of days, she was able to see an oncologist who could provide some perspective and hope, and she continues to do extremely well more than a year later and on maintenance chemotherapy. She participates regularly in online activities and actually blogs on her own Website as well as for a national lung cancer organization, though she finds that many cancer Websites don’t resonate with her particular needs. She is an e-patient, a term coined by Dr Tom Ferguson, who led the e-Patient Scholars Working Group funded by the Robert Wood Johnson Foundation, to represent the growing population of patients who are “equipped, enabled, empowered, and engaged in their health and health decisions” (

	Melissa’s experience of turning immediately to the Internet for answers reflects the emerging reality within the United States. According to the Pew Research Center, more than 61% of American adults now seek out healthcare information online, a percentage that has risen rapidly over the last decade. Oncologists discussing how practice has changed also readily corroborate these trends, noting that patients are coming armed with new questions and concerns, and often with a list of potential options they have compiled from scouring the Internet. Some oncologists consider this new vanguard of well-informed patients a favorable development, while others consider it yet another challenge in their practice of medicine as they are now expected to address an increasing number of questions and concerns generated from online communities. But as with nearly all complex social issues, the reality is that the e-patient movement engenders a gray area that will usher in neither a bright new age of medicine, nor its downfall. Although the benefit of this movement remains debatable, its growing impact is not.

	Oncology is a setting particularly well suited to this initiative. While there is little need for dedicated patient study of the innocuous Gilbert’s syndrome or many other relatively non-threatening conditions, the stakes are literally life and death with cancer, so patients have a great incentive to ensure that they are aware of a full range of treatment options and receiving the best care possible. Most other life-threatening medical conditions are emergent situations that require immediate medical care (most people wisely call 9-1-1 before doing an Internet search for “crushing chest pain AND shortness of breath”), whereas the clinical decisions made for cancer are generally less time-sensitive, offering a time frame during which patients can become informed participants rather than passive recipients of medical care.

	The e-patient movement provides some clear benefits for oncologists in particular and cancer care in general. One of the most important is support for patients and caregivers, ranging from emotional to practical. The 

 aggregates people directly affected by dozens of different common cancers and now coordinates over 150 different mailing lists that reach thousands of people each year. These participants share questions, discuss symptoms, and offer emotional support to each other. Many common cancers also have dedicated online discussion forums, such as the

 hosted by Lungevity, and the Breast Cancer Support community sponsored by the 

. Participants can gain a better understanding of why they are undergoing multiple staging studies and on the symptoms they should expect as they embark on a new treatment. Users provide hopeful stories of clinical successes and a sympathetic connection for people who need to vent their fears and frustrations about having cancer. For those who lack access to local support groups of people facing similar challenges, and even for many who do, the online connections people make to others around the country or world can provide deep and meaningful support.

	For those affected by uncommon cancers, online communities can provide a lifeline not only of support but critically important clinical information not available elsewhere, even from local oncologists. For example, someone with adenoid cystic carcinoma (ACC), a rare malignancy, is quite unlikely to find a local physician with significant knowledge of this entity, nor could this patient’s oncologist rely on the few pages of scant information provided on this cancer in a 3000-page general oncology tome or in the leading oncology journals since there is almost no published literature on the subject. The Adenoid Cystic Carcinoma Research 

, however, provides a list of specialists around the United States in various disciplines, all with a stated interest in ACC. In addition, dozens of people affected by ACC can share information through the Adenoid Cystic Carcinoma Organization about clinical trials and even promising anecdotal experiences, which are arguably of significant value in settings where so little published data exist. Indeed, as the saying goes, “in the land of the blind, the one-eyed man is king,” and oncologists may welcome aggregated online reports that summarize clinical experiences that may eclipse the meager information provided through more academic channels.

	At the same time, e-patients can often find excellent medical information to supplement what can be offered by their oncologist and medical team. With patients and caregivers often turning immediately to the Internet, even before their initial appointment with an oncologist, they can potentially get an early understanding of the prognosis and general treatment options for their particular cancer. They can also corroborate the information they receive locally, which can be especially helpful when their oncologist outlines a terminal prognosis and relatively limited treatment options. In addition, the reality is that oncologists cannot hope to remain completely updated on the latest information for every cancer, so a well-informed patient may well become aware of very timely research and new treatment options. For example, e-patients on lung cancer Websites are currently sharing information about the newly identified EML4-ALK mutation in non-small cell lung cancer, for which the investigational agent PF-02341066 has been reported to have a greater than 50% response rate and prolonged benefit (

 A6.4), though many oncologists are not aware yet of such recent developments. Dissemination of such information through inquiries from e-patients may well contribute to a faster transmission of emerging research findings within the professional medical oncologist community.

	Beyond providing potential options for patients to consider with their oncologists, the e-patient movement has facilitated clinical research, particularly in less common disease settings. A patient and caregiver group focused on gastrointestinal stromal tumors (GISTs), known as the 

, has centralized a collection of patients who are eager to hasten the pace of scientific research. The organization has published data based on these patients’ experiences with the side effects of imatinib, and has taken a proactive role in conducting patient-based research that it shares regularly with scientific leaders in the fi eld. As noted on the organization’s Website by Dr George Demetri, medical director of the Center for Sarcoma and Bone Oncology at the Dana Farber Cancer Institute in Boston, “The new research model pioneered by the Life Raft Group is making it possible for patients and family members to contribute to clinical research for their diseases in unprecedented ways.” Other groups are currently working to develop their own patient consortia who wish to volunteer for clinical trials and even provide their own tissue samples if it can accelerate the pace of research and improve understanding of their particular cancer. With the bottleneck that most clinical cancer research faces because of the limited patient enrollment into trials, leveraging the desire for ready-made patient consortia to cooperate in completing clinical trials provides a unique opportunity for harmaceutical companies, investigators, and patients to collaborate in the study of new treatments.

	Of course, as with any medium, there is a wide range in the quality of information presented on the Internet and accessed by e-patients. While content provided by oncologists and professional societies is typically vetted for accuracy, content on many sites open to the general public contain a combination of appropriate insights and links to other Web-based information along with recommendations from medically unqualified individuals and promises from individuals and organizations that may be providing false hope. Perusing discussion forums from the general public, topics range from questions about managing side effects to exhortations such as “don’t let your doctor say no” to various interventions of dubious medical value, such as radiofrequency ablation for multifocal metastatic disease and unproven predictive assays for chemosensitivity of tumors, some marketed aggressively to the general public. Patient testimonials about everything from laetrile to dichloroacetate, sometimes replete with links to Websites that facilitate opportunities to obtain these agents, offer the conviction that unproven or even potentially detrimental interventions can yield the “miracle” that the conventional oncology world is too circumspect to offer. Some vocal members of e-patient online communities betray their suspicion of the medical system in the prevalent discussions of a myth that the oncology and pharmaceutical industries collude to deprive cancer patients a secret cure because treating cancer is too profitable.

	There is also the danger of online information undermining the relationship between a patient and his or her oncologist. This may come in the form of an opinion about a different chemotherapy regimen described on a Website provided by medical professionals. Another patient in an online forum may describe their negative experience with that same treatment and recommend an alternative based on their anecdotal experience. Patients may read a recommendation about a different physician or institution from another member of the online patient community, along with the reasonable but arguably over-emphasized recommendation that patients obtain multiple opinions. Finally, a patient may discuss their symptoms and share their concerns more readily to a relatively anonymous online environment, even when this information may be important for their oncologist to know.

	The Internet is currently a leading source of healthcare information for patients, and its importance is likely to increase in coming years. Information will be provided from a range of sources, some highly credible and a potential benefit to the oncology world, and some far less credible and likely detrimental to both patients and oncologists. As oncologists, we may participate in and shape the educational opportunities, or we may stand on the sidelines and cede the content and tenor of the online information primarily to people with less understanding and sometimes questionable motives.

	Several years ago, I started a nonprofit organization called the Global Resource for Advancing Cancer Education (

) as a primarily online resource for patients with cancer as well as other oncologists. Starting with a core of content from within my leading clinical and research focus of lung cancer, I and several other lung cancer experts have provided discussion of what are widely considered to be the current best practices in various clinical settings, as well as presentation of and commentary on new clinical data coming out of journals and key oncology meetings. These brief summaries, written using blog software, and in a language accessible to the general public, include key figures and links to journal abstracts. The goal is to provide patients and caregivers with a thorough overview of potential risks and benefits of various approaches, in contrast with the media-driven sound bites that hype too many reports as a potential miracle breakthrough in an attempt to drive up viewership. These summaries can offer the same information provided in a detailed one-on-one discussion with a patient, but are now freely available to people around the world at any time.

	In an effort to provide valuable summary information in a range of formats, GRACE also offers brief podcasts that include general information about treatment approaches for various cancers in an audio-visual format that largely includes slide presentations with synchronized narration. These are available through the GRACE Website or through iTunes, YouTube, and other online media resources. Finally, there is an online question and answer forum, mediated by the GRACE faculty, which includes medical oncologists and other cancer specialists. This forum provides general information but not medical advice for particular cases, in keeping with the understanding that this content is meant to supplement the information provided by a patient’s own medical team.

	GRACE is only one of many credible sources of information provided and mediated directly by healthcare professionals. The argument in favor of providing these opportunities directly to patients is that the relationship between physicians and patients is now affected by sources outside of medical offices, and this trend will only become more pronounced in the future; this genie isn’t going back in the bottle. Physicians can be part of the Internet- based conversations or potentially cede their role as the primary educators on healthcare issues and be forced to react to healthcare information that is readily offered by dubious sources. 

Dr West is a medical oncologist and medical director of the Thoracic Oncology Program at the Swedish Cancer Institute in Seattle, Washington. He also serves as president of the nonprofit organization Global Resources for Advancing Cancer Education (GRACE).

Melissa received a metastatic lung cancer diagnosis just a few weeks after celebrating her 40th birthday. Within hours of hearing her diagnosis from her primary care physician, she started searching the Internet about her disease and what to expect in terms of treatments.

October 2009 | Oncology Live®

Nothing Is Ever Simple with Windows

Vascular Designs' IsoFlowTM Infusion Catheter: Enabling Regional Chemotherapy Delivery

E-patients: The Genie is Out of the Bottle