AI IN HEALTHCARE: A SKEPTICAL OUTLOOK

RADIOLOGISTS PRONE TO MISTAKES BECAUSE OF AI

BY SIMON SPICHAK

Brain CT scan.
Photo source: Freepik; author: DC Studio

AI was supposed to help radiologists screen for cancer more accurately. Instead AI is making them doubt their own expertise and inadvertently harming their patients.

Imagine you’re screened for cancer at a state-of-the-art institute
using the latest and most powerful imaging techniques. You’ve read about the clinic online, rather than just getting a radiologists’ opinion, the diagnosis is made all the more certain as with the help of artificial intelligence (AI). Even though the radiologist doesn’t pick up anything strange on the scan, the AI alerts them of a suspicious-looking part of the scan — convincing the radiologist to order further testing. You might feel relieved that the AI was able to spot something the radiologist couldn’t - but then it turns out the AI is wrong.

Research recently published in
the Radiological Society of North America’s peer-reviewed scientific journal Radiology suggests that relying on AI to help make these clinical decisions sways radiologists across different levels of expertise toward making the wrong call, leading toward expensive and unnecessary testing.

Worse at assessing mammograms

The study was conducted by
a group of researchers and radiologists in Germany and the Netherlands, co-led by Thomas Dratsch and Xue Chen.

The researchers presented 27 radiologists with 50 mammograms, using the Breast Imaging Reporting and Data System (BI-RADS) assessment in conjunction with an AI assistant.

Rather than having two radiologists look at the image, this AI can act as the second pair of eyes. But, when the AI assistant provided an incorrect BI-RADS assessment, radiologists were much more likely to second-guess themselves, dropping their assessment accuracy from 80 percent to less than 20 percent.

Because these radiologists considered the AI assistant as a trusted source, they were more likely to defer to its judgment, even when it was wrong. Even the most experienced radiologists in the study were prone to this cognitive error, called automation bias.

Accept a false conclusion?

“Even if the radiologists have excellent medical training, and they are looking at an image, and they know by their reasoning that this
is a negative exam, but the AI flags it as positive that they have this introduced doubt,” Jordan Perchik, MD, assistant professor at the department of diagnostic radiology at the University of Alabama at Birmingham, who was not involved in this study, tells Digest in a personal interview.

“They might trust the algorithm over their clinical reasoning and accept a false conclusion over their own true conclusion.”

Computer-aided detection for decades

As AI is rolled out across more settings in radiology, clinicians are in a race to figure out the best ways to integrate these tools safely to minimize harm to patients. “We’ve had computer-aided detection and mammography for decades now, and that was marketed as something that would be this big leap forward in patient safety and diagnostic accuracy and physician workflow,” Perchik says. “But it turns out that this particular tool had an overall very low accuracy and very high level of false positives.”

What’s the harm?

A false positive test disrupts the workflow, making the clinician waste extra time looking at the patient’s case. The clinician has to rush through the rest of their cases, leading to expensive, unnecessary testing and anxiety for the patient.

“The problem goes beyond how we clinicians use these AI assistants; there are also built-in algorithmic biases that can embed racial biases and lead to poorer health for women and non-white patients.”

AI underdiagnoses women, low socio-economic status and non-white patients

A landmark 2021 study in Nature Medicine led by Laleh Seyyed-Kalan- tari at the University of Toronto found that AI used to read chest X-rays would underdiagnose Black and Hispanic patients, as well as women and those with a lower socioeconomic background, compared to white patients.

Judy Wawira Gichoya, MD, MS, assistant professor in the Department of Radiology and Imaging Sciences at Emory University, who studies algorithmic fairness and biases built into these AI tools, tells Digest why this should be a key concern.

Gichoya explains that the AI model underdiagnosed the patients who already had the worst health outcomes and least access to care. These outcomes were encoded in the data scientists used to train the AI, so it learned a shortcut. Since these patients were less likely to access timely care even with a positive X-ray, the model would consider them healthy.

In an international setting, this suggests that AI bias could make health outcomes worst for the groups of people who have least access to healthcare. “What we need to do is come up with better frameworks for real-world moni- toring,” Gichoya says. Rather than focusing all the energy on devel- oping the algorithm, clinicians must ensure that the outcomes are fair — meaning patients aren’t underdiagnosed because of their race, sex, or socioeconomic status.

Judy Wawira Gichoya, MD, MS, an assistant professor of interventional radiology and informatics at the department of radiology and imaging sciences in Emory University, cautions that AI and author automated systems could worsen outcomes for underdiagnosed populations due to built in racial and algorithmic biases. Credit: Emory University

AI IN HEALTHCARE: A SKEPTICAL OUTLOOK

INTEGRATING AI INTO HEALTHCARE

BY SIMON SPICHAK

J. Raymond Geis, MD, a senior scientist at the American College of Radiology’s Data Science Institute, believes that healthcare systems aren’t yet ready for widespread adoption of these tools.

“Today, almost all clinical AI tools in medical imaging are installed and used on an ad hoc basis, with no or minimal formal monitoring or quality controls,” Geis says. “To me, this is the greatest challenge: what skills do we need, what processes do we need, and how do we start to build the framework to run cascades of ensembles of clinical AI tools that receive and deliver information among themselves and humans.”

Problems for patients may arise when an AI introduces a false negative. “For something like mammography, where giving the wrong answer means a patient
has undiagnosed cancer that has potentially major consequences, the need to incorporate human+machine intelligence accurately is extremely important,” Geis continuous. “Like anything, overreliance on computer programs when we don’t know how well they work is not safe, and it is dangerous to trust those systems.”

Using AI Responsibly

Learning to use and integrate AI responsibly into certain parts of the radiology workflow is a far cry from the disruptive game changer that prominent computer scientists like Geoffrey Hinton believed AI would become. In 2016, at the Machine Learning and Market for Intelligence Conference in Hinton, he boldly proclaimed that these algorithms will replace radiologists altogether, comparing them to “the coyote already over the edge of the cliff who hasn’t yet looked down.” He also proclaimed it made no sense to continue training radiologists.

Instead, AI algorithms are a new type of tool, unlike X-ray machines and other diagnostics. The software has built-in algorithmic biases, and the technology is prone to sway experienced radiologists to the wrong medical decision.
The problems can be addressed by training medical school students and tracking patient outcomes.

Radiologist conducting a scan.
Photo source: Freepik; author: @wawebreakmedia_micro

Using AI Responsibly

J. Raymond Geis, MD, senior scientist at the American College of Radiology’s Data Science Institute, says that overreliance on automated systems like AI can be dangerous without understanding the underlying limitations. Credit: Photo courtesy of J. Raymond Geis.

AI IN HEALTHCARE: A SKEPTICAL OUTLOOK

RESPONSIBLE AI 101: AUTOMATION AND ALGORITHMIC BIAS

BY SIMON SPICHAK

Dr. Jordan Perchik, MD, is assistant professor at the Department of Diagnostic Radiology at the University of Alabama at Birmingham. Since 2020, Perchik has been running a week-long AI Literacy course to make AI practical and understandable. He spoke with Digest about automation, algorithmic bias, and the challenges of integrating AI into clinical practice.

Patient undergoing a scan.
Photo source: Unsplash; author: Accuray

What exactly is automation bias?

Perchik:
When you have an algorithm deployed in clinical practice, someone who’s using that algorithm, even if they have excellent medical training and know by their reasoning that this is a negative exam, if the AI flags it as positive, they have introduced doubt. They might trust the algorithm over their clinical reasoning and accept a false over their true conclusion.

How does that affect the workflow?

Perchik:
When AI would flag these things, they would add another step for the radiologist: instead of looking at a mammogram, seeing something negative and saying, Okay, this was a negative study. I can sign this off in two minutes. Now, they have to go back and scrutinize these areas marked as false positives by the AI. And the two-minute exam becomes a five-minute exam. And you also have this extra cognitive load and the feeling of doubt that, in addition to your diagnostic process, you’re having to disprove the AI.

How big of a risk is automation bias?

Perchik:
As we bring in more applications, it will be complicated because the vast majority of radiologists in practice, even those using AI currently, have yet to have formal AI training and may not be aware of this bias. That puts us at risk.

What about algorithm bias?

Perchik:
That’s an area that I am very passionate about and something that is not discussed enough. Many of these, like computer vision and image-related algorithms, are prone to minor imaging differences.

If an AI for pulmonary scans was trained entirely on patients from the northeast US, and now encounters cases from the southeast US, its performance worsens. The AI algorithm starts to see a lot of pulmonary nodules in the southeast and might begin to classify almost everyone down there as having cancer. It will not realize that the nodules are common and caused by endemic fungi.

What exactly does that mean for the patients?

Perchik:
These are the kinds of things that are within the spectrum of normal. If the algorithm is trained on one area, it doesn’t see the other side of normal. This causes patient harm and cost thousands or tens of thousands of dollars in additional patient workup.

What kinds of diagnostic or screening applications is AI currently used for?

Perchik:
The AIs are used for flagging things like pulmonary nodules and breast masses. So, it’s very limited right now. We had our AI boom about one or about two years ago, and we still are having, you know, dozens and dozens of new applications getting FDA clearance, but they’re going for these same targets. High-volume, high-acuity studies for targeted cancer applications have not been as highly researched.

What should radiologists know about integrating AI? What do you tell new clinicians and trainees?

Perchik:
The most important thing is fundamental knowledge of
how the AI works. This means understanding what type of data the AI uses and how well this was trained. Was it challenged with a lot of external data? Or was the AI developed in a single institution?

Those kinds of single-institution tools are the most brittle and
might perform worse if challenged with new types of data. Beyond that, knowing how to roll AI out in
a regimented, meticulous way is important. This isn’t like buying a new X-ray machine; it won’t work right out of the box. You have to test it. You have to have feedback; you have to have a close relationship with the vendor. You have to be more meticulous, and you have to monitor its performance over time.

Do you have any final words of advice?

Perchik:
AI is not something that’s going to replace your clinical judgment. It
is something that can supplement your clinical judgment or help you to prioritize and work faster. It’s an AI assistant. It’s not an AI replacer.

“Clinicians need to understand the way that these AI algorithms work”: Jordan Perchik, MD, assistant professor of abdominal imaging and informatics. Credit: University of Alabama at Birmingham.

PATIENT STORY

THE TABOO OF BREAST CANCER IN A MUSLIM COUNTRY

BY FAZILA RAJAB

Photo source: Unsplash; author: Accuray

In Pakistan, it’s not uncommon that husbands leave their wives when they find out they have breast cancer. Even though the Islamic Republic has the highest rates of breast cancer in Asia, it remains a taboo topic. The cultural diversity, religious beliefs, patriarchal society, myths, and misinformation contribute to diagnostic delays and enhanced burden on the healthcare system. This is the story of Zahra - a survivor who had the help of her husband.

Zahra’s life took a sharp turn in January 2021 when she was diagnosed with breast cancer. While changing clothes, she randomly examined her body and found a lump in her left breast. As was rightly put by Zahra, “The second you accept that you have it and accept that you will suffer from side effects of the treatment process, the easier it is to go through these things.”

40’000 deaths per year

Globally, female breast cancer has surpassed lung cancer as the most commonly diagnosed cancer. According to the World Health Organization, in 2020, around 2.3 million women were diagnosed with breast cancer worldwide, and 685,000 died of it. In Pakistan, the stats are not any different. Annually, around 40’000 women die of breast cancer in Pakistan, with an additional 90,000 being diagnosed with the disease.

World Health Organization (2020, 2023)

“It didn’t feel like the end of the world, but I certainly cried. It was shocking, but not like I was in a complete state of shock.” Being a Muslim, she said breast cancer strengthened her faith in Allah. “I believe that Allah makes you go through everything for a reason. During cancer, my baking business went up exponentially, so much so that I had to leave my job,” she added. “Allah compensated me.”

Muslims and mammograms

The benefit of mammograms in detecting breast cancer early and saving women’s lives is clear, as Zahra’s experience illustrates. However, many women in Pakistan, a predominantly Muslim country, do not even bother to go through the annual procedure. Some women even believe that God controls diseases and cures.

A study involving 1,000 women analyzed knowledge, attitude, and practice (KAP) regarding breast cancer among Pakistani women and found that only 32% of the participants had proper awareness regarding the disease process, the purpose of mammography, and breast cancer prevention, and only 19.6% of them had undergone mammographic screening. Another study published in “BMC Women” explored the barriers that hinder women in Pakistan from seeking timely screening and treatment. The study found lack of awareness, hesitance in accepting social support, spiritual healing, feminine sensitivity, stigmatization, aversion to male doctors, lack of financial resources, and apathetic medical services as some of the barriers that hinder screening and treatment.

Modesty and social stigma

Modesty is a significant factor that influences Muslim women’s health decision-making. Adherence to religious teaching in covering the aurah (the intimate parts of body) caused some Muslim women to be concerned about having close physical contact and exposing their body parts to others of the opposite gender.

Worrying about maintaining modesty during a mammogram is one reason some respondents do not want to have one. Studies reported that some Muslim women were concerned with the altered image of losing their breasts and becoming less attractive and feminine if diagnosed with breast cancer. This is because, culturally, women’s breasts are associated with motherhood, feminity, and sexual desire.

“People are ashamed of breast cancer, which one should not be as no one goes through it with her own will,” said Zahra. Pakistan is ranked amongst the emerging and growth-leading economies, it is not progressive in the way its society addresses this issue.

While discussing her journey with our magazine, Zahra talked about one of her acquaintances who was in her 80s when she was diagnosed with breast cancer. Due to cultural constraints, she refused to go through a mastectomy after chemo sessions and got the disease back after five years. “Women are not putting themselves first; they are putting society first.”

Her husband, Babar Shaikh, remained the biggest support system throughout her journey: “Life is much better now. Cancer made me realize life’s real importance and has changed me for the better.” Photo Courtesy of Zahra Khan

The role of spirituality

Zahra got her treatment done at Aga Khan University Hospital, one of the top tertiary care hospitals in Karachi, Pakistan. Since Zahra was diagnosed with stage 2, grade 3, triple-negative breast cancer, an aggressive type, the doctors acted quickly. She underwent 16 chemotherapy sessions, a double mastectomy, and 19 radiotherapy sessions. As of now, she is cancer- free.

According to Zahra, faith helped her throughout her treatment journey. “My journey brought me closer to Allah. It was faith that got me where I am today, that got me through my journey quickly and easily.”

“I found the CT scan very scary, and I was constantly reciting Surah Fatiha; I was praying to Allah that my cancer had not spread. When Ihadthedyeinme,Ididnot overthink anything and underwent the procedure in the dark. I did not ask anyone about their experiences, which calmed me. When the dye was in me, I did not feel anything.”

After the CT scan, a bone scan was conducted to see if the cancer had spread to the bones, which was another horrible experience for Zahra. “I was constantly reciting duas (Islamic chants) the whole time, which helped me through it.”

Zahra went through psychotherapy night before her first chemo session, which she found very helpful. “That set up the tone of my journey, and the next day, I woke up for my chemo and went in like a boss.”

The challenge of mastectomies

Since breasts constitute a main part of femininity for women, mastectomy is the hardest decision for women with breast cancer. So, as for Zahra, she had second thoughts about keeping one breast to breastfeed her child whenever she had one.

Here, her husband tried convincing her, saying, “Do not risk your life for someone who does not even exist yet.” Hence, she put her life first and underwent a double mastectomy. Had she decided to keep her other breast, the likelihood of getting cancer back would be much higher.

Apart from that, Zahra talked about the effects of chemotherapy, like losing hair and energy. “Losing hair on my head was fine for me. I was prepared for it. It did not hit me hard. But losing my eyebrows was everything. I wanted to keep them, so I would buy eyebrow tattoos from Daraz (an e-commerce platform).”

While going out, people could barely tell that she had cancer, as she used to cover her head when going out. “Sometimes I would go out completely bald, and there one beggar asked me why I was bald, and I boldly replied, I’ve got cancer.”

When asked about the effects of the treatment she experienced, Zahra said, “It affects me now. During treatment, I was a crazy warrior, but now that treatment is over, I’ve had trouble sleeping and do have epiphanies like, Oh my God, they are gone. A woman is supposed to look a certain way; that is what we are constantly taught. And once that is gone, what are you going to do? There are options for reconstruction, which I do not want to go for right now as it causes much pain.”

Zahra and her husband, before and during the treatment.
Photo courtesy by Zahra

Breast cancer myths - shared by Zahra

Since Zahra was quite young, the doctor had to see if the cancer was genetic. Although she has strong genes of cancer from the paternal side, she was told that cancer passed down from the maternal side, so they are all clear, which was a myth.

As she continued to hold talks for breast cancer awareness, she tells Digest about myths around breast cancer in Pakistan, which included that cancer being contagious and radiation from microwaves or wearing a black bra may cause cancer.

A study highlighted myths and misconceptions about breast cancer in the Pakistani population. Some common myths include that breastfeeding offers immunity to breast cancer, breast cancer spreads after biopsy, faith healers and alternative medicine can cure breast cancer, and only painful lumps are associated with breast cancer. Some participants also believed breast cancer resulted from God’s curse or evil eye.

A taboo in Pakistan

The fear, stigma and shame associated with cancer within Pakistan hold people back from talking about their experiences, going for screenings, and even treatment. Zahra says: “People would be talking to me about my health and used to mute breast from the conversation, which offended me. It’s a Pakistani cultural thing.”

Men leave their wives when they find out they have cancer. People fear their daughters won’t get married if someone in the family has/had cancer, and the male family members will not support them or stick around. Zahra had married the love of her life in 2018. Life with Babar was perfect, they run a thriving baking business.

“My friends tell me it’s remarkable that your husband is there for you. I know that it is coming from somewhere, as they have seen men leaving their wives for having cancer. When I was undergoing radiation therapy, one lady asked if my husband would allow me
to undergo surgery. I could not comprehend the question.”

Cancer treatment cost in Pakistan

“The first thing on my mind was how I would pay for this. I did not realize I had a corporate job and health insurance. My husband has health insurance for his spouse. My company was very supportive throughout my treatment. They bumped up my insurance.”

The average annual income in Pakistan is about 150 Euros. The treatment cost may range from as little as 300,000 to over 2 million Pakistani rupees (7000 Euros). The most basic form of chemotherapy for one patient can cost as much as 60,000 to 80,000 rupees, so early detection can reduce costs. Given that there is no health insurance for common citizens in Pakistan, many breast cancer patients cannot afford the treatment cost and benefit from the welfare.

Shaukat Khanum Memorial Trust, Bait-ul-Sukoon Cancer Hospital, Indus Hospital, and Kiran Cancer Hospital are some of the best cancer hospitals in Pakistan that use state-of-the-art facilities and are established to meet the growing demand of poor, deserving cancer patients free of charge.

According to Zahra, who got her treatment at Aga Khan University Hospital, western hospitals have better facilities and rooms. They have a tradition of ringing a bell to celebrate the end of chemotherapy sessions. Hospitals abroad have a better quality of treatment, not in terms of medicines but in terms of taking extra care of their patients, which Pakistan lacks.

She also pointed out the lack of healthcare resources in Pakistan: “We don’t have enough oncologists and breast surgeons. Government figures have revealed that less than 250 individuals have qualified in the country as trained medical or radiation oncologists, and the country has 27 cancer treatment centers, a figure experts deem insufficient given the high number of cancer patients.”

Photo obtained from public sources

Supportive friends and family

While answering whether one should go for treatment in Pakistan or abroad, she said, “Do it where your support system is because you need your family and your friends around you throughout your journey; that is very important for recovery. It is nice to have your doorbell rung with a bouquet of flowers daily.”

For a Muslim country like Pakistan, visiting the sick for a short while is part of Sunnah. Even if physical visits are not possible, family and friends should maintain connection via phone calls, WhatsApp, or other ways to stay in touch.

She emphasized that while some people are afraid upon hearing about a cancer diagnosis and disappear, they must face up to this and offer support.

While advising people who have cancer, Zahra stressed the importance of adhering to the treatment being recommended by their doctor. She said, “Know what you have got to do to beat it and make sure you do all of it. Cancer treatment is so difficult that you do not want to go through it again.”

From the Islamic perspective, there are some positive aspects of illness in general and breast cancer in particular, as it gives Muslims the opportunity to assess, reassess, and think deeply about life here and whether or not they are walking on the path that will find them the solace in this world and the other world. “My life is better after cancer because it has opened up my mind.”

PATIENT STORY

BUILDING A PATH ALONG THE WAY

BY SERG VALENCIA

Living not so far from each other on the American East Coast, two women from entirely different backgrounds embarked on unmapped journeys propelled by cancer diagnoses, touching countless lives in their paths.

What would you do if you received a cancer diagnosis? Marianne Sarcich (58) thought about her daughters. “I was diagnosed in 2016, and I had a single mastectomy. Yes, I was afraid of the disease. But beyond that, I was concerned for my children.” Marianne’s youngest was 9, and her oldest was a senior in college. Despite the passing of time, the questions that filled her mind when diagnosed still echo. “Who would take care of them?”

Annette M. Goldberg, MBA, MS, RDN, is an oncology dietitian at Mass General Brigham and Dana Farber Cancer Institute in Boston, Massachusetts. She’s an active woman passionate about nutrition and athletics. Then, “one day,” as she puts it, a cancer diagnosis turned her world upside down.

Annette soon had to find out: There’s no instruction manual to navigate cancer. Marianne’s experience is illuminating as it illustrates the many aspects a woman faces when she receives a diagnosis. “Looking back to
2016 when I was diagnosed, and reflecting on the experience, I consider how I happen to be a very resourceful person who knows how, if I’m given a situation, to navigate it,” explains Marianne. She touches on a critical point. Navigating a breast cancer diagnosis is not as straightforward as it may appear.

Marianne Sarcich took action when diagnosed: ‘’ I didn’t find the psychosocial support I needed for my anxiety, so I created a group for women to fill this gap.’’
Courtesy of Marianne Sarcich

Forced identity shift

Marianne explains: “When I was diagnosed, I knew I had a new job, and because of that, I moved ahead to figure out how to deal with the situation. I’m that person, and I’m also a very vocal person. So I brought a lot to the plate that I didn’t know helped me move through back then, but now, as I look back, I understand the difference it made.”

As a cancer survivor herself, Annette knows too well the uncertainty that comes with a cancer diagnosis. “When working with breast cancer survivors, the first step I take is dispelling myths around nutrition, lifestyle, and cancer. The misinformation available through social media and the internet is stressful for a survivor trying to evaluate the appropriate path for change. It is important to eliminate unnecessary worrying.” Paradoxically, in the information age, it’s easy for cancer survivors to feel lost.

Marianne’s character and personality helped her direct her energy in a way that made all the difficulties less overwhelming. However, as she reminds us, not every person is the same.
‘My ability to navigate diagnosis and treatment may have been smoother than that of someone who doesn’t know their patient rights, doesn’t understand medical terminology, or feels emotionally overwhelmed and paralysed with fear, so they cannot act on information.”

Women’s unique stories are not an afterthought. They are central to creating effective interventions for breast cancer, as Annette explains. “I focus on outlining the factors where the survivor has control and can successfully make changes in their lifestyle. It is important to meet the person where they are – emotionally, financially, and physically.”

Marianne is a fighter. Leaving women on their own is not on her agenda. On her survival journey, she encountered talented and caring clinicians, the support of friends and family, but also bureaucracy, misinformation, and unmet emotional needs.

That’s why Marianne became a national advocate, leading “In This Together Philly Wilmington”, a peer support group for breast cancer patients with 1,300 members.

“The personalities women bring to the exam room take them on different routes with their cancer experience.”

Marianne’s support group closes unmet gaps by providing evidence- based help, encouraging early mammograms, explaining patients’ rights, and empowering women to find help for their bodies but also for their emotional needs with the service of dedicated peers.

“We cannot put the person aside from their disease. We have to bring the person how she is and mold the protocol to fit them, not the other way around,” Marianne explains. Annette concurs. That’s why her nutrition practice is based on evidence-based science and healthy doses of compassion and empathy.

Marianne Sarcich’s family, was the fuel that stimulated her relentless work helping breast cancer survivors.
Courtesy of Marianne Sarcich

Personalised medicine

Annette’s philosophy of personalised care is straightforward. It considers each person’s unique stories: “Individual counselling will help develop a plan that addresses change at a pace that is comfortable for the patient and fits within their abilities and lifestyle.”

Women shouldn’t become someone else to navigate cancer or suppress their feelings, doubts, or worries to embark on treatment. ‘’Personalised medicine doesn’t leave anyone behind,’’ complements Marianne.

Personalised medicine accepts the person as they are and delivers care that works for every woman, no matter her background, medical expertise, or personality.

Nourishing life

Cancer clinicians dedicate their lives to serving women affected
by breast cancer. However, sometimes, their expertise is not communicated in a way that women feel empowered to act on it. Marianne elaborates: “Oncologists share incredibly valuable information about risks and lifestyle interventions with women, but how much are they hearing when they’ve got so much going on because
of the emotional impact of their diagnosis?”

Emotional needs are as important as physical ones. Marianne Sarcich and Annette Goldberg, each in their unique, remarkable ways, have embraced the challenge of a cancer diagnosis and utilised it to fuel deeply inspiring missions that share a common belief.

Marianne Sarcich describes:
“Women should be met where they are. We want to be seen. We want to be heard. We want to be fixed.”

Annette Goldberg’s guiding light is clear: ‘’I follow the recommendations of the American Institute for Cancer Research – which focus- es on the connection between lifestyle and cancer.’’ Courtesy of Annette Goldberg

ENVIRONMENT, NUTRITION AND WELL-BEING

INVISIBLE DANGERS MAKING WOMEN SICK

BY SERG VALENCIA

Invisible substances in food, products, and the environment may quietly raise breast cancer risk, especially for future generations.

Digest interviews Emory University’s Dr. Dean Jones, director of the Clinical Biomarkers Lab, and epidemiologist Prof. Prisco Piscitelli of the Italian Society of Environmental Medicine, whose work disentangles how everyday exposures can cause disease.

Medical research is in the midst of a revolution, with breakthroughs across fields like immunology, genomics, and microbiology converging exponentially. With
the power of AI and big data, this knowledge explosion promises to rapidly transform the understanding of diseases, offering new hope for conditions like breast cancer. Dr. Jones is among those researchers paving new hopeful ways in the fight against breast cancer.

Dr. Piscitelli is the Vice President of the Italian Society of Environmental Medicine. He’s a leading researcher trying to leverage epidemiological studies’ power to tackle cancer growth challenges, with most of his work focused on the Mediterranean region:

Their research focus is very different; however, they’re both primarily interested in studying the exposome: how do the chemical, physical, biological, and social influences surrounding an individual affect their health, and specifically, how can they increase a woman’s risk of developing breast cancer?

Is it dangerous out there?

Life in the 21st century feels at 2x speed. The new rapidly becomes old, and losing track of what’s essential is easy. In the past 50 years, social, industrial, and economic changes have created conditions that are easy to miss and provoke health hazards, increasing the risk of breast cancer. To build and keep running the modern world, with its fast food and fast fashion chains, industrialised crops, and smart electronic gadgets, it’s necessary to rely on materials that pose health challenges to men and women everywhere. These dangerous companions of daily life are, in most cases, invisible. So, relying on experts like Dr. Jones to bring them to light is essential.

“I’m convinced epidemiology can change the world if we think about cancer more holistically.”
Prof. Prisco Piscitelli

Toxic suspects

“A non-exhaustive list of global changes is overwhelming,” warns Dr. Jones. “Our food chain is changing rapidly, with hybrid varieties and monocultures altering the landscape. New processing methods, preservatives, and delivery systems provide less variety in plant-based foods.”

“A chemical cocktail of insecticides, herbicides, fungicides, antibiotics, and persistent pollutants like DDT permeate our world. Consumer products are no better, loaded with flame retardants, toxic metals, and plasticisers that leach into the environment,” adds Dr. Jones.

Measuring the invisible

Distinguishing between genetic and environmental factors that predispose to diseases like cancer is complex. “An individual’s epigenome can regulate gene expression, and its interaction with the environment is constant. It never stops,” declares Prof. Piscitelli, explaining the relationship between bodies and places.

So, how are scientists tackling these research difficulties to uncover unexpected breast cancer risks?

Dr. Jones explains: “The assays we developed over the past 15 years substantially improve surveillance of such diverse human exposures. We found that high-resolution mass spectrometry with data science tools provided the capability to measure tens of thousands of chemical signals.”

In a paper he coauthored and published in the August 2023 issue of Environment International, Dr. Jones and his team applied their toolkit to identify “suspect chemicals” for breast cancer risk. Analysing biospecimens from 566 pregnant women – 182 who ultimately developed breast cancer – scientists found elevated levels of specific chemicals.

In the second trimester, compounds associated with insecticides correlated with disturbances in cell growth and inflammatory pathways.

The third trimester showed increased additives linked to fuels and carbazole oils, chemicals that may disrupt sugar metabolism.

Dr. Jones’s findings shed light on how toxic exposures, even before birth, may predispose some fetuses to higher breast cancer risk later in life.

Dr. Dean Jones, Director of Emory’s University Clinical Biomarkers Laboratory.
Courtesy of Dean Jones

Applied knowledge

Prof. Piscitelli views research as a means, not an end. “I believe our responsibility as scientists is to help prevent. Epidemiology findings shouldn’t be limited to counting cases. How to stop is the real goal.”

Dr. Jones concurs: “Our research is now focused on applying new methods to detect early-onset cancers. Our collaborator, Barbara Cohn of the Child Health Development Studies, has shown that children born between 1959 and 1967 had earlier onset cancers than their parents. This highlights the importance of the exposome - exposures during critical developmental windows - in contributing to earlier cancer onset.”

Dr. Jones’s research on the exposome during pregnancy provides valuable new information on multigenerational cancer risks.

If certain behaviors, products,
or environmental situations
during specific periods of life can predispose to later developing breast cancer, these findings could push forward the necessity of taking an active approach at the political and individual levels.’ with: ‘If certain factors can predispose people to breast cancer, it highlights the need for proactive measures at both the political and individual levels.

Preventing first

People might avoid behaviors, products, and places that expose them and their future children to harmful substances, just as they do with cigarettes. The world is not a toxic place according to Dr. Jones.

Thinking about cancer holistically: Prof. Prisco Piscitelli, Vice President of the Italian Society of Environmental Medicine. Courtesy of Prisco Piscitelli

Annette Goldberg’s Lifestyle Tips

Avoid processed meats and alcohol

Minimize red meat intake

Rebalance your plate to incorporate more plant-based foods

Get excited about plant-based nutrition

Rebalancing your plate doesn’t mean eliminating all the foods you enjoy

Balance dishes to 50% fruits and vegetables, 25% whole grains, and 25% protein

Shift from “feeding” your body – to nourishing your body by selecting food with high nutritional value

Avoid supplements – Obtain nutrition from whole foods

Maintain a healthy body weight

Keep moving and exercising

Example of food with high nutritional value
Photo source: Unsplash; author: Reka Biro-Horvath

ENVIRONMENT, NUTRITION AND WELL-BEING

ULTRA-PROCESSED FOOD CHOICES

BY SERG VALENCIA

Research published in 2023 studying 10 European countries suggests that specific foods and diets can minimise or exacerbate the risk of developing breast cancer. If replicated by more robust studies, these findings can potentially transform prevention and lifestyle interventions for breast cancer.

Ultra-processed foods (UPF) reflect modern times.
Photo: Brooke Lark/Unsplash

People demand convenient eating alternatives as the pace of life accelerates, but does convenience increase breast cancer risk? A study by “The Lancet” found that for every 10% increase in UPF (Ultra- processed foods) consumption, there is a 2% higher incidence of overall cancer. UPF intake was associated with a 16% increased risk of breast cancer-related mortality. Why is UPF a breast cancer risk factor?

Empty food promises

UPF are often nutritionally inferior, with more calories, saturated fat, salt, sugar, and less fibre and vitamins than unprocessed foods. The manufacturing techniques behind these foods also change the molecular structure of foods, degrading beneficial compounds and reducing nutrient bioavailability and bioaccessibility.

UPFs carry potentially harmful components, including additives, neoformed contaminants, and toxins that may migrate from packaging. Ingredients like artificial sweeteners, nitrate, and food additives have been associated with increased breast cancer risks. Endocrine- disrupting chemicals, like phthalates and bisphenols, have been detected in individuals with higher UPF consumption, raising concerns about their role in breast cancer.

No woman is an island

UPFs are not the only environmental risk under research scrutiny. A heavenly touristic destination sheds light on additional invisible dangers. The Canary Islands are an ideal place to study a population due to geographical constraints. A study published in the “Spanish Magazine of Public Health” found that their population’s environmental exposures contain at least 110 compounds, 99 tracing back to the womb.

Chlorinated pollutants and metals stand out, with evidence linking them to the islands’ high breast cancer rates. Where do these toxic exposures come from?

The study team recommended monitoring water and soil for pesticides that may contaminate food. Research indicates that some foods may increase breast cancer risk, which raises the question: is there a diet with potentially healing properties?

Feasting for life

The Mediterranean Diet (MD) is
a plant-based dietary pattern characterised by high consumption of fruits, vegetables, legumes, nuts, seeds, whole grains, spices, herbs, and olive oil, with moderation in seafood, poultry, eggs, wine, and low-fat dairy.
In a recent study published in “BMC Medicine”, researchers explored the relationship between adherence
to the Mediterranean Diet (MD)
and the longevity of breast cancer survivors in Europe.

The study, encompassing 13,270 survivors across France, Italy, Spain, the United Kingdom, The Netherlands, Greece, Germany, Sweden, Denmark, and Norway, assessed MD adherence before diagnosis, with findings suggesting that low adherence to the MD is associated with 13% higher risk of all-cause mortality, and increasing the consumption of the MD was linked to an 8% reduced risk of overall mortality.

What’s for dinner?

No time in history has offered
such a vast array of food choices. Science continuously expands the collective knowledge of how certain foods can increase or decrease
the risk of breast cancer. Changing your genetic makeup by sheer will is unfeasible, but deciding what food you consume daily is not. Every bite you take can become an investment in your future health. So, what’s for dinner?

Ultra-processed foods (UPF) reflect modern times.
Photo: Unsplash, author: Brooke Lark

PERSPECTIVES ON PERSONALIZED HEALTHCARE

SHOULD PERSONALIZED MEDICINE COME WITH A WARNING LABEL?

BY LAVONNE ROBERTS

Cancer treatment has been at the forefront of precision medicine’s development. The age of personalized medicine promises treatments is tailored to our unique genetic makeup. But does this innovative approach warrant the hype and investment? A medical ethicist explains why precision treatments are neither cure nor revolution.

A 2018 study by Jama Oncology, a journal for scientists, found that 31 anticancer drugs had been developed that target specific genetic mutations or use genetic information to guide their use as of January of that year.

Dr. James Tabery, a medical ethicist at the University of Utah, draws
on his father’s battle with lung cancer in his new book published in August 2023, “Tyranny of the Gene: Personalized Medicine and Its Threat to Public Health”. Tabery contends that too many doctors and researchers fixate on genetic causes of disease while overlooking the significant role that external factors play in health outcomes. He argues that while genetic testing has benefited some patients, the hype around personalized medicine has distracted from cheaper, more equitable approaches to improving public health.

Tabery’s family was given hope by Erlotinib, a targeted therapy drug that initially shrank his tumors. However, the drug’s high cost and limited efficacy led James to question the promises of personalized medicine.

Mike Tabery with a successful catch on a trout fishing trip to Alaska in 2009.
All photos courtesy of James Taber

”After taking the Erlotinib for a brief period of time, my father was able to wiggle his toes—some- thing that he couldn’t do ever since he entered the hospital paralyzed. That signaled to us in a very powerful way that the drug was working and also gave us some hope that the mobility he lost due to the cancer might also be recoverable.” James Tabery

A father’s devastating diagnosis

On August 16, 2011, Mike Tabery, James’ father, woke up unable to get out of bed. Just the day before, he had been his usual active self. At sixty-four, he had just retired and was an avid outdoorsman, looking forward to spending more time fishing. But that morning, he was paralyzed and unable to stand.

A bleak prognosis

Scans showed Tabery’s father’s body riddled with tumors—in his brain, ribs, pelvis, and spine. The spinal tumors had grown silently, compressing his vertebrae until they completely cut off nerve signals to his legs. In an instant, he went from being an energetic, healthy man to being paralyzed and facing devastating late-stage cancer. The prognosis was bleak. Overnight, the rock the family depended on needed care and support. Though the odds were against them, Tabery’s family resolved to fight the disease and seek any treatment that could prolong his life.

An ounce of prevention

Drawing on his father’s ordeal, Tabery cautions that expensive targeted therapies often only briefly stall terminal diseases like lung cancer. He advocates for more focus on preventing illness by improving socioeconomic determinants of health.

“Personalized medicine holds promise to tailor cancer treatment based on an individual’s genetics and biomarkers. However, this emerging approach also poses some risks to public health.”

Quoting Benjamin Franklin in his book, “An ounce of prevention is worth a pound of cure,” Tabery believes these words are still relevant, as public health efforts
like anti-smoking campaigns have done more to curb lung cancer rates than expensive new drugs that treat disease after diagnosis. He argues that communities of color and those living in poverty bear the brunt of unhealthy environments, citing their proximity to pollution sources like factories, landfills,
and highways. These marginalized groups often lack access to green spaces, healthy food and walkable neighborhoods.

The socioeconomic divide

Tabery makes the case that racial and economic health disparities are not caused by genetic differences but rather by inequitable environmental exposures. As evidence, he notes that Black patients with lung cancer have higher mortality rates than white patients. This is not due to susceptibility in their DNA but because Black communities disproportionately breathe more polluted air and receive inferior medical treatment. Cost and access are major concerns. Genetic testing and targeted therapies come with a high price tag that could worsen disparities.

The whole family towards the end of my father’s battle with cancer. We’re all wearing the “Tabery’s Bait & Tackle” T-shirts that he got them. James is on the left.

Lung cancer is the leading cause of cancer deaths worldwide. In 2020, over 1.8 million people died from lung cancer, accounting for about 18% of all cancer deaths. Non-small cell lung cancer is the main form but is often diagnosed late. Only 16% are caught early, so 5-year survival is just 18% overall and 5% once spread. Without treatment, median survival is under a year, demonstrating the need for better early detection.

World Health Organization (2020)

Overlooking important factors

Patients without the means to access personalized testing and treatments would be left behind. There are also worries that an overly narrow focus on genes and biomarkers could lead researchers to overlook broader lifestyle and environmental factors that impact cancer risk. Additionally, an overemphasis on personalized medicine could shift resources away from public health efforts like smoking prevention and improved screening that prevent many cancers at the population level. In comparison, precision treatments benefit a few privileged individuals, and those without access face worse outcomes.

Overwhelmed by complexity

Precision medicine promised to revolutionize cancer treatment by matching patients to drugs based on their tumor’s unique genetics. But the approach has fallen short of expectations. Sequencing reveals most cancers harbor countless mutations, leaving doctors overwhelmed by complexity. Worse, they often lack drugs to target key mutations driving growth. Cancer’s adaptability also foils precision medicine’s static view. Tumors constantly evolve new mutations that resist targeted drugs. Yet testing typically only analyzes genetics at one point in time, unable to keep pace with cancer’s mutability.

“Erlotinib didn’t cure my father. For a very high price, the drug slowed his terminal disease down for a short period of time, and even that limited benefit is not available to everyone.”
‍
James Tabery, Center for Health Ethics, University of Utah

High costs

The reality is that while some patients see remarkable responses, most eventually relapse as their cancer learns to evade these narrowly focused treatments, and because of high costs, access is limited only to the privileged few.

A study conducted by “Frontiers in Medicine” in Lausanne in February 2023 found that multigene testing increases total costs over five years by 47% in China to as much as 162% in the United States compared to no testing. With testing, per-patient costs reached nearly $400,000 in the U.S. Proponents argue precision medicine needs more time to fulfill its potential. But so far, it has yet to move beyond a specialized strategy to a new standard of care.
Genetic testing has not significantly improved outcomes for most, drastically increasing costs and disparities. Access is limited to the privileged few who can afford six- figure price tags.

Precision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person. This approach should allow doctors and researchers to predict more accurately which treatment and prevention strategies for a particular disease will work in which groups of people. It is in contrast to a one-size-fits- all approach, in which disease treatment and prevention strategies are developed for the average person, with less consideration for the differences between individuals.The role of precision medicine in day-to-day healthcare is relatively limited. Researchers hope that this approach will expand to many areas of health and healthcare in coming years.
‍
NIH National Library of Medicine (2016, 2018)

Warning on personalized medicine

Tabery concludes that to improve population health, we must study environmental factors that truly determine health outcomes rather than focusing narrowly on genetics. “The threats posed by unsafe living environments are clear, and yet there are still many ongoing debates about the nature of those problems and how to effectively intervene in order to limit the harm they do,” says Tabery. He cautions that while genetic research generates headlines, it cannot reverse negative health trends, reduce racial disparities, or keep people healthy.

All the personalized medicine advertising about miracle cures and impending revolutions simply doesn’t hold up to scrutiny. “What personalized medicine really needs is a warning label: Side effects may include financial devastation and social inequity.”

PERSPECTIVES ON PERSONALIZED HEALTHCARE

Did targeted therapy offer false hope?

BY LAVONNE ROBERTS

James and his son share the passion for fishing with Mike Tabery.

Digest spoke to James Tabery about his motivation for chronicling the rise of personalized medicine and the reasons he thinks paying attention to the environment might have a more significant impact on health care. What is the difference between precision medicine and personalized medicine, and why is there so much confusion and overlap between the two terms?

From 1997 to 2007, personalized medicine was promoted as matching your genome to tailor-made drugs. In 2011, genetics researchers rebranded it as “precision medicine” because “personalized” was confusing. Now, both terms cause confusion and are not fully accurate. Promoters claim precision medicine identifies root causes and gives diagnostic clarity, unlike traditional medicine. But this is misleading - uncertainty and differing treatment recommendations still occur. The idea that precision medicine eliminates these problems is an illusion. Both terms overpromise the power of genetics to determine health outcomes. The rebranding to precision medicine did not resolve underlying confusion over what genetics can realistically deliver for individualized healthcare.

Gleevec was hailed as a breakthrough targeted cancer therapy for precision medicine when approved in 2001, but its history of massive price hikes, patent tactics, and the launch of costly follow-on drugs reveals the economic downsides and limitations of genetics-guided treatments. Can you explain why you believe the story of Gleevec is a cautionary tale?

The price of the life-saving drug steadily rose over the years, eventually reaching
over $150,000 annually before multiple generics arrived and finally drove down the cost. The drug giant that manufactured the pharmaceutical used various tactics to maintain and extend its monopoly. Though it effectively treats a rare blood cancer, Gleevec set an unsustainable precedent of skyrocketing costs that created barriers to patient access and added financial toxicity to cancer care. While scientifically a breakthrough, Gleevec demonstrated the risks of leaving drug pricing solely to corporate interests rather than ensuring affordability for the people who need the drug most. Its story should temper expectations about personalized medicine.

What are the limitations and pitfalls of personalized medicine for cancer treatment that require tempering expectations?

While personalized medicine holds promise to improve cancer outcomes for certain patients, it has significant limitations and pitfalls that temper expectations of a revolution across health care. Challenges include tumors having numerous complex mutations, prohibitive costs that worsen disparities, unrealistic hopes for a miracle cure, and cancer’s ability to resist targeted drugs over time. Precision medicines offer static snapshots, but cancers are dynamic. As evidenced by my father’s experience with lung cancer, dramatic responses are rare and often short-lived. The genetics approach has a role in care, it should complement public health efforts and conventional treatment options rather than drive all decision- making. For now, personalized medicine remains a specialized tool, not a new standard. Rather than buying into the hype, oncologists need a balanced perspective on its pros and cons to apply this limited approach judiciously.

Some critics say too much funding supports genetic research over environmental health research. Given the NIH’s (National Institutes of Health) billions invested in genetics for personalized medicine, how should research areas be prioritized to best improve public health?

We need to shift more funding to studying and intervening in environmental factors affecting health through public and population research. As I argue in my book, it has become more technologically and politically easier to study genetics than the environment. We now take for granted that smoking and lead paint are unhealthy, but public health research proved these hazards decades ago when they were debated. This research changed how society views risks like DDT, and we cannot forget that environmental factors were not always considered dangerous. However, we cannot neglect ecological determinants of health just because genetics research is more profitable and less controversial. To truly improve public health, we must balance support for genetics with environmental health research.

How did experiencing your father’s treatment impact your views on cancer care?

The experience drove home for me just how desperate patients and their families are for any sign of hope, whether that’s in the form of news of a new drug or something more personal like a scan that shows tumors are shrinking. The treatment is a never-ending hurricane of tests, exams, and procedures, so anything that looks like good news is held

Tyranny of the Gene

In his book, published by Knopf, James Tabery argues that the concept of personalized medicine emerged more from pharmaceutical industry marketing interests than as an inevitable scientific watershed. He traces how this idea spread from the Human Genome Project to become promoted by influential government scientists as well as biotech companies. However, Tabery contends that this notion of personalized medicine tailored to our individual genomes is an overhyped marketing ploy, not a medical reality.

Digest

THE VALUE OF THERAPY FREEDOM

RADIOLOGISTS PRONE TO MISTAKES BECAUSE OF AI

AI underdiagnoses women, low socio-economic status and non-white patients

INTEGRATING AI INTO HEALTHCARE

RESPONSIBLE AI 101: AUTOMATION AND ALGORITHMIC BIAS

THE TABOO OF BREAST CANCER IN A MUSLIM COUNTRY

BUILDING A PATH ALONG THE WAY

INVISIBLE DANGERS MAKING WOMEN SICK

ULTRA-PROCESSED FOOD CHOICES

SHOULD PERSONALIZED MEDICINE COME WITH A WARNING LABEL?

Did targeted therapy offer false hope?

INSIGHTS FOR Q3 2023

THE NEXT ISSUE WILL BE PUBLISHED IN January 2024