May, 2013

No Brainer

By Michael J. Katin, MD

In 1961, President John F. Kennedy stimulated the scientific and adventurous spirit of the United States by announcing the plan to, by the end of the decade, put a man on the moon and return him safely. Adding the second part made the challenge that much more complicated, and restricting this to the male gender was horribly politically incorrect, but, regardless, this was fulfilled by July, 1969.

In 1987, during the Reagan Administration, the challenge was put forth to identify the entirety of the human genome. This project was officially launched in 1990 and completed in 2003, two years ahead of schedule.

Unfortunately, even though the human genome project will result in enormous advances in basic science, patient care, and producing mutants, it did not have the same popular appeal as the Moon landing or, for that matter, a Kardashian wedding.

Now that these two national objectives have been accomplished, it seems appropriate for a new one to be proposed. In that spirit, President Barack Obama has announced a national effort to map out the human brain.

The question is raised as to the timing of this enterprise. When some citizens/voters cannot recall the name of the Vice-President, and others may believe that the Middle East is an NCAA football conference, it is uncertain that there would be concern about the function of the cingulate gyrus. Certainly brain-mapping can have benefits in the long-run. There could be more effective rehabilitation for stroke victims if pathways are better defined. There could be a greater understanding of intervention for chronic debilitating diseases, such as Parkinson's, multiple sclerosis, and Alzheimer's. There could be far more profound discoveries, such as to identify what really happens when we dream, where voices arise when we think , and to even pinpoint the specific location of the soul. Others, certainly not I, would be concerned that the main intention may be to identify the optimal location for placement of chips to allow monitoring of thought and, ultimately, to achieve mind control

There probably should be acknowledgment that the intention of this project is to motivate and direct scientific research and coordinate funding efforts but the question has to be raised regarding the need to divert resources. This may be the absolute opposite of being shovel-ready and possibly not even micro-pipette ready. We all have our own prejudices regarding where money and staffing is consumed in research and clinical care. In oncology, there certainly should be a lot more done in identifying what specific treatment should be delivered for the malignancy in each individual person and what can be done to increase sensitivity or reduce resistance to chemotherapy, radiation therapy, and other modalities. Perhaps there should be a crash program to learn everything possible about the immune system, since this is being approached from multiple directions by nearly every field of medicine from rheumatology to cardiology to dentistry and even sports medicine. In addition to the well-known immune therapies for certain types of cancer such as melanoma, spontaneous remissions in patients with other types of cancer have been attributed to activity of the immune system. I'm sure everyone may have his or her own preference for the next national effort, but our President has made his mind up to study the brain.

Maybe it's the neat way that the acronym, BRAIN, was able to be put together (Brain Research through Advancing Innovative Neurotechnologies). It might have lost some of its appeal if it had come out BRANE (Brain Research by Assisting Neurology Education) or BRAN (Bowel Regulation Aided by Nutrition). Maybe it recognizes that there will ultimately be an enormous burden on our country by the need to support millions of persons with Alzheimer's, autism, and other neurologically-related illnesses and this may be the way to reduce this threat or at least make management more effective.

It is somewhat disheartening to recognize that centralized direction may not be the most effective way to produce maximized brain function. This can be illustrated by two recent examples:

1. For decades, it has been emphasized that, for quality of life, efficiency, and economy, cancer care is best delivered in the community setting. In fact, the National Cancer Institute had set up a Community Cancer Centers Program (NCCP) to promote this. However, due to recent reimbursement policies, cancer care is being driven back to large institutions where treatment is more expensive and personal attention cannot be provided to the same extent as with local centers. By last year, 166 community cancer clinics had closed over the preceding three years and this is destined to worsen. Not only was outpatient radiation oncology affected dramatically by a 9% overall reduction in the Medicare fee schedule ,but the administration of outpatient chemotherapy is on the verge of being devastated if the decrease from 6% to 4% in margin on drug reimbursement, due to the sequester, is not reversed.

2. One of the most accomplished persons in the healthcare field, Ezekiel Emanuel, who is a medical oncologist deeply involved in health policy matters and a consummate insider, had an article in the Journal of the American Medical Association on April 17, 2013,entitled "The Future of Biomedical Research." In this, Dr. Emanuel describes the following dilemma: Due to medical research, treatment techniques have improved. Due to improved treatment, patient survival has improved and cost of delivering care has increased. Due to increased costs, more resources are directed to patient care. Due to increased cost of patient care, less money is available for research. Since less money is available for research, special efforts must be made to find legislators who will champion research funding, to explain the value of research, and to work for cost control in health care.

The classic problem is that the better treatments work and the longer people stay alive, the more the medical care system costs. There's no easy way around this. When everybody died at age 70, Social Security and Medicare were solvent. Our profession is being condemned because of its own success. Dr. Emanuel is unquestionably a brilliant person, but his conclusion that biomedical research needs to concentrate on 'cost-lowering, quality-improving interventions" implies that ahead of time it is possible to know what these are. If this were the case, they would have been developed long ago! ? It's like replacing fossil fuels with alternative energy after spending billions to subsidize their development...oh, that didn't actually, work, did it? He gives the usual example of bevacizumab, which costs thousands of dollars per month and extends life by several months but doesn't cure anyone. He doesn't say, however, that this should be withheld or the drug production process should be nationalized to reduce costs -- what other solutions could there be?

At least the Moon project worked and the Genome Project worked and maybe BRAIN will be successful as well. If nothing else, maybe after the brain is mapped out it will show government officials the pathway to be able to think straight, resulting in prevention of any more bizarre, inconsistent government policies.