Stanford Report, January 12, 2005

THE YEAR AHEAD: 2005 forecasts: new cancer therapies, surgical robotics and better sex

Predicting the future is tricky business, but one can certainly try to make some educated guesses about the year ahead. Medical Center Report asked seven members of the medical school faculty to peer into the future and forecast some trends and advances for 2005. Here are brief summaries of what they offered.

CANCER

Steven A. Leibel, MD, FACR, professor of radiation oncology and medical director of the Stanford Cancer Center

In 2005, doctors will pioneer the use of advanced image-guided radiation therapy to enhance the potential for cure in several types of tumors that had previously been considered resistant to radiation therapy.

The recent emergence of molecular imaging has opened the door for noninvasive approaches that define with incredible detail the biological features and location of patients’ tumors—and that then allows doctors to pursue specific radiation therapies to zero in on cancer cells with greater precision than ever before.

At Stanford, doctors will begin using a simulator that combines PET and CT scans to create three-dimensional anatomical and metabolic images that pinpoint a tumor’s position and distinguish tumor tissue from normal tissue structures. With these images in hand, doctors will be able to apply the latest radiotherapy delivery systems, such as the Varian Trilogy linear accelerator and the CyberKnife, to produce dose distributions around tumors that correspond to the images’ data, with rapid diminution of the dosages at the transition from the tumor to the adjacent normal tissues.

What this means is that patients with cancers of the head and neck, lung, pancreas, liver and kidney and with tumors of the brain and those arising around the spinal cord will have options for radiation therapy in 2005 that could drastically change the course of their lives.

EDUCATION

Julie Parsonnet, MD, senior associate dean for medical student education and associate professor of medicine (infectious diseases and geographic medicine) and of health research and policy

The rapid expansion in medical knowledge over the last decade has forced medical schools to reconsider what they teach and how they teach it. With so much to learn and so little time, medical schools risk scratching the surface of a wide expanse of knowledge without fostering intellectual engagement. This risk is magnified by the “googling” of knowledge. Why learn what can be gleaned (and then forgotten) in a 15-second interaction with a handheld computer? Yet, this “Google” approach—increasingly common among students—can sacrifice context for quick facts.

To prevent cookie-cutter superficiality, medical schools of the future will focus less on knowledge acquisition and more on skills, specifically skills to investigate deeply at the bedside, at the research bench and at the desktop. Pedagogical tools to teach these skills will include strengthened individual mentorship experiences, broadened use of patient-care simulation exercises and development of interactive learning with health professionals, scientists and others previously outside the sphere of medical education.

At Stanford, these currents have stimulated the formation of a scholarship-centered curriculum (the Scholarly Concentration), the development of a Program for Immersive and Simulation-based Learning and the formation of interdisciplinary institutes that aim to stimulate a new generation of creative thinkers.

INFORMATICS

Henry Lowe, MD, senior associate dean for information resources and technology, director of the Stanford Center for Clinical Informatics, and associate professor (research) of medicine

Last year President Bush set the goal that within 10 years every American must have a personal electronic health record, and he created a new sub-cabinet position of Health Information Technology Coordinator to implement this initiative. The electronic record has the potential to significantly improve human health by making critical information available to providers anywhere anytime, by helping to reduce medical errors and by improving the overall quality of the care provided. It will be a major focus of work in the coming year, and Stanford will participate in the research, development and training related to this important national initiative through its new Center for Clinical Informatics.

Informatics will also have a significant impact in 2005 on translational and clinical research. There is increasing realization, in part based on the conclusions of a report from the National Academy of Sciences, that effective translational research depends upon the development of an informatics infrastructure that can effectively integrate clinical and research data while providing robust, standards-based data management services. The medical school has embarked on such an initiative with its new Stanford Translational Research Integrated Database Environment system, which will integrate a wide variety of clinical and research data within a large-scale, secure, HIPAA-compliant data management environment.

STEM CELLS

Theo Palmer, PhD, assistant professor of neurosurgery

This spring the California Institute for Regenerative Medicine, established by Proposition 71, will begin dispersing $3 billion in grants to fund stem cell research in California. This new source of funds will bring significant changes to stem cell research in 2005.

Stanford researchers have already begun assembling grant proposals and establishing working groups to take advantage of the new funds. For many labs, this will mean a chance to expand existing areas of stem cell research and pursue new research using cell lines that are restricted by federal funding guidelines.

These restricted human embryonic cells are available without fees, unlike the approved stem cell lines, and many were generated using improved methods that make them more suitable for use in medical applications. Although it might be too soon for results from experiments using these cells in 2005, many labs will likely have begun working with new cell lines to treat Parkinson’s disease, diabetes or stroke damage in the brain.

Prop. 71 also opens the door to creating new embryonic stem cell lines using nuclear transfer. No labs at Stanford are currently pursuing this line of research, but with funding available some groups may begin working with outside labs to bring this technology to Stanford.

Ongoing projects will also see advances in 2005. This year should bring progress in the search for cancer stem cells—cells that fuel cancer growth and are likely targets for cancer therapies—and new insights into how these cells replenish themselves. Other work may provide insights into how stem cells may be able to replace cells damaged by disease.

SURGERY

Thomas M. Krummel MD, Emile Holman Professor and chair of surgery and the Susan B. Ford Surgeon-in-Chief at Lucile Packard Children's Hospital

While the Department of Surgery is a federation of distinct clinical divisions—including emergency medicine, general surgery, pediatric surgery, plastic and reconstructive surgery, multi-organ transplantation and vascular and endovascular surgery—there are a number of trends that span all of them.

In 2005, we’ll see more use of minimal-access techniques and surgical robotics. Many of our faculty have already pioneered advances in laparoscopic, minimal-access, catheter-based, image-guided and robotic techniques, and in the coming year there will be new applications that may enhance patient care as well as provide fertile ground for research. There also are likely to be new developments in the coming months in the field of tissue engineering and replacement biology. Based on research from the different divisions in the Department of Surgery, laboratories have already developed cellular and tissue replacements for patients, and this work will undoubtedly expand even further.

On a broader policy note, those working in the areas of emergency medicine and trauma surgery are likely to feel increased pressure on our already stretched capabilities as a result of for-profit hospitals fleeing this space. The most notable example locally is the closing of San Jose Medical Center, but the problem extends beyond Stanford and the Bay Area and unfortunately, over the next year, is going to grow worse nationwide.

The creation of a surgical component in the Biodesign Innovation Program, which seeks to encourage the invention and patenting of new concepts and techniques, points to another avenue of advancement: the increased application of engineering to medical science. In this instance, a two-year fellowship, focused on identifying new technologies based on the needs of surgical patients, will undoubtedly strengthen the Department of Surgery’s links to the Department of Bioengineering and the Bio-X Program.

TRANSPLANTATION

Carlos Esquivel, MD, PhD, the Arnold and Barbara Silverman Professor in Pediatric Transplantation, chief of Lucile Packard Children’s Hospital Division of Multi-Organ Transplantation, and associate director of the Stanford Institute for Immunity, Transplantation and Infection

Solid organ transplantation is a young discipline that has evolved into a dynamic field in medicine. It was only 50 years ago that Joseph D. Murray, MD, performed the first successful kidney transplant, between identical twins, later earning him the Nobel Prize for Medicine. While transplantation of the heart, lung, liver, intestine, kidney or pancreas has become a common event in many hospitals, two main challenges have emerged: the shortage of organs and the side effects of drugs used to suppress the immune system so that it will not reject the donated organ.

During 2005, we will witness a continuing effort for increasing organ donor awareness in our country. Because of our ethnic diversity and varying cultural beliefs, education programs to enhance organ donor awareness will be tailored to more effectively target specific ethnic groups, but at the same time these programs will be sensitive to their spiritual needs. The policies for organ allocation also will be further refined to pursue a more equitable system and to develop deterrents for the commercialization of organs.

The other challenge relates to the side effects of the immunosuppressive drugs. During the next year, newer and more selective drugs will be undergoing phase-I and phase-II trials. By having more selective drugs, the goal is to create an effective immunosuppression, but avoiding the side effects. Induction of tolerance (no need for immunosuppression) will continued to be pursued with utmost interest; however, immunotolerance will unlikely be conquered during the next year.

Finally, at Stanford, the initial stage of development of the Institute for Immunity, Transplantation and Infection will take place during 2005. The principal goal of this institute is to create a venue where scientists from different disciplines will collaborate in translational research and educational programs to develop innovative protocols for:

- The prevention and treatment of infectious diseases that affect millions of people worldwide such as HIV, malaria, tuberculosis and others.

- The prevention and treatment of autoimmune diseases such as asthma, arthritis and many others.

- The induction of immunotolerance in transplantation (the “holy grail”) and the creation of artificial organs.

WOMEN’S HEALTH

Mary L. Polan, MD, the Katharine Dexter McCormick and the Stanley McCormick Memorial Professor and chair of obstetrics and gynecology

Very little is currently known about female sexual function and therefore the 43 percent of women with sexual dysfunction lack both adequate diagnosis and treatment. New studies on brain activation patterns during sexual function will define and clarify differences between male and female arousal patterns allowing the potential for new therapies for female sexual dysfunction, thus enhancing women’s control over their sexual and reproductive lives.

Another area in which progress is likely to be made in 2005 is urinary dysfunction. Many women develop this problem as they age, particularly after childbirth and after surgical trauma. This debilitating situation confines women to home and enormously impacts their social interactions. New information on the physiology and structure of the urinary and vaginal tract will shed light on why some women become incontinent and how these women could better be prospectively diagnosed and treated.

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