Rethinking Never Events

It’s a lot more fun to write about exciting new technologies, or companies in other industries that healthcare could learn from, than to pick on healthcare for its many, well-known shortcomings, but there was an article in JAMA Forum last week that I had to note and perhaps expand on: A New Category of “Never Events” – Ending Harmful Hospital Policies, by  Dave A. Chokshi, MD, MSc and Adam L. Beckman, BS (he is also an MD/MBA student). 

The concept of a “Never Event” is well known by this point.  Coined some twenty years ago by Ken Kizer, MD of the National Quality Form (NQF) and soon widely adopted and expanded, it recognizes that healthcare sometimes has egregious errors that shouldn’t happen:  the wrong foot is amputated, the wrong drug/dosage is given, surgical instruments are left inside a patient, and so on.  Organizations like The Leapfrog Group exist largely to try to measure and compare hospitals on such patient safety issues. 

Whoops

Never Events still happen, but hopefully less often.  However, Dr. Chokshi and Mr. Beckman argue that clinical events are not the only ones that should never happen, that there are several other categories that should be included as Never Events. “Hospitals should be places for healing,” the authors say, “not agents of harm—and there is precedent for addressing harm in hospitals. Now, another category of hospital behaviors should be rendered unacceptable—a different set of never events. Five are especially harmful.”

Their list:

1. “Hospitals should never pursue aggressive debt collection tactics against patients who cannot afford their medical bills;
2. A hospital should never spend less on community benefits (such as providing care to uninsured; patients or funding public health programs) than it earns in tax breaks from its nonprofit status
3. Hospitals should never flout federal requirements to be transparent with patients about the costs of their care;
4. Hospitals should never provide compensation worth less than a living for hospital workers;
5. A hospital should never deliver racially segregated medical care, whereby it systematically underserves its surrounding communities of color;”

The authors acknowledge that other healthcare organizations (they mention insurance companies and medical device makers, but could have easily included pharma, dialysis centers, certain physician practices, etc.) are similarly at fault, but felt hospitals deserved particular attention because “the fact that the majority of hospitals are engaged in 1 or more of these 5 behaviors…necessitates attention.” 

I’ve written before about shady hospital billing practices, those faux community benefits, issues with price transparency, inadequate wages for healthcare workers, and inequities in health care, so I feel pretty good about their list.  I hope the article gets the attention it deserves, and that “visionary hospital leaders” and thoughtful policymakers take appropriate action, as the authors call for.  I hope that it doesn’t take another twenty years for these five things to be seen as Never Events. 

But they’re not enough.

I don’t minimize the challenges of ending, or at least lessening those five practices, but I don’t want us to lose sight of other health-related events that we, as a society, should not tolerate.  The complete list is longer than I have room, time, or energy to fully enumerate, but here are some of the ones that should have highest priority:

Hunger: No one in America should go hungry.  Yes, we have SNAP, school lunch programs, and other efforts to make food more affordable/available, but an estimated 34 million people – including 9 million children, are still “food insecure” – never quite sure when or what their next meal might be.

    

Housing: No one in America should go homeless, or live in housing that poses risks to their health.  Estimates for both are tricky, but there is thought to be at least a half million homeless at any point in time, and another 6 million homes (with 16 million living in them) considered severely or moderately substandard housing (some estimates put the number as high as 30 million homes). 

Clean air/water: No one in America should lack clean water/air. We like to think we live in a developed country, but some 2 million people are estimated to lack clean water (and sanitation); think Jackson (MS) or Flint (MI). Even more shocking, 135 million Americans are forced to breath polluted air.   

Hiding errors: No one in America should be subject to medical errors that could have been prevented. How many medical errors are there?  Who is committing them, and why (e.g., incompetence versus situational)?  We don’t know.  Due to concerns about medical malpractice, professional autonomy, and other factors, we don’t have solid mechanisms to report errors, analyze and act on them, or to ensure that problematic healthcare professionals either get better or get out the profession.

Ineffective/harmful care: No one in America should receive care that is unlikely to actually help them. We don’t like to admit it, but most of the care we receive is not based on solid research. We don’t like to admit it, but even when such research is available, it may take years, if ever, for practitioners to adopt it.  Too much care is based on “this is how I was trained” (whenever, wherever that was) or “this is how others around me practice” (whomever, wherever that is).  “How much will I make from this?” also plays too much of a factor.

Limiting care: No one in America should be prevented from receiving care they need. “Rationing” healthcare is universally denounced by politicians, but anyone working in healthcare or receiving healthcare knows it happens all the time. It happens when people can’t afford it, it happens when tests or procedures are denied, it happens when patients are forced to only use network providers.  Not all care is appropriate (as noted above), more care isn’t always (or even usually) better, and some healthcare professionals cause harm, but here’s the thing -- the goal of everyone in healthcare should be: how do I help get this patient to the right person/place for the right kind of treatment? 

Credit: Glow Wellness/Getty Images

All of these should be Never Events in a civilized society and in a healthcare system that we’re proud of.  Sadly, they’re not, and I’ll bet that Dr. Chockshi and Mr. Beckman see their list accomplished before I see mine.  But that doesn’t mean we shouldn’t be working on both. 

Kudos to Dr. Chokshi and Mr. Beckman for broadening the issue, and it’s on all of us to make Never Events – of all kinds -- never happen.

Art Is in the Eye of the Computer

It turns out that I’ve been writing about Generative AI without even realizing there was something called Generative AI, such as articles about the robot artist Ai-Da, the AI image creator DALL-E, or patent protection for AI inventors.  Generative AI refers to AI that strives not just to process and synthesize data but to actually be creative.  It’s starting to both become more widespread and to attract serious attention from investors. 

Credit: AWP Life

James Currier of investment firm NFX sees “Generative Tech” as the next big thing: “If crypto hadn’t happened, we’d probably be calling THIS Web3.”  He distinguishes Generative AI from Generative Tech as:

Some have called it “Generative AI,” but AI is only half of the equation. AI models are the enabling base layers of the stack. The top layers will be thousands of applications. Generative Tech is about what will actually touch us – what you can do with AI as a partner.

He predicts Generative Tech will generate “trillions of dollars of value.”  I’m hoping that healthcare is paying attention.

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Let’s start with OpenAI and its DALL-E 2.  DALL-E 2 got much attention earlier in the year with its startlingly unique images, and now is more broadly available, with more than 1.5 million users.  The Wall Street Journal calls its images “amazing – and terrifying.” 

OpenAI is overseen by a non-profit company, and its mission is “to ensure that artificial general intelligence benefits all humanity,” presumably meant to draw the distinction from AI developed by for-profit companies (such as DeepMind, which is owned by Alphabet).  Its charter explicitly states that it seeks that AI/AGI “is used for the benefit of all, and to avoid enabling uses of AI or AGI that harm humanity or unduly concentrate power.”  Its “primary fiduciary duty is to humanity.”

Credit: OpenAI

Microsoft invested $1b in 2019 (in return for OpenAI using Azure as its cloud partner and giving Microsoft priority in brining new technologies to market), and The Wall Street Journal now reports that the companies are in “advanced talks” for a new round of funding. OpenAI is valued at nearly $20b.

Then there’s Stability AI, which just announced a $101 million funding round that values the company at $1b. It bills itself as “the world's first community-driven, open-source artificial intelligence (AI) company,” with a slogan “AI by the people, for the people.”  Emad Mostaque, founder and CEO, states:

Stability AI puts the power back into the hands of developer communities and opens the door for ground-breaking new applications. An independent entity in this space supporting these communities can create real value and change.

Its competitors to DALL-E are Stable Diffusion, released in August, “a powerful, free and open-source text-to-image generator” that already has been licensed by 200,000 developers, and DreamStudio, its consumer-facing image product that has a million registered users. 

A New York Times article noted that Stable Diffusion has limited safety filters, which has made it popular among artists and has led to some, shall we say, objectionable images.  Mr. Mostaque is undeterred, telling the NYT: “We trust people, and we trust the community, as opposed to having a centralized, unelected entity controlling the most powerful technology in the world.” 

He made a similar point to TechCrunch: “Nobody has any voting rights except our employees — no billionaires, big funds, governments or anyone else with control of the company or the communities we support. We’re completely independent.” 

Credit: Stability AI

Still another Generative AI company, Jasper, also scored a funding round last week, with the $125 million round valuing it at $1.5b.  Jasper bills itself as an “AI Content Platform,” including both generating text and text-to-images.  Interestingly, it uses OpenAI’s GPT-3 to power the platform. 

Jasper CEO Dave Rogenmoser says: “Generative AI represents a major breakthrough in creative potential, but it's still inaccessible and intimidating to many. Jasper is working to bring AI to the masses and teach people how to leverage it responsibly so that businesses and individuals can better convey their ideas.” 

I’d be remiss if I didn’t at least mention Anthropic, which has raised close to $800 million, or MidJourney, which boosts 3 million users taking advantage of image generator on its Discord server.  Anthropic is set up as a public benefit corporation, and is “working to build reliable, interpretable, and steerable AI systems,” while MidJourney describes itself as “a small self-funded team focused on design, human infrastructure, and AI.”  I’m sure there are others.

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Joanna Stern, writing in the WSJ, marvels: “The stuff once found in AI research labs is now making it into our homes and offices…For decades, we’ve been hearing AI is going to change how we interact with computers and the world. These tools may be the first time most of us recognize it in action.”

There’s already much concern about the “black box” of AI – we may not know how or why AI comes up with things – and the implicit biases that may be built it (e.g., most healthcare data sets will include the results of the inequities in our current healthcare system).  Stability AI’s Mr. Mostaque told NYT: “Ultimately, transparency, not top-down control, is what will keep generative A.I. from becoming a dangerous force,” and I hope he’s right – but I’m not sure he is.

I love the idea of “democratizing” AI, putting it in our homes and offices.  I like the idea that some of this is happening through non-profits, like OpenAI.  I’m highly intrigued that some of it is open source, like Stability AI.  And I’m wondering what the impetus in healthcare will be to bring it to our care and to our daily lives.

Credit: Pixabay

If Mr. Currier is remotely right that Generative Tech will unleash trillions of dollars in value, healthcare is not going to be untouched.  I’d love to see a collection of our healthcare giants – health systems, health plans, pharma, etc. – pool their data for use by a non-profit focused on AI for healthcare.  I’d like that AI not just be better supportive tools for clinicians, but also to be creative, up to and including “AI physicians,” whatever they may be.  And I think it’d be cool if much of this work could be open source and aimed at the masses.    

Mr. Currier predicts: “In the next 10 years, we will expect software to collaborate with us. It will be the new normal. Steve Jobs said in 1980 that the Apple personal computer was a bicycle for the human mind. You might say that Generative Tech is a rocketship for the human mind.” 

Buckle up: it’s going to be a bumpy ride. 

Sticks and Stones...

According to the old saying, sticks and stones may break your bones, but names can never hurt you.  I’m not sure that still applies in a social media environment that can have real impacts on mental health of both teenagers and adults, but I have to note that healthcare seems to be pretty sensitive about who calls whom what. 

I’ll start with a new study from The Mayo Clinic about whether patients addressed their physicians by their first name.  It’s a tricky thing to get a gauge on; one could do surveys of both populations, or implant observers in exam rooms, but these researchers had the clever idea of examining how patients addressed their physician when using portal messaging.  They looked at over 90,000 messages from nearly 15,000 patients, with about 30,000 messages from 15,000 patients including a physician’s name (first or last).

The researchers don’t seem to have provided an overall percent of patients using the doctors’ first name, but they did report:

• Female doctors were twice as likely as male doctors to be called by their first name;
• DOs were similarly almost twice as likely as MDs to have their first name used;
• Primary care doctors were 50% more likely than specialists;
• Female patients were 40% less likely to use first names when addressing their physician.

The authors noted that they don’t know if physicians had expressed preferences about how they should be addressed, but warned:

The pattern of addressing physicians with different titles based on gender, degree, and specialty may be forms of bias…Whether being informally addressed by other medical professionals or patients, untitling (not using a person’s proper title) may have a negative impact on physicians, demonstrate lack of respect, and can lead to reduction in formality of the physician-patient relationship or workplace.

In a New York Times article about the study, Debra Roter, an emeritus professor of health, behavior and society at Johns Hopkins’ Bloomberg School of Public Health, said: “Doctors might find it [patients using first names] is undermining their authority.  There’s a familiarity that first names gives people.”  However, doctors calling patients by their first name also carries risks, she acknowledged: “It could infantilize the patient or establish the paternalism of the doctor.”

Similarly, in an accompanying commentary, two female physicians (who were not involved in the research) state: “Use of formal titles in medicine and many other professions is a linguistic signal of respect and professionalism,” although they also add: “Such respect in professional communication should be bidirectional, as medical students learn early in training to ask patients how they prefer to be called during medical encounters.”

Most of my physicians must have missed those classes. 

I’ll note that pharmacists these days have PharmD’s, and physical therapists have DPTs, but few of us have qualms about addressing them by their first name.  Lawyers have a JD, but don’t usually insist on being addressed by the title.  University professors and judges are the only two other professions I can think of with expectations about being called by their title instead of their name.  Make of that what you will. 

I don’t know what most physicians prefer to be called, but I know what they hate to be called: providers. I don’t know how many op-ed pieces, tweets, LinkedIn posts, etc. I’ve seen over the years in which physicians complain about the practice.  It’s been associated with how the Nazis minimalized Jewish physicians in 1930’s Germany, called “a powerful tool to confuse and dehumanize a physician,” and led to warnings that “the adaptation of this terminology led to medicine being thought of only as a business, a commoditization of care.” 

Using “provider” to describe physicians, physicians say, disrespects them, understates their years of training, confuses patients, causes “moral injury” to physicians, and may lead, or at least contribute to, physician burnout.  A rose by any other name might still smell as sweet, but a doctor by that term is, apparently, catastrophic.   

I have a pretty good guess as to how physicians who object to being referred to as a provider probably feel about being called by their first name.

While we’re being sensitive, some of us have an issue with being referred to as a patient.  I’ve written before that use of the term is a design problem.  It’s an implicit expectation that we should literally be patient (think of all that time we are expected to just wait), and trust in the greater expertise of physicians; as Dr. Roter noted, it infantilizes the patient and perpetuates the paternalism in the physician/patient relationship.  Moreover, it ignores our existence outside the healthcare system, failing to acknowledge that we have lives outside of it and how those lives impact our health.

As Matthew Zachery recently wrote about the practice, “We are no longer people.”  He goes on to elaborate:

We are products on a shelf, numbers on a page, ink stains on a fax transmission, and zeroes and ones existing only in data centers polluting the earth with their carbon footprints. Patients today are loss-leading, actuary-derived, health-economic meat on a stick.

And to think that some physicians believe that it is using “provider” which led to the commercialization of health care.

Mr. Zachery prefers the term “consumer,” as does my friend Jane Sarasohn-Kahn, but I have to admit that I don’t like that term much better.  We don’t do much intelligent shopping in health care: we don’t really have the right tools, not much in the system is oriented towards encouraging us to try, and there are too many health episodes when we have neither the time nor inclination to consume wisely. 

The bigger problem, as I’ve also written about before, is that, forget healthcare: we’re not really very good consumers of anything.  The concept of a “rational consumer” is a “myth,” says psychologist Peter Noel Murray.  We’re swayed by too many superficial factors that often bear little relevance to quality or value, whether that is healthcare, mobile phones, or automobiles.    

Patients as patients, consumers, or what?

So here’s where I come down: to all the people working in healthcare, or those using healthcare services, who have issues with what they are called: get over it. If that’s the problem in healthcare you are focused on, you are focusing on the wrong problem.  Healthcare has much bigger problems, that need more immediate solutions, and I hate that anyone is spending any extra time or emotional energy on this particular issue.

Treat people with respect; treat them as individuals, whether they are doctors, people receiving services, the person cleaning up, or anyone else.

Better Living Through Better Design

We’re almost two weeks past Hurricane Ian. Most of us weren’t in its path and so it just becomes another disaster that happened to other people, but to those people most impacted it is an ongoing challenge: over a hundred people dead, hundreds of thousands still without power, tens of thousands facing a housing crisis due to destroyed/damaged homes, and estimated $67b in damages.  It will take years of rebuilding to recover. 

Credit: International Union of Architects

In the wake of a natural disaster like a hurricane – or a tornado, a flood, even a pandemic – it’s easy to shrug our shoulders and say, well, it’s Mother Nature, what can we do?  There’s some truth to that, but the fact is there are choices -- design choices -- we can make to mitigate the impacts. A Florida community called Babcock Ranch helps illustrate that.

Babcock Ranch is located a few miles inland from Ft. Myers, which was devastated by Ian.  It bills itself as “America’s first solar-powered town,” with an impressive array of almost 700,000 solar panels. More than that, it was built with natural disasters in mind: all utilities are underground, it makes use of natural landscaping to help contain storm surges, streets are designed to divert floodwaters, making use of multiple retaining ponds.

Credit: Babcock Ranch

It survived Ian with no loss of power, no flooding, and no major damage.  Its community center is serving as a refuge for people from communities that were not as fortunate. A spokesperson for Syd Kitson, the man behind the development, told CNN: “It’s a great case study to show that it can be done right, if you build in the right place and do it the right way,”

Mr. Kitson told 60 Minutes: “So as soon as the sun came up the next morning, I jumped in my car and I started driving out. And the only damage were a few down trees and a few shingles off the roofs. That's it. And so our recovery was maybe a day.”

Good luck, or good design?  As NPR said about one Babcock Ranch family whose home escaped damage: “But it wasn't just luck that saved Wilkerson and his wife, Rhonda, or prevented damage to their well-appointed one-story house. You might say that it was all by design.”

The project was begun in 2015, with first residents moving in in 2018.  It currently has some 2,000 homes – ranging from condos to starter homes to estate houses – and 5,000 residents (which Mr. Kitson expects will grow to 50,000).

Jennifer Languell, a sustainability engineer who helped design the project and now lives there, told NPR:

We felt you could develop and improve land, not just develop in a traditional way where people think you are destroying the land.

The things that we do, you don't see. The strength of the buildings, or the infrastructure that deals with stormwater, or the utilities. You don't see that stuff.  Which is good, because most people don't need or want to think about it.

One could argue, well, Babcock Ranch was further inland, it had more recent construction with more stringent building codes, it didn’t have mobile homes, it wasn’t built in floodplains.  To which I’d argue: Those. Are. Design. Decisions. 

Babcock Ranch was designed not just to withstand hurricanes but also:

…to offer residents multiple ways to improve their physical and mental wellbeing. From the Lee Health Healthy Life Center, to carefully planned greenspaces and nature trails, to our robust resident programming, there are countless ways to get active, expand your social circle, and build a life that positively shapes your overall wellbeing.

It’s all about design, about the choices we make…or don’t think to make.

As hurricane damage goes, not so bad Credit: Nancy Chorpenning/CNN

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I’ve been thinking about the role of design in health since I was fortunate enough to get to know Steve Downs, then at Robert Wood Johnson Foundation and now at Building H. Back in 2017 he wrote about how it was important to “build health into the OS of our daily lives.” As the Building H website warns:

Modern life is great at making us happy – in the short term.

In the long term, it’s killing us. By design.

 

From cheap calories to free freeways, from second cars to second refrigerators, our everyday environment is engineered for convemience, passivity, and gratification.

The result: An epidemic of obesity & diabetes, depression & chronic pain.

 

And if you’re thinking healthcare can solve this…you’re already too late.

To this point, The New York Times recently reported about how trying to contain the epidemic of diabetes through medical care is doomed to failure.  In words Steve would agree with, Dr. Dean Schillinger, a professor of medicine at UCSF, told NYT: “Our entire society is perfectly designed to create Type 2 diabetes. We have to disrupt that.”

The article further asserts:

There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care, particularly in minority communities.

Dr. Schillinger was one of numerous experts who was part of the National Clinical Care Commission, which issued a report earlier this year urging Congress to put more focus on the social and environmental factors that contribute to diabetes and make managing it more difficult. They called for a “health-in-all-policies” approach, whether those are health, housing, nutrition, or environmental policies.

Credit: National Clinical Care Commission

As Dr. Schillinger told NYT:

It’s about massive federal subsidies that support producing ingredients that go into low-cost, energy-dense, ultra-processed and sugar-loaded foods, the unfettered marketing of junk food to children, suburban sprawl that demands driving over walking or biking — all the forces in the environment that some of us have the resources to buffer ourselves against, but people with low incomes don’t.

Steve would urge that this approach should not just apply to diabetes.   

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Babcock Ranch isn’t Utopia.  I doubt there aren’t many low income people there. I suspect it doesn’t have many people of color. I’d be interested to know what happens to its sewage and trash. Its residents probably still drive too much, eat too much (of the wrong foods), and get too much medical care.  It may have survived Ian very well, but it is still in Florida, where there will always be another hurricane, which might prove more damaging.

But still.  Babcock Ranch is an example that design can make a difference in our lives, in our safety, and in our health.  Let’s hope it doesn’t take too many more disasters for us to learn that lesson.   

About That Cancer Moonshot...

Joe Biden hates cancer.  He led the Cancer Moonshot in the Obama Administration, and, as President, he reignited it, vowing to cut death rates in half over the next 25 years.  Last month, on the 60^th anniversary of President Kennedy’s historic call for an actual moonshot, he vowed “to end cancer as we know it. And even cure cancers once and for all.”

Credit: Evan Vucci/AP

But, as several recent studies show, cancer is still surprising us. 

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Our body has its own defenses against cancer, such as T-cells, and great strides have been made in cancer therapies, including immunotherapies.  Still, though, as first author of a new study from Tel Aviv University, Amit Gutwillig, pointed out: “Despite its remarkable success, the majority of patients who receive immunotherapy will see their tumors only shrinking in size temporarily before returning, and these relapsed tumors will likely be resistant to immunotherapy treatment.”  

One reason, it turns out, is that some cancer cells have learned to hide – in other cancer cells.

The research found: “While the outer cells in this cell-in-cell formation are often killed by reactive T cells, the inner cells remain intact and disseminate into single tumor cells once T cells are no longer present.”  Sneaky little bastards.  Or, as Professor Yaron Carmi, who heads the lab, told The New York Times, “It was like seeing the devil.”

Cancer cell hiding. Credit: Carmi & Gutwilling/The Carmi Lab

This is groundbreaking stuff.  The authors conclude:

Overall, the ability of tumor cells to transiently enter and disseminate from each other in response to T-cell killing is a biological process that has never been described heretofore. It better explains how immunogenic tumors can survive in the host and provides a novel framework for immunotherapies

This may point to the need for new approaches.  Dr. Carmi believes:

This previously unknown mechanism of tumor resistance highlights a current limitation of immunotherapy.  Over the past decade, many clinical studies have used immunotherapy followed by chemotherapy – but our findings suggest that timed inhibition of relevant signaling pathways needs to occur alongside immunotherapy to prevent the tumor becoming resistant to subsequent treatments.

As interesting as the findings are, the NYT article suggests caution: “it remains to be seen whether it will lead to improvements in the treatment of cancer patients.”

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The next set of studies are, if anything, even more startling.  It turns out that cancer has a microbiome.  And a mycobiome.  Cancer tumors are filled with microbes, particularly fungi. 

Two studies published in Cell last week document the presence of fungi in cancer tumors. The first study looked at 35 types of cancers – and found fungi, in varying degrees, in all of them.  In many cases, they were coexisting with bacterial colonies (the presence of bacteria in cancer tumors had already been uncovered in the past five years).

Credit: Narunsky-Haziza, et. al./Cell

First author Lian Narunsky Haziza, of the Weizmann Institute of Science in Israel, told the NYT: “I think this is an ecosystem.  It means the cancer cells are not alone.”

It's not so much there are huge amounts of fungi present, but as STAT put it, “why are they there? And how did they get there?”  Amit Bhatt, a professor at Stanford who was not involved with either study, told STAT; “Or maybe there are immune cells that ate fungi and carried sequences to a tumor site.  Or maybe since you have a trillion microbes in and on you, it’s just not surprising that every now and then one makes its way into the body.” 

However they got there, Illana Livyatan, one of the researchers, notes: “Fungi can be food for bacteria and vice versa. They can even live within bacteria or bacteria can live within fungi. They can do a lot of biochemistry. Any of those avenues might have an effect.” 

A second study, looked specifically at fungi in gastrointestinal, lung, and breast cancers, and its findings suggest that presence of certain kinds of fungi are correlated with lower survival rates.   It’s not clear why.  The NYT article notes: “It’s possible that some microbes don’t just take up residence in tumors but help them grow. They may cloak the tumor from the immune system, neutralize drugs or help tumors spread through the body.”

Credit: Dohlman, et. al./Cell

Deepak Saxena, a microbial ecologist at New York University who was not involved in either study, told Nature that “more work is needed to understand whether fungi can contribute to cancer progression by causing inflammation, for example, or if advanced tumours create a habitable environment that encourages fungal cells to take hold.”

Dr. Saxena also told the NYT: “I was not expecting this amount of fungus in cancer.  This will change the way we think about it.”  Dr, Bhatt concurs, telling Stat: “We don’t have the experiments to present a causal link between tumor initiation or progression and fungi. But this really encourages future research to think about designing experiments with microbiome and mycobiome investigations in mind.”

Co-corresponding author Ravid Straussman, MD, PhD, from the Weizmann Institute of Science, added: “The finding that fungi are commonly present in human tumors should drive us to better explore their potential effects and re-examine almost everything we know about cancer through a ‘microbiome lens.”

Dr. Livyatan is optimistic about the potential applications, telling The Times of Israel: “This could offer a new avenue for diagnosis of cancers using a simple blood test that detects fungi in tumors.  And beyond diagnostics, this could really shake things up in tumor research. This is one of these eye-opening moments that makes us revisit our assumptions about cancer, as fungi now represent a whole new consideration in analyzing tumors.”

We’ve only been scratching the surface at understanding the presence of our microbiome/mycobiome, much less its effect on our health, so to just now realize that we need to look at cancer through that same “lens” just illustrates how far we most likely are from “ending cancer.” 

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Cancer cells hiding in other cancer cells, cancer cells cohabiting with fungi and bacteria; who knows what else there is left to surprise us about cancer (and other illnesses)? It’s an admirable goal that President Biden wants to end cancer “as we know it;” the problem is, we may not really know it all that well yet.