Why Calculators Are the Future of Medicine

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[this is a post I did for TheHealthcareBlog, crossposted here]

Want to know the future of medicine and healthcare in one sentence?

For my money, it goes like this: The real opportunity in healthcare is to combine our personal data with the huge amount of general biomedical and public health research, in order to create customized information that's specific to our person and our circumstance. We need relevance, and the right information at the right time will help us make better choices for prevention, helping us stay healthier longer, it'll help us navigate diagnosis, letting us select screening tests that are useful and not unnecessarily fearful, and it'll let us make better decisions on care and treatment - when we're trying to choose among various treatments to find our way back to health.

It's in the last category - care and treatment - that I wrote a recent post at the Huffington Post about one man's story with prostate cancer. Tom Neville got a diagnosis and then had to struggle to find information to help him make sense of what to do. Ultimately, he chose surgery, but the difficulty of the choice led him to create Soar Biodynamics, a company that offers decision-making support for men assessing their prostate health.

You can read his story here and learn more about his tool here, but for the purposes of this post I wanted to consider the kind of decision-making tool he created. It's called a nomogram, and it's one of my favorite discoveries in researching The Decision Tree.

A nomogram is basically a calculator - a way to assess our risk or outcome for a particular condition. A nomogram starts with an interface where a few telling datapoints can be entered, and then turns to an algorithm that crunch those numbers together with broader data about the condition. The result is a statistical prediction - the prediction can concern the outcome of the disease, or it can be a recommendation for particular treatment (a medical nomogram is not to be confused with mathematical nomograms, which are tools for calculating geometrical something or others).

The Framingham Risk Calculator, which calculates your risk of heart disease, is a kind of nomogram. Memorial Sloan-Kettering Cancer Center, the research institute and hospital in New York City, has developed almost a dozen nomograms for a range of cancer conditions. There are tools for predicting the spread of breast cancer, a tool for assessing lung cancer risk among smokers, a tool for predicting the prognosis after colon cancer surgery, and more. Dr. Pierre Karakiewicz at the University of Ottawa has developed nomogram.org, which offers prediction calculators on four different types of cancer. Nomograms are one of the best examples of Decision Tree thinking, the sorts of tools that are easy for patients and doctors alike to use and understand—particularly when they’re available online and free of charge. They're brilliant and auspicious because the turn research around so that it faces the patient: An individual can interrogate medical science for how it applies to his specific circumstances, rather than having to navigate through stacks of research papers and findings for some wisp of relevance.

Nomograms are especially powerful when they’re combined with a screening test, because they help people understand what to make of the test and point to what to do with the result. They immediately customize the clinical data, be they nanograms-per-milliliter figures or spots on mammograms. Nomograms let patients ignore the inscrutable repository of jargon that is medical research in favor of something personal, something real, and something to go on. They allow us to make sense of a screening test’s result, and allow us to take some measure of meaning from it.

The University of Texas at San Antonio, for instance, has developed a prostate risk calculator that lets a man enter his PSA level along with his age, race, family history, and a couple of other metrics and churns out his risk of developing prostate cancer. Importantly, the calculator also calculates the risk of a high-grade cancer, accounting for the fact that not all prostate cancers are lethal. The value of such a tool, says Ian M. Thompson, professor and chairman of the department of urology at the University of Texas Health Science Center at San Antonio, who developed the calculator, is that it turns the PSA figure from one isolated data point into one of many inputs. “We need to build in characteristics about the person, their age, their race, their family history,” says Dr. Thompson. “It’s not just what one test tells us.”

Nomograms, of course, are no substitute for a doctor's definitive assessment and treatment (or better yet, more than one doctor). And they are only as good as the data that goes into them; if they're not kept up to date on the latest information and research, they can lead people astray. But especially for conditions where we have some agency - where we can take actions today that can enhance our tomorrow - they are a terrific tool.

The catch with nomograms is that they must be developed one disease at a time, which means they don't scale up so well. Each one takes a great deal of work and expertise. But if I had millions of dollars for philanthropy, I'd spread it around to smart researchers across a lot of fields where nomograms could help people assess their risk for disease and potentially take actions today. It would be money well spent.

Calculator image via Flickr by Ian Ruotsala