The following questions were posed to the attendees of the 2000 Miami Breast Cancer Conference. The percent of attendees responding is shown along with comments from two faculty members, Dr Patrick Borgen and Dr Andrew Seidman.

General Questions

1. How often do you . . .

A. use e-mail for any purpose?
B. access the Internet for medical purposes?

Andrew Seidman, MD

The use of e-mail has become ubiquitous. I use it every day. If I take a day off on the weekend, I consider that a vacation. It has changed the way both academic and community-based oncologists live. There's a lot of work that we get done more efficiently by the use of e-mail. Some of us prefer answering questions in our own time and on our own schedule and be in control of the length of our response. E-mail is a way to control the situation. I encourage colleagues, if they have straightforward questions, to just e-mail them to me.

I think there's also a potential that e-mail could be used in the patient-physician relationship, although I've really stayed at arm's length away from that. I think it's a floodgate and, when it's opened, there's this incredible potential for it to become so consuming that physicians might not have time to do anything but respond to patients' e-mail inquiries.

Patrick Borgen, MD

E-mail is rapidly becoming the preferred method of communication. People don't want your phone number anymore, they want your e-mail address. In a place like Memorial where you've got 80 doctors involved in breast cancer, it used to take several weeks to meet and address a simple question about a consent adjustment or some other detail. Now, it's done in five minutes with e-mails. We use it five or six times a day in a practice like ours.

We actually set up a consult service for our former fellows via e-mail so that when they go out into practice and realize that most of their lives are not Whipples but breast biopsies, they can e-mail us and say, "What about LCIS with such and such margins? Should I re-excise this patient?" It's hard to imagine how we lived without it before.

Never mind if you and I are on the Internet. Our patients are on the Internet, and what we are learning is that about half of what they are exposed to we would disagree with. This is really the source of a lot of concern for us. In these chat rooms they're getting medical advice from who knows who, or they are looking at a website that wasn't updated since 1994 or simply opinion rather than fact. So, helping patients sort this out is going to be important.

2. What do you consider the greatest impediment to physicians participating in Phase III randomized clinical research protocols in breast cancer?

Andrew Seidman, MD

At Memorial, we're piloting alternative ways of providing informed consent. The idea that patients don't like to be randomized is not a new one, and there clearly are geographic and even ethnic variabilities.

When explaining randomized trials to patients, physicians need to be very clear that the control arm is felt to be at least standard treatment and that the experimental arm or arms are felt to be possibly superior.

Patients fear that in departing from standard treatment they're going to do themselves a disservice. They need to understand that these studies were designed not only to be scientifically rigorous but to be ethically valid. Patients wouldn't be asked to be randomized to a treatment that would be expected to be inferior. Quite the contrary, they should be aware that the experimental arm or arms very well may be superior.

It may be convenient for physicians to turn this around and say that patients don't like to be randomized. More frequently, physicians just don't have the time, and they're pressured to get their job done. The practice of medical oncology is demanding, and it cannot be like a fast food process. Patients need time, and medical oncologists are seeing more and more patients. Something has to give somewhere. It is not that medical oncologists do not value clinical research, but this is not often the key ingredient that's necessary for their survival.

Patrick Borgen, MD

We found is that the busier a clinician is, the less likely he or she is to accrue patients to any kind of trial. In my opinion, time is absolutely the rate-limiting step to accrual to trials.

It's true that patients may be biased against a trial, but in general, whether it's a New York patient or a Miami patient, if they believe that the physician's heart is in the trial and they think it's a win-win for them, they usually will participate.

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