Bariatric surgery for diabetes deemed Cleveland Clinic’s top medical innovation for 2013

What innovations will change the course of medicine over the next 12 months?

Each year, the Cleveland Clinic makes its predictions in the form of its Top 10 Medical Innovations list. This year’s list contains no surprises, with technology that addresses some of the country’s biggest problems including diabetes, pain, hospital-associated infections and cancer.

A committee interviewed more than 100 Cleveland Clinic physicians and researchers, screened their nominations and presented them to two panels of leading physicians who discussed and voted.

Because of conflicts of interest with its doctors and many of the technologies discussed, the Clinic doesn’t name companies, just technologies. So any companies you see mentioned have been inferred by the writer.

10. Healthcare programs with monetary incentives: About 75 percent of deaths each year are related to complications of cardiovascular disease, obesity, diabetes and cancer, many of which are preventable with better health behaviors. It’s expected that getting people to engage in preventive health practices and live healthy lifestyles will drive down health costs. “If we can share some of those savings and use a monetary incentive to get people to make the right choices, we will be well on the road to wellness and health in this country and significant savings down the line,” said Dr. Bruce Rogen, chief medical officer of the Clinic’s employee health plan.

The Clinic has been running an employee incentive program, and more than 60 percent of employees with chronic diseases are participating in health management programs, Rogen said, and save up to $1,300 a year when they meet their objectives. A bill to introduce these kinds of wellness incentives to Medicare has also been presented to Congress.

9. Breast tomosynthesis: Mammography remains the gold standard for breast cancer screening, despite a high rate of false positives and missed cancers. Tomosynthesis, or 3-D mammography, isn’t meant to replace that but to build on top of it to allow better visualization of tissue, especially in women with dense breasts. It doesn’t eliminate other concerns about mammography, like patient discomfort or exposure to radiation, but studies have shown an increase in cancer detection and a decrease in recall rate. Startup costs for the technology depend on whether new equipment is needed or just a system upgrade. 3-D mammography systems from Hologic are U.S. Food and Drug Administration approved and on the market.

8. Modular devices for treating complex aneurysms: As many as 40 percent of patients with aortic aneurysms can’t be treated with the stent graph treatments currently on the market and are not eligible for open surgical repair.  A new, off-the-shelf fenestrated stent graft system recently approved for trials in the U.S. could expand this successful technology to high-risk patients who couldn’t previously be treated, said Dr. Daniel Clair, the chair of vascular surgery at the Clinic.

7. Ex vivo lung perfusion: Donor lung shortage is a major limiting factor in treating disorders of the lungs. But data suggests that as many as 40 percent rejected donor lungs could be made transplantable with this technology, which draws water out of the lungs to reverse injury in many lungs considered previously unsuitable for transplantation. “And that number might be a conservative estimate,” said Ken McCurry of the Clinic’s Thoracic and Cardiovascular Surgery Department. The procedure is already approved in Canada and Europe, and is undergoing trials in the U.S. “We hope that by the end of this year it will be approved by the FDA,” McCurry said. “A lot of us see this as a platform that we could use to modify organs and improve long-term outcomes.”

6. Femtosecond laser cataract surgery: Cataract surgery is the most commonly performed surgery in the U.S. and is regarded as a safe and effective way to replace clouded lenses in the eye. The problem is, it’s done freehand, so minute movements of the patient can cause errors. Femtosecond laser technology reduces procedure time and could potentially improve the procedure. “It has the speed and the accuracy, and the precision that we don’t have currently,” said Dr. Rishi Singh of the Cole Eye Institute. “It’s also very targeted to make these incisions on the front of the eye.” The big question that remains is whether it will improve outcomes over time, as it’s only currently being used in five centers in the U.S., Singh said. At least three companies have technology that is FDA approved for use in this procedure.

5. Hand-held optical scan for melanoma: A hand-held device that dermatologists can have in their offices uses imaging technology to analyze suspect lesions, providing doctors with extra information that helps them identify melanoma and order biopsies. In a trial of 1,300 patients, Verisante’s Aura device found 98 percent of melanomas. The Clinic’s chair of the Department of Dermatology, Allison Vidimos, said previous devices that have looked at noninvasive imaging for melanoma have not been as good at finding it at such an early stage.

4. Novel medications for advanced prostate cancer: Androgen deprivation therapy is the standard of care for advanced prostate cancer, but it is not curative. In the past two years, five new drugs for prostate cancer have been FDA approved (abiraterone, enzalutamide, sipuleucel-T, denosumab and cabazitaxel), with a sixth expected later this year (radium-223 dichloride). “The genomic revolution has really led us to better understand the biology of prostate cancer,” said Eric Klein, chair of the Glickman Urological and Kidney Institute. “They take men with the worst cancers and they make them live longer.” Klein said he feels the medical community is on the verge of a cure, but still faces challenges with diagnosis. “The biggest problem we face in prostate cancer is the over-detection of nonlethal cancers,” he said. “Currently, we don’t have the tools to tell someone whether they have a lethal one or not.”

3. Mass spectrometry for bacterial infections: Clinical microbiology labs can perform tests that identify bacterial infections, but not all hospitals have these labs so they must send tests away and wait for their return. A 2002 Nobel Prize-winning technique called MALDI improved mass spectrometry to make growing and testing bacteria quicker, cheaper and more accessible. Kandice Marchant, chair of Pathology and Laboratory Medicine Institute, said that although equipment for this kind of protein analysis is not cheap, the low cost of labor and supplies as well as saved time makes it ready for widespread use.

2. Neuromodulation therapy for cluster and migraine headaches: The sphenopalatine ganglion nerve bundle has been a target for the treatment of severe headaches for years, but current treatments are short-lived. A new on-demand, implantable stimulator developed by Autonomic Technologies Inc. aims to provide side effect-free relief for headache pain. The almond-sized device is placed in the upper gum through a minimally invasive procedure, and the patient places a remote-controlled device against his cheek to deliver stimulation when he feels pain coming on. It’s approved in Europe and is in clinical trials in the U.S. (in collaboration with the Clinic).

1. Bariatric surgery for control of diabetes: Diabetes has been treated the same way for a decade, and although we have seen advances in pharmacotherapy, less than half of type 2 diabetics achieve good glycemic control, said Phil Schauer, director of the Bariatric and Metabolic Institute. Over the years, doctors have observed diminished type 2 diabetes associated with weight-loss surgeries.  Two studies published this year in the New England Journal of Medicine delivered evidence that bariatric surgery worked better than standard therapies for type 2 diabetes in obese and overweight people over the long term. “A lot of these patients, before they even leave the hospital, can be weaned off of their insulin,” Schauer said. “There’s something else going on besides weight loss.” Schauer said researchers are studying different factors including hormones that could be affected by these surgeries.  Although it’s expensive up front, bariatric surgery could pay off in the form of reduced need for care, medication and supplies within a few years. “We need to do more detailed studies to determine how these procedures work,” he added.

[Photo from Flickr user stevendepolo]