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October 2003

How Laboratory Test Analysis Alters the Course of Life
The Importance of a Medical Detective Mindset to Achieve an Early Diagnosis, Proper Evaluation and Successful Treatment
By Stephen B. Strum, M.D., Medical Oncologist Specializing in Prostate Cancer

A Practical Application of the Above Concepts
All of the above serves little or no purpose if we cannot elevate the utilization of what we garner from testing biological systems. It gets back to the issue of translational medicine. The proof of the pudding when it comes to the laboratory is not just the eating, but also the assimilation of information and its utilization. How then, can the empowered patient utilize what has been discussed in the foregoing sections regarding laboratory testing?

1. Take Advantage of Biomarkers
Understand that your body and mind sends out millions of signals every moment. These are more or less specific to body systems but are clearly interlinked in truly integrative circuits (upper portion of Figure 1). At the present time, we have an expanding repertoire of laboratory and other markers of biologic activity involving history and physical examination, pathology testing and radiologic studies. If these are available to you, then use them.

2. Confirm a Medical Problem with Concordant Testing
If you appear to have a particular diagnosis or a change in the status of an existing illness, investigate to see if there are corroborating tests available. Enhance the accuracy of any clinical evaluation by using the principle of concordance. If it looks like a zebra, sounds like a zebra, has stripes and four legs, and runs like a zebra, it is probably a zebra.

3. Validate Critical Laboratory Test Results
If your medical situation is such that you are at a juncture that is possibly critical, then repeat any result that comes back abnormal or different from a previous result. This confirmation process may require you to obtain a third value as a “tie-breaker.” Use your common sense to ascertain whether you have a situation that appears to be going from good to worse. If the laboratory interpretation requires the expertise of a recognized expert, obtain such consultation. Search for the people of special talent. Don’t ignore signals from the body or mind. Listen to your biology!

Table 2: The Flow Sheet. The flow sheet uses the dimension of TIME to show how treatment or simply observation may be affecting a biomarker (response parameter). The front of the flow sheet is focused on the laboratory parameters. This is done in the context of also listing the patient’s current medications and their doses in order to determine if any laboratory result is being affected by a treatment or therapy. Using the flow sheet improves the quality of the physician’s care of the patient. Trends are easily seen and adverse effects due to therapy are easily noted.

4. Plot Your Lab Results to Determine a Trend Line
Use the dimension of time to investigate the significance of a finding. If a test result is changing, pay attention. “Abnormal” rarely happens suddenly; it develops over time. Look for physicians who present data in a graphic format.[18,19] If you cannot find such a service, then use your own mathematical and/or computer skills to create a spreadsheet, graph or other tool to visually portray what is happening to your biomarkers. One such tool that is able to fulfill some of these objectives is a simple form called a flow sheet (Table 2). The flow sheet, used properly, objectifies and emphasizes the concepts of trends over time and response parameters. It accomplishes this by showing correlations between treatments of any kind (medications, surgery, radiation) and laboratory, radiology, physical examination findings; it does this in the context of results depicted over time. Flow sheets should be a mandatory part of every physician’s chart work. They can be tailored specifically to the patient’s unique medical issues.

5. Use Biomarkers as Response Parameters (Biologic Endpoints)
If you are being treated for iron deficiency anemia, then use endpoints like hematocrit, MCV, serum ferritin and possibly soluble transferrin receptor assay as means to determine the success or failure of a therapy.[19-21]

If you have been diagnosed with osteopenia or osteoporosis, you may receive treatment with oral bisphosphonate medications such as Fosamax® or Actonel®, or intravenous bisphosphonates such as Aredia® or Zometa® to stop bone loss (bone resorption) and reverse osteoporosis. Such medications work by inhibiting the osteoclasts that break down bone. If anti-resorptive therapy has been successful, then a decrease in the metabolic breakdown products of the bone found in the urine will be confirmed. The latter test is called Pyrilinks-D or free deoxypyridinoline (Dpd). It is all too common to see patients taking bisphosphonates for many months or years without any testing to see if a key biologic endpoint of bone resorption has been altered. “If it’s broke, see if it is being fixed.” Some patients taking bisphosphonates do not absorb these agents well and may need dose modification or some other type of therapeutic change. Don’t waste a year or more of time and money without knowing if you are headed in the right direction.

6. Use Combined Variable Analysis
When biologic inputs, each with independent statistical significance, are used together, they present a more powerful tool that may enhance the accuracy of diagnosis, staging, treatment assessment and prognosis, as well as prevention. In such a scenario, the total is greater than the sum of its parts. This is the essence of combined variable analysis—a landmark concept linked with the previously discussed concepts of medical profiling and concordance.[22-28] Combined variable analysis presents the patient’s biology within the framework of the medical histories of thousands of patients who have presented in a fashion similar to the patient under study. This is medical history. Patients, partners and their physicians must learn the lessons that such history teaches us, or regrettably, the patient is forced to repeat it.

The majority of patients that utilize the above approaches have realized the significance of the preceding concepts. It’s your life—take the very best care of it!

Biography of Stephen B. Strum, M.D.
Dr. Strum has been a board-certified medical oncologist since 1975. In 2000 he became the first medical director of the PCRI (Prostate Cancer Research Institute) in Los Angeles. Dr. Strum has published widely about prostate cancer as well as other areas to optimize the outcome for those faced with the challenge of having cancer.


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