On the Way to New Horizons: Telemedicine in Oncology.
Breathtaking insights into carcinogenesis and tumor biology have been gained mainly by recent technical advances in molecular-biological and genetic techniques. Thus, dimensions of earlier diagnosis and the development of new concepts in therapy arise, which were previously unavailable. There is no doubt that through these techniques the future role and tasks of surgical oncology will change. New indications will result, for example, in the context of prophylactic therapy of hereditary malignant disease or the removal of tissue predisposed to tumors. However, modes of therapy orientated toward molecular biology will still be dependent on specialist surgical interventions in the future. Examples are such innovative concepts of therapy as transport of a therapeutic device to or into tumor cells (e.g., gene gun), or even simply obtaining the necessary tumor tissue for therapy (vaccination with transfected autologous tumor cells). Therefore, the future of surgical oncology will be influenced quantitatively as well as conceptually by new qualitative requirements. Improving precision of the surgical intervention will have to go hand-in-hand with a further reduction in surgical trauma. The consistent use of laser, video, computer and communication technology can be seen as an important predeterminant here for optimizing diagnostic and therapeutic procedures. If correctly guided, the professional experience of the individual surgeon and his personal efficiency can also be positively influenced by the swift conversion of society to multimedia and information technology. Major advances in interdisciplinary communication, as one important factor in the choice and the course of suitable complex therapies in oncology, will have to target and help to overcome former weak spots. Communication in and outside one department or hospital, as well as external communication between different medical disciplines and specialists, is being developed further and increasingly refined. The possibilities of modern technology in addition to verbal exchange include visual and interactive "tele"-communication. This renders a new option to the physician, as without direct patient contact he is able to observe, counsel and actively interact - the latter even more so in the future. In oncology the increase of knowledge thus far has gone hand-in-hand with further specialization. This explains the difficulties one encounters in the correct evaluation of relevant data of one specific patient. Telemedicine will help to focus on the advantages of specialist knowledge by rendering access to all available data. These possibilities should furthermore be accessible during a consultation, an examination or in the course of a surgical intervention. Real-time modalities are referred to as telepresence and exceed by far a mere electronic version of the patient's medical folder. Especially in oncology, interdisciplinary collaboration is immensely important for successful therapy. Preoperative diagnostic data are still to be evaluated according to the intraoperative findings. At this decisive moment, it is necessary to involve specialists of other oncological disciplines. Real-time communication devices have to be present in order to transfer image data and clinical observations and ensure the best possible transmission quality to resident and geographically distant experts. With further technological perfection and widespread availability of interactive consultation, other applications include the "second opinion" in the daily routine. Another fascinating option in oncology is offered by visual computer simulation in virtual reality (VR). Medical data are visualized according to the human perception by the means of scenic simulation. From that point of view, VR technologies represent a practicable user interface between computer technology and the individual human being. Through VR, three-dimensional worlds containing virtual objects, which consist of computer-generated data, are created, which the user may explore and liberally interact with. The perfect simulation of realistic settings offers a method of training that may be extended to the field of oncology, as it has been known for a comparatively long period of time from flight simulators in space and air technology. In contrast, medical training is currently achieved mainly by "training-on-the-job." There is well-proven and widely acknowledged certainty of the tremendous influence that the number of surgical interventions-in other words, the training skills of the surgeon-has on the success of a diagnostic or therapeutic intervention. Previously, the subjective experience of the physician acquired from earlier cases determined his efficiency to a large extent. It was, in addition, influenced essentially by perception, "performance on the day" and personal attitude. The goal must be to strengthen the objective criteria as the basis for consistent decision-making processes and clear instructions for therapy. Strict quality management as practiced in air technology has clearly led to a reduction in accidents, and, accordingly, a similar effect is imaginable in oncology with continuous training using VR simulators, leading to improved therapeutic outcome. Other possibilities for use are principally implied and similarly useful for medical school and postgraduate training. The idea of computer-guided medical procedures or medical robots is therefore no longer a mere utopia. Telepresence, telerobotic and VR techniques should, in principle, effectively support the physician in diagnostic processes and therapy. The responsibility for coordination and sensible use of new technological developments will still remain with the physician, such as improving and simplifying medical procedures. Technology should be used according to the situation, not to adapt the patient to a technocratic environment, but to emphasize human treatment of the individual patient. From the opinion of the telephone being a futile technical invention to the other extreme of computed technology as a substitute for the physician (Dr. Cyber), the future role of telemedical techniques and their potential for medical advantage or support, especially in the field of oncology, should be critically viewed and evaluated.
Schlag
PM
Medizinische Fakultat der Humboldt Universitat zu Berlin, Surgical Oncology, Robert-Rossle-Klinik, 13122 Berlin, Germany. schlag@rrk-berlin.de