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Panelists of The Future of Point-of-Care Technologies in Cancer Care and GHDonline staff

The Future of Point-of-Care Technologies in Cancer Care

Posted: 30 Apr, 2014   Recommendations: 15   Replies: 66

Moving cancer treatments out of specialized centers and into local clinics or home care settings could significantly lower healthcare costs. Often patients have to travel long distances to receive treatments at cancer centers. In low resource settings in the developing world, there may not be any options for cancer treatment. Surgical treatments carry infection risks, and in many places there are not enough surgeons to treat all of the patients in need. Technologies like targeted ultrasound and light-based treatments could allow providers with less specialized training to treat more patients for less money. Tools for monitoring chemotherapy patients at home between treatments could eliminate travel and office visits. Mobile health strategies for collecting data about high-risk populations could lead to new interventions to directly impact cancer screening rates.

The Center for Future Technologies in Cancer Care is focused on translational technologies that meet a need in contemporary cancer care both in the United States and internationally. The Point-of Care (POC) can be a home, primary care office, clinic, or other location, provided that the technology enables a task to shift from a more to a less sophisticated setting. Cost reduction is one metric on which technologies are judged, but an increase in positive patient outcomes and/or quality of life should be paramount. For example, an intervention that allows for chemotherapy drugs to be given at home, rather than in a special treatment center could both reduce costs and increase patent quality of life.

To address these issues, the Center is focusing on the identification, prototyping and early clinical assessment of innovative point-of-care technologies for the treatment, screening, diagnosis and monitoring of cancers. A major aspect of this effort involves assessing early stage technologies in terms of clinical needs, market demands, setting appropriateness and commercialization strategies.

To begin a dialogue about the best use of resources in a variety of settings, we pose the following questions for an Expert Panel discussion from May 5 - 9:

1. What is the most difficult part of treating cancer patients in your area? Which Point of Care Diagnostics and mobile health applications would address the major challenges surrounding effective screening, staging and diagnosis?

2. How are existing tools delivered to the patients who need them? How do these tools change treatment courses?

3. What kinds of tools do you envision that could change how you practice?

4. How do we deliver this data to the people who need it most? The practitioners? The patients?

We’re grateful to have the following panelists to lead our discussion:
     * Franklin W. Huang, M.D., Ph.D., Co-founder, Global Oncology, Inc., and Clinical Fellow in Hematology and Oncology, Dana-Farber Cancer Institute, Massachusetts General Hospital
     * Catherine Klapperich, Ph.D., Director, The Center for Future Technologies in Cancer Care, and Associate Professor, Biomedical Engineering, Boston University
     * Leslie Lehmann, M.D., Director, Clinical Pediatric Stem Cell Transplantation Center, Assistant Professor of Pediatrics, Harvard Medical School
     * Bernhard Weigl, Ph.D., Director, Center for Point of Care Diagnostics for Global Health at PATH

We look forward to a rich discussion next week—please join the conversation and share your questions or comments for our panelists.



Patricia Brock Howard Replied at 10:37 AM, 30 Apr 2014

Looking forward to participating in this discussion.

Keith King Replied at 11:22 AM, 30 Apr 2014

Hi Cathie,

I would like to hear thoughts from the panel on the potential usefulness of using 3rd party demographic data and public health data to augment the providers’ EHR data.

Furthermore, how useful would it be if the corresponding data was geo-enabled? This would permit the use of systems with simple to understand map-based user interfaces for managing population health and outcomes. Geo-enablement of data would also permit the use of location-based analytics to identify the best sites for cancer care treatment facilities. Retailers have been using location analytics to site-select stores for years. Should healthcare providers be doing the same?

To support this questions, please reference this map on Colo-Rectal cancer. Simple visualization of the data shows clear geographic trends. More advanced analytics on 3rd party and EHR data could pinpoint the optimal locations for cancer care clinics.,39206...


Joaquim Da Silva Replied at 11:26 AM, 30 Apr 2014

Looking forward to follow the discussions.

Fisseha Eshete Replied at 3:10 PM, 30 Apr 2014

Thank you, I will attend

Ruth Staus Replied at 6:30 PM, 30 Apr 2014

I am wondering how the increasing use of targeted molecular genetics based treatments, such as gefitinib (Iressa) for lung cancer, will change the care needs of patients with cancer. These targeted genetic treatments do not have the same kind of side effect profile seen with chemotherapy- nausea, hair loss, etc.- so it would seem that the care issues that take up a great deal of our time and effort will be less of an issue.

Sandeep Saluja Replied at 8:18 PM, 30 Apr 2014

This is a truly exciting and innovative area.I would love to learn and would be happy to be part of the innovation process.Possibly,we would need to take it forward through a few clinicians first and I would be happy to be among them.

One suggestion may be to try and have most of the training process online so that one does not have to leave important clinical responsibilities and travel out of remote areas.

Radha krishna Behara Replied at 11:19 PM, 30 Apr 2014

Hi Cathie
As a Technology guy I suggest that all the experts should look at other industries such as Manufacturing to learn how problems (cancer treatment in this case) are fixed by using some of the manufacturing concepts such as Just in time, lean manufacturing, configured to order and toyota's Andon methodology ( or supply chain logistics of Walmart etc I will also try to answer your specific questions as a outside of health care. By the way I teach students at the university and write blogs at

1. What is the most difficult part of treating cancer patients in your area? Which Point of Care Diagnostics and mobile health applications would address the major challenges surrounding effective screening, staging and diagnosis?

Answer: There is a need for educating the people on how to recognize the symptoms of cancer or any other deadly disease . We have government agencies that work in every village called Anganwadi ( who can be used to educate about Cancer, diabetics etc. and notify the healthcare providers the information for Point of care Diagnostics. Mobile health applications won't work in rural areas in developing and underdeveloped countries because internet penetration is too low and also mobile applications are still in English not in local language. The best is to use village healtcare volunteers to help in this whole process of Point of care diagnostics.

2. How are existing tools delivered to the patients who need them? How do these tools change treatment courses?
Answer: People who have healthcare problems depend on a friend or neighbor to know about a Doctor (word of the mouth ) and visit him. Here we a system where the corporate hospitals have agents in every nook and corner of Indian villages in the form of local doctors,others who practice medicine. This agents first try to cure some of the common ailments but always suggest patients to visit this corporate hospitals so they can get their monthly commissions. So this system can be used properly to treat cancer patients locally but unfortunately healthcare in India is corrupted by this corporate hospitals to such an extent that we find very few Honest Doctors who really respect their profession and do their job well.

3. What kinds of tools do you envision that could change how you practice?
Answer: Spreading awareness to grassroot levels about the diseases and collecting information (Data mining) using Anganwadi system is very effective if everyone in the chain works honestly

4. How do we deliver this data to the people who need it most? The practitioners? The patients?
Answer: Mobile applications using local language in the form of downloaded games without a need of internet will work in educating people about health and also about the availability of cancer treatment centers.

A/Prof. Terry HANNAN Replied at 12:29 AM, 1 May 2014

The topics listed in the introduction have stimulated me to write the following text. I hope my input has value. Terry Hannan
1. What is the most difficult part of treating cancer patients in your area?
a. In a regional Australian township ~90,000 people that has a widely dispersed population, temporal access to care is a major issue.
b. Within 10 minutes of the main centre there is no significant public transport and access to the oncology centre is usually by car, patient ambulance (limited hours) service or emergency patient ambulance service.
c. Some may consider the size of human resources or funding as issues however what should be considered is are the current resources being used “efficiently”. That is the variation phenomenon of overuse, underuse and inappropriate use of resources as described by J. Wennberg.(1) Therefore we need the proper tools to ‘measure and reduce variation’.(2)
d. What also needs to be discussed is that “treatment” is much different from “screening and prevention” so the decision support tools and the clinical processes involved will require significantly different tools.
2. Which Point of Care Diagnostics and mobile health applications would address the major challenges surrounding effective screening, staging and diagnosis?
b. Breast cancer screening has a highly emotive component (3, 4) but has a major focus of resources so how does the system provide an effective balance to its use?
c. Bowel cancer screening: Australia has a national bowel cancer screening program [1. and ] The participation rates and costs-effectiveness are unclear and the program which used ‘mail out’ kits rather than the use of mobile health applications to promote use. (5) One study using internet based Personalised Decision Support System concluded, “It is necessary to restrict participants to Internet users to provide an appropriately controlled evaluation of PDS. Once efficacy of the approach has been established, it will be important to evaluate effectiveness in the wider at-risk population, and to identify barriers to its implementation in those settings.”(6)
3. How are existing tools delivered to the patients who need them? How do these tools change treatment courses?
a. The Australian national cancer support group (Cancer Council: provides web-based access to information on cancer screening, detection and their management. This information is for the patients, carers and health professionals. Part of the site provides Social Media access.
4. What kinds of tools do you envision that could change how you practice?
i. I am not a cancer specialist but do diagnose and manage patients at various stages of their illnesses and have completed more than 10 years in Palliative Care.
ii. The core to good patient care is their involvement by providing them with their own record [e-format or paper] and provide electronic access to their care teams.(7-10)
5. How do we deliver this data to the people who need it most? The practitioners? The patients?
a. See section 4.

1. Wennberg JE. Practice variation: implications for our health care system. Manag Care. 2004;13(9 Suppl):3-7. Epub 2004/10/21.
2. Howard DH. A better understanding of variation in cancer care. Med Care. 2012;50(5):363-5. Epub 2012/05/26.
3. Schonberg MA, Hamel MB, Davis RB, Griggs MC, Wee CC, Fagerlin A, et al. Development and evaluation of a decision aid on mammography screening for women 75 years and older. JAMA internal medicine. 2014;174(3):417-24. Epub 2014/01/01.
4. Fuhs A, Bartholomaus S, Heidinger O, Hense HW. [Evaluation of the impact of the mammography screening program on breast cancer mortality: feasibility study on linking several data sources in North Rhine-Westphalia]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2014;57(1):60-7. Epub 2013/12/21. Evaluation der Auswirkungen des Mammographie-Screening-Programms auf die Brustkrebsmortalitat : Machbarkeitsstudie zur Verknupfung verschiedener Datenquellen in Nordrhein-Westfalen.
5. Javanparast S, Ward P, Young G, Wilson C, Carter S, Misan G, et al. How equitable are colorectal cancer screening programs which include FOBTs? A review of qualitative and quantitative studies. Preventive medicine. 2010;50(4):165-72. Epub 2010/02/16.
6. Wilson CJ, Flight IH, Zajac IT, Turnbull D, Young GP, Cole SR, et al. Protocol for population testing of an Internet-based Personalised Decision Support system for colorectal cancer screening. BMC Med Inform Decis Mak. 2010;10:50. Epub 2010/09/17.
7. Roter DL, Larson S, Sands DZ, Ford DE, Houston T. Can e-mail messages between patients and physicians be patient-centered? Health Commun. 2008;23(1):80-6. Epub 2008/04/30.
8. Sands DZ. ePatients: engaging patients in their own care. Medscape J Med. 2008;10(1):19. Epub 2008/03/08.
9. Sands DZ. Help for physicians contemplating use of e-mail with patients. J Am Med Inform Assoc. 2004;11(4):268-9. Epub 2004/07/16.
10. Sands DA, Galassi A, Chisholm L, Dimond E, Caubo K, Jenkins J. A cancer day hospital: an alternative approach to caring for patients in clinical trials. Oncol Nurs Forum. 1993;20(5):787-93. Epub 1993/06/01.

Devon McGoldrick Replied at 10:15 AM, 1 May 2014

This discussion of great interest, and well timed as The LIVESTRONG Foundation is currently running a social innovation challenge that will support innovations and solutions improving the daily lives of people facing cancer around the world. Many of you may be working right now on projects that could use a boost with some seed funding and/or exposure to global corporations and foundations. Submitted ventures will compete for $140,000 in seed funding, mentoring and global exposure to a community of potential customers and investors to develop programs, services, new technology and inventions that improve cancer patients' and survivors' daily quality of life. There are two weeks left to submit your product/service/innovation. Visit by May 15th to learn more and submit your idea.

Asfawesen Gebreyohannes Woldegiorgis Replied at 4:51 AM, 2 May 2014

I am certain that the issue is timely and very relevant to practioners and patients in developing countries like Ethiopia. I lookforward to attending the discussion.

Jesse Gitaka Replied at 6:58 AM, 2 May 2014

Count me in. There is a critical need to address diagnostic challenges for the high and rising cancer burden in developing countries.
Innovative POC strategies will be very useful in this.

Sandeep Saluja Replied at 11:25 AM, 2 May 2014

What would be of utmost importance is to have access to technology which can be practised in remote areas and this has to take all aspects into consideration.

Chemotherapy,for instance may actually not be very expensive or difficult to administer.What may turn out to be difficult is management of its adverse effects especially with poor blood banking etc.

JOSEPHINE RIOKI Replied at 3:04 PM, 3 May 2014

This is a great discussion! I am very much interested in the POC especially in the screening and diagnosis of cervical cancer. I am looking forward to learn from experts in those areas.
I need suggestions on how cytology services can be utilized in the point of care testing (in cervical cancer screening and diagnosis) in resource constrained settings

Bright Msukwa Replied at 3:34 AM, 4 May 2014

Great discussions. Learning alot great ideas you people are putting in.
Good thing.

Catherine (Cathie) Klapperich Replied at 12:42 PM, 4 May 2014

I hope we do get around to discussing the following comment from above:
"The core to good patient care is their involvement by providing them with their own record [e-format or paper]"
I think that in any setting, keeping the patient involved and fully informed is key to good care. How can new technologies help educate and involve patients without overwhelming them?

Catherine (Cathie) Klapperich Replied at 2:19 PM, 4 May 2014


I just wanted to introduce myself before we get started. I am Director of the CFTCC. I'm an engineer by training, but I have become very interested in diagnostics and how they can affect patient quality of life in cancer care. My main goal in this discussion is to get more insight into where and how POC technologies can help providers and patients make better decisions about care. As engineers and technology developers, we often lose sight of this most important information.

Thank you all for your participation in advance! I look forward to a lively discussion.

Karolina Maciag Replied at 2:28 PM, 4 May 2014

Diagnostics for the presence of pathogenic microbes - and their drug
sensitivity - are likely to get an infusion of funding, since antibiotic
resistance is a major focus of governments around the world right now.
Since drug-resistant microbes can easily cross borders, rich governments
have no choice but to include LMIC patients and providers in the global
quest to conserve effective antimicrobials.

A/Prof. Terry HANNAN Replied at 5:22 PM, 4 May 2014

Catherine, here is a back to the future story from Larry Weed on this topic. It is a lovely read and encapsulates what we need to aim at solving. Also there is the extensive work by Dr Danny Sands (from Beth Israel Deaconess medical Centre) on e-patients that is worthwhile reading. Terry

Attached resource:

Nachiket Mor Replied at 1:12 AM, 5 May 2014

I am associated with a group ( in India that is experimenting with rolling out a version of “Managed Care” of which a key component is the provision of primary care in close-to-habitation settings. The primary care takes the form of a Nurse Practitioner (or equivalent) led clinic with a locally hired high school graduate acting as the support person. Both these individuals receive between 6 months to one year of training and are able to deal with almost 95% of the conditions that present themselves in primary care settings using very detailed protocols. The clinic has the capacity to handle 10,000 patient visits per year and is viable at total expenses (including medicines, physicians, infrastructure) at $0.70 per patient visit. It costs about $5,000 to set up each clinic. Our collaborators are the Penn School of Nursing.

In these settings we want to offer a strong Primary care Cancer Programme for multiple types of cancer. We have started with Cervical Cancer (VIA-VILI) but have not moved beyond that. And, even in the case of Cervical Cancer we have not yet started the single-visit-treatment programme. Some of the difficulties we face on the ground include:

1. Absence of a specialist partnership that is willing to train and mentor.

2. Absence of a high quality referral linkage

3. Absence of detailed protocols that can be followed in primary care settings for most cancers.

4. No cost-effectiveness information either.

5. High levels of false positives which creates much unhappiness amongst villagers (“you needlessly frightened us”)

6. High elasticity of demand for primary care – may require negative pricing (patients to be paid) to get good compliance – free care may not be enough.

In my view merely getting more devices will not be helpful if these broader “technologies” (systematic treatment of an art, craft, or technique) that I have listed earlier are not in place.

Rajan Dewar Replied at 3:24 AM, 5 May 2014

Dear Nachiket and others

This is a great forum. Thank you Dr. Klapperich…
I work in Boston and head a forum of volunteer pathologists to create diagnostic capacity for cervical cancer in rural Tamil Nadu.
We started with VIA-VILI, cytology and HPV in 2011 in rural TamilNadu, India; Within a year we realized the high FP (and false negatives) with VIA and abandoned it within a year. HPV is too expensive for mass screening (estimated 5 million dollars just for one district). Our cytology program is working well. We focused on training human-capacity (cytoscreener): About 6 trainers from the United States have visited in regular intervals, spend a week to two weeks - screening and training the personnel in Trichy. In 6 months, our cytoscreener is capable of (a) good quality staining (b) screen Satisfactory from Unsatisfactory smears © mark suspicious cells (d) attempt Normals from others. All the slides are screened by a trained pathologist (Dt. Gita Jayaram). The objective is to have about 5-10 trained cytoscreeners in the next few years.

Positive outcomes
1. It is definitely possible to train Capable cytoscreeners with very little input. We have screened close to a 1000 patients in the last 8 months.
2. With very brief training sessions of the providers (social workers who obtain the Pap smears) we have reduced our Unsatisfactory rates from over 40% to 9% within 7 months (submitted for presentation at ASC meeting).
3. Costs about 60-75 rupees (1.1 USD) for the process.
4. Closing the loop -of the 120 positives/suspicious, we have referred and treated about half.

1. The other half of patients - do not want to hear about a positive result and do not come back for treatment - (similar to your skeptical patients, Nachiket).
2. The turn around time is about a month - since our pathologist is an unpaid volunteer.
3. Air-drying artifact is still a limiting factor.
4. Defraying Travel costs of cytotech trainers / volunteers from US to India.
5. Often the local villagers have a lot of other problems (eg., alcoholism, diabetes). As a responsible provider it is difficult to turn away from what the community has, and focus only on one disease that "We are interested in" - especially when they don't have any symptoms for this disease.

We are now working with IIT, Madras (through a Socially Responsible Project initiative and a company called Dimagi Inc) to develop a cell phone based reporting system to reduce result reporting time.
We are now ready to absorb more work through other local NGOs - all we require is the willingness to be trained in good collection (Pap smear) practices and show the ability to close the loop.

As for the earlier comment about Patients getting access to their own medical records - reference: "The core to good patient care is their involvement by providing them with their own record [e-format or paper) etc.,)"
We plan to focus on that when our villagers start wearing 'Google Glasses'… That is way down on our priority list. While I personally think this may not be relevant to the LMIC context, our cell phone reporting proposal messages a simple 1 line SMS that tells the village patient about a "Positive Pap smear - contact the doctor" in English and local language. This SMS messaging is expected to be piloted this summer - please stay tuned.

WRT Problem #4, please look at another obtuse angled approach:

Thank you for your patient reading,
- Rajan Dewar MD PhD
Beth Israel Deaconess Medical Center,
Boston, MA 02215

Jumatil Fajar Replied at 6:36 AM, 5 May 2014

1. What is the most difficult part of treating cancer patients in your area? Which Point of Care Diagnostics and mobile health applications would address the major challenges surrounding effective screening, staging and diagnosis?

We do not have pathologist that can determined the grade and stage of cancer. After surgery, usually we will send sample to another province in order to know the result. After confirmed that the sample is cancer we will start the therapy, depend on type of cancer. The available treatment in our district general hospital is chemotherapy.

For diagnostic of cervical cancer, our district has several general practitioners that had training on using visual inspection using acetic acid. Until now our hospital does not have mammography.

2. How are existing tools delivered to the patients who need them? How do these tools change treatment courses?
The patients should attend to district general hospital to get examined. If we need more sophisticated tools, we will refer them to better hospital at another province.

3. What kinds of tools do you envision that could change how you practice?
The availability of mammography, machine that can read the result of pap smear quickly, etc.

4. How do we deliver this data to the people who need it most? The practitioners? The patients?
In our district we still need the help of pratitioners because the level of education in our district still low.

manu noatay Replied at 9:02 AM, 5 May 2014

Addressing Nachiket's query

1.Absence of a specialist partnership that is willing to train and mentor.- We at Niche cover almost entire India from Meghalaya to Kashmir

2. Absence of a high quality referral linkage- In cervical cancer- we believe in taking mountain to mohammed..i e we do skill building of local healthcare professional so that they can manage cases locally as far as cervical preneoplastic screening and management is concerned..

3. Absence of detailed protocols that can be followed in primary care settings for most cancers.- We follow ( in cervical cancer ACOG guidelines)

4. No cost-effectiveness information either - we have a programme costing from 7USD to 32 USD and we do skill building at pro rata.

5. High levels of false positives which creates much unhappiness amongst villagers (“you needlessly frightened us”)- Our tests reduce unnecessary follow ups and interventions..

6. High elasticity of demand for primary care – may require negative pricing (patients to be paid) to get good compliance – free care may not be enough.- WE need local support to pitch in for CSR funding which is sufficient usually.

Catherine (Cathie) Klapperich Replied at 10:36 AM, 5 May 2014

I also want to stress that POC technologies can and should include treatment and monitoring of patients! Your comments in these areas (drug delivery, monitoring of therapy) are welcome as well!

Catherine (Cathie) Klapperich Replied at 11:01 AM, 5 May 2014

Here are many useful documents from the WHO. Cathie

Attached resource:

Lena Liu Replied at 3:22 PM, 5 May 2014

To give a little bit of background/introduction on the topic of point-of-care technologies and global health I have linked a paper below. It gives an introduction to point of care testing and its impact on global health.

Attached resource:

Bernhard Weigl Replied at 5:25 PM, 5 May 2014

Hi all - wanted to introduce myself a bit belatedly due to technical issues as one of the panelists.

I am Bernhard Weigl, Ph.D.,Portfolio Leader, Chronic Disease Diagnostics, PATH and Affiliate Professor, BioE, University of Washington. I am also the former Director of the Center for Point of Care Diagnostics for Global Health at PATH.
I am an analytical chemist by training, with most of my work in microfluidics in both academic and start-up company settings. Sicne joining PATH in 2004 I have worked on diagnostics for global health applications, and since 2009 have mostly focused on chronic disease diagnostics as I felt that this area was grossly underrepresented in relation to its morbidity and mortality figures and economic and human impact, in the global health community. My work is now mostly in diabetes, and cervical and more recently breast cancer screening and diagnostics. We may look at other cancers also in the near future.

Our cervical cancer work has included the co-development of the Qiagen CareHPV screening device for low resource settings, and the Arbor Vita Corporation OncoE6 strip test for the detection of the oncogenic protein E6 also for LRS. For those of you interested in more information about PATH's cervical cancer work I would be happy to send you more material.

For breast cancer we are trying to come up with methods that either simplify or replace the need to do immunohistochemistry to determine, for example, hormone receptor status on breast cancer cells, and to simplify and improve the biopsy process.

Looking forward to an interesting discussion this week!
Bernhard Weigl

Franklin Huang Replied at 6:46 PM, 5 May 2014

Hi everyone,

As an introduction, my name is Franklin Huang and I am the co-founder of Global Oncology, Inc and a fellow in hematology & oncology at Dana-Farber Cancer Institute. I am also a cancer researcher based at the Broad Institute with a focus on cancers that affect underserved populations. For the past few years another major interest has been in working to improve cancer care, research, and education in resource-limited settings and to accomplish this, I and another fellow, Dr. Ami Bhatt, founded Global Oncology (, a non-profit volunteer organization composed of health, IT, and business professionals whose mission is to help cancer patients and providers in resource-constrained communities. We accomplish this mission through strong collaborations with local partners, with projects in technology development and patient educational materials, and the training of providers just to name a few. I have worked/am working with many others in a number of countries on cancer care including Malawi, Rwanda, and Botswana.

Looking forward to a great discussion this week and nice to meet everyone.
Franklin Huang

Nachiket Mor Replied at 12:07 AM, 6 May 2014

This is a very interesting discussion and lots to think about and learn
from. I think though that any solutions will need to be developed and
deployed keeping in mind the context in which we seek to operate. Average
Indian health care expenditure (all levels of care) is $55 per year per
capita. Of this the government spends only about $14 per capita. More than
half of all this money goes in for hospitalization care and there is a great
deal of inequality in the Indian society. While there are no exact numbers
available our sense is that we have about $15 per capita available to spend
for all levels of care. If we take out about $4 for secondary and tertiary
care (hospitalization) then all we have is $11 for primary care per person,
per year. Cancer screening alone cannot absorb $7 of that or even $1. The
methods needed have to be far lower cost and need to be able to:

1. Offer comprehensive care - not vertical cancer care alone - this
whole vertical approach favored by specialists and doctors in general is
inconsistent with the resource availability in a country like India and from
the little I know, not even good for patient wellbeing. The whole effort to
build a vertical maternal and child health structure in India has left us
with a very skewed healthcare system.

2. Needs to be conscious about availability of trained specialist
manpower in the country - this is not a variable that can be changed quickly
or easily.

3. Needs to risk stratify populations using non-laboratory methods,
for a variety of diseases and then target only those that are most-at-risk
for disease - for cancers I feel that this is where one might see the most
value - if there are devices that cost under $100 which do not have any
disposable components (chemicals, strips, slides, etc.) they could be very
useful. Automated BP measurement machines, pulse-oximeters, a new device for
testing hemoglobin levels, digital ECG monitors, digital x-ray machines,
low-cost ultrasound machines which do not have a screen, are some of the
examples that to me look promising and we have deployed them in our primary
care settings (not yet x-ray and ultrasound but we are getting there).

4. Even with the false positives to me the VIA-VILI with the
cryotherapy looks promising from a cost point of view even it is not quite
the gold standard (

5. For breast cancer I understand there are strong risk-stratification
methodologies available ( that
could be deployed effectively.

Radha krishna Behara Replied at 1:17 AM, 6 May 2014

Nachiket you have wonderful points that are practical for implementation for during and post operative care. Due to high connectivity and technology improvements there is a marked shift in the intelligence of the society and that is now visible when a remote village person was able to use Mobile services with ease. But lifestyle practices, belief systems, educational levels and non uniform economic systems are hindrance for implementing all the above suggestions uni formally across the globe. Till all the citizens of the globe are comfortable using the technologies and life style practices recommended by experts above, i recommend that we should leverage the knowledge for finding solutions to prevent diseases rather than curing.

In India Grass root education in preventing diseases should be promoted and I suggested that we use local language mobile games that can be fun to play but also contains messages about hygiene and information to identify Cancer , diabetics etc. Other steps should include the following
Clean water for all : There are many NGO's in providing clean drinking water (one example is
A clean environment for cooking . solar lighting and fuel efficient stoves should be promoted (example and energy efficient stoves
In India people believe in alternative medicines and this will prevent some cancer patients approaching western medical practitioners so i suggest that experts should mix and match the best medicines, practices of Ayurveda, Homeo and Western medical treatments along with natural therapies to attract patients for treatments and post operative treatments.
I'm thinking that this forum should involve experts from different fields other than Medicine to get a different point of view and a out of the box best practices for treatment and post operative care.I'm a software professional with 18 years of global ERP software project implementation experience and i teach at local university on call and write blogs at

Reginaldo Banze Replied at 3:57 AM, 6 May 2014

Dear Nachiketi and other.
My name is Reginaldo Banze, a medical doctor and 2nd year intern in Cardiology at Maputo Central Hospital.I would like to shared my experience on the issue of community adherence to locally-based Health services.Two years ago I worked as Research team member in a remote area and one of the initial challenge was adherence and visit complience.To address this issue a community board was set up and one of its role was to laise and help to adress the community concerns related to some of the sudy procedures(blood collection, STD screening, sexual behavioral questionaire).This community board was formed by locally selected stakeholders with diferrent background including religious leaders.Meetings were scheduled on a regular basis and whenever a community concern related to a study was raised. Since rumors related to blood collection and STD screening were frequent and affecting complience, community meetings were organized in collaboration with traditional leaders and the results were positive.Deppending on the cultural and social reallity of the community around the cancer treatment set up facility, straight collaboration with the local stakeholders can positively impact the community adherence to the Health services.The downside is that this poses additional costs if the service provider assumes alone and long sustanability is at risk.

Nachiket Mor Replied at 8:42 AM, 6 May 2014

There is clearly a lot of value in helping people change their lifestyles.
But it is my understanding and the limited field experience I have also
supports it, that getting people to change behaviour is hard and the key
question is that IF they do then there will be a great deal of impact but
the IF THEY DON'T then there will be a great deal of expense with no impact.
And the consistent experience is that they don't change lifestyles easily
making (in the post penicillin, statin, metformin, anti-hypertensives world)
life style modification (LSM) as the most expensive set of interventions per
DALY saved. I feel that while LSM is a useful add on, it would be very
important to develop proper clinical pathways for early diagnosis of many of
these conditions and their treatment. This is where POC technologies can
help a great deal.

Catherine (Cathie) Klapperich Replied at 8:44 AM, 6 May 2014

Responding to Keith King. I think that any data we can put into the hands of providers at the planning level is good. If this can be done at low cost and can aid providers in making sure that high risk populations are screened at higher rates, it could be a very good thing. But this entails a flip from putting the responsibility on the patient to seek screening to putting it on the provider to screen the appropriate populations.

Keith King Replied at 10:23 AM, 6 May 2014

Thanks for the thoughts Cathie,

The potential return on investment of using EHR and publicly available health data to analyze and visualize disease "hot spots" could be very high.

In terms of the investment portion, geo-enabling the data is something that is routinely done with Geographic Information Systems (GIS). GIS has been around for a long time (40+ years). In fact, one might say John Snow used a primitive form of GIS to stop the cholera outbreak in Soho, London, back in 1854. In short, the capability of GIS is proven and it is an ideal platform for bringing together data from disparate systems (internal and external).

In terms of the value of having geo-enabled systems, below are some high level thoughts on the potential benefits:

* A map showing problem areas by location is a universal language that everyone understands and can take action on.

* Once these geographic hotspots are identified, it becomes obvious to all stakeholders where to deploy POC resources

* Patients can better understand their status as compared to the population around them

* It is easy to spot treatment disparities based on geography

* The analysis and visualization would be a great tool to objectively measure progress over time. This would provide a feedback loop so POC methods could be adjusted

* The analysis and visualization can be delivered to most any platform (desktop, smartphone, tablet).

* As POC and population health management merge and become more sophisticated, GIS is an ideal technology for managing and analyzing data associated with wearables and monitors

Since there is such a strong correlation between geography, health, and health-related behaviors, I wonder if GIS should be more widely used in the analytics associated with POC strategies. Additionally, I wonder if the operational tools used to deliver and manage the cancer treatments would be more valuable and effective if they were geo-enabled.

It is intriguing to think of the possibilities.....

Catherine (Cathie) Klapperich Replied at 1:24 PM, 6 May 2014

An issue that recently came up in a clinical needs study we are working on here at the CFTCC ( Clinicians are not highly interested in mHealth applications that would give a patient test results. If this kind of application of mHealth is not desired, which applications are?

Margie Hollands Replied at 3:28 PM, 6 May 2014

Hi Bernhard
We offer comprehensive HIV care and treatment services in Harare, Zimbabwe,for close to 5000 patients, approximately 2500 are women in the sexually active age group.
We offer VIAC services with cryotherapy and LEEP as interventions and would like to look at HPV screening strategies and would be most grateful if you would us information on the Qiagen careHPV device,
Regards and thanks, Margie Pascoe, Newlands Clinic, Harare, Zimbabwe

Bernhard Weigl Replied at 11:50 AM, 7 May 2014

Hi Margie,
thanks for your interest. We have a short movie about this on our website ( and there are a number of publications also on the CareHPV results.There is also a fact sheet on the two tests that we have co-developed:
A more comprehensive document is here:
There are also some recent publications on careHPV use in China: and here:, and in Africa:

Hope this helps! If you or others on this panel are interested in starting an HPV screening program in low resource settings then feel free to contact me directly also - i would be happy to connect you with Dr. Jose Jeronimo who leads these activities at PATH.


Bernhard Weigl Replied at 11:58 AM, 7 May 2014

Hi all,
I was curious about the current use of tamoxifen in low resource settings for breast cancer. Does any of you have programs to do this in anothing other than the highest levels of health care centers in your countries? How do you test for ER/PR status? Have you implemented immunohistochemistry? What do you see as the main bottlenecks that keep you from implementing breast cancer treatment?
We are trying to develop alternatives for immunohistochemistry for ER/PR determination, btu we are very curious about all bottlenecks in breast cancer care.

Franklin Huang Replied at 4:04 PM, 7 May 2014

In my work with GO and through experiences on the ground in settings in Uganda and Rwanda and elsewhere, there is a strong need for accurate and rapid diagnostic technologies to make pathologic diagnoses that are essential for cancer care. POC diagnostics that could make accurate diagnoses would be enormously helpful given insufficient pathology capacity. Pathology plays such an enormous role in cancer care that for instance, in many circumstances immunohistochemistry is not readily available and thus it is extremely difficult to determine hormone receptor status to guide the treatment of breast cancer. As many know, the consequences of this are significant.

Other challenges clinicians may face include lack of oncology expertise or expert knowledge in a given cancer type, monitoring for side effects in the outpatient setting, communicating with patients in a regular way, and the coordination of care among surgeons, pathologists, and other specialists.

There is certainly a lack of patient education regarding cancer and one project that GO has worked on with the MEME, a design firm here in Cambridge, MA, has been to design Patient Educational Materials aimed at low literacy patients in resource-limited settings. Thinking about how we might improve patient education or social/community support through POC technologies would be helpful since these are often overlooked and unmet needs of patients.

Tools or technologies that could address some of these areas could have enormous impact for cancer patients.

Timothy Simard Replied at 7:31 AM, 8 May 2014

As the founder and CEO of a five year old healthcare technology company ( Franklin's point is a good one and I agree. In our effort to combine medication management and disease management with collaborative and unified messaging at the POC and virtually is complex but possible. If ePayments can work then eHealthEducation, eHealthMessaging, ePharmacyConsult, eMentalHealth and eCancerConsult can work not just in low-resource areas but globally as well. Thus, improving self-management capability, access, and quality.

Sandeep Saluja Replied at 7:58 AM, 8 May 2014

It may be a good idea to have a portal dedicated to cancer management in
low resource and remote areas.Physicians working in such areas should be
able to post actual cases with practical limitations including issues like
patient refusal to undergo biopsy or chemotherapy or surgery.
Despite all such issues,every patient needs to be helped in the best
possible way within the confines of the limitations imposed.

Dedicated experts should be on the panel of the portal to extend genuine
advice and willing to innovate for each patient.

Catherine (Cathie) Klapperich Replied at 8:03 AM, 8 May 2014

I want to address clinicians in low resource settings specifically.

What is the single piece of information that would help you or your patients the most, if we could get it quickly and without too much technical expertise necessary into your hands on the same day you see the patient?

I think that as engineers, especially as engineers in academia (me!) and in the USA, that we often overlook the needs assessment piece, simply because we do not know how to do it effectively. Often, in fact, there are technologies available to solve some of the most pressing needs, but those outside of a particular setting are completely unable to assess needs from afar.

Which beings up another question! This is one way to assess needs remotely, are there other ways?

Catherine (Cathie) Klapperich Replied at 9:12 AM, 8 May 2014

In your setting, why do people refuse treatment or biopsy? Lack of information?

Anna E. Schmaus Replied at 9:23 AM, 8 May 2014

We from One World Medical Network use the web-based platform CampusMedicus. There is an Open Pathology and an Open Cytology Group where expert doctors from all over the world read the cases on an every day basis and write comments and diagnoses. If you are interested in joining these groups contact Klughammer at . Joining the groups, uploading a certain amount of patient cases (including images and text files) and receiving diagnoses is for free.

Nachiket Mor Replied at 9:31 AM, 8 May 2014

Thank you Cathie. The BIG questions for us in primary care settings
(, particularly in the context of cancer, is to do
effective triage and to decide who we should send home and who we should
refer up (and in some exceptional cases, treat). So I would say technologies
(software and hardware) for risk stratification of patients (this is a
problem in CVD and Diabetes as well) where we can do this in our primary
care clinics or by going door to door at the community level would be what
is needed. False negatives are the bigger problem but false positives are a
problem too, as is cost. Which is why tests / tools that are both highly
sensitive and highly selective but have (ideally) zero variable costs
(somewhat higher fixed costs could be potentially be absorbed) are perfect.
Which is why we like things like questionnaires, AI systems that pick up
risk factors, etc. as technologies, instead of expensive hardware devices
that consume a lot of variable costs. Also we cannot really do this cancer
by cancer or even disease by disease so technologies and approaches that
have multiple uses and become an integral part of the clinics'
infrastructure are highly desirable.

What low resource settings can deliver, in my opinion, is a great deal of
time from the patient and from locally hired personnel, who, over time, can
become very skilled at repetitive tasks (including the use of CDSS type
systems) - settings like India have slack labour economies and a trained
nurse costs less than $200 per month and locally hired health worker half
that much. So technologies that seek to enhance their capabilities to do
accurate diagnosis (and treatment where possible) have the best chance of
success. Simple tools such as electronic BP monitors, retinoscopes, pulse
oximetres, etc. have proved to be really useful as have CDSS systems
deployed in primary care settings. Full service blood tests are not a
problem as well. One can get CHEM 7 and KX 21 for under $10,000 and an x-ray
machine for $5,000 and deploy them in central locations with locally hired
qualified technicians and push a great deal of volume at them. If
approaches towards diagnosis of cancer that use what we already have the
ability to deploy can be developed it would be transformative.

If we can minimise needless referrals to next level centres then potentially
one can deploy far more expensive technologies at that level but still
absorb them within the $30 per person, per year, total healthcare budget,
particularly for low-incidence diseases such as cancer. For conditions CVD +
Diabetes which are much higher incidence we have had to push much-much more
care to primary care settings.

Catherine (Cathie) Klapperich Replied at 10:28 AM, 8 May 2014


I find the following intriguing:
"Which is why we like things like questionnaires, AI systems that pick up
risk factors, etc. as technologies, instead of expensive hardware devices
that consume a lot of variable costs. Also we cannot really do this cancer
by cancer or even disease by disease so technologies and approaches that
have multiple uses and become an integral part of the clinics'
infrastructure are highly desirable."

So, when you use questionnaires, are you looking for high risk behaviors? Or are you looking for symptom reporting? If you cannot work cancer by cancer, when you identify a high risk patient, what is the next step?


Nachiket Mor Replied at 11:07 AM, 8 May 2014

With questionnaires, depending upon the condition we are looking for either
risk factors or risk behaviours ("suicidal ideation" in the case of mental
health for example or "family history" and "tobacco consumption" in the case
of CVD + Diabetes or "in-home cooking" for COPD). Once we have the data
(and we now have good data for CVD + Diabetes) for the communities around
each our clinics we can then start to make recommendations to the individual
about the next step to follow.

For cancers, other than Cervical Cancer (where we try and follow the VIA /
VILI protocol to screen all sexually active / married women upto the age of
50 that visit our clinic for any reason whatsoever - if they agree that is),
we do not currently have any protocols. I understand however that for
various cancers there are risk factors that are either common to all cancers
or specific to a particular types of cancers and the hope is that with the
help of good questionnaires as well as the case history data stored in our
health management information system for each individual that lives in our
communities, we can build a risk scoring algorithm / CDSS / AI system that
allows us to decide what recommendations to make to the patient even before
any obvious cancerous symptoms become visible.

Franklin Huang Replied at 12:08 PM, 8 May 2014

Regarding Sandeep's comment, this is clearly an area of need and one GO is trying to address through a secure, web-based Collaboration and Advising Platform (CAP). This is a portal that GO is piloting because of a great collaboration with the company Best Doctors that has provided us with this software platform to use with our collaborating sites. Treating clinicians from our collaborating sites in low- and middle-income countries post cases including imaging and we facilitate expert guidance and advising through the portal. Through our pilot, we are working on how to scale this process - as many on this forum know, treating clinicians have heavy clinical duties and responsibilities, and having the time to post cases is a challenge. It would be good to hear from others what might be the best ways to manage or obtain expert guidance or communication that would be best suited to local workflows. Also happy to discuss more off-line with people interested in the platform.

Franklin Huang Replied at 12:23 PM, 8 May 2014

re: Bernard's question, I can only speak to the sites where I've visited and worked but I imagine at least in low-income settings, the experience is similar in that access to immunohistochemistry and ER/PR testing is nonexistent or extremely limited; In some of the sub-Saharan countries, if there is a way to pay for it (obviously a non-starter for poor patients), clinicians/patients/families can send tissue to South Africa to have IHC for hormone receptor status performed. Private labs in some cities are available as well. Tamoxifen has been readily available in the settings where I've worked and in all likelihood patients are treated with tamoxifen without knowing the receptor status and monitoring for response which makes sense. The analagous situation occurs in the treatment of lymphoma in settings where CHOP is given for all lymphomas, which likely treats many cancers but also overtreats and undertreats a signficant percentage.

Leslie Lehmann Replied at 3:55 PM, 8 May 2014

Apologies for joining late - I am a pediatric oncologist who is part of the GH initiative at Dana Farber Cancer institute/Boston Children's Hospital. I have been involved with DF and Partners in Health in setting up pediatric oncology program in rural Rwanda. With the support of the Ministry of Health, PIH and DFCI all physicians in Rwanda underwent a National Training over 4-5 days on the basic approaches to oncologic care with an emphasis on how to recognize POTENTIAL cases of cancer and refer in a timely fashion. I totally agree with Nachiket that any technology that facilitates this process would be of great import - the training sessions were very well received but it would be very helpful to have the ability for providers of primary care to be able to video conference with those providing oncologic care to help determine which patients to refer/pre-referral tests that can be done locally etc.

Leslie Lehmann Replied at 4:14 PM, 8 May 2014

Another area with which we have struggled and where POC technologies may be of use is in home medication compliance. for example we treat children with a low intensity ALL regimen. There are many months of hoem oral medications (6MP/methotrextae). We have seen a worrisome incidence of relpase and worry whether parents understand the importance of consistency with these drugs. We are working on an education intervention - pill boxes/discharge teaching etc but if there were a way for parents or patients to be reminded electronically to give the medication and to record on a mobile device once it is given we could better understand the contributions of noncompliance to treatment failure.

Maggie Sullivan Replied at 5:19 PM, 8 May 2014

Another late joiner to the conversation - I volunteer with PIH's cervical cancer screening project in rural Guatemala. As many have mentioned before me, if you have high-quality labs, well-trained cytotechnologists and guidelines for quality assurance, paps are the way to go. Access to these resources have not been my experience in Guatemala. VIA and cryotherapy are true point of care technologies - a test is done, a result is provided and treatment is offered all on the same day. Though VIA does have a higher rate of sensitivity than paps, a well-trained nurse will counsel patients on the risks vs benefits of testing. The sensitivity of paps ranges anywhere from 50%-80%, but it is important to keep in mind that in LMICs we are using conventional testing (slides - on the lower range of sensitivity) than liquid-based testing. And we will almost never hear from the woman who says, "but I had a pap smear before and it came back fine, why now is it abnormal?" We must keep this in mind when responding to the women who ask why they are "needlessly" diagnosed. In the end, I think all can agree that point of care HPV testing is where the future of cervical cancer screening is at. Once we have this in all LMICs, only then will we begin to see a drop in mortality rates (assuming it leads to treatment).

A/Prof. Terry HANNAN Replied at 5:38 PM, 8 May 2014

Catherine, your question "What is the single piece of information that would help you or your patients the most..." highlights one of the major differences between pure engineering and health. We needs LOTS of pieces of information and we need the proper tools to INTEGRATE these when we most need them-at the bedside. If you see the graphic in the paper I have attached it demonstrates how much information we have available and need e-support to manage. Terry

Attached resource:

Sandeep Saluja Replied at 9:10 PM, 8 May 2014

Thanks Franklin for your inputs.One of the needs of such a portal would be a clinical moderator who can help clinicians seeking help present and put forward the case as also the local problems.The moderator should also be able to motivate experts to provide solutions which are innovative and target the problem in the local context.

Such a model would possibly be helpful in all clinical areas and not limited to cancers.

I would be happy to be part of any such initiative.

Bernhard Weigl Replied at 1:34 PM, 9 May 2014

Franklin, thanks for responding re tamoxifen as breast cancer treatment. Could you (and others in this discussion) expand on the major bottlenecks in current breast cancer care in LRS? What are the main tools that would enable physicians in LRS to provide any, or better, care to most women presenting with apparent breast cancer?

Ethan Bindelglas Replied at 5:25 PM, 9 May 2014

Dear Leslie, you might consider a very simple low-tech solution search as the multiple dose MedPAC my wife uses please check out Medi– and look at the multiple dose pack pictured on the front page.
Hope that can be of help.
Ethan Bindelglas

Leslie Lehmann Replied at 4:52 PM, 11 May 2014

thank you Ethan ! we are beginning to incorporate such strategies - I htink there will be a huge educational ocmponent as there is not really a smuch experience with chronic medical conditions that require precise ongoing therapy for months or years - I think we can use lessons from HIV/TB programs as we move into chronic NCDs.

Catherine (Cathie) Klapperich Replied at 4:41 PM, 12 May 2014


Thanks for participating. If you would like to be aware of the new opportunities at the CFTCC, email Lena Liu () and she can subscribe you to our newsletters. We are also on twitter @CFTCC_NIBIB and on facebook
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Marie Connelly Replied at 4:42 PM, 12 May 2014

Many thanks to our panelists, and all of our community members who participated in this rich discussion, and of course to The Center for Future Technologies in Cancer Care for helping to plan and organize this Expert Panel.

We will be working on a Discussion Brief to summarize the key points from this discussion, and will share details as soon as that is available on the website.

Catherine (Cathie) Klapperich Replied at 4:50 PM, 12 May 2014


Thank you for your comments. Really, your comment is most valuable at pointing out the disconnect between providers and technology developers. For you, it seems like information, access to colleagues and synthesis of large amounts of information in a quick manner are the biggest needs.

Some of the Health IT people here have suggested some applications of "big data" to community level issues, looking for highly impacted populations etc. It seems like too much data is a problem at the level of the patient-provider interaction.

What you get when you talk to colleagues about a particular case (as discussed by @Franklin and @Sandeep above) is the ability to get right to the core of the issue. Something that might never be possible with a search engine or an electronic handbook or casebook. So, live moderation of a clinical forum that could be reliably accessed might be "ideal" for clinicians working in relative isolation.

Making this kind of interaction "point of care" might be possible, but higher cost than many (all?) of the proposed mHealth interventions out today.

Could we create "virtual practices" consisting of a core of physicians connected by phone, computer, device in different locations that agree to work together to support each other? Technology could make this a reliable resource....

Any more thoughts are appreciated.

Catherine (Cathie) Klapperich Replied at 4:53 PM, 12 May 2014

My apologies for missing @Franklin Huang's comment below:

"Regarding Sandeep's comment, this is clearly an area of need and one GO is trying to address through a secure, web-based Collaboration and Advising Platform (CAP). This is a portal that GO is piloting because of a great collaboration with the company Best Doctors that has provided us with this software platform to use with our collaborating sites."

I hope we can support efforts like this one in the future.

A/Prof. Terry HANNAN Replied at 5:57 PM, 12 May 2014

Catherine, thank you for taking the time to reply. I do have some 'extras' for you. Yes, more "information"! Here are some references you may enjoy.
The opening paragraph in the Tierney paper should be hung over every "informaticians" doorway!
Topol E, The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care [Hardcover]
by Eric Topol
Weed LL, Weed L. Medicine in Denial. Version 1.0 ed: Createspace; 2011.
Tierney WM., Kanter AS., Fraser HSF., C. B. A Toolkit For eHealth Partnerships in Low-Income Nations. Health Affairs. 2010;29(2):268-73.

Attached resource:

A/Prof. Terry HANNAN Replied at 6:00 PM, 12 May 2014

Catherine, I do not have your email address to send off line however I believe the article will also be of value to other participants on this site. Terry

Attached resource:

Catherine (Cathie) Klapperich Replied at 10:17 AM, 14 May 2014

Thank you, Terry and all. If you would like to talk with me about the Center offline, my email is

Aric Weinberg Replied at 8:38 AM, 4 Jun 2014

Hi all!

Apologies for coming into this discussion late however I just connected to this wonderful website today. I am a business development consultant in Israel working to promote the development of new medicines and medical devices that improve and protect health around the world.

Currently I am running a crowd funding effort on behalf of my client, MobileOCT. Our device—the Mobile Colposcope—gives health workers a life-saving 2.5-to-10x better view than they have using just the naked eye, raising diagnostic accuracy from 17% to 70%. The handle provides stability and a battery-powered bright light illuminates structural and compositional changes in the tissue. Our device enables health workers to provide the same high level of care in low-resource areas as they would at advanced medical centers. Our solution will help health care organizations screen more patients, while reducing over-treatment due to false positive diagnoses and its costs.

If you are interested in learning more, discussing more or even finding ways to help promote the device feel free and connect with me.

Links are attached below!

Attached resources:

Catherine (Cathie) Klapperich Replied at 9:26 AM, 4 Jun 2014

The CFTCC is hosting a workshop on POC diagnostics next week. It is an online and in person class. There is an opportunity to participate virtually if you register online. We will be on the EdX platform. If you are in Boston, you can come in person, too.
Here are links, Cathie

Attached resources:

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