Saturday, January 31, 2015

New York Times Coverage of the Obama Precision Medicine Initiative

In the State of the Union Speech on January 20, 2015, the President mentioned he would soon unveil an initiative in precision medicine.  The unveiling came on January 30, with both a detailed White House press release and a 20-minute televised speech by Obama.   For more on the Precision Medicine Initiative, see here.

Between January 20 and January 30, there were two interesting pieces in the New York Times, one a news report and the other an Op-Ed.   Discussion below.

The New York Times' senior health reporter, Robert Pear, had an article on January 25 (herethat preceded the January 30 information release.  He explained the basic concept of precision medicine to the reader and several experts offered suggestions as to what the President's initiative would offer.  Interestingly, the article alluded briefly to the January draft LCD from the Palmetto GBA MolDX program that promises to offer limited coverage for next generation sequencing for some lung cancer patients (here).  

On January 30, Pear summarized the several workstreams of the $215M Precision Medicine Initiative as the White House released it (New York Times, here.)

In between, on January 27, the NYT ran an Op Ed from a Mayo physician, Dr. Joyner, which raised questions whether this was, or wasn't, a realistic "moon shot" - here.   Joyner emphasized that in some cases, genetic tests had failed to improve on the existing standard of care (for example, for the drug warfarin), that new technologies were liable to hype, and that perhaps the country should be devoted more resources to behaviors that have huge leverage on health outcomes, like smoking and obesity. 

Surprise: It's not either-or. 

The President's proposal, and the many other efforts in precision medicine, are neither a moonshot nor hype.  A moon shot was one thing: put a man on the moon.  Precision medicine is a broadbased effort to improve the efficiency and effectiveness of disease management across a range of healthcare conditions.  And the President didn't use the phrase "moon shot" - he expressed the goal that America holds a leadership role in efforts from year to year to make medicine more effective in a molecular era. 

Efforts in precision medicine do come back to the core issues in genomics -
  • There are single-hit, high-impact genes that cause severe illnesses - for example, the Huntington's disease mutation and the cystic fibrosis mutation.   Sometimes these are known for many years and prove maddeningly resistant to druggable solutions.  
  • There are plethoras of genes with minor, interacting effects on conditions like hypertension.  In any case, one might yield an impactful, druggable target, or often, may not.
  • In cancer, there is no question there are driver mutations that can yield druggable targets with considerable impact.  Too often, rapidly developing treatment resistance intervenes.  But two- or three-drug combinations (tailored to a patient's cancer genomics) will likely come to play more and more important roles over time.  And someday, growing libraries of targeted oncology drugs will roll into the generic category as patents expire.
Dr.  Joyner makes the right point in reminding us, amidst the genomic enthusiasms, that initiatives like stopping smoking dwarf the impact of most line-item medical technology advances.   I was recently at a talk where the speaker listed the top ten causes of death in Japan, the top ten in the U.S., showed that about 7 of them were the same, and that the biggest driver in 5 or 6 of these was behavioral.   The United States is #36 in life expectancy (here) which means 35 countries with better life expectancy spend less on healthcare per person - as much as ~80% less (here).   

As Joyner writes, the research community won't raise too many objections to new genomic funding, but we "have more control over how much we exercise, eat, drink, and smoke than we do over our genomes" and there is "a dominant role of culture" in what ails us.   And the limits of most cancer screening was beautifully shown recently by infographics at Wired (here). 

We should look not only to the high-profile moonshots - like Gleevec and Kalydeco - but to ways genomic medicine can make our interventions 10, 20 and 30% more effective in efficient ways (e.g. here).

For another op-ed skeptical of precision medicine hype, see New Yorker, here.

In an opinion echocing Joyners, in the NYT on February 16, 2015, see here.