Very Brief Blog: Forbes Posts Strategic Analysis of Roche's Flatiron Acquisition

On February 15/16, there was a flurry of initial press about Roche's $1.9B acquisition of Flatiron (of which it already owned 12%). 

On February 26, Reenita Das, an SVP at Frost & Sullivan, provided a deeper-dive strategic review in Forbes - online and open access here.

A few takeaways, with direct quotes indicated:

• Flatiron provides EHR services to oncology clinics, but "regulatory barriers prohibit a pharma from directly collaborating with a provider."   
• Like any business or service, Flatiron has to create value - it sells something for $500 that creates $1000 of value for the buyer - yet not underprice or "create too much value" that might seem like a giveaway from one healthcare entity to another, especially where one is an ordering provider.
• Flatiron has huge potential to facilitate "clinical trial eligibility assessment," improving speed and registration in clinical trials for Roche (versus other pharmas?)  
• By speeding patient identification Flatiron "can help save developers millions of dollars."
• Roche, with a market cap of about $200B, had $55B in 2017 sales, $40B in gross profit (above cost of goods), and $8B in net profit.  It's 60% oncology - think Genentech drugs like Avastin and Herceptin - much of its oncology franchise is burning through its patent life.
• Flatiron is potentially a world pioneer in large scale real-world evidence.  
• Chief Medical Officer Amy Abernethy MD has written a range of articles on RWE in the last couple years; see PubMed.
• The "Flatiron oncology practice network and patient data can be used by Roche in its digital marketing programs, patient assistance programs, and other commercial applications."  (Direct quote from Das.)
• Flatiron, Foundation Medicine, and Roche Oncology form a trio.  Roche also has agreements with digital genomics and machine-learning company GNS Oncology "to analytize proprietary EHR and next generation sequencing data for insights on drivers of drug response and cancer progression....Roche has one of the strongest portfolios of database and analytics platforms at its disposal to support its personalized drug discovery program in oncology."
• GNS raised $6M last summer from Amgen and others.
• Other biopharmas may look for NGS or EHR tie-ins to remain competitive against the Roche-Flatiron-FMI triad.  
• On February 22, 2018, COTA (a "healthcare real world evidence and data analytics company" raised $40M in Series C funding from IQVIA, EW Healthcare, MSKCC, Horizon BCBS, and others.

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For an earlier article on Flatiron at the time of its 2016 $175M round, here.  Aetna oncologist/medical director Michael Kolodziev joined Flatiron in July 2016 and transitioned to consultancy ADVI in October 2017.

Investors in GNS include:  Amgen, Celgene, Zambon Pharma, Regence BCBS, Horizon BCBS, Mitsui, GHO Capital, Fort Rock Capital.

Investors in COTA include:  IQVIA (publicly held holding company), EW Healthcare Partners, MSKCC, Boston Millenia Partners, Horizon BCBS, Hackensack Meridian Health, ATOC Holdings.

Prior investors in Flatiron included founding investor Google Ventures, Roche, Allen & Company, Baillie Gifford, Casdin Capital.

Very Brief Blog: AMA Posts CPT Decisions from February 2018 San Diego Editorial Panel

CPT meets three times a year and posts decisions about 30 days after each meeting.  Decisions on proposed codes from February 2018 (San Diego) are posted at AMA, here.

The subsequent CPT application deadline was in mid February and the next CPT panel meeting is May 17-19, 2018, in San Antonio.  After that, the next CPT deadline is June 25, 2018, for the September 27-29 meeting in Boston.

My strictly informal tally (your count may vary) is 2 deletions, 8 revised codes, and 11 new code actions.  (Within the lab field, these include 30 new Cat I genetic codes as a set, and 10 new PLA codes as a set.) 

4 applications were rejected, 2 tabled, and about 10 withdrawn prior to voting. 

The panel passed a set of mixed revisions, deletions, and new codes regarding BRCA testing. 

BMJ Publishes Article Criticizing Level of Evidence in NCCN Drug Recommendations

BMJ has published a six page article by OHSU authors Wagner et al. that reviews and critiques the level of evidence used to issue NCCN drug recommendations, in comparison to the level of evidence used in FDA labeling.

• The 2018 BMJ article, by Wagner et al, is online here.
• The authors conclude, "The strength of the evidence cited by the NCCN supporting [non FDA labeled] recommendations is weak. Our findings raise concern that the NCCN justifies the coverage of costly, toxic cancer drugs based on weak evidence."
• The authors note that 6 of 44 NCCN recommendations progressed to FDA-labeled approval during the writing of the publication.
• Opinion piece in BMJ by senior author Vinay Prasad is here.
• See a like minded summary here.
• Trade press at Medscape here
• Trade press at CNN here.
• The last time this topic received a major airing was in 2009.
• Annals of Internal Medicine review by Abernethy et al. here.
• 2012 Deck by Abernethy at NAS, here.
• Additional 2009 piece in JNCI by Twombly, here.
• 2009 in NYTimes, here.
• A 2016 article in JAMA Oncology looked at financial conflicts among NCCN reviewers, Mitchell et al., here.
• Medicare regulations for the admission or exclusion of cancer compendia
• At 42 CFR 414.930, here.
• Rulemaking, November 27, 2007 (72 FR 66303ff) here.
• Revisions, November 25, 2009 (74 FR 61901ff) here.
• Medicare webpage for anticancer compendia here (numerous links).
• 2006 MedCAC on anti-cancer regimen compendia here.

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Footnote.

In 2014, Wang et al. used a similar approach to critique the level of evidence used by FDA authors for inclusion of pharmacogenetic labeling in drug labels; here.

In his OpEd, Prasad notes the project took 1000 hours of manual review of PDFs, and that review at BMJ was onerous, the project in total close to 24 months to publication.

FDA Allows DTC Access to 23andMe's 3-mutation BRCA test; Trends and Controversies

FDA has approved 23andMe to provide non prescription, direct to consumer marketing of a 3-mutation BRCA risk test.   The 3 mutations are founder mutations in Ashkenazi populations.

According to readily available press, about 1 in 400 people have a BRCA mutation, while the founder mutations may occur in 2% of Ashkenazi women.   Highly aware that a negative test does not rule out other BRCA mutations (or mutations in other breast cancer risk genes), the FDA released the test with "special controls" (which can include warnings and education).   The 13 page letter to 23andMe is already online and lists a description of the special controls.

• NBC published an article as, "FDA OKs 23andMe Home Breast Cancer Test, With Warning." [!]  
• Dr. Lichtenfeld of American Cancer Society wrote an article about this test as a "brave new world."

Shorter and longer articles at Genomeweb here and here.   A deeper dive additional article by Turna Ray here [2800 words].  New York Times here.  WSJ here.   23andMe's own blog about the authorization here.

Manyu Different Genetic Regulatory Innovations from FDA 

This new authorization follows a trend of rapidly released genomic test regulatory innovations at FDA.  The following form a moving wavefront of FDA innovation:

1. Allowing easier release via new pathways for FDA endorsed DTC genetic testing in early 2017.
2. Approval of the OncoMine Dx Target 23-gene panel in lung cancer, with 3 PMA approved genes and also with 20 clinically reportable genes in June 2017.  
3. Clearance of the MSKCC large gene panel tumor test in mid November 2017 based on a pathway using New York State approval has the linchpin.
4. Approval of the Foundation One CDx test in late November 2017 with two novel features:
1. Most of the PMA genes were based on analytical concordance or bridging studies.  For these genes, the results are analytically similar to results with at least one previously approved kit (and not necessarily on clinical trial or clinical data specimens).   
2. Release to clinicians and patients of "signatures" that are not FDA approved, such as MSI and TMB. 
5. Release of BRCA testing with very small DTC panels (this article).

Mutation Prevalence in 4-Grandparent Ashkenazi Populations

Last summer, Walsh et al [UW-Seattle] ran a 23-gene test breast cancer risk test in 1007 women with breast cancer and 4 reported Ashkenazi grandparents.  74% of all breast cancer risk mutations were a BRCA founder mutation, 5% were a different BRCA mutation, and the remaining 22% had a mutation in an entirely different breast cancer risk gene.   Altogether, a mutation in some gene was found in 14% (142 of 1007) patients in this ethnic cohort.   Presumably, as soon as you move to less than 4 Ashkenazi grandparents, results will diverge.  In a different area of genetics, Haque et al. (2017) reported widely different recessive risk profiles across ethnic groups in over 300,000 persons tested.  

Summary

As the FDA becomes more flexible and less paternalistic, fewer will complain the agency is too paranoid.   

But the flip side is that more stakeholders will be concerned about unintended risks or adverse events.  While the FDA allows this DTC test, the FDA press release states that: "The use of the test carries significant risks if individuals use the test results without consulting a physician."

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Endnotes

While CEO Anne Wojcicki noted that "being the first and only DTC genetics company to receive authorization to test for cancer risk without a prescription is a major milestone" - and that's true - the authorization is based on technical accuracy and controls such as patient warnings, which other labs should find easy to replicate if they want to.

The FDA cited a 1997 NEJM study as its source of statistics.

Note that the test is described as "authorized" rather than cleared or approved.

The approval is described as de novo, but the detailed documentation for the authorization and pathway may not appear on the FDA website for weeks or months.   An example of a 77-page earlier FDA scientific review and decision on 23andMe testing is here.   [Update: At least a 13-page letter to 23andMe is already online; in other de novo approvals, full FDA paperwork can lag a long time before public display.]

BioPharmaDive describes the test as "tentatively OK'd by FDA" but I can't tell what's "tentative."

In her long-form article, Turna Ray notes the paradoxical positioning of FDA regulation.   FDA authorizes accurate DTC testing by 23andMe, but requires confirmation by another lab for clinical action, and the second lab is likely to be a "pure LDT" and not be FDA reviewed at all.  

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FDA does not generally regulate LDT genetics.  However, it does proactively regulate DTC genetics with clinical implications; (ancestry or paternity is non regulated). 

CMS Creates Special Webpage for MoPath Date of Service Rule

CMS has created a special website that lists the lab CPT codes where, for a hospital outpatient origin specimen, the performing lab must bill, rather than the hospital.    The instructions conform to codes that were, and remain, OPPS "Status A" which means that up til now, the hospital was responsible for billing but the codes weren't bundled to a visit or procedure.

CMS is ignoring some misstatements in its November final outpatient rulemaking, such as saying the new billing principle didn't apply to genomic sequencing procedure codes [82 FR 52536 sic].   CMS said that, but didn't mean that, and is applying the DOS exception to Status A mopath codes.   These are human molecular pathology codes; microbial molecular codes are not part of this exception.

Find the CMS webpage here; download a zip file from it.  The zip file includes an Excel spreadsheet of Status A OPPS Lab Codes, and a PDF with a paragraph of explanation. 

The billing authority is obligatory.  Up until January 1, the hospital was obligated to bill Medicare (whether the test was performed at-hospital or at a referral lab).   This year, the performing lab is obligated to bill (whether it be the hospital or an outside lab.) 

The rule is difficult for some referring labs because they often don't know if the specimen is from an inpatient, hospital outpatient, or just an incoming sample to the hospital (not a patient of the hospital on the day).   The rule also creates a new date of service, which is the "date the test is performed."  In rulemaking, CMS declined to define this date further, and, when asked, declined to formally define it as "the date of the final report," [82 FR 52538] leaving implementation to the laboratory. 

March 6: CMS Updates New, Later Completion Date for NCD for NGS Testing in Oncology

For the CMS NCD on NGS testing in oncology, the agency has officially pushed the completion deadline from February 28 to March 16.

Details

On November 30, CMS released a highly impactful proposed National Coverage Determination governing uses of next gene sequencing testing in oncology, with wide-ranging inclusions and exclusions.   The original comment closure date of December 30 was extended, on December 20, to January 17, because the FDA had newly (finally) released its evaluation paperwork on the Foundation One CDx test. 

On Wednesday, February 28, CMS missed the original final NCD announcement date. 

On Tuesday March 6, CMS posted the new final date as Friday March 16.   This fits a statutory deadline of 60 days after the extended January 17 comment period.   CMS explained: "We are continuing to review and evaluate the high-volume of public comment, and expect to complete the process soon." 

The final NCD could appear before the announced deadline of March 16.   For my comments a few days ago on the rationale for the extended process, see an earlier blog, here.

CMS Hasn't Released a Final NGS NCD for Cancer Patients: Here's Why

Update - CMS released the Final NCD on March 16, 2018, with revisions that met most of the concerns raised by the WSJ author and others.   See Final NCD here.

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Update: On Tuesday, March 6, about a week after the original  completion date, CMS updated its website to give a new expected completion date of March 16.   The rest of this original blog stands as written, below.
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On November 30, as part of its joint review with the FDA of the Foundation One CDx test, CMS released a wide-ranging NCD with implications for all Medicare patients with a early or late stage cancers.    The normal 30-day comment period was extended from December 28 to January 17, because FDA didn't release its evaluation and review of the FMI test until just before Christmas. 

As of early March [Until March 6], CMS was still posting that the NCD completion date would be February 28:

But CMS didn't release the finalized NCD.  What happened?

All signals are that the NCD was probably finished and ready for release on time, on February 28.  CMS took no opportunity to revise the release date, as it had when it publicly posted a revised comment period date.   It's likely that something intervened - the Weill-Cornell Op Ed in the WSJ on February 25.   Here's a screenshot:

This Op Ed hits the right key words - "needless limits," and "regulatory threat," etc.   And consider where this lands.  On Monday morning, this Op Ed was on the breakfast tables of senior health staff for Senator McConnell, Senator Hatch, Senator Schumer, Senator Feinstein, and so forth.   Lots of retirees also saw it early in the morning.  Staffers at the White House and OMB saw it, many of which had no clue what was being discussed. 

This was enough to slow down the process.  And CMS had another justification, if it needed:  it should get 60 days from the end of the comment period, which was January 17, so probably Friday March 16 rather than Wednesday February 28.   This 60 days is pretty black and white; it's at SSA S. 1862; "60 days from the end of the comment period."

What will happen next?

What will happen next will depend on whether the "pull the brake" moment resulted in a short extra review at higher levels, which could lead to a delay of a couple days in the finished document, or whether enough confusion is raised to lead CMS to release the document on a new deadline of March 16, perhaps with new revisions. 

Analysis.  Most higher-ups could probably be calmed down by explanations by medical staff (e.g. mid level staff) that the NCD was correctly drafted, wisely revised, and ready to go.   Since higher level staff probably won't have new articulate questions of their own, the extra review (for better or worse) would probably not be very long nor result in document changes.   Still, I'd look for CMS to release the NCD on a Friday evening at 5 or 6 pm - thus arguing for Friday March 9 or Friday March 16, even if it's ready to go on March 5.
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A Forbes op ed on March 6 by health journalist Elaine Schattner supported wide access to NGS testing for cancer patients.
A subscription article in StatNews on February 21 made points similar to Elemento's WSJ piece.

In CMS CLFS Data: What Part of Lab Billing is Hospital Based Billing?

A major issue in the implementation of PAMA is that CMS surveyed almost no hospital outreach labs, which would have raised the median PAMA prices for the 2018 CLFS.

CMS releases copious data on Part B provider billing, including lab and all other CPT based services.   However, CMS doesn't release the same granularity of billing for Hospital outreach lab services.   However, there's a way to impute the hospital billing relative to the Pt B independent lab billing.

Here's the trick.  For the past 3 years, OIG has released an annual report of all payments on the CLFS (whether to hospital labs or independent labs.)   The October 2017 version, showing CY2016 data, is here.   In particular, OIG provides a table of all CLFS payments for the top 25 CPT codes in its report.

On a separate website, about the same time, CMS released all the Part B (independent lab) payments by CPT code.  That's here.  CMS and OIG don't do this for us, but in a few minutes you can list the OIG payment data (A+B) and the Pt B data (B), and subtract the difference to get the "A" or hospital reference lab payments, by CMS, on the CLFS.   The data here:

click to enlarge;  dollars in Millions; see notes

   A few notes.  First, OIG posts "CMS payments" data, whereas for the table I pulled "CMS price allowed data" which is about 2% higher.  In the math for the percentages column, I used 98% of the B table to compensate.

  You'll quickly note that hospital CLFS payments are generally about 30% of all CMS CLFS payments by dollar volume.  It does vary by code.  Note that G-code drug panels are almost entirely Pt B independent labs.  Note too, that hospitals don't bill Cologuard or Oncotype DX (81528, 81519). 

There's not that much grand variation in most of the other 25 codes.   CBC and chem panels are almost half dollar volume at hospital labs (85027, 80048).   PSA and Folic acid are not so common in hospital labs (23%). 

Remember that these data would have looked very different before 2014 or so, when CMS stopped paying for hospital clinic outpatient lab tests separately.[*]  The data above for 2016 would be for hospital reference lab CLFS tests that are not clinical outpatients. 

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[*] Except for genetic/genomic tests, which are still paid separately.  Outpatient clin chem was bundled into fees that support outpatient visits or procedures.

Brief Blog: Is procalcitonin the most cost effective life saving test ever?

In the last couple years there have been several articles in CAP TODAY about procalcitonin, which is most typically elevated in bacterial sepsis (here, here, here).    It caught my attention that there was a favorable review of procalcitonin in Cochrane Reviews, whereas technology assessments usually beat the (x) out of clinical laboratory tests.

See short summary in Annals of Internal Medicine and full review by Shuetz at Cochrane. In a meta-analysis of 6708 patients in 26 trials, mortality was reduced from 10% to 8.6%, giving a number needed to treat of 65.   That suggests, in simple math, circa 65x$20 or about $1200 per death avoided. 

Very Brief Blog: The PIE Act (HR 2027): Pre Approval Value Communications with Payers

Section 502 of the FDCA regulates communications before a drug is approved.  It has allowed some health care information to be conveyed to payers, and was expanded by a few phrases in the December 2016 "21st Century Cures Act."   Just weeks later, FDA released a guidance on interpretation of this section that included changes from 21CC (draft guidance here.)

The "Pharmaceutical Information Exchange Act," or PIE Act, was introduced in 2017 and advanced a bit in the legislative cycle in January 2018.  It's strongly supported by AMCP (Association of Managed Care Pharmacists).  They view early economic and value communications as helpful in making more rapid decisions once a drug has been approved.

The revised proposal under PIE is simply a paragraph of text (much of which already is there at 502, having been modified by S. 114 of FDAMA 1997, and then tweaked a bit by 21CC):

“(2) Health care economic information or scientific information provided to a payor, formulary committee, or other similar entity with knowledge and expertise in the area of health care economic analysis carrying out its responsibilities for the selection of drugs for coverage, reimbursement, or other population-based health care management, shall not be considered false or misleading or any other form of misbranding under this paragraph, or a violation of section 505 of this Act or section 351 of the Public Health Service Act, or otherwise prohibited pre-approval promotion of a drug, if it is based on competent and reliable scientific evidence and relates to an investigational new drug or an investigational use of an approved drug. In order for information relating to an investigational use of an approved drug to be provided pursuant to this subparagraph, there must have been submitted to the Secretary a supplemental application for approval of such use, or the study or studies needed to support the submission of a supplemental application for such use must have been completed with the intention that a supplemental application will be submitted to the Secretary for approval of the use. For purposes of this subparagraph, scientific information includes clinical and pre-clinical data and results relating to an unapproved drug therapy, or drug indication, or other condition of use being investigated or developed.”

This section clearly looks to "promotion of a drug" but the corresponding FDA guidance, cited above, is for drugs and devices.

Medicare specifically solicits pre-approval information in a few cases, such as for new technology add-on DRG payments and new HCPCS codes.  In both cases value arguments and data can be submitted to CMS ahead of the FDA approval, and this has been the status quo for quite a few years. 

Very Brief Blog: Licenses for Tumor Mutational Burden and MSI

A news item in Genomeweb today notes that Personal Genome Diagnostics, a Baltimore-based lab stemming out of Johns Hopkins, has newly licensed IP regarding Total Mutational Burden (TMB) from Memorial Sloan Kettering Cancer Center (MSKCC).   Earlier, it had licensed MSI IP from Johns Hopkins.

The "aha" moment for me was that there is IP to license in commonly discussed areas like TMB and MSI.   Given the evolving legal climate for diagnostic patents in recent years, from Supreme Court down, it must be an intriguing area for molecular IP attorneys.

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PGD raised $21M in 2016.  This week, there are 40 papers on Pubmed discussing TMB and 7045 on "microsatellite instability."

Very Brief Blog: Mamuszka's Articles on What Bad Things Happen When Dx Are Under-Valued by Payers

Hannah Mamuszka is founder of ALVA10, a Boston-based consultancy that aims to help diagnostics innovators work with payers from early on. 

She has an interesting article in the December 2017 issue of Journal of Precision Medicine.  Titled, "Economics for Diagnostics: Why Paying for Value is Necessary to Drive Market Success and Uptake."  It's one of 3 articles she's written for J.P.M. on the economics and dynamics of the market for diagnostics to serve precision medicine.   I've stored the 3 PDFs in a cloud zip file here.

She gives the example of a costly drug that is overused 60% of the time.  A diagnostic could control that overuse effectively.   However, developers might presume, and safely, that the diagnostic would be priced at $200 or less.  Given the costs of clinical trials (falling on the diagnostic manufacturer, because they lower drug use and aren't an interesting investment for the pharma), the test won't be developed.

If the test COULD be developed, it might require a $5K price tag to recoup its investment - but could dramatically lower total health system costs for the $100,000 drug, while also preventing treatment of patients for whom the drug is ineffective (see her Fig. 2).[*]

She includes a nice figure how, rationally, all the stakeholders would need to work together (her Fig. 3):

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For another example of payers working with diagnostics manufacturers ahead of coverage, see CareFirst's effort called HealthWorx.

In an early entry in this blog series, I noted that there's little motivation for work on generic genes to improve outcomes of generic drugs, despite the potentially large health system benefits.

For a link to a 2017 FDA guidance document about pre-approval value communications between manufacturers and payers, here.

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[*]  A Feb 28 article in Genomeweb may be unrelated, but has an eerie echo to Mamuszka's hypothetical case study.  According to the article, Nanostring was developing an immunotherapy selection signature with "exciting results" but it was "scrapped" due to a "strategic decision" by a pharma.

Very Brief Blog: Flurry of Articles on Breast Cancer Prognostics

Briefly catching up with a flurry of new articles on breast cancer prognostics.

As discussed in Genomeweb, Sestak et al. did a large scale study of five prognostic tests, including Genoptix IHC4, Genomic Health Oncotype DX, BioTheranostics BCI, Nanostring Prosigna, and Myriad EndoPredict. 

• Prosigna, BCI, and EndoPredict were "more prognostic."  
• See Sestak et al  in JAMA ONCOLOGY in February, 2018.

In Journal of Clinical Oncology:

• Holowaty et al. found that given the Oncotype Dx test, non hispanic blacks (NHB) had significantly higher risk scores on average than non hispanic whites (NHW); especially in the <50 group.  
• This was a study of scores reported; not clinical correlations.
• Chandler et al. found a range of cost per QALY values for Oncotype Dx "in community use," from $28,947 to $188,125 per QALY.
• The "ASCO Post" provided its own news-item summary of Chandler; here.
• Cost effectiveness of breast cancer profiling has been newly revisited by NICE (here).  
• In Nature Reviews Genetics, Payne et al. provide a review of how messy genetics cost effectiveness studies are.
• Mittmann et al. found that in many scenarios, Oncotype Dx somewhat increased (rather than decreased) costs.
• Costa et al. provide an op ed "Do genomic assays [in breast cancer] provide the necessary confidence to de-escalate adjuvant therapy?"  Reviewing recent data, the answer seems yes, consistent with earlier recommendations of some major clinical groups.

Though not directly on breast cancer, current issues of Journal of Clinical Oncology provides two related articles, one on "fear of cancer recurrence" in an era of better therapies and better prognostics (Thewes et al.; open access) and a "Grand Rounds" review on prostate cancer recurrence prognostics by Morgans.

Very Brief Blog: Website Up for HIMSS Precision Medicine Summit, Washington, May 17-18, 2018

The website is up for a May 17-18, 2018, Precision Medicine Summit sponsored by HIMSS.

It's in Washington...Website here:
http://www.theprecisionmedicinesummit.com/washington-dc/2018

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HIMSS is also holding a one day workshop on implementing PM in health systems as part of its upcoming annual conference (workshop Monday March 5 in Las Vegas, here).

Brief Blog: Price Waterhouse Releases New 28 Page Study of Precision Medicine Opportunities

With an article at its website Strategy+Business, and with a 28 page PDF online, Price Waterhouse gives us a February 2018 update on "How precision medicine will transform the pharma and healthcare industries."

The web article is here.   The PDF is online here. 

The main focus is on interview responses from 100 leaders in the biopharma industry.  Barriers were listed as "unstable legal/regulatory framework" and "lack of access to relevant data."  Precision medicine requires more "collaboration expertise" than simple pop-the-pill drug development.

The three lead authors are based in Frankfurt, Dusseldorf, and Berlin.  Readers interested in a C-level health system view of precision medicine may enjoy a 4-page interview based report by Intel, here.