MABS in history of medicine

The Lock and Key of Medicine Monoclonal Antibodies and the Transformation of Healthcare

While reading FT this summer I came across an article quoting a unique book on history of monoclonal antibodies (MABS). Right now there are more than 30 drugs in the market based on hybridoma technology that was created in 1975.
The birth of MABS is explained with full details, how the creators finally didn't patented it and why, the difficulties for research in an unconnected world, etc... An exciting story that is worth reading. Right now, it would be completely different, commercialization of research and medicine has raised considerably.

That a British company spearheaded the first marketing of Mabs, a technology devised in a British laboratory by an émigré Argentinian scientist with his German colleague, highlights the international nature of biotechnology commercialization. Sera- Lab’s venture to sell Mabs took place in the midst of the excitement generated by the founding of Genentech in 1976. The emergence of Genentech, which had been set up
to market recombinant DNA products, galvanized numerous alliances among academics, entrepreneurs, and venture capitalists to launch new companies to commercialize biotechnology. Most of the early enterprises set up in the wake of Genentech’s birth were dedicated to exploiting recombinant DNA for the mass production of natural products such as interferon and insulin for drugs. But the early germination of the modern biotechnology industry did not rest solely on recombinant DNA. By the 1970s a number of pioneering companies were developing Mab products, including Sera- Lab and two startups: Hybritech in San Diego and Centocor in Philadelphia. Entrepreneurs who risked entry into the field had no guarantee of success and were entering totally uncharted
territory. Such individuals faced major fi nancial, personal, professional, and regulatory challenges as well as a great deal of hostility, pessimism, and litigation.

Milstein with Köhler at the time of their receiving the Nobel Prize in 1984 together with Nils Jerne.

Mabs have had their strongest therapeutic impact in the field of cancer. The first Mab to reach the market for cancer was edrecolomab (Panorex), which was granted German regulatory approval in 1995 for the treatment of postoperative colorectal cancer. Developed by Centocor in partnership with the Wistar Institute, it was withdrawn in 2001 because of its poor effi cacy in comparison with other drugs. Since 1997, however, the U.S. Food and Drug Administration (FDA) has approved twelve Mab drugs for cancer treatment, including rituximab (Rituxan), approved in 1998 for the treatment of non- Hodgkin’s lymphoma. By 2012 there were over 160 candidates in clinical trials for cancer, with seventy of them in phase III trials, the stage before a drug is submitted for regulatory approval.

Mabs have enabled the identification and characterization of cancerous tumors previously difficult to detect and diff erentiate from other tumors, thereby providing a better understanding of cancer. They have also opened a path to more personalized medical treatment. Trastuzumab (Herceptin), for example, was specifically developed to target HER2/neu, a protein overexpressed by tumors found in 25 percent of newly diagnosed breast- cancer patients

Alcohol and health

Alcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality: a prospective cohort study

The relationship between alcohol intake and health is a complex one. A recent article in The Lancet tries to disentangle the causes and consequences:

The amount, type, and pattern of alcohol consumption can have differing associations with health outcomes. For example, low–moderate regular intake of alcohol is associated with reduced risk of myocardial infarction, whereas heavy episodic drinking is associated with sudden cardiac death.6 Risk of injury increases with extent of intoxication, whereas risk of cancer is related to the amount consumed over time.

In a study of 114.970 participants from 12 countries on the relationship between alcohol and its impact on certain diseases has allowed to understand that geographic location plays a relevant role, beyond the type of alcohol consumption. These are the results:




In summary, the study shows that current drinking is not associated with a net health benefit. We confirm that high intake is associated with increased risk of mortality, cancer, and injury. A serious alert for spirit drinkers and a key message for an updated public health strategy. Have a look at the UK example.

Disposable income trends

From: EU Statistics and book.

Healthy longevity

Health at a Glance 2015

Every year OECD updates health database. The latest one was released yesterday. Japan, Spain and Switzerland are at the top of life expectancy at birth with 83 years. However,  in healthy life expectancy at 65,Switzerland is in the 9th position, and Spain in the 13th. Why is this so?. The priority on quality of life should increase.

Physicians' quality: incentives and information

In the USA, the Affordable Care Act requires the federal government to post information about physician performance and quality of care on a public website. The recent experience of public and private initiatives has been reviewed in a Health Affairs Brief. If you want to know the implications and details on how to make information accessible for citizens, this is a key document to read.

• By 2019 doctors who treat Medicare beneficiaries must choose between two options—enroll in a program called the merit-based incentive payment system or sign up to be part of an alternative payment model.
• The merit-based incentive payment system will adapt and combine multiple programs —PQRS, the EHR meaningful-use program, and the value-based payment modifier initiative—into one.
• Doctors opting for the merit-based incentive payment system must report quality-of-care measures to CMS. How is to be determined, but CMS likely will use an upgraded PQRS reporting system.
• Physicians will be scored on four components of care: quality (30 percent); resource
use (30 percent); meaningful use of EHRs (25 percent); and practice improvement  activities (15 percent).
• Physicians choosing the alternative payment model path would have to be part of an integrated health system, join an ACO.

Sounds interesting. Incentives and information altogether, a hint for other health insurance markets on what to do about it.

Owners and managers in state owned firms

Governance issues are at the center of current debates in public and private firms. Unfortunately, too often as a cosmetic perspective. The roots of the problem are left for another day. Let me give an example. Recently, a hospital selected its CEO by a unique procedure: asking the physicians about the right candidate (at least this is what has been published in the press).
Selecting the right leadership for a firm is the most relevant issue for any board of directors. However, in this case, they will have only one candidate coming from a proposal of professional employees of the firm. The board will confirm their option, for sure, otherwise it will boost a huge crisis.
The worst approach to selecting leadership is to confound participation with governance. In state owned firms, the governance belongs to elected politicians (of course they delegate to appropriate professionals selected for the board). The ownership is public, and citizens are represented through politicians. That's it.
In this unique case, politicians or their delegates have been supplanted by professional employees. This is a biased way to understand governance functions in state owned firms, and somebody should review it in depth before this approach is converted into a trend for other hospitals. Here you'll find the roadmap.

The Theranos contretemps as a serious scandal

Last Thursday WSJ released a long article on Theranos clinical lab. In this blog you may check my February and July posts on this firm under the title: A closely guarded secret. As you may imagine, such a title was not coincidental. There were some clues that justified it, something unusual was happening. And WSJ has contributed to shed light on the issue. All the details in it. Basically, the summary is that analytic validity and clinical validity is under compromise. This is an exemple:



If you want to read a first person account, you'll find it here and here. Some additional articles: Wired, New Yorker, Clinical Chemistry and Laboratory Medicine (CCLM), Forbes, NYT, WP,...
This is not only a contretemps, it is a serious scandal and a huge problem to credibility for this start-up.
From Wired:

Theranos got a lot of traction by tapping into the frustration—both from consumers and the medical community—that diagnostic testing is too painful, too slow, and too expensive. “Their problem is they tried to do it with existing diagnostic instrumentation, instead of innovating new diagnostic instrumentation,”

Theranos is a black box that has touted results rather than process. “The ability of the lab medicine community to police and correct itself depends on that flow of information,” says Master. Instead, Theranos’ research was internal, and rather than submit their work to peer review the company cited their FDA approvals as evidence that the technology worked.

At least in the USA there is a regulator, the FDA, lab regulation in Europe was enacted in 1998, completely outdated under a third party scheme, not a direct public regulator. Therefore, there is a pressing motive to speed up new and different rules in Europe. Microfluidics and nanotechnologies are calling for and urgent overhaul.


 PS. An statement from WSJ:

In 2005, Ms. Holmes hired Ian Gibbons, a British biochemist who had researched systems to handle and process tiny quantities of fluids. His collaboration with other Theranos scientists produced 23 patents, according to records filed with the U.S. Patent and Trademark Office. Ms. Holmes is listed as a co-inventor on 19 of the patents.

The patents show how Ms. Holmes’s original idea morphed into the company’s business model. But progress was slow. Dr. Gibbons “told me nothing was working,” says his widow, Rochelle. In May 2013, Dr. Gibbons committed suicide. Theranos’s Ms. King says the scientist “was frequently absent from work in the last years of his life, due to health and other problems.” Theranos disputes the claim that its technology was failing.

Precision medicine in an outdated regulation

Specially dedicated to european politicians, this was my op-ed in Diario Médico last week:

La medicina de precisión en una regulación obsoleta

El retraso regulatorio europeo en pruebas diagnósticas y suministros médicos es descomunal

El avance tecnológico coge por sorpresa a gobiernos y parlamentos. El retraso en actualizar la regulación a las nuevas realidades frena a su vez la difusión de las innovaciones e introduce incertidumbres sobre la eficacia y seguridad. Desde hace más de una década sabemos que el impacto en la asistencia sanitaria de los avances en el genoma humano tendría lugar algún día inexorablemente. Sin embargo,a fecha de hoy, estamos a la espera de su regulación.
En 2005 un periódico anunció que llegaba la medicina personalizada pero muy pronto nos dimos cuenta que todo era más complicado de lo que algunos proclamaban. En 2011, Science decía en portada: “Lo mejor está por venir”. A la secuenciación del genoma humano le faltaba todavía mucho trayecto para que se concretara en impacto en la salud poblacional. Y en el mismo año se publicó el informe del National Research Council estadounidense: “Toward Precision Medicine”. En él se mostraba el impacto del conocimiento biomédico en la clasificación de la enfermedad, describía el reto de la redefinición de la enfermedad a partir de la biología molecular, a la vez que popularizaba el nuevo término: Medicina de Precisión.
En marzo de 2012, Cell publica un artículo crucial donde se relata la aparición molecular de una enfermedad. Un profesor de Stanford relata la evolución de su perfil ómico personal, analiza qué ocurre durante dos años, cómo surge la enfermedad y cuál es la reacción molecular del cuerpo. Explica cómo descubre el riesgo de diabetes y cuando se confirma, qué hace a partir de aquel momento.
Del titular del periódico de hace una década nos acercamos, ahora sí, a la medicina de precisión, intensiva en datos. Las inversiones públicas en iniciativas de investigación son tan solo una parte del todo. Lo que llamábamos “medicina estratificada”, la que une pruebas diagnósticas complementarias (companion diagnostics) para determinar el tratamiento farmacológico, ya está entre nosotros. Ahora es un ejemplo más de medicina de precisión. Y resulta que a fecha de hoy, en Europa tenemos una regulación vigente de 1998 (!). Desde 2012 circula un borrador para actualizar la directiva sin éxito. Recientemente, el pasado 23 de septiembre, ha surgido un nuevo borrador que la Comisión quiere elevar al Parlamento para su aprobación. Veremos qué sucede en esta ocasión.
El texto considera las pruebas diagnósticas complementarias esenciales para definir aquellos pacientes que son candidatos a un tratamiento específico con un medicamento, a través de la determinación cuantitativa o cualitativa de marcadores específicos que identifican los sujetos con mayor riesgo de desarrollar reacción adversa al medicamento o la identificación de los pacientes en la población para los que el producto terapéutico se ha estudiado de manera adecuada, y es seguro y efectivo. La forma como se evalúa la seguridad y eficacia queda al margen de los procesos equivalentes en los medicamentos y se mantienen las entidades certificadoras, si bien con cierto control adicional. Y la pregunta es la de siempre: ‘Quis custodiet ipsos custodes?’, ¿quien vigila al vigilante?. Este “cierto” control gubernamental será suficiente? O quizás cada estado lo resolverá a su propio estilo?.
El sistema europeo basado en la autoregulación, en entidades certificadoras privadas, queda lejos del sistema norteamericano donde las pruebas diagnósticas complementarias se regulan públicamente por la FDA. De esta forma, un medicamento que requiere una prueba diagnóstica queda regulado en Europa en dos ámbitos distintos, con requisitos de evaluación desiguales. En definitiva, estamos a las puertas de una regulación que es incapaz de tener en consideración que la validez y utilidad clínica en la medicina de precisión debe ser objeto de regulación pública directa.
El retraso regulatorio europeo en pruebas diagnósticas y suministros médicos es descomunal. A fecha de hoy se sigue un proceso para acceder al mercado que requeriría una revisión profunda de su impacto en términos de validez y utilidad clínica. La credibilidad de la evaluación se confirma siempre que existan criterios objetivos, fiables y homogéneos. Los mecanismos actuales de certificación son insuficientes para los objetivos que se esperan de una regulación avanzada. Del mismo modo que el escándalo de los implantes mamarios PIP recordaron la falta de garantía y control en suministros médicos, las pruebas diagnósticas requieren una regulación fiable que garantice seguridad y calidad, al mismo tiempo que aporte información sobre su efectividad. No hay opción para más demora. La nueva propuesta de regulación de pruebas diagnósticas necesita una mejora inmediata o, de otro modo, se convertirá en obsoleta a corto plazo.

 

Mapfre Foundation. Barcelona exhibition.

Disentangling ageing and health

World report on Ageing and Health

Although it may surprise, there is no clear pattern to indicate that elderly people  always utilise more health services. When one looks at the aggregated indicators, one may reach this conclusion, however taking into account the realities and individual characteristics, there are many remaining factors to explain the situation. This fact is evidenced by the last WHO report on aging and health. (P.90).
Even considering the increased morbidity at older ages, the burden of chronic diseases is diverse in terms of cost. Thus, few users and its distribution in the phase prior to death, it is the main cause of the high cost of chronic disease. Proximity to death and corresponding therapeutic effort confound the ageing factor in increasing health costs.
Furthermore, it has been shown that the compression of morbidity continues to advance. That is, the occurrence of chronic diseases is delayed gradually, the phenomenon of "survival of the fittest" is confirmed. The impact or impairment of chronic disease in human physiology for the very old is attenuated .
It is for these reasons that the report is worth, a new look to a reality that is already upon us and we need to give appropriate response.

A cause and consequence of progress (again)

Today I would like to suggest you check my previous posts on Angus Deaton, the economics Nobel prize winner. And if you have more time, a close reading of his book is required: The Great Escape: Health, Wealth, and the Origins of Inequality.
Angus Deaton deserves the prize -NYT dixit-. John Cassidy writes an excellent op-ed (The New Yorker) with the title: Angus Deaton: A Skeptical Optimist Wins the Economics Nobel. Nothing to add.

Using behavioral insights for policy

Social and Behavioral Sciences Team 2015 Annual Report

Some weeks ago, an executive order by President Obama boosted the application of behavioral insights to policy.

To more fully realize the benefits of behavioral insights and deliver better results at a lower cost for the American people, the Federal Government should design its policies and programs to reflect our best understanding of how people engage with, participate in, use, and respond to those policies and programs. By improving the effectiveness and efficiency of Government, behavioral science insights can support a range of national priorities, including helping workers to find better jobs; enabling Americans to lead longer, healthier lives; improving access to educational opportunities and support for success in school; and accelerating the transition to a low-carbon economy.

Sounds interesting. It poses a tweak on the current approaches to policy design. Cass Sunstein says in NYT:

 When government programs fail, it is often because public officials are clueless about how human beings think and act. Federal, state and local governments make it far too hard for small businesses, developers, farmers, veterans and poor people to get permits, licenses, training and economic assistance.

 Behavioral research shows that efforts at simplification, or slight variations in wording, can make all the difference.

The UK and now the USA are introducing this new way to define policies (and health policy). Let's keep an eye on its application and performance. What are we doing in this respect? Why are we waiting to introduce something similar?


 President Barack Obama speaks with members of the Social and Behavioral Sciences Team in the Oval Office in January 2015.

Cost-effectiveness of public health interventions

The case for investing in public health

The evidence shows that a wide range of preventive  approaches are cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening. The evidence in this report shows that prevention is cost-effective in both the short and longer term. In addition, investing in públic health generates cost-effective health outcomes and can contribute to wider sustainability, with economic, social and environmental benefits.

Cost-effectiveness studies  are usually focused towards treatments. This report shows some examples related to public health. Unfortunately,  this is not so common. Up to now my reference on this tòpic was this article. Now I'm adding this report by WHO Euro. And the question remains: if these interventions are so cost-effective, why are we waiting for their implementation?

It is recognized that a comprehensive strategy needs to include a combination of population and targeted individual preventive approaches, but it should be noted that, on average, individual-level approaches were found to cost five times more than interventions at the population level (WHO, 2011a). In general, evidence also shows that investing in upstream population-based prevention is more effective at reducing Health inequalities than more downstream prevention (Orton et al., 2011). Meanwhile, the National Institute for Health and Care Excellence in the United Kingdom found thatmany public health interventions were a lot more cost-effective than clinical interventions (using cost per QALY), and many were even cost-saving (Kelly, 2012).

The healthcare funding conundrum (once again) (2)

Fiscal Sustainability of Health Systems. Bridging Health and Finance Perspectives

Sustainability defined by OECD (p.25):

The OECD defines fiscal sustainability as the ability of a government to maintain public finances at a credible and serviceable position over the long term (OECD, 2013). Fiscal sustainability implies governments are able to maintain policies and expenditure into the future, without major adjustments and excessive debt burdens for future generations. The term refers to overall government spending, revenues, assets and liabilities that reflect past commitments and adapt to future trends such as socio-economic trends and environmental factors.

For the health sector, fiscal sustainability is perhaps best understood as a constraint that needs to be respected, rather than an objective in itself (Thomson et al., 2009). This implies that how governments achieve fiscal sustainability matters, rather than it  becoming a simple cost-cutting exercise.

Of course!. Sometimes OECD writes obvious statements. There is a budget constraint! Perhaps someone has forgotten it.
I understand that in some countries the budget is not credible, because its health basket is more generous and prices are higher compared to the available resources. Is  this a reason to complain about cutbacks?. If there is a budget, the role of any politician is to comply with the budgetary constraint, they must prioritise. Health care is not an excuse to surpass the budget and responsible citizens and parties should acknowledge it.

The healthcare funding conundrum (once again)

Fiscal Sustainability of Health Systems. Bridging Health and Finance Perspectives

Forget economic forecasts, most of them have failed many times. You don't need to be precise about the size of the GDP devoted to health in 2030, it will definitely be more expenses than now. The OECD tries in a new report to review these forecasts and to spread fear in the near future. I think that our societies before the great recession, were able to manage to some extent fiscal deficits. Now it is different, the size of the deficit for future generations is unacceptable.
The report reviews former approaches to supply side and demand side measures for cost-containment. A well known story on the macro-prescription for governments.  My view is not reflected in the document. I have highlighted many times the importance of organizational change, the micro-perspective, i.e. the changes in the structure of incentives and coordination mechanisms in the health system.
This is the most challenging effort for any government, because organizational change and prioritisation represents an attempt to modify the current status quo. Governments are affraid of it, but in my opinion somebody has to handle this conundrum and tell  the population exactly that unless we change current health care organizations, taxes will not be sufficient to pay the bill. Then two options will be open to us: out of pocket or no access. This is the message that this report is unable to explain clearly and now it's time for somebody to disseminate it.

PS. Read the Fiscal Sustainability of Health Systems: Policy Brief