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Personalized Medicine: The Changing Landscape of Health Care
The 2nd Biomarker Meeting in Personalized Reproductive
Medicine
Valencia, Spain
11 April, 2014
Edward Abrahams, Ph.D.
President | Personalized Medicine Coalition
Ancient Precedent
“It’s far more important to know what person the disease has than what disease the person has.”
Hippocrates (ca. 400 BCE)
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Moving from Art to Science
“If it were not for the great variability among individuals, medicine might as well be a science, not an art.”
Sir William Osler, Physician (1892)
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The right treatment for the
right person at the right
time
Trial and Error
Personalized Medicine Current Practice
Defining Personalized Medicine
One size fits all
Trial and error
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PCAST Definition of Personalized Medicine
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“Personalized medicine” refers to the tailoring of medical treatment to the individual characteristics of each patient… to classify individuals into subpopulations that differ in their susceptibility to a particular disease or their response to a specific treatment. Preventive or therapeutic interventions can then be concentrated on those who will benefit, sparing expense and side effects for those who will not. President’s Council of Advisors on Science and Technology (PCAST), Priorities for Personalized Medicine, September, 2008
Revised Definition of Personalized Medicine
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Personalized medicine is an evolving field in
which physicians use molecular diagnostic
tests to determine which medical treatments
will work best for the patients. By combining
the data from those tests with an individual’s
medical history and circumstances, health care
providers and patients can develop targeted
treatment and prevention plans.
Reactions to Definitions of Personalized Medicine
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Reactions to PCAST and revised definitions of Personalized Medicine were dramatic. People who saw the new definition responded positively, saying it was clear, easy to understand, and consistent with the term.
Preferred Name for Personalized Medicine
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By far, the two favorite names were “individualized medicine” and “personalized medicine.” The word, “targeted” was also a favorite. “Precision medicine” was more negative than positive; and “stratified medicine” was disliked most of all.
Hope and Fears for Personalized Medicine
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The majority of those surveyed feel excited about personalized medicine. The biggest concerns were regarding cost and access to treatments. The most exciting ideas were around better more informed tailored treatment options
What is Driving Personalized Medicine?
Safer, More Effective Drugs
Faster Time to a Cure
Cost-Effective Healthcare
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The Benefits of Personalized Medicine
•Diagnose disease more accurately
•Select optimal therapies and target medicines and dosages
more precisely
• Increase safety, reduce adverse drug reactions
•Detect onset of disease at the earliest moments
•Shift emphasis in medicine from reaction to prevention
• Increase the efficiency of the health system by improving
quality, accessibility and affordability
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Asthma Drugs 40-70% Beta-2-agonists
Hypertension Drugs 10-30% ACE Inhibitors
Heart Failure Drugs 15-25% Beta Blockers
Anti Depressants 20-50% SSRIs
Cholesterol Drugs 30-70% Statins
Major Drugs Ineffective for Many
Source: Spear B, Heath-Chiozzi M, Huff J Clinical Trends Molecular Medicine 2001; 7(5):201-4. 11
Ineffective Therapies Waste Money
Major Drug
Hypertension Drugs
Ace Inhibitors
Heart Failure Drugs
Beta Blockers
Anti Depressants
SSRIs
Cholesterol Drugs
Statins
Asthma Drugs
Beta-2-agonists
Cost of Ineffectiveness to Healthcare System
$390 million – $1.2 billion
$345 million – $575 million
$2.3 billion – $5.8 billion
$3.8 billion – $8.8 billion
$560 million – $1.0 billion
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Ineffective Therapies Can Cause Harm
Adverse Events
• Estimated 100,000 deaths per year (in 1994; Lazarou et al 1998)
• 6th leading cause of death in the US
• Experienced by approximately 7% of patients (2.2 million) per year
• Medication-related health problems account for an estimated 3% to
7% of hospital admissions (Pirmohamed M, et al 2004)
• During their hospital stay, 15% of patients experienced adverse
drug reactions (Davies, et al 2009)
• Increased patient non-compliance
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The Old Paradigm: Treatment of Disease
Reactive Medical Care
Select Drug
Diagnosis
Switch Drug
Switch Drug Again
Diagnose Disease; Treat Symptoms; Costly, Trial and Error Treatment
Dis
ease S
everity
Time
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Effective, Efficient Health Management
Efficient Medical Care
Health Management; Molecular Screening; Early Detection; Rapid Effective Treatment; Improved Quality of Care
Predisposition
Right Drug
Diagnosis/Prognosis
Screening
Monitoring
Dis
ease S
everity
Time
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Personalized Medicine: Impacts Care
"Disease of the Blood"
Leukemia or Lymphoma
Chronic Leukemia Acute Leukemia Preleukemia
Indolent Lymphoma Aggressive Lymphoma
~38 Leukemia types identified: Acute myeloid leukemia (~12 types) Acute lymphoblastic leukemia (2 types) Acute promyelocytic leukemia (2 types) Acute monocytic leukemia (2 types) Acute erythroid leukemia (2 types) Acute megakaryoblastic leukemia Acute myelomonocytic leukemia (2 types) Chronic myeloid leukemia Chronic myeloproliferative disorders (5 types) Myelodysplastic syndromes (6 types) Mixed myeloproliferative/myelodysplastic syndromes (3 types)
~51 Lymphomas identified: Mature B-cell lymphomas (~14 types) Mature T-cell lymphomas (15 types) Plasma cell neoplasm (3 types) Immature (precursor) lymphomas (2 types) Hodgkin's lymphoma (5 types) Immunodeficiency associated lymphomas (~5 types) Other hematolymphoid neoplasms (~7 types)
60
Years Ago
50
Years Ago
40
Years Ago
Today
5 Year Survival
~0%
70%
Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Feuer EJ, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2002, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2002/, based on November 2004 SEER data submission, posted to the SEER web site 2005.
Source: Mara G. Aspinall, former President, Genzyme Genetics 16
The Blockbuster Model is “Broken”
“The power in tailored therapeutics is for
us to say more clearly to payers,
providers, and patients -- ‘this drug is
not for everyone but it is for you.’”
John C. Lechleiter, Ph.D.
Chief Executive Officer
Eli Lilly and Company
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Trends in R&D Costs and Drug Approvals
0
10
20
30
40
50
60
1975 1980 1985 1990 1995 2000 2005 2010
R&D Expenditures ($ Billions)
New Drug Approvals (3 year moving average)
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October 2, 2013
Decreasing Cost of Genome Sequencing
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Target
Identification
Target
Validation
Lead
Development Preclinical Clinical
Faster path to
disease targets
using genetic data
Speed trials by testing on
patients selected for likely
high response and safety
Safer, More Effective Drugs Identify disease targets, speed clinical trials, and advance more
drugs that are safe and effective for specific populations
Personalized Medicine in R&D
Over 400 drugs currently under review at FDA include biomarkers
100 in late stage oncology clinical trials.
Market
Knowledge of biological
pathways helps eliminate
poor candidates
Target optimal population by
combining drug with
molecular diagnostic test
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Source: Wall Street Journal Copyright 2011 by DOW JONES & COMPANY, INC. Reproduced with permission of DOW JONES & COMPANY, INC.
Tackling Tumors
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As Science Advances, Oncology Drug
Development Accelerates
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9
4
0
5
10
15
20
25
30
35
40
45
BCR-ABL 2001 EGFR 2003 BRAF 2011 ALK 2011
Years From Discovery of Target to Approved
Treatment
Target and Year of Approved Treatment
Adapted from Gerber and Minna Cancer Cell: 18: 548, 2010 23
Many Biopharma Companies have Launched
Therapeutics Informed by CDx Tests
Source: L.E.K.
Launch timeline of targeted therapeutics with required or recommended CDx
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Marketed Therapeutics with an Associated
CDx Test Generate $12B
Source: L.E.K.
Note: * Branded drug sales; does not include sales of Zelboraf (~35M in 2011) and Xalkori (sales unkown), both approved Aug 2011
** Other includes: Iressa (AstraZeneca), Camptosar (Pfizer), Selzentry (Pfizer), Tegretol (various), Ziagen (GSK), Imuran (GSK)
*** Other includes infectious disease and CNS 25
Note: * Includes non-unique tests
Source: L.E.K.
Significant Growth for Commercial
Personalized Medicine Diagnostics
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Personalized Medicine:
How Will It Affect Healthcare?
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Changing Role of the Patient
• Greater knowledge of one’s genetic risks
• Actionable lifestyle prescription for reducing risk of disease
• Greater control and patient-centered access to medical records
• Treatment decisions will be improved by patient education
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Changing Role of the Health Care Provider
• Health care providers as manager, rather than repository of medical knowledge
• Greater reliance on HIT for decision support
• Improved care through use of aggregate patient data
• Highly networked, team-based care
• New ethical and legal issues/quandaries
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New Business Strategies for Pharma
• Uncertain economics of drug development and commercialization
• Regulatory mandates could disrupt development budgets and market plans
• “Personalization” of drugs will require partnering with diagnostics companies
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New Demands On and From Payers
• Greater emphasis on clinical validity and utility of diagnostic tests
• Increased need to demonstrate cost efficiencies
• Proactive strategies to limit reimbursement
• Increased pressure to change paradigm towards preventive medicine
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Personalized Medicine Will Become
Fundamental to Our Healthcare Systems
• Our current healthcare practices cannot continue and still be affordable.
• Pharmaceutical companies need to increase their probability of technical success to maintain profitability.
• The public is genuinely interested in genetic information and in having personal choices.
• We have a regulatory framework that is being designed to meet our future needs.
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Making the Case for Personalized Medicine
“We face significant challenges in
accelerating growth in this field –
scientific, business, regulatory and policy
challenges. Together we must break
down the barriers and move personalized
medicine forward.”
John Castellani
President and Chief Executive Officer
Pharmaceutical Research and Manufacturers of America (PhRMA)
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Policy Issues In Personalized Medicine
Personalized Medicine
Reimbursement
Health care Provider
Education and Adoption
Comparative Effectiveness
Research
R&D Incentives
Intellectual Property
Privacy / Ethics
Patient Education
Regulation
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Barriers Implementing Personalized Medicine
”There is nothing more difficult . . . than to take the lead in the
introduction of a new order of things. For the reformer has
enemies in all those who profit by the old order, and only
lukewarm defenders in all those who would profit by the new
order. This indifference arises partly from fear of their
adversaries . . . and partly from the incredulity of mankind, who
do not truly believe in anything new until they have had actual
experience of it.”
— Niccolo Machiavelli
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The Personalized Medicine Coalition,
representing innovators, scientists, patients,
providers and payers, promotes the
understanding and adoption of personalized
medicine concepts, services and products to
benefit patients and the health system.
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1710 Rhode Island Ave., NW
Suite 700
Washington, DC 20036
202.589.1770
www.personalizedmedicinecoalition.org