Seeing (the future) clearly: pharma in 2020
At eyeforpharmas Oncology Summit Europe in January, Professor Gordon McVie of the European Institute of Oncology in Milan spoke about his visions for oncology pharma in the year 2020. How will cancer care in Europe be managed in 12 years time? In his presentation 20:20 Vision, McVie talked about the radical changes just a little over a decade could bring.
There is a bit of unpalatable news, says McVieunpalatable for pharma, anyway. The truth is that most doctors who cure cancer patients are surgeons. Beyond new anesthetics, these doctors dont use a lot of drugs. They are using new technologies that make operations shorter and less intrusive. After surgeons, according to McVie, the next highest contributors to the cure rate are the radiation therapists (or clinical oncologists as they are called in the UK). Medical oncologists working alone without surgeons or radiation therapists account for only about 5% of the cure rate. Given this, for those countries that dont have a great deal of money to spend, the focus of the budget should go to infrastructure: surgery, pathology and radiation.
However, that doesnt mean there isnt a very important role for pharma. Demographics for 2020 point to a large and increasingly aged population in Europe. Across big Europe (27+ countries), the population could reach as high as 800 million. The rate of the disease would be around 3 million new cases of cancer each year. McVie predicts an increasing epidemic of smoking related cancers, as well as a huge problem with hepatoma (particularly Hep. C). The gap in funding between emerging countries and the wealthier countries will widen over time.
On the plus side, McVie hopes that oncotourism will become the norm; legislation now pending would allow drugs to be made available in some countries despite being restricted by health authorities in others, and patients would be able to travel across borders for treatment and still get reimbursement.
Governments, McVie believes, at least at the European level, will be looking more and more into preventative care. Hopefully, he says, the research that has been done and will be done will help us wise up about genes, tobacco and the business of addiction; well better understand genes and viruses; well have clever immune tricks and consequently better vaccines; intelligent screening will help identify those at the highest risk of disease, and with sophisticated genetic profiling, pre-malignant conditions will be spotted early and reversed. Says McVie, no government will be able to screen everyone, but at least those at high risk can be discovered and targeted for early treatment. Chemoprevention (for reversal of pre-malignancy) is already happening now, so theres clear evidence that drugs can have dramatic impacts in the early stages of disease.
Future of prevention
McVies predictions for prevention in 2020, then: tobacco use will continue, but largely among the economically deprived. Conversely, obesity will transcend social exclusion to include people from all classes, as is already happening in the U.S. According to McVie, neo-natal vaccines will expand to include EBV, HPV, Hep.C and HIV. The Guthrie test (a screening of blood obtained from a newborn to check for evidence of phenylketonuria) will be broadened to look for genetic tendencies to cancers, and there will be more widespread screening for those whose genetic profile makes them high risk for cancer.
Many of the benefits, however, will be limited only to those countries with the money and infrastructure to make them possible. According to McVie, the landscape for developed countries is very different than for emerging ones. In wealthy countries, early cancer will become the norm as sophisticated screening and diagnostics catch the disease sooner. Screening programs will be targeted to high-risk individuals; premalignancy clinics, McVie says, will be open and busy. Simple, one-stop diagnostics will be available in the workplace, with the high-tech surgery and intra-operative radiotherapy being conducted at cancer centers.
For pharma, McVie claims the greatest opportunity will be in the field of cheap, oral, adjuvant systemic therapies. Early cancer patients will get the lions share of the budget because they will be the loudest, says McVie. There are no advocacy groups for lung or pancreatic cancer patients, he says, because there are so few long-term survivors to treat. But with cancers caught so early, the population of patients eligible for pre-malignant treatments will only expand.
New technologies
For McVie, one of the most exciting areas of development in health care is in diagnosis and prognosisor, as he calls them, -omics and pixels. Dont just watch what your own end of the business is doing, McVie warns; keep an eye on whats happening in the rest of medicine. Theres a revolution going on in imaging thats at least on par with whats happening in medicinal chemistry, and eventually these two sciences will converge, almost certainly by 2020, he says.
Take, for example, no-touch imaging for colorectal cancer. Patients are far more comfortable with this method, and doctors can detect early lesions, look at them, biopsy them and get the information to researchers who then enroll the patient in clinical trials for reversal-of-malignancy agents. A swallowable, diagnostic pill already exists that allows doctors to study six hours of film from inside a patientharmless and painless, the biggest problem with the existing pill is that the battery life is too short.
In 2020, McVie predicts, diagnostics will be carried out primarily through no-touch methods, including natural radio isotope imaging. In the post-MRI, PET landscape, well have miniature, intravascular chip monitors, viral and chemical carcinogens will be monitored by nano-sensors, and well be able to detect genetic signatures on (pre)malignant lesions.
What, then, are the clinical applications of the -omics such as genomics and proteomics? (And how will they impact the business of managing cancer care?) Says McVie, well be able to find patients quicker and earlier, and diagnoses will be more accurate. He points to such benefits as high-risk group identification and disease prevention, early diagnosis, clarification of diagnosis, prognostication (using genomics, distinguish those who will profit from a therapy from those who wont), drug selection (via genetic or proteomic profiles), etc. In future, prediction wont just tell us who is at risk but even better, what treatment would benefit that at-risk person best.
Another medical advance is the imaging of drugs operating in patients. Using sophisticated imaging techniques with trace amounts of labeled molecules of interest, doctors can actually see that the drug reaches the target site and produces desired effects. This, of course, strengthens the argument for using that drug with that patient. With this level of imaging, doctors will have two sets of information on patients before they determine which drug to prescribe: theyll have a genomic or proteomic readout and information from the labeled trace element.
Resultant treatments from these innovationswhich, McVie warns, may only be available for the richinclude earlier diagnosis and intelligent imaging. Conservative surgery that includes reconstruction at the same time will become the norm. Radiation will be targeted and shaped. There will be new drug targets (gene products, signal pathways and telomerases, for example), about 1000 of which are currently in the pipeline. There will also be new delivery vehicles in the form of smart, oral medicines. IV delivery will be non-existent, says McVie, or of very short duration. And there will be increasing patient involvement as patients survive longer and are better educated.
Conservative surgeries are already being conducted: for breast cancer, its possible for the patient to have reconstructive surgery during the operation, plus a short course of intraoperative radiotherapy. Doing all these procedures at once increases efficacy and shortens recuperative time. Robotics are also already playing a role, one that McVie anticipates will greatly increase in future. Robots are able to target and remove tumors or conduct other surgeries less intrusively, freeing up bed space and saving money on care.
The 2020 outlook for emerging countries is somewhat less optimistic, McVie admits. While greater education and patient pressure could change the scenario somewhat, such change seems unlikely in the near future. McVie predicts that emerging countries will see little change in their health care options. Late referrals will continue to result in cancers that are advanced and incurable. Palliative care will be handled by charity, health budgets will be focused on drugs to the detriment of technological advances, and there will still not be enough money to go around.
There will, at least, be greater and more accessible education. Communication has changed. The professional journals printed on paper are losing readership and advertising revenue. Already many journals have made the jump to online subscriptions, while others are openly available and free to anyone. Patients are doing their research, says McVie, and they are able to find out whats happening faster and more easily than we imagine.
The social outlook for 2020 is scarcely less bleak, according to McVie. In the next 12 years, the poverty gap between wealthy and struggling countries will only widen; politics will continue to be bland, neurotic and impotent in the face of increasing health concerns; the public will continue to be anti-science, anti-GM (genetic modification), anti-stem cell research. Northern Europe will become a sort of theme park; Southern Europe will be populated by the rich and the privileged.
The end of cancer by 2020 is a fantasy, McVie says. However, think how far weve come: in 1975, there were no microwave ovens, no cell phones, no PCs, no DNA sequencing. Dolly was the stuff of science-fiction, not science; there was no fiber optic endoscopy, no interferons, no suppressor genes or NMR or PET scanners. In short, weve come a very long way in 33 years, and the pace of technological development has only increased. We have every reason to believe that new and greater treatments await.
Author: Shannon Perry, journalist, eyeforpharma