Precision Medicine in Context
In the State of the Union speech delivered on January 20, President Obama made the first announcement of what seems to be a major policy initiative:
I want the country that eliminated polio and mapped the human genome to lead a new era of medicine – one that delivers the right treatment at the right time. In some patients with cystic fibrosis, this approach has reversed a disease once thought unstoppable. So tonight, I'm launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes, and to give all of us access to the personalized information we need to keep ourselves and our families healthier. We can do this.
That's all he said about it in that speech, though one cystic fibrosis patient, William Elder, was invited to sit with the First Lady. (By the way, the cystic fibrosis reversal is not exactly news, and not as widely applicable as once hoped. Only 4% of those affected by cystic fibrosis benefit, as Elder does, from Kalydeco, a drug approved by the FDA in 2012, which incidentally costs some $300,000 a year.)
Some observers felt "a bit of déjà vu" – Jeremy Gruber found a rather similar statement in the 1998 State of the Union delivered by President Clinton. Indeed, then-Senator Obama proposed legislation to promote "genomics and personalized medicine" in both 2006 and, with Republican Senator Burr, 2007.
We soon learned that the historical connections go much further back. More than four decades, in fact, to Richard Nixon's 1971 State of the Union.
That connection was made clear at the end of January, when Obama, just before formally presenting his budget to Congress, officially launched the Precision Medicine Initiative at the White House with remarks in front of a distinguished invited audience. Among those present were patients (including Elder and Kareem Abdul-Jabbar), politicians, public officials and other researchers. Also in attendance were both biotech entrepreneur Craig Venter and National Institutes of Health head Francis Collins, who famously competed in the late 1990s race to "map" the first human genome.
The related fact sheet included the $215 million price tag that reached many headlines, though the President stuck mostly to generalities. Collins and Harold Varmus simultaneously released an article in the New England Journal of Medicine, which was much more specific:
The proposed initiative has two main components: a near-term focus on cancers and a longer-term aim to generate knowledge applicable to the whole range of health and disease. … Oncology is the clear choice for enhancing the near-term impact of precision medicine. … Although cancers are largely a consequence of accumulating genomic damage during life, inherited genetic variations contribute to cancer risk, sometimes profoundly.
An important part of the proposed approach is to "engage a million or more Americans to volunteer to contribute their health data." The idea is to encourage "strong partnerships with existing research cohorts, patient groups, and the private sector" while simultaneously "developing new approaches to patient participation and empowerment." The President stressed in his remarks that
we're going to make sure that protecting patient privacy is built into our efforts from day one.
He also lauded "patients' rights advocates" who will "help us design this initiative from the ground up, making sure that we harness new technologies and opportunities in a responsible way." In case any skeptics are not reassured by this, the fact sheet also refers to privacy experts and medical ethicists (apparently they get $5 million).
Summaries can be found at Reuters, GenomeWeb and The New York Times, among others. NIH is holding a conference on the initiative on February 11-12.
Policy proposals offered by a Democratic President to a Republican Congress are, to say the least, unlikely to be translated unchanged into legislation. But this one may sail through, suggests Politico, partly because it "doesn't cost a lot" (ouch, but the money is basically a rounding error in a $4 trillion budget). Also, some Republicans are already generally on board. It probably helps that a bipartisan group in the House of Representatives has announced a "21st Century Cures" discussion document [pdf], which bids to reform the way the FDA translates research into clinical application.
There are critics and caveats, as well as giddy boosters. David Altshuler (formerly of the Broad Institute, now of Vertex Pharmaceuticals) warned that any new medicines are 10–15 years away. Mayo Institute researcher Michael Joyner called it "'Moonshot' Medicine" in The New York Times and predicted that "precision medicine is unlikely to make most of us healthier." Hank Greely of Stanford told Vox that "It's been the hot thing coming for almost 20 years."
But the publicity-savvy process has started a conversation – in The New York Times, Washington Post, NBC, National Journal, and elsewhere. So we might as well throw in a few questions that have not been adequately addressed:
- Is this initiative going to over-emphasize a gene-focused view of disease? Since the vast majority of common complex diseases are influenced by many genes, how much practical help will genetic sequences – even a million of them – turn out to be?
- Might it lead, in practice, to racialized medicine? Like "personalized medicine" (the now discarded term for what's being proposed), precision medicine will likely be tailored not to individuals, but to groups. Will people be categorized on the basis of actual genetic information, or will researchers and physicians continue to use "race" as a biological proxy?
- Will it detract from other public health approaches? It is discouraging that the hoopla over this announcement seems to have overshadowed a much larger, and likely more important, commitment to funding research on antibiotic resistance: that's penciled in for $1.2 billion but didn't receive the celebrity treatment.
- Will the (welcome) nods to privacy concerns be adequately backed up in practice? Will those who turn over their DNA sequences be adequately informed of the breach-of-privacy possibilities and consequences?
- And why this rebranding? "Personalized medicine" has been the most common term for the kind of individualized care being discussed here. "Precision" sounds, perhaps, more high-tech – but it turns the focus away from people and toward the technology. That might be the wrong direction.
Finally, we must not forget the history. President Nixon, in the 1971 State of the Union declared:
I will also ask for an appropriation of an extra $100 million [worth over $500 million today] to launch an intensive campaign to find a cure for cancer, and I will ask later for whatever additional funds can effectively be used. The time has come in America when the same kind of concentrated effort that split the atom and took man to the moon should be turned toward conquering this dread disease. Let us make a total national commitment to achieve this goal.
We have been "at war" with cancer for nearly half a century. There have been advances in both treatment and prevention, certainly, but we are nowhere near "conquering" the disease. Genomic analysis of tumors, for instance, may help in targeting interventions, and research funds are always welcome, but hype can lead to deadly disappointment. Let's not get too excited yet.
Previously on Biopolitical Times: