Once upon a time a new cancer drug achieved marketing authorisation after randomised controlled trials demonstrated effectiveness treating carefully calculated numbers of patients with a given disease or condition. The critical patient outcome for the trials was a comparison between the experimental and control arms using a measure of patient survival which gave a high degree of statistical significance. It was also important that safety was demonstrated and that side effects were tolerable and manageable.
We are entering an era where a drug with a specific mode of action for a specific genetic alteration can achieve marketing authorisation in an accelerated process after small clinical studies, offering no comparative data, using endpoints where patient benefit is unclear, and without long term measurement of issues such as survival or side effects.
We made this transition, seemingly without open debate amongst stakeholders. The move is justified by the term “personalised medicine”, which in its fullest sense would include radiotherapy and surgery but is usually focussed exclusively on drugs. It has been carried along by enthusiasm and hype and it requires genetic testing, the demand for which is driving costs down. Technology is proving disruptive.
But patients have lost something in this transition. The science behind repeating studies, using control arms, good statistical practice, endpoints with real meaning etc has been built-up over years. It is robust good practice and provides a very high level of certainty that authorised drugs deliver patient benefit safely. Based on the data at registration these new drugs promise hope for a few but uncertain patient benefit overall.
It is important to acknowledge that when a treatment has a high probability of treating a disease effectively then practice needs to change so that relevant patients can be treated without delay. We are now recognising that in doing so we lose important evidence which is very relevant to patients and society, even if it is less important to pharmaceutical companies.
What about dose determination, treatment sequencing, duration of treatment, combination therapies, toxicity management, quality of life, patient compliance? They all get forgotten in the rush to get the treatment into routine practice where we are reassured that any problems which arise will be handled by doctors. Perhaps, but their experience is not shared and collectively analysed as it would be in a study. Evidence based medicine it is not. Nor is it truly personalised medicine, it is simply drug-centred medicine.
However, patients want it. They want the tests and if they are eligible they want the treatment.
Some patients will be denied by cost. These drugs are expensive. Larotrectinib, approved by the FDA for a rare mutation in a wide range of cancers based on data from 55 patients, is estimated to cost over $330,000 a year – assuming anyone lives for a year. Compassionate and discounted programmes are available but no major HTA body has yet got into discussion with the drug company. There will soon be tales of patients selling homes and using crowd-funding to raise the money for drugs like this.
We must move fast to apply scientific process and rigour to personalised medicine. It is not about denying treatment to anyone. Drug companies must not determine what happens, much as they might wish to. At present they are succeeding. We must change the balance. Put patient interests at the centre of drug regulation, not pharma interests.
So what are our interests? Safety (the minimum effective dose), side effects (nature, treatment, duration), duration of response to treatment (combination therapy, therapy sequencing), longevity (real life outcomes), quality of life (in all its dimensions), holistic issues of care, cost.
Establishing this kind of treatment optimisation is a theme supported by European research organisations, professional associations, patient groups and by a considerable body of influential MEPs. The move calls for protocols to guide treatment and for data to be gathered centrally for all treatments which use an accelerated approval process. By gathering data prospectively according to a protocol we can avoid bias and a picture can emerge dynamically as a treatment gathers numbers of patients. Quite separately the FDA has suggested a form of ‘synthetic’ control group based on historical data to empower comparison.
This might result in treatments which are not effective, and we might see treatments which patients dislike, using patient reported outcomes. These treatments could be withdrawn, that would be an innovation. This kind of treatment optimisation approach importantly provides a framework for testing lower dose levels than were used in the trials for drug registration. This is not a favoured idea of drug companies either.
Support Treatment Optimisation, it is in our interests as patients.