Latest Drugwonks' Blog
Study Divides Breast Cancer Into Four Distinct Types
By GINA KOLATA
In findings that are fundamentally reshaping the scientific understanding of breast cancer, researchers have identified four genetically distinct types of the cancer. And within those types, they found hallmark genetic changes that are driving many cancers.
These discoveries, published online on Sunday in the journal Nature, are expected to lead to new treatments with drugs already approved for cancers in other parts of the body and new ideas for more precise treatments aimed at genetic aberrations that now have no known treatment.
The study is the first comprehensive genetic analysis of breast cancer, which kills more than 35,000 women a year in the United States. The new paper, and several smaller recent studies, are electrifying the field.
“This is the road map for how we might cure breast cancer in the future,” said Dr. Matthew Ellis of Washington University, a researcher for the study.
Researchers and patient advocates caution that it will still take years to translate the new insights into transformative new treatments. Even within the four major types of breast cancer, individual tumors appear to be driven by their own sets of genetic changes. A wide variety of drugs will most likely need to be developed to tailor medicines to individual tumors.
“There are a lot of steps that turn basic science into clinically meaningful results,” said Karuna Jaggar, executive director of Breast Cancer Action, an advocacy group. “It is the ‘stay tuned’ story.”
The study is part of a large federal project, the Cancer Genome Atlas, to build maps of genetic changes in common cancers. Reports on similar studies of lung and colon cancer have been published recently. The breast cancer study was based on an analysis of tumors from 825 patients.
“There has never been a breast cancer genomics project on this scale,” said the atlas’s program director, Brad Ozenberger of the National Institutes of Health.
The investigators identified at least 40 genetic alterations that might be attacked by drugs. Many of them are already being developed for other types of cancer that have the same mutations. “We now have a good view of what goes wrong in breast cancer,” said Joe Gray, a genetic expert at Oregon Health & Science University, who was not involved in the study. “We haven’t had that before.”
The study focused on the most common types of breast cancer that are thought to arise in the milk duct. It concentrated on early breast cancers that had not yet spread to other parts of the body in order to find genetic changes that could be attacked, stopping a cancer before it metastasized.
The study’s biggest surprise involved a particularly deadly breast cancer whose tumor cells resemble basal cells of the skin and sweat glands, which are in the deepest layer of the skin. These breast cells form a scaffolding for milk duct cells. This type of cancer is often called triple negative and accounts for a small percentage of breast cancer.
But researchers found that this cancer was entirely different from the other types of breast cancer and much more resembles ovarian cancer and a type of lung cancer.
“It’s incredible,” said Dr. James Ingle of the Mayo Clinic, one of the study’s 348 authors, of the ovarian cancer connection. “It raises the possibility that there may be a common cause.”
There are immediate therapeutic implications. The study gives a biologic reason to try some routine treatments for ovarian cancer instead of a common class of drugs used in breast cancer known as anthracyclines. Anthracyclines, Dr. Ellis said, “are the drugs most breast cancer patients dread because they are associated with heart damage and leukemia.”
A new type of drug, PARP inhibitors, that seems to help squelch ovarian cancers, should also be tried in basal-like breast cancer, Dr. Ellis said.
Basal-like cancers are most prevalent in younger women, in African-Americans and in women with breast cancer genes BRCA1 and BRCA2.
Two other types of breast cancer, accounting for most cases of the disease, arise from the luminal cells that line milk ducts. These cancers have proteins on their surfaces that grab estrogen, fueling their growth. Just about everyone with estrogen-fueled cancer gets the same treatment. Some do well. Others do not.
The genetic analysis divided these cancers into two distinct types. Patients with luminal A cancer had good prognoses while those with luminal B did not, suggesting that perhaps patients with the first kind of tumor might do well with just hormonal therapy to block estrogen from spurring their cancers while those with the second kind might do better with chemotherapy in addition to hormonal therapy.
In some cases, genetic aberrations were so strongly associated with one or the other luminal subtype that they appeared to be the actual cause of the cancer, said Dr. Charles Perou of the University of North Carolina, who is the lead author of the study. And he called that “a stunning finding.”
“We are really getting at the roots of these cancers,” he said.
After basal-like cancers, and luminal A and B cancers, the fourth type of breast cancer is what the researchers called HER2-enriched. Breast cancers often have extra copies of a gene, HER2, that drives their growth. A drug, Herceptin, can block the gene and has changed the prognosis for these patients from one of the worst in breast cancer to one of the best.
Yet although Herceptin is approved for every breast cancer patient whose tumor makes too much HER2, the new analysis finds that not all of these tumors are alike. The HER2-enriched should respond readily to Herceptin; the other type might not.
The only way to know is to do a clinical trial, and one is already being planned. Herceptin is expensive and can occasionally damage the heart. “We absolutely only want to give it to patients who can benefit,” Dr. Perou said.
For now, despite the tantalizing possibilities, patients will have to wait for clinical trials to see whether drugs that block the genetic aberrations can stop the cancers. And it could be a vast undertaking to get all the drug testing done. Because there are so many different ways a breast cancer cell can go awry, there may have to be dozens of drug studies, each focusing on a different genetic change.
One of Dr. Ellis’s patients, Elizabeth Stark, 48, has a basal-type breast cancer. She has gone through three rounds of chemotherapy, surgery and radiation over the past four years. Her disease is stable now and Dr. Stark, a biochemist at Pfizer, says she knows it will take time for the explosion of genetic data to produce new treatments that might help her.
“In 10 years it will be different,” she said, adding emphatically, “I know I will be here in 10 years.”
A research letter published in JAMA says “closer attention” should be paid to the lack of risk information in advertising for the OTC switch versions of prescription drugs. Research sponsor CVS Caremark says OTC ads should convey the same information as Rx ads.
Facts are facts – Drug Facts, to be precise. And, no doubt, when prescription drugs become available over-the-counter advertisements are less likely to tell consumers about the potential harms and side effects.
But how little is too little – and how much is too much?
To say (as many now are) that OTC ads should carry the same warnings as their Rx brethren is to assume that Rx warnings are useful. When it comes to, for example, the so-called “Brief Summary,” that’s an open question (and that’s being charitable). More of what the consumer doesn’t understand isn’t the solution.
Is it the FDA’s responsibility to figure this out? Before we answer that, perhaps a more direct question is, does the FDA have the social science chops to do so? With all due respect to Kit Aikin and crew – this issue will be best resolved through the joint efforts of industry and agency.
And one size may not fit all.
Beyond BTC, it’ll be interesting to see how various Rx-to-OTC applications address the question of consumer education.
Ladies and Gentlemen of industry – it’s time to step up to the plate.
From The New York Post
An ugly way to get insurance
By ROBERT GOLDBERG
Last Updated: 11:23 PM, September 19, 2012
Posted: 11:10 PM, September 19, 2012
The good news: More Americans have health insurance. The bad news: It’s because they don’t have jobs.
ObamaCare supporters hail the drop in the number of uninsured, announced by the Census Bureau last week, as a sign of the new law’s success. In fact, it’s a sign of continued job-market decline and of how many of us have to depend on government programs for far too long.
Nearly 1.4 million more people had health insurance in 2011 than in 2010 — but that includes nearly 800,000 who gained coverage despite not working at all.
In short, the rise comes mainly from more Americans being forced into safety-net programs by declining incomes and reduced job opportunities.
Look at this trend another way: In 2011, the number of people covered by Medicaid jumped 2.3 million, while Medicare saw 2 million new enrollees.
And only 575,000 of those new Medicare cases were people turning 65. Most of the other 1.5 million is associated with the exponential growth in people becoming Medicare-eligible because they’ve filed for Social Security disability coverage.
By comparison, the number of people gaining health insurance via work rose only 730,000.
ObamaCare fans also claim that much of the increase in coverage came from the Obama law’s mandate that young adults can stay on their parents’ health plans until they turn 25.
Indeed, the administration boasted earlier this year that 3 million young adults got insurance that way. But the Census Bureau report shows that health coverage for people in that age bracket rose by only 540,000.
And it’s clear that ObamaCare was not responsible for much of even that increase. Past Census reports show the share of 19- to 25- year-olds on Medicaid or Medicare doubling from 2000 to 2011. That long-term trend — not the ObamaCare mandate — plainly accounts for a good chunk of the rise in coverage of these younger folks.
Slice it another way. The total increase in health coverage for ages 18-24 in 2011 was 825,000. Nearly 331,000 of that was from employer-based coverage. More than 220,000 was from Medicaid enrollment.
So, at most, that’s 247,000 from ObamaCare’s under-25 mandate.
And that gain comes at a hard-to-measure cost: The price of forcing insurers to cover under-25s on their parents’ policies is higher premiums for other people.
Let’s be clear: Medicaid, the Children’s Health Insurance Program and Medicare make health insurance affordable for tens of million of Americans. But that safety net, in place before ObamaCare was enacted, is supposed to be a temporary source of support when we need it, not a permanent solution.
And a jump in the number of Americans who have to use that safety net is nothing to brag about.
Robert Goldberg is vice president of the Center for Medicine in the Public Interest.
http://www.nypost.com/p/news/opinion/opedcolumnists/an_ugly_way_to_get_insurance_etNZJPm74YKgP0euAZJWSM#ixzz271N2B2m9
Drugs elude cookie-cutter approval process
A powerhouse mix of pharmaceutical companies including Abbott, AstraZeneca, Boehringer Ingelheim and Bristol-Myers Squibb has launched a non-profit tasked with making it easier for companies to bring news drugs to market.
The initiative, called TransCelerate BioPharma, is headed up by J&J alum Garry Neil. Its first project focuses on clinical trial execution and will include creating an investigator site, developing clinical data standards and establishing a comparator drug supply model, according to a statement. More tangible details were not forthcoming, other than the comment that the goal is to help speed drugs to market, but the news release quoted FDA Director Janet Woodcock as saying the collaboration “has the promise to lead to new paradigms and cost savings in drug development, all of which would strengthen the industry.”
In other words, it appears to be a project that tries to pin down the very thing that has roiled industry watchers when it comes to the FDA's review process: predictability and its seeming absence. Yet experts have told MM&M in the past that uniform standards won't create an if-then scenario in which the FDA will approve drugs based on meeting the demands of a checklist.
“Predictability assumes that you can approve drugs in a cookie-cutter kind of fashion and you just can't do that,” Dr. Steven Nissen, a frequent member of FDA advisory panels and chairman of the Cleveland Clinic's cardiology department, told MM&M. “It's always going to be a nuanced decision. It's always going to be a careful evaluation of benefit vs. risks,” he added.
The agency has come under a mixed review, with critics saying the FDA is approving drugs without adequately considering a drug's risks. Advocacy group Public Citizen is suing the agency over its approval of the Alzheimer's drug Aricept 23, an approval which its deputy director of the Health Research Group Michael A. Carome told MM&M was made even though the agency acknowledged that the drug didn't meet the standards the regulators demanded even before it came up for review. The drug, at a higher dose of the 5- and 10-mg versions which have gone generic, has been linked to nausea, vomiting and dizziness, but with little benefit, according to Carome and other critics.
“This represents an extreme example of the FDA's failure to properly weigh the evidence and only approve drugs when there's clear evidence [that] benefit outweighs the risk,” Carome said.
Nissen, who was not part of the Aricept 23 review and does not specialize in Alzheimer's, said that the risk-benefit equation had a degree of flex that depends on who's doing the calculation.
“I think the most salient example is cancer drugs. You're dealing with a disorder with often a lethal disorder. These drugs that are used to treat cancer are pretty toxic, but the disease is a pretty lethal disease,” he said.
Former FDA Associate Commissioner Peter Pitts said the FDA gets knocked in part because it doesn't do a very good job at explaining how the drug review and approval process works.
Among the steps is a clinical trial design that the FDA approves before it's kicked off. Pitts noted that hitting all the right design notes doesn't guarantee a panel's endorsement if the results raise questions.
“Those questions need to be answered.” Pitts highlighted two other components of the FDA's decision-making process which includes basing its decisions on “the twin pillars of safety and efficacy,” a balance he said is important because “you can't look at safety independent of benefit.” He also noted that the committees are comprised of experts that see data differently, which can add nuance to discussions.
But nuance or heated argument doesn't always mean pushback. The May debate over the blood thinner Xarelto was a contentious committee hearing, in which panelists took serious issue with the quality of the data presented. The drug passed with a panel endorsement despite the attacks on missing patients and an inability to state just how many patients may have died during the clinical trials.
Adding to the fuzziness is that what constitutes acceptable risk is also subject to change. Recent examples: weight-loss drugs Qsymia and Belviq which failed to clear the FDA the first time they were up to review, which was before the CDC declared obesity an epidemic.
Pitts said one way to provide continuity would be to use the same requirements for drugs that have the same purpose and said that this industry push is not about lower standards, but about making smart investments. He said ambiguity in that regard is "not fair and that's not good science." He said it could also help within the wider context of creating a single standard that can be used for both international and domestic regulatory review.
Such a change will not remove risk, and both Pitts and Nissen said results can't simply be accepted because panelists didn't know what to ask before results roll in. Even when a clinical trial meets expectations and has the FDA's go-ahead, Nissen noted that new risks are bound to surface because clinical trials are little more than real-world approximations. “You have done a series of studies with a drug in a few thousand people and the drug may be used in a million . . . there is no way to be absolutely certain whether a drug is going to be helpful or harmful,” he explained.
Nissen said he understands the drug industry's frustration with the case-by-case approach, but he said it can't be avoided. “It's about their investment and their bottom line and I completely understand that but the FDA has a different mission and that mission is to protect public health.”
Two items for your consideration:
EC Does It
BioCentury reminds us that the House Energy and Commerce Committee is expected to vote this week on a bill that would allow FDA to collect newly enacted generic drug user fees, a committee spokesperson told BioCentury. The bill does not include a provision that would allow FDA to collect new biosimilar user fees.
Last week, the House of Representatives passed a continuing resolution that would extend funding at current levels for government operations but omitted technical language that would have allowed FDA to benefit from an increase in drug and medical device user fees and to spend the newly enacted user fees for biosimilars and generics.
FDA had planned to use $299 million from new generic drug user fees in FY13 to reduce huge application backlogs, increase postmarket safety oversight, and ramp up inspections of generic drug manufacturers outside the U.S.
Occupy Pharmalot
I was pleased to offer a guest op-ed on Ed Silverman’s Pharmalot blog. Here’s a link. Of particular interest is the comments section. Have a look and see how the other 47% lives.
The Patient Centered Outcomes Research Institute began accepting proposals for up to $96 million in grants for research projects addressing four of its five priorities.
The fifth element, the one it’s ignoring, however, is the most important.
The four priorities are: comparing alternative prevention, diagnosis and treatment options; improving healthcare systems; comparing communication approaches to providing comparative effectiveness research information; and addressing potential differences in prevention, diagnosis or treatment effectiveness, or preferred clinical outcomes across patient populations.
(Earlier this month, on BioCentury This Week, PCORI Executive Director Joe Selby told that low back pain, uterine fibroids and depression could be early targets for comparative effectiveness research.)
What’s not being addressed, is PCORI’s fifth priority, improving the nation's capacity to conduct patient-centered outcomes research by building data infrastructure, improving analytic methods and training researchers, patients and other stakeholders to participate in the research.
Hello! That’s the most urgent need but, alas the least agenda-driven for those whose ultimate goal is a US NICE. After all, why fund programs to advance a science-based understanding of patient outcomes data when you can fund “research” programs to find the best way to “communicate” about comparative effectiveness.
Say it ain’t so Joe.
Since the end of 2011 the FDA has sent 11 warning letters to companies in seven different countries that were exporting drugs to the U.S. after having let their required registration and listing expire.
The warning letter recipients also failed to respond to letters FDA sent them last year notifying them that they were not registered or listed for imports into the U.S., according to nearly identical language in the warning letters.
“FDA has established an ongoing program to identify drug manufacturing firms that have not complied with registration and listing requirements and to notify such firms of their ostensible noncompliance,” the agency said. “FDA has issued warning letters to some of the firms that have not responded to this notification and are out of compliance with registration and listing requirements. These warning letters have targeted firms whose lack of compliance has the greatest potential impact on FDA's regulatory mission.”
FDA’s focus on compliance at foreign drug manufacturing facilities has been sharper since the tainted heparin scandal in 2008, and new provisions in the recently passed user fee legislation is designed to reduce the number of unregistered facilities -- particularly for generic drugs.
But that was before sequestration.
We’ll see.
“The convergence of two powerful forces is driving today’s medical innovation to the top of the national agenda: The urgent need for medical breakthroughs and the unprecedented opportunities created by recent advances in science.”
So said El Lilly & Company’s Grand Poobah John Lechleiter at yesterday’s “Advancing Medical Innovation” summit in Washington, DC. (The event was co-sponsored by Lilly and the Washington Post.) I was pleased to attend.
More Lechleiter:
“Our only hope of breaking our of the crisis is through innovation that changes the terms of the trade-offs we must make and expands the scope of what’s possible.”
The Hoosier Honcho then offered a very potent example of what he meant:
“In the early 1950s, the cost of polio care in the US was predicted to be $100 billion by the year 2000 but, thanks to the advent in 1954 of the polio vaccine, the cost of treating polio in the US in the year 2000 was $100 million.”
In other words – the prediction was off by 99.9% because of game changing innovation. Can we do that again? We’d better try – and try hard.
But Lechleiter offered a crucial caveat, “Realizing the benefits of medical innovation requires an ecosystem where innovation can thrive.”
Are we there yet?
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
