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Second Chance:
Lukas Wartman, a leukemia doctor and researcher, developed the disease
himself. As he faced death, his colleagues sequenced his cancer genome.
The result was a totally unexpected treatment.
By
GINA KOLATA New York Times Health, Published: July 7, 2012
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For our first case study, from New York Times Health please read this article:
http://www.nytimes.com/2012/07/08/health/in-gene-sequencing-treatment-for-leukemia-glimpses-of-the-future.html?_r=1&pagewanted=all
Assignment: Take a look at the readers' comments as well and note some of the questions/concerns raised by the general public/scientists in the field/tax payers, and cancer survivors on this topic. Some of the techniques mentioned in the article might be new to you so please do a web search and read up on some of the basic information of these techniques to be prepared for class discussion.
Please post a response to these two questions:
- Do you feel encouraged or discouraged by this article in regards to cancer therapy?
- What are some flaws or concerns you can identify in the diagnosis, treatment and handling of Dr. Wartman's case by his doctors, insurers, and scientific colleagues?
This is really encouraging work and could lead to personalized medicine, however, the article assumes that insurance companies will cover this kind of treatment. This particular individual was in the right place at the right time with the right team who were willing to go the extra mile for him. While care can and should be individualized, it's often not.
ReplyDeleteTraditionally underserved populations will not have access to this kind of specialized, individually targeted treatment. Without financial assistance programs, like ADAP, many HIV positive people can't afford their medication. However, perhaps the drug companies can be pushed to provide lower cost access.
What a lucky doctor!
I completely agree with Mo - this is truly amazing that we've gotten to the point where cancer genes can be screened against normally functioning genes. The fact that we can directly target problem sequences is like being able to remove a splinter with tweezers instead of amputating the whole finger!
ReplyDeleteFrom an ethical standpoint, it is indeed discouraging that insurance companies are so reticent to cover medication, as in Dr. Wartman's case. Needless to say, it is doubtful that the average person, or below average person as far as income goes, could possibly manage to afford the drugs let alone have access to the equipment and expertise that he had. The way this plays out will likely depend on how our health system looks in the next few years. It is very saddening, though, to know that so many people are suffering from similar if not identical diseases and have zero access to this type of treatment. Hopefully, as gene therapy becomes normalized, this will change.
While this is an encouraging article, Dr Wartman was in extremely fortunate circumstances. Not only was he immersed in the medical research community and therefore able to tap into gene sequencing resources unavailable to the average layperson, the mutated gene causing his leukemia already had a tested, available drug capable of inhibiting its expression. Still, of course, this is a fascinating method of treatment, and one that I imagine will become more popular and effective as developments in the technologies of gene sequencing continue to make it a more viable option for doctors wishing to diagnose disease. The Mayo Clinic already has plans to sequence the genomes of most of its patients.
ReplyDeleteMany of the comments on the article address the unethical role that drug companies like Pfizer play in medical research. It is likely that as Pfizer begins to realize that Sutent can fight cancers beyond those approved by the FDA, the company will begin to funnel more research into the type of whole genome sequencing treatment that Dr Wartman received. I suppose the money for research needs to come from somewhere...
After reading the article, I am not sure if I am discouraged or encouraged by Dr. Wartman’s story. This story has a few encouraging points. I am encouraged by the fact Dr. Wartman was able to send his leukemia into remission despite a slim four to five percent chance of surviving. In addition, he was supported by his fellow doctors who helped supply the anti-cancer drug when Dr. Wartman was financially unable to fund for the drugs himself. It is also encouraging that he was able to send his cancer into remission not once, but twice. However, this article does leave me in a somewhat discouraging life condition. First, I find it rather ironic that he contracted the illness that he spent his entire career dedicating his research to. Second, I was saddened by the fact his insurance companies and the drug companies did not pay for his drugs despite Dr. Wartman’s low probabilities of leading a full, healthy life again. And finally, although he was able send his leukemia into remission twice, he describes his situation as “in uncharted waters,” (Kolata, 2012) explaining about the uncertainty whether his illness may return and haunt him again. In addition, I find it very discouraging that he was able to contract the diseases even though he had a very healthy lifestyle.
ReplyDeleteIn the end, I find it appalling that his health insurance companies did not provide any financial support. I do not understand why – maybe because he IS a leukemia research doctor and his insurers think that he will be able to cure himself? It is also concerning that he apparently is the only doctor who knows about leukemia. After reading the article, it sounds like the other doctors had no extensive knowledge about the disease since they conducted an analysis “they have never done before” (Kolata, 2012). Why was there not a leukemia research team that accompanied Dr. Wartman? I would like to think there is/was, but it seems like their knowledge of leukemia is not as advanced as Dr. Wartman’s. I was also concerned at the fact his genes attributed to his cancer. This frightens me because anyone can get cancer despite how healthy of a lifestyle one is leading (as in the case of Dr. Wartman’s). I hope that one day, doctors would be able to find a way to halt genetic hereditary illnesses such as Type 1 diabetes, leukemia, and other deadly diseases. However, I would like to shed light at the fact the Dr. Wartman’s unique case can facilitate new findings and more effective methods to combat leukemia. While it may start off rather rough at first, I am earnestly praying that creates a new beginning to the end of incurable diseases.
Dr. Wartman was extremely lucky to be in a situation that allowed him to receive treatment. The advances made in cancer therapy are encouraging but still very distant from what is available to the “average” person. I’m a bit skeptical about the idea of insurance companies being willing to foot the bill for this type of personalized medicine despite the optimism that this will happen in the next five to ten years.
ReplyDeleteAgain, Dr. Wartman was very lucky to be in the midst of cancer research and working with a group of people who fought for his treatment. I don’t see anything ethically wrong with his colleagues wanting to test a new therapy on him since he was in the unique position of knowing what the potential outcomes of treatment might be. I am not at all surprised that Pfizer was not initially interested in giving him the drug, Sutent, but then later change their decision after it appeared that Dr. Wartman was in remission. The potential profit is huge, especially since the drug already exists. I am concerned that preemptive whole genome sequencing could lead to discrimination by for-profit insurance companies. What regulations are in place to ensure that those who will potentially get sick will not be dropped from their policies?
I am encouraged by the findings presented in this article and look forward to the cures that might develop from Dr. Wartman’s experience. It is amazing to think that two cancers, otherwise similar in location and proliferation, are cured via different means according to the patient’s genetic needs. I was astounded by the notion that Pfizer refused to supply the drug that might keep someone alive, all because it was too expensive. As with all good stories, that snafu worked itself out in the end and Dr. Wartman was supplied with his necessary allotment.
ReplyDeleteMy concerns with Dr. Wartman’s diagnosis and treatment plan deal mainly with the fact that the most effective method for dealing with the cancer was employed last. It seems to me, with the vast amount of technology and resources at his colleagues’ discretion, that at least one of the attending physicians should have realized his chances if the cancer flared up. Even Dr. Wartman was able to recognize his survival rate as it compared to the average cancer patient with his symptoms as being very low (almost zero) once a patient relapsed. Aside from almost missing the chance to find an effective solution, Dr. Wartman’s colleagues came through in the end and showed true compassion by chipping in to supply him with his necessary Sutent.
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ReplyDeleteThis article does a great job of highlighting many of the important and interesting issues surrounding the field of genetics (including many of those raised by my peers on the first day of class) such as the mystery (hopefully not for long) of gene sequencing and using genetics to develop more specific treatments for many diseases, including cancer. I think it also raises many important ethical questions about and clinical care and prescription drug use more generally.
ReplyDeleteI have numerous questions about the process of gene sequencing. There is clearly a very complex process used in analyzing the genes that I hope we can learn more about in this course. I wonder who designed the sequencing machine and how it operates. How long does sequencing all 23,000 genes in the human genome take? The author suggested it takes a long time, as the machine in use was running day and night.
Obviously, the success of Dr. Wartman’s colleagues in identifying his rogue gene and effectively treating his cancer is promising. As pointed out by the author, the genetic drivers of cancer are often very unique to an individual and so the ability to sequence that individual’s genes and determine any abnormalities is going to be an unbelievably powerful tool in the future. Although gene sequencing is currently cost prohibitive for most patients, the author offers hope that it will become a much more common tool at some point. This must mean that the technology for gene sequencing will have to become widely available, but perhaps more important is that doctors (old and new) will need to receive the appropriate training to understand and interpret genetic information for their patients.
There are many ethical questions that surfaced in this summary of Dr. Wartman’s case. First, was it ethical for Dr. Wartman’s colleagues to become so directly involved in his care? I am assuming that it was a close bond with his colleagues that motivated them to put aside all of their work and focus on his case. Ethical or not, the results were obviously very positive not only for Dr. Wartman but for the identification of the rogue FLT3 gene and possible treatment. Many of my peers mentioned in their posts that they were surprised that Pfizer initially refused to provide the drug to Dr. Wartman. I am more surprised that they ever provided him with the drug because using it for leukemia when it was approved for kidney cancer treatment is an off-label use. A quick read of Wikipedia tells me that off-label use is not illegal, but off-label promotion by drug companies is illegal. (Off-label prescribing is very common in cancer treatment.) Was Pfizer able to supply the drug because it was requested for an off-label use in the absence of their promotion? This leads to an important question about when off-label drug use and prescribing is okay. Obviously Dr. Wartman, his colleagues, and doctors would be very knowledgeable about the appropriateness of this particular off-label use, but are all doctors informed enough and isn’t there a conflict of interest? Certainly, off-label uses also give rise to important discoveries as evidenced by the fact that Dr. Wartman’s colleagues now want to engage in a clinical train of sunitinib for cancer treatment.
This is an inspirational article and one that gives some hope to families who have been touched by cancer, both in the past and in the present. Dr. Wartman was extremely lucky to be in his professional position, providing him with ties to great resources and technology that allowed him access to his "cure". However, as many of my peers have voiced, few people are in the same privileged position as Dr. Wartman is. The average person does not have access to the technology, drugs, and resources that Dr. Wartman did. Because of this huge access disparity, this article is not very encouraging in terms of finding a viable treatment for cancer.
ReplyDeleteIn addition to the access problem, I had the same question as Allison regarding how long it takes to sequence a person's genome in order to identify the mutant genes. If the process takes too much time and labor, then it may not be possible (as of now) to offer this approach to the public. Once the sequencing issue is resolved, you come up against another challenge: developing a treatment for each individual gene mutation that is found. Since the approach is to treat the gene that is causing the over-proliferation of cells instead of treating the cancer itself, that would mean thousands of individual medications would have to be produced to meet every individual's needs. Again, this may not be a feasible approach to offer to the public.
In terms of Pfizer's role in this particular story, I am not surprised that the drug was initially denied. Hundreds (maybe thousands?) of requests are denied every year by drug companies with the interest in mind of saving the company money. Though unethical, drug companies and insurance companies have come to operate based on profit and maximizing profits for themselves rather than focusing on their patients' best interests. With a potential treatment in gene sequencing, I can see this becoming another money-maker for the drug companies. If based on profit, the cycle continues on spurring more lack of access for those unable to pay.
One more thing I thought was interesting is the idea that Dr. Wartman could have contracted the cancer in some way via the environment he was working in (studying cancer). Could this be another gene-environment interaction?
The sequence of events described in this article is incredible. The fact that these researchers were able to determine which gene was overactive, and that there was already an available drug that could inhibit the activity of FLT3, is unbelievably fortunate. Most impressive to me was that the researchers in this story had the wisdom to look beyond just the DNA (which, as the article states, provided very limited useful information since there were numerous mutations and no remedies available) to the RNA. I don't know very much (at this point) about genetics-based cancer research, but this seems to me to be a brilliant approach, that is likely to provide information that is a) more conclusive, and b) more conducive to action than simple DNA analysis.
ReplyDeleteWhile the results described here are impressive, the article raised a number of questions. If is of course possible that FLT3 is responsible for proliferation of cancer cells in other types of cancers, but it is likely that other genes are responsible, and that those other genes do not have readily available treatments that have been developed. Generally speaking, I wonder about the applicability of this strategy to other types of cancer--in particular, to those cancers that demonstrated very different types of cell proliferation in different organs. I wonder whether the RNA of a primary tumor is the same as that of a metastatic lesion, and, if not, whether this type of treatment would be of limited use in patients with tumor metastases.
Regarding the ethics of the case, I agree that it is unfair that novel, cutting edge treatments are limited to those with money or connections. I believe, however, that investing in a single case such as this one where there is the possibility of gaining important insight outweighs the ethical issues of access to care. If this research is in fact applicable to other cancer patients, and can provide knowledge that will lead to a cascade of better, more informed cancer treatment, then it is a worthy investment, regardless of the details of who invested and why.
I ultimately found this to be an encouraging article on the future of cancer therapy. It's heartening to know that we are moving in the direction of better specificity when it comes to treatments. I think this trajectory can already be seen in the history of cancer treatments (e.g. total mastectomies are not a given in the treatment of breast cancer) and this article offers a glimpse of a future where the general cell death caused by chemotherapy could be replaced by targeted therapies.
ReplyDeleteAs many have pointed out already, Dr. Wartman's treatment was the result of the rare opportunity not afforded many cancer patients. Both the article and many commenters question whether the well-connected or wealthy should have access to this treatment. I would certainly not begrudge Dr. Wartman the good fortune of having access to a novel form of treatment, but I do think it's important to examine who benefits from cutting-edge research. A bioethicist quoted in the article questions why rich people can even access this kind of treatment. This question called to mind medicine's dark history of using poor, disenfranchised people for experimental treatments. While I don't think the two are equivalent, it suggest the importance of avoiding exploitation while broadening access for experimental treatments.
Some of the commenters also pointed out the role of environment in the development of cancers. I can see how easy it is to get excited about the stories like Dr. Wartman's, but I agree that research is also needed to explore ways to prevent cancer in the first place, though this may not be as glamorous a pursuit.
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ReplyDeleteHello, classmates! I've enjoyed reading your responses so far. I apologize in advance for being so (characteristically) wordy, and surely typo-riddled.
ReplyDeleteTo put the second question first, I am of the opinion that Dr. Wartman's colleagues acted as they should: a perfect case study for their research literally walked into their office, and as Dr. Ley pointed out, no other patients were being neglected when the research focused on Dr. Wartman. The flaw is not seeking subjects from the population at large. Ones with unhealthier (it's the American way!) lifestyles than Dr. W's are invaluable for this work.
As for Dr. W's insurance, do remember that insurance in America is new enough to be bogged down terribly with rhetoric, but old enough that “personalized gene sequencing” would have been be a nonsense phrase to any policy writer until recently at best. It will be years before the fine print of medical payment catches up to the fine print of gene sequencing – but that could be a college course in and of itself. Insurers are far from perfect, but it is important to remember that every decision they make sets a precedent. I can't imagine any company yet well-equipped for a precedent like this one.
As for the first prompt, I think any of us would be hard-pressed to feel “discouraged” by leaps and bounds in medicine. Yes, they are often limited to the wealthy and connected. As Jessica pointed out, though, the developmental benefits of single-patient treatment often outweigh “the ethical issues of access to care” (well-said!), to a point. My only discouragement stems from that point, and how far US healthcare remains from it. Yes, private insurers are choosy (to put it gently) about costly treatments. Yes, those costly treatments often arise from the “glamorous” pursuit of a panacea and a profit by major pharmaceutical developers. And as NYT commenter Val Main pointed out, the use of federal (thus, if indirectly, tax) money for research is often bound by the same fine print and bureaucratic connections as any sluggish legislation in a modern democracy. Freely flowing cash would be a boon in medical research, and think of the brilliant implications for gene sequencing!, but temper your excitement with a dystopian novel or two.
Allison duly pointed out the complications of off-label use – one of countless restrictions in place by precedent from the FDA. I doubt that anyone would argue against the benefits of an FDA at large, but I do like to imagine a tax system that supports both public healthcare and, as one NYT commenter put it, “researching environmental toxins that cause cancer.” Of course, then you're faced with the twin giants Big Pharma and Big Chem, surrounded by lobbyist lackeys. I'll need costly, personalized blood pressure medication just to think about it.
Overall, I feel encouraged by the outcomes of Dr. Wartman’s case and the future for cancer therapy. As many of my peers have mentioned, it is exciting to see the changes being made and the future of cancer treatment resulting from our ability to fully sequence and interpret the human genome. It is exciting to be entering a time in cancer treatment where specific treatment plans can target the sequences causing the cancer, rather than treatment plans involving chemotherapy and radiation that result in non-targeted cell death, ultimately making the body weaker during a time when it needs strength to heal.
ReplyDeleteAlthough I am ultimately encouraged by Dr. Wartman’s case and the impact it will have on cancer treatment, I feel our current healthcare system will result in major inequalities, especially when considering expensive individualized treatment plans. Until we are able to reduce the cost of full genome sequencing/analysis and drug treatments, this case is not very encouraging for the future of cancer treatment for the majority of individuals. I don’t know much about the cost of genome sequencing and analysis and hope to learn more about this in our class, but the article implies that it takes a tremendous amount of resources. I am curious to know how much money is being put into research on making genomic sequencing a more efficient and less cost-prohibitive process.
There have been many comments regarding the medical ethics of this case. Dr. Wartman was incredibly fortunate to be researching leukemia and surrounded by other doctors who were able to pool their resources to help Dr. Wartman fight his cancer. The average person would not be able to afford such specialized care. Many would argue that if the majority cannot receive this type of medical treatment, it should not be offered to anyone regardless of their ability to pay and/or the connections they may have. However, I feel that the findings that came about in this case will only help advance our understanding of cancer and viable treatment options which will hopefully make treatment affordable in the near future. Where this may backfire is if we use these findings to identify new treatment options, but the individuals for whom the treatment options would work for would only be affordable to those who are able to pay/have great insurance coverage. I think the outcomes of findings such as this case will depend greatly on the direction healthcare takes in the near future.
To reiterate, I think we are entering a very exciting time in cancer treatment. It will be interesting to see how these changes in treatment plans will impact the training medical doctors will receive, as well as the new investments that will need to be made in technology and resources in order to make this personalized treatment possible. I am hopeful that we can make this cutting-edge treatment a viable option for all individuals diagnosed with cancer in the near future, but pessimistic given the current state of healthcare system and the existing disparities in medical care.
Researchers are banging down cancer’s door by “simply” turning research on its head: by shifting the way in which cancer research is approached, we’ve found a path that could potentially lead to a cure. After all this time, what if the answer to cancer was to study rogue genes that promote the growth of cancerous cells rather than the location wherein the deadly cells lie? This discovery would certainly change health care and medicine for centuries. Consequently, I definitely feel encouraged by reading the article. Perhaps too encouraged though. I found myself overwhelmed with a sense of quiet invincibility. My mind tip-toed around questions like, “Hmm, is aspartame really that bad?” … “Do I really need to eat tomatoes?” … “Now can my fair-skinned counterparts get their base tans without fear of proto-oncogenes going bad forever?” As ridiculous as these questions may seem, the point is that although this is very exciting news, we should approach results and new discoveries responsibly.
ReplyDeleteSide note: I’m interested to see how the funding for cancer research will change. Currently research seems to generally be funded by cancerous locations on the body: breast, colon, pancreas, prostate, etc. In their effort to raise money, programs, teams, and organizations have wrapped themselves around a particular cause, i.e. body part. They encourage donations to specific factions within cancer research. But now what? Once the general public and pop culture learns that two people suffering from breast cancer may have nothing in common from a scientific perspective, will they begin to change their donation habits? Would their monies be better served by donating to gene research? Will the average Joe who normally donates to prostate cancer research for emotional reasons need to become more versed in scientific inquiry so that his donation matters? Will Gene FLT3 Walks replace Breast Cancer Awareness month? I wonder: will the shift in research cause a subsequent shift in funding.
The concerns I have regarding Dr. Wartman’s case were already outlined in the article. Cancer treatment should not come down to economics. At present, it’s safe to say that treatment is far too expensive for most people. On the other hand, should those who have enough money to afford treatment be penalized for having a disposable income? Dr. Wartman’s case is no doubt riddled with ethical dilemmas. However, just as Wylie Burke noted, the methods and approach used for Dr. Wartman’s case will eventually be available to all people.
As someone who hasn’t fervently followed the progression in cancer research over the past several years, I have to say I was incredulous reading the first few pages of this. While reading that article, I felt myself assimilating a new idea about the kind of HOPE available for those fighting this type of cancer. Survival doesn’t have to be about having good luck as you make your way down the check list manifesto of lengthy, arduous, and uniform palliative care treatment programs. Not anymore. This type of research signifies a new level of advancement in the effort to find cures—we are not only looking, but we are extremely close. And while genome sequencing in its current application doesn’t qualify as being a cure, it is certainly the type of technology that lends more hope than the widely ominous notion that there is hardly any cure at all. Furthermore, if we continue supporting the research and technology revolving around understanding the human genome, I know we will unearth a myriad of knowledge pertaining not only to cures, but protective and preventative measures, as well.
ReplyDeleteOur health care system has had problems for years, and, as a whole, seems to act as more of a proprietor for the accumulation of wealth than an entity conditioned for the sake of healing. This was evident in the hardships faced by Dr. Wartman, as insurers refuted his needs in spite of data clearly indicating to proceed with treatment. These types of interactions will remain until the economics revolving around health care has changed, a phenomenon dependent on many underlying social and political factors.
Like most of my classmates, I am encouraged by the developments in cancer treatments that this article outlines. Specifically, I am encouraged by a seeming paradigm shift in how cancer treatment is regarded and treated. I would imagine that is is a difficult task to change the way that an illness is researched and treated, and an even more difficult task to offer up a solution that shifts the focus off of treating an already affected organ and on to treating the origin of the disease. I believe that in a field like medicine, it is this flexibility of thinking that truly engenders innovation.
ReplyDeleteHowever, I have persisting questions about just how helpful this approach will be--innovative as it is. Like some have posted previously, would it be more beneficial to the masses to advance research that looks at why a cancer gene "goes rogue" in the first place? I appreciate the approach of Dr. Ley's team, and in many ways I agree with the idea that medical care should always be individual--which would be be necessary in the case of genetic sequencing and treatment-- and that we should be educating doctors to be conscientious and learned enough to provide such care. On the other hand, I don't know about the feasibility and affordability of this kind of treatment, which is why I tend toward looking for a preventative approach to illnesses like cancer.
In terms of the ethical issues surrounding Dr. Wartman's particular case, I think that just by virtue of his position and illness, he was able to benefit and science was also furthered. I think that in many ways, Dr. Wartman being the subject of his own research is some what of a perfect storm--a coincidence that gives me no ethical qualms. My questions about the ethics of this case pertain more to how this research is used and how treatment methods are developed and made available to everyone, regardless of their means.
1. In regards to cancer therapy, I feel encouraged by this article. Any sort of cancer research is a step forward, even if it does raise more questions or uncertainties than before. In this case, researchers found that genetic sequencing can provide information about the individual's own genetic mutations causing the cancerous growths. It is these individual differences that will allow physicians to target cancerous cells more effectively, since "one woman’s breast cancer may have different genetic drivers from another woman’s and, in fact, may have more in common with prostate cancer in a man or another patient’s lung cancer." We cannot continue to treat all cancers the same. Genetic sequencing will help us do this in the future.
ReplyDeleteHowever, why are drug treatments so expensive? The cost for his medication was $330/day. What drives this price and why will insurance not help cover the costs? This is a bit discouraging.
2. Firstly, the fact that the insurers paid for his drug therapy because of a note that a nurse practitioner wrote seems wrong (if true). If a medication has been shown to help a patient, they should receive that medication. I don't think it should be taken on a case by case basis like that.
In terms of diagnosis, of course the question has been raised, why did HE receive free genetic sequencing and not another newly diagnosed cancer patient? Well, as many of my classmates have pointed out, he was in the right place at the right time and I see nothing wrong with that. Some people may have chosen NOT to be guinea pigs in that situation, but he was willing to become a subject for research. It does beckon the question raised in the article, though: should rich people/people with connections be able to have sequencing done before normal people can or before insurance can pay for it? I found one readers comment to be particularly reflective of my own opinion on this matter : "Without the money or connections a lot of radical new ideas would not be tested. If they work, then the cost of the drugs and therapies will come down, hopefully fast enough to cure my cancer." We also know, that just because you have enough money to have your genes sequenced doesn't mean that you will be cured of your cancer. Both Steve Jobs and Christopher Hitchens had their genes sequence but still unfortunately died of cancer.
Finally, in regards to treatment I learned a lot about different ways to test whether or not cancerous cells still exist in the body: biopsies, flow cytrometry, and the FISH test. Very cool! However it is important that he be continually tested for cancerous cell growth and drug therapy, since we all know that mutations can occur very rapidly among cancer cells that can make them resistant to drugs. A reader made a good point that I hadn't thought of regarding this, saying: "often drug resistance develops along a finite number of similar related mechanisms for which it is possible to develop another effective drug. In that way, the cancer may not be gone, but may develop into a manageable and ultimately survivable disease." This is also very encouraging.
While any story of triumph, of life persisting in the face of death, is encouraging to hear, with regards to cancer therapy this article does more to highlight the blind spots in treatment than it does to lift the spirit. There are too many disconnects between Dr. Wartman's treatment options and those of the average American. The cited researchers' predictions of the general availability and insurance coverage of the whole genome sequencing necessary here have an uncomfortable margin of error. The exponential drop in sequencing cost seen in the last several years may be a very positive trend, but even the current low of $5000 is beyond the reach of most Americans without insurance backing, especially when, as in Dr. Wartman's case, multiple cell types must be sequenced and compared. This comparison itself would also be outside the grasp of the average citizen (full-time researchers working only on his case and a university supercomputer running around the clock), especially if self-funded. Most would be unwilling or unable to foot this tremendous bill for a diagnostic test, treatment notwithstanding. Dr. Wartman was also fortunate enough to have an approved, available drug specifically suited to his malfunctioning gene. And, of course, the issues with insurance's coverage of the drug, which Dr. Wartman only was able to afford with the help of multiple colleagues, will likely remain dicey for a long time. If not for Dr. Wartman's own background and connections, not only would his treatment have been inaccessible, his diagnosis may have been further postponed. Even in his initial urgent care visit in 2003, his doctor's initial relative optimism ("his symptoms might come from depression") was supplanted by Wartman's own suspicions. For a layman, this story certainly would have ended very differently, but it even might have begun differently.
ReplyDeleteBut, ultimately, even in atypical cases such as this, the exposure of these issues in modern health care, its hurdles and triumphs, push us closer toward accessibility and affordability. For many, insurance coverage is the final bottleneck, and public awareness can help narrow the divide between science and insurance. And we should keep in mind that although this was a very particular case, having another weapon in the arsenal of cancer treatment (especially one without the wanton destruction of chemotherapy and radiation) is certainly cause for celebration, even if its use is so heavily restricted. With the extension of the technique used here, we may be moving toward personalized, gene-based cancer treatment, as opposed to our current shotgun-style organ-directed treatments.
I agree with all of Roger's comments (above) as well as others' about the unfortunate inaccessibility of treatment to the majority of patients. It is simultaneously encouraging and also disheartening to hear Dr. Wartman's case. It is exciting to see how the leaps in genetics research has improved cancer treatment by illuminating novel root causes of cancer, and thereby illuminating new approaches to treating cancer. At the same time, as we see from the special case of Dr. Wartman's connections and expert knowledge of cancer, it is not likely that many people in a similar position will receive the attention, funds, and treatment necessary. However, I cannot help but be fascinated, impressed, and ultimately, hopeful for the future of cancer treatment. Every new success paves the way for more funding and spurs the minds of researchers and physicians.
ReplyDeleteOne question or concern I have about the treatment of Dr. Wartman remains. In the fifth paragraph of the article, the author says "There was a promising new drug that might shut down the malfunctioning gene..." What are the side-effects of shutting off a gene that, when healthy, provides (I presume), a very necessary function for the body? This raises a larger question for me: What are the limits of gene therapy? Are there certain cancer or disease-causing genes that, if "shut off", will cause different or even greater harm to a patient? I am so curious to see how this medicine/science of gene therapy will be developed and finessed over the years to provide relief from disease. I wonder what secondary problems scientists will have to tackle along the way, and how much more we will learn about the role of each gene as we encounter malfunctioning ones and impose our own alterations on them.
I came back to review what my classmates had posted and found my original response didn't get successfully submitted. (???) I really enjoyed reading everyone's responses; there are so many great points I look forward to discussing tommorrow. My thoughts are essentially the same:
ReplyDeleteI definitely think this article is encouraging in the sense that real progress has been and will continue to be made in successfully treating cancer. I agree with others and predict that the technology that makes genetic screening possible will be more focused, more efficient, and much, much more affordable in the future. I believe this would make genetic based treatments (which are actually already a common diagnostic/therapeutic tool in some cases- breast cancer, melanoma) available on a wider scale for the general public and for a great many more cancers.
A common response among the public and class comments is the frustration with the disparity in healthcare resource allocation and the questionable motives behind the gatekeepers of these resources (insurance carriers, pharmaceutical companies, etc.) While I agree that these issues are a major concern in healthcare, the denial of Dr. Wartman's insurance carrier and Pfizer to cover the cost of Sutent, in my opinion, is not the best example to illustrate this problem. Before Sutent was tried to treat Dr. Wartman's case, there was compelling, but only hypothetical evidence to support its use for his cancer. There was no testing, no actual data to support it. It would be rather irresponsible for insurance and drug companies to fund every treatment that is only hypothetically beneficial. Medical therapies, particularly chemotherapies can potentially not be of any help at all and have high potential to do a lot of harm. Furthermore, the article stated that Pfizer eventually supplied the medication to Dr. Wartman and though it is not certain why, the article suggests that the decision was made based on a letter sent by a nurse practitioner involved in his care. The content of the letter is not known, but I imagine that it detailed the amazing test results after taking the medication, providing some evidence of Sutent's efficacy for Dr. Wartman's cancer.
I believe that in the near future as research progresses in this field, despite the inital cost of genetic-based diagnostics and therapy for cancer will eventually be widely covered by insurance companies because safer, more effective therapy for cancer would likely cost less than the therapies that are currently in use. One of the questions in my mind that the article raised is that I wonder how much the cost of the genome sequencing and Sutent therapy for Dr. Wartman compares to the cost of all the other previous tests, therapies, hospitalizations, treatments for side-effects, complications, etc. that in the end failed him prior to the genome sequencing/Sutent therapy? I actually wouldn't be surprised if it was about the same if not more.
Another encouraging aspect of this article is that the genome sequencing uncovered several defective genes in the DNA. The unfortunate aspect at present is that there are currently no drugs developed to address those particular genes. It was really the serendipitous finding of the FLT3 RNA gene that has an effective treatment in existence that made Dr. Wartman's recovery possible. However, I predict that in the future, clinicians will have a variety/combination of gene-based therapies at their disposal to treat cancers. Therapies can be carefully selected for to increase specificity and reduce the serious side effects.