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Thinking about Life Sciences

http://blog.aesisgroup.com

Monday, January 22, 2007

Lance Armstrong and the Future of Cancer Care

Lance Armstrong is a unique phenomenon. He’s a talented athlete, a cancer survivor and a political activist.
He is in a league by himself. Or is he? As many people know, survivors of cancer are much more common
today. A recent National Center for Health Statistics report released by the American Cancer Society showed
a drop in cancer deaths for the second year in a row. Cancer patients as political and even business activists
are also increasingly common. In a Dec. 2006 column on MidwestBusiness.com, I wrote about this growing
phenomenon:
Various disease-oriented non-profit groups, charities and government groups are actively providing
venture financing to new biotech start-ups.

If the trend of socially driven popularization of biotech investment continues, investors would be looking
not just at financial returns but also at social returns.

Ultimately, this is what most patients want. Though it is not yet clear whether or not this will require new
legal frameworks, it is clear that it would involve new paradigms.
For example, it may imply regulations that make it easier for smaller companies to access the public or
semi-public financial markets. Let’s first discuss more about the increasing numbers of cancer survivors, the
reasons for that and the implications for future technologies.
Major Technology Trends
There are four major technology trends that have impacted cancer care over the past decade. I’ll discuss
each with some implications for the industry.
1. Earlier detection and diagnosis
2. Targeted therapies
3. Personalized medicine
4. Minimally invasive surgery
Earlier Detection, Diagnosis
The explosive advances in imaging technologies (computerized tomography (CT), magnetic resonance
imaging (MRI), ultrasound (U/S), mammography and others) have completely revolutionized cancer care.
With most cancers, earlier detection and diagnosis means more localized disease.
There are two implications to earlier and more localized disease: the disease has a higher chance of being
cured and surgical options generally figure more largely in the treatment of early disease. The second point
also relates in that advances in minimally invasive techniques have further contributed to growth in the
surgical management of cancer.
There have been several industry implications of earlier detection including an increase in demand for
radiology services. This has not only spurred growth in the sales of these complex machines but also in

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ancillary services such as free-standing diagnostic centers and even teleradiology.

As cancers are detected earlier, there is an inverse pattern between increasing surgical care and decreasing
(in relative terms) chemotherapy. In addition, as disease is caught at earlier and at less-symptomatic stages,
the importance of drug safety will also increase. All of these trends will continue.
Targeted Therapies
Even back in the days of Richard Nixon and his “war on cancer” (and even before then), there have been
dreams of a magic bullet that will kill only cancer cells and preserve normal cells. For most people, cancer
chemotherapy is associated with dreadful side effects from relatively benign but certainly concerning hair
loss to severe bone-marrow suppression and fatal infections. A recent CNN article on Lance Armstrong’s
cancer crusade showed a gallery of cancer patients. All of them were bald from undergoing their respective
chemotherapies. Ironically, this picture is becoming less common with the new generation of targeted
therapies such as Herceptin, Gleevec and Erbitux.
The mechanism of action of these newer, more targeted drugs is not on inhibiting cell growth in general
(with moderate levels of differentiation between cancerous and normal cells) but rather on affecting
specific functions and pathways unique to cancer cells. Even though these targeted drugs are darlings of
the media and Wall Street and they still only represent a small proportion of overall cancer chemotherapy,
the industry implications have been profound. These new drugs have impacted longer survival and hence
have contributed to the concept of cancer in many cases now being a chronic disease. Another important
trend has included a marked decrease in the level of in-patient cancer care (much of which is often related
to the serious side effects of chemotherapy).
Personalized Medicine
Personalized medicine is not specific to cancer as it represents a new paradigm in medicine in which
individual genetic variations become relevant in fine-tuning the diagnosis and treatment. While people had
“high cholesterol” just 20 years ago, they now have various syndromes relating to subtypes of blood-borne
cholesterol such as HDL, LDL and VLDL. Even more finely-tuned genetic subtypes are available for
what was once a simple and monolithically defined syndrome. To some extent, the phenomenon of
personalized medicine overlaps with the targeted therapies above. These targeted therapies are in some
cases not just directed more effectively toward cancer cells but are also targeted by virtue of patient-
specific genetic factors. Women with certain mutations in the BRCA1 gene, for example, have an 80
percent lifetime risk of breast cancer. For these women, radical mastectomy is not such an extreme
therapeutic (preventative) option. To a lesser extent than early detection and targeted therapies, this
nascent era of personalized medicine has likely also reduced death rates from cancer.
The wider implicationss of personalized medicine for cancer care are still being explored and understood.
Apart from the improvements in survival as suggested above, one absolutely critical impact is on how
clinical trials for cancer are designed and constructed. As therapies become more personalized, the patient
pool correspondingly gets smaller. This means the statistical power of large population-based clinical trials
is less or even not available for these highly personalized and targeted drugs. This is a problem that the
FDA is addressing now. It will impact drug development and drug pipelines for years to come.
Minimally Invasive Surgery
In addition to earlier detection, the remarkable advances in minimally invasive surgical techniques – not
just traditional “cutting” surgery but other approaches such as interventional radiology, endovascular
methods, lasers and radio-frequency ablation – have also raised the profile of surgery as a part of the care
of many cancers. New minimally invasive techniques have caused a complete paradigm shift in the
understanding of surgery particularly as applied to cancer. In the traditional paradigm, surgery was a “last-
resort treatment” in which (generally speaking) only one, definitive operation was possible. t was literally
“do or die”.
Incremental surgeries can now be performed along with combination diagnostic/therapeutic surgeries,
second-look diagnostic procedures, drug-delivery system implants and repeat surgeries. A host of other

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interventions for previously unresectable metastases are all part of the surgical armamentarium.
The implications - which will continue in the future - will be a further stimulus to interventional radiology,
ambulatory surgery centers and the surgical device market serving this sector. We’ve seen a remarkable
confluence of technology trends that have (among other factors) contributed to recent successes in the
“war against cancer”.
As implied earlier and in other columns, we may also be amid an inflection point in business models for
biotech and medical technology in which patients and patient-care groups become increasingly involved in the
expensive financing of such technologies.
While unique in his own way, Armstrong’s efforts are one of many in this direction. What is unique about
Armstrong is that he is applying his exquisite sense of timing in “entering the cancer field”. On the bicycle:
… Armstrong was the king of the decisive moment. He knew exactly when to put the hammer down, and when
he did, you could see in the faces of his rivals that they knew they were competing for second place. Source: Freelance
writer Nick Swallow
Let’s see if the face of cancer is beginning to give that look as if it is doomed to place second.

Ogan Gurel, MD MPhil

gurel@aesisgroup.com
http://blog.aesisgroup.com/

Cancer Personalized medicine cancer diagnostics minimally invasive surgery personalised medicine Aesis Research Group Ogan Gurel MD

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