The Cancer Drug Dark Ages Are Coming to an End
Only a couple stories in the past decade have given advocates of personalized cancer medicines much to brag about. There was Genentech’s Herceptin for a form of breast cancer in 1998, and Novartis’ Gleevec for chronic myeloid leukemia in 2001.
But just a few short weeks ago, in August, we saw a flurry of FDA approvals that I believe will go down as a turning point in the history of personalized medicine. Industry has paid lip service to this idea for years, but I’m starting to believe that many in pharma and biotech are getting real about changing their ways, and making drugs that are superbly effective in small niches of patients, rather than settling for mediocre advances for the masses.
Even with an explosion of knowledge in biology over the past 40 years, most of the new cancer drugs produce humbling results. Many drugs shrink tumors for one-fourth or one-third of patients, and nobody knows (or at least not enough have seriously bankrolled efforts to find out) how to pick which patients would fall into the lucky few. These drugs might extend lifespan a couple months, but there’s so much variability it can look like a roll of the dice—sometimes the drug could provide zippo benefit for you, or, it might extend your life a few years.
Two things, though, were certain. Patients would endure some significant side effects, and insurance companies would get some extremely high drug bills.
That’s why this past August was so important, and why people in biotech are still buzzing about what happened. Consider this string of FDA approvals, which the agency granted ahead of its usual legal deadlines, so it could get these life-saving therapies to patients sooner.
—On August 17, Roche’s and Daiichi Sankyo/Plexxikon’s vemurafenib (Zelboraf) was cleared for sale as a new treatment for a deadly form of melanoma that has spread through the body. This drug is tailored to treat about half of melanoma patients with a mutated form of a protein called BRAF. Clinical trials showed this treatment reduced the risk of death by 63 percent in this distinct genetic population, when compared to standard chemo. Researchers are still following patients to see how much longer people can expect to live with the new drug. Importantly, the treatment was approved with a companion diagnostic test that will help doctors determine whether patients should get the drug or not. The diagnostic test costs $150, and the drug will go for the premium price of $56,400 for a six-month course of therapy.
—On August 19, Seattle Genetics (NASDAQ: SGEN) won FDA approval for brentuximab vedotin (Adcetris) for patients with a couple of rare lymphomas—Hodgkin’s disease and anaplastic large cell lymphoma. This is a targeted drug that acts like a “smart bomb” by delivering a potent dose of chemotherapy directly to cancer cells that carry a signature marker known as CD30, while mostly avoiding healthy cells. The treatment was able to significantly shrink tumors for about 75 percent of patients with Hodgkin’s disease that had relapsed, and it produced an even better 86 percent response rate for very sick patients with anaplastic large cell lymphoma. Researchers are still following patients to see how long they are living, beyond the 2-3 year life expectancies they were given at the outset of the trial. Doctors can easily figure out which patients should get this drug based on their CD30 status, before they prescribe a product that is expected to cost about $108,000 per patient on average.
—On August 26, Pfizer showed that even though it made its fortune on mass-marketed blockbuster drugs like Viagra and Lipitor, a significant part of its future will depend on a so-called “nichebuster” in cancer. This one is called crizotinib (Xalkori), which is designed to treat about 3-5 percent of patients with non-small cell lung cancer that overexpresses a protein called ALK. The drug showed it was able to shrink tumors in a majority of patients—50 to 61 percent—and the spread of tumors was halted for close to a year. The responses have been so encouraging for this specific group of lung cancer patients that researchers, again, will have to follow patients for an extended time to get an accurate read on how long it will help patients live. Abbott Laboratories has agreed to sell the companion diagnostic test to determine a patient’s ALK status, so doctors can see which patients should get this $9,600-a-month treatment.
There’s a pattern here. These drugs are going after well-defined patient populations, not the broad-brush, organ-based classifications of the past like “breast cancer,” which made everybody’s disease sound the same. As any biologist will tell you, cancer is nefarious in its complexity. But by homing in on biologically distinct malignancies, these drugs were able to offer excellent benefits to people who otherwise had been given a death sentence. And while all these drugs are expensive, I would argue these prices are more defensible than many cancer drugs for a couple reasons. One, these treatment offer major benefits to people without other options. And two, there are diagnostics that can help weed out most of the waste by ensuring the drugs go exclusively to people most likely to benefit.
The results are starting to change the way people in biotech and pharma think.
This week at the BIO Investor Forum in San Francisco, Alan Wahl of Abbott Laboratories said his company won’t advance a biotech drug in development anymore unless it has a diagnostic to push in parallel. “Companies that get personalized medicine will win” because they will have the data that can truly justify high prices when insurance companies start pushing back, said Rollie Carlson, the CEO of Austin, TX-based Asuragen, on the same panel. And later in the conference, Bryan Roberts of Venrock related a story about how one senior Genentech executive is so pumped about cancer drug development that he said it is getting to the point where scientists can basically move down a checklist, knocking out aberrant cancer pathways one-by-one.
There will be losers in the push toward more personalized cancer medicine. Cancer drugmakers (think Dendreon, and in some instances Genentech) are going to continue to have a hard time justifying high-priced medicines that have no real way of predicting who will respond, and who won’t. The diagnostic companies are going to have to fight tooth and nail for every dollar they get on reimbursement, because society still puts most of the value on drugs. Some patients are going to struggle with denial when they get the bad news that there’s a lifesaving new drug out there for their form of cancer, but they can’t have it because there’s something in their genes that says it won’t do them any good.
But there’s no other way to put it, the rules of the cancer drug development game are changing for the better. Companies who base their work on great science will have a shot at running leaner, meaner, shorter, and cheaper clinical trials that have a good chance at satisfying the FDA. It’s great news for insurers, who can now show their shareholders that when they pay six-figure sums for cancer drugs, they are no longer flushing two-thirds of the money down the toilet on patients who see no benefit.
This switch toward personalized cancer drugs won’t happen overnight, and FDA official Janet Woodcock recently said it will be a “long slog.” Personally, I loved hearing her say that. I love climbing mountains in my spare time, so I can appreciate that some of the very best things in life come at the end of a long slog. Personalized cancer medicines like the ones being approved today are worth every ounce of effort and every penny of investment, even if it takes a long time for us to see the summit.