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Vinay Prasad, M.D., M.P.H.: Hallmarks of Successful Cancer Policy | The Drive with Peter Attia #133

Key Takeaways

  • Medicine is an art: sometimes you have to make decisions with less than perfect information
  • There is often a disconnect between what patients perceive as the benefit of a procedure versus what doctors know as the likely outcome 
  • Despite a lot of propaganda, we really haven’t had a lot of success in cancer
  • Oncology drug studies are conducted on patients who don’t resemble what is happening in reality
  • New drugs are often tested against the oldest, weakest drug in the space to prove efficacy and game the system
  • Conflicts of interest and financial influence distort the true outcomes and benefit to the end-user 
  • We need practitioners with no financial relationship with companies that make the product
  • Drug research needs to focus on improved quality of life, not just arbitrary cut-points (e.g, measuring tumor size)

Introduction

Vinay Prasad, M.D., M.P.H., (@vinayprasadmdmph) is a hematologist-oncologist and Associate Professor of Medicine at the University of California San Francisco. His research focuses on cancer drugs, health policy, clinical trials, and ultimately better decision making in medicine.

In this episode of The Drive, Vinay Prasad and Peter Attia discuss clinical trials, the structural problems in oncology medicine and research, and hallmarks of successful cancer policy.

Host: Peter Attia (@PeterAttiaMD)

Books: Ending Medical Reversal(2015), and Malignant(2020) by Vinay Prasad, M.D., M.P.H.

Oncology Research: Good Intentions Gone Awry

  • Despite a lot of propaganda, we haven’t had a lot of success in cancer
  • Research needs to aspire to more
  • The average benefit of cancer drugs is 2.1 months
  • Drug studies are conducted on carefully curated study populations who are younger and healthier than cancer patients in the real world
  • “Oncology clinical trials are best-case scenario by a log order based on participant selection.” – Peter Attia
  • Research is not producing many novel, transformative drugs but mostly drugs that are just extensions of existing
  • “If you have metastatic breast cancer in 2020 versus 1960 or 1970, you’re not a hell of a lot better off.” – Peter Attia
  • Some of the drugs may have a net downside: side effects, spending more time in doctor’s office receiving and monitoring treatment
  • Progression-free survival: from the time a patient enrolls in the study until 1 of 4 things happen – (1) patient dies; (2) new lesion on CAT scan; (3) tumor is larger (above 20% growth); (4) tumor got smaller before it got bigger
  • Trials are driven most by the tumor size which is an arbitrary cut point and not indicative of how a patient feels or does in the long run
  • New drugs are tested against the oldest, weakest drug in the space to prove efficacy and game the system
  • New medications routinely run $100-200k/year of treatment
  • A drug that is too expensive and can’t get in the hands of people who need it is not better than no drug at all

Fundamental Issues In Oncology Research

  • Cancer is a category term, not a single monolith
  • For all intents and purposes, each cancer is a totally different disease
  • It’s really hard to get funding to explore topics without a promise that you are trying to cure something or have a hugely novel idea
  • Pharmaceutical companies are tasked with running a clinical trial to test their own drug – of course, they want it to succeed
  • Conflicts of interest and financial influence distort true outcomes and benefit to the end-user  
  • Even meals sponsored by industry are associated with small increase in prescriptions written
  • Some senior oncologists receive more than $100k in consulting fees and millions in research funding from private industry
  • Possible solution to conflict of interest:  incentivize professors and physicians not participating in consulting and private industry
  • The goal is to have practitioners with no financial relationship with companies that make the product
  • Profit promotes innovation but needs to be removed from people who are supposed to be neutral arbiters of our health
  • “The people you need to change the system, the people with the power – are the people benefitting most from the system.” – Vinay Prasad
  • We incorrectly subsidize marginal drugs the way we subsidize transformational drugs

Six Hallmarks Of Successful Cancer Policy

  • Independence: we need rules in the space to minimize conflicts of interest and freely advocate for constituents
  • Evidence: measure what matters and do it fairly – we want people to have an improved quality of life, not just reduced tumor sizes
  • Relevance: do more studies on people that look like average patients
  • Affordability: give Medicare the ability to decline to pay for drugs – in the U.S. Medicare must pay for the drug and can’t negotiate the price
  • The pre-clinical pipeline must be expanded: we need to crank up funding for science slowly and steadily – separate science from political cycles and evaluate how we give out the money
  • Agenda: people are running redundant and duplicative trials – we need to see what the agenda looks like across the entire field

No Regret Moves In Oncology

  • Cut out tumor
  • Radiotherapy is useful in many cases
  • Hodgkin’s lymphoma is curable
  • Testicle cancer that spread to lungs can be cured in 95%+ patients
  • Patients with chronic myeloid leukemia (CML) have near normal life expectancy now 

Differences In Clinical Treatments By Setting

  • Things that are widely practiced don’t always work as intended
  • Some medical practices are adopted with high uptake based on old, low, or incomplete levels of medical research
  • Clinics and medical facilities vary in decision making
  • There is often a disconnect between what patients perceive as the benefit of a procedure versus what doctors know as the likely outcomes
  • It’s ok to accept the risk of a complication if the procedure has a net benefit
  • Can’t ignore conflict of interest that exists in medicine: physician reimbursements for certain procedures, pharmaceutical companies, etc.
  • There have been broad reversals of medical practice based on newer, thorough clinical trials
  • “When you don’t have any skin in the game, you’re incapable of making any rational decisions.” – Peter Attia

Importance Of Bedside Manners

  • Practitioners have friction around exhaustion of taking care of patients versus the privilege to serve people in their vulnerable moments
  • Physicians need to be in the moment every time they approach a patient
  • “Patients who are dying need us more than patients who are living.” – Peter Attia  
  • The patient is in a difficult, vulnerable position trying to make choices that are best with limited information
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Notes By Maryann

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