Brainstorm Health: Clinical Trials, Health Care Startup for the Poor, The Cost of CHIP

At the turn of the most recent millennium, when one large international clinical trial was recruited to test whether colchicine could prevent post-pericardiotomy syndrome—a common complication following cardiac surgery—something marvelous was discovered: colchicine seemed to prevent post-operative atrial fibrillation (AF) as well. In a follow-up trial, results of which were published in 2011, patients given the drug had nearly half the incidence of AF as those not receiving it.

But when the same lead investigators repeated the trial with 360 new heart surgery patients at 11 hospitals across Italy, testing the age-old poison against a placebo, “there were no significant differences between the colchicine and placebo groups” when it came to AF. Both studies were randomized and double-blinded. Both, naturally, crossed all their t’s and dotted all their i’s. And both came to entirely different conclusions.

So began a cycle that is all too familiar in the clinical trials arena today: a round-robin of studies that never quite concludes and rarely emerges with a clear victor. In 2016, when researchers gathered up data from 10 randomized controlled trials (aggregating the results from 1,981 patients in all), they found—“Colchicine therapy was not associated with a significantly lower risk of post-operative AF.” A year later, another so-called “meta-analysis”—this one rounding up six randomized controlled trials with 1,257 patients—found the opposite: “Colchicine significantly reduced the odds” of post-operative a-fib.

You can find the same types of long-running disagreements across the therapeutic board in clinical trials, as I wrote about years ago in an essay for the New York Times, entitled “Do Clinical Trials Work?” The striking example I focused on then was the cancer drug Avastin, developed by Genentech (now Roche)—which, at the time, had been studied in at least 400 completed human clinical trials for various cancers. In spite of all that testing—at a financial cost of untold billions of dollars and an immeasurable time cost for the patients who volunteered—no one was able to say with any certitude whether the drug would work in any one patient or not. As a Genentech spokesperson told me at the time: “Despite looking at hundreds of potential predictive biomarkers, we do not currently have a way to predict who is most likely to respond to Avastin and who is not.” (FYI, there are now 767 completed clinical interventional trials studying Avastin. And we still don’t know the answer.)

The question is, Why? Why do clinical trials, so often, tell us so little?

Well, there’s a long answer for that—and for those interested, I humbly refer you to here and here. (Yes, the latter link is a shameless book plug.) But the short answer for anyone who doesn’t want to buy a book is that the standard old-fashioned clinical trial is designed to answer a specific question about a population with lots of different specific characteristics. (Thanks to differences in physiology and pharmacogenetics, a single drug, for instance, can work very differently in two different healthy people, as it is. Throw in the complexities and heterogeneities of an evolving disease of genetic mutation, such as cancer, and the drug response from one person to the next can be even more variable.) And so often—too often, really—the message that emerges from trials is a jumble.

That doesn’t mean we should throw out clinical trials. Nothing of the sort. What it does mean is that we should reinvent them. We should develop clinical studies that actually teach us something in every study.

Which brings me, at last, to my fourth prediction for 2018. Faithful readers will recall that I’ve written about three developing trends for the new year and beyond: self-aggregation, de-hospitalization, and (yesterday) the bet on RNA-based therapies. In addition, I think we’re going to see—or begin to see—a radical rethinking of the clinical trials process. The urgency for this change will be particularly acute when it comes to testing investigative drugs (and cocktails of drugs) in disease settings where there’s a great deal of variability between patients (as in most cancers) and where the patient populations are small (as in rare diseases).

There are lots of good ideas on this front—including trials that are designed to adapt, which I’ve written about earlier. But this year, I believe we will have a new tool to explore in the clinical research setting: artificial intelligence. In a realm of swirling, incomprehensible big biological data—which is, perhaps, another way of thinking about the human body—the opportunity to use computer learning to better anticipate which drugs will work well (and not so well) in any one person is one we shouldn’t pass up.

As one of the world’s premier experts in clinical trials, Don Berry, told me, “The standard clinical trial is pretty much the only thing in medicine that hasn’t changed in the last 70 years.” Well, a change is gonna come.

DIGITAL HEALTH

This Silicon Valley upstart wants to help poor people get health care. Silicon Valley sometimes draws criticism for what some might call its more... Self-indulgent ideas (see: "raw water" for $20 per gallon as the latest health fad?) Of course, plenty of startups are at the cutting edge of innovation, including in the health care space. But what about a digital health firm specifically focusing on one of the most neglected populations in the U.S.—the poor? Google parent Alphabet spinoff Cityblock has raised $20 million to do just that. The company is attempting to help low-income, elderly, and homeless Americans connect to basic health care services with the help of a tech platform called Commons. Read from CNBC's Chrissy Farr here.  (CNBC)

INDICATIONS

Japan's Takeda snatches up stem cell biotech TiGenix. Japanese pharma giant Takeda will buy TiGenix, a Belgian biotech focused on stem cell therapies, for $630 million in cash. The acquisition is meant to build on Takeda's forays into drugs for gastrointestinal disorders; TiGenix is on the cusp of securing a European regulatory approval for a treatment for Crohn's disease. (Reuters)

THE BIG PICTURE

CHIP extension would be way less expensive because of... Obamacare mandate's repeal? File this one under "Irony." The Children's Health Insurance Program (CHIP), which Congress failed to renew at the end of September because of disagreements over funding sources, is set to run out of money imminently. That's been causing the families of some 9 million children who rely on the program some serious anxiety. But a new Congressional Budget Office (CBO) analysis suggests that extending CHIP for five years would actually cost $7.5 billion less than originally expected, or just a $800 million addition to the deficit over 10 years relative to current law. The reason? Of all things, repeal of Obamacare's individual mandate, which passed alongside the GOP tax bill in December. Here's the TL;DR version: Repeal of the mandate would drive up premiums in Obamacare's markets, but federal subsidies would still have to be paid out to those who qualify. CBO is saying that children and their families who flock to Obamacare markets in the absence of CHIP would be more expensive for the federal government to cover than simply extending CHIP.

REQUIRED READING

What the New Federal Rules Mean for Recreational Marijuana, by Emily Price

Ripple's Cofounder Is Now One of the World's Richest People—On Paper, by Robert Hackett

Millennials and the Death of Imperfection, by Sy Mukherjee

Angered By the Rise of the 'Raw Water' Startup? Don't Be, by Andrew Nusca