Richard Smith: Stratified medicine vs the polypill

Richard SmithIn the past month I’ve attended contrasting meetings on the polypill and stratified medicine that leave me wondering about the future of medicine.

The problem that the polypill tries to solve is that only about 10% of people in the world get the simple drugs that could dramatically reduce their chances of having a heart attack or stroke. Other polypills—combinations of drugs that are off patent and have different actions—could help with other conditions. In stark contrast stratified medicine is attacking the problem that many people who take drugs do not benefit from them: stratified medicine uses genetic information to identify those who will benefit.

Another contrast is that stratified medicine is attractive to big pharmaceutical companies, whereas the polypill is not. Pharmaceutical companies see the future as developing at high price ever more specific drugs accompanied by diagnostic tests. Polypills can be prescribed for as little as a dollar a month and could destroy lucrative markets for pharmaceutical companies. They might be given without involvement of doctors, something that has considerable benefits when many people in the world cannot access a doctor. Stratified medicine will demand ever more sophistication backed up by huge datasets.

Stratified—or precision—medicine is fashionable, the concern (I wondered about writing “plaything”) of the elite of medicine. In contrast, at least some supporters of the polypill are seen as close to a lunatic fringe, although the polypill meeting did include a few of medicine’s high priests.

How do these two possible futures fit with the world in 2012? One stark reality is that most people in the world do not get even basic medical care. Will stratified medicine help with this? No matter how cheap it becomes to sequence the human genome it’s hard to imagine how stratified medicine will help with this gross inequality. Polypills might.

Within developed countries like Britain healthcare is mostly about elderly people with multiple conditions. In the US 60% of Medicare expenditure is on people with more than five conditions. It must be similar in Britain. So far stratified medicine is mostly about people with cancer, identifying people who will not benefit from chemotherapy. What does it mean in the world of comorbordity? It’s not clear to me. I have a feeling that the model I was taught as a medical student—“diagnose, treat, cure”—is almost dead. We know the diagnosis, although not precisely, in most patients, and there is almost no curing: people have their long term conditions for life.

Many of these people with multiple conditions are taking 5 to 15 drugs. Will stratified medicine allow them to take fewer? Perhaps. Would a polypill substitute for some of the drugs or add to the burden? Again, that’s not clear.

Then life expectancy in developed countries is already around 80, and among people who die between 90 and 95 50% are demented. Perhaps stratified medicine will come up with an effective treatment for dementia as we recognize that dementia has multiple causes and that the concept that amyloid is the main cause looks wrong. My mother has no short term memory, and my grandmother went the same way. I may be a few years away from dementia, and I doubt that I’d say no to a treatment that could prevent dementia.

But I can’t live for ever—and wouldn’t want to. I’m very conscious of the saying that “without death every birth would be a tragedy.” Worse, I feel that we are very close to that point—indeed, probably past it—in a world where we need more than two planets to support our lifestyles and yet have only one.

And how does stratified medicine fit into a world of health costs being unsupportable in many countries, including the richest? Perhaps the better targeting of innovative treatments will in the longer term allow savings, but in many ways it seems to continue a model of medicine whereby medical inflation always runs ahead of general inflation. How can this work in countries like Britain and most of Europe that have had to borrow excessively in order to pay for healthcare and other activities?

When at Stanford in 1989 I learnt about “flat of the curve medicine,” the point when increased expenditure and activity no longer leads to benefits. I saw too that increased expenditure on medicine may even lead to the curve dipping—through overdiagnosis and excessive treatment. Perhaps the most thoughtful presentation at the polypill meeting was by Anthony Rodgers, a professor from Sydney, who argued that in medicine we make the mistake of constantly pursing the perfect, the best, failing to recognise how the best is usually the enemy of the good.

I can’t believe that the development of stratified medicine will be halted, and who would want to stand in the way of scientific and medical advance? But perhaps there is some sort of judicious combining of the worlds of stratified medicine and the polypill.

Competing interests: RS is a longstanding enthusiast for the polypill and takes one every night. UnitedHealth, the company he works for, helped sponsor the polypill meeting, and he helped organise the meeting and spoke at it. He’s a fellow of the Academy of Medical Sciences, which organised the stratified medicine meeting—but has had very little involvement with the academy. His overnight accommodation and food at the meeting was paid for by a variety of sponsors of the meeting.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.