Precision medicine – the good and the bad

PRIME – April 2015 By Victor Acquista, MD Integral Health Specialist In this year’s State of the Union Address, President Barack Obama mentioned the term “Precision Medicine.” Indeed, in his proposed budget over $200 million has been allocated for a Precision Medicine Initiative. Many people are unfamiliar with this term. What exactly does it mean? Put very simply, this has been characterized as “…a cutting-edge medical approach that provides treatments that are as unique as your own body.” I would like to share with you, from a perspective that includes primary care and Integral health why I think this is both good and bad. Precision Medicine– the good Well, it only makes sense that a medical approach which tailors treatment to a unique individual would be more desirable than less tailored or specific treatments. The basis for these more individualized treatments lies in better and more sophisticated gene analysis and studies demonstrating how certain treatments are more effective for certain gene profiles. A good example of this relates to the use of Warfarin, a common medication which reduces the bloods ability to form clots (a blood “thinner”), prescribed for a variety of conditions such as atrial fibrillation. Because Warfarin can be dangerous if the dose is too strong (may promote bleeding or hemorrhaging) and dangerous if the dose is too weak (will not accomplish the desired benefits of thinning the blood) we consider this a “narrow therapeutic index” medication. Think Goldilocks, porridge, and the three bears – too hot is not good, too cold is not good, we want the porridge to be just right. In the same way, we want the Warfarin to be just right. But people vary quite a bit in how their bodies metabolize Warfarin and as a result, dosing the medication can be especially tricky. Enter Precision Medicine. Now we have a laboratory test to help determine how a single person will process Warfarin. This takes out some of the guess work and reduces some of the risk of incorrectly dosing the medication. The same is true of some other medications which we can now prescribe using a more sophisticated scientific understanding of what is most likely to benefit an individual patient. We now have tests that identify which patients are more likely going to respond to certain chemotherapies and cancer treatments, based upon their genetic makeup and the genetic makeup of their cancer. As our understanding of an individual’s genetic profile becomes more sophisticated and this information is paired to correspond to different treatment alternatives, we can tailor our treatment better. I think most people would agree that this is a good thing. Precision Medicine – the bad Sometimes Precision Medicine is confused with Personalized Medicine. While this is conceivably a piece of Personalized Medicine, it is a small piece in my judgment. Integral theory informs us about the multifaceted aspects of people and what makes them different at many different levels. This includes body, mind, and spiritual aspects of any single individual. It also includes things such as their values, beliefs, relationships, socio-economic status, etc. A true personalized medicine recognizes these unique characteristics at both the assessment (diagnostic) phase and the treatment (therapeutic) phase of care. Philosophically, Precision Medicine is rigorously and elegantly based on the scientific method. In the modern Western approach to care, this means things such as case-controlled research studies to prove the value of a particular treatment. These scientific studies require large groups (a cohort) of people whose many individual and unique characteristics are factored away to consider only a single variable. They are artificially contrived to reduce variance in order to study a particular element. In this sense, the cohort becomes a homogenized group of “non-individuals,” the very antithesis of personalization! In Integral theory, this approach to care would be called single quadrant thinking. There is not much room for real people with complex differences and confounding variables in this kind of scientific model of care. The era of the “e-patient” I have had the great pleasure of occasionally teaching medical residents in training. I have noticed over the years that the residents are quite skilled at treating the “e-patient,” the compiled electronic record with various test results that represent that individual. But the e-patient is not the patient. I recall a story of a patient quite dismayed when the specialist she had travelled from a foreign country to see, never made eye contact with her while he focused on his computer the entire visit! I view Precision Medicine as another step down the path of a more sophisticated e-patient and consequently, a more dehumanizing approach to care. I don’t know about you, but I do not want to be reduced to a genetic profile as the basis behind my enhanced medical care. On this last point, one of the biggest dangers of Precision Medicine is how the information derived from genetic profiling can be misused by insurance companies, drug companies, and even marketing companies. At the very least, we need to be wary of what this potentially represents. It’s not all good and not all bad so much as a mixture of both. Hopefully you are now better informed about this taxpayer funded Precision Medicine Initiative and the potential benefits and pitfalls. Integrally yours, Dr. Vic Victor Acquista MD is an international speaker, author, teacher. For information on his writings, presentations, and workshops visit http://victoracquista.com/.