How do you define “health?” What are the metrics that prove one is healthy? And how do you personalize healthcare to best suit each individual patient?
These were some of the questions raised by Dr. David Agus, well-known physician and popular author, when he spoke at the Cleveland Clinic’s Ideas for Tomorrow speaker series.
Agus, who contributes frequently to CBS News health coverage, is viewed by some as controversial, Cleveland Clinic CEO and president Dr. Delos “Toby” Cosgrove said in his introduction. Agus takes a “holistic view” of illness and healthcare that takes into account lifestyle data, Cosgrove said. And that involves using a variety of data to pursue more personalized treatments for patients.
Healthcare should be about “delivering the right treatment – or no treatment – to the right person at the right time,” Agus told the crowd. With technological advancements and good data, providers are continually inching closer to the ideal of truly personalized medicine.
Big data studies can reveal links between illnesses and potential causative or contributing factors that biology can’t see, Agus said. He cited two examples:
- A study unexpectedly discovered women with ovarian cancer who took beta-blockers lived an average of 4 years longer than those that did not.
- Another study stumbled upon a correlation between people living close to airports and brain decline, indicating a potential link between quiet, restful sleep and brain health
While neither study by itself changes healthcare’s approach to treatment, they both provide hard data that indicate promising directions in which research should continue, he said.
To further illustrate his point, Agus discussed a 1950s study — dismissed by many at the time as ghoulish — in which an older rat was stitched to a younger rat to join their circulatory systems. When the blood from the younger rat entered the older rat’s system, the older subject began to exhibit more youthful-looking tissue. It took another half-century before researchers returned to this study to examine if the same concept could revitalize stem cells.
“At age 25, stem cells go to sleep,” Agus said, “but what if we could wake them up again … Cancer in kids is 90% curable. After age 25, it’s not. If we could trick the body into thinking it was younger, it could heal.”
This study, Agus noted, contributes meaningful data that could actually develop into life-saving treatment. The value of the data was obscured by the immediate reaction to the initial experiment.
Without data to back up treatment decisions, we may ultimately be causing patients more harm than good, Agus said. Provoking many a concerned murmur in the audience, he noted that there have been 63 randomized, controlled studies on multi-vitamins and supplements, and “not one showed any benefit.” Historically, society has jumped to act on anecdotal evidence when it comes to healthcare, he said, and that often causes more long-term harm than good. Later in response to audience questions on the matter, he added, “I’m not against supplements. I’m against decisions without data … as soon as there’s data, I’ll be behind it.”
Take a closer look
When it comes to treatments, data shows that “environment matters,” Agus said. Not just the environment in which the patient lives, but the environment in which the disease or condition develops.
This is a concept that received a major setback due to a 1923 experiment that, Agus asserted, “ruined everything.” The experiment, which coined the term “germ therapy,” led to the common practice of using antibiotics to cure identifiable infections. The problem with this, Agus said, is that this is only appropriate for what he termed “exterior diseases.” An “internal disease,” like cancer, does not grow or function like an infectious disease, as it can be directly affected by its environment.
To illustrate the point, he cited a decade-old study of young women with breast cancer receiving hormonal therapy. Half of the patients also received bone therapy usually used to treat osteoporosis. The women receiving bone strengthening therapy alongside hormone therapy saw a 36% decrease in risk of metastasis. This, he explained, is because breast cancer metastasizes into bones, where it “grows.” The osteoporosis therapy wasn’t a cure, “but we changed the soil,” Agus said, thus changing how and whether the cancer grew or thrived.
Agus tossed out several examples of times where new studies or second looks at data altered thinking on common medical and healthcare practices:
- Appendicitis — There are approximately 300,000 appendectomies performed every year, but five studies performed in Europe in 2015 found that 70% of test subjects treated only with antibiotics never required surgery and had no complications.
- Alzheimer’s Disease — Agus noted that studies show that the incidences of Alzheimer’s decrease with every year a person delays retirement. “So, the adage, ‘If you don’t use it, you lose it,’ is probably correct.”
- Diabetes — An experiment showed that incidences of diabetes increased with use of artificial sweetener. While that may not be a surprise, Agus noted that subjects who were treated with antibiotics did not show any increase in diabetes, despite the artificial sweetener. It raises the question of what bacteria in our bodies might be contributing factors to developing diabetes.
With new discoveries occurring daily, it may necessitate changes in ethical approaches, Agus said.
As an example, he brought up the BRCA1 genetic mutation that can be a predictor of breast cancer. When the mutation was initially discovered, it was patented by a private company (prior to the Supreme Court’s 2013 decision barring patents on human genes), and the test to find it was priced exorbitantly. That, he noted, slowed the development of breast cancer treatments while women died without having simple access to this potentially life-saving information.
This raises the ethical issue of if potentially life-saving healthcare services should be made readily available despite private interests. And, Agus asked, when it comes to gene alterations, who decides what’s right?
“It can’t be national,” he said of a potential governing body for these advances. “It must be global.”
He also asked if it is ever ethical to hold patients responsible for their own illnesses. Agus noted that regular colonoscopies help prevent 90% of colon cancers. However, if a patient skips their tests and develops colon cancer, it will likely cost their insurance company or the government around $160,000 to cover their treatment. Agus posed the question: Should that individual have to pay out of pocket for his lack of compliance when accessible preventative medicine could have averted the issue?
Agus has had occasion to push his personal ethical viewpoint up against current regulations. He shared a story of his work studying a new drug for patients with advanced lung cancer. His studies showed a 70% survival advantage for patients taking the drug, but when it came time to perform the placebo trials mandated by FDA to achieve approval, he refused, saying he couldn’t knowingly put patients at risk by giving them a placebo.
Leveraging his prominence in the media, Agus told his story to the Wall Street Journal in a provocatively titled article that effectively pressured the FDA into approving the drug.
Agus concluded by looking forward at important factors that he believes will impact the development of more personalized medicine and improved health:
- Proteomic profiling
- Genetic sequencing, which has decreased thousands of dollars in cost to the patient since it was first introduced in the 1970s
- Continuing studies of microbial cells, which he said outnumber human cells 10:1
- Further studies of environmental factors on health. Agus cited a study that showed Chinese-born immigrants to the U.S., after a decade in the States, began to exhibit the same significantly elevated prostate and breast cancer rates that Americans exhibit over Chinese patients.
- Technology advances to facilitate personalized medicine
“Hopefully I stimulated you to think a little differently about the concept of what health is and what technology is when applied to health,” he concluded.
David B. Agus, MD, is a professor of medicine and engineering at the University of Southern California Keck School of Medicine and Viterbi School of Engineering and heads USC’s Westside Cancer Center and the Center for Applied Molecular Medicine. He has published three books and frequently appears on CBS News.