Citizen Tribune

CITIZEN TRIBUNE

Health

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Tuesday, October 24, 2017

Millions die suffering amid global opioid gap, report says

WASHINGTON (AP) — Near-

ly 26 million people around the

world die each year with serious

suffering in part because of a huge

gap in pain relief: The U.S. may

be awash in opioid painkillers, but

they're rare or unavailable in doz-

ens of poor countries, says a new

report.

The challenge is to improve pal-

liative care in low-income coun-

tries while avoiding mistakes that

led to the U.S. addiction crisis.

The report to be published Fri-

day in The Lancet says one key

is using off-patent morphine that

costs pennies a dose — not profit-

able for drug companies that push

pricier, more powerful opioids in

rich countries, but critical to eas-

ing a health emergency.

In some places, even children

dying of cancer or children in

treatment for cancer can't get pain

relief, said University of Miami

professor Felicia Knaul. She co-

chaired a Lancet-appointed inter-

national commission that spent

three years studying the disparity

and what she calls "the moral ob-

ligation" to help.

"This report finally gives voice

to the suffering and a roadmap to

governments," Knaul said.

Of the few hundred tons of

morphine and equivalent opioids

distributed worldwide, less than 4

percent goes to low- and middle-

income countries, the researchers

reported.

How much is needed? The Lan-

cet Commission provided the first

global estimates of the need for

palliative care, defined as "seri-

ous health-related suffering" from

certain life-threatening condi-

tions, including cancer, HIV and

trauma.

Some 2.5 million children are

among the annual count of nearly

26 million who die without ad-

equate relief, the team calculated.

Another 35.5 million people a

year have serious pain and suf-

fering from those conditions but

aren't dying, and most live in low-

or middle- income countries.

The world's poorest countries

have access to enough morphine

to meet less than 2 percent of their

palliative care needs, the report

found. India fares little better, at

4 percent; China meets 16 percent

of its need, and Mexico 36 per-

cent.

The 2010 earthquake in Haiti

highlighted the scarcity, as doc-

tors lacked opioids for people who

were severely injured or needed

surgery, the commission noted.

Beyond painkillers, the panel

urged health systems to make

available an "essential pack-

age" of palliative care services

that also includes medications to

ease breathing problems, muscle

spasms, complications of heart or

liver failure, and depression and

psychological suffering. The list

also includes practical equipment

like pressure sore-reducing mat-

tresses, adult diapers — and a lock

box for any needed morphine.

The Lancet panel looked to les-

sons from the U.S. opioid crisis,

and from Western Europe, which

has avoided similar abuse thanks

to strict opioid monitoring and

to universal health coverage for

non-opioid treatments for chronic

pain, said report co-author Dr.

Lukas Radbruch, a palliative care

specialist at Germany's University

of Bonn.

Among the recommendations:

-Countries should use cheap,

immediate-release oral and inject-

able morphine for severe pain.

Closing the pain gap would cost

$145 million.

—Don't allow drug company

marketing to patients, physicians

or other health care providers. In

the U.S., prescriptions soared af-

ter marketing of newer opioids for

less severe types of pain.

—Closely monitor morphine

supply, and train health workers

in proper pain treatment.

The $1.5 million study was

funded by the University of Mi-

ami and Harvard University and

with grants including from the

U.S. National Cancer Institute,

American Cancer Society and

drug maker Pfizer. Another drug

company, Roche, provided a grant

to help the University of Miami

disseminate the findings.

One specialist who has long

warned that the U.S. addiction

crisis could spread internationally

said the proposal for poor coun-

tries to avoid patented opioids was

a "sensible" approach.

Still, "I wish they had included

a stronger warning regarding the

risks of a pain management agen-

da being co-opted by profit-seek-

ing pharmaceutical companies as

it was in the United States," said

Stanford University psychiatry

professor Keith Humphreys, who

wasn't involved in the Lancet re-

port.

SAN DIEGO (AP) —

Doctors were just guessing a

decade ago when they gave

Alison Cairnes' husband a

new drug they hoped would

shrink his lung tumors. Now

she takes it, but the choice

was no guesswork. Sophisti-

cated gene tests suggested it

would fight her gastric can-

cer, and they were right.

Cancer patients increas-

ingly are having their care

guided by gene tumor

boards, a new version of

the hospital panels that tra-

ditionally decided whether

surgery, radiation or chemo-

therapy would be best. These

experts study the patient's

cancer genes and match

treatments to mutations that

seem to drive the disease.

"We dissect the patient's

tumor with what I call the

molecular microscope," said

Dr. Razelle Kurzrock, who

started a board at the Univer-

sity of California, San Diego,

where Cairnes is treated.

It's the kind of care many

experts say we should aim

for — precision medicine,

the right drug for the right

person at the right time,

guided by genes. There are

success stories, but also

some failures and many

questions:

Will gene-guided care im-

prove survival? Does it save

money or cost more? What

kind of gene testing is best,

and who should get it?

"I think every patient

needs it," especially if can-

cer is advanced, said Kurz-

rock, who consults for some

gene-medicine companies.

"Most people don't agree

with me — yet. In five years,

it may be malpractice not to

do genomics."

Few people get precision

medicine today, said Dr. Eric

Topol, head of the Scripps

Translational Science Insti-

tute. "The only thing that's

gone mainstream are the

words."

HOW IT WORKS NOW

If you have a cancer that

might be susceptible to a

gene-targeting drug, you

may be tested for mutations

in that gene, such as HER2

for breast cancer. Some

breast or prostate cancer pa-

tients also might get a multi-

gene test to gauge how ag-

gressive treatment should be.

Then most patients get

usual guideline-based treat-

ments. If there's no clear

choice, or if the disease has

spread or comes back, doc-

tors may suggest tumor

profiling — comprehensive

tests to see what mutations

dominate.

That's traditionally been

done from a tissue sample,

but newer tests that detect

tumor DNA in blood — liq-

uid biopsies — are making

profiling more common. The

tests cost about $6,000 and

many insurers consider them

experimental and won't pay.

Gene tumor boards ana-

lyze what the results suggest

about treatment. They focus

on oddball cases like a breast

cancer mutation in a colon

cancer patient, or cancers

that have widely spread and

are genetically complex. The

only options may be experi-

mental drugs or "off-label"

treatments — medicines

approved for different situa-

tions.

But as tumor profiling

grows, it's revealing how

genetically diverse many

tumors are, and that oddball

cases are not so rare, said

Dr. John Marshall. He heads

the virtual tumor board

at Georgetown Lombardi

Comprehensive

Cancer

Center that also serves can-

cer centers in Pennsylvania,

North Carolina, Michigan

and Tennessee.

"There is a little bit of

faith" that testing will show

the right treatment, but it's

not a sure thing, said Dr. Lee

Schwartzberg, who heads

one participating center,

the West Cancer Center in

Memphis.

Dr. Len Lichtenfeld, the

American Cancer Society's

deputy chief medical officer,

is optimistic yet wary. Drugs

that target BRAF mutations

work well for skin cancers

called melanomas, but less

well for lung or colon can-

cers.

"Just because a mutation

occurs it doesn't mean that

drug is going to work in that

cancer," he said.

LUCKY CASES

When it does, results can

be dramatic. Cairnes' can-

cer was between her stom-

ach and esophagus, and had

spread to her liver, lungs and

lymph nodes. Tissue testing

found 10 abnormal genes,

but on the liquid biopsy only

EGFR popped out as a good

target.

Two drugs aim at that

gene but aren't approved for

her type of cancer. A tumor

board advised trying both

— Erbitux and Tarceva, the

drug her husband also had

taken.Within two weeks, she

quit using pain medicines.

After two months, her liver

tumor had shrunk roughly

by half. There are signs that

cancer may remain, but it is

under control. She feels well

enough to travel and to take

care of her granddaughter.

"I'm very, very grateful

to have a targeted therapy,"

Cairnes said.

"I cannot expect a better

outcome than what we're

seeing right now," said her

doctor, Shumei Kato.

WHAT STUDIES SHOW

But is gene-guided treat-

ment better than usual care?

French doctors did the first

big test, with disappointing

results. About 200 patients

with advanced cancer were

given whatever their doc-

tors thought best or off-label

drugs based on tumor profil-

ing. Survival was similar —

about two months.

Another French study, re-

ported in June, was slightly

more encouraging on sur-

vival but exposed another

problem: No drugs exist

for many gene flaws. Tests

found treatable mutations in

half of the 2,000 participants

and only 143 got what a tu-

mor board suggested.

Some doctors worry that

tumor boards' recommend-

ing off-label treatments di-

verts patients from research

that would benefit all can-

cer patients. For example,

the American Society of

Clinical Oncology's TAPUR

study tests off-label drugs

and shares results with their

makers and federal regula-

tors.

LETTING PATIENTS

CHOOSE

Ann Meffert, who lives on

a dairy farm in Waunakee,

Wisconsin, endured mul-

tiple standard treatments that

didn't defeat her bile duct

cancer.

"She was going to be re-

ferred to hospice; there was

not much we could do,"

said Dr. Nataliya Uboha,

who took the case to a tu-

mor board at the University

of Wisconsin-Madison. The

panel gave several options,

including off-label treat-

ment, and Meffert chose a

study that matches patients

to gene-targeting therapies

and started on an experimen-

tal one last October.

"Two weeks in, I started

feeling better," she said, and

when she saw test results, "I

couldn't believe the differ-

ence."

Many lung spots disap-

peared and the liver tumor

shrank 75 percent. She is

not cured, though, and doc-

tors are thinking about next

steps. And that could involve

a fresh look at her tumor

genes.

Gene tumor boards

guide cancer care

Ultra-personal Therapy

Cancer patient Alison Cairnes poses for a portrait at the University of California San Diego

in San Diego, Calif., on Aug. 15, 2017. Doctors were just guessing a decade ago when they

gave Cairnes’ husband a new drug they hoped would shrink his lung tumors. Now she takes

it too, but the choice was no guesswork.

In this Aug. 17, 2017 photo, doctors, pharmacists, geneticists and oth-

ers meet to discuss how to best treat cancer patients at the University

of Wisconsin Carbone Cancer Center in Madison, Wis.