The golden pyramid of precision medicine implementation
In many disease areas, precision-medicine is already becoming the norm - but when are we going to begin the conversation about ‘precision-prevention’? In many ways, they are two sides of the same coin.
Last week, I had the pleasure of attending the BiotechX conference in Basel, Switzerland. A collection of many of the brightest minds in the healthcare industry offering fresh perspectives on novel drug discovery, research, and personalised medicine.
A great place to go if you want to feel intellectually inferior!
A frequent discussion was around the use of traditional diagnostic measures (like biomarker analysis or genetic testing) to offer patients information about their potential risk for disease, years before the actual diagnosis. The intention of this would be to offer some kind of intervention that could be leveraged to reduce the probability of progression or the condition ever occurring.
This sounds like a brilliant idea on the surface, but it raises an interesting ethical dilemma.
For example, if I could tell you that you were at a high risk of developing breast cancer in the next 10 years, or were likely to suffer from a neurodegenerative disorder, like ALS - would you want to know? Would you know what to do with that information? And importantly, should I tell you?
My immediate answer to this question was a resounding yes. I thought “patients have a right to know”, right?
In the first example, women with the faulty BRCA1 gene, have a 65%-79% lifetime risk of breast cancer (1) - and therefore many opt to have a preventative mastectomy (the surgical removal of the breasts) to mitigate that risk. Unfortunately, in the case of ALS (also known as Motor Neurone Disease), if you are unlucky enough to carry multiple copies of a deterministic gene, there is little we can do (at this time) to affect the terrible eventuality of disease onset.
In other (less severe) diseases, like obesity, many genetic variants have been demonstrated to influence an individual’s predisposition to excess weight gain. Like the FTO gene, in particular rs1421085 and rs9939609 (2,3), are highly correlated with adiposity, body mass index, obesity risk, and type-2 diabetes - which means, in theory, that we can assess an individual's overall probability and risk of developing the disease and implement strategies to combat that prospect over their lifetime.
This raises another interesting set of potential issues:
By providing this information, in many ways we remove the locus of control away from the patient themselves - and in the absence of adequate counselling, they may stray down a path of despondence whereby they feel that no matter what they do, their innate biology will work against them.
How can we adequately convince a person to partake in an intervention when the outcome is not necessarily predetermined? And in theory, when the intervention requires a lifelong commitment?
As someone who works in commercial strategy, I approach these human matters with a business mindset. So, with my commercial hat on, I wanted to share my thoughts on how we - in the precision medicine and precision-prevention industry - can tackle the challenges of implementation. I call this the golden pyramid of precision medicine:
Humans have an innate inability to make appropriate or value-based decisions when the outcome appears too far in the future. Psychologists, economists, and marketers have long been fascinated with the mechanisms of how human beings make choices - and research has made it abundantly clear that at an individual level, decision-making is insanely challenging to predict because it is almost entirely down to context.
Take this example, if I offered you $20 today or $30 in a years-time - which are you more likely to choose?
An economist would tell you that the rational and value-based decision would be the $30 option. However, in practice, very few people select that option because the near-sighted prospect of being $20 richer outweighs the extra 10 bucks over the longer time horizon.
The problem is that most people overstate the value of the present and understate the value of the future.
What if I offered you the same $20 or $100 in a years-time - would your decision be any different to the above?
This leads me to my point, when it comes to providing information to patients about their propensity for developing negative health outcomes - we need to take into account this idea of value-based decision-making. The idea is that, when it comes to health, we already know objectively the right things we should be doing for our health (for the most part) and yet very few people do it. Eat less, move more, etc.
For instance, I know many medical doctors who smoke cigarettes.
In theory, these people should be the most informed individuals on the planet about the potential long-term negative health consequences of smoking, but it doesn’t seem to help them kick the habit. Now, if we could say you may develop lung cancer within the next month - then my presumption is that most individuals would be inclined to quit. This demonstrates my point; information alone is not the answer - we have to create some kind of immediacy around why a behaviour should be taken and reinforced in the current moment.
This is why urgency sits at the base of this hypothetical pyramid because I think it is not only the most important but also the most challenging and complex problem to address.
Another classic marketing buzzword, particularly in the world of SaaS (Software-as-a-Service), is the concept of ‘stickiness’ which describes the tendency to gain repeat business from the same customer. Stickiness determines the likeliness of a customer “sticking” to your brand by making a purchase more than once (7).
Many factors go into your brand’s stickiness, including product quality, pricing, convenience & customer experience - and as marketers, it’s important to understand how sticky your product or business is if you want to gain insight into why a customer is continuing to use your services. The difference between this and simply customer retention is that ‘stick’ demonstrates the perceived value a customer sees in your product or service.
This ties in pretty closely with friction (as you’ll read below) because to an extent, friction is an element that can affect how ‘sticky’ your product or service is - but it requires separation because friction alone does not entirely determine how likely a consumer is to stay with you.
But how can we apply this to healthcare and more specifically, precision medicine?
Maintaining our health requires a life-long commitment.
So naturally, the solutions we implement have to be congruent with that. My view, which I believe we all share, is that the current healthcare system will require a shift from the reactive model, to a proactive approach. Here are a few of the ways I think about making a health solution (like a nutrition plan, supplement, medicine, or exercise regime) more ‘sticky’:
Personalize the solution - people are much more likely to engage with products that appear to be designed for them, a Mckinsey & Company report showed that 78% of customers are more likely to make repeat purchases from a company that personalizes (8).
Provide immediate and regular incentives - as discussed above, a health solution needs urgency to be successful. Therefore, if there is a demonstrable short-term benefit to your product or service, it is much more likely to be maintained. This could be implemented through the gamification of a digital health solution - or perhaps through some sort of financial incentive. For the sake of argument, individuals who partake in certain behaviours could be rewarded through discounts, access to additional services, or tax/national insurance deductions - though this does begin to get dangerously close to some kind of Orwellian existence!
But when you think about it, considering one person costs the NHS around £500,000 over their lifetime (9) - by implementing a solution that could reduce that figure by say 25%, you could see a world where consumers or patients are actively rewarded by society by taking positive actions in pursuit of better healthspan.
In the business world, friction is anything that causes your customer to hesitate as they move through (or completely leave) your conversion funnel or your company (4). Put simply, friction is resistance. What do I have to invest in the product as a customer to achieve the desired outcome? This ‘investment’ can come in many formats; monetary, time, solution quality, etc.
For a product or solution to be adopted at a wide scale for a significant period, it must be low friction.
If we can provide a medicine or nutritional product that can reduce the chances of an individual developing a health condition in the long-term and requires little effort/investment on behalf of the patient to partake in, then there is a much higher chance of adoption.
This is demonstrated by the data surrounding poor adherence to restriction dieting in humans. Research has consistently shown that when you limit food selection, adherence to the diet is reduced (5). However, by introducing less friction into the equation by allowing for an occasional indulgence, as demonstrated by this study in the Journal of Consumer Psychology, one can facilitate considerably better long-term goal adherence.
To summarise, not only are there incredible challenges associated with the development of precision medicines but there is also a major hurdle surrounding how best to implement such solutions when they actually arrive for patients and consumers.
The fact of the matter is though, that it's worth it. Because once we get to the point where we have products or services that are low friction, high ‘stick’, and can effectively communicate the urgency of their requirement - then the consumers, the producers, and the health systems to which they belong, will all benefit.
Written by Theo Wiley, Founder of Wiley Nutrition, & Commercial team at Sano Genetics
These views are the explicit perspective of the writer and do not reflect those held by the organisations to which they are associated.