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The Problem With Personalized Medicine 216

gManZboy writes "Talk of individually tailored medical treatment isn't pie in the sky. This approach eventually will help us address risk factors even before a disease can invade our cells, and detect preclinical disease before it gets out of hand. What role will medical informatics play in this brave new world? Hint: Little data projects may be as important as big data projects such as gene sequencing. At a recent symposium on personalized medicine, Ezekiel J. Emanuel, MD, chairman of the Department of Medical Ethics and Health at the University of Pennsylvania, questioned whether it would make more sense to target all the lifestyle mistakes that patients make rather than analyze genetic defects. His view: 'Personalized medicine misses the most important fact about modern society--little ill health and premature death is genetic, much more is lifestyle and social.' Is Emanuel a dinosaur or a pragmatist?"
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The Problem With Personalized Medicine

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  • by Anonymous Coward

    Everybody knows this, but medicine is a business first. Excuses sell better than solutions. End of story.

  • He is just a sane and honest man. It is no coincidence that in some areas live people more than 100 years without any medical treatment, and snacks, and chips, and coke, and GMO (as a matter of fact), and ......i arrested my case.
  • The preclinical diagnostic power suck.

    That is why this is not a good route.

    Diagnostics even in the clinical stage is not often very well founded, unless you have a broken leg or something to that effect. Psychological disorders are really, really difficult to diagnose with decent accuracy, and therefore should never be treated a preclinical stage.

    A can of worms or a jar of pills?

    • by Belial6 ( 794905 )
      Psychological disorder diagnosis gets even worse when you consider that as frequently as not, being PC is used as a diagnosis method.
  • Part of the question is CAN it really be effectively changed by lifestyle changes over a whole population?

    It's easy to say "eat less fat, and fewer calories and it will be better". We hear that all the time. Exercise more. No alcohol to excess.

    But, actually getting people to follow it in a sustainable way hasn't happened in many cases.

    When you have a method that well work, but you can't get people to follow, it's not very effective.

    In some cases, drug interventions are more likely to be followed. Take a loo

    • Have you seen any FAT lion??? I wonder why not!!!
      • by Hartree ( 191324 )

        Because though there is an illusion of freedom in the wild, lions are strictyly hemmed in by mother nature in terms of calories.

        They have to compete with other predators whose territories surround theirs and the reality that they can only harvest so much food and not deplete their territory. That's why there hasn't evolved such a strong ability to limit intake. It's mandated by the physical environment in animal societies.

        Do you really want a society where caloric intake is strictly regulated by physics (or

    • Last year I was told that I should have my gallbladder taken out. Instead I changed by diet. I became a full vegetarian and use olive oil instead of vegetable oil and olives instead of fish. I eat a lot more raw fruits and vegetables now and I still have my gallbladder.
      • by Hartree ( 191324 )

        Indeed. It worked. What worked was one of the most effective ways of changing behavior there is. Fear.

        But, as I mentioned in another post, just relying on fear is limited. We've been getting out the word on obesity for decades. But, it's not producing fear in sufficient amounts to broadly change behavior. Our minds adapt to the situation, and we have an amazing ability to rationalize. Those traits served well in an animal environment where calories were limited by the environment. If there was excess food,

        • by Belial6 ( 794905 )
          You are wrong about that though. While we have been getting the word out on obesity for decades, we have also seen HUGE changes in behavior from it. The problem is that much of the advice is counter productive, and a major reason for people getting heavier.

          First, the normally accepted definition of "obese" is stupid to begin with. This is what is considered obese by our government/medical/insurance industries: []

          That's right. 100% of the time that
    • You can get people to take a pill a day more easily than giving up the cheeseburgers.

      Then why not bring back Ayds? Unlike AIDS, Ayds was a safe and effective appetite suppressant candy that one would eat before a meal to decrease one's desire to "has cheezburger".

      • If it worked that well, it's hard to believe they deep-sixed the product rather than just change to a new name (Gee, going from "Ayds" to "Diet Ayds" didn't break the memetic connection to AIDS? SHOCKER!).

  • by fuzzyfuzzyfungus ( 1223518 ) on Friday January 20, 2012 @10:48AM (#38761090) Journal
    Arguably, targeting things like lifestyle factors is also "personalized medicine", in the sense that treating patient X specially because a defect in their homozygous foo allele predisposes them to cardiac disease isn't all that different from treating patient X specially because getting no exercise predisposes them to cardiac disease.(and, in uncomfortably-many-but-not-all cases, the "personal" element is just the most visible factor in a stew that includes environmental and social influences, like diesel soot and cube farms...)

    I'd be inclined to say that Emanuel is neither a dinosaur(he isn't rejecting the new-and-shiny out of hand, just pointing out that much of it offers questionable bang-for-buck compared to the low hanging fruit offered by seriously boring lifestyle stuff), nor a pragmatist(y'know why people like to ignore lifestyle factors and focus on genetic whiz-bangs and hypothetical personalized super-pills? Because lifestyle intervention lies dead at the center of the intersection of "really boring", "really hard", and "lousy patient compliance".

    We already have plenty of good advice to go around(by no means perfect knowledge; but we know much better than we do), largely unheeded and often coexisting with social conditions that actively work against heeding it. We don't actually have personalized genetic-super-pills(with limited but important exceptions: oncology, for instance, has a number of genetic markers that have proved tractable to test for and highly useful to know. Some rare hereditary disorders have also been well worked up. Much of the rest of it remains in the "yeah, it sure does appear to run in families; and we made this mouse model by tweaking the genes like so; but that doesn't help you very much...); but we could probably get people to take them fairly regularly if we did...
  • by fish_in_the_c ( 577259 ) on Friday January 20, 2012 @10:50AM (#38761120)

    One of the things 'personalized' medicine addresses is the 'well that's not me' factor that is in may people mind.
    The reality is that a percentage of people in the population will never need to worry about cholesterol problems and the knowledge that such people exist allow others to live in the illusion that they may not have to worry about it either.
    Personalized medicine will allow the Dr, to tell a person YOU need to not 'X' or you will have 'Y' happen.

    The problem however is that it is always a percentage game. Some of the genes we have found so far increase a persons chances of developing a certain type of cancer by 1 or 2 %. So is that enough to warrant changers in behavior.

    People who work in computers for a living already know that their carrier choice raises their cancer risk by something like 20% ( how many of them left their careers because of it though).

    Part of the problem is understanding the risk ... and them excepting the consequences if they show up.
    ( are we allowed to do that anymore !!)

  • by Anonymous Coward on Friday January 20, 2012 @10:52AM (#38761148)

    Emanuel is right, but experience tells us that people don't want straight-forward advice about not eating deep-fried butter or exercising more. They want to do it anyways and be saved by medicine when it catches up to them.

  • He's right, it would be vastly more effective (not to mention cost-effective) to address the lifestyle risks.

    Now: for a quick assessment of his chances: how many of us are sitting around on our butts reading /. instead of getting some exercise?

    Yeah, I thought so. Maybe the genetic screening is worth doing after all.

  • It is easier to "sell" (as in commercial, or even simply convincing) some treatment against a silent potential killer in your gene, than asking you to change your habit (stop smoking, drink less, ...) for an actual killer in your lifestyle. Same thing happen for about anything: people are scared of terrorists, but do not driving or even go boozing in high criminality area.

    People do not give a shit when they are in charge, so in practice, short of making lifestyle change mandatory by law, you can only rea

  • ...targeting lifestyle "mistakes"

    Doesn't that sound like a conveniently vague catch all for justifying corporate or governmental control over people?

    • ...targeting lifestyle "mistakes"

      Doesn't that sound like a conveniently vague catch all for justifying corporate or governmental control over people?

      I'm sorry Citizen, but your statement fails to inspire happy-happy, joy-joy feelings in everyone around you.

      Please remain at your present location and await a Protect-Serve patrol that will assist you by transporting you to the nearest Community Adjustment Center to modify your outlook and behavior so as to inspire happy-happy, joy-joy thoughts in yourself and those around you.

      Failure to comply may result in a minimum 70 year stay at the nearest cryo-prison facility where you will be subliminally re-educat

  • by Samantha Wright ( 1324923 ) on Friday January 20, 2012 @11:02AM (#38761290) Homepage Journal
    ...Emanuel seems to be missing it by a mile.

    This field is for dealing with the little ugly gaps that neither broad pharmacology nor lifestyle adjustment can correct. Take the case of antidepressants, for example: they're extremely finicky (not all work in all people) and have a huge cost in side-effects before the benefits arise. It is an extremely high cost to both the patient's health and the support system to cope with a bad choice of antidepressant. The basis of this fickleness is genetic, and running the right test in advance can prevent bad combinations.

    Personalized medicine is not a cure-all, it's a very precise tool in drug design and selection. I'm sure that won't stop lazy physicians and marketers from calling the regular diagnostic process "personalized," though.
    • But maybe it can lead to better knowledge of what lifestyle factors matter to an individual. This idea that there is the One True Lifestyle is just as silly as the idea that one drug works for all. Different people have different things they need and so on. This would be why there are those people who can drink and smoke and not exercise all their life, and yet live to a ripe old age (my grandpa is one of those). For most people, those choices are harmful, for some that matter little to not at all.

      Or things

  • by Idou ( 572394 ) on Friday January 20, 2012 @11:06AM (#38761354) Journal
    There are examples of people who have been very absusive to their bodies and yet lived long, healthy lives (Ossy, anyone?). There are other people who seem to be cautious enough, yet deal with various health issues. Having better information up front about one's own genetic risks allows for better decisions based on reality, not "professional" opinions founded on years of "experience" of observing the outputs of a very complicated black box by your doctor.

    Bottom line, DNA is the source code of how our bodies work. Some may think it is pretty useless at this point, but we will only truly understand its value once we understand it. Most of science works like this . . .
    • the big problem with DNA = Source code for person = Absolute Gospel on That Person is one of those simple/complex things

      Even if you have source code delivered as a set of QRcodes engraved on Gold tablets by Angels you still need to worry about

      1 the developers "stack"
      2 the System it is run on
      3 what other programs are running on The System
      4 versions of various system libs installed
      5 Power and other Environmental concerns

      Hitlers Own Superman would still drop dead at 13 if he was not fed correctly and given a d

  • all jobs needs paid sick days as some places make sick people come in to work and even with paid sick days to many boss have the suck it up idea and that just get's the full office sick. In foodservice this get's others sick as well.

  • by RandCraw ( 1047302 ) on Friday January 20, 2012 @11:36AM (#38761700)

    The goal of personalized medicine is to identify which genomic pattern in a population will respond to a given drug, or identify which drug will work for a given person's genome. It has nothing to do with improving public health policy and only tangentially with reducing health care costs. It has a lot to do with reducing time-to-treatment and making drugs more efficacious.

    Emanuel is right that it's nuts to waste money on gene-based treatments which target only the symptoms of disease, when fixing the disease itself necessarily requires a change in lifestyle, which is something that technology cannot and will not fix. Once we accept this, the next step is simply, "How"?

    All western countries are healthier than the US. Let's start by looking at what they're doing and then reward americans for doing more of that.

  • Dr. Emanuel's thinking seems right on this; there's evidence that "genetics only account for approximately 20 to 30 percent of an individual's chance of surviving to age 85." (see Scientific American []) Maybe rather than provide cures, personalized medicine could be used to give people a more accurate estimate of how long they're going to live, based off various lifestyle decisions. Nothing motivates like a deadline.

  • Is Emanuel a dinosaur or a pragmatist?

    Of course, the submitter left off the fact that he might be neither a dinosaur nor a pragmatist. Rather, he could be quite correct in his assessment.

  • Honestly, if you do the things you do you've decided that the perks outweigh the disadvantages. If you decide that gorging at McDonald's is better than eating a salad, that's a choice. If you decide a night out on the down getting seriously drunk or high is worth it, it's a choice. As long as I've paid plenty money in beer taxes and you can probably chop a year or two off my pensions relative to the healthy guys to cover any alcohol related injury or illness, what business is it to anyone else if I choose t

  • Any person with a single serious disease has to get personalized medicine.

    I am constantly bombarded by idiots telling me things like "eat less carbs", but my personal medical issues makes eating more protien worse for my body than eating carbs.

    ALL medicine should be personalized - not just for your genes, but for your particular conditions.

"This is lemma 1.1. We start a new chapter so the numbers all go back to one." -- Prof. Seager, C&O 351