#109: ENCORE Breakthroughs in Cancer Research with Dr. David Hong
This is an encore presentation of healthcare rounds. Today, we are rebroadcasting episodes forty four and forty six with Dr David Hong Associate Vice President of Clinical Research at MD Anderson Cancer. Center. This episode was originally uploaded on April eleventh two, thousand and nineteen. Welcome to healthcare rounds the podcast serving you the INS and outs of health policy and business topics as well as our take on the rapidly evolving healthcare delivery ecosystem. I'm your host John Marceca Co Darmon Research Group and faculty associate at the W. T. Carey School of business and the College of Health Solutions at Arizona State University. This week I'm speaking with Dr David S Hong Deputy Chair of Investigational Cancer Therapeutics at the University of Texas MD Anderson Cancer Center. Where he also serves as associate vice president for clinical research and clinical medical director of the clinical. Center for therapy. Dr Hong received a bachelor's degree in biology, from Yale University and a medical degree from Albert Einstein, college, of medicine, he completed an internship in residency at Thomas Jefferson University Hospital, and a medical oncology fellowship at MD Anderson during which time he was appointed chief medical. Oncology fellow. In two thousand and five, he joined. MD Anderson's faculty. Dr Hong is the recipient of many awards including the two thousand four young investigator award from the American Society of Clinical Oncology he has published more than two hundred and seventy articles in peer reviewed journals. So To kick US off. Tell me a little bit about your role. Within MD Anderson Oh I am the deputy director of what's called the Department of Investigational Cancer Therapeutics. It's a specific unit within MD Anderson dedicated to doing early drug development studies in cancer, and these studies are really the first in human studies oftentimes phase ones that they have evolved in some sense. over the last several years. but the steps after animal testing. That goes into cancer patients, and so we run that unit or department within the institution and I'm also the associate vice president trump research. And in that role I, I've played a number of different roles Do a number of things. One is one of the important things. I think one of the challenges I. Think Academic Medicine is. You know we have large bureaucratic structures have been trying to get some of these trials up and running as quickly as possible and I'll talk a little bit about that in context of how changing. But also some of these emerging challenges overall in oncology drug development it's it's been a challenge for us here to get trials of growing fast but we we have just recently. Relate implemented some. Key changes as that has. A. Lot to shrink our timelines. And I. Called in a number of things in that role, I help with managing grants, the internal grants that are being distributed to junior investigators and involved in kind of going through our clinical trials process. Here we have a huge number studies. You have close to three thousand files at Anderson Different Trials with our survey or treatment trials in. So a lot of details have to go through. In trying to help manage the infrastructure here at Anderson, which is one of the probably I would argue probably one of the largest in the world. So anybody WHO's watching the pharmaceutical industry has noticed a surge in cancer drug approvals in recent years, and some of these drugs are showing remarkable results and that's one of the reasons that I wanted to speak with you. was to get your insight from a research perspective how and why things have changed and can you talk about what's new in the last five to ten years and why the research landscape is so different today. Good question one you're absolutely right There's been really a record number of. Kinda new molecular entities, orphan drugs, both new and also generics by similar two, thousand eighteen. There was a total of. Oracle seventy six new indications for new drugs in cancer over the last five years and right now There is close to a thousand. Of Thousand Two hundred different agents or new molecular entities in clinical trials as of two thousand eighteen. But that's been that's been growing over the last. Decade. In two, thousand, eight, there was about seven hundred fifty but has been slowly climbing. Now it's close to twelve hundred and why is that? While part of that is too large extent is because we are reaping the harvest of molecular science and investment that has been in discoveries that have been. Implemented, over the last several decades, right At the Hanna Hanna Dot. Weinberg are scientists in college who wrote this a seminal review called the hallmarks of cancer in their first time occasion was in two thousand time they had listed the classic hallmarks, six hallmarks of cancer. But they republished the publication again in two thousand eleven. In the added, an additional four hallmarks cancer. tickly avoiding immune destruction that was one of their emerging hallmarks since then the discovery under pinning of the understanding of how cancer is so destructive has led to ways to target it. So you know I'm in Texas. So we talk about oil a lot, right? Right and We had we had a fracking event in two thousand eleven and that fracking event on that new technology was immunotherapy that was the first time when bloom Mab was approved in. Melanoma. And soon, afterwards, we had a number of. new immunotherapy agents, particular PD one inhibitors that augmented the Anti Taylor for bloom APP that led to obviously even more activity. And also then has emerged other things such as car t-cells, etc.. These numbers are probably out day but as of March of two thousand seventeen, there was close to a thousand one, hundred, twenty, two cancer immunotherapy combination trials while again, this is the individual agents I talked about the twelve hundred agents in two, thousand eighteen. So, there's been really an explosion of new trials new agents. In particular therapy, it's really transformed landscape for cancers that we never. Ever thought were GONNA be amenable immunotherapy such as long such as bladder I. Mean we we had some indication that melanoma was responsive to immunotherapy such as I'll to high-dose too but. those are oftentimes limited in really patients who can tolerate that drug, but these drugs are now. Have some side effects have relatively well tolerated. Third thing beyond the new molecules on immunotherapy in number three as rolling been in parallel to immunotherapy has been just the refinement and the ability to cut have molecular phenotype tumors. and. That's all the way from things like Brca mutations which we knew for a long time. But until just recently had been able to target patients with Bracken ARP inhibitors. And also other mutations that are relatively rare but are truly transformative such as entrance fusions. I was involved in the phase one, but also the New England journal Phase to and kind of. Paper. That was pivotal nor the studies that were pivotal in the approval of colour threatening, which is the first intrigue fusion inhibitor. And what's unique about this approval was that it was approved across all tumor types. irregardless of the type of cancer you had as long as you had entered fusion and so this was really the second type of that was approved What's call independent of histology or tumor type? The I was actually was called. pendulism have won the immunotherapy checkpoint inhibitors in a subset of tumors call MSI high. I'm coining this phrase but I I'm sure if you talk with other experts would say it truly is kind of this golden era of oncology drug development that we haven't seen for a while. So that that personalization that you're talking about I had a I was at a conference in their two doctors one that was. Really strong on clinical pathway development and the other one that was speaking about more the precision medicine, and it was really interesting to see these two different perspectives that they're mutually exclusive. But seeing these these two physicians talk about the advantages of. Ver- either standardization or personalization what are your thoughts on that I agree with you they're not mutually exclusive and I'm both of them are valuable in in many ways I think they will intersect as we become more personalized. So imprecise therapy I think one of the the reason that this is happening more and more is because actually know profiling molecular profiling tumors have become much much cheaper I remember when I was in resident in I think it was Around two thousand, two Francis Collins? Think Bill. Clinton and. Craig venter made an announcement that they was on national. TV. That they had done some Then this incredible, a- profiling of a human, a whole Xm sequencing or whole genomic sequencing of a person's whole genome right and I remember the reporter saying that it was a mere two billion dollars to to make this happen right? In what what they didn't really full tell it was they hadn't done i. think it was only the Exxon's I I may be in criteria, but they hadn't really fully profiled everything. It was they had profiled the vast majority of the genome. In and that technology has gotten increasingly better and cheaper than even silicon chips. You know there's that Moore's law. And you can get online now and you can get your whole xm sequence or a whole genome sequence for like under a thousand bucks. and. So that technology has just incredibly evolved to the point where we are. You know routinely getting that and all of our patients here in the Anderson. Recently made that announcement that they would pay for the mutational profile in there have been some incredible examples like the Lehrer tracking. Of example, that I mentioned to you that truly has shown that the advantages of kind of profiling tumors etcetera. The are still skeptics a the skeptics would argue that only a percentage of the patients were maybe even a small percentage of those patients actually benefit from personalize therapy, but that's an assumption that that's assuming the current technology and. The current drugs will stay the same and obviously that in my opinion is short-sighted, we will develop new drugs and they're all V more knowledge imitations that personalized therapy approach. I suspect will be much more a approach that we can follow, and this is being or out particular lung cancer or lung cancer for example, is really been being sliced into smaller pies as suit targeted therapy. So it's important to note that that that trend in technology impresses will continue and I suspect that. You know five years from now there will be many more targeted therapies, many more patients who may benefit from personalized therapy than than they are right now the vast majority of patients are still Kinda using standard you know chemotherapy in for example, the NC, guidelines are a very good guideline as to how we treat patients all the way from early stage later stage. So they're not necessarily mutually exclusive. I helped develop a something called a pourquoi protocol green tea constitutes member home that's actually a combination targeted therapy plus chemotherapy. Regimen that we we identified high activity and benefit in patients would be Rafi six, hundred, eighty colorectal cancer that has been now incorporated into the guidelines for colorectal cancer, and that is a pathway which on colleges used to make determinations as to how to treat patients. So these aren't mutually exclusive pathways. I suspect though that you know not just five years from now ten years or even further down line there may be even more nuance ways more complex ways in which we. Live pathways, personalized pathways. Whether it's using a guy right and use it utilizing things like whole genome profiling identified drugs that may cause too much Choksi or may Ashley and also benefit. The data that we use in the context of profiling tumors or using a profiling patients is really determine which patients may actually. Benefit rather than which patients may Ashley Gain Toxicity. So all of that is going to be incorporated in the future to make maybe even personalized pathways. So there may be really a convergence of the both of those. Processes. Interesting. I. Noticed. You're actually published MD Anderson actually publishes all of your pathways on on the website. Why find that's remarkable is as part of our research into different institutions I often run into people who I don't know if the word is proprietary, maybe it's third they're secretive about their pathways within their organization which I don't understand. Why that would be the case when certainly MD Anderson is. As I said publishing them for the world. So ahead, a an a recent conversation with another academic institution where many of their docks their careers advancing through research publishing and sometimes. At least according to this person, they struggle to get them to spend time with patients. Obviously MD Anderson is known for world class care as well as being renowned research institution. Do you find it difficult to do both wealthy face the same kind of challenges with your researchers. Yeah, I think I think that's that's an increasing challenge given the current reimbursement environment. But you know if you look at the vast majority of revenue and what you need to kind of cover operating costs think eighty five to ninety percent of that. Still comes from clinical revenue. Don't don't quote me on I. Don't think I know the exact number, but it's around there. Right. So the other like seven percent I think is like is research NCI. I'd sponsors, it's address the other three percent is philanthropy. We know the most academic centers recognize. Where their bread is being buttered Sir they you know continuing push academic. Departments and chairs ensure that they meet their clinical revenues targets, but as a academic institution and in order to attract people are interested in research. US Chair, need to kind of balance. All of that ensure that you know you have some time to do research but I will tell you that it is becoming increasingly more difficult. I mean, I you know if you don't have a grant in some of our departments, you're you know you're seeing patients four days a week, and that's essentially the same same amount of. Clinical effort you put in usually in private practice, you do four days a week in the day off to try to catch up and follow patients in order sets, orders, and stuff like that. Right the challenge though is for an academic senators they can't pay them pay these colleges for pay the physicians as much as they as they will get in private practice, right? So, if you increasingly make it equivalent, you know time that you're spending son doing clinical care as you would do a group practice or outpatient practice without giving them time to research than what incentive is there to stay in an academic institution I've seen that happen with a number of my colleagues who actually graduated from the inner cells which I did went off to academia. Brilliant people who were you know had really promising early careers got lasko CDA's etcetera or ask a young investigator awards but their respective institutions would require them to see a lot more clinical care than they initially signed up for. Eventually, they just said you know what's the point you know and they leave and usually they leave for two areas. One is private practice or industry. I'm seeing more and more colleagues of mine leaving for industry that has pharmaceutical companies etcetera who need on colleges need that these experts that help them develop their molecules. So I don't I don't know the answer. What is the right answer to? How do you make this balance? I think it's a very it's a big challenge for chairs and administrators to try to ensure that academics have some time because you know you can't do research with like. One day a week off I. Really. It's really hard because you know you're spending some of that time already on clinical care follow up with patients at. CETERA. into try to actually write papers, write protocols beyond teleconferences or run a lab it's almost impossible and so you have to give some margin of time to for these researchers but understandably, if these researchers not bringing grants or Rian protocols or funding. Institutions are losing money on every single one of them right? Not entirely sure which direction this is gonNA. End Up going for academic year in the United States, I think there are different challenges particularly if you're outside the United States but I'm seeing more and more trials actually moving outside the United States for a number of reasons one. It's cheaper for drug companies to actually do trials outside the united. States. And to there are more investigators or clinical trial has to know how to run a clinical trial or even even early clinical trials. In Asia in Europe in eastern Europe particularly and so companies are moving towards their so. some of these new novel ages may not become available for patients here in the United States in the future. So finally, just to wrap things up before I got on the call, I saw a New York Times propublica article about a another cancer center where they've had some issues with conflicts of interest in. To comment on on that, you may be aware of it but but rather, how do you partner with industry in? What's Pharma's role as a partner in research in caring for patients? Yeah. That's a really good question. Former is I would argue instrumental at least in the in the clinical aspect of research I think the NIH in the has a very obviously central strong role in preclinical research. and. and to some extent Pharma is having increasingly there. There are needs for affirmative also have increasing role or by TechNet forming biotech role in also preclinical research. Most of the drugs. That are currently approved in the United States was not developed by the government. It was developed by the pharmaceutical industry, the vast majority of new drugs whether it's an oncology. Those seventy-three indications came from drug companies who invested in poured out, argue billions of dollars into research. Now, one can argue I'm not gonNA argue about drug pricing, which is I think complicated her and nuanced here. But part of the reason that they're able to do research is the money that they've poured into this area. We do have collaborations the NCI in doing clinical trials with them but the vast majority of clinical trials are done in this country in the world are conducted by pharmaceutical companies in what what I think Propublica, some of the other ten of venues that are trying to that out this conflict of interest they may or may not realize this is that this research probably would not be conducted if it wasn't for Pharma trying to, you know get drugs approved and investing the money in order to try to get these drugs improved. Clinical trials isn't incredibly expensive endeavor and that's also very complicated reason as to why but you know the numbers ranged from phase ones from twenty to fifty million dollars of phase one, and then you get into large phase randomized phase two can run up to one, hundred million, and then doing an international phase three study can be up to three hundred million. There's debate as to how much this whole process costs. But if you look at the institude Joe, democracy has been working in this area for decades. And their data suggests that capitalized cost that means the cost incurred to get one drug approved, which is usually a a ten percent. Likelihood of a drug, one drug that only one drug out of ten that gets into the clinic gets approved that capitalized cost is probably three billion or more Again, one can debate as to why these drug costs are so high, but without Pharma, the United States government does not have. That kinda cash. To invest in research and getting new drugs out there. So fortunately or unfortunately, that's just the nature of the reality of drug development at this well and Pharma wouldn't be able to implement those trials unless they were in partnership with the the Anderson's of the world right I mean, yes and no increasingly Pharma is moving outside of academia. There's a one of the largest conch proud units in the world or in the United States at least is something called Sarah Cannon Cancer Center and they're not necessarily affiliated with the university. they're part of a C-, a dedicated oncology practice that is really kind of focused on clinical trials in oncology. And they are Juggernaut in oncology trials, but they're not affiliated with any university of any sort and so that that allows them to have low lower overhead costs and also them to have faster implementation clinical trials, which which always leads to decrease research costs. Right. So to date, we know on average from drug getting into the clinic in getting approved still takes about eight years before FDA. approval. Things have gotten faster in the last couple of years but. You know the last paper I read on this still the average was like eight to nine years. and. So if you're for example small biotech. You are burning through incredible amounts of cash to pay for your staff, the clinical trials, etc.. into the faster, you get that up and running and completed the better and so. The Anderson's and Danafarber Casey see they're still very important in the KHL trial infrastructure. But there are other alternatives that drug companies farm are looking at not including Sarah. Cannon. But also outside of the United States. There are other entities now outside the United States that are also doing these kinds of clinical trials. Now, you know the FDA singer their mandate is is that you know long as the data's good right and it's it's been audited and vetted appears good. They're not going to necessarily disapprove a drug because it's not done it in the Enersen caring right? They just WanNa, make sure that the right protocols have been followed in all the essentials of running clinical trial is done properly is essentially. So you're all in competition with each other for those those clinical trials. Right I mean ideally, we should. We shouldn't be in competition, right ideally, we should all be working together towards You know getting these trials up and running and completed for cancer patients but there is some level of competition I would really academic competition but also trying to get slots for patients who are at your institution. I wanted to pick up where we left off on our discussion of Pharma and the cost to bring a drug to market I think you throw to figure something like two billion dollars. That's the number that I've seen something around that, and we're talking offline about the decisions that Pharma companies need to make whether to even enter clinical trials or move from phase one to two. To, three bringing drug markets on every stage of the every step of the way in stages decision needs to be made it go no go decision what are your thoughts on that process and the the issues that people think about when making those decisions? Yeah. That's a really excellent question. So I had that same question to my colleagues in Pharma, and so I actually pitched A. A Educational Session on this very topic and we titled at the art and Science of go no go decisions in oncology drug development. And the reason we titled that is, is because I, it's not a science scientific process, right? There are many different factors that make a decision about whether a drug will move into not only into the clinic but from each step in the process and there were three kind of industry veterans who are part of that educational session. If some of your audience were at a CR, they can log onto the website and actually it was recorded. Nancy Cole, who is was kind of the head biologist or head she scientific officer blueprint biology. She's now consulted for a number of companies institutions. The second person was David fell quite who is the head of early drug development at ems the last person was Sandra Horning who's chief medical officer at Genentech. And so I posed this question to all three of them who how do you make these decisions in each step from the preclinical to the early and late? Nancy. Obviously shared there are a number of key decisions. Is there activity in certain models? Can you actually create a molecule that will have the right stability and characteristics in a clear environment that we can? Can you scale it? Right? Can you make enough drugs so that you can get this into the clinic and what in the context of all of this you know what are your competitors out there? What drugs already in that space Dave had a really interesting perspective. He's a huge fan of economists. Named diversity, who was a behavioral economists? Who won the Nobel Prize in the and and really believed that in complex decision processes you really need clear try to make as much objective decisions as possible outside of your own personal kind of agenda has I think we're all whether it since to some extent in science, but also in complex decision process such as drug development in your all we all have biases right for and Dave has tried at least in his processes still eliminate that by looking at certain. He's actually got an algorithm where he looks at the characteristics of that molecule in clinic. So I in early trials. So does this is their activity is there does inhibit what we think it does in biomarkers a both what's called proximal biomarkers and distant biomarkers, and what level of activity are we seeing is safe for less toxic and human beings all these criteria he kinda posed and he uses somewhat of an algorithm to make to help their team make decisions. Sandra was much more broad and she posed a number of challenges. I think that the industry is facing and that is you know we have gone from this period of scarcity where we had very few drugs and entries can into a clinic now with a huge abundance of new trials and new molecules what's challenging for somebody like Santa? Horning is there is a lot of competition out there. Right? There are at least there's already five approved pd one or Pedia one inhibitors. There's another ten in the in in the space. Where do you go right? There are multiple agents in every single class. How do you proceed? and. So She just post a lot of questions and for them I think how do you navigate the process? In the context of the larger challenges such as patient enrollment research cost. How much is this GONNA cost us to eventually get an approval. I would argue the regulatory framework she brought up the regulatory framework which has has really changed over the last several years and I I give credit to. Our colleagues at the FDA, they've really tried to look at alternative ways to get approved in a way that we hadn't seen before the breakthrough indication histology, agnostic trials, real world data et CETERA. And so I think a lot of what Sandra in one of a large Pharma and so forth are doing is how do you navigate that? How do you best execute your go? No go decisions in that in that environment. So. Yeah. So it is truly I would argue more of an art right now there's not a sign if it was a science and it was easy enough that you you did this and add this and mixed up this and you'd get an approved drug. We'd have a lot more drugs approved, but that's not the case at this time follow up question and this is going to really show my lack of drug knowledge. But in the in the simple what I would call the simple space rather than in the biologics during the cancer space. Let's say blood pressure drugs. In that space, you have your calcium channel blockers. Ace inhibitors are some Alpha blockers. Are Trying to think I'm probably forgetting a few diabetics. and. It's always been my sense that physicians view. The category is the drugs in the category being relatively interchangeable and how this relates to go decisions. As you know, once you hit the fifth ace inhibitor, do we really need a sixth or seven or eight days? And especially in in these days when formularies are tightening up and putting products and preferential position. So my question is, is it different in the world of oncology? Do you view products in a given category as being relatively interchangeable or does it go to our last conversation about? Precision medicine and maybe one particular drug is better than another. That's a really good question. I mean today to most of these drugs are oftentimes approved any specific indication. For example, you know like I said, there's like five different PD, one inhibitors out their PD L. One inhibitors, but each of them have taken different niches, right so for example, value MAB which is PD L. One inhibitor I think AstraZeneca owns at is approved in from a large say which was called the Pacific trial, which was in the context of Ashvin therapy after Chemo Experti- Chemo, radiation radiation in in lung, cancer patients. I'm pretty sure I'm sure that there are other drug companies now like Merck and B. M. S. looking to use that space. But at this point, I don't think you can just ask. Your Insurance Company to add Nivo in that context of that setting. Because these drugs are so expensive right satellite. Change out one ace inhibitor for another right right and some of these drugs have only indications in certain specific disease states. So I think one of the reasons that there's not kind of interchangeability is that these drugs were so expensive and specialty pharmacies are becoming much much more strict about what indications who can use did what setting etcetera etcetera off label use in this country is legal, right? In fact, I think the formation, the FDA, their their intent was never to tell doctors exactly how to use this drug they were initially. Commission to really say drugs are safe right? But but because of the expense of these drugs specialty pharmacies, sherm plans, reckon very strict about how these drugs can be used in not used. And what indications and so I see that being different than just standard other drugs like ace inhibitors. CETERA. What implication. Application does that have for biosimilars? Well so biosimilars will I. Think we'll be increasingly be used I. Think they they will I mean I mean you know the it'll be a while before I think anybody can develop a bio similar to some of these PD one inhibitors but there's now by similars now rolling out for like Redux mad which has come off I think patent and there's other biosimilars for, for example, the GMC F. and Jesus analogs. So in those settings are pretty straightforward I. I don't think anybody's done large scale studies comparing you know the boss similars as to whether they're any lesson essay in fear to like Rotunda Mab or whatever. Theoretically, they should be very almost exactly. The same right because these molecules are are the all by complex you know the they're very precise. So I'm assuming that they will have a role because the cost will go down They're not going down as much as like you know if you had a generic of in ace inhibitor partly because they're just much more difficult to make a more complex to make. I I do think that biosimilars will and they are beginning they are taking off I mean we The institution here at the Anderson I think oftentimes uses biosimilars. or by Bison wish because they are cheaper than than the other standards. I think that that has been a good change for overall drug costs, but remember the patent life or at least the the drug exclusivity rights of a drug right give it a forget exactly what the time point is. But give give it a exclusively for a long period of time. So I. Try to or Nivo we'll have drug exclusivity for many more years and they're gonNA charge what the market will bear. Right right. Right as talked about last time the drug pricing is a very complicated. Very trying to explain somebody how drugs are paid for in the US is and why they're priced the way that they are. Is a challenge it is complicated. You know I think that this is one of the things I posed in that that that educational session as you are I I do think that Pharma is coming upon their kind of tobacco moment right from suitable companies used to be an if they ever. But they you know they weren't necessarily seen like the bad guys like tobacco companies, right? But. Then you have the whole March skelly story. You have this whole stories about the EPI pen. You now have the whole stories of the purdue family, and then you know just recently the CEOS of the Pharma companies were all brought forward the in front of Congress right if you look at Gosh any survey looking at particularly Medicare and Medicaid drug pricing in negotiations. Despite the fact that we as a country are divided almost every major issue. The only thing that we're actually united about is drug pricing right Republicans and Democrats Liberals, and Progressives, and conservatives they are and I think that what's going to end up happening whether it's trump next year in two thousand twenty or whoever there's GonNa be a push towards somehow you know. Allowing Medicare to negotiate prices. And I think if that happens, you know the other the shoe falls, which is insurers will fall on that. Also, I mean, there is already. Drug pricing negotiation going on particularly with a church companies. But I think that Medicare pricing comes into the plays GONNA drive down costs even more. So drug companies are going to have to figure out how do they you know given the increasing research costs and maybe likely drug reimbursement is going downwards. You know, how do they make decisions based upon that right and they you know? As much as we'd like to think that drug companies purely make decisions on science alone and efficacy of drugs they don't they have to be fiduciaries to their stockholders and they have to make decisions based at that will make revenue, right? Yeah and I think today it's It's an even bigger issue but the the example that I used to use is Zithromax saw three mice now. Granted. We're talking a much much lower scale in terms of dollars. But I always just to say Pharma has a hard time selling value. You know here you have you can take for your sinusitis you can take. A Salon for mock cicilline three times a day for ten days not sure if that's exactly accurate, but if you look at the Z pack. You know you load up on the first day and then you take something for four more days than you're just much more convenient. You're much more likely to be compliant. But when you go to the pharmacy and you see this, it's off pat now that you see this, you say, well, wait a minute I'm going to pay seventy dollars or this cost a hundred dollars for six pills and people just think and it's the same kind of thing with the Gilead drug or suite of drugs for Hep say. People look at that and they say their the value can't be there for what I'm getting and I. Just I don't disagree at all by the way that they're having their tobacco. Moments here with a string of these kinds of things hitting the news and I also think that they just haven't done as an industry a good job explaining the value of of what it is that they bring to the table. I agree. You know I mean it's it's a it's a part of the larger story of healthcare here in the United States right? I don't know what the right answer is. I definitely envy some aspects of like kind of centralized. Manage systems like Canada or in Europe but at the same time like I, tell you the number of clinical trials number amount of research says being done here in the United States number of drugs that are available. Are Not available to cancer patients in Canada or the UK? UK. has something called the Nice System Right which is a committee that makes decisions based upon the value of life year right? Whether or not that drug is going to be of value to a cancer patient. You know how do you put a price on that? I it's hard to put a price in my opinion it's hard if it's especially if it's your if your wife or your son or whoever right? The committee, a government committee says, we know that this drug can extend possibly extend the life of a somebody by six months, but we don't think that is enough for us as government to pay. Well, that's a curve right? That's that's a curve. Some of those patients who may benefit six months may also benefit five years right? It's it's it's the tail end, but there's still that chance I, I don't know. If Americans are GONNA want to to make those kinds of decisions or want somebody in a central government to make that kind of decision right and there are number of health economists? Is You we all know who argued there are three things in healthcare and it's it's different than most other economic kind of markets. One is quality availability and then cost in most health economists would argue you cannot have all three. It is very hard to have all. Even, in socialized systems like the UK or Canada, their costs are skyrocketing. And so it's a balance and I it's it's one of those things where I. It'd be hard for me to see. Consumers Union, the United States Oh, you know what I'll. I'll wait I'll wait three months for my hip replacement right or or you know what? I'm not going to get the latest drug because you know it's too costly the government's as to but now you can have it two tier system where those who could pay into that system. You know have a private insurance which does occur in like Canada to some extent in other countries. But at the same time, also I could see just an uproar about the inequality of something like that inevitably would draw inequalities because no matter how much. Money, you pour into a system like healthcare which were pouring tons of money into they're still going to be inequality. So I don't know the right answer to you. John I don't know the answer either I certainly have my my opinions. I mean the reality is using the Canada Canadian example in the UK. I would imagine that the people that you see. Down, MD Anderson who come from those countries are wealthy right I mean. They have the ability to to come to you know top medical institution have their care and no matter what direction we go in its I, don't see that changing yes. Yes and I you know I can't speak to the full population patients that come to the tonight. We definitely do of kind of indigent care here in the Houston community because it's a Texas mandate but you're correct in the sense that a lot of patients who do come here from. Outside of Houston have the resources to come right especially if you're from another country, we're seeing a whole lot of patients actually coming from China you know it's a socialist system in China. There says, says a kind of a videography essay on Chinese healthcare. It is abysmal about what's going on there and there's there is going to there likely is probably already two-tiered system. But the system. Currently of those who get socialized healthcare there is is abysmal I mean it's just it's just really sad. On that article. But we are seeing yes we are seeing lots of plenty of patients from other countries coming here is because. A lot of them are from socialized countries. Right? We have the the best potentially the best care here in in the US but then there's the question about why is it that we're not at the top of the list in outcomes in just about Agree that you look at why is that well show? So in cancer care, we actually are better than like social systems like UK and so forth. If you look at life expectancy and so forth I think it's far more complex than just Oh, you know our healthcare system I mean you'd think about health health is the human bodies. Health is a very complex system right? I mean like we Americans eat crap. and. If you're seriously, if you were to bring the full Japanese population here to our healthcare system, I bet our life expenses would be a lot better right because Japanese eat much healthier than us they way lot less than us. Probably Habits they're better than us, but we Americans eat a lot of fatty fried food and we were overweight. And we overwork by the way. I think a lot of people like to compare healthcare systems by those outcome saying, APP, apples, oranges, but apples, apples but that's not true because our populations are entirely different. You know a lot of the socialized systems exist in very smaller countries Sweden. Whatever they have populations. I think is Norway has has north. Finland has a population of Houston. Right right. I didn't bring you still how do you? How do you come in? You say while you know they're they're they're they're such higher life expectancies. Well, that's hard to compare three, hundred, million to five, million population you know and and much more headed much more homogeneous population relative to heterogeneous, population. And so you know I kind of oftentimes take those kind of comparisons with somewhat grain of salt because I don't think that you can just throw the United States population say well, you know therefore the healthcare system is failing them. I totally agree that there are definite aspects in Christie's of the current modern are American, modern healthcare system that is failing the American populace but there's also many aspects of American healthcare that is truly benefiting us as a nation particularly innovation if he talked with people in Pharma. To large extent and I'm not saying that this is the the major reason. But you know a lot of the research costs are borne by the fact that we have higher drug prices here in the United States right now people don't want to say it. And but that's the truth right? You know a few say, okay we're GONNA now not allowed drumbeats to make profits or whatever will the money flowing into research decline I bet it will. I'm just making my best assumption that probably likely will will they make it up by increasing prices in Canada and the UK and other places? I doubt it because those governments will just say, no, we're not paying more her night they've already those agreements I'm not sure what the right answer is. We haven't cured cancer for and we still need new drugs and we as many new drugs are out there we need to you know every day I you know I see patients were dying, right? I mean most of my patients. Despite these new drugs die on me and And it's easy to say I think if you're a critic when you don't have a a mother or a father or a life or a child who is suffering from cancer, say you know what it costs too much and it will make sure that the drug companies don't make any profits or just reasonable prophets. But when you have somebody who has cancer, it's not that easy to say, no, I lost both parents to cancer different types, cancer and watch them. In the last days of of their their lives and it was horrible. In a needs to tell you, you see it every day. Yeah. Yeah. Well, this is an enlightening. Yet. Again I'm sure we could talk for another half an hour but I think I be wearing out my welcome Dr Hong Thank you. You know this obviously our opinion piece. Obviously, this is my opinion that the opinions Anderson Suppress. Pathetic. But yeah, it's it's fun. It's fun talking about this. This is stuff that have a passion for you know alternately, you know why do what I do is because I really want to help our patients and ultimately I really believe that clinical research particularly new innovations will transform not only cancer but you know health in general in the world, and so I'm you know I'm I'm I'm passionate about that. Thanks for interviewing me a happy to do this again sometime. At some point leader in. Whenever you have this and so happy to talk about other topics. That sounds great. Thanks again, Dr Hong Terrific. 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