Coronavirus: A catalyst for digital health?

Every cloud has a silver lining. Coronavirus will be the same. One of its silver linings may be faster uptake of digital health tools and gadgets, as individuals are compelled to remain at home amid one of the century’s most concerning pandemics. 

 

The merits of digital health products – from online doctors’ appointments, to wearable heart rate monitors and life-style support apps – were apparent before COVID-19 swept the globe. Health systems were already over-burdened, with many patients, especially those with chronic conditions like diabetes, unable or unwilling to make regular physician visits.  

 

Now, however, all of us are being forced to change our ways and conduct even more of our lives online. This change of mind-set may be the catalyst that’s needed to support wider adoption of virtual clinics such as those offered to diabetes patients by the likes of Onduo (backed by Verily/Google) or LivongoThese app-based products connect to glucose monitors and provide coaching and online doctors’ visits. (Livongo in January 2020 tied up with continuous glucose monitoring company Dexcom, offering data-synching across the platforms.)  

 

Most of these tools, though clever, have struggled to overcome the core challenge in helping people effectively manage their diabetes. Patients don’t want the disease to encumber their daily lives. Sure, they want help and they want convenience, but they don’t want to be lectured or coached every day, nor do they want constant reminders of their condition. They are after quick, simple-to-use, non-invasive solutions that are discreet, that provide the data they need when they need it, and which are otherwise silent. 

 

That is a tricky balance to get right. Sanofi CEO Paul Hudson said as much when he pulled out most of the French pharma’s investment in Onduo in December 2019, saying it was a waste of money. The e-commerce component of diabetes “is a much harder nut to crack” than expected, he said – not least as the margins on digital health products are nothing like those achieved by novel therapeutics. (And in diabetes, with insulin commoditized and GLP-1 agonists the main growth area, finding novel therapeutics isn’t easy either: days before it retreated from the Onduo venture, Sanofi had announced it was stopping all R&D in metabolic and cardiovascular disease, to focus instead on rare diseases and oncology.) 

 

Maybe coronavirus – and the awareness it brings – will help crack that nut. It may compel more people to consider more proactive online disease management, and to better appreciate the value of such virtual monitoring. The virus has already provided a global wake-up call for the importance of coordinated diagnostic testing. 

 

If coronavirus provides a boon to some consumer-facing diabetes management products, though, its impact on other serious chronic diseases could be much darker. Rates of obesity and heart disease may increase as people are forced to stay at home and order take-out. Anxiety and depression may spread further, due to social isolation and fear. 

 

Hopefully, the virus will endure only long enough to instil healthy, sensible habits, a stronger sense of community look-out, and an appreciation of the virtues of digital health products – and not long enough to provoke a spike in other conditions. 

More Options for Ovarian cancer

One in 78 women will suffer from ovarian cancer during their lifetime. The condition accounts for more deaths than any other cancer of the reproductive system – and ranks fifth in overall cancer deaths among women. 

The good news is that the range of available treatments is expanding. Precision medicine continues to generate therapies that are more targeted to particular genetic mutations, and more treatment combinations are being tested. If the disease is picked up early, five-year survival rates are very good – up to 80% or moreThat has led some to consider ovarian cancer a chronic disease, as is the case for some breast cancers that are diagnosed promptly. 

But about three quarters of women suffering with ovarian cancer – over half of whom are in their mid-sixties or older – are diagnosed only when the disease has advanced to stage 3 or 4. Standard treatment is surgery to remove tumors, followed by chemotherapy with or without the VEGF-inhibitor Avastin (bevacizumab). This has not changed much in the last decade, although the disease will recur in most women. 

That’s why scientists are investigating the merits of using more targeted treatments – notably, PARP inhibitors – both earlier and later in the treatment pathway. PARP inhibitors block the body’s attempts to repair mutated DNA found in many cancers. They include Lynparza (olaparib), sold by Merck and AstraZeneca, Zejula (niraparib), sold by GSK, and Clovis Oncology’s Rubraca (rucaparib).  

PARP inhibitors have for several years used in women whose cancer has returned after several rounds of chemotherapy. Lynparza was initially approved in 2014 for heavily pre-treated patients with advanced disease who had defective BRCA genes –  mutations that occur in an estimated one in three ovarian cancer patients. Three years later, approval was expanded to maintenance therapy for all patients with recurrent disease – as Zejula, too, reached the market.  

As scientists work out which combinations and treatment sequences work best – not an easy task, given ethical and competitive hurdles – the PARP inhibitors are becoming more widely available. In late 2018, Lynparza got a green light as first line maintenance therapy for BRCA-mutated advanced ovarian cancer, meaning it can be used after a round of chemotherapy, not only after recurrence. Approval was based on a trial showing a 70% reduction in the risk of disease progression or death, compared to placebo. 

Last year, Zejula was approved as a late-line monotherapy, in patients with advanced disease that had had three or more prior chemotherapy rounds. Eligible women must have either a BRCA gene mutation, or genomic instability – as defined by a molecular test. Such patients are said to be “HRD positive” – homologous recombination deficient. They may not specifically have a BRCA gene mutation. 

GSK is testing Zejula as a maintenance therapy in newly-diagnosed ovarian cancer patients, while Lynparza is combined with Avastin to determine whether these two therapies work better together for some patients. Trials are not limited to patients with HRD mutations, but those groups did tend to show the greatest benefit. As yet, though, data is inconclusive over whether to exclude non-HRD patients; researchers are still trying to work out where, and whether, to genetically segregate. There are also questions around whether early use of PARP inhibition may impact the effectiveness of chemotherapy, if it is required. 

There may be more PARPs to come: AbbVie has a late-stage candidate that has shown some promise in ovarian disease, though earlier trials in breast and lung cancers failed.  

Meanwhile, immuno-therapy (I-O), which works by harnessing the body’s immune system to fight cancer, may yet have a role in ovarian cancer. So far, checkpoint inhibitors such as Merck’s Keytruda have had little success fighting ovarian tumors, due to their particular immunogenic profile. But there too, combinations are under investigation – of different I-O approaches, and of I-O drugs with PARP inhibitors or Avastin. So are personalized vaccines, tailored to individual womens’ tumors. 

Determining which treatment combination and sequence will benefit which patients is a work in progress, as is it across most other cancer types. Yet as the therapy armamentarium grows and as genetic testing becomes more widespread, ovarian cancer patients today unquestionably have more options.