Market size and total profit over the lifetime of the patent is the primary factor that is considered at every step from random screening to clinical trials. Spinning up a clinical trial requires many tens or hundreds of man-years of work by very specialized and hard to find scientists/doctors before you even sign up your first human subject so even the biggest pharma companies have limited bandwidth. This forces them to be very selective, even when they have multiple high-potential targets, and that means choosing to run the clinical trials for drugs with the highest potential ROI and lowest regulatory approval risk. For a variety of reasons, cures are usually much more complex and difficult to develop and get approved than simple drugs that treat symptoms and since the US has a complex, opaque network of insurance companies instead of a single payer, no one is in a position to negotiate prices that maximize healthcare ROI at scale.
There is little incentive for pharmaceutical companies to develop cures for diseases when they can provide a "good enough" quality of life boost for the entire lifetime of the patient and sell it for the exact same price. This means that often times cures won't even be researched past animal testing because the pharma company has a large pipeline of less risky, more profitable drugs to get through the FDA
Second, it's typically the science that limits the effectiveness of therapy, not the potential ROI. The reason why many drugs only treat symptoms is because that's the best science can do right now.
Third, curing a disease can often have a much better ROI than just treating symptoms forever. Look at Gilead's hepatitis C cure. Before it came to market the drug revenue for that disease was maybe $2 billion. The first year that Gilead's drugs were on the market, they sold $12 billion. The cure was way more profitable.
If, just as a thought experiment, it was possible to treat a disease quickly with a cheap drug or intervention, for example a cheap herbal drug that is available patent-free and for mere cents per liter, there would be no business in it, so no company could viably pursue this. The market selects for treatments that give a lot of profit. That always or even merely "usually" automatically somehow translates into the best option from a public health point of view only if you close your eyes and make lots of assumptions about how great the market magic works - in a market with extremely unequal information and very high pressure on customers (when you are sick).
On the other hand you are right that symptom treatment usually is the best we can do. The body is built during the early years and from then on it's maintenance, also what the body itself does and not just the doctors (it does not regenerate most structures, only repair). Just more and more ever more horrible hacks, workarounds and kludges and patches delaying the long decline more or less well. Or as most drugs do, don't even repair anything, just push levers and buttons in the body, but it doesn't do anything structural unless the body does it on its own. So if the structures don't regenerate the button-pushing drug has to be take lifelong.
That is so fundamental to complex life forms that current medicine simply cannot work against it. Maybe never, because replacing a structure in the grown body is much more difficult than growing it with everything else. For example, the difficulty of finding the path for new axons after a spinal injury is much greater than building everything together during very early development. Medicine would not just have to achieve what nature already does (when the body is assembled) - it would have to become far better! Repairing something often is much more difficult than starting from scratch.
At that level of cheapness, individual patients can buy it themselves. If it became popular enough, somebody would research it. That's already happened with many Traditional Chinese Medicine herbs. Of course, they turned out to be ineffective but one of them might have worked.
I wonder how low the average HN reader IQ has gotten lately that my insightful comment got downvoted and that I have to deal with crap like yours. Way too many total little teenagers and idiots on this site now.
Either you're using a wildly different definition of "biotech companies" than the vast majority of people in the life sciences industry or we're talking about entirely different things. Comparing biotech ventures to established pharmaceutical giants and their research pipelines is like comparing a seed stage social network startup to Google: it's a nonsensical and uninformative exercise. The entire biotech industry exists because the pharmaceutical conglomerates are willing to pay hundreds of millions to billions of dollars for a single promising patent acquisition as long as VCs, LPs, and Joe Shmoe's pension shoulder the 99% failure rate. When you're a biotech, you're not afraid of cannibalizing existing revenue or wasting precious resources better allocated elsewhere and pharmaceutical companies are perfectly willing to let everyone else light their money on fire. The successful biotech investors that have decades of positive returns most certainly look at market potential when deciding where to invest but even they have to make wild shots in the dark because they lack the massive amount of data that pharmaceutical companies work with.
Oh and "typically the commercial viability of a drug isn't examined until about phase 1" is downright false unless "until about" means years in advance. Any biotech company that hasn't figured out whether to treat their potential targets as normal or orphaned drugs by the time they get to animal testing has no business developing medicine and spending other people's money in the process. That most basic step necessitates analyzing the market potential of drugs.
> Second, it's typically the science that limits the effectiveness of therapy, not the potential ROI. The reason why many drugs only treat symptoms is because that's the best science can do right now.
That's obvious, given that ROI doesn't effect biochemistry. There is a whole universe of molecules but which ones we actually find out about and bring to market is dependent on a complex equation balancing luck, science, and a bunch of actuaries. Biotech companies can ignore that last one because it's not their cash that is going up in flames.
> Third, curing a disease can often have a much better ROI than just treating symptoms forever. Look at Gilead's hepatitis C cure. Before it came to market the drug revenue for that disease was maybe $2 billion. The first year that Gilead's drugs were on the market, they sold $12 billion. The cure was way more profitable.
I don't think you could have chosen a worse example to make your case. Sofosbuvir was a once in a lifetime discovery made by a biotech startup, Pharmasset, that resulted in the largest pre-approval acquisition and one of the fastest FDA approvals for a major drug in the history of medicine. That company was started in the late 90s with the express purpose of curing hepatitis C and the second it was clear that Sofosbuvir was on the road to breakthrough therapy designation by the FDA, every single pharma company was scrambling to acquire it. The only way to get such a designation is if the existing treatments had a high toxicity, caused many unbearable side effects, and weren't that effective in treating chronic infections with a rapidly oncoming patent cliff. For all intents and purposes, there was no consistently effective treatment for hepatitis C, let alone a cure, before Sofosbuvir.
Oh, and what happened next? Gilead lost almost half of its market cap from its 2015 peak after missing quarter after quarter of earnings estimates and downgrading revenue projections for its entire antiviral portfolio. If competition continues chipping away at their hep C products, their 2011-2015 gains (80+% of their peak market cap) will be wiped out. That's what a cure gets you: a shrinking market and brutal competition that wants to cash in before the well runs dry.
1. Yes, companies will target certain diseases based on their economic viability. However, the work they do is about 5% of what's required for a fully vetted molecule. Take the number of patients and multiply by some price pulled out of the air and they can slap "a $5B potential market" on their pitch slides. Until they actually have some clinical data and start to dig into the pricing/reimbursement environment, those numbers are just wild-ass guesses. How do I know? My old job was doing commercial assessment for in-licensing and phase 2 molecules. Even the big companies had to shut down programs post-phase 1 because their initial commercial assessment was way off the mark. To say that hundreds of clinical programs never make it past screening because their don't have a good ROI isn't true. Companies just don't have enough data that early to make those kind of calls.
2. Sure Gilead lost almost half their market cap in 2015 since they were missing estimates. But that was simply because they missed some pretty ridiculous earnings goals. The fact remains the company made tens of billions of dollars over a couple years based on selling a cure. Both of their HCV drugs sold more in two years than most drugs sell over their entire lifecycle. They were simply a cash cow.
Sure we have a lot of drugs related to Morphine, but most of them are not significantly different from Morphine as to be worth high prices. When viagra goes generic at the end of the year the hurdle for the next male 'enhancement' drug ratchets up.