Comment by jseliger | Hacker News Reader

Comment by jseliger | Hacker News Reader

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The biggest question in oncology today is whether this approach could also be used for solid tumors

Yeah. I'm dying of a squamous cell carcinoma infestation: https://jakeseliger.com/2023/07/22/i-am-dying-of-squamous-ce... and the most recent clinical trial drug that was working, has stopped working: https://jakeseliger.com/2024/05/20/in-which-the-antibody-dru....

One of the options for a next trial is from TScan, "A Basket Study of Customized Autologous TCR-T Cell Therapies." https://www.clinicaltrials.gov/study/NCT05973487?term=tscan0.... On the one hand, it looks very promising; on the other hand, lots of promising treatments fail during dose-escalation, first-in-human trials. To my knowledge, the first humans dosed with TScan's TCR-T therapy got it a few months ago.

I got lucky, too, in that a slot for BGB-A3055 with Tislelizumab, an immunotherapy drug and trial, opened up at NEXT Oncology-Dallas: https://clinicaltrials.gov/study/NCT05935098?term=BGB-A3055&.... One challenge, however, is that I received a bispecific antibody called petosemtamab from Sept 2023 to March 2024, then PDL1V (an antibody drug conjugate), and they're considered immunotherapies, so there's a question of whether continuing to pursue immunotherapies makes sense. By now the number of lines of therapy I've gotten make me ineligible for some trials: https://bessstillman.substack.com/p/the-drugs-killing-dying-..., and I've also blown through the more promising drugs for what is a difficult-to-treat cancer type.

It took just five years to get from their first promising results to FDA approval

This sentence is insane. "Just?" It should be happening in months, not years. These are people with fatal diagnoses. Having the FDA hold up therapies like this is criminal.

This community may be of interest to you: https://community.cancerpatientlab.org/

It is comprised of very knowledgeble patients (like you) that are very actively involved in their treatment. I have been researching a lot of these resources due to my mother's condition, so feel free to let me know if you'd like to do some knowledge sharing.

Wish you all the best on your journey. God bless.

Thank you for this, I have an extremely rare subtype of sarcoma and it’s been tough to a) find any research about it specifically and b) find high-quality resources about state of the art treatments and interventions that aren’t like, Facebook groups where people post wacky articles about homeopathic stuff or whatever.

Would love to hear about any more recommendations you or OP might have for good forums etc.

And they're slow to avoid approving dangerous treatments, but that's absurd since the patients are already dying. The risk of not approving needs to be taken into account.

There is the "right to try" act in the US.

https://www.fda.gov/patients/learn-about-expanded-access-and...

It seems like the drug maker needs to participate in the program. What is the rate of participation?

I believe patients need a doctor to advocate for them.

There's another difficulty: to get the numbers needed to validate that a drug works, an equivalent large number of people need to enter the trial in the non-treatment arm, typically foregoing other treatment. Many people refuse to join trials for this reason, and that contributes to the delays in completing trials with sufficient power.

I get the why we in a ideal experiment would like to have a control group but these are human livesvnot rats in lab, so why does every trial need a new control group? If we already know what a baseline untreated group looks like why cant we just compare new drug test to a know control from previous trials thus reducing the need for more dying?

> If we already know what a baseline untreated group looks like

There isn't really a single baseline untreated group. For a comparison between groups to be valid, all groups must be obtained by unbiased random sampling of the same population. In a clinical trial, that population is the patients served by the participating clinical center. Patient characteristics differ by time and place.

You can try to retrospectively construct a control group using a case control study design, but then you're getting to pick what control group to use, so the results are less reliable (more opportunity for human bias).

Unless a treatment is both miraculous in effect and works for everyone, it's hard to figure out if it works.

> Unless a treatment is both miraculous in effect and works for everyone, it's hard to figure out if it works.

Yup. It's worth noting that "all or none" evidence is still considered category 1 evidence on many scales. (If you treat a group where all would be expected to die, and some survive... or a group where many would be expected to die, and all survive). It's only valid for the most dramatic effects, but you don't need randomization. During a safety trial you might come up with "all or none" evidence if your effect is strong enough.

But otherwise, you're going to need to compare the treatment to something else. There's no ability to magically draw the exact same population from some earlier trial.

Yes it's strange to tell a dying person "this drug is too dangerous to try because it may kill you".

Okay - but what happens when your doctor is getting bribed to say you're dying to get you to try expensive experimental drugs with no evidence of working?

In the best case, you end up bankrupt. In the worst case, you end up bankrupt and dead.

This is only a slightly more extreme version of the Sackler problem.

Deregulation sounds great if you believe everyone is logical and has accurate information to make decisions for themselves.

I'm sure there must be a much better solution than what we've got for the people who are dying.

But I doubt the answer is to just let drug companies sell anything to anyone and make Medicare pay for it.

> what happens when your doctor is getting bribed to say you're dying

We pay people to figure out that this is happening (the police), then we prosecute the doctor and if that is what happened we hit the doctor with the full force of law, and they never walk as a free person ever. We also do the same thing with those who bribed the doctor and they also never walk as a free person again.

What you describe already crosses into criminal conduct. We do not need FDA approval process to prosecute it. In fact I’m not sure how the FDA approval of the drug prevents it in your opinion.

> What you describe already crosses into criminal conduct.

Does it? How many people from Purdue Pharma went to prison exactly?

There are no consequences for the behavior you describe regardless of whether it's technically illegal.

> How many people from Purdue Pharma went to prison exactly?

Have they told the patient that they are dying?

This is an understated reality of the situation. Patients are already able to receive treatments with experimental drugs. It's the "forcing medicare and insurance companies to pay for it" part that's not a good idea, especially considering that most of these treatments may be worse than the current ones.

Treatments should have solid evidence they improve overall survival when compared against the best treatments available today, and unfortunately too many studies either aren't aiming at revealing that info, and/or are comparing against inferior treatment options.

No, medicare shouldn't pay for it, but it should be completely legal for patients to take whatever drug or procedure they want, and for startups to provide those drugs and services. The medical industry in the United States is a gate kept, over-credentialed, bureaucratic mess.

>Okay - but what happens when your doctor is getting bribed to say you're dying to get you to try expensive experimental drugs with no evidence of working?

You might as well be saying "what happens if some improbable risk of X exists in this very unusual context". That's existence, especially in complex and fraught situations. You can't completely regulate it away and especially not if the regulations themselves can cause much greater harm in the much, much more probable situation of patients who are already dying being willing, as human beings with autonomy, to try something personally risky.

Deregulation shouldn't and doesn't depend on the world being one of everyone being logical and always having accurate information. Those two conditions don't exist in the human world at all times, period. Furthermore, the exact same problem applies to regulators and legislators as well, whose poorly reasoned decisions can cause broad harm too. Making a lack of perfect information and attendant risk into the key basis for onerous regulations is bad reasoning with sometimes grotesque consequences, particularly in situations where the regulations are known to cause suffering to people in extremes (as is the case with denying risky treatments to those who are in any case at death's door..

Also, very basic but obvious: anyone in the extreme situation of having a doctor suggest a very experimental treatment can go and get a second opinion from another doctor.

This isn't an improbable situation. They literally mentioned the Sackler family, which is a real world example of corruption is medicine of the type they're talking about.

The Sackler's company bribed and "financially encouraged" doctors into over-prescribing opioids to millions of people who weren't necessarily mortally ill and with lesser individual risk of those people dying from these prescriptions.

It's a largely different clinical and treatment situation from specific cases in which people are genuinely, terminally ill and a genuine though dangerous treatment option exists that might save their very lives. The Sackler case is a valid and powerful criticism of medical/pharma dishonesty, but it's extremely unfair to desperate patients that it be used to prevent them from having the autonomy over their own bodies and literal chance at life that they might legally be allowed to pursue.

Also worth noting that even in the market for prescription opioids, the Sackler case has more recently been used to wrongfully prevent patients who are in deep pain from obtaining a drug that provides needed relief despite its addiction dangers. So even here, obsessions about malpractice are hurting legitimate use.

>Okay - but what happens when your doctor is getting bribed to say you're dying to get you to try expensive experimental drugs with no evidence of working?

If it's experimental it shouldn't be expensive. In fact it probably should be free until it's approved as effective. So with that out of the way, what are your other objections? (I am genuinely interested)

Nothing is free, including the clinical trials, which are funded often by the government.

> but what happens when your doctor is getting bribed to say you're dying

That was like Robert Stack, in Joe Versus the Volcano[0].

[0] https://www.youtube.com/watch?v=oAB9Y2CVqZU

There is an additional problem in that you want to avoid having people try to sell snakeoil to the desperate because "who knows, it might work."

Especially when, if that were possible, it would be hard to get people enrolled in trials to show any new drug actually did work.

I think it's better to understand why a pharmacist or oncologist will not prescribe medicine that could kill a patient, due to either the Hippocratic oath or through malpractice.

Most competent doctors will explain WHY they cannot prescribe something, and it's usually more specific such as "your liver is failing and this drug will accelerate that process, perhaps we can find something else".

It's really something like "this drug is too dangerous to try because if it kills you we will get a lot of bad PR".

It’s also a bit of “if you die anyway even if you take our drug, you screw our numbers, so we don’t let folks take it if they’re too ill”.

I don't know anything about this, but jseliger specifically said it was the FDA who are responsible for these delays.

So, here's the thing-- drugmakers can get compassionate use exceptions.

But the pharmaceutical companies really want to prove that their drugs work. If their drug doesn't work, nothing is lost or gained by having people try it.

If the drug does work, but the study of it is confounded by giving it to people in a haphazard way, such that we don't know if it works--- more people suffer.

It sucks, but most things don't work. Occasionally people are screwed by not being able to get into a trial for something that might have saved them or lengthened their life. But much more often they're spared false hope and suffering from side effects, and we end up with trials that we can trust.

Yes, I do mean that FDA is worried about getting bad PR.

The incentives of the FDA are unfortunate. If they don't approve a drug that would have saved 100k people there is no bad press for those 100k deaths. But if they approve a drug that kills 1k people there is a lot of bad press.

So they have strong incentives to not approve anything unless absolutely needed.

you missed the second part of that sentence. "it may also kill you in ways that is even worse than your current prognosis"

Has anybody ever just straight up stolen a drug from a clinical trial and had it save their life? If there was ever a case for jury nullification..

It's a real life Trolley Problem

Right to try makes this a variation of the Trolley Problem, because the person to pull the lever is the same person that's tied to the tracks.

Except they don't know if either they or the cancer dies in either switch state.

It's Schroedinger's trolley, basically.

Aka one hell of a tough call

The solution to the Trolley Problem is to perform a "slipping the switch" maneuver.

The solution for terminal cancer patients is to let them use any experimental services they please.

Next.

Thanks you for posting your story in details, as someone who's wife had oligometastasis on her spine from breast cancer (nothing compared to you, but incredibly stressful nonetheless) you give me hope that when Ribociclib stop working, M.A.I.D. is not the next step.

I wish you all the best in your trial, I wish that it's effective and may the side effects spare you !

I'm sorry to hear that. My mother in law has stage 4 lung cancer. She has some mutations for which there are targeted treatments, but the cancer mutated in one area. Fortunately there were more treatments for that mutation, but she's had some significant side effects from that one. There's potential clinical trials but there's lots of criteria, some may not even be near by: a lot of noise, not much signal. Every quarter's CT scans might tell us medication has stopped working, and she needs to start chemo (with the side effects/lower QOL).

It's just all really hard. I try to keep present when spending time with her.

It's not possible to evaluate efficacy any faster than that. I suppose we could just let everything on the market and see what happens, but it would still take years to accumulate efficacy data. So you'd just be left with preclinical data which isn't that useful (if it was the failure rate of oncology clinical trials wouldn't be so high)

Coming from Cancer Alley (Long Island, New York), I have been watching people battling cancer for 34 years. I wish you the very best.

FWIW if the drug was approved faster, most immunotherapies are very hard to scale.

I worked in specialty pharma for 6 years and the ability to expand capacity is very limited, a rock star drug will take 2-5 to reach full production.

Sometimes people see Covid / Ozempic and think it would be easy to scale like that, but the requirements and challenges are completely different.

Pembrolizumab and the like scale just fine.

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