The drug works. End of story

Of late I've witnessed plenty of angst amongst pharma marketers trying to discern the 'narrative' behind the product they sell.  

I've sat in too many workshops, the purpose of each is to apply The Hero's Journey to the fact that Drug A has an effect on Tumour Type B.  Invariably, inevitably the analogy collapses under the weight of the exercise.  Is it the drug that's the hero or is it the doctor?  If the drug is the hero then doesn't that relegate the doctor to the role of squire to some tumour-fighting knight-errant? Easier to agree that the doctor is hero, which makes our drug Excalibur.  But what about the competition?  Aren't they the ones we're really fighting against, even though it's poor form to describe them as the enemy?  Or is it the patient?  People with cancer can be pretty damn heroic y'know.  After a while the only thing that we can agree upon is that the tumour is the bad guy.

It's around this time that someone jokes that this exact exercise is probably being attempted by a dozen groups somewhere around the world at this exact moment.  So we take lunch.

Afterwards we agree that The Hero's Journey is a bit cliché and we cast around for other narratives and so arrive at Journey From Darkness to Light.  But the medical team shuts that one down immediately because it implies a promise that our trial data won't support.  We are talking about cancer after all.

There is only one successful narrative for pharma products: it works.  If you're lucky you might be able to say it works in a surprising way.  Say this in the right way and let the doctor see for himself (in the right patient).  After which we pretty much lose control of the situation.  The doctor either believes that it works or she doesn't.

Energy spent trying to reframe the customer's relationship with the disease in question is energy wasted.  Doctors know the condition better than we ever will because they live with it every day.  The more poetic amongst them will describe their jobs in terms of warfare ('battle') or travel ('journey') or vigilance ('watch'n'wait') or strategy ('chess game') or problem solving ('cracking the code', 'solving the puzzle') but that's them using metaphor to describe their world to us.  Medicine is all those things and many more and we do well to listen to the words used by the individual.

But it is a mistake for us to gather around a flipchart to concoct some grand narrative that suits our purpose.  In the sales situation it will add a layer of complexity, as metaphor often does, or oversimplify or distort our message in some other way.  Instead, speak plainly and let the facts do the rest.

So cool

 I've only just found xkcd.

So, so cool...

Fixing pharma

Matthew Herper writes at Forbes about health care.  Last week he wrote a piece entitled Big Pharma: What Went Wrong?  Much of the article is a direct quote from Peter deVilbiss an ex-employee of Merck, who makes the obvious and off-stated point about pharma R&D: -

It takes a lot of profits from the few approved drugs that make it to market to pay for all the basic research and failed development candidates that lie beneath the surface and out of view of most people

Herper and many others are calling for two key reforms to 'save' Big Pharma: open source sharing of trial results and an end to direct-to-consumer (DTC) advertising.  I have no problem with either suggestion as either or both would improve the bottom line via a reduction in expenses and, in the case of DTC, improve the industry's American reputation.

As a consultant that works mainly outside the US (although regularly in Canada) and usually in more rarefied therapy areas like renal disease and oncology it strikes me that a lament on the evils of DTC is an analysis that is looking at the obvious rather than the important.  DTC is as much a symptom of the Blockbuster era as a cause.  I doubt that medical advances will ever again be as simple or as widely beneficial as the advent of the statins, COX-2 inhibitors and erectile dysfunction agents.  You won't see much DTC advertising of monoclonal antibodies because they're targeted therapies and the ROI on that sort of ad spend won't be there.

This is not to say that commercial medicine is about to get all classy: get ready for a massive increase and unedifying in TV ads for genetic screening: -

Did you know that you could be one of the millions of Americans who have cancer and don't even know it?  Call this number now...

The callous disinterestedness of the NHS

In the last month I've been out ‘on the road’ for three days observing sales representatives selling into the NHS.  As with any sales job the days are long and usually frustrating.  Busy doctors are always cancelling appointments.  The rest of the time gets filled with the strange burden of minor expectations that health care professionals, from the most senior doctor to the student nurse, have of the pharmaceutical industry.  Branded pens and Post-It notes have been banned but the ‘drug rep’ is still the conduit for funding for educational meetings here and abroad and for sandwiches (“We prefer a selection of wraps from M&S”) at least once a week.

What struck me hardest was the visible level of stress being carried by every NHS employee.  It had been a couple of years since I’d been out in the UK system and I was surprised by the universal interest in the price of the drug being sold.  Once upon a time only pharmacists and payers bothered to discuss cost; doctors and nurses didn’t sully their minds with such mundane financial matters.  But last week I watched a junior nurse, who is years away from prescriber status, quiz the rep about the comparative cost of rival treatments.  The nurse didn’t seem to be aggressive or point-scoring nor was he being clever for the sake of it; he just saw it as part of his job to understand the treatment options from a financial as well as a scientific-clinical standpoint.

I can’t think of another government department anywhere in the world where cost-consciousness pervades so thoroughly through the hierarchy as in the NHS.  Of course everywhere there are low-ranking teachers, police and perhaps even soldiers who are aware of their departmental budgets but not so consistently across an entire system.  By some counts the NHS is the second largest employer on the planet and every one of those employees has been trained to count the pennies. 

The taxpayer in me supposes that this is a good thing but I'm also sure that this cost-consciousness contributes significantly to the stress levels I saw in English hospitals.  No one ever went into the caring professions because they enjoyed the budgeting process yet this is now a substantial part of the job.

The reps I shadowed were selling expensive drugs.  This is true by definition: the only cheap drugs are ‘off-patent’ and so with insufficient margins to justify the formidable expense of a sales team.  With the NHS set up the way it is, any conversation with a drug rep is going to end with him asking for something that is difficult financially.  The medicine in question may amount to a revolution in the fight against a given disease but the health care professional is still left with the same old zero-sum game: - 

I cannot treat any patient as well as I would like to treat every patient

This has seeped into the organisation’s DNA.  Last year when the new Coalition government announced its Cancer Drugs Fund (CDF) the idea was for doctors to stop acting as financial comptrollers and get back to practicing medicine.  Yet the initial budget of £50,000,000 for the first twelve months will be underspent by a considerable margin.  This is not because Britain doesn’t have enough cancer sufferers to justify the money but because doctors across the country are genuinely suspicious about the long-term consequences of adopting newer, more advanced treatments in case the funding is later withdrawn

I've sat in on those sales calls.  I've seen doctors agree that there are patients under their care who would benefit from the drug in question.  But when the CDF is mentioned I've watched them narrow their eyes and ask for assurance that they weren't being tricked into changing their practice in an ultimately unsustainable way.  The logic being that it would be better to deny all current patients a better treatment if future patients would be denied it also.

 At the heart of the global financial crisis is the dawning realisation that for the first time in centuries we have to accept that future generations may lead less happy lives than us.  We are faced with the fact that the constant improvement in general wellbeing that the West has enjoyed since the mid-18^th Century is not inexorable.  If you work in the NHS then every day you're learning this unpalatable truth first hand: Britain cannot afford to keep offering every citizen continually improving health care.

By God that’s a stressful way to work.

The sharp end of the Greek financial crisis

Greece has stopped paying the pharmaceutical companies.  A letter from the local pharmaceutical industry association to the Greek government reads in part: -

In the first quarter of 2011, hospitals and pharmacies purchased medicinal products worth about €70 million, of which only €332 have been paid!  That is not a typing error.

In response a number of the majors are apparently just going to cut off supply of medicines.  Watch out for a proliferation of black market and counterfeit medicines at home as well as wealthier Greek citizens seeking out treatment in other European countries.  I don't know how easy it would be for someone to rock up to an NHS cancer centre and demand access to Herceptin but you can bet that some of the private clinics on Harley Street will see an uptick in business.

Apologies for the blitheness of that last remark but the fact remains: many middle class and poor Greeks will be denied access to a lot of modern drugs.  Whilst this puts them in the same boat as most people world, including lots of poorer Americans, it is at odds with what might be described as a broader European health care ethos.

Not a good time to be one of the 42% of Greek adults who smoke.

Narcissism of small differences

No surprises in these articles from Pharmalot and Reuters outlining the shift in balance between Primary Care (GP) sales teams and their hospital colleagues.  For years to come the biggest selling drugs in the world will be prescribed by oncologists and other specialists so that's where the reps will be pointed.

From the inside there might be seem to be a disctinction between these two branches of pharma selling: -

Hospital or specialty sales jobs require more intellectual horsepower than the primary care rep has.  That’s why they’re paid more and get more face time with the doctors

'Industry Insider' commenting on the Pharmalot article

In my experience the jobs are essentially the same.  Okay, the science might be more complex and illnesses more serious but the marketing is very simple in both cases; Freud's 'narcissism of small differences' comes to mind.

Embracing ever-increasing complexity

I've just finished Kevin Kelly's What Technology Wants.  The central thesis of the book is that technological advance is an inevitable extension of the natural development of, well, everything.  Kelly grandly posits that technology ('the technium') should be seen as the seventh Kingdom of Life, alongside archaebacteria, eubacteria, protista, fungi, plants and animals.

Kelly describes a number of key trajectories for his technium, one of which is 'complexity': -

This arc of complexity flows from the dawn of the cosmos into life.  But the arc continues through biology and now extends itself forward through technology.  The very same dynamics that shape complexity in the natural world shape complexity in the technium.

Kelly, p.287

I've spent my entire career working on product launches; i.e. trying to anticipate the Next Big Thing the consumer wants, building that thing and making it available.  I've always believed this drive for novelty to be one of capitalism's fundamental impulses but I'd not before seen it as embedded in the very fabric of the universe.  It makes sense: increased variety engenders complexity thus life will get evermore complex, be it in the jungle, supermarket or hospital pharmacy.

Last Thursday I was discussing an upcoming oncology launch with a new client.  I made the pedestrian observation that ever-expanding choice in cancer treatments added complexity to the medicine and therefore to the marketing task also: -

Once upon a time there was no treatment for cancer at all.  Then there was surgery.  Then chemotherapy.  Then radiotherapy.  Then tumour-activated monoclonal antibodies.  And so on.

The oncologist's job has gotten more complicated at every turn, especially as alongside a dizzying variety of potential combinations, sequences and so on, the original option (do nothing at all) is still on the table and must always be entertained.

Me

Marketers charged with launching a new drug must acknowledge that they are automatically complicating the customer's working life.  Doctors understand that part of the job of medicine is to understand all of the available options, which in a launch-heavy specialty like oncology can seem like a full-time job on its own.  Time-poor doctors will often actively resent the advent of a new therapy, especially if it doesn't represent an immediate and obvious medical advance.  There has to be clear communication that this additional complexity is justified by a worthwhile improvement in clinical outcome for a sub-cohort of patients.

Inexperienced marketers tend to focus on the novelty of the treatment (hence the proliferation of messages around 'mode of action', etc.) whereas the key word is sub-cohort.  Because we now know too much about genetics to take an undifferentiated approach to therapy disease, no cancer drug will ever again be right for all patients.

We are in the business of increasing complexity in the world and we need to embrace it.  It is the inevitable consequence of a defined population of cancer sufferers getting better treatment today than yesterday.

Personalised medicine v. National debt

Another day, another expensive cancer treatment gets rejected on cost grounds.  This time it's the turn of Novartis' renal cancer drug Afinitor: -

Despite appeals from Novartis and Kidney Cancer UK against the National Institute for Health and Clinical Excellence's decision, the watchdog maintains that Afinitor (everolimus) simply does not provide enough benefit to justify its high cost...

The overall treatment cost (is) about £34,235 per patient per year, or around £205,000 for a full course of treatment.

Pharma Times Online, April 19

These stories are commonplace across the Western World and for the moment, they are seen as part of the everyday argy-bargy of Big Pharma's negotiations with the national governments that are their ultimate customers.

But note the complete alignment between the pharma company and Kidney Cancer UK, a patient advocacy group that most likely receives funding from Novartis.  As stated previously, I have no problem with pharma companies pushing the patient to the centre of the treatment discussion.  There are neither cloaks nor daggers here and Kidney Cancer UK would exist even without the support of the various purveyors of renal cancer therapies.

As cancer is a quasi-chronic condition (i.e. one you see coming and so fight on your own behalf), sufferers and their families tend to be highly motivated people with an automatic tendency towards political agitation.  Cancer is hitting the baby boomers hard and they're unlikely to accept the withholding of any therapies whatsoever.  They will place inordinate pressure on a health system, which often leads to politicians creating release mechanisms: -

If doctors feel that any of these individual patients would benefit from the drug then they can still apply for exceptional funding from their primary care trust or the Cancer Drugs Fund, the Institute noted.

Ibid

All of which is fine if you live in the UK (and have a doctor sufficiently motivated to fight the good fight on your behalf).

But what if you're a Greek, Portuguese or Irish national?  As sad as your story undoubtedly is, given its current financial predicament, can your government honestly justify spending €38,500 on one citizen when that amounts to a year's wages for a senior nurse?

Watch the Greek, Portuguese and (especially) Irish baby boomers heap increasing political pressure on their governments; directly via advocacy groups and indirectly by turning up in person at British, German and French cancer centres.  Then watch for renewed pressure on the cost of the drugs themselves.