Until the late 1990s, almost all cancer drugs killed dividing cells rather indiscriminately. Targeted therapies are much more subtle, influencing specific processes that control the growth, division, spread and death of cancer cells. Some targeted therapies (e.g. trastuzumab, gefitinib and imatinib) block growth factors, others (e.g. bevacizumab) block angiogenesis, starving the cancer of oxygen and nutrients.
Rapid advances in molecular biology over the past 21 years identified numerous genetic aberrations, which inspired the targeted therapies currently in development for a wide range of malignancies. While targeted therapies save lives and prolong survival, they are expensive. Rows about funding new cancer drugs are likely to rumble on.
The jury is still out regarding e-cigarettes, but there is no doubt that antismoking legislation has helped to cut tobacco-related harm. In 1974, 45 per cent of adults smoked – in 2014 it was 18 per cent. Smoking at home dropped from 65 per cent of adult smokers to 55 per cent within six months of the English ban on smoking in public places in 2007.
The number of smoke-free homes lived in by children whose parents smoked increased from 34 to 41 per cent within a year of the ban. The ban reduced hospitalisations for respiratory tract infections in children less than 15 years of age by about 11,000 a year.1 Nevertheless, 100,000 smokers in the UK still die from their addiction every year.
1. Eur Respir J 2015: 3; 697-706
Advances in electronics, software, imaging and analytical technology have meant that systems that once occupied a laboratory bench can sit by the patient’s bedside or in the corner of a pharmacy. Rather than needing specialists, any healthcare professional can learn to use most point-of-care (PoC) technologies.
For instance, Abbott’s handheld i-Stat measures troponin, blood gases, coagulation, lactate, chemistry, electrolytes and haematology. Alere’s Afinion AS100 also performs several tests, including measuring C-reactive protein, which helps target antibiotics and tackle resistance. Unfortunately, inadequate funding hinders uptake, so realising the undoubted benefits of the growing number of PoC technologies depends on developing alternative funding mechanisms.
The finding that ketamine, used as an anaesthetic and a ‘recreational’ drug, rapidly improved severe depression that did not respond to conventional antidepressants proved a revelation. Intravenous ketamine’s antidepressant effects can emerge within two hours and last for between three and 10 days. Several drugs acting through the same mechanism as ketamine are in development. Science described ketamine’s benefits as “arguably the most important discovery [in depression] in half a century.”2
2. Science 2012;338:68-72
Over the past 21 years, we’ve become aware that we are home to some 100 trillion bacteria – the microbiota (also called microbiome). The bacteria occupy five zones: the skin, nose, mouth, lower gastrointestinal tract and vagina. Each zone is remarkably diverse: bacteria on the inside of the cheek are different to those causing dental plaque.
The lower gut comprises more than 30,000 strains of microbiota. Bacteria in the GI tract break down foods that we cannot otherwise digest (increasing the energy released by about 10 per cent), make vitamin K, modulate immune responses and influence the risk of certain conditions, including colorectal cancer, obesity, atopic conditions, metabolic syndrome and insulin resistance. Over the years, studies into the microbiome have produced numerous surprises – no doubt there will be many more to come.
Research published over the past 21 years unequivocally shows that tightly controlling diabetes improves outcomes. UKPDS 35, for example, found that in type 2 diabetes, each 1 per cent decline in HbA1c reduced heart attacks by 14 per cent; deaths related to diabetes by 21 per cent; and microvascular complications by 37 per cent3. Meanwhile, the diabetes armamentarium has expanded dramatically and now includes novel insulin analogues, dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, enabling tailored treatment that increases each patient’s likelihood of attaining control.
3. BMJ 2000; 321:405
Public Health England estimates that about 214,000 people in the UK are chronically infected with hepatitis C virus (HCV). According to PHE statistical models, 10,470 people currently live with HCV-related cirrhosis or hepatocellular carcinoma (HCC) – a figure that could rise to 12,510 in 2025 if current treatment patterns continue. Interferon-based regimens transformed HCV management, curing about 40-45 per cent of patients with HCV genotype.4 Treatment, however, lasted six to 12 months.
New direct acting antivirals produce sustained virological responses (SVR) 12 weeks after the end of a shorter (e.g. three-month) treatment course – widely regarded as equivalent to a cure – in between 90-100 per cent of patients.1 The new regimens might even “make HCV the first chronic viral infection eradicated worldwide”.5 In June, NHS England announced that the budget for antivirals for HCV would increase to £190m, from approximately £40m in 2014, raising the prospect of many more cures.
4. Therap Adv Gastroenterol 2015; 8:298-312
5. Liver Int 2011; 31 Suppl 1:68-77
For decades it was thought rickets was history, yet almost one-fifth of UK adults and up to a third of children aged four to 10 years have low vitamin D levels. Vitamin D is essential for the uptake of calcium and phosphorus from the diet. Bones and teeth contain most of the body’s calcium but calcium has other roles, including nerve transmission, muscle contraction and blood coagulation. Over the past few years it has also been recognised that non-skeletal tissues and cells, including the skin, brain, prostate, breast, colon and immune cells, respond to vitamin D.
Vitamin D directly or indirectly controls more than 200 genes, and, among other actions, promotes insulin action and secretion, and modulates lung development. Meanwhile, there is been a growing appreciation that it is difficult to get enough vitamin D. The chief medical officers of the UK advocate increased supplementation among at-risk groups, while the Scientific Advisory Committee on Nutrition, in draft guidance, recommends giving “consideration … to strategies for the UK population to achieve” the recommended intake.
Concerns about the demise of the antibacterial miracle have persisted for the past 21 years – and unfortunately show no signs of abating. Resistant bacteria already kill some 25,000 people across Europe each year, similar to the number of road accident deaths. Governments worldwide are worried that the numbers will rise dramatically as resistance spreads.
But a consensus seems to have now emerged that tackling resistance depends on a multifaceted, co-ordinated, sustained response involving responsible use of antibiotics in humans and animals; improved design of healthcare environments and processes; greater investment in healthcare professionals, researchers and support staff; greater investment in basic and applied research; and improved diagnostics. We can only hope that the political will remains undiminished over the next few years or our next round-up might well be noting the return of widespread mortality from childbirth, scarlet fever and tuberculosis.
The number of people dying from coronary heart disease fell from 166,000 in 1961 to about 80,000 in 2009, according to the British Heart Foundation. Nevertheless, cardiovascular disease remains the UK’s biggest killer. The decline reflects the marked improvements in treatment, diagnosis and management of cardiovascular disease and risk factors over the past 21 years.
Drugs and surgery have been important but lifestyle advice, such as that offered by community pharmacists, also made a difference. For instance, reduced salt intake, rather than antihypertensives, probably drove the average fall in blood pressure of 3.0/1.4mmHg between 2003 and 2011 in England. Average salt intake decreased by 1.4g a day (a 15 per cent reduction).
In people not taking antihypertensives, blood pressure fell by 2.7/1.1mmHg after adjusting for confounders. Reductions in salt added to processed foods, which contributes about 80 per cent of salt intake, probably accounted for most of the fall.6
6. BMJ Open 2014; 4: e004549