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Prevention Trumps Cure

Climbing Grace. Pen and ink on paper. Discovery Bay, Sep 2022.

I recently attended the annual conference for my professional medical college. This was one of the largest medical meetings in the US, typically hosting around 10,000 participants. One of the sessions that I attended was presented by a prominent national expert on dementia.

This speaker reviewed the latest scientific findings, including new medications for dementia, as approved by the FDA over the past year. He also discussed the latest findings in terms of dementia prevention, which were very much in line with what I’ve been teaching in my practice.

Don’t despair

The next day, I attended a lecture by a couple of panelists who were addressing the question of whether elders should be screened for dementia. This is relevant because a number of diagnostic tests will soon be widely available that would allow us to detect early signs of those at risk for Alzheimer’s disease.

I was incensed by the hopelessness and despair engendered by the panelist

I was stunned by the pessimism in the tone of their message, which was strikingly different compared to that of the expert from the day prior. In fact, one of the panelists even went so far as to say something to the effect that, “We are waiting for a drug. None of the ones we have are any good, and so there’s no point in even discussing early detection. You don’t want to give people false hope, when we don’t even know when something effective is going to be discovered.”

I was so incensed by the hopelessness and despair engendered by this remark that I got up to the microphone to chastise both panelists. I wanted the audience to know that there are in fact many nonpharmacological interventions available to patients diagnosed with early memory loss. Such as reducing alcohol, hearing loss, depression or sleep issues that are likely compounding any issues related to hearing loss., to name a few.

I suggested to the audience that they could consider attending one of the multiple excellent training options available to doctors, for learning how to advise families and patients struggling with issues related to memory loss. For example, the University of Washington’s Cognition in Primary Care program teaches primary care providers how to approach basic diagnostic questions, when to refer for specialty care, and what support to offer.

It’s not hopeless

The field of neuroscience has been evolving so quickly over the past decade or so, that it’s hard for most of us to keep up. And while we have learned a great deal about dementia, there is still so much that we don’t know. For starters, it’s not even clear that Alzheimer’s is a single disease process.

It’s like when we used to believe that cancer was a single disease that caused tumors and death. Nowadays, we recognize that there are hundreds of different types and subtypes of cancer. And cancer research has been tremendously successful in identifying more and more tools for diagnosis and treatment. Note that we don’t yet have a “cure for cancer,” but we are much closer to being able to manage some cancers, with such tools in our arsenal.

Cancer Types Graphic.

The recent spate of new drugs approved for treatment of Alzheimer’s disease have made headlines because they have been the most promising breakthroughs to achieve the rigorous safety and effectiveness standards required by the FDA. Despite decades of research, there have been disappointingly few such breakthroughs. And that’s in part because there has been relatively sparse levels of funding for research into Alzheimer’s and dementia treatments (see Fig 1).

Figure 1 - NIH Funding Trends. Harvard Kennedy School Belfer Center Dec 2022

It turns out that NIH funding for research into Alzheimer’s disease has only picked up in the last decade, but still falls sadly short of what is likely to be required over the next decade. At present, funding for cancer and AIDs research still outpace dementia research by multiples, despite the fact that the prevalence of dementia is projected to grow exponentially as the population ages. (See Fig 2).

Figure 2 - UCSF Institute for Neurodegenerative Diseases

The reality is that there are over 143 candidate drugs currently in the FDA pipeline, with 31 already in Phase 3, or the final stage required for approval. The vast majority of these agents target disease mechanisms with that goal of modifying or slowing the course of degeneration. This means that while we can expect to be seeing more and more new medications coming to market in the coming years, we may continue to be disappointed if we are waiting for a “silver bullet” cure.

Cummings et al. Alzheaimers & Dementia 2022

It reminds me of when we were watching hundreds of young men die of AIDS during the 1980s, early on in my training. When the first antiretroviral drug (AZT or zidovudine) came to market, it was hailed as the miracle cure. And yet, here we are almost 40 years later with no “cure for AIDS.” And yet we have achieved a kind of victory in the sense that HIV is now a manageable condition. The fact that we now have over 30 effective drugs for treatment of HIV is a testament to the power of science and the tenacity and innovation capacity of the many excellent scientists in this field.

14% a scary number, but not if we choose to see it as an opportunity

Of course we want to believe that diseases are simple and that science can deliver us a magic silver bullet to cure us. But that’s not how science works. As we have seen in glorious technicolor over the course of the global pandemic, science is an iterative process. This means that scientists will have different ideas on how to solve a problem such as vaccine development. And human biology is endlessly complex, especially when we are testing new approaches.

Prevention is key

Even now, diagnostic testing is available to identify whether or not we have early signs of the pathology that is linked to Alzheimer’s disease (AD). In fact, some experts estimate that there are up to 45 million Americans (14%) currently living with preclinical AD. That’s a scary number, but not if we choose to see it as an opportunity.