2023-11-13 13:27:00
To begin, could you introduce us to the SFMPP?
Pr Pascal Pujol: As its name suggests, this learned society is dedicated to personalized medicine and predictive medicine. The first, also known as precision medicine, makes it possible to better characterize the typing of a given pathology, for example using genomics. If it has, for a long time, been used in the context of screening and prevention, it now has therapeutic applications, mainly in oncology and for rare diseases, where it allows the implementation of à la carte therapy, or therapy. targeted. As for predictive medicine, it consists of using markers, most often biological, to prevent, detect or treat diseases. In the latter case, it will for example be a question of anticipating a therapeutic response in order to favor the treatment which will be the most beneficial for the patient.
Personalized medicine is regularly presented as the medicine of tomorrow. What is your position here?
This vision is not entirely correct, or at least no longer is! In 2022, for example, no less than 120 targeted therapies were available in France for oncology, compared to around ten at the start of the 2010s. We can therefore measure the progress made by personalized medicine since its very first therapeutic applications in the years 1990… The trend is less obvious for rare cancers, but it is also very real. You will have understood, personalized medicine is already taking place before our eyes, it is part of our current arsenal. It is still necessary that all the people concerned can have access to it. And that’s precisely where the problem lies…
What do you mean ?
Genomic tests, which therefore represent a major component of personalized medicine, are only reimbursed within the framework of the RIHN, the Referential of innovative acts excluding nomenclature. If the CHUs and CLCCs, which are today the provider establishments, manage to do well to a certain extent, this is far from being the case for the beneficiary establishments, that is to say those not not carrying out these tests themselves. The remaining cost is far too high for them, which effectively limits the use of precision tools and creates inequalities for patients in the areas concerned. This RIHN system is therefore no longer adapted to current therapeutic advances in personalized medicine and must absolutely be rethought.
Could you talk about some of these advances?
The search for the BRCA gene mutation, involved in breast cancer, represents a fairly telling example. As I said, this has, for 20 years, been used for preventive purposes. The inclusion of this analysis within the framework of the RHIN when the system was created in 2015 could therefore to a certain extent be understood… except that it already made it possible, at the time, to develop targeted treatments. Today we are observing a real gain in overall survival – in this case a mortality rate halved – with targeted therapies which are now challenging chemotherapies. Limiting its use for economic considerations is not justifiable, either ethically, scientifically or medically. Especially since, for around four years, the BRCA gene mutation has also been used for the treatment of certain ovarian, prostate and pancreatic cancers. And we’re just talking about a single mutation on a single gene. The therapeutic possibilities of genetic data are expanding day by day, in nephrology, cardiology, for the treatment of autoimmune diseases, the care of people with autism, etc.
The SFMPP was therefore created to move the lines…
Long vertical, genetics is in fact becoming transversal. Geneticists, oncologists, pathologists, ethicists have therefore joined together in a learned society to support this decompartmentalization, acculturate prescribers and organ specialists and advance the public debate. For example, we develop recommendations for good practices relating to the use of a marker in a given disease. The need here is very real because, of the 120 targeted oncology therapies mentioned above, only half are currently the subject of recommendations from the High Authority of Health (HAS) or the National Institute of Health. Cancer (INCa). We are also regularly asked for expert opinions and advisory opinions. As I pointed out, we are also seeking to train health professionals in genomic medicine, in order to broaden access. But this necessary shift cannot truly occur until the financial aspect has been rethought. At the risk of repeating myself, it seems unthinkable to me that genetic analyzes for therapeutic purposes, which have largely demonstrated their usefulness, are maintained in the RIHN system…
Isn’t a reform being announced here?
In 2021, Professor Axel Kahn effectively protested against the high cost of genetic tests, pushing the Minister of Health at the time, Olivier Véran, to contact the High Authority of Health. It was May 2021. More than two years later, in June 2023, the HAS identified three genomic markers to be removed as a priority from the RIHN system and created a commission to this. We will therefore have to wait another year… and further losses of opportunity for patients. Especially since there remain 24 other markers that can be considered priorities for exit from the RIHN! I can understand that the HAS is not formatted for this type of diagnostic evaluation, and that it lacks resources. But this temporality is not compatible with the requirements of care. Decision-makers must hear this, and above all be aware of the consequences. On the ethical level, firstly, with harm that is difficult to justify. But also in terms of the attractiveness of our health establishments: if they are not able to offer care which, elsewhere, is already part of the standards of care, patients will turn away. Many oncologists know this and are also sounding the alarm.
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