COMMENTARY

Eric Topol's Top 10 Tech Advances Shaping Medicine

Disclosures

January 11, 2018

Each year, I look back at the top 10 tech advances that made headlines the previous year, and these technologies promise to revolutionize medicine in the coming year. Here they are, not in any particular rank order.

1 and 2. Gene Therapy and Gene Editing

These two biotechnologies are being used in clinical trials for diseases that once were deemed untreatable but now are believed to be curable someday, largely due to these important new tools. First, let me differentiate the two because there is considerable conflation and confusion about what they mean.

Gene therapy scored some rapid-fire successes this past fall[1,2,3] after a 20-year "winter" during which things looked pretty bleak and even some advocates feared that there might never be a comeback. On December 19, 2017, the US Food and Drug Administration (FDA) approved the first gene therapy that targets a disease caused by mutations in a specific gene. The treatment, voretigene neparvovec-rzyl (Luxturna™; Spark Therapeutics), is delivered surgically via subretinal injection to treat a rare form of inherited vision loss that can lead to blindness.

As for genome editing, ex vivo manipulation of T cells for leukemia[4] and HIV[5] has been used for several years, but the first case of in vivo editing was performed just this past November in a 44-year-old man with Hunter syndrome. We do not yet know the outcome.

3. Deep Learning of Skin Cancers

Esteva and colleagues at Stanford University created a deep-learning algorithm to diagnose skin cancer, and then tested it against 21 board-certified dermatologists. As they reported in Nature ,[6] the algorithm matched the clinicians' ability to correctly identify malignant and benign lesions.

This represents an "in silico" demonstration or computer modeling of a biological process; a prospective real-world study in patients will be necessary to assure that the very high accuracy of the deep-learning algorithm is clinically validated. If it is, the developers hope that it can then be transitioned to mobile devices and that the visual diagnosis technology will be used in other fields as well.

4. "Panoromic" Cancer Evaluation

Last year I was able to visit Tempus Labs, a Chicago enterprise operated by Eric Lefkofsky, the co-founder of Groupon. He launched Tempus in 2015 after his wife developed breast cancer and they were unable to find a place for her to undergo a comprehensive evaluation.

Now, Tempus is collaborating with most of the National Cancer Institute's comprehensive cancer centers in the United States and providing across-the-board cancer testing: sequencing of patients' tumors and germline DNA; liquid biopsy of cell-free DNA; RNA sequencing of tumors; immune system characterization of tumors and patients; organoid cultures of tumor cells with drug testing; machine learning of all of these layers of information with the electronic medical record; pathology reports; and all medical imaging.

Previously, some companies offered isolated tests, but this is the first one to do them all. We await publications that spell out whether this rigorous, multilayered information approach will change patient outcomes.

5. Smartwatch Diagnosis of Atrial Fibrillation

In November 2017, AliveCor announced that it had received FDA approval of an algorithm for its watch band with a built-in ECG sensor. KardiaBand, when used with an Apple Watch, tracks a person's heart rate–to–physical activity ratio, learned with several days of data capture. When an outlier reading is captured, showing a heart rate considerably outside what would be expected for the person's activity, he or she gets an alert to record their ECG. A PDF of the reading can then be sent via the individual's smartphone. This represents the first FDA-approved artificial intelligence algorithm to aid consumers in obtaining data for a medical diagnosis.

6. Pathogen Sequencing

Technological advances now make it possible to sequence pathogen genomes rapidly with tools (eg, MinION; Oxford Nanopore Technologies) that can be deployed anywhere in the midst of an outbreak, facilitating much quicker public health responses.[7] Other means of sequencing are now being used in patients with sepsis. The early diagnosis via sequencing may someday preempt the need for blood cultures and the 2 (or more)-day delay in waiting for those results to be available.

7. Better Continuous Glucose Sensors

Both Abbott and Dexcom introduced new FDA-approved glucose sensors that are user-friendly. Abbott's FreeStyle Libre Flash is easily applied on the arm and does not require fingerstick calibration. The Dexcom sensor, typically applied on the abdomen or arm, sends blood glucose values to a smartwatch and smartphone, while Libre has a small dedicated receiver. With the recent FDA approvals, these sensor readouts can now be used directly to dose insulin, in contrast to the historic reliance on fingersticks.

8. CAR-T Immunotherapy for Cancer

The treatment of hematologic malignancies was transformed with the approval last fall of the first products based on chimeric antigen receptor (CAR) T cells. Axicabtagene ciloleucel (Yescarta™; Kite Pharma) received FDA approval for the treatment of patients with relapsed or refractory aggressive B-cell non-Hodgkin lymphoma who are ineligible for autologous stem cell transplant. This followed the FDA's approval of tisagenlecleucel-T(Kymriah™; Novartis Pharmaceuticals Corporation), indicated for use in pediatric and young adult patients (aged 3-25 years) with relapsed or refractory acute lymphoblastic leukemia.

This individualized therapy involves engineering a patient's T cells to express a CAR that will then target the antigen CD19, a protein expressed on the cell surface of B-cell lymphomas and leukemias. The cells are then redirected to kill the cancer cells, with dramatic results in some patients who otherwise had limited or no treatment options. Work is being done currently to extend this favorable effect in solid tumors, while also trying to prevent cytokine release syndrome and engineering the T cells to be more specific and efficient for an individual's cancer.

9. Blood Pressure Watch

Omron, the most popular home blood pressure device manufacturer in the United States, had FDA approval for the first smartwatch that takes a blood pressure reading via a brief occlusion of the radial artery. The latest version of the device, pictured above, was just unveiled at CES 2018, the annual electronics trade show held in Las Vegas, Nevada.

10. Artificial Intelligence for Eye Diseases

New computer programs draw on large datasets of retinal images to screen for diabetic retinopathy and other eye diseases, and these "deep-learning programs" have continued to improve since Google unveiled one a year ago.[8,9] In a deep-learning system, the computer is not told which features of an image are important; rather, it develops its own rules as it is exposed to an increasing number of annotated images. Developers of these systems believe that they will be more accurate than clinicians and eventually will be cheaper and more efficient in detecting eye disease.

I hope you find this list useful. I try to put up daily notices on Twitter about important advances in medicine and technology, so follow me there @erictopol if you want a constant infusion.

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