Saturday, January 16, 2016
Those dealing with ALS pay the price continuously for the myths that are propagated about the disease.
The ALS neurologist told Mom and our family on every visit that ALS was a pretty linear downhill path. He was the expert, right? That was helpful to know. There wouldn't be ups and the downs would be pretty consistent and constant. There were no ups for Mom, but the steady, downhill path careened off a cliff very quickly one day. It certainly wasn't linear. Mom's case must have been an anomaly, eh?
And as I have known more people with ALS, the downhill path is certainly unpredictable and it can slow (and then pick up again like an out-of-control train). But docs keep telling families to expect linear. And in hindsight, everybody feels like a the anomaly.
Now some neurologists are finally admitting that there can by ups and downs and it is hardly linear. It's difficult enough to deal with ALS and to prepare for what's next, and to assume that the path will have a constant slope doesn't help families meet the demands of the disease that in reality is unpredictable in many ways.
Doctors are trained not to look for zebras when most things are horses. Some are told that they may see at most one case of ALS in a career. They, therefore, don't look for it. And we have an unconscionable delay to diagnosis with ALS simply because docs miss it.
But wait, there's so much more. Painless, ha! $200K per year cost, ha!
Organizations and scientists now speak of the heterogeneity of ALS, yet they still toss out generalizations and averages that distort what families should expect. Those averages also result in gross misunderstandings of ALS by healthcare professionals. And those healthcare professionals repeat them from their positions of authority and the myths live on.
The time-honored benchmarks somehow became embedded in stone It's time to remove those benchmarks and gather the complete and granular data needed to explain ALS correctly.
Thursday, December 31, 2015
When we were kids we loved to go to the pool. But when we got there, it really wasn't a pool. There was a baby pool, a junior pool, a lap pool, a shallow pool, a deep pool, a diving tank. They were separated. Some of the water sloshed from one to the other, but they were built separately and cabbaged into a complex as the Boomer population grew.
Today we have scientists claiming to share data, but they're not building a pool. Much like our swimming pool, they are adding different pools to serve different purposes. Sure, they all contain data and some slosh around, but it's not a pool. They people using the junior pool are not able to swim into the deep pool.
From the recent "Ask the Experts" session at the ALS Symposium in Orlando, there is a question at around 1:35 about two of the databases in our growing complex of pools...
The answers weren't very good. The projects are "different." "Registry" is a bad word (no kidding). They can work together. Right. Show us exactly how the expensive CDC ALS Registry can work with the NIH CReATe Registry.
We need a pool for smart ALS intelligence. We don't need a complex of segregated and redundant and expensive pools that serve independent needs.
Calling the place we went in the summer "the pool" didn't mean that it was really a pool.
Friday, December 11, 2015
Well over a decade ago, those involved in the fight against ALS have wanted a good, central census of people with ALS -- a complete, statistically meaningful nose count of the who, where, when of the incidence and prevalence of ALS.
The ALS Association proposed that the CDC create such a central "registry." That seemed like a good idea since individual state and private registries were counterproductive to getting a good national census.
ALSA (The ALS Association) has an annual advocacy legislative agenda. Funding was to be requested for "building block" projects. Seeds were sewn to have an ALS Registry enacted into law. The ALSA approach is for advocates not to worry about the technical details -- just tell your stories. We had little information about the project design or anticipated budget details. Many of us worked hard at our own expense to get the Registry passed. Certainly it was important for us to collect the dots if we ever were to connect the dots. The ALS Registry Act was finally signed into law in 2008. https://www.govtrack.us/congress/bills/110/s1382
The annual dollars that we were to request to actually develop and deliver the Registry increased. Development of the Registry would be expensive. We received no businesslike itemization of the dollars we requested annually. ALSA told us what to ask for. We told our stories. We worked hard.
The project was "generously funded" (the words of the CDC project leader in 2010).
The design of the new Registry turned out to be based on passive data mining of government files -- Medicare, Medicaid, VA. People with ALS are eligible to get into those systems fairly quickly, so that looked like fertile ground for finding them (and avoiding any attempt at mandatory reporting of ALS as is done for cancers). The concept of a web portal for voluntary reporting was added to the base design. And we waited. The most recent government files are already several years old by the time the CDC could get them. Even though the web portal finally launched late in 2010, we couldn't get any data out until the passively-mined government files caught up. We were curious and asked about progress and patient uptake. In addition to the time lag excuse, ALSA staff told us that no information based on portal data entry could be released because of OMB rules. The OMB excuse came up repeatedly from ALSA as those of us anxious to know how things were going asked questions. The portal was clunky by 2010 standards. We wondered how many people with ALS were finding it and entering their data. Were there barriers that needed to be addressed? Our questions weren't answered.
Just tell your stories and continue to ask for unsubstantiated millions of dollars annually. We were good soldiers. We trusted. We believed. We didn't ask enough questions (not that they would have been answered anyway).
We weren't to get any until 2014. Keep being good advocates and ask for the annual appropriations you're told to request.
The Accidental Discovery
In June, 2013, I ran across something at usaspending.gov quite by accident. There were some large contracts handed (no-bid as the sole source for the services) to The ALS Association for "education and outreach" for the Registry. Surely this wasn't what it appeared to be! It was. The organization that works with the CDC and tells us the appropriation needed annually was actually a large contractor on this very project. And we had never been told.
We were dumbfounded that ALSA was being paid to do what we thought our donations were already paying them to do -- to raise awareness of the Registry and to promote patient self-enrollment. And substantial taxpayer funds were being directed to ALSA without transparency or any competitive bidding. They failed to tell us! That's a pretty important tidbit since they are the ones who tell us advocates the grand sum to request (without any businesslike accounting of details) on Capitol Hill every year.
Add the fact that ALSA and MDA are the only ones allowed to nominate patient participants for the Registry annual meeting. It looked bad. It smelled bad. It was way too cozy for good oversight.
With a little more digging, we found that the MDA was about to be handed a no-bid contract of its own. https://govtribe.com/project/als-outreach-and-education-activities-to-support-the-national-als-registry-2 Two sole sources? What was going on here? The phrase "turn at the trough" came to mind.
The FOIA Request
I asked the CDC ATSDR ALS Registry administrator what work product, deliverables, and work standards were on those no-bid contracts. What were ALSA and MDA actually doing for those large sums? The response was that I would have to file a Freedom of Information Act request. What was a simple question took us on a long journey.
The FOIA requests I submitted in 2013 were simply for the work product, deliverables, and work standards for two of the contracts -- one for ALSA and one for the MDA.
And we waited.
Fortunately I'm persistent and healthy (knock on wood). For over two years I followed up on the status of the requests. The CDC FOIA office form response was that these things can take years. Two of my friends with ALS who helped with the FOIA request died during the wait.
During the course of the wait, the first report from the ALS Registry was finally published in 2014, and it was certainly disappointing in substance. It raised a lot of questions about the completeness of the Registry. It raised a lot of concerns about self-enrollment. It yielded numbers that the very organizations that got big contracts on the projects don't seem to want to use, yet they continue to pat themselves on the back.
Any oversight on this project seems to be done by people with substantial financial interests in calling the project a success. Just tell your stories, advocates. There are always new, naive ALS advocates to take the places of those who start to ask questions like my buddies who died waiting for the FOIA requests. The annual meeting patient representatives are hand-picked by the contractors ALSA and MDA. And we've never seen the budget discussed in the minutes of those annual meetings.
Finally, Two Contracts
In November 2015, after another status inquiry, a large envelope appeared in my mailbox. It contained a letter explaining some of information withheld along with a CD with two files. A CD. Who still has a computer with a CD drive? Oh, well, I'm persistent. Here they are: an ALSA contract and an MDA contract. Both have information redacted, but there's plenty there to substantiate concerns about these sweet deals.
The first contract was signed on September 19, 2011 Keep in mind that the Registry had been promoted by ALSA for years before that and that the online portal for people to self-enroll had been opened in 2010.
The contract purpose is pretty a pretty vague "to promote the National ALS Registry through an exptensive nationawide network of ALS Clinics, Chapters, and Certified Centers of Excellence."
The "technical requirements" provide us with some deliverables that are things and tasks (and not Registry results). ALSA will fulfill their responsibilities by doing the things many of us thought they should do as part of their mission that we already support with donations. They are being paid to do tasks but there is no linkage to any results in increasing or even maintaining self-enrollment in the Registry. It's a pretty sweet deal, especially when you don't have to bid. And it amounted at that time to over $1.5 million over five years. But wait, there's more!
Less than two weeks after both parties signed the original contract, it was modified to an even bigger, sweeter deal. The amount was increased to a redacted amount. ALSA got the leeway to expand Registry education and outreach work to MLB, the NFL, MLS. And that has increased self-enrollment how? Again, there was still no tie or performance expectation to maintain or increase self-enrollment in the Registry.
And the seeds of scope creep were planted.
And in this bigger, better version of the contract, the monthly compliance-reporting requirement in the first contract was suddenly changed to, "To be discussed at Kick-off Meeting." OK, who was at that rather important Kick-off Meeting?
In both editions of the contract, there is a clear obligation that a contractor may not lobby for funding:
And we who go to the ALSA Advocacy Conference or who are online advocates hear about how great the Registry is from ALSA. ALSA employees tell us to ask our legislators for another $10 million. I suspect that through an intricate tapdance of who is on whose meter while talking to advocates, ALSA managed to fulfill the letter of that clause while defying its spirit.
There is also a requirement: "4. Educate and train Contractor's local chapters' staff to identify ALS patients, increase awareness about the National ALS Registry, and if necessary, provide assistance in registry enrollment. Contractor's chapter staff will not recruit ALS patients for the registry and will only assist with registration for those patients who request such assistance." Read that paragraph a few times and scratch your head.
There are pages and pages in that pdf that was on the CD, and it's not easy reading for a lot of reasons. By the time you plow to the end, you see a contract that somehow grew to $2.2 million.
A copy of some pages of the contract with my comments is here. I will call them lowlights rather than highlights.
The MDA no-bid contract was dated September 12, 2013, two years after ALSA had received its no-bid contract. The amount is a whopping $2,695,642 over five years. It has another interesting clause: "The contractor chosen must have direct and proprietary access to a high percentage of ALS patients in the United States." Chosen? Proprietary access?
In the base year MDA was to produce a Registry toolkit whose requirements are remarkably like we just paid ALSA to do. Why not just use ALSA's, folks?
MDA got the same missive as ALSA to supply "relevant equipment" to district offices, clinics, and support groups help promote the registry. There is no standard for "relevant equipment" nor is there any accountability. That's kind of hard to swallow when we see how hard people with ALS have had to fight government rules to supply them basic communication technology.
MDA is also being paid to educate its own "stakeholders" about the differences between the CDC's ALS Registry and other ALS-related registries. You see, MDA launched its own registry after the CDC's launched. Now we pay the launcher to clear that up among its own "stakeholders." Perhaps they can enlighten us on comparative data at the annual CDC Registry meeting sometime.
And maybe at the next CDC Registry meeting each invitee will introduce herself or himself as a project contractor, if appropriate. And perhaps the patient and caregiver representatives will tell us which ALS organization nominated them for participation.
We got the dirty deal. We got a national Registry with significant design flaws. We got poor execution. We got insider oversight and no accountability. We got a project whose scope was allowed to creep to fit a very generous, unsubstantiated budget. We got a project that continues to grow in search of things it might do well. We got a cozy, secretive relationship that defies the spirit of government rules that prohibit agencies and contractors lobbying for funds. We got a dirty deal. People with ALS were fleeced. We taxpayer-advocates were fleeced. Or loofaed.
Sunday, November 15, 2015
welcoming conference for people with ALS and caregivers who are interested in science. Access to a variety of scientists, especially during break time and lunch, was outstanding. Many of the conversations were candid and unfiltered, and that's a refreshing concept in the fight against ALS. Some miscellaneous impressions follow.
- In the last decade it seems like we've gone through a full philosophical cycle -- From trying to understand a complicated disease to trying to throw things at it regardless of the rationale (just put out the fire) back to trying to understand the many things going on with ALS (figure out if it's a grease fire or an electrical fire).
- The people with the most at stake in the fight against ALS don't have the benefit of a lot of institutional history. Those with ALS and their loved ones are largely new at it. Few with ALS live long enough to remember all that had been tried in the past, and organizations are not good at keeping the loved ones engaged for the long-term. This provides some convenient blind spots when some of the science is explained.
- Many promising drugs have been screened and tested over the last decade, and there is an ever-growing dud pool. Knowing about the volume and variety of duds is helpful to put the difficult road ahead into perspective. And we have to be realistic that today's "promising" may well end up in the dud pool. That doesn't mean stop. It means that we need to smarten up and shorten the route.
- Fundraising is essential, and it's a lot easier to raise funds based on "promising" than it is looking at a rear-view mirror full of expensive duds. Are we distorting the difficult road ahead by doing what's best for fundraising?
- People with ALS want to assume more risk, yet the scientists and clinicians aren't likely to step forward and lead that fight (or even lock arms with them as one man with ALS suggested). I'm more convinced than ever that patient-led movements will cause the change in this area. Organizations simply won't take the professional, public risks to be that bold in a heavily regulated field.
- Having a gentleman with professional and academic chops on the afternoon panel was priceless. The lithium story is one that has been subject to a lot of revisionist history. Sometimes the establishment tries to tell that story in a way that makes the patients look gullible. We had a person with ALS remind the panelists that the patients were the ones who showed that lithium didn't work. People with ALS were the ones who begged everyone to stop wasting money on trials. They should be respected for what they did.
- We heard that small ALS trials are largely destined to fail. It sounds more credible when panelists say it. Some people with ALS have been saying it for years. We even heard that at one time some clinicians wanted a very small lithium trial destined to fail to make that problem go away. There was some refreshing candor from Dr. Katz about the hype of some clinical trials. At the end of that discussion on trial design, some of us in the audience had a serious question as to whether there is anything currently worth the investment in a clinical trial? And I wondered what would happen to fundraising today if an organization would honestly say that there is nothing currently worth that investment?
Depressing? Not at all if you acknowledge the rear-view mirror and decide to take some new roads forward. We need to learn not only from the duds but also from slow, inefficient processes.
The father of a remarkable young woman with ALS asked if we are letting the perfect get in the way of the good. That sums it up. We need to forge ahead with admission of what's in the mirror and a willingness to take risk ourselves in many new ways so that people with ALS can take the risks that they accept (with eyes wide open) in order to move the science ahead faster.
Saturday, November 7, 2015
Especially when the waiting person is in a wheelchair.
Yet we close the door in the faces of those with ALS all the time.
Here's an example from twitter today.
It was an interesting article on the virus theory that has been in the news lately. A woman with ALS responds below. She's interested in the trial cited in the article. The article failed to contain trial contact information for those who actually have ALS.
Everything is hard for those with ALS. Life would be so much better for them (and quite frankly, trials would be filled much sooner) if people would simply make sure that they're holding the door open for those who don't need more barriers in their lives.
After all, they are why you're doing the science that is published in the first place.
Friday, November 6, 2015
Everybody has an opinion about the problem --
The GM is the problem.
The coach is the problem.
The offensive coordinator is the problem.
The QB is the problem.
And with every assessment of "the problem," there is an expected action that someone will be let go and changes will be made.
I live in a world of ALS that has teams that have set high expectations and have yet to deliver a big win.
It's much more than a game.
Do we ever assess "the problem" and take expected actions?
Thursday, November 5, 2015
- NIH funding is precious.
- Why were NIH funds needed for this new report? ATSDR has generous funding for the Registry.
- The delay to diagnosis for ALS is outrageous. Charlie Rose grasped it. Jay Fishman lived it. Dr. Rothstein didn't want to cast aspersions on the fellow physicians who fail to diagnose it. That delay to diagnosis is costly in many ways, and the patient is the one who pays the price, yet we give physicians a professional free pass when they miss it, and they often miss it.
- The ALS Ice Bucket Challenge missed opportunities.
- We need better accounting and accountability in the fight against ALS.
- Money won't cure a disease that is short on new ideas.
- The cure isn't "around the corner." I took that to mean that Dr. Rothstein has no impending treatment for Mr. Fishman. I appreciated the candor.
- Too bad the conversation didn't then jump on shortening "the corner" by getting experimental drugs to PALS much more quickly.
- Charlie Rose is on too late in my city.
- Jay Fishman has an attitude that reminds me of my mother when she faced ALS.
We need to have more serious conversations and more action to change the status quo. Thanks, Mr. Fishman.
Wednesday, October 21, 2015
To have neuroscience students interested in this beast of a mystery disease is so important! And those of us fortunate enough to be graduates of the University of Notre Dame have a big added dose of joy to see them raising awareness, research funds, and their prayers to fight ALS. It is a special place and so many alumni, family members, and friends of the school (and its rivals) have been lost to ALS.
Please participate. The campus is gorgeous in the fall and is not far from a lot of major cities in the midwest. And the t-shirts are awesome. Please support these students. Thank you. Go Irish! Beat ALS.
Hi! My name is Chris Ferari and I am a junior at the University of Notre Dame as well as one of the officers of the new Neuroscience Club on campus. I am very excited to announce that this year the Neuroscience Club will be hosting the 1st Annual Notre Dame ALS Walk, co-sponsored by the College of Science! This scenic approx. 2.7 mile walk around campus will begin and end at Jordan Hall of Science and include a short group prayer in the grotto. Here are the details of the event:
When: October 31st, 9-11 AM
Where: Across campus, beginning and ending at Jordan Hall of Science
Who: Notre Dame students, faculty, and friends
- -Proceeds benefit ALS Research and Programs at Notre Dame
- -Bagels, muffins, and coffee will be served before the walk!
- -Costumes are encouraged!
- -Notre Dame ALS Walk t-shirt guaranteed for the first 300 people to sign-up
- -Sign-up is $10 per person and additional donations are encouraged!
- -Sign-up and donate by following the link below:
We are incredibly excited about starting this walk on campus, and we hope that it can become a yearly opportunity for the Notre Dame community to raise money for a damaging neurological disorder that has affected many members of the Notre Dame family. Please consider donating to or attending this special event! Thanks in advance for your support!
Saturday, October 17, 2015
Monday, October 12, 2015
Families rely a lot on Dr. Google to find things to try. They search. They try to sort thought it all. They are fighting a terribly fast clock. The information they seek is in stunning disarray.
The information gaps have us blindly trying the same things over and over.
We need to capture information. We need to let the data speak. PALS need to be encouraged to self-report their information in a public and organized and searchable manner.
PALS and CALS are vulnerable to hucksters, and often on the day of diagnosis they are warned of
predators who will want to replace their fillings or shoot some fat cells into them. And new PALS and CALS are often frightened by their clinic staffs and ALS organizations on the perils of the internet.
This is so wrong. It is so wasteful. Instead why don't we encourage some productive use of the internet (beyond the miracle of fundraising)?
Let the data speak. If everyone who had fillings popped out self-reported on results, it would give PALS information for more intelligent choices. If everyone who tried Vitamin E self-reported on results, it would let PALS make more informed decisions.
Please, let the data speak.
Ironically, www.alsuntangled.com has been using self-reported data at www.patientslikeme.com where the data contributions from PALS seem to have dropped off severely in recent years. The ALS establishment needs to encourage the self-reporting rather than frightening PALS away!
People with privacy concerns can be as obscure in their personal identities as they want. A right-handed ballerina can call herself "Lefty" and post her data at patientslikeme. I cite that website simply because it has a good data presentment dashboard for those with ALS.
The information waste we are experiencing today is insane. It is wrong. Self-reported data are not perfect, but with a fatal mystery disease with no good treatment options, the imperfect data are valuable. To bury clues with PALS is just madness.
And perhaps it's time for all involved in the fight against ALS to ask PALS why they aren't self-reporting data today.
Let the data speak. Let PALS make more informed decisions. Give scientists a clue, too. Please. Information is a terrible thing to waste.
Sunday, September 27, 2015
Information. It’s the food we use to improve everything we do. It’s the feast that drives innovation, yet we waste so much.
Food deserts are a big problem in our urban areas. I think that information deserts are a big problem in healthcare. Do we find ourselves munching on what’s convenient rather than what’s really good for us?
People dealing with ALS have a bumper crop of information that is often left to wilt on the vine. That's an unacceptable waste, especially with a fatal mystery disease.
You see, the ice didn’t cure ALS. There is still no known cause. There is no effective treatment. It is a difficult, steep, downhill path to death.
Yet everyone in this room, regardless of what your role is in medicine, can benefit from information from those dealing with ALS – you, physicians; you, drug developers; you, entrepreneurs; you, smart students. Let’s talk a little about harvesting that information.
Before Mom died from ALS, she liked to take a trip every now and then. American Airlines retained more information about her travel history than medical science retained about her case of ALS. That’s outrageous. All the clues that her life and medical history harbored were buried with her. We’ll never connect the dots if we don’t start collecting the dots in an orderly and complete manner. Somebody, call American Airlines, please!
Shopping for shoes is challenging for me, but not nearly as challenging as shopping for an ALS clinical trial. Often when someone is diagnosed, a family member is put in charge of Dr. Google to go find something.
You hope that “something” is a clinical trial. It advances the science and is a legitimate Hail Mary for someone with ALS, but trials are not easy to find. You have to sift through enrolling interventional trials to try to find the most “promising” science. And you get emails out of the blue. It’s confusing. It’s time consuming.
And speaking of time, most ALS trials have a 24-month eligibility window from onset of symptoms. There is typically a 12-month delay-to-diagnosis with this disease. See a problem with time, here?
Last week I got an email from 6pm.com, Zappo’s outlet store – “The perfect shoes for you, and on sale!” I took the bait. I clicked on the message. Up popped a cute pair of shoes that looked like they would work for me. I’ve bought a total of three pairs of shoes in my entire life from 6pm.com, and they were able to make a pretty good match for me, yet clinical trial matching is stuck in the 1980s. Somebody, call 6pm.com, please!
Yesterday we talked a lot about precision medicine. I think we need to talk about accurate medicine, too – the right intervention at the right place at the right time. So often with ALS it looks more like this… We constantly throw the ball five yards behind the receiver. That does not help the patient. It’s wasteful. It’s expensive.
I have a wonderful old reading chair – a 50-year-old La-Z-Boy. It is so comfortable. Last winter it broke. It was stuck in the upright and locked position. I was heartbroken. I called my local La-Z-Boy store and a fellow in the warehouse was able to diagnose the problem over the phone – a broken part. Oh, no. He said not to worry. They would find one. I could pick it up after noon the next day. Really? Try breaking a part on a power wheel chair that is far more important than my reading chair. You get a shrug and , “Four to six weeks, what can you do…”
I’ll tell you what you can do. You can and you must measure. It’s about information. You measure performance. You set benchmarks. You improve processes. Somebody, call La-Z-Boy, please!
I have a challenge for you all and it doesn’t involve ice. Please consider ALS to be a stress test for whatever it is you do in medicine.
You’ll never become a great skier if you stay on the bunny slopes, and trust me, ALS is no bunny slope. It’s a difficult disease. It’s a demanding disease. It’s often a very fast disease.
If you can learn from those dealing with ALS, you will improve. You will innovate. And I guarantee you will be better for every patient you ever serve.
Copyright 2015 @ALSadvocacy All rights reserved.
Saturday, September 19, 2015
I took one of my everyday dishes to the testing site and brought along one of Mom's dishes that she and our family used every day for half a century. Hers was Franciscanware, a high-quality, everyday china that millions of housewives of the 1950s treasured for their families. The patterns each family had were expressions of mothers' favorite colors and themes.
When I had the china tested, I expected that my everyday china that I had bought on sale at Marshall's would test high and I would toss it. Lead is never good.
I also expected that the Franciscanware would be deemed safe. What a surprise I got. Yes, my inexpensive everyday china tested high, but the Franciscanware tested even higher. Yikes. Lead is never good, and if you've ever seen ALS, you have no desire to take any potential chances with any substance that can possibly mess with your neurons.
On a recent webinar on possible causes of ALS, I asked if anyone had ever studied the lead content of the dishes that people with ALS had used. I didn't get a direct reply to my question. The scientist just said, "Lead is never good."
ALS is a fatal mystery disease, yet we have no nimble systems for gathering and reporting on possible risk factors or causative factors. The studies take years and the information-gathering nets are not cast widely (quite possible because the studies take years and the disease often kills people quickly).
We need nimble. We need complete and organized information. This is not rocket science. We need ways to gather and harvest information quickly. What if there are some simple preventive measures we can take in our everyday lives? This is a matter of life and death.
Lead is never good. In the meantime, I've tossed all the dishes. I've seen ALS and it is never good, either.
Sunday, August 23, 2015
Of course not if you have a fire extinguisher in your hands and are trying to clear a path to help.
It would be very wrong if you have a great blueprint for an awesome extinguisher (that you consider to be a "breakthrough" in snuffing fires) and a successful experiment and a patent application but have yet to go through rigorous testing, certification, approvals, pilot production, or production. You would set a really cruel expectation amidst a lot of people facing death.
Last week was an interesting one in the fight against ALS. We had already seen the news published August 7 about TDP-43 in Science https://www.sciencemag.org/content/349/6248/650.abstract
That was certainly another good scientific step forward.
In a tenuous attempt to link the scientific good news to last August's ALS Ice Bucket Challenge, we started getting crafty statements. What better way to encourage donations this year than to associate it with a recent advance in understanding ALS?
Media coverage was being cultivated, and this makes a feel-good story about the marvelous, fun phenomenon of August, 2014. It makes a wonderful feel-good story.
As Answer ALS aptly described in a statement on Facebook, "The headline seen this evening had the phrase 'A Cure for ALS Could Be Coming Soon.' As the last few days have gone on, the headlines seemed to create themselves... "
And for families craving optimistic sound-bites as they deal with ALS, were they ever getting the optimistic sound-bites, right from the scientist's mouth.
And the ecstatic news went on and on. Mission accomplished?
- When did this work start?
- How much did the project cost and exactly who supplied what funding?
- What are the next steps?
- How much money is needed for the next steps?
- What is the most optimistic timeline for the next steps?
- What are the barriers (scientific or regulatory) to bringing this finding to a therapy?
That clarity and perspective will help us all to understand not only the significance of the findings but also what we all need to do to help bring those headlines to reality.
Maybe we need to talk about patient-centric p.r. and fundraising. A respected medical institution needs to celebrate its achievements and raise funds with respect for the patients and caregivers and loved ones who are trapped in a burning theatre. They just heard "fire extinguisher" on the national news last week.
Wednesday, August 19, 2015
Yes, amazing. Fabulous. Incredible. Say what?
We didn't get a good list of #ALSicebucketchallenge checks written to researchers last year. We saw numbers related to committed funds. In these lists of funded research, I don't see this project listed in the 2014 file but Dr. Wong is listed as a $160,000 grant recipient in 2015.
- The Robert Packard Center for ALS Research
- Muscular Dystrophy Association
- The Amyotrophic Lateral Sclerosis Association
- Target ALS
- The Johns Hopkins University Neuropathology Pelda Fund
- The Johns Hopkins University Alzheimer's Research Center (NIH P50AG05146)
- The Samuel I. Newhouse Foundation
Monday, August 10, 2015
That's a movement that originated with @speed4sarah. You can read up on it on her blog http://www.speed4sarah.com/sarahs-blog/
I decided to give it a try. I would try to give up something that ALS takes from people. It would raise some awareness. It would raise some funds.
One thing that really stuck with me when Mom had ALS is that we take so much for granted -- taking a sip of water without choking, working a door lock, talking to one another. There was such a spectrum of things that I could "give up" for #whatwouldyougive.
Mom still had good grip strength during her ALS but it was terribly difficult for her to lose the dexterity in her fingers. The inability to work a lamp switch or button a button was so frustrating for her. More on that later.
I set my #whatwouldyougive bar very low. I didn't want to fail. My left hand in a ski mitten for a day shouldn't be that tough. I'm right-handed. I picked a weekend day when I wouldn't have to do my day job. I didn't want to have to ask anyone for help, so I kept it simple. One free hand would work. I would be safe driving. The bar was so low that I felt like a sissy.
Enter Sunday morning. I put the mitten on first thing. Immediately I realized I couldn't scratch the dog like she expects every morning. Not a big deal, right? On to fix my toast and tea. It wasn't pretty when I realized that I could not slice my toast the way I've sliced my toast since I was six years old and learned to make my own toast. Thirty minutes into my experiment, I said, "Boy, I'll be glad when this day is over." Ninety minutes in, I was totally frustrated. I wanted my old life back where I could slice my toast my way.
I've broken my right wrist twice in my life and I was never this frustrated (there's that word again). I decided that immobilization feels good when something hurts and there is healing going on. That's not how this was. It was just exasperating. I couldn't clean my eyeglasses. I couldn't floss. My right arm itched. It was incredibly frustrating.
For my sanity, I decided to try some distraction and went to the grocery store. It went well until I needed a produce bag. Ah, plastic bags were my bane all day, at the store, in the wastebasket, on the dog walk.
By late morning I was really hungry and had no desire to frustrate myself more by cooking. I stopped in a local restaurant that was still serving breakfast. It was one of the best experiences of the day. We talked about the mitten and the hashtag and they fixed me a good breakfast that required no knife dexterity.
I had been making a list of the day's challenges and finally stopped listing them. We take so much for granted.
The first time Mom asked me to help her button her blouse, she asked, "Do you know what the worst part is?"
No, I didn't.
"When I've lost the ability to do something, I know I'll never do it again."
She had buttoned her last button.
At the end of my experiment I took off my mitten. My life goes on. My toast is right this morning. And how many mothers with ALS buttoned their last buttons yesterday?
Please set a challenge for yourself and try it. Low bars are fine. Trust me, it's not easy. And then support https://www.razoo.com/story/Sarah-Coglianese-Fundraising-For-Whatwouldyougive
Or give directly to @speed4sarah 's research cause at www.als.net
Or give to www.teamgleason.org that supplies technology to those with ALS to help compensate for those abilities that ALS steals.
Or do all of the above. After all, we take so much for granted.
Wednesday, August 5, 2015
The Sensations - 1962
Let me in whee-ooh (whee-ooh, whee-ooh, hoop-whee-ooh)
(Whee-ooh, whee-ooh, hoo-ooh-oop-whee-ooh, whee-ooh)
I can see the dancin' (let me in)
The silhouettes on the shade
I hear the music (music), all the lovers on parade
Open up (let me in), I wanna come in again
I thought you were my friend
The big ALS symposium is coming up in December. Already we're seeing news of abstracts accepted and discoveries that will be presented.
The registration fee of approximately $600 goes up even more after August 19. http://www.mndassociation.org/research/international-symposium/registration/
There are people with ALS and their loved ones who are interested in good science. They spend countless hours searching. A gentleman I knew with ALS attended the symposium in 2010 and found an interesting drug candidate and enrolled in the clinical trial as soon as it was available.
Why would we not want people with ALS or their loved ones at such a symposium?
Why would there be so many barriers between PALS and this festival of information about good science?
The fee without any consideration for people with ALS and caregivers is one of the big barriers.
The lack of welcoming information for those who aren't insiders is another.
The spirit and letter of the Patients Included movement needs to be in the fabric of every ALS meeting, especially the premier scientific symposium. It's past time for this meeting to be physically and virtually accessible to every PALS or loved one who is interested.
Thursday, July 30, 2015
It's happening thanks to some formidable people with ALS and caregivers. They aren't waiting for a system that doesn't understand urgency.
Here is a posting from a gentleman with ALS on the forum (it requires registration to view) at als.net:
Rich Casey, the CEO of Neuraltus, mentioned that ALSA is considering funding an Expanded Access (Compassionate Use) program for NP001, in addition to its $1.5M grant for a new clinical trial. As you know, Phase II clinical trial of NP001 yielded promising results in 2012, though falling short of its effectiveness goals. However, post hoc analysis identified "responder" biomarkers. Neuraltus has been trying to secure more clinical-trial funding ever since. Now ALSA expressed interest in underwriting a Compassionate Use program for NP001, along with the trial. Neuraltus believes there is an immense interest in the ALS community for this idea, but would like to have concrete evidence. Having a ready list of potential participants would help this cause, demonstrating the unmet need to ALSA as the sponsor. If you are interested, send a letter to Neuraltus requesting compassionate use access to NP001. This would strengthen Neuraltus's hand in dealing with the FDA as well as ALSA. We also should emphasize that the drug should not be withdrawn from those it helps, to prevent " crashes", like those experienced by Persevering and others during the wash-out period of the 2012 trial.
To: Rich Casey email@example.com
Below is a bare-bones sample letter to sign and send, but it would be good include your personal information and why you need NP001.
Dear Mr. Rich Casey,
As a person with ALS I want to join the Compassionate Use program for NP001. I am aware that the upcoming clinical trial would have only a limited enrollment. A large Expanded Access arm would benefit ALS research and help PALS. It is also important that long-term access to the drug should be ensured for those participants that benefit from it. Sincerely,
There are a number of threads on the forum at www.patientslikeme.com that discuss NP001. I urge any PALS, CALS interested to read them. It definitely did something in some PALS in the Phase 2 trial. Some also crashed terribly when the drug was taken away.
Here is an article from the WSJ regarding one of the PALS who was in the last Phase 2 trial in 2012:
And finally, here is a powerful letter that one of the Phase 2 volunteers just wrote to Mr. Casey:
Dear Mr. Rich Casey,Certainly an expanded access program isn't ideal, but it is something. This potential therapy for some PALS (elevated IL-18 was cited as being characteristic in responders) has sat on the shelf for almost three years while the drug developer has not been able to raise the capital needed for a Phase 3 trial. The system is broken. Why scientists have not been more curious about what was happening with this drug is beyond me.
As a person with ALS I want to join the Compassionate Use program for NP001. I was in the NP001 Phase II trial and received the high dose. NP001 stopped my ALS dead in it's tracks during the time I was on it. I know first hand that NP001 is a safe and effective treatment for ALS patients. I am aware that the upcoming clinical trial would have only a limited enrollment. A large Expanded Access arm would benefit ALS research and help PALS. It is also important that long-term access to the drug should be ensured for those participants that benefit from it. Thank you for the opportunity to provide NP001 to the broader ALS community, I know it will save many lives.
People with ALS and their caregivers are taking matters into their own hands and trying to open up some options. They are demanding and getting attention.
I encourage all PALS, CALS who are at all interested in trying to email Mr. Casey now at firstname.lastname@example.org .
Thursday, July 23, 2015
People who work for a large government agency simply don't.
It's time for the former to change the latter.
The people with ALS and caregivers at HopeNowForALS.org have issued an update and a call to action. It is long but well worth reading below. It will enlighten some and it will make us all think. These are grassroots people with the ultimate skin in the game. They have studied. They are thoughtful. They are leading. They have made tangible, reasonable proposals to the FDA. They will also listen to you if you have different or better ideas.
Then please act. A few messages to FDA officials won't make a difference. A few hundred might. A few thousand will. Please contribute your thoughts directly to FDA employees who work in a bureaucracy that simply does not grasp urgency.
Then please ask others to act. This is how we all can make a tangible difference.
Thank you. It's urgent. The FDA needs to know that we're not going away.
Please read and share this important update!
Hope Now for ALS update: Summary of July 6th call
Dear Hope Now for ALS (HNFA) supporters,
We apologize for the delayed update. We have been trying to schedule the next meeting so we could report that in this update. After our July 6 meeting, we submitted a detailed proposal to the FDA and requested a timely response, but it appears the FDA is stalling. They suddenly want to invite other “stakeholders” to our meeting. We believe this is a tactic to bring people and organizations into the discussion that will defend the status quo and to convert the role of actual PALS and CALS into a minority voice. With much regret, we need to report that after three meetings we see little evidence that the FDA is willing to be flexible with respect to clinical study designs and data analysis approaches that could accelerate the development and delivery of safe and effective medicines for ALS. WE WILL NOT ACCEPT THIS!
Please write the FDA today and copy members of Congress and the media expressing your outrage that ALS is still not being treated with urgency. Demand that the FDA respond immediately to Hope Now for ALS (HNFA) in a substantive and meaningful way as they promised they would. State that you regard Hope Now for ALS as your representative for this process and that you expect the FDA to continue timely, direct discussions with HNFA on expedited and modernized development and approval pathways for ALS treatments – a 21st Century Approval Process!
Please email Dr. Woodcock at the FDA:email@example.com and copy the people below and your representatives and media firstname.lastname@example.org@email@example.com@firstname.lastname@example.org@email@example.com@firstname.lastname@example.orgGrace_Stuntz@email@example.com
Summary of the July 6th conference call
Our third meeting with Janet Woodcock and her staff focused on finding common ground; specifically, balancing the need for faster, less costly, more conclusive trials and the FDA’s desire to keep ineffective treatments off the market. We were able to agree on FVC (change) as a primary endpoint, and ALSFRS (change) as a secondary endpoint. The ensuing discussion focused on topics fundamental to designing quick confirmatory studies that could lead to approvals for drugs/treatments that have demonstrated safety and preliminary evidence of efficacy in Phase 1 or 2 trials. Two principal topics that emerged from this discussion were (1) use of a patient-specific ALS progression predictive algorithm to construct a virtual and homogeneous placebo trial arm designed to reduce statistical noise in trials caused by the heterogeneity of ALS; and (2) understanding where and how the FDA can show some flexibility in the use of its statistical significance standard based on calculation of a p value as the standard for establishing “efficacy.” Achieving a p-value of < 0.05 in a trial where measuring a modest improvement in ALS progression is the primary endpoint necessarily increases trial size to substantiate positive outcome, adding time, cost and other complications that function as disincentives for companies to pursue approval of new medicines for ALS. However, by incorporating progression prediction models and patient-specific data, a 21st century approach to trial design, we would be more likely accurately measure the effect of the drug, improving the chances for recognizing of success when it occurs. We also advocated for the collection of secondary data in trials especially investigational biomarkers, and stratification of patients to better discern evidence of “efficacy” and to identify subsets of patients who benefit from a drug when efficacy is not seen in a majority of the patients. Unfortunately, as with our previous in-person meeting and our prior teleconference with FDA, we did not receive clear, actionable responses from FDA, and on some critical points of discussion, we encountered firm resistance to any form of new thinking in how drugs for ALS are developed and approved.
Detailed Notes of the July 6th Conference Call
On June 6, 2015, Hope Now for ALS held its third meeting with the FDA to discuss creation of an expedited development and approval pathway for new ALS treatments. We opened the meeting with some sad news, informing the FDA that a member of our leadership team, Dr. David Huntley (husband of Linda Clark – also on our leadership team) lost his battle with ALS on July 4th. We informed the FDA of his passing at Linda’s request to remind everyone that making and delivering progress for ALS is a matter of extreme urgency. FDA responded with an expression of sorrow and a statement that they understand and share the urgency felt by the patient community.
Bob Hebron led the meeting for Hope Now for ALS (HNFA). The primary participants for FDA were Drs. Janet Woodcock and Ronald Farkas, although most of the FDA participants from the prior call also attended.
HNFA introduced the concept of using a predictive algorithm to select patients for a study, and then to serve as a second control arm alongside an actual control arm with the objective of reducing the statistical noise caused variability in the rates and characteristics of progression among PALS. The predictive algorithm approach was then discussed in some detail, including input from experts developing a predictive algorithm for ALS using existing patient data. It was explained that the algorithm accurately predicts decline in ALSFRS and can be adapted to predict other measurement endpoints, such as FVC.HNFA then proposed that a clinical study designed to test for a slowing of progression could be conducted by using the predictive algorithm to select fast-progressing patients (termed “enrichment” by FDA) that could fill the study with “like” patients in terms of rate of progression. A positive effect on fast progressors might be seen more quickly (statistically), and in a smaller study population, than trying to discern the same effect in a population of mixed rate progressors. FDA indicated that enriching the study with fast progressors might be acceptable to them, and they expressed an openness to using the predictive algorithm for that purpose; however, they noted that if the study were populated only with fast progressors, the results might not be as generalizable to the larger ALS population as it would be if the study were run in a broader population of PALS (i.e., fast and slower progressing PALS).
HNFA then proposed that the study could perhaps be stratified (meaning looking at subgroups within the population) to learn more from the study, and to try to further reduce the statistical noise generated by the variability in the progression rates and types of motor functions lost as the disease progresses, seen at the individual patient level. FDA responded that attempting to stratify a study prospectively would complicate study design, lengthen the time needed for enrollment and cause the study to have to be larger (i.e., FDA would be looking for a much larger, longer study with each subgroup large enough to have adequate statistical power if the sponsor intended to draw conclusions regarding drug effect based on any subgroup analysis). FDA then said that retrospective analysis could be conducted on the study results to try to understand what happened, but the implication was that retrospective analysis would likely not support an approval.
HNFA then made the point that the patient community is looking for an agreement with FDA on smaller, smarter studies to keep the cost down and speed up the entire process.
FDA’s response was entirely statistics-based and summarized below:• A study can be small if there is a huge treatment effect• A small study risks statistically missing a small treatment effect• FDA reported that some Breakthrough drugs approved based on early data didn’t show a large treatment effect in later confirmatory studies.• FDA advised that once an expected treatment effect is estimated (e.g., how much more slowly a drug might cause ALS to progress in the study population), cut it in half and design the study to be large enough to detect the smaller treatment effect to a level of statistical significance.FDA did not directly respond to our statement regarding an agreement on smaller, smarter studies.
[Explanation – not from the FDA. What FDA actually said here is that they expect any entity trying to develop a new drug for ALS to do conduct the same large, time-consuming. randomized controlled studies today that the agency would have required 10, 20 or even 30 years ago. The FDA’s response is rooted in its long-standing its adherence to a purely statistical approach to designing studies and evaluating study results, and is based on the results of at least one, and preferably two, randomized controlled studies producing positive results at a measure of statistical significance, called a p-value, of 0.05 or less. Setting the p-value requirement at 0.05 or less means (in simplified terms) that the chance the results seen in the study happened because of chance (and not because of the drug) is 5 percent or less. FDA was explaining that an acceptable p-value can result from a large treatment effect in a small population of patients; however, to detect a small slowing of progression to a level of statistical significance acceptable to the FDA (p = 0.05 or less), a much larger, longer, more expensive study would need to be run. This convention, which has been relied on by FDA for decades as its standard for approving new drugs (since the 1960s), creates a reality in which getting a modestly effective drug approved by FDA takes much longer, costs much more and is much more uncertain for sponsors, than getting a highly effective drug approved. Given the current state of the medical science for ALS, all the drugs currently in the pipeline appear to have the potential for causing modest positive effects on disease progression and symptoms; thus, the FDA’s position on study size and statistical significance creates a financial and technical barrier to sponsors who might otherwise be interested in trying to navigate the agency’s development and approval process if a more creative and financially-feasible pathway was available. It also creates an obvious problem for the current and future generations of PALS and CALS who are faced with a drug development and approval process that makes approval of a new drug in a timeframe meaningful to them, all but impossible. HNFA is attempting to negotiate a more reasonable and productive development and approval path for ALS treatments with the FDA. So far, it appears that FDA has no interest in joining us in thinking outside the traditional statistical box.]
HNFA raised the concept of using the predictive algorithm to analyze the study results as a second control arm (run alongside an actual control arm with patients receiving a placebo) that might be a better way to control a study because of the algorithm’s potential to reduce statistical noise associated with variability among patients and the accuracy/precision noise known to be associated with measures like the ALSFRS and FVC. FDA replied that they would not object to looking at its use as a control arm, and that the usefulness of the algorithm could be evaluated by comparing the control outcomes predicted by the algorithm with the outcomes from the actual control arm. FDA described use of the algorithm for this purpose as exploratory, and appeared to be disinclined to rely on anything learned from its use to interpret the study results.
HNFA then asked: What is different about the input we are receiving from FDA today from what we would have heard 5, 10, 15 or even 20 years ago? FDA responded that the difference is they are talking to us about it – something they would not have done in the past. FDA did not offer any other explanation of differences between the advice they are offering us now versus what they would have advised in the past. HNFA then proposed that the study should include a cross-over provision (to the active drug) for patients randomized to the placebo control group, if after an appropriate period of following the patients in their respective groups (treatment and control), the drug appeared to be having a positive effect for some patients. FDA responded that they thought we were talking about a delayed start trial where some patients would start on a placebo, then be switched to the active drug. We responded that we were actually proposing a more traditional randomization to treatment or placebo at the start, with cross-over at the end of the monitoring period, and that if some of the patients who crossed over to the active drug then responded to treatment (for example by seeing their progression slowed), those responses should be considered favorable and could be compared to the predicted rate of progression using the algorithm. FDA did not provide a clear response to this concept but seemed to be discouraging it, and we raised the question regarding why FDA had never developed a way to consider patient responses observed after cross-over from the control to the treatment group as evidence supporting efficacy of the drug being tested? FDA responded that they were talking about these kinds of concepts at a high level but had not begun applying them at the study design and review level.
HNFA expressed its growing frustration that we do not seem to be getting clear and actionable responses from FDA. In response FDA asked that we submit a list of things the FDA had expressed “openness” about so they could confirm or clarify their position.FDA reiterated its concerns about trying to use biomarkers as supporting evidence in an ALS study, stating that they had been burned by biomarkers too many times. (We did not pursue this discussion further since based on previous discussions, use of biomarkers at this time appears to be off the table with FDA. It seems they have no objection to collecting biomarker data – but they are not open to using them for purposes of regulatory decision-making regarding an ALS treatment.)
On endpoints, FDA stated that they think there is significant variability in ALSFRS and FVC measurements, and stated that if FVC is selected as the primary endpoint, it would not be evaluated in a vacuum. They would be looking for concordance in other measures (e.g., they would want to see ALSFRS and other patient outcome measures generally go in a positive direction if FVC outcomes were statistically positive).
During the meeting, HNFA expressed the following to FDA and FDA provided the following responses:• We have made clear to FDA the ALS community’s perception of risks versus benefits, and that the community considers the risks of the disease to substantially outweigh the risks of investigational treatments that, based on early data, indicate they may provide some benefit.FDA responded that they understand that the ALS community supports approval of treatments with adverse side effects if the drugs also provide some benefit.• HNFA clarified that the community extends their position on risk to FDA being open to approving drugs in an expedited manner based on limited data, and then relying on post-approval studies and registries to learn more, faster about the safety and efficacy of the treatment and how to optimize its use, even if granting the early approval might result in some treatments ultimately being found less safe or effective than originally thought, requiring re-labeling or even withdrawal from the market. Presently, PALS have almost nothing available to them and the pipeline is thin in part because of the high regulatory hurdles for ALS treatments; problems that can only be addressed through a stream-lined and expedited development and approval path. A specific recommendation that was made during the meeting was that FDA should be more flexible with its statistical significance standard (p = 0.05) for diseases like ALS with an extreme unmet medical need, which would allow for smaller, faster studies that, if positive at a lower level of statistical significance, could lead to a conditional approval (which is what accelerated approval already is), supported in the post-approval space by continued study.FDA responded in a noticeably rigid manner that it must meet its statutory standard in the Food Drug and Cosmetic Act (FDCA), and that if the ALS community wanted the standard changed, they should pursue that with Congress.[Explanation – not from FDA . The standard for approval in the FDCA is generally worded and allows broad discretion to FDA in deciding what the standard for approval should be for any drug intended to treat any disease. Congress has directed FDA to be more flexible when setting the standards for new medicines intended to treat serious and life-threatening diseases with unmet needs. ALS is among the most serious of all known diseases, and is almost universally fatal within 2 to 5 years) In our case, FDA has firmly indicated that they do not intend to be flexible.]HNFA responded that FDA has broad discretion in interpreting and applying the approval standards in the FDCA, and that Congress had already instructed them to use that discretion for new medicines intended to treat diseases like ALS.HNFA explained to FDA that our goal is to complete these discussions regarding a streamlined development and approval path for ALS drugs in a few additional weeks, then move to the next stage of proposing the pathway to sponsors for comment and potential use in starting registration clinical studies within the next few months, with the goal of completing the data collection portion of those studies by the end of this year, and that we expected FDA to partner with us in achieving this goal.In follow up communications between HNFA and FDA since the July 6th meeting, HNFA has opted to submit a conceptual study design to FDA, and FDA agreed to provide feedback within approximately one week. The conceptual study design was provided to FDA and we expected a response this week. Instead, we received an e-mail from FDA stating that they would “…like to broaden the participants so more members of the ALS community can participate and provide input.” This decision by FDA, which was made unilaterally without consultation with HNFA, appears to mean that they do not intend to respond to our proposal in a timely manner. It also means that the pace of discussions with FDA regarding the modernization and acceleration of new drug development programs for ALS will be substantially slowed, and will lose focus as “stakeholders” with goals that differ significantly from the urgent needs of PALS and CALS are selected by FDA and brought into the process.