Where will medicine be 20 years from now?

My answer from this question on Quora.

I can answer this question, at least speculatively, from the perspective of clinical practice and medical technology. The other side of “where medicine will be” is the question of healthcare delivery systems, reimbursement, etc. To get that part of it out of the way, it is clear that some form of reform in healthcare will result in a consolidation of the infrastructure paying for and managing patient populations. The infrastructure is bloated and expensive, unnecessarily adding to costs that neither the federal government nor individuals can sustain. This is not to say that I predict movement to a single payer system — that is just one perceived solution to the problem. There are far too many costs in healthcare that offer no benefits in terms of quality; indeed, such costs are a true impediment to quality. Funds that go to infrastructure (insurance companies and other intermediaries and the demands they put on healthcare delivery work directly against quality of care. So, whether it is Obamacare, a single payer system, state administered healthcare (exchanges) or some other as-yet-unidentified form, there will be change in how healthcare is delivered from a cost/management perspective.

From the clinical practice and technology side, there will be enormous changes to healthcare. Here are examples of what I see from tracking trends in clinical practice and medical technology development:

  • Cancer 5 year survival rates will, for many cancers, be well over 90%. Cancer will largely be transformed in most cases to chronic disease that can be effectively managed by surgery, immunology, chemotherapy and other interventions.
  • Diabetes Type 1 (juvenile onset) will be managed in most patients by an “artificial pancreas”, a closed loop glucometer and insulin pump that will self-regulate blood glucose levels. OR, stem cell or other cell therapies may well achieve success in restoring normal insulin production and glucose metabolism in Type 1 patients. The odds are better that a practical, affordable artificial pancreas will developed than stem or other cell therapy, but both technologies are moving aggressively and will gain dramatic successes within 20 years.
  • Diabetes Type 2 (adult onset) will be a significant problem governed by different dynamics than Type 1. A large body of evidence will exist that shows dramatically reduced incidence of Type 2 associated with obesity management (gastric bypass, satiety drugs, etc.) that will mitigate the growing prevalence of Type 2, but research into pharmacologic or other therapies may at best achieve only modest advances. The problem will reside in the complexity of different Type 2 manifestation, the late onset of the condition in patients who are resistant to the necessary changes in lifestyle and the global epidemic that will challenge dissemination of new technologies and clinical practices to third world populations.
  • Cell therapy and tissue engineering will offer an enormous number of solutions for conditions currently treated inadequately, if at all. Below is an illustration of the range of applications currently available or in development, a list that will expand (along with successes in each) over the next 20 years.
  • Gene therapy will be an option for a majority of genetically-based diseases (especially inherited diseases) and will offer clinical options for non-inherited conditions. Advances in the analysis of inheritance and expression of genes will also enable advanced interventions to either ameliorate or actually preempt the onset of genetic disease.
  • Drug development will be dramatically more sophisticated, reducing the development time and cost while resulting in drugs that are far more clinically effective (and less prone to side effects). This arises from drug candidates being evaluated via distributed processing systems (or quantum computer systems) that can predict efficacy and side effect without need of expensive and exhaustive animal or human testing.
  • Most surgical procedures will achieve the ability to be virtually non-invasive. Natural orifice translumenal endoscopic surgery will enable highly sophisticated surgery without ever making an abdominal or other (external) incision. Technologies like “gamma knife” and similar will have the ability to destroy tumors or ablate pathological tissue via completely external, energy-based systems.
  • Information technology will radically improve patient management. Very sophisticated electronic patient records will dramatically improve patient care via reduction of contraindications, predictive systems to proactively manage disease and disease risk, and greatly improve the decision-making of physicians tasked with diagnosing and treating patients.
  • Systems biology will underlie the biology of most future medical advances in the next 20 years. Systems biology is a discipline focused on an integrated understanding of cell biology, physiology, genetics, chemistry, and a wide range of other individual medical and scientific disciplines. It represents an implicit recognition of an organism as an embodiment of multiple, interdependent organ systems and its processes, such that both pathology and wellness are understood from the perspective of the sum total of both the problem and the impact of possible solutions.


There will be many more unforeseen medical advances achieved within 20 years, many arising from research that may not even be imagined yet. However, the above advances are based on actual research and/or the advances that have already arisen from that research.

Applications, global markets in tissue engineering and cell therapy

Screen Shot 2014-04-17 at 7.37.44 AMThe market for tissue engineering and cell therapy products is set to grow from a respectable $8.3 billion in 2010 to nearly $32 billion by 2018. This figure includes bioengineered products that are themselves cells or are actively stimulating cell growth or regeneration, products that often represent a combination of biotechnology, medical device and pharmaceutical technologies. The largest segment in the overall market for regenerative medicine technologies and products comprises orthopedic applications. Other key sectors are cardiac and vascular disease, neurological diseases, diabetes, inflammatory diseases and dental decay and injury.

Cell-tissue-applications

Factors that are expected to influence this market and its explosive growth include political forces, government funding, clinical trial results, industry investments (or lack thereof), and an increasing awareness among both physicians and the general public of the accessibility of cell therapies for medical applications. Changes in the U.S. government’s federal funding of embryonic stem cell research has given a potentially critical mass of researchers increased access to additional lines of embryonic stem cells. This is expected to result in an increase in the number of research projects being conducted and thus possibly hasten the commercialization of certain products.

regional-forecast

Source: Report #S520, “Tissue Engineering, Cell Therapy and Transplantation: Products, Technologies & Market Opportunities, Worldwide, 2009-2018.”

Another factor that has influenced the advancement of regenerative technologies is found in China, where the Chinese government has encouraged and sponsored cutting-edge (and some have complained ethically questionable) research. While China’s Ministry of Health has since (in May 2009) established a policy requiring proof of safety and efficacy studies for all gene and stem cell therapies, the fact remains that this research in China has spurred the advancement of (or at least awareness of) newer applications and capabilities of gene and stem cell therapy in medicine.

Meanwhile, stricter regulations in other areas of Asia (particularly Japan) will serve to temper the overall growth of commercialized tissue and cell therapy–based products in that region. Nonetheless, the growth rate in the Asia/Pacific region is expected to be a very robust 20% annually.


MedMarket Diligence’s Report #S520 remains the most comprehensive and credible study of the current and project market for products and technologies in cell therapy and tissue engineering.

Technologies and Areas of Clinical Focus for 2014 Medtech Startups

Since January 1 of this year, we have identified 42 medical technology startups and added them to the Medtech Startups Database. As is the case with all of the companies in this database, these recently added companies represent a wide range of focus in clinical practice and technology:

Screen Shot 2014-04-16 at 8.12.15 AM

(Note: Multiple categories possible per company, such as minimally invasive and surgery)
Source: MedMarket Diligence, LLC

Below is a list of the technologies under development by these startups:

  • Ophthalmology prescreening technology for detection of diabetic retinopathy, cataract, glaucoma, cornea problems and refractive errors
  • Tissue engineered scaffolds to generate synthetic tracheas
  • Embolectomy devices
  • Resorbable embolization material for use in interventional radiology and drug delivery.
  • Time-varying electromagnetic fields for the treatment of inflammatory, autoimmune and degenerative diseases
  • Tissue attachment technology
  • Devices and procedures to improve nasal breathing
  • Devices for minimally invasive, augmentative or reconstructive mastopexy
  • Ocular stent for treating age-based vision changes
  • Ophthalmic device company focusing on age-related macular degeneration, diabetic retinopathy, retinitis pigmentosa, hemianopia, and glaucoma
  • Neuroscience-based technology (neuromodulation) for enhancing performance on cognitive tasks, for the healthy and impaired
  • Portable, ultrasound-based device non-invasive, transcranial diagnosis of stroke
  • Temporary cardiac pacing as treatment for reversible symptomatic bradycardia
  • Product to improve treatment of kidney stones and product to reduce pneumonia in intubated patient and ventilated patients in the ICU
  • Biometric medical device for orthopedic and other diagnostic applications
  • Technologies for treating urological conditions and disorders
  • Use of biomaterials in aesthetics for non-surgical temporary & permanent breast and buttock enhancement, facial rejuvenation solutions and adipose tissue engineering related therapies
  • Custom surgical implants including using 3D printing
  • Targeted, localized drug delivery
  • Protein-free tissue sealants in surgery, initially targeted to vascular applications
  • Hemostatic dressing for non-compressible hemorrhage
  • High resolution imaging in cancer
  • Image-guided surgery
  • Cardiac assist device for patients otherwise needing transplant
  • Implant to restore some sight for patients with retinitis pigmentosa
  • Device to harvest bone grafts
  • Device and method for self-collection of samples to screen for HPV, chlamydia, and gonorrhea
  • Implantable neuromodulation device for the treatment of chronic pain and overactive bladder
  • Encapsulated pancreatic cells for treatment of type 1 diabetes
  • Embolization device
  • Deep brain stimulation for Alzheimer’s and other cognitive disorders.
  • Magnetoencephalography and magnetocardiography
  • Technologies to manage core temperature in critical care and post-surgical patients
  • New method to use pulse wave velocity to measure arterial stiffness as indicator of heart attack risk
  • Autologous cell therapy delivered at the intraoperative point of care
  • Minimally invasive hip implants and other orthopedic implants
  • Orthopaedic implants
  • Tactile stimulator to work with fMRI, a dermatome for skin grafts and other technologies
  • Carbon nanotube fiber material to treat ventricular arrhythmia
  • Devices for cardiac and vascular procedures designed for easier use and lower cost
  • Knotless suture technology

For a historical list of technologies at medtech startups in the full database, see link.

The Aesthetics & Reconstructive Surgery Products Global Market

Global medical aesthetic products are to achieve sales of more than $6.5 billion in 2013. Through 2018 the market is expected to reach a value of about $10.7 billion. Europe has been witnessing relatively a slower growth of 6.6% per year. Declining purchasing power, particularly in southern Europe affects the European market and this geographical segment is estimated at $1.84 billion in 2013 to reach $1.94 billion in 2018. The U.S. and the Latin America markets will have a CAGR close to 10%. The U.S. and Latin America will experience a growth respectively of 9.2% and 10% in line with global trends. The U.S. market still represents 45% of the global market.

Screen Shot 2014-04-15 at 7.27.04 AMThe Asia/Pacific region will have an overall CAGR of more than 14.1%. Asia will experience the strongest growth through 2018 and exceed the level of the European market in 2018 to $2.24 billion. Overall, the annual growth of the world market between 2013 and 2018 should be 10% to $10.7 billion.

The injectable products (botulinum toxin and fillers mainly hyaluronic acid) constitute the top market segment in value and will have a CAGR of 10.8% until 2018, thus confirming their constant development potential. Since 2012, the toxins market marginally exceeded the dermal fillers market in the world but with a few exceptions such as Europe. The main markets for injectable products by decreasing order are the U.S., E.U., Asia and South America.

The energy-based devices (laser, radiofrequency, ultrasounds) will have an average CAGR of 10.3% until 2018. The sub-segment of body contouring devices will have an average CAGR of 12.1% until 2018. It should represent as nearly half of the activity-based equipment energy by 2018. The main markets for energy-based devices by decreasing order are the U.S., E.U. Asia and South America.

The cosmeceuticals (active cosmetics) will follow the same trend as the injectable products. The major markets for active cosmetics in decreasing order are the U.S., Asia, South America and the E.U. The market for active cosmetics in 2013 and 2018 will be $1,026 million and $1,677 million respectively. The breast implants will have a reduced progression of 5.2% per year until 2018. The major markets for breast implants by decreasing order are the U.S., South America, E.U. and Asia. The 2013 and 2018 market for breast implants will be about $1,066 and $1,370 million respectively. The two most popular cosmetic surgery procedures are still, in the world as well as for each geographical area, the liposuction and the breast augmentation with prosthetic implants. Breast implants experienced a slowdown of about 9% mainly due to concerns about the safety of their components, but this suspicion seems to disappear gradually in recent months.

More limited surgical procedures now are performed in the face, arm, or the internal face of thighs. The goal is primarily to make a change with a natural result. For the face it is readily associated with fat injection to recover volumes. Minimal invasive therapies enjoy a strong growth in 2013, especially with the new botulinum toxin. Alternative techniques to the toxin as cryomodulation begin to develop. The non-invasive techniques are increasingly linked to each other: toxin for the upper face and hyaluronic acid for the lower face, willingly associated with rejuvenation and retightening techniques of the skin by radio frequency and light peels. Far from being opposed to surgery, these techniques maintain surgery result. There is strong growth of surgical cosmetic procedures for men and women above 50 years old in Western countries due to the demand for anti-aging treatment and social pressure. These procedures increased from 28% to 36% between 2005 and 2011, this demand is also significant for invasive treatments and non-invasive.

From “Global Markets for Products and Technologies in Aesthetic and Reconstructive Surgery, 2013-2018″, Report #S710, published by MedMarket Diligence, LLC.

Wound management spans big to small, established to startup

The worldwide wound management market is represented by a mixture of a small group of well established companies like Johnson & Johnson, 3M, KCI, Smith & Nephew, Systagenix and Covidien and a large number of mid-sized and smaller companies with niche product offerings; see Report S249 for a list of profiled companies (and note that we have profiled a select number of active companies discussed in the report).

Screen Shot 2014-04-14 at 2.39.41 PM

Source: MedMarket Diligence, LLC; Report S249.

The fastest-growing market segment is the Growth Factors market, with a compound annual growth rate well in excess of 20% annually since 2012. Favorable clinical evidence is a major driver of that growth. The largest product segment is Traditional Adhesive Dressings, followed by Negative Pressure Wound Therapy. The largely generic adhesive dressing continues to be used for the majority of wound care cases. Negative Pressure Wound Therapy is coming into increasing use as smaller devices allow use in non-hospital settings, and as the technology demonstrates efficacy.

The wound management market is, overall, a mature business sector which contains both long-established product groups and more recently developed approaches to wound care. Price competition remains the key strategy in maintaining value share for the major players. The major components of the market include:

  • Traditional wound care products, such as bandages, dressings and swabs made of generic cotton and textile fabrics.
  • Wound closure devices, including familiar devices such as sutures and staples, as well as newer methods of wound closure such as tissue sealants and glues; also hemostatic devices to help arrest bleeding while closing the wound. Wound closure devices are primarily used in surgery, and are not addressed in this report.
  • Advanced wound care (AWC) products. This umbrella covers dressings which are based on moist wound healing concepts, active therapies such as biomaterial composites and tissue engineered products, and products encompassing aspects of growth factors and angiogenesis. AWC products may be made of biopolymers, hydrocolloids, composites, foam materials, films, etc. These are used mainly for the treatment of chronic and slow-to-heal wounds.
  • Consumer wound care. This sector includes a wide range of wound care products, primarily for use in first aid. The consumer wound care market is not addressed in this report.

A company which develops expertise in engineering and manufacturing in one area of wound management will frequently leverage those skills by expanding into related areas of wound care. For this reason, a number of the leading wound management companies market products within most or all of these categories. When it comes to the advanced wound care products, wound management businesses may choose a strategy of partnering with specialist developers of these novel technologies. Such collaborations often lead to the larger firm acquiring the technology and/or the company that developed the technology, in order to bring the intellectual property in-house, as well as to optimize manufacturing and supply.

Global health care expenditure is expected to grow by at least 6% compound annual growth rate (CAGR) between 2011 and 2020. The demographic changes driving this growth include the aging of the population, the continuing increase in new technologies commanding ever higher prices, and improved understanding of disease processes. This last leads to development of new procedures, products, and therapy regimens to treat disease, which feeds (at least in the USA) into an increasing desire on the part of patients to have the latest and greatest in treatment, no matter the cost to society. Chronic wounds are born out of vascular disease and insufficiency, and diabetic conditions. These are prevalent within the older populations that are showing strongest growth in the developed economies.

Growth in Sales of Products in Cell Therapy and Tissue Engineering

Tissue engineering and cell therapy comprise a market for regenerative products that has been growing and will continue to grow at over 20% annually through 2018. This market spans many specialties, the biggest of which is therapies for degenerative and traumatic orthopedic and spine applications. Other disorders that will benefit from cell therapies include cardiac and vascular disease, a wide range of neurological disorders, diabetes, inflammatory diseases, and dental decay and/or injury. Key factors expected to influence the market for regenerative medicine are continued political actions, government funding, clinical trials results, industry investments, and an increasing awareness among both physicians and the general public of the accessibility of cell therapies for medical applications.

The current high rate of growth in cell therapy and tissue engineering product sales is due to the confluence of multiple market drivers:

  • Advances in basic science revealing the nature of cell growth, differentiation and proliferation
  • Advances by industry to manipulate and determine cell growth toward specific therapeutic solutions
  • Low barrier to entry for competitors in the market
  • Broad range of applications of cell/tissue advances to many different specialties with modest adaptation needed
  • Strong venture funding

The dominant clinical area driving cell therapy and tissue engineering product sales is orthopedics and musculoskeletal, wherein bone grafts and bone graft substitutes are well-established. Below is the projected balance of cell therapy and tissue engineering product revenues by clinical area through 2018.

Screen Shot 2014-04-08 at 9.26.25 AM

Source: MedMarket Diligence, LLC; Report #S520.

While orthopedics, musculoskeletal and spine applications will remain a huge share of this market, more growth is coming from cell/tissue products in most other areas, which have only recently (within the last five years) begun to establish themselves.

Screen Shot 2014-04-08 at 9.34.50 AM

Source: MedMarket Diligence, LLC; Report #S520.

Cellular Growth Factors in the Wound Management Market

From a previous post on growth factors in wound management, we highlight this due to a recent burst of activity in research leading to commercial products.


Extensive research has demonstrated that wound fluid is rich in growth factors. Growth factors are naturally occurring proteins found primarily in platelets and macrophages. They are needed for normal wound healing to promote growth and migration of fibroblasts, endothelial cells and keratinocytes. The functions of growth factors include; attraction of cells to the wound site (chemotaxis), stimulation of cell division/ proliferation (mitogenic competence/progressive), differentiation of cells into specific phenotypes (transformation), and stimulation of cells to perform functions or secrete other growth factors. Growth factors bind to receptors on the cell surface where they activate cellular proliferation and/or differentiation. There are a number of growth factors which are involved in wound healing at different points in time. Many are quite versatile and capable of stimulating cellular division in different cell types; others are specific to a particular cell type.

Growth factors applied to wound management fall into the following categories:

 

Growth
Factor
Sources
Effects
Epidermal growth factor (EGF)Activated macrophages. Salivary glands. KeratinocytesKeratinocyte and fibroblast mitogen. Keratinocyte migration. Granulation tissue formation
Transforming growth factor-? (TGF-?)Activated macrophages. T-lymphocytes. KeratinocytesHepatocyte and epithelial cell proliferation. Expression of antimicrobial peptides. Expression of chemotactic cytokines
Hepatocyte growth factor (HGF)Mesenchymal cellsEpithelial and endothelial cell proliferation. Hepatocyte motility
Vascular endothelial growth factor (VEGF)Mesenchymal cellsVascular permeability. Endothelial cell proliferation
Platelet derived growth factor (PDGF)Platelets. Macrophages. Endothelial cells. Smooth muscle cells. KeratinocytesGranulocyte, macrophage, fibroblast and smooth muscle cell chemotaxis. Granulocyte, macrophage and fibroblast activation. Fibroblast, endothelial cell and smooth muscle cell proliferation. Matrix metalloproteinase, fibronectin and hyaluronan production. Angiogenesis. Wound remodeling. Integrin expression regulation
Fibroblast growth factor 1 and 2 (FGF-1, FGF2)Macrophages. Mast cells. T-lymphocytes. Endothelial cells. FibroblastsFibroblast chemotaxis. Fibroblast and keratinocyte proliferation. Keratinocyte migration. Angiogenesis. Wound contraction. Matrix (collagen fibers) deposition
Transforming growth factor-? (TGF-?)Platelets. T-lymphocytes. Macrophages. Endothelial cells. Keratinocytes. Smooth muscle cells. FibroblastsGranulocyte, macrophage, lymphocyte, fibroblast and smooth muscle cell chemotaxis. TIMP synthesis. Angiogenesis. Fibroplasia. Matrix metalloproteinase production inhibition. Keratinocyte proliferation
Keratinocyte growth factor (KGF)KeratinocytesKeratinocyte migration, proliferation and differentiation

Source: MedMarket Diligence, LLC; Report #S249

The emergence and rapid adoption of growth factors in wound management is testimony to the expectation that they will hasten wound healing and result in better outcomes, lowered cost or both. While the market for growth factors in wound management is largely represented by the U.S. market (as with most advanced medical technologies), economics, technology diffusion and other forces will lead to more rapid growth in the use of these products in Asia/Pacific (in particular, China will see strong growth, given that powerhouse country’s propensity to bypass progressive development in favor of very rapid adoption of new technologies).

Distribution of Wound Growth Factor Markets, 2013 & 2021

GF-pie-2013-2021

Source: MedMarket Diligence, LLC; Report #S249

Feel free to contact us directly if you have further questions on the wound management market.