Published on 23 May 2024

Preventive Medicine or Precision Medicine: How should we choose?

Professor Joseph Sung
Dean, Lee Kong Chian School of Medicine

Last week, I attended a medical conference on Gastroenterology & Hepatology in Washington, D.C. This is one of the largest academic conferences called Digestive Disease Week, pooling together gastroenterologists, surgeons, hepatologists, public health experts, basic scientists, epidemiologists and even patient advocates for academic sharing and debates. The conference attracted 15,000 participants from all over the world. Exciting topics presented included new drugs for inflammatory bowel disease and obesity, innovative endoscopic and minimally invasive surgery, artificial intelligence and medical imaging interpretations for GI condition.  This year, one of the highlights of the meeting is Preventive Medicine. 

In the United States, the number of people who die from liver disease every year has almost doubled in the past two decades. This figure comes as a surprise to many of us as there have been major advances in therapy for hepatitis C and hepatitis B infection; breakthroughs in management of portal hypertension in advanced cirrhosis; and many other new medications for liver cancers. Translational science should have improved the survival of patients with chronic liver diseases as well many other medical conditions. Unfortunately, clinical studies and statistics show that most of these new treatments can only prolong survival of patients with end-stage liver disease by weeks, or months. All the years of life saved by these advancements are easily offset by the ageing population, increase in obesity metabolic syndrome, increased consumption of alcohol and failure to monitor progression of viral hepatitis B.  

At the same time, according to statistics in the United States, the number of hepatologists in the country is declining. There are more doctors willing to be trained as gastroenterologists and endoscopists than hepatologists, as these specialties and interventional procedure can generate more revenue for the individual and for institutions. Primary care doctors do not feel that they can take care of patients with viral hepatitis,  MASLD and chronic liver diseases. The majority of cases are referred to tertiary hospitals and specialist clinics. Waiting time to get a medical or radiological appointment is prolonging every year to an intolerable state, making surveillance of chronic liver conditions more and more difficulty. The liver community is not thriving, likewise for other specialities in medicine.

The solution put forward by experts is simple: in order to improve the survival of patients with chronic liver disease, prevention of disease progression (to cirrhosis and end-stage liver failure) is key. Early detection and surveillance of liver fibrosis in MASLD (using non-invasive methods such as FIB-4 and abdominal USG); proper education of the public and counselling of patients with diabetes and metabolic syndrome; empowerment of patients to take responsibility of their health in lifestyle modification – these are good strategies to reduce progression of chronic liver disease. These are the most effective, as well as cost-effective measures to maintain good health and quality of life of our populations. But the question is, are we doing it?

Well, all these seem to be motherhood and apple pie in science and clinical medicine, something that we hear and talk about a lot but nothing much has been achieved. Yet the message is written on the wall: our current healthcare model is unsustainable. Advancement of medical technology is astounding but also painfully expensive. We gave up bedside examination and clinical judgement and rely on CT/MRI in almost every patient. Back then, our pharmacies stocked up no more than a dozen antibiotics and a handful of chemotherapy agents. Now they are furnished with hundreds of expensive antimicrobial, monoclonal antibodies, biologics, target therapy and immunotherapy just to name a few. Furthermore, before we prescribe these drugs, we are now checking the genomic and metabolomics of patients, testing the molecular subtype of cancers and predicting clinical support using AI.  These are great advancements in Precision Medicine. Question is, would this be sustainable?

Healthcare costs have escalated in every country around the world. In Singapore, the health budget has doubled in the past 10 years. With our ageing population, pandemic of  obesity and metabolic syndrome, and proliferation of new technology, the bill is going to go up and up every year. While we are excited about what we can do, we should also think of value-based healthcare. We should endeavour to optimise our limited resources to take care of every individual in the country. The importance of health equity is evermore indisputable.

This question often comes up in our discussion: I have $1,000 to spend on a single case of liver transplantation that can save the life of one person from end-stage liver failure,  but I can also use $1,000 to provide vaccine for viral hepatitis preventing cirrhosis and liver cancer for 1,000 subjects. Which one should I choose? There is no correct answer. The choice is a balance between equity and efficacy. As an academic and a specialist working in a tertiary care hospital, I do not deny the value of science and innovation, and I support the development of precision medicine and pharmacogenetics. I just want to say that implementing population health (instead of modelling and theorising), empowering primary care practitioners to take care of common but important conditions, encouraging the public to live a healthy life… these are the crucial measures to ramp up if we do not want to see our healthcare system collapse.