Big Data Probably Knows More About You Than Your Friends Do
A representation of the digital lifestyle prevalent today that enables the collection of a wealth of data.
Data is the new oil. It is highly valuable, and it is everywhere, even if you're not aware of it. For example, it's there when you use social media. Sharing pictures on Facebook lets its facial recognition software peg you and your friends. Thanks to that software, now anywhere you visit that has installed cameras, your face can be identified and your actions recorded.
The big data revolution is advancing much faster than the ones before, and it carries both promises and perils for humanity.
It's there when you log into Twitter, posting one of the 230 million tweets per day, which up until last month were all archived by the Library of Congress and will be made public for research. These social media data can be used to predict your political affiliations, ethnicity, race, age, how close you are with your family and friends, your mental health, even when you are most likely to be grumpy or go to the gym. These data can also predict when you are apt to get sick and track how diseases are spreading.
In fact, tracking isn't limited to what you decide to share or public spaces anymore. Lab experiments show Comcast and other cable companies may soon be able to record and monitor movements in your house. They may also be able to read your lips and identify your visitors simply by assessing how Wi-Fi waves bounce off bodies and other objects in houses. In one study, MIT researchers used routers and sensors to monitor breathing and heart rates with 99% accuracy. Routers could soon be used for seemingly good things, like monitoring infant breathing and whether an older adult is about to take a big tumble. However, it may also enable unwanted and unparalleled levels of surveillance.
Some call the first digital pill a snitch pill, medication with a tattletale, and big brother in your belly.
Big data is there every time you pick up your smartphone, which can track your daily steps, where you go via geolocation, what time you wake up and go to bed, your punctuality, and even your overall health depending on which features you have enabled. Are you close with your mom; are you a sedentary couch potato; did you commit a murder (iPhone data was recently used in a German murder trial)? Smartphone-generated data can be used to label you---and not just you, your future and past generations too.
Smartphones are not the only "things" gathering data on you. Anything with an on and off switch can be connected to the internet and generate data. The new rule seems to be, if it can be, it will be, connected. Washing machines, coffee makers, medical appliances, cars, and even your luggage (yes, someone created a self-driving suitcase) can and are often generating data. "Smart" refrigerators can monitor your food levels and automatically create shopping lists and order food for you—while recording your alcohol consumption and whether you tend to be a healthy or junk food eater.
Even medicines can monitor behaviors. The first digital pill was just approved by the FDA last November to track whether patients take their medicines. It has a sensor that sends signals to a patient's smartphone, and others, when it encounters stomach acid. Some call it a snitch pill, medication with a tattletale, and big brother in your belly. Others see it as a major breakthrough to help patients remember to take their medications and to save payers millions of dollars.
Big data is there when you go shopping. Credit card and retail data can show whether you pay for a gym, if you are pregnant, have children, and your credit-worthiness. Uber and Lyft transactional data reveal what time you usually go to and leave work and who you regularly visit (Uber data has been used to catch cheating spouses).
Amazon now sells a bedroom camera to see your fashion choices and offer advice. It is marketing a more fashionable you, but it probably also wants the video feed showing your body measurements—they're "a newly prized currency," according to the Washington Post. They help retailers create more customized and better fitting clothes. Amazon also just partnered with Berkshire Hathaway and JPMorgan Chase, the largest bank in the United States by assets, to create an independent health-care company for their employees--raising privacy concerns as Amazon already owns so much data about us, from drones, devices, the AI of Alexa, and our viewing, eating, and other purchasing habits on Amazon Prime.
Data generation and storage can also be used to make the world better, safer and fairer.
Big data is arguably a new phenomenon; almost all the world's data (90%) were produced within the last 2 years or so. It is a result of the fusion of physical, digital, and biological technologies that together constitute the fourth industrial revolution, according to the World Economic Forum. Unlike the last three revolutions, involving the discoveries of steam power, electrical energy, and computers—this revolution is advancing much faster than the ones before and it carries both promises and perils for humanity.
Some people may want to opt out of all this tracking, reduce their digital footprint and stay "off the grid." However, it is worth noting that data generation and storage can be used for great things --- things that make the world better, safer and fairer. For example, sharing electronic health records and social media data can help scientists better track and understand diseases, develop new cures and therapies, and understand the safety and efficacy profiles of medicines and vaccines.
While full of promise, big data is not without its pitfalls. Data are often not interoperable or easily integrated. You can use your credit card practically anywhere in the world, but you cannot easily port your electronic health record to the doctor or hospital across the street, for example.
Data quality can also be poor. It is dependent on the person entering it. My electronic health record at one point said I was male, and I was pregnant at the time. No doctors or nurses seemed to notice. The problem is worse on a global level. For example, causes of death can be coded differently by country and village. Take HIV patients: they often develop secondary infections, like TB. Do you record the cause of death as TB or HIV? There isn't global consistency, and political pressure from patient groups can exert itself on death records. Often, each group wants to say they have the most deaths so they can fundraise more money.
Data can be biased. More than 80 percent of genomic data comes from Caucasians. Only 14 percent is from Asians and 3.5 percent is from African and Hispanic populations. Thus, when scientists use genomic data to develop drugs or lab tests, they may create biased products that work for only some demographics. Take type 2 diabetes blood tests; some do not work well for African Americans. One study estimates that 650,000 African Americans may have undiagnosed diabetes, because a common blood test doesn't work for them. Using biased data in medicine can be a matter of life and death. Moreover, if genomic medicine benefits only "a privileged few," the practice raises concerns about unequal access.
Large companies are selling data that originated from you and you are not sharing in the wealth.
We need to think carefully and be transparent about the values embedded in our data, data analytics (algorithms), and data applications. Numbers are never neutral. Algorithms are always embedded with subjective normative values--sometimes purposely, sometimes not. To address this problem, we need ethicists who can audit databanks and algorithms to identify embedded norms, values and biases and help ensure they are addressed or at least transparently disclosed. Additionally, we need to determine how to let people opt out of certain types of data collection and uses—and not just at the beginning of a system, but also at any point in their lifetimes. There is a right to be forgotten, which hasn't been adequately operationalized in today's data sphere.
What do you think happens to all of these data collected about us? The short answer is the public doesn't really know. A lot of it looks like what is in a medical record—i.e. height, weight, pregnancy status, age, mental health, pulse, blood pressure, and illness symptoms--- yet, it isn't protected by HIPPA, like your medical record information.
And it is being consolidated into the hands of fewer and fewer big players. Large companies are selling data that originated from you and you are not sharing in the wealth.
A possible solution is to create an app, managed by a nonprofit or public benefit corporation, through which you could download and manage all the data collected about you. For example, you could download your credit card statements with all your purchasing habits, your Uber rides showing transit patterns, medical records, electric bills, every digital record you have and would like to download--into one application. You would then have the power to license pieces or the collection of your data to users for a small fee for one year at a time. Uses and users could be monitored and audited leveraging blockchain capabilities. After the year is up, you can withdraw access.
You could be your own data landlord. We could democratize big data and empower people to better control and manage the wealth of information collected about us. Why should only the big companies like Amazon and Apple profit off the new oil? Let's create an app so we can all manage our data wealth and maybe even become data barons—an app created by the people for the people.
Questions remain about new drug for hot flashes
In May, a new drug, Fezolinetant, was approved by the FDA to treat hot flashes associated with menopause.
Vascomotor symptoms (VMS) is the medical term for hot flashes associated with menopause. You are going to hear a lot more about it because a company has a new drug to sell. Here is what you need to know.
Menopause marks the end of a woman’s reproductive capacity. Normal hormonal production associated with that monthly cycle becomes erratic and finally ceases. For some women the transition can be relatively brief with only modest symptoms, while for others the body's “thermostat” in the brain is disrupted and they experience hot flashes and other symptoms that can disrupt daily activity. Lifestyle modification and drugs such as hormone therapy can provide some relief, but women at risk for cancer are advised not to use them and other women choose not to do so.
Fezolinetant, sold by Astellas Pharma Inc. under the product name Veozah™, was approved by the Food and Drug Administration (FDA) on May 12 to treat hot flashes associated with menopause. It is the first in a new class of drugs called neurokinin 3 receptor antagonists, which block specific neurons in the brain “thermostat” that trigger VMS. It does not appear to affect other symptoms of menopause. As with many drugs targeting a brain cell receptor, it must be taken continuously for a few days to build up a good therapeutic response, rather than working as a rescue product such as an asthma inhaler to immediately treat that condition.
Hot flashes vary greatly and naturally get better or resolve completely with time. That contributes to a placebo effect and makes it more difficult to judge the outcome of any intervention. Early this year, a meta analysis of 17 studies of drug trials for hot flashes found an unusually large placebo response in those types of studies; the placebo groups had an average of 5.44 fewer hot flashes and a 36 percent reduction in their severity.
In studies of fezolinetant, the drug recently approved by the FDA, the placebo benefit was strong and persistent. The drug group bested the placebo response to a statistically significant degree but, “If people have gone from 11 hot flashes a day to eight or seven in the placebo group and down to a couple fewer ones in the drug groups, how meaningful is that? Having six hot flashes a day is still pretty unpleasant,” says Diana Zuckerman, president of the National Center for Health Research (NCHR), a health oriented think tank.
“Is a reduction compared to placebo of 2-3 hot flashes per day, in a population of women experiencing 10-11 moderate to severe hot flashes daily, enough relief to be clinically meaningful?” Andrea LaCroix asked a commentary published in Nature Medicine. She is an epidemiologist at the University of California San Diego and a leader of the MsFlash network that has conducted a handful of NIH-funded studies on menopause.
Questions Remain
LaCroix and others have raised questions about how Astellas, the company that makes the new drug, handled missing data from patients who dropped out of the clinical trials. “The lack of detailed information about important parameters such as adherence and missing data raises concerns that the reported benefits of fezolinetant very likely overestimate those that will be observed in clinical practice," LaCroix wrote.
In response to this concern, Anna Criddle, director of global portfolio communications at Astellas, wrote in an email to Leaps.org: “…a full analysis of data, including adherence data and any impact of missing data, was submitted for assessment by [the FDA].”
The company ran the studies at more than 300 sites around the world. Curiously, none appear to have been at academic medical centers, which are known for higher quality research. Zuckerman says, "When somebody is paid to do a study, if they want to get paid to do another study by the same company, they will try to make sure that the results are the results that the company wants.”
Criddle said that Astellas picked the sites “that would allow us to reach a diverse population of women, including race and ethnicity.”
A trial of a lower dose of the drug was conducted in Asia. In March 2022, Astellas issued a press release saying it had failed to prove effectiveness. No further data has been released. Astellas still plans to submit the data, according to Criddle. Results from clinical trials funded by the U.S. goverment must be reported on clinicaltrials.gov within one year of the study's completion - a deadline that, in this case, has expired.
The measurement scale for hot flashes used in the studies, mild-moderate-severe, also came in for criticism. “It is really not good scale, there probably isn’t a broad enough range of things going on or descriptors,” says David Rind. He is chief medical officer of the Institute for Clinical and Economic Review (ICER), a nonprofit authority on new drugs. It conducted a thorough review and analysis of fezolinestant using then existing data gathered from conference abstracts, posters and presentations and included a public stakeholder meeting in December. A 252-page report was published in January, finding “considerable uncertainty about the comparative net health benefits of fezolinetant” versus hormone therapy.
Questions surrounding some of these issues might have been answered if the FDA had chosen to hold a public advisory committee meeting on fezolinetant, which it regularly does for first in class medicines. But the agency decided such a meeting was unnecessary.
Cost
There was little surprise when Astellas announced a list price for fezolinetant of $550 a month ($6000 annually) and a program of patient assistance to ease out of pocket expenses. The company had already incurred large expenses.
In 2017 Astellas purchased the company that originally developed fezolinetant for $534 million plus several hundred million in potential royalties. The drug company ran a "disease awareness” ad, Heat on the Street, hat aired during the Super Bowl in February, where 30 second ads cost about $7 million. Industry analysts have projected sales to be $1.9 billion by 2028.
ICER’s pre-approval evaluation said fezolinetant might "be considered cost-effective if priced around $2,000 annually. ... [It]will depend upon its price and whether it is considered an alternative to MHT [menopause hormone treatment] for all women or whether it will primarily be used by women who cannot or will not take MHT."
Criddle wrote that Astellas set the price based on the novelty of the science, the quality of evidence for the drug and its uniqueness compared to the rest of the market. She noted that an individual’s payment will depend on how much their insurance company decides to cover. “[W]e expect insurance coverage to increase over the course of the year and to achieve widespread coverage in the U.S. over time.”
Leaps.org wrote to and followed up with nine of the largest health insurers/providers asking basic questions about their coverage of fezolinetant. Only two responded. Jennifer Martin, the deputy chief consultant for pharmacy benefits management at the Department of Veterans Affairs, said the agency “covers all drugs from the date that they are launched.” Decisions on whether it will be included in the drug formulary and what if any copays might be required are under review.
“[Fezolinetant] will go through our standard P&T Committee [patient and treatment] review process in the next few months, including a review of available efficacy data, safety data, clinical practice guidelines, and comparison with other agents used for vasomotor symptoms of menopause," said Phil Blando, executive director of corporate communications for CVS Health.
Other insurers likely are going through a similar process to decide issues such as limiting coverage to women who are advised not to use hormones, how much copay will be required, and whether women will be required to first try other options or obtain approvals before getting a prescription.
Rind wants to see a few years of use before he prescribes fezolinetant broadly, and believes most doctors share his view. Nor will they be eager to fill out the additional paperwork required for women to participate in the Astellas patient assistance program, he added.
Safety
Astellas is marketing its drug by pointing out risks of hormone therapy, such as a recent paper in The BMJ, which noted that women who took hormones for even a short period of time had a 24 percent increased risk of dementia. While the percentage was scary, the combined number of women both on and off hormones who developed dementia was small. And it is unclear whether hormones are causing dementia or if more severe hot flashes are a marker for higher risk of developing dementia. This information is emerging only after 80 years of hundreds of millions of women using hormones.
In contrast, the label for fezolinetant prohibits “concomitant use with CYP1A2 inhibitors” and requires testing for liver and kidney function prior to initiating the drug and every three months thereafter. There is no human or animal data on use in a geriatric population, defined as 65 or older, a group that is likely to use the drug. Only a few thousand women have ever taken fezolinetant and most have used it for just a few months.
Options
A woman seeking relief from symptoms of menopause would like to see how fezolintant compares with other available treatment options. But Astellas did not conduct such a study and Andrea LaCroix says it is unlikely that anyone ever will.
ICER has come the closest, with a side-by-side analysis of evidence-based treatments and found that fezolinetant performed quite similarly and modestly as the others in providing relief from hot flashes. Some treatments also help with other symptoms of menopause, which fezolinetant does not.
There are many coping strategies that women can adopt to deal with hot flashes; one of the most common is dressing in layers (such as a sleeveless blouse with a sweater) that can be added or subtracted as conditions require. Avoiding caffeine, hot liquids, and spicy foods is another common strategy. “I stopped drinking hot caffeinated drinks…for several years, and you get out of the habit of drinking them,” says Zuckerman.
LaCroix curates those options at My Meno Plan, which includes a search function where you can enter your symptoms and identify which treatments might work best for you. It also links to published research papers. She says the goal is to empower women with information to make informed decisions about menopause.
A company in England has made a test that picks out the compounds from breath that reveal if people have liver disease.
Every year, around two million people worldwide die of liver disease. While some people inherit the disease, it’s most commonly caused by hepatitis, obesity and alcoholism. These underlying conditions kill liver cells, causing scar tissue to form until eventually the liver cannot function properly. Since 1979, deaths due to liver disease have increased by 400 percent.
The sooner the disease is detected, the more effective treatment can be. But once symptoms appear, the liver is already damaged. Around 50 percent of cases are diagnosed only after the disease has reached the final stages, when treatment is largely ineffective.
To address this problem, Owlstone Medical, a biotech company in England, has developed a breath test that can detect liver disease earlier than conventional approaches. Human breath contains volatile organic compounds (VOCs) that change in the first stages of liver disease. Owlstone’s breath test can reliably collect, store and detect VOCs, while picking out the specific compounds that reveal liver disease.
“There’s a need to screen more broadly for people with early-stage liver disease,” says Owlstone’s CEO Billy Boyle. “Equally important is having a test that's non-invasive, cost effective and can be deployed in a primary care setting.”
The standard tool for detection is a biopsy. It is invasive and expensive, making it impractical to use for people who aren't yet symptomatic. Meanwhile, blood tests are less invasive, but they can be inaccurate and can’t discriminate between different stages of the disease.
In the past, breath tests have not been widely used because of the difficulties of reliably collecting and storing breath. But Owlstone’s technology could help change that.
The team is testing patients in the early stages of advanced liver disease, or cirrhosis, to identify and detect these biomarkers. In an initial study, Owlstone’s breathalyzer was able to pick out patients who had early cirrhosis with 83 percent sensitivity.
Boyle’s work is personally motivated. His wife died of colorectal cancer after she was diagnosed with a progressed form of the disease. “That was a big impetus for me to see if this technology could work in early detection,” he says. “As a company, Owlstone is interested in early detection across a range of diseases because we think that's a way to save lives and a way to save costs.”
How it works
In the past, breath tests have not been widely used because of the difficulties of reliably collecting and storing breath. But Owlstone’s technology could help change that.
Study participants breathe into a mouthpiece attached to a breath sampler developed by Owlstone. It has cartridges are designed and optimized to collect gases. The sampler specifically targets VOCs, extracting them from atmospheric gases in breath, to ensure that even low levels of these compounds are captured.
The sampler can store compounds stably before they are assessed through a method called mass spectrometry, in which compounds are converted into charged atoms, before electromagnetic fields filter and identify even the tiniest amounts of charged atoms according to their weight and charge.
The top four compounds in our breath
In an initial study, Owlstone captured VOCs in breath to see which ones could help them tell the difference between people with and without liver disease. They tested the breath of 46 patients with liver disease - most of them in the earlier stages of cirrhosis - and 42 healthy people. Using this data, they were able to create a diagnostic model. Individually, compounds like 2-Pentanone and limonene performed well as markers for liver disease. Owlstone achieved even better performance by examining the levels of the top four compounds together, distinguishing between liver disease cases and controls with 95 percent accuracy.
“It was a good proof of principle since it looks like there are breath biomarkers that can discriminate between diseases,” Boyle says. “That was a bit of a stepping stone for us to say, taking those identified, let’s try and dose with specific concentrations of probes. It's part of building the evidence and steering the clinical trials to get to liver disease sensitivity.”
Sabine Szunerits, a professor of chemistry in Institute of Electronics at the University of Lille, sees the potential of Owlstone’s technology.
“Breath analysis is showing real promise as a clinical diagnostic tool,” says Szunerits, who has no ties with the company. “Owlstone Medical’s technology is extremely effective in collecting small volatile organic biomarkers in the breath. In combination with pattern recognition it can give an answer on liver disease severity. I see it as a very promising way to give patients novel chances to be cured.”
Improving the breath sampling process
Challenges remain. With more than one thousand VOCs found in the breath, it can be difficult to identify markers for liver disease that are consistent across many patients.
Julian Gardner is a professor of electrical engineering at Warwick University who researches electronic sensing devices. “Everyone’s breath has different levels of VOCs and different ones according to gender, diet, age etc,” Gardner says. “It is indeed very challenging to selectively detect the biomarkers in the breath for liver disease.”
So Owlstone is putting chemicals in the body that they know interact differently with patients with liver disease, and then using the breath sampler to measure these specific VOCs. The chemicals they administer are called Exogenous Volatile Organic Compound) probes, or EVOCs.
Most recently, they used limonene as an EVOC probe, testing 29 patients with early cirrhosis and 29 controls. They gave the limonene to subjects at specific doses to measure how its concentrations change in breath. The aim was to try and see what was happening in their livers.
“They are proposing to use drugs to enhance the signal as they are concerned about the sensitivity and selectivity of their method,” Gardner says. “The approach of EVOC probes is probably necessary as you can then eliminate the person-to-person variation that will be considerable in the soup of VOCs in our breath.”
Through these probes, Owlstone could identify patients with liver disease with 83 percent sensitivity. By targeting what they knew was a disease mechanism, they were able to amplify the signal. The company is starting a larger clinical trial, and the plan is to eventually use a panel of EVOC probes to make sure they can see diverging VOCs more clearly.
“I think the approach of using probes to amplify the VOC signal will ultimately increase the specificity of any VOC breath tests, and improve their practical usability,” says Roger Yazbek, who leads the South Australian Breath Analysis Research (SABAR) laboratory in Flinders University. “Whilst the findings are interesting, it still is only a small cohort of patients in one location.”
The future of breath diagnosis
Owlstone wants to partner with pharmaceutical companies looking to learn if their drugs have an effect on liver disease. They’ve also developed a microchip, a miniaturized version of mass spectrometry instruments, that can be used with the breathalyzer. It is less sensitive but will enable faster detection.
Boyle says the company's mission is for their tests to save 100,000 lives. "There are lots of risks and lots of challenges. I think there's an opportunity to really establish breath as a new diagnostic class.”