Tempting, it becomes, therefore, to think of all which preceded this juncture in medical history as 'imprecise.'
"What?" we might ask now, as pundits might ask decades or centuries on, is and was representative of pre-Precision Medicine? Leeching, commonly known as bloodletting, the practice of ridding the body of 'evil' forces within - one which, in retrospect, depleted many a critically-ill individual of that which was necessary to sustain life? Was it that of a ship's surgeon up until the 18th century - a.k.a. the chief carpenter - whose primary qualification for 'moonlighting' in Medicine was his handiness with a saw and skill at amputation? With these tongue-in-cheek examples, the answer is "No," not by a longshot.
While tempting to think of that which is not precise as 'imprecise,' it would be a misnomer and an injustice to assign such a label to modern-day pre-Precision Medicine. The truth is, despite the fact that this form of medical practice did not target genetic makeup - something it was in many measures incapable of, technologically, by default - advancements, breakthroughs, and lives improved and saved are in many cases nothing less than profound and immeasurable.
Let's look at just a few illnesses which have a genetic component for which 'imprecise' Medicine - that is to say, non-genetic targeting and treatment - have massive and lasting legacies.
The Primary Immunodeficiencies are a group of some 250 disorders in which, for the most part, the body is incapable of producing adequate (or in some cases, any) amount of antibodies, and, as a result, incapable of mounting a defense against pathogens. For many of these disorders, researchers have discovered a strong genetic component. Non-treatment of these disorders, both historically, and presently (when timely, accurate diagnosis does occur) can result in critical illness, and death, oftentimes as a result of the most 'mundane' and treatable pathogens. That is, and was, until the advent of intravenous immunoglobulin (IVig) therapy. Lives saved and improved by monthly, and in some cases, weekly, antibody infusions can probably be measured in the past half-century, in the millions. But the scope of this biotechnological breakthrough does not end there. IVIg has been both repurposed and repositioned to treat a myriad of non-PI conditions. From Neurology to Hematology, Kawasaki disease to ITP, Guillain-Barre disease to sepsis, IVIg has become frontline therapy. IVIg has proven to be a flexible, dependable, life-saving treatment. Imprecise Medicine? Perhaps. But only when one considers that its use does not target the genetic cause of any of these illnesses.
Only very recently have we come to discover that "Childhood cancers more likely to come from major cancer genes than scientists thought." Historically, though scientists posited and theorized genetic links to pediatric cancers, little of the concrete was known. DNA sequencing has altered the equation as studies regularly accumulate and expand on the genetics of kids' cancer. And while a Precision Medicine approach to childhood cancer is now proceeding beyond its infancy - from the experimantal and theoretical, to, in many cases, the applied - one should not forget or understate the 'imprecise' Medicine which has gotten us to today. Chemotherapy and radiation, long the mainstay of treating childhood cancers have been likened to carpet-bombing, a military style of warfare in which a large area is bombed/leveled in the hope of hitting 'something.' Compared to precise treatments coming to fruition - treatments which can be likened to 'smart-bombs,' the negative legacy of the status-quo is profound. Childhood cancer survivors pay a heavy price, often spending a lifetime facing debilitating side-effects of treatment - from fertility issues to physical effects, from neurological to cognitive. Yet the bottom line is this: Survival rates for many childhood cancers have increased exponentially. Many cancers, historically considered automatic death-sentences, are being survived more often than not. Survival rates for many of these cancers - rates which once meaured in at the 20 to 30 percentiles - are now at 80 to 90. Fantastic? Yes. Imprecise? Only if one considers that treatments have not targeted the genetic make-up of diseases with very strong genetic underpinnings.
Insulin for diabetics. Anti-epileptic agents. Replacement therapies for enzyme deficiences. Many hundreds of rare diseases have found new treatments and therapies in the pre-Precision Medicine Era. Newborn screening, quickly becoming a part of Genomics and Precision Medicine (at least in the NICU), traces it roots back over five decades, to a time when many of the leaders of the precision movement were themselves children.
Groundbreaking surgeries that correct congenital defects? Ask John (Cougar) Mellencamp who, unbeknownst to many, was the first infant to survive pioneering surgery for spina bifida (John Mellencamp meets doctor who saved his life), a congenital disorder with an oft-times genetic component, a disorder, with a historically negligible survival rate. The physicality of the disorder, not the genetics, were the target. For Mellencamp, it has meant a lifetime of music, for tens-of-thousands of babies with spina bifida, it has meant a new, status-quo, lease on life.
And more. The number of diseases, disorders and defects which have gone from untreatable to treatable, from unsurvivable to survivable, run not in the dozens or scores, but into the hundreds.
Non-genetic treatments (and in some cases cures) for diseases with underlying genetic factors abound. Treatments and cures for which, in the context of Precision Medicine, are considered 'imprecise' - imprecise in that they target the phenotype, not the genotype...the symptom rather than the genetic root.
Precision Medicine has the potential to change everything. The excitement, as it should be, is tangible and palpable. From La Jolla to DC, Scripps to the National Cancer Institute to the NIH and Illumina, with names like Topol, Venter and Collins at the helm, Precision Medicine is in the visionary and more-than-capable hands it should be. Breakthroughs of the fantastic and previously unfathomable will be forthcoming, have no doubt. Novel genes and new diseases will be identified and treatments will spring forth. Targeted treatments, in many cases kinder and gentler. Massive databases will be compiled and analyzed like never before. DNA sequencing will take place en-masse. Gene-therapy 2.0. CRISPR. And new technologies, in the pipeline, that have yet to be named or revealed. Lives will be transformed. What seemed science fiction has become, and will continue to become, science without fiction.
Yet, with many diseases and disorders, from the common to the rare, now in the crosshairs of Precision Medicine, discoveries and treatments of, and by, the imprecise...will continue to take place. Precision Medicine might supercede, but it should not supplant, nor displace. There seems ample room for the precise and the quite-precise, the tailored-and-targeted and the more one-size-fits-all, to meaningfully co-exist. Though absent of the word precision, 'pre-Precision Medicine,' might be/have been more precise than history might judge, at least if semantics get in the way. As such, the value of Imprecise Medicine should be recognised, lauded, and yes, valued. Its accomplishments and indeed breakthroughs are many, its legacy secure. It deserves a thank-you for a job well-done, but by no means a farewell.