May-Jun '09 | briefing | mail | interviews | articles | psorchatdon't say this | flaker creativity | flakers' jargon | other places | archives | send mail | ed dewke | search | acknowledgments | legal stuff | Flake: Confessions of a Psoriatic | 2009 FlakeHQ, Inc.
 

FlakeHQ Interviews:

Bruce F. Bebo, Jr., Ph.D.
Director of research and medical programs
for the National Psoriasis Foundation

 Interviewed by Ed Dewke
in April, 2009

Dr. Bruce Bebo (Ph.D.) may be the right man in the right place at the right time. To begin, he's got a 20 year background in autoimmune disease research. Associating psoriasis with immune system dysfunction took a series of accidents and speculation beginning in the 1960s. This might suggest that we should have known to get an immunologist on the case a lot sooner. Better late than never, I say. Immediately prior to joining the executive staff of the National Psoriasis Foundation in 2008, Dr. Bebo worked for a pharmaceutical company in Germany developing topical and oral treatments for skin diseases including psoriasis. So, not only is he from the new-most-correct discipline (immunology), he's also focused on skin diseases. And to make it a perfect fit, he's articulate and knows how to talk about science in a language we can all understand. You will appreciate this fact as your read this interview. -Ed

*****

DEWKE: First, help us understand the science of immunology and the role it plays in health care. I saw a dermatologist about my psoriasis until I also manifested Psoriatic Arthritis. At that point my derm referred me to a rheumatologist. For a year I saw both. After that, my rheumatologist took over. I've had better treatments for both skin and joints through the rheumy. The connection is, what? Immunology? Why don't I go to an immunologist?

BEBO: Both psoriasis and psoriatic arthritis are immune-mediated diseases and share some common characteristics. However, they are also different and often require different treatment strategies that can make treating a person with both diseases a challenge. I think the key issue from a patient's perspective is rather than focusing on a particular specialty — dermatology, rheumatology, immunology — finding a physician that has experience treating both diseases is critically important. Alternatively, there are a growing number of joint (no pun intended) clinics were dermatologists and rheumatologists practice side-by-side in treating patients with both diseases.

In regards to the second part of your question, both dermatologists and rheumatologists treat people with immune-mediated conditions — i.e. psoriasis/psoriatic arthritis, rheumatoid arthritis — as well as non-immune-mediated conditions — e.g. skin cancer/osteoporosis. Allergy and immunology is a medical specialty that focuses on the management of disorders involving the immune system. Therefore, one might expect that a physician trained in this specialty would also be a good choice for treating psoriatic diseases. However, I am not sure how common it is for an allergy/immunology specialist to treat psoriasis/psoriatic arthritis.  

Finally, the term immunologist can also refer to an academic scientist focusing on immunology. This person could have training in any number of scientific and/or medical disciplines. These are the folks working at the universities or the pharmaceutical companies that are doing research advancing our knowledge of the diseases and helping us get closer to a cure.

 

DEWKE: As an immunologist yourself, do you think the "cure" for psoriasis, when and if one is found, will likely be closely related to curing other immune system diseases (e.g., Crohns)?

BEBO: The quick answer to your question is yes. But let’s not stop there; I also have a long answer. First, I think a cure for psoriasis is within our grasp and that it is just a matter of time. The reason for this optimism is that the pace of our understanding of this disease is accelerating tremendously. I think one has only to look at the growing number of new effective treatments that have been approved for psoriasis in the past few years as evidence. As we gain more knowledge, particularly of the immune system, more and better treatments will become available and ultimately a treatment will come that will result in a permanent suppression of psoriasis. The fact that psoriasis is generally not a degenerative disease means that once we conquer the immune system we will have a cure. This is in contrast to other autoimmune diseases like multiple sclerosis or rheumatoid arthritis where tissues (central nervous system and joints, respectively) are damaged and must be repaired before one can claim a cure.

Psoriasis likely shares common elements with Crohn’s disease and for that matter with other autoimmune diseases. An increased understanding for psoriasis certainly helps accelerate the understanding and treatment of other autoimmune diseases like Crohn’s. Because the organ affected by psoriasis (the skin) is easily accessible, one could argue that research in psoriasis might provide more clues than studying autoimmune diseases where the site of action is not as accessible MS–the brain, RA–the joint, Crohn’s–the GI tract.

 

DEWKE: I understand most of the systemic medicines, including biologics, typically used as psoriasis treatments involve immune system suppression in various limited fashions. How satisfied are you — wearing your immunologist hat — that our immunosuppressive drugs are the right approach to palliating our conditions?

BEBO: I do think manipulating the immune system is one of, if not the most promising area of focus for psoriasis. If for no other reason than the fact that drugs targeting the immune system have such a dramatic ability to suppress the disease. As we progress, I am confident more specific, more targeted biologic drugs will be developed that are efficacious for psoriasis and at the same time reduce the risks and side effects of the currently available biologic drugs. I am also confident that an increased understanding of the immune system will lead to more permanent methods for controlling specific aspects of the immune response and one day a permanent solution for psoriasis will be found using this route.

Of course, immunology is not the only important scientific discipline to be studied for psoriasis. An increased knowledge of genetics, epidermal cell biology, epidemiology and many other disciplines will be required before a complete understanding of this disease is to be obtained.

 

DEWKE: A sentence in the research section of psoriasis.org says, “we fund early stage research projects that demonstrate the potential to significantly increase our understanding of the genetic and environmental basis for psoriasis and psoriatic arthritis.” This question focuses on the “environmental basis.”  What kind of research contributes to our understanding of the environmental basis for psoriasis? Can you give us any examples of recent work or on-going work in this area?

BEBO: While the cause of psoriasis is not completely known, it is now clear that both genetic and environmental factors are involved. So really, when we say environmental, we are referring to any agent or activity that promotes psoriasis that is not genetic. The primary area of study that explores the environmental aspects of disease is called epidemiology. Epidemiology is the study of factors effecting health and illness in populations. Epidemiologists have made a number of important findings about psoriasis in the last few years including:

  1. People who smoke are at an increased risk for developing psoriasis,
  2. People with psoriasis have an increased risk for being obese,
  3. People with psoriasis have an increased risk for cardiovascular diseases and
  4. People with psoriasis have a shorter life-span than people without psoriasis.

The study of epidemiology has the potential to teach us a great deal that will both improve the quality (and perhaps quantity) of life for those living with psoriasis as well as identifying triggers for disease that may yield important clues to the cause of psoriasis.

 

DEWKE: When completed, the Victor Henschel BioBank is supposed to be “the largest source of DNA samples and clinical registry in the world for psoriasis and psoriatic arthritis research.” First, when do you anticipate completing the sample collecting? Is the Foundation likely to fund some amount of the research done using Biobank material? Will the Foundation be involved in selecting all the research involving that material?

BEBO: Currently, the Victor Henschel BioBank has almost 800 samples collected and we would like to thank everyone who has donated their DNA to help find a cure for psoriasis. The rate at which we are collecting samples has accelerated over the last few months. The primary reason why is that we now have the ability to collect samples at our community events. For example, we collected 50 blood samples at the Walk for Awareness in Miami and 21 samples at our Capitol Hill Day in Washington, D.C. We will be collecting blood samples at most, if not all of our walks scheduled for this year and at our annual Leadership Conference in San Antonio. Have a look at our website to find more about how and where you can donate your DNA.

We hope to reach our goal of 2,000 samples by sometime next year. We expect to start releasing samples to researchers before reaching this goal, perhaps as soon as this summer. The process for releasing the samples will require an application be made by the interested researcher that outlines the experimental plan and review of this application by a panel of scientific peer reviewers.

Our grant awards are competitive and awarded after review by a different panel of scientific peers. It is quite likely that one or more grants will be submitted to the Foundation proposing to use the BioBank samples in their study. It will be up to the grant review committee and the research committee of our Board of Trustees to determine whether a grant proposing to use BioBank samples merits funding. I suspect that we will receive numerous competitive grants and that we will ultimately fund research using our BioBank samples.

 

DEWKE: The Foundation also tracks the impact psoriasis and psoriatic arthritis has on patients. Can you explain how that is done? What are some of the findings so far from this patient tracking?

BEBO: The Foundation conducts survey panels twice each year to understand the experiences and opinions of people with psoriasis and/or psoriatic arthritis and document the burden of these diseases. The surveys are conducted by both email and telephone and usually the responses of about 400 people are included. The questions include a scientifically validated quality of life questionnaire, we ask what types of treatments people are taking and how satisfied they are with them. We ask how severe is their diseases and how does it affect their daily lives, and many other questions.

Some of the most important things we have learned from the surveys include:

  1. About 70% of people with psoriasis consider it to be a significant problem in their everyday life,
  2. 57% of people with psoriasis are not treating their disease,
  3. 40% of people with severe psoriasis are being treated with only a topical steroid, and
  4. About 30% are very satisfied with their treatment.

You can find the results from our surveys in the form of survey “snapshots” on our website: http://www.psoriasis.org/research/foundation/survey_panels.php/

 

DEWKE: As we begin to associate psoriasis with other diseases and conditions through a more thorough understanding of the genetic underpinnings, might we see research with a broader focus? For example, studies that might measure results in both rheumatoid arthritis and psoriatic arthritis and/or psoriasis at the same time?

BEBO: It is true that there are genes associated with psoriasis that are also associated with other autoimmune diseases. The case is strongest for Crohn’s disease, but psoriasis also shares genes with rheumatoid arthritis and lupus. It is also interesting that the TNF blocker class of biologics is effective in psoriasis as well as Crohn’s, rheumatoid arthritis and several other forms of arthritis, suggesting a connection between psoriasis and these conditions. It is quite possible that there is a common link between psoriasis and other autoimmune disorders and there are a number of prestigious research groups focused on understanding how and why the immune system becomes unbalanced in these diseases. This could, one day, lead to a treatment that slows down or even prevents all autoimmune diseases.

 

DEWKE: Regarding Genentech’s pulling Raptiva from the market as a result of associated fatal cases of PML: Is this likely to make it more difficult to bring future biologics to market — or make the studies more difficult or longer? Might it make dermatologists more skittish about prescribing biologics?

BEBO: The regulatory environment for biologics was getting stricter even before the news about Raptiva. The FDA has been asking for better surveillance of drug effects after market and it will require new drugs to do a better job of this. Many if not all new biologics will require a Risk Evaluation and Mitigation Strategy (REMS) which will require the company to monitor efficacy and side effects quite closely after approval. Since PML appears to be a long-term risk for some psoriasis drugs, it will be difficult to establish this risk during the course of a clinical trial, thus a REMS will serve to monitor for this and other potential drug safety issues. [Re: "long-term risk." Extant PML cases involved people who have taken Raptiva for 2 years or longer. -Ed]

It is hard to know how this news will affect the prescribing habits of dermatologists. Raptiva had a unique mechanism of action. It is quite different from the TNF blockers and from the new class of biologics called IL-12/23 blockers. Some of the TNF blockers have been around for more than a decade with little or no indication of PML, so some dermatologists consider this class relatively safe from this risk. The risk of PML for the IL-12/23 blockers is simply not known, so they might be a bit more cautious with this class of treatment (when it becomes available).

 

DEWKE: Does the Foundation endorse proposals for research grants that scientists pitch to third-party funding sources? I’m thinking specifically about groups going after continuation funding for what the Foundation might have funded as an “early stage research project.” 

BEBO: The purpose of our pilot grant program is to provide initial funding for researchers so that they can develop their research programs to the point where they will be competitive for more comprehensive funding from other sources. For example, the National Institutes of Health support projects that last from 3 to 5 years and cost upwards of $1.5 million dollars. This type of funding is absolutely necessary to advance our knowledge of psoriasis but is currently beyond the scope of what the Foundation can support. When one of our researchers applies for NIH funding for a psoriasis and/or psoriatic arthritis project from the NIH and asks us for a letter of support we are very happy to provide it.

It is interesting to point out here that results from a recent survey of our pilot grant recipients suggest that our funding strategy is working. 93% of Foundation grant awardees are still active in psoriasis research; 73% of them have published their findings in peer-reviewed scientific journals (80 papers in total); 75% have submitted one or more grants to the NIH; the result of which was that 17 grants submitted by Foundation sponsored scientists were funded by the NIH totaling over $5 million in research support.

This might also be a good place to announce the Foundation’s new emphasis on research. The Board of Trustees recently approved a new 5-year strategic plan that places research as its number one priority. The research investment will be placed into defined areas of biomedical science that have the best chance of advancing us closer to a cure. We have assembled a prestigious committee of psoriasis and psoriatic arthritis leaders to help advise the Foundation how best to make this research investment. Stay tuned for more announcements about our new research initiatives.

 

DEWKE: That's exciting news. Thank you very much for your time. We're looking forward to a bright (as in illuminating) next few years.

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The "Research" page at psoriasis.org:
http://www.psoriasis.org/home/cure03.php

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