Tom Addison

Policy Manager, The Physiological Society

https://doi.org/10.36866/pn.113.16

The time sensitive nature of health interventions is a concept that is well understood by health policymakers and, increasingly, the public. The cost of “avoidable illness” is highlighted as a priority in the NHS Five Year Forward View and recognises that improved long-term well-being and early intervention are crucial for managing the demands on the health service. More broadly, the impact of time (in this case, the day of the week a patient is admitted) on survival rates in hospitals also made the news during the 2015 General Election campaign when the Conservative government promised a ‘Seven-day NHS’.

The health system is also increasingly focused on a patient-specific approach to medicine with the emergence of personalised medicine, which recognises that diseases (and their treatment) involve a “complex interaction of our biological make-up and the diverse pathological and physiological processes in our bodies” (NHS England, 2016). In essence, policymakers appreciate that the era of “silver bullets” is at an end.

The positive therapeutic benefits of time, however, are less well understood by policymakers despite a growing body of evidence across life sciences of the benefit of timing diets and medical treatment with the body’s natural circadian rhythm that dates back to the 1960s. Last year’s Nobel Prize for Physiology or Medicine was awarded to three researchers who discovered the molecular mechanisms controlling the circadian rhythm.

Despite hints that chronotherapy could be beneficial in treating a number of forms of prevalent cancers, a survey, published the year before the 2017 Nobel Prize was awarded, found that only 0.1% of ongoing clinical trials incorporated time-of-day considerations into their analyses (Selfridge et al., 2016).

The lack of research that has made it to the stage of clinical trials is at odds with the likely traction that this field of science would generate with policymakers and the general public. Interest would likely be driven by three factors: financial burden (or lack thereof), simplicity of the argument, and the NHS’ focus on technology.

To the first point, superficially at least, chronotherapy will appear like something for nothing. Policymakers understand the value of other forms of personalised medicine but associate these with a substantial financial burden that will need to be met by a public system but will not necessarily generate uniform outcomes across patients – some very expensive drugs will have no benefit for certain patients depending on their genetic make-up. Crudely put, everyone has a circadian rhythm and chronotherapy is currently focused on using existing (and approved) therapies more effectively rather than segmenting patients.

Secondly, chronotherapy is straightforward to explain and, as touched on above, fits within the public’s existing scientific understanding. The public can describe how something like exercise or eating makes them feel at different times of the day. Transposing this knowledge into the field of medicine should (in theory!) therefore be straightforward.

Finally, chronotherapy fits comfortably within the new Health Secretary’s drive to use technology to ease the burden on the NHS. A blood test to check the synchronicity of a patient’s body clock could be administered at home and technology used to alert patients to the need to take medication at the most effective time of day.

The challenges for policymakers are two-fold. Should research prove the value in chronotherapy, reorganising healthcare systems to accommodate the circadian rhythm of individuals has the potential to be a huge administrative task given the often sizeable delay between diagnosis and beginning treatment. On a related note, one of chronotherapy’s biggest benefits could also become a challenge. The number of conditions and patients that might benefit could be enormous. As just one example, 41,000 people are diagnosed with bowel cancer in the UK every year.

Chronotherapy is an exciting field of study for policymakers and the public alike given its potential to improve efficacy, or at least lower toxicity, at a negligible financial cost to the health system. The challenge, unusually, is not one of direct costs but of shaping a service around this level of personalised care and ensuring that patients are engaged with harnessing the science to maximise its benefits.

References

NHS England (2016). Improving outcomes through personalised medicine: Working at the cutting edge of science to improve patients’ lives. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/09/improving-outcomes-personalised-medicine.pdf.

Selfridge, JM et al. (2016). Chronotherapy: Intuitive, sound, founded…but not broadly applied. Drugs 76, 1507–1521.