Alasdair Milton, KPMG | Why Precision Medicine Still Fails Patients (SPARK20 – 168)

Only one in three eligible lung cancer patients receives the targeted therapy they should get.

That is not a failure of science.

It is a failure of delivery.

After more than two decades of precision oncology, biopharma has never had better tools: cell and gene therapy, in vivo CAR-T, antibody-drug conjugates, AI-enabled diagnostics, organoids, multi-omics, and global clinical data.

Yet too many breakthroughs still fail to reach the bedside.

Patients fall through fragmented systems.
Data does not move cleanly.
Community oncologists are overloaded.
Tests are missed, delayed, or misread.
Promising assets die in quarterly portfolio reviews.
And healthcare systems built for pills, tablets, and chronic disease management are now being asked to deliver personalized medicine at scale.

In this SPARK20 highlight episode, Alasdair Milton, PhD, Principal at KPMG and leader of the firm’s Precision & Advanced Therapies practice, explains why the future of biopharma will not be decided by science alone.

It will be decided by translation.

From lab bench to boardroom.
From data to decisions.
From treatment to prevention.

Alasdair brings more than 20 years of experience across life sciences strategy, commercial due diligence, precision medicine, advanced therapies, cell and gene therapy, biopharma M&A, diagnostics, and global healthcare transformation.

This conversation moves from the precision medicine delivery crisis to China’s biotech acceleration, from AI and organoids to trapped pharma assets, from lifelong wellness to the one skill every future biotech leader needs:

The ability to translate complex science into business strategy, capital allocation, and patient impact.

What You’ll Learn in 22 Minutes

Why only one third of eligible lung cancer patients receive targeted therapy
(00:01:53)
And why precision medicine still breaks in everyday clinical practice.

Why science keeps compounding even when systems fail
(00:04:33)
Including in vivo CAR-T, functional cures, gene therapy, and antibody-drug conjugates.

Why innovation does not move in a straight line
(00:05:20)
How technologies can look dead for years before suddenly changing the market.

Why China’s biotech speed matters
(00:07:36)
How AI, organoids, scale, and execution are changing the global innovation map.

Why great science dies inside Big Pharma
(00:09:20)
And how deprioritized assets can become billion-dollar companies when externalized properly.

Why the industry must move from sickness to lifelong wellness
(00:10:03)
Alasdair’s vision for a more proactive, preventive, data-driven healthcare system.

Why pharma needs better ways to rescue shelved assets
(00:13:06)
Including examples such as SpringWorks, Cerevel, and new models for unlocking trapped value.

How a 400-person Scottish island shaped Alasdair’s worldview
(00:15:07)
The personal story behind his resilience, discipline, and leadership style.

Why careers and companies are never linear
(00:17:19)
What Alasdair learned after moving to Boston and losing his role within weeks.

Why the future belongs to translators
(00:20:06)
The most valuable skill in biotech: explaining complex science to business leaders, investors, and boards.

How to connect with Alasdair Milton and the KPMG Precision & Advanced Therapies team
(00:21:47)

Quotes to Carry With You

📌 “We’ve been doing precision medicine in lung cancer for decades, over two decades, and we’re still not getting it right.”
 (00:01:53)

📌 “This is where this incredible world of genomic science bumps up against the realities of everyday clinical practice.”
 (00:03:31)

📌 “When I was doing my PhD 28 years ago, the idea that you could even have a targeted cell therapy was almost like science fiction.”
 (00:04:41)

📌 “The speed was just astonishing.”
 (00:07:47)

📌 “We’ve been a sickness industry. We’ve treated disease, chronic disease. But can we move more towards lifelong wellness and preemptive health?”
 (00:10:03)

📌 “There’s not a systematic way to collect all of the incredible science and incredible assets that go on the shelf every quarter.”
 (00:13:06)

📌 “There’s great science that never sees the light of day because it’s killed in a quarterly portfolio review.”
 (00:15:00)

📌 “Your career is never linear.”
 (00:17:19)

📌 “You have to be able to build the bridge between the lab and the business world.”
 (00:20:06)

Why This Conversation Matters

Precision medicine is often described as the future of healthcare.

But the future does not arrive because the science is ready.

It arrives when diagnostics, data, reimbursement, clinical workflows, manufacturing, capital, leadership, and incentives finally work together.

That is the real challenge now facing biopharma.

Not whether innovation can happen.
 It already is.

The question is whether leaders can build the systems that allow innovation to reach patients.

Alasdair Milton is one of the rare voices who can explain that challenge across science, strategy, capital, and execution.

If you are a founder, investor, operator, scientist, board member, policymaker, or family office looking at the future of biotech, precision medicine, advanced therapies, pharma M&A, AI in healthcare, or China’s rise in biopharma, this episode is worth your time.

👉 Listen now.
Share it with someone building the future of medicine.
Follow Beginner’s Mind for more conversations with the people shaping biotech, capital, and healthcare.

Topics: precision medicine, biopharma, biotech, KPMG, Alasdair Milton, cell and gene therapy, in vivo CAR-T, targeted therapy, lung cancer, oncology, AI in healthcare, organoids, China biotech, pharma M&A, SpringWorks, Cerevel, advanced therapies, diagnostics, translational science, venture capital, healthcare strategy.

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Transcript

Christian Soschner 0:00

What if the greatest medical breakthroughs in history are reaching only one in three of the patients who desperately need them? 20 years into precision oncology, and we are still not getting it right. Functional cures now exist in cell and gene therapy. Artificial intelligence is rewriting diagnostics overnight. China is moving from generics to first-in-class innovation in under five years. And yet? Fragmented data, quarterly portfolio refuse that kill promising assets and community oncologists drowning in volume mean most of these breakthroughs never reach the bedside. This is not a science problem. It's a systems, incentives, and leadership problem. My guest today has lived every single layer of it. From a 400-person island off the west coast of Scotland, the first in his family to university through a PhD on a $15,000 debt with side sales jobs, a brutal 2007 move to Boston, where his entire division was shut down within weeks, to principal at KPMG, where he now leads the precision and advanced therapies practice, advising the largest biopharma companies and investors on exactly how to win this decade. Alistair Milton doesn't just diagnose the crisis, he gives you the precise mental models the builders and capital allocators who will define the next 10 years are already using. This is the conversation that separates those who watch the future arrive from those who shape it. 20 years of precision oncology, one third of the patients who should be cured actually get the therapy.

Alasdair Milton 1:51

Why? If you took a thousand of them who should get a targeted therapy, right? That thousand on the far left, how many actually get that therapy? And it's only around a third. Now, bearing in mind that we've been doing precision medicine in lung cancer for decades, over two decades, and we're still not getting it right. Okay, so we we see drop-offs of patients because perhaps the right test wasn't ordered. So maybe the physician orders a PCR test and they should order an NGS test. There's maybe a drop-off because the pathology report comes back and it's not interpretable by the physician. There could be a drop-off because there wasn't enough tissue taken. So there's all these different reasons. We go through these, you know, these multiple steps here, where by this analysis, anyway, only a third of advanced non-small cell lung cancer patients who should get a targeted therapy actually get one. Now, again, this dynamic is probably not happening to the same extent in large academic medical centers like the FARBA, like MSK, um, like City of Hope, but it still happens. The challenge is that in this country at least, 80% of oncology patients are not treated in large academic medical centers. They're treated in the community where they're seeing an oncologist, two maybe Cs, two head and neck, four breasts, three lung every day. And so they're just trying to get through their day and and and testing, testing in the right way. It's just, it's just very hard. And this is where this incredible world of genomic science bumps up against the realities of everyday clinical practice. And so, you know, for those physicians who are in the clinic, they just need to know for this patient with these symptoms, what test do I order? And what do I do with the result? Right? What's the translation of that result? If they have a report that comes back and says variants of unknown significance, what does that mean for them? Uh and so that's the challenge. And so while I get so excited about all of the science, all the things we've talked about, all the opportunities, cell and gene therapy, targeted therapies, AI, you know, we're in a post-genomic era, all this incredible data we're collecting, the fundamental challenges of a system that is designed for delivering pills and tablets and was designed 20, 30 years ago, now bumping up against the reality of that science. This is unfortunately what we see.

Christian Soschner 4:34

So the science keeps marching forward anyway. What does that actually look like right now?

Alasdair Milton 4:41

We have the first in vivo car Ts. So we have in vivo car Ts in humans, phase one trials ongoing. I think that that could be a significant game changer. Because when I was doing my PhD 28 years ago, the idea that you could even have autologous cell therapy was almost like science fiction, right? How could you extract a patient's T cells, re-engineer them in a lab, infuse them back in, and in some cases have a complete um remission or or cure. But here we are, we have that technology, and now we've gone even further with the inn vivo CART. So to me, that's like that's one of the most exciting things from this particular year to two years for me.

Christian Soschner 5:20

That's a good point. You mentioned uh GLP1 and CAR T, and I think both technologies were deemed dead for a very long time. And this is what's amazing for me in the industry is uh that innovation doesn't happen linearly in a in a straight line from bottom left, no innovation to upright, we have solved everything, but it's always this almost nothing for a very long time. I mean GLP, I think it was GLP1 1985 or something, where they started, then turn it down, brought it back, turn it down, brought it back, and suddenly you see the spike. Kati, pretty much the same. Um, why is the innovation? I want to hear your opinion. Why is the innovation in in our industry, in the biopharma industry, not something that you can predict on a linear scale? It's just a left, right, linear every year, a little bit of progress, and we know what's coming. Why does it happen in a way that is a straight line, almost nothing, and then suddenly it works and we get the results and it really changes the world for the better?

Alasdair Milton 6:14

Yeah, I it's a great question. You know, I think you could almost tell in the story of gene therapy, which at this the early 2000s there was a lot of promise in gene therapy. And then there was a trial where um there was a death, um, and and that kind of killed that field for for a number of years. Um we couldn't optimize the dosage with the AB vectors. Um, we were seeing significant liver tox issues, and those still played that market. But that that death in that clinical trial in the early 2000s really killed the field for a number of years, and yet it came back because we we spent time tweaking the technology, the scientists went away, they figured out how to you know maximize the the payload without the tox side effects. You could almost say it was the same with the antibody drop conjugates. I mean, at that a number of years ago, ADCs, nobody was really investing in that area. It was very difficult to manufacture. You had problems with the linker technology, with the payloads, but we spent time. We we tweaked the technology, we improved the manufacturing, um, and the science advanced. And so here we are, ADCs again, super hot area that everyone is investing in. So I think it's just those incremental things. You take, you know, uh, you know, a couple of steps forward, one step back, and then you take another couple of steps forward, and then we'll so the the science keeps evolving, the science keeps maturing, and I think eventually we get there.

Christian Soschner 7:35

When you look at China, um what advancements do you see coming out of China that personally excite you?

Alasdair Milton 7:44

Um I think that story around Cygnet is what really blew my mind. Um it it's again, it's the first, as far as I'm aware, it's the first ever drug that combines organoids and AI. And again, that speed, the FDA stamp of approval to get that fast track designation. Um it's in the clinic now. Like that to me is that really kind of blew my mind a little bit, is that you had this Chinese company that developed its first ever drug using AI and organoids, and it was now in humans within a couple of years of just the inception of the company, I think. So yeah, again, we we talked earlier around a lot of the molecules that we saw in that chart where Me Too, Me Better, uh, and it wasn't truly innovative stuff, but there's a perfect example of of true innovation there. Um so that that to me was was very exciting to see. Now let's wait and see what the clinical data looks like. Let's wait and see what the clinical data looks like outside of China. There's a long way to go, but again, it just speaks to the the focus the drive of the Chinese to be at the forefront of biomedical innovation.

Christian Soschner 9:11

Great science dicing quarterly portfolio refuse every single quarter. What would it take to actually rescue it?

Alasdair Milton 9:20

There's a lot of great science that goes on on the four walls um uh on these pharma companies, uh it never sees the light of day. And we're seeing more companies externalize the these these deprioritized assets. There was an example earlier this year of BMS doing a deal with Bain Capital. So again, PE company, externalized a lot of that science. So that would be my one one thing I'd love to see in the short term. Um, but I think that for the longer term, um the more aspirational, I actually think not just biopharma, but I think it's time for the life sciences industry to move away from uh being an industry that's more reactive to one that's been more proactive. So we've been a sickness industry, right? We've treated disease, chronic disease, but can we move more towards lifelong wellness and and and kind of preemptive health? So instead of selling drugs to treat conditions once they appear, um, we I think we need to be working harder as an ecosystem to predict disease risk years out and and developing interventions that help to reverse things like cell damage before it becomes a diagnosed illness. And I think that puts the patient at the center of things. I think the industry overall and life sciences overall, um, we talk a really good game about patient centricity, but an approach that's actually focused on wellness, it that's inherently just more personal. You know, it requires a continuous understanding of someone's biology, their lifestyle, their environment. Um, you know, you'd have to create platforms that people can engage with throughout their lives, provide personalized guidance and interventions, um, rather than just interacting them, interacting with them when they're sick. Um, and to be honest, I think we we need this approach. We all know the healthcare systems around the world are really buckling under the pressure of aging populations with chronic diseases like diabetes and Alzheimer's. Um, and I understand it's a huge ask of the industry, but and it doesn't move fast. I understand that our biopharma companies, our life science companies, for the most part, are for profit and they need to make their quarterly numbers. But I think it would take some really bold C-suite executives to make this happen. But I also think we could we could actually change some of this through the incentive structures. So whether it's you know government or private insurance, we start rewarding outcomes and not procedures. So maybe we give higher reimbursement rates for proactive screenings or wellness consultations. But I think that would be for me the thing I would try and change about the industry over the next the next decade. I think the the current business model, I'm not sure, is entirely sustainable.

Christian Soschner 12:12

Yeah, great ideas, great ideas. And I think for the first time in human history, we have also the tools and the means to do that. We didn't think the past was probably more uh restrictive in in the available tools now with AI, with all these uh capturing tools, data capturing tools. You mentioned a really interesting point. Uh maybe we dive a little bit deeper into that, incentivize the big companies to externalize their data at the end of the day. Um, it sounded to me you were talking about especially data of trials that failed, or when companies make a strategic decision and say we don't move forward um into that direction. So they just scrap the whole part and drop it and say no, we don't need it anymore. And uh there is no incentive for us uh to publish the data or give it away because it for us it's it does not have uh any value. Uh, did you understand you writing that part that you mean this part of this data?

Alasdair Milton 13:06

Yeah, no, it's it's it's so sure it's the data, but it's the data tied to the asset. So what I mean is that you know every quarter, every pharma company goes through a portfolio exercise where they say what are we going to fund and what we're not gonna fund. Yeah. And the drugs that don't get funded, they go on the shelf. And that IP expires and the drug is is not commercially viable. Now, sometimes they'll try and externalize it, sometimes they'll give it to um patient groups, but there's not a systematic way to collect all of the incredible signs and incredible assets that go on the shelf every quarter from the industry and figure out how to fund them and get them out of big pharma and and and new vehicles where we can get those assets to patients. So um I worked on a project in 2017 um with a prior firm where we took deprioritized assets from Pfizer and we spun it out to a company called Springworks. Uh, and Springworks was subsequently sold to Merck KGA, so German Merck, earlier this year for about $4 billion. And Pfizer had some upside there. And similarly, Pfizer did something very similar not long after the Springworks deal. They took um neurological assets that they deprioritize and spun it into a company called Cerevel. And now BMS has just done it with some, I believe it was um immunological, immunological assets in that partnership with Bain. And so companies are thinking about it a little bit more, but we're seeing it uh sporadically. I'd like to see a systematic approach to that where pharma companies can come together and pull those assets and then figure out how we get funding for them. Because patient groups have some money, there's um other types of capital that can be deployed, PE money. Um so I think that would be to me um a great thing to do because it's just I just I just know there's great science that never sees the light of day because it's killed in a commercially portfolio review.

Christian Soschner 15:06

Before we go further into the strategy, I want to understand where this mindset actually comes from. Tell me about the island in Scotland.

Alasdair Milton 15:18

Sure. So um I was born and brought up in a very rural part of the west coast of Scotland. Um when I say rural, it's a small island. It's called Seal Seal Island, S-E-I-L. It's about 15 miles southwest of a town called Auburn, which is if anyone who's watching this is a a whiskey fan, it's a very famous whiskey town in Oban, in Scotland rather. And so Seal Island is I don't know, a couple of miles wide, three or four miles long. It's a population of about when I was growing up there, maybe three or four hundred people. So very, very small place. Um, my dad was a fisherman, my mom worked in the local school, you know, solidly blue-collar. Um, and you know, my dad especially was very focused that um I would go to university. Uh, was actually the first one in my family to go to university. Left cling down, rolling up your sleeves, and and you know, um, you know, just uh go for your dreams, you know, just try and you know, push, push on, push hard and try and achieve your dreams. I I loved growing up on that island, it was incredible. But there comes a time when you feel like you're a little bit, it's a little bit claustrophobic and you have to go out into the big bad world.

Christian Soschner 16:33

How how was life on that island for you as a kid?

Alasdair Milton 16:36

Uh idyllic, really. Uh it really was. It was a great upbringing. Um great friends, uh the kind of place where during the summer holidays, your mom and dad would kick you out of the door at eight o'clock in the morning on your bike, you'd go and play football uh with your friends, come back at five o'clock, and you know, very safe. Um it was it was a great, great place to grow up. So I'm very it was very, very lucky. Um, but like I say, you I think you eventually, you know, I I still have friends who who live on the island who stayed around that area. I think you know, some folks uh just never wanted to leave, and there was other folks like myself who just felt they wanted to go out and and do other things. So one of the biggest lessons I took was that your career is never linear. And that you you find that one door closes and actually another one opens, and it when that door closes at the time, it can seem like the end of the world. But when I look back now, it was probably one of the best things that happened to me. Um, you know, if I hadn't lost my job at Wood Mackenzie, I'd probably have gone back to the UK and I I probably wouldn't be here at KPMG doing the work I'm doing. So in many ways it it kind of worked out well. But again, I I keep I feel like I'm like a broken record here with the resilience and the tenacity. Like I'd always wanted to come work in the States, right? That was my drive. I didn't necessarily want to live here forever, but I was was willing to go on a two year Seconman, and that was just so exciting to me, right? The idea that I could come here, be exposed to new culture, um, learn some new skills, um, and then take that back to the UK fantastic. All of a sudden that's closed on you within just a matter of weeks. And so again, I come back to the tenacity, the resilience. And if you have a drive, you have a goal, you're gonna say, okay, that that's not, I'm not gonna let this be the end of the story. And so ultimately the the the life sciences team, um, the research side of the team at least was bought out by by a company called Decision Resources. And I started my new job on the first of January 2008. So within just three months of arriving in the US, I'd lost the job, got a new job, and and then that was a big decision, right? My wife and I had a had a big decision to make. Do we go back, right? You know, do we go back to the UK? Do we try and start somewhere else in the UK? We wouldn't have been able to go back to Scotland because that job had gone. It was probably gonna have to be the southeast of England, which is another that's a big change as well. Or do we stay here? And do we go with decision resources and try and make a life of it here for the next few years? And so ultimately we decided we would try and make a go of it. And it was not easy at all. I mean, we we spent a number of years where a wife in particular struggled. She was a or is a nurse, she had worked in um, she's always been an oncology nurse. She had worked in the the um in the UK at the beats in in Glasgow, and so she had to give up her job because her skill set here they wouldn't accept. She had to retrain. And so she was out of work for a long time, and so it was really tough on her. Um, and so it it was a it was a tough few years. You don't really know anyone, you don't have that many friends, but again, it's just that resilience and that push and that drive that's kind of just in you that kind of pulled you through, I think, a little bit.

Christian Soschner 19:54

So if that's the mindset required, what advice would you actually give someone in their early 20s who wants to play in this space?

Alasdair Milton 20:07

I think you have to be someone who can be um a good translator. And and and by that I mean can you explain complex science to a business leader in terms of market opportunity, right? We we talked about this before, um, or it to an investor in terms of risk and return. You you have to be able to build the bridge between the lab and the business world, and that's an invaluable skill. I said before that scientists they tend to get knee deep in the detail, and that's great, but you have to be able to bring it up a level to something that's understandable to business executives. So um I'd spend time learning about the industry. You don't have to do another degree, you know, listen to podcasts like this, read books, take online courses, you know, connect with people in the industry. I'm always happy to connect with people and share my experience and my perspectives, try and, you know, carve out time with them to learn, you know, learn about the industry, learn about regulatory affairs, RD, and commercialization. It's not an easy road, but if you've got the drive and if you've got the focus and you've got the energy, then then you'll make it happen. But um, yeah, that would that would be my advice. Is um, and also I think sometimes I've heard I I didn't have this myself, but I've heard other folks who've been very successful in their careers. They had mentors from outside of their own industries. So they had people, maybe they were they were a scientist themselves, but they maybe had a mentor who was from the finance world who could impart their own advice uh as well. And so if you can find that mentor um to help support you, I think that can be that can be a very, very powerful um kind of um you know guiding hand for you.

Christian Soschner 21:46

My final question to you is uh how can listeners best reach out to you?

Alasdair Milton 21:52

Yeah, I um I had my email up on some of those slides. If folks didn't manage to uh know that down, then happy to share my email. Address. Um, also I'm on LinkedIn. Um, those those would be the two best ways to contact me.

Christian Soschner 22:07

Alistair just gave you the blueprint. The science is ready, the data is clear. The only question left is whether your portfolio, your company, or your patients will actually benefit. The full conversation goes much deeper. China's real playbook, the exact artificial intelligence use cases across the entire precision continuum, and how to build the translator muscle he described. Listen to the complete episode now. Follow the show. And if you allocate capital or build companies in life sciences, reach out to Alistair and the KPMG Precision and Advanced Therapies team directly. The bridge is open and the window is closing.