Gene therapy has finally moved out of the realm of science fiction… and this time, it may be here to stay.

But with price tags edging toward the million-dollar mark, will anyone but the mega-wealthy be able to afford these new treatments?

, the Food and Drug Administration (FDA) approved a new gene therapy treatment for a rare, inherited form of blindness.

The cost? — lower than the $1 million that many analysts expected.

Still, that’s $425,000 per eye. For a drug that doesn’t fully restore vision. And that’s only known to work for up to four years in some patients.

Only around 1,000 to 2,000 people in the United States may benefit from this one-time treatment. Like other super-expensive treatments for uncommon diseases, the rarity of this disorder partially explains its high cost.

People with this condition have a particular gene, known as RPE65, that causes their vision to deteriorate. In some people, it may cause complete blindness.

The drug, called Luxturna, was developed by Philadelphia-based Spark Therapeutics.

As the manufacturer and insurance companies wrestle with how to make this drug affordable while allowing the company to still turn a profit, the gene therapy field continues to move ahead.

Treatments on the horizon

What happens in 2018 for gene therapy will build on what scientists and drug companies accomplished last year.

“Some of the more exciting developments last year concerned successful product development and pricing in the commercial arena. I expect that to move forward some more,” said Dr. Sanjeev Gupta, a professor of medicine and pathology at Albert Einstein College of Medicine and Montefiore Health System.

In the cancer arena, the for certain children and young adults with one type of acute lymphoblastic leukemia (ALL).

This type of immunotherapy involves genetically modifying a person’s immune cells — T cells — to boost their ability to attack cancer.

The FDA also approved a CAR T-cell therapy for the treatment of a type of B-cell lymphoma that occurs in adults.

With scientists achieving this “major progress in treating cancers [that occur in the blood],” Gupta said “we’ll hopefully see more such progress for solid tumors.”

Another area that will continue to see progress is gene editing, the ability to make precise changes in a cell’s DNA sequence.

“Gene editing with CRISPR technologies is becoming more and more exciting,” Gupta told Dr.China. “Several companies are competing in gene editing — the Sangamo trial for Hunter syndrome was an early example — but we’ll be seeing more trials of gene editing.”

CRISPR-Cas9 is a that allows scientists to add, remove, or alter specific sections of DNA, not just in people but in other organisms as well.

Scientists at Harvard University recently used this technique to slow a progressive form of in mice.

The genetic mutation that causes this condition also occurs in people, although only in a small number of families — so it may not be long before scientists try this treatment in people.

Another area that Gupta expects to see developments in the near future is gene expression regulation. Being able to control which genes are active may give scientists a way to treat diseases without having to alter the DNA.

Diseases ripe for gene therapy

While any disease is a potential target for gene therapy, some treatments are easier to achieve in the clinic.

It’s no coincidence that one of the first gene therapies approved by the FDA is a treatment for blindness.

“Eye conditions are amenable to gene therapy for various reasons,” said Gupta, “including easy access to the eye and treatment outcomes that are more readily evaluated than in some other cases.”

More complex genetic diseases, such as , involve multiple organ systems and the damage occurs deeper inside the body than the eye.

Blood diseases are also easier targets because blood cells can be removed, genetically modified, and then put back into a person’s body.

This includes the leukemia treated by the recently approved CAR T-cell therapy. But there are other potential treatments.

“Hemophilia A and B are major targets that many companies are actively pursuing,” said Gupta.

Hemophilia is a genetic disorder that impairs the blood’s ability to clot.

“Also, we should see developments in sickle cell disease or beta thalassemia,” added Gupta, “where discrete mutations may be edited to correct abnormal hemoglobin production that causes rapid destruction of red blood cells and anemia.”

Gupta thinks muscular dystrophy may be another major target for gene therapy in the near future.

Making gene therapy more accessible

Even gene therapies that would help only a couple thousand people would be a remarkable achievement.

But what happens when people who are blind, have a blood clotting disorder, or have cancer can’t afford the treatment?

Gene therapy techniques are still fairly new, so we may see a drop in price once the research and development for these drugs becomes more commonplace.

“In the short term, the costs will likely be high,” said Gupta. “Eventually, with economies of scale, pricing should come down as it usually does.”

Part of the high cost of gene therapy is the one-off treatment. Drug companies have to recover their development costs in a single payment.

Compare this to a pill taken every day by a person for the rest of their life — the high costs spread out over this longer period are much less steep.

The question, though, is how much will the price drop?

Drug companies still charge that need to be taken every day. And let’s not forget the that debuted last year.

David Mitchell, founder and president of the advocacy group Patients for Affordable Drugs, told that drug companies will charge “what they think they can get away with.”

Spark Therapeutics has been negotiating with insurance companies to woo them into covering the blindness treatment. This includes a partial refund if the therapy doesn’t work during the first three months.

One insurer, Harvard Pilgrim Health Care, has already agreed to pay for the Luxturna therapy.

So even with an $850,000 price tag, many people with insurance may never pay this amount out of pocket.

But like much of healthcare in the United States, this won’t help someone who is uninsured, underinsured, or whose insurance hasn’t signed on to cover a flashy new gene therapy treatment.

Over the past decade, the challenge of gene therapy has been making it work in the clinic. Next in line is making sure everyone with a disease gets the help they need.

“We must remain vigilant to make treatments accessible,” said Gupta. “These wonderful achievements of science have resulted from work supported by taxpayer funds over a long period of time. The future of gene therapy is bright, but we must make it brighter by making it affordable for each and every individual.”