This is an in depth review of the American Society of Clinical Oncology’s (ASCO) panel on their State of Cancer in America annual report released January 31st, 2018. MyOncoPath is dedicated to providing cancer patients and oncology providers with genetic counseling for somatic and diagnostic genetic testing to expand access to precision medicine.
Through our overview of the panel discussions on genetic testing and precision medicine one can gain comprehensive knowledge about the current state of cancer treatments, understanding of cancer genetic testing and how it correlates to precision medicine, the benefits for patients, and the challenges for providers. You may also view the three hour video of the panel here or continue reading for a detailed summary of the exciting oncology advancements of now.
“Precision medicine has transformed how cancer is treated and the lens through which it is diagnosed and studied.” – ASCO
Chief Executive Officer of ASCO, Clifford Hudis, MD introduced the panel noting that twenty years ago trastuzumab was approved as a breast cancer treatment. This was the first monoclonal antibody targeted to treat breast cancer that is HER-2 receptor positive. It marked the beginning of the modern era of precision medicine at the clinical level.
Understanding Precision Medicine
How some cancers are treated, along with diagnosed and studied is precision medicine. The benefits of precision medicine aren’t yet available to everyone, there are disparities. Precision medicine includes the sequencing, next generation panel sequencing, of tumor DNA for the use of identifying targeted therapies. Precision medicine also applies molecular diagnostics to identify opportunities to treat with immunotherapies. A major obstacle within the oncology community is how to convert these technical advancements into practical applications. MyOncoPath was founded to bridge the gap in the disparities, helping patients and oncology providers understand genetic testing and have access to genetic counseling to navigate which tests are appropriate and help interpret the results.
Targeted therapies, including immunotherapies, are chosen based on genetic changes in tumors or cancer DNA. There is a perceived practical need: for example patients can go to ASCO with DNA sequencing results already done to find out about treatments but patients need access to the genetic tests in order to have these results. MyOncoPath’s genetic counseling telemedicine clinic is available across the United States and acts as part of a patient’s oncology team to provide the appropriate testing.
This past year the CAR-T cell therapy was approved and noted to be the cancer advancement of the year. CAR-T genetically alters a patient’s own immune cells to target tumors and ultimately destroys cancer cells. The CAR-T cell therapy is part of the latest precision medicine advancements that needs to be widely accessible. Working collaboratively in the oncology industry is key to the advancements in reducing the disparities to access and care. To make sure the right therapy, the best therapy, is available to every single patient that would benefit.
Precision medicine shouldn’t be a cutting edge science with those cancer treatments being delivered to a select few. Precision medicine should be making sure the highest quality of care is available to all eligible patients based on the science. Personalization of the care decisions should reflect the individual patient goals.
Over the past 20 years the Suzanne Topalian, MD Associate Director of Johns Hopkins Bloomberg-Kimmel Institute for Cancer Immunotherapy, notes two revolutions in oncology: targeted drugs and immunotherapies. The first are targeted drugs that attack cancer cells directly by interfering with signaling pathways that fuel the cancer cell. Biomarkers are developed in the form of companion diagnostics to know the genetic makeup of an individual patient’s tumor that indicate a potential positive response to a targeted therapy. She goes on to say precision medicine is finding the right drug for the right patient. This is also known as personalized medicine, however precision medicine is considered a more modern term. The second revolution is immunotherapy, which act indirectly by using a patient’s immune cells to attack the cancer. The diagnostics developed are different than those for targeted therapies. These two types of treatments were thought of as two different fields but there are a lot of intersections in the two.
In May of 2017 a landmark in cancer treatments was made with the FDA approval to give immunotherapy to patients who had a genetic marker in their tumor. This was the intersection where seemingly distinct fields of science converged, the meeting of cancer genetics and cancer immunology. We have covered how precision medicine is translated into care and now will continue on to better understanding the vast field of genetic cancer tests.
The President of ASCO, Bruce Johnson, MD went into how precision medicine is being translated into care of patients and whether or not the hope is worth the hype. He stated that precision medicine is allowing the oncology community to deliver better cancer care faster than ever before and that it is able to do so in defined subsets of patients. Cancer care is transforming the lives of patients by allowing them to live longer and better – this is the promise of precision medicine.
At first oncologists treated all cancer patients the same, depending on the size, the location, and how disseminated the cancer was. Nearly all patients received combination chemotherapy. Decades ago with this approach applied to lung cancer, one third of patients saw tumor shrinkage and the survival rate was 12 percent.
Today the outlook is very different based on the ongoing discoveries to genetic changes that are driving cancers, the ability to effectively target the cancer, and the recently introduced immunotherapies.
To better understand how precision medicine is translated into care with genetic testing Dr. Johnson gave three patient vignettes:
– The ALK rearrangement patient was first treated for EGFR mutation based on the characteristics of her cancer, but her cancer had not been genetically tested and it did not have this mutation. The result of her first round of treatments was not successful. She then had genetic cancer testing that showed she had an ALK rearrangement. She was successfully treated, going on to see her children into college and she continues to strive. Genetic testing identified a targeted therapy which the patient’s cancer responded to after previously being unable to stop the cancers progression.
– The next patient received genetic testing with no targetable lesions found. Knowing this information about the makeup of the patient’s cancer allowed the creation of a treatment plan with several drugs to be chosen with a higher success. In the case of this patient, genetic testing eliminated targeted treatment options allowing the patient to receive the best drug combination for her cancer.
– The third patient had non-hodgkins follicular lymphoma and was an initial CAR-T clinical trial patient. This patient had previously received chemotherapies that weren’t killing the cancer. After completing a round of chemotherapy a PET scan showed more spots. The patient was advised to seek out clinical trials because of the cancer’s lack of response to chemotherapy. The patient was hesitant due to the side effects listed for the clinical trial and reluctant to try. With no other options, she proceeded with the clinical trial. The CAR-T therapy took T-cells out of her blood, reprogrammed her T-cells, and put the cells back into her body. It took three days for the side effects to take hold and about a month for them to reside. (A common misconception is that targeted therapies and immunotherapies don’t have side effects; they can have side effects that differ from other chemotherapies and at times these may be more or less severe based on a patient’s response. There are pros and cons to any cancer treatment). It has been eighteen months since the patient underwent the CAR-T cell therapy and her PET scan is all clean.
The stories of these patients show three vastly different results from utilizing precision medicine. Genetic testing helped each patient identify a cancer treatment for a better outcome.
Understanding Genetic Testing
The field of companion diagnostics is at an interesting point at the moment. There are two ways genomic testing is being implemented, which range from testing for a specific alteration on a specific gene, to the large panel tests that report out findings on many hundreds of genes all at the same time.
The classical diagnostic approach is to test for specific mutations we need to look for in order to prescribe the optimal therapy. For example, with a lung cancer patient a test may be ordered to determine is the EGFR mutations. With large scale genetic profiling the test is not targeting a specific mutation and there is not a predetermined plan for the results. Currently there are approximately thirty to forty genes known that are clinically actionable with available therapies. Some oncology providers may struggle with what to do with this information.
MyOncoPath’s expert genetic counselors help identify the right genomic testing approach for a patient with their medical history and cancer diagnosis. The question of if only individual companion diagnostic test should be order versus the utility of the broad panel can be determined based on several factors. Our genetic counselors also assist with interpreting the information in an final clinical report for providers and patients.
An example of when broad spectrum genetic testing is an ideal choice would be if a patient has a small tumor with only one or two chances of obtaining a biopsy. In this case it would be prudent to get all the information you may need. Another example is with a patient that fails with a first clinical trial or treatment, then it can be good to know what else the patient is eligible for. It may be best to look at a multi gene panel, look at markers for immunotherapies, and look at general mutation burden of tumor.
With next generation sequencing the possibilities are limitless and far less expensive than they used to be. NCCN guidelines assist with our determinations as well. The panelist noted that the cost of getting a wrong test can be as catastrophic as getting the wrong treatment.
Overall most patients are not aware of precision medicine and the benefits of genetic testing unless treated a facility where this is available or offered and their insurance covers it. Based on insurance patients may not get offered it even if it is available. This is a problem, as is the time consuming process of waiting for insurance approval for genetic testing. At MyOncoPath, we offer low cost convenient services to help patients get genetic testing immediately. This allows patients and providers the opportunity to quickly identify the potential treatment options or rule out treatments. With cancer, delays negatively affect success rates and outcomes.
Edward Kim, MD Chair of Solid Tumor Oncology and Investigational Therapeutics, said a critical crisis right now is how we empower providers at the community level, in less populated areas, to deliver the kind of care that is expected with precision medicine. Not all providers, oncology practices, cancer centers, and hospitals are necessarily going to have genetic tests, experts to interpret findings, and access to therapies based on the results of tests. MyOncoPath’s genetic counseling telemedicine clinic was founded to help empower all oncology providers and patients, across the U.S., with the access and ability to implement precision medicine with genetic testing. Collaborative medicine is vital for precision medicine and better outcomes.
MyOncoPath is part of the precision medicine delivery system by assisting in the streamlining precision medicine to patients and providers via our genetic expertise. We are here to assist with the challenges in the system. Unlike labs, MyOncoPath is a clinic — we’re unbiased when it comes to choosing the best test for a patient. We don’t try to sell a specific test or brand of tests (or any tests at all, for that matter). We make testing recommendations based on what is most appropriate for the patient. We provide with actionable and accurate information from the CAP-accredited and CLIA-certified labs we have strategic partnerships with based our working experience. To offer the best selection of genetic tests in one clinic.