Precision Medicine in Oncology: Overcoming Obstacles



Benjamin P. Levy, MD: So what’s the final message to the community out there about testing? Is there a statement or 2 to say, “This is what you need to do,” and how and when? What does the community need to know, given the context of this conversation, about these rare genotypes and wedding them to targeted therapy?

Mark Agulnik, MD: I would say test early and read the reports. Don’t just test and not read them. Figure out how to interpret them. If you have challenges in interpreting, there are tons of people at academic medical centers who would love to see these reports, love to see the patients. Ask questions. But I definitely think test early. There are some incredible drugs out there that will have an impact. The adverse effect profile is better. And, test the right patient. The stage I breast cancer patient is probably not the right case, but certainly test the right patients. Stage IV patients—test them early and read the reports when they come to you.

Philip Agop Philip, MD, PhD, FRCP: I think the way you can encourage them is by showing them the benefit of doing it. As you said, you’re detecting patients’ conditions that may benefit. But also, down the road, patients are hopefully living longer. Clinical trials—that’s another thing. This can help, in terms of doing that. And sometimes, prognostication. That’s the part we don’t talk about much. But there is an element of prognostication in some of these tests we do. The patients will feel more comfortable that everything is being done for them.

Benjamin P. Levy, MD: Ed, did you have any comments?

Edward S. Kim, MD: Yes. I think one of the messages I’ll give in New York this weekend is you need a molecular tumor board. You have to be associated with one. We all find our regular tumor boards, disease-specific tumor boards, to be really important. In fact, especially in the community, it’s part of the natural routine to show up to tumor board and present cases. There is not an adoption out there with these molecular tumor boards, and it’s absolutely essential. Either you’ve got to find an external one or you’ve got to create one internally. It’s as important as going to breast tumor board or to lung tumor board to discuss these cases. I think that’s a message out there, other than getting the tissue and all those things, regarding the help that’s needed. We’ve got how many experts up here and we still don’t know what crosses into other people’s boundaries and what to do with some of this. You can only imagine how confusing it is for a community oncologist.

John L. Marshall, MD: Well, the extension of that is I think, ultimately we, as oncologists, have to learn this, right? We have to teach old dogs new tricks, and we have to keep up with the space. It’s not going to be spoon-fed to us. It’s not a new medicine that we’ll figure out how to use. It’s an entire culture. We learned it at some point, in some classroom somewhere, but we’re going to have to understand what molecular profiling is all about and how to interpret a report. We’re going to have to make those decisions. Do I rebiopsy for a low incidence problem? Do I have enough tissue to do this? Can I interpret from what I’ve got? We haven’t touched at all in this space on what we call pre-analytic quality. We get more intricate molecular profiling, proteins, some of the RNAs; ischemia matters. So if it’s an old sample that’s 14 years old in a basement somewhere, it probably is not very good to run on. A bone biopsy—not very good to run on. We have to understand the principles of this so we can guide our patients.

Philip Agop Philip, MD, PhD, FRCP: There are institutions that can do 50 genes, and then there are people like myself who do 500 genes or 600 genes, or close to 600 genes. Some do liquid biopsies. Not everyone is on the same page. Some will ask, “Do you really need to do the 500-plus genes?” And that also confuses other people out in the community. What is the real answer here? Do you need many? Is it too many? Is the IHC [immunohistochemistry] that important to be part of it or not? Again, those questions are still not as clear as they should be.

Benjamin P. Levy, MD: Marcia?

Marcia S. Brose, MD, PhD: I think organizations like ASCO [American Society of Clinical Oncology], AACR [American Association for Cancer Research], and these places—we need a lot more education. A consensus of opinion would probably be really helpful to guide the discussion. I think that’s where some of the organizations can put together panels and do something like what Ed did for the clinical trials. They can get together and say, “What do we want to say,” and maybe have guidelines per tumor type. There might be overall reaching properties that everybody is saying stage IV should get. But then if you’re in sarcoma, do this, and give some real guidelines that then could be in the hands of some of the community doctors. Because I think trying to keep up with the literature is just asking too much. But it is something we have to know.

Benjamin P. Levy, MD: With excitement and science comes more confusion. They go together. It makes for a very interesting time in the field of oncology.

This has been extremely informative. Before we end the discussion, I’d like to get final thoughts from each of you. Mark, we’ll start with you. Final thoughts on this?

Mark Agulnik, MD: I think the winner is the patient here. Patients finally get all of us in a room together. We’ve never all sat in a room together because we all do different diseases, even all under the umbrella of medical oncology. We will start to learn from each other, and I think the bottom line is that the patients are definitely going to win from this.

Benjamin P. Levy, MD: Marcia?

Marcia S. Brose, MD, PhD: I think the rare cancer patients, especially, are winning and are going to get to have a little bit of their heyday as far as therapies go. But also, remember that with each of these molecular markers now, everything becomes a rare therapy. And now we have options for some of these people who wouldn’t have otherwise had them.

Benjamin P. Levy, MD: Philip?

Philip Agop Philip, MD, PhD, FRCP: I always put myself in the shoes of the patient. I look at it that way. If I’m a patient, even the 1% is something for me. That’s what I like to do for the patients because I feel they need that help. Even if it’s a very low possibility of something helping, we have to go for it.

Benjamin P. Levy, MD: Ed?

Edward S. Kim, MD: I love the fact that Fellows want to go into lung cancer. I think the personalized therapy story, it’s been 12 years since we launched BATTLE, and it’s nice to see things coming into place across the tumor types. But let’s not forget that we have a long way to go here.

Benjamin P. Levy, MD: John, I’ll give you the final thought.

John L. Marshall, MD: I bet we have all said to a patient, at one time, “If you just hang on long enough, we might find something.” And when you see something like we’ve discussed today, a transformative therapy, even though for a rare subtype, it gives truth to that. And whether it’s the I/O [immune oncology] space or all of the other things that are emerging, I’m so excited for the years ahead. I think precision medicine will be at the core of discovery.

Benjamin P. Levy, MD: That’s a good ending. So thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.

Transcript Edited for Clarity

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