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Personalized Medicine Continues to Evolve in Oncology

Caroline Seymour
Published: Monday, Aug 20, 2018

Leonid Shunyakov, MD

Leonid Shunyakov, MD

The use of next-generation sequencing (NGS) is a novel means of improving cancer care, but there are other methods of improving care that extend beyond the panel itself, explained Leonid Shunyakov, MD, a hematologist/oncologist at Central Care Cancer Center.

In November 2017, the FDA approved the use of Memorial Sloan Kettering Cancer Center’s integrated mutation profiling of actionable cancer targets (MSK-IMPACT). It is the first 468-gene oncopanel to be authorized by the FDA to identify somatic mutations.1

The application of NGS was well reflected in the phase III CheckMate-227 trial, in which high tumor mutational burden (TMB) was associated with greater response to immunotherapy. Treatment-naïve patients with non–small cell lung cancer who received the combination of nivolumab (Opdivo) and ipilimumab (Yervoy) more than tripled the 1-year progression-free survival (PFS) rate versus those who received chemotherapy.

Patients with TMB ≥10 mutations/megabase treated with the combination showed a PFS of 43% at 1 year as opposed to 13% in those treated with platinum-doublet chemotherapy. Investigators also reported a 42% reduction in the risk of disease progression or death (HR, 0.58; 97.5% CI, 0.41-0.81; P <.001).2,3 However, Shunyakov noted that the number of patients who benefit from NGS hovers around 15% to 20%. In addition to streamlining existing assays, Shunyakov says that further investigation of the biology and pathways of patients’ tumors will better guide treatment selection.

He also added that proteomics and the microbiome will assume greater responsibility in predicting response to therapy in the future.

In an interview during the 2018 OncLive® State of the Science SummitTM on A Summer of Progress: Updates from ASCO 2018, Shunyakov discussed the impact genomics has on personalized therapy and the roster of available therapies that continues to grow as a result of identifiable genomic drivers.

OncLive®: How do genomics impact personalized therapy in oncology?

Shunyakov: Genomics is a huge subject. It’s important because we all use genomics in our practice. There are limitations to NGS. There is significant discordance between different assays. FoundationOne and Guardant360 are the 2 most commonly used assays in our practice, but they don’t really match up. The discordance rate is about 70% and the concordance rate is about 20% to 25%. That’s one of the problems with using NGS. The second issue is how to use NGS in novel ways. We used to use NGS to guide our therapy [decisions in a patient with a] single driver mutation, but most cancers are much more complex and have more than one driver.

[We now know that we can] assess TMB. There was a publication in the New England Journal of Medicine in May 2018 by Dr Matthew D. Hellmann about the use of high TMB as a predictive response to the combination of nivolumab and ipilimumab in lung cancer. At 1 year, the study showed a 43% PFS in the combination group compared with 13% in chemotherapy. Assessing TMB is one of the novel ways of using NGS.

Gaining knowledge at the molecular level about how genes work and using [that knowledge] to guide therapy is another novel way [of using NGS]. In kidney cancer, one of the most commonly mutated genes is PBRM1. It’s associated with activation of a certain inflammatory pathway, and whenever it’s activated, there is a higher likelihood of response to immunotherapy.

I also wanted to point out that NGS is not the final answer to everything. In addition to NGS, we also have proteomics. Exosomes are produced by cancer [and expulse] microRNA. The tumor has a 3-dimensional structure. That’s why there is tumor heterogeneity. Solid biopsies may not reflect everything. To get a more complete picture, we may use the combination of liquid and solid biopsies.

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Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: Addressing Post-Transplant Obstacles: Current and Emerging Strategies to Evolve the Standard of Care for Patients With Graft-Versus-Host DiseaseMar 28, 20192.0
2017 Year in Review™: Clinical Impact of Immunotherapies in the Treatment of CancerMar 30, 20191.75
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