Molecular Oncology – The Final Subspecialty in Cancer Care
by Cyriac Kandoth, PhD
We often hear that every patient’s cancer is unique. This may refer to the different ways tumors start and spread, how they can react differently to the same treatment, or how each patient may have different symptoms. Over the last decade, we have explained some of these differences in the mutated DNA of cancer cells. Just like clues in a crime scene, these so-called “biomarkers” reveal the tumor’s behavior, give us clues on its weaknesses, and help us choose drugs to target those weaknesses. We call this “molecular profiling”, one of the many steps in the United States’ Precision Medicine Initiative.
Since 2005, my colleagues and I have been working on The Cancer Genome Atlas (TCGA) project, which revealed hundreds of ways in which cells in our body can develop into cancer, after their DNA is mutated by carcinogens like cigarette smoke, ultraviolet radiation, asbestos, etc. At the same time, hundreds of molecular profiling tests are being invented with the promise of smarter ways to prevent, identify, and treat cancer earlier and more effectively. New biomarker-based cancer treatments that are more effective and less toxic, are being tested and approved faster. And health insurance companies are also beginning to reimburse innovative tumor profiling technologies.
Many biomarkers are shared across tissue types like lung, breast, prostate, etc., suggesting that they can be treated with similar drugs. For example, a certain type of breast cancer is very different from other breast cancers, but genetically more similar to a common type of lung cancer, a very different organ tissue. The tissue type is important for decisions like surgery, radiation, or symptom management. But today, over 40 biomarkers are proving more important than tissue type, at telling us whether a treatment will work or not, or at least slow down the cancer. We see signs that there will be an explosion in the number of clinically relevant biomarkers, over the next few years. And we need to make sure that every oncologist is using this information.
Oncology trainees at major cancer centers are already learning about these biomarkers, how they inform treatment decisions, and what they mean to a patient’s survival. We call them “molecular oncologists”: armed with molecular profiling tests, treatment decision support systems, and data from cases with similar biomarkers. However, these resources are developed and implemented only at major academic cancer centers, and even then, a multidisciplinary team of experts need to review many cases. Although the technology and data is available, there aren’t enough molecular experts to personalize treatment for everyone. So we need to automate and scale up that expertise, for patients and physicians in non-academic cancer centers in the United States and abroad.
As populations rise and life-expectancy increases, cancer will become one of the most prevalent diseases in the world. This will bring a tremendous demand for cancer care, particularly in remote and underserved communities where oncologists are too often overworked and understaffed to keep up with the latest research, targeted therapies, and clinical trials. When faced with a complex case, they usually refer the patient to specialists at academic cancer centers. But patients often have restrictions in travel, insurance, health, work, or family obligations.
All oncologists are lifelong students who research every case and learn how to treat it. But the increasing workload, paired with many new tests and biomarkers per patient, makes it challenging to consider all of the latest information into a treatment decision. So we immediately need decision support platforms that automatically present the most clinically relevant information for each patient. The cancer research community has the critical mass of knowledge to end cancer, but we need to expand and validate that research, and translate it into helpful websites and guidelines for oncologists and patients everywhere. Many practices and physicians are at risk of falling behind on the latest testing and treatment strategies, more commonly outside the United States. Only their patients can keep them on task.
Many academic cancer centers, non-profit organizations, and biotechnology companies are creating websites, algorithms, and guidelines to educate patients, and assist oncologists in biomarker-based testing and treatment. Some of these resources are listed at poa.massbio.io. There are also companies that do tumor profiling as a service, where they find biomarkers in the DNA of the tumor, shortlist the important ones, and report matched treatments. However, their technologies have complex strengths and weaknesses that the average oncologist cannot easily identify. These companies are also detached from the patient’s overall health and place the burden on the oncologist to design a treatment strategy that takes into account the patient’s previous test results, reactions to other treatments, clinical status, eligibility for clinical trials, and insurance coverage.
This new market for remote molecular oncology advisory, which is predominantly online, is evolving steadily into something that could be a part of every patient’s care. Massive Bio, Inc. (MBI), the company I co-founded with my colleague Selin Kurnaz, PhD, offers a first-in-market molecular advisory service for patients, and a virtual genomics tumor board for oncologists. Our vision to “democratize precision oncology” states that all patients should have access to the same level of personalized treatment protocols at their local hospital, without having to travel to a major cancer center. Companies like ours work with each patient’s oncology team and health insurance, providing scientific evidence to ensure that patients receive a personalized treatment plan for their molecular profile, while taking into account the patient as a whole, not just a test result. As personalized testing and treatment are becoming the standard-of-care, it could reduce the number of lines of treatment, bringing down overall costs, and allowing more patients to receive the highest quality cancer care.