Expert perspective, insight and discussion
By Dr. LenJune 06, 2011
I don't often write blogs about articles that appear in newspapers, but in this case I am going to make an exception for today's excellent front page story in the Wall Street Journal by Ron Winslow discussing the coming of age of genetics and genomics in diagnosing, treating and predicting the behavior of the disease we now know as cancer.
But even though Mr. Winslow may have pre-empted the thought that for me the seminal theme of this year's annual ASCO meeting in Chicago was related to the impact of genetics on cancer research and treatment, his well-written "scoop" won't prevent me from weighing in with my opinion that this year represents another one of those seldom moments when we reach a tipping point in cancer research and the application of that research to the diagnosis and treatment of cancer.
It was obvious literally from very beginning of the meeting when Dr. George Sledge--the President of ASCO--addressed thousands of cancer professionals from around the world and talked about the impact of the forthcoming era of personalized medicine.
In the past, we have had the chemotherapy era, where we were able to put combinations of toxic drugs together to cure and control some forms of cancer. We have had the adjuvant era, when we learned that using chemotherapy could delay the progression of cancer after primary treatment, usually surgery. We have most recently had the targeted therapy era, when we learned that drugs targeted at genetic changes in cancer cells could impact survival, sometimes substantially. We wish we had a vaccine era, although there have been some practical successes and hopeful research that continues in that arena.
And now we have the genomic era.
Of course, all of those past eras are still around in one form or another. Successes, controversies and disappointments of those eras will likely be with us for some time. But they will be moved aside just a bit it as the overriding theme of genetics on cancer reaches a crescendo level as technology and demonstrated results in clinical practice forces the tipping point/watershed noted above.
It certainly has been a long time coming.
There are those who have voiced their criticism and disappointment (sometimes loudly and prominently) about the lack of progress in cancer research and treatment following the beginning of the "War on Cancer" in 1971. Perhaps the tide is finally shifting. Genomics is pervading the basic science research, clinical trials and general discussions of so much that we are hearing at ASCO 2011.
There was one lecture where the researcher showed a large box that looked to be the size of a refrigerator which can analyze the entire genome of a person or a cancer over a matter of days, followed by the prediction (that many share) that these types of tests--which were the stuff of science fiction just a few short years ago--will be routine at a reasonable cost in a very short period of time (in fact, some well-known cancer centers are already employing this technology as part of their routine evaluation of a patient's cancer).
There was a presentation where researchers did a very early clinical study where they based their treatment on genetic changes in a patient's tumor rather than what the tumor looked like under the microscope. The results in patients with very advanced cancer showed that this approach actually resulted in responses that were greater than what one would have otherwise anticipated.
Perhaps the most telling and exciting research was the presentation on the new melanoma treatment yesterday (anddiscussed at that time on this blog). By analyzing the tumors of patients with advanced melanoma for a particular genetic abnormality present in approximately half of the patients with the disease, researchers were able to shrink the tumors in almost all the patients by using a new drug with about 50% of the patients going on to a meaningful response. (Of course, we should not forget that 50% of the patients did not have this genetic marker. We still have much to do for them as well.)
So why did it take so long to get here, and where will we be going?
To me, this has been like building the interstate highway system in this country.
For you young folks out there, it is hard to believe that the highway system that criss-crosses this country never existed. Believe me, it didn't. And when I had to travel with my family as a young child from our home in southeastern Pennsylvania to my extended family's home in Philadelphia--a distance of 90 some miles--it was a laborious, long adventure.
Along comes President Eisenhower and proposes that the interstate system be built. After approval, the land had to be purchased and cleared, the reinforcing rods had to be placed, the cement had to be poured.
And today, one thinks nothing of cruising along at 70 MPH (well, OK--maybe I do travel a bit faster than that from time to time) and going great distances over just a couple of hours.
That's what has happened in cancer research. We have built the highway, and it is time to cruise. We have had some fits and starts along the way, as when we used targeted therapies on everyone to benefit only a few. We still don't have a target for bevacizumab in breast cancer, for example. But we do have a target for some colon cancer, breast, lung, leukemia and now melanoma treatments. Our world is getting just a bit flatter and more connected.
Over the past several years I have had discussions with several reporters about the "sense of the situation" in cancer research and treatment. Among other topics, we invariably discussed the potential future impact of genomics on cancer medicine. We talked about what the future could bring, and how long it would take to get to this brave new world.
Well, my friends, we are now here. Not very far into the woods, but certainly on the periphery of the forest. Give us a couple of more years, and we will be blazing the path into worlds about which we can only dream of today.
We will be routinely analyzing the genetic map of people as part of routine medical practice to offer some predictive assessment of their future health risks. We will be doing tests to determine if they actually have a cancer before we can see it with currently available technology. We will be analyzing tumors through genetic analysis instead of through a microscope to diagnose them (microscopic diagnosis will be oh-so-21st century!!!!). We will use that information to pull medicines off the shelf that are chosen by the genetic profile of the cancer rather than the pathologist looking through the microscope and calling a tumor lung cancer, breast cancer, etc. We will even be able to avoid toxic therapy by determining that a cancer will be indolent and not cause a problem over a lifetime, or monitor that cancer over time to see if it is morphing into something more problematic. We will be able to do cancer clinical trials in the fraction of the time it takes today, meaning that new medicines will move from the bench to the bedside more quickly than ever before.
Make no mistake: this is not going to be a simple journey. There is much we have yet to learn, not the least of which is how we translate all of this into something that is useful and practical in our everyday medical lives as health professionals and patients. But those concerns are not going to hold back this progress and excitement. We are moving forward, we are at the tipping point of a new era.
And after several years of disappointments I am going to leave Chicago tomorrow more excited than when I arrived. An era has dawned, and that should make many of us very optimistic about what is now within our grasp.
This is really exciting stuff and I am leaving with a renewed sense of optimism. Can't wait to come back next year.
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