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Technology & Innovation
Precision medicine is increasingly becoming the standard of care in the practice of oncology, and its use is likely to spread much more widely in medicine as a whole, according to experts in the recent webinar “Precision Medicine: Your Role in Advancing the Future of Cancer Care” from the American College of Healthcare Executives.
With regard to the old empirical approach in oncology of “just dabbling around” to see if something will work, “those days are going away,” said William Fintel, MD, medical director of Hematology and Oncology at Carilion Clinic. In its place is the precision approach that determines the genetic nature of the cancer and uses a therapy specifically for it.
3 steps in the development of a precision medicine
“If you think of a bullseye, to be precise is to hit the same place on the bulls-eye, again and again,” Dr Fintel said. Precision oncology is a 3-step process. “The first is to define the bulls-eye,” the molecular target, such as the estrogen receptor for breast cancer, which was one of the first precision medicine targets to be identified. Not every breast cancer patient has the marker that indicates susceptibility to targeting this receptor, but for those who do, it is a powerful approach. “Once you identify that unique target on a cancer cell, the second step is for really smart people, PhDs and physicians and other clinicians, to say, ‘How do I tap that specific target?’” This is the drug discovery step. “And then once you find that new molecule or therapy that attacks that target, the third step is to develop that drug and get it out to patients.”
Once a new precision therapeutic is available, getting it to the right patient is crucial. “At the core of all of this is diagnostic testing,” pointed out Mark Kruzel, MD, medical director of Oncology at Quest Diagnostics, to match the right therapy to the patient’s tumor. The goal is to avoid both underutilization of testing as well as overutilization, and to identify those patients who would benefit most from the therapies that are available today. Overutilization can be a problem, he noted, especially as the number of “actionable markers” in oncology has exploded; there are now over 100 diagnostic markers across the field.
The right test, the right drug, and the right team can save money
“In oncology, there are really 3 cost centers: end-of-life care, therapies, and unnecessary hospitalizations. If we're able to identify patients that might be the most responsive to a particular therapy, the cost of treatment for that patient might go down over the long term. As you start the most appropriate therapy first, rather than taking an empirical approach, it can also have a benefit for unnecessary hospitalizations,” both because the therapy may be more effective and may have fewer toxic side effects. “Mitigating the side effects through a precise approach can help prevent unnecessary hospitalizations.”
Immunotherapies, the most advanced kind of personalized approach in oncology, “are not insignificant in their costs,” Dr Kruzel said, “with some ranging up to $250,000 a year, so making sure that the appropriate testing has been done and that everything is in place so that those decisions about therapy can be made is pivotal.”
The best outcomes with precision medicine come when there is strong interdisciplinary collaboration among a health system’s pathology, laboratory, and disease specialist team (such as oncology or neurology). “If I leave you with 1 thing, I think this would be that achieving the promise of precision medicine through the development of pathways is possible. Number 1, start having the discussion, making sure that you're bringing in the right people to have those discussions, whether it's the neurologist, if your health system has a large population of neurology patients, or whether it's the oncologist because you're a cancer center. Any disease state can benefit from a precise approach.”
One of the key strategies that Dr. Fintel implemented at Carilion to optimize the precision approach was to bring together the major decision-makers and experts every month to look at friction points. “I call it my four-legged stool meeting. We quickly realized that we can head off problems if a member of the medical oncology team and the pathology team and the Quest lab team and the current administration get together for developing the best plan we can then implement, and then everybody's going to live with it because they had a say in the decision.” These regular meetings reduced a lot of errors, he added.
“And these discussions really are to whittle down and refine [to determine] the right test for the right patient at the right time in their disease process. And hopefully at the right cost, in partnering with a reference lab that can serve all of the needs of your cancer center or your institution.”