COMMENTARY

Managing Patients' Belief That 'Precision Medicine Is a Panacea'

Leonard B. Saltz, MD

Disclosures

June 21, 2018

Hello. My name is Leonard Saltz. I'm a professor of medicine at Weill Cornell Medical College and the executive director for value and sustainability at Memorial Sloan Kettering Cancer Center in New York City.

One important focus of the 2018 ASCO meeting is the advancement of precision oncology.[1,2,3,4,5,6,7,8,9,10,11,12] Often, when we're talking about precision oncology, we're referring to next-generation sequencing and targeting tumors on the basis of molecular profile. This is undoubtedly going to be one of the important steps that we will focus on, in terms of improving treatment for cancer patients. It is already part of standard practice in many ways.[4] You wouldn't think about taking care of a patient with non–small cell lung cancer without understanding the mutational profile for EGFR, ALK, ROS, BRAF, and so on.[10,13] Similarly, for colorectal cancer, we have to know a patient's RAS and BRAF mutation status to make appropriate therapy selections.[3,9,11]

What we're really talking about when we talk about precision medicine is using the molecular profile of a tumor to try to identify treatment options for a patient that we otherwise wouldn't have tried. We are also looking for treatment options that are going to be highly effective [in a particular patient].[11] For some people, this is going to be a reality. We already understand that with mismatch repair–deficient tumors or high-MSI [microsatellite instability] tumors, the molecular profile of the tumor dictates its responsiveness to immunotherapy, rather than the tissue of origin.[12] Other tissue-agnostic treatments are coming down the pike that are going to be part of our armamentarium.[14,15] They're going to be effective for a very, very small group of patients that we will need to identify.

We're also going to have to think about how we're going to manage the expectations, because not everybody is going to have a highly targetable mutation profile. I'm worried that many patients view molecular profiling as a panacea that's going to solve their problem.[16,17] For far too many people, genetic testing is not going to yield actionable information.[18] Some of the data that I reviewed at this meeting were about managing both expectations and cost of precision medicine.[17,18] In the clinical trials where we have used next-generation sequencing to try to match patients to targeted therapies, often it's a relatively modest percentage of patients who have a targetable match, and all too often, either that match doesn't work or we find that a relatively low percentage of patients respond to or benefit from targeted therapy.[18]

It's very rare that we identify an unexpected mutational profile that leads to a very specific, highly effective therapy, which leads to disappointment for many patients. We're going to have to help manage this expectation.[16,17]

Of course, we want to balance [this with] optimism and hope for our patients. The reality is that we're going to be able to help more patients each day as time goes on, but we still have a substantial number of people for whom we don't have the answer that they're looking for.

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