Opinion: How precision oncology is transforming patient care
Cancer is fundamentally a genetic disease, driven by mutations that drive cancer growth. Just as each person is genetically unique, so the genomic profile of no two cancers is the same.
Precision oncology uses knowledge of the genomic profile of each patient’s cancer to guide accurate and personalised therapy. Rapid developments in two related fields have enabled precision oncology. First, the robust and affordable access to genomic tools in the clinic. Second, the development of biomarker-dependent drugs that can exploit the genomic vulnerabilities identified.
The effects of these innovations are transformative.
Patients may be able to avoid treatment that is unlikely to work, and have an increased likelihood of more effective treatment, which has the potential to reduce healthcare costs and improve patient outcomes.
Precision medicine using genomic tools is the future for all cancer treatment. As with all cancer treatments, precision oncology will be initially used in advanced cancers, with the greatest impact in rare and high-mortality cancers like sarcomas and cancers of unknown primary1,2. In these settings, genomic medicine could be a game changer. Rare cancers are often misdiagnosed, and suffer from a lower priority in cancer research, leading to a paucity of standard treatments and new therapies.
The future for precision oncology is illustrated by lung cancer. Lung cancer is a leading cause of cancer death in most higher income countries. Lung cancers are both common, and often diagnosed very late in the illness. Each year, about 12,000 Australians are diagnosed with lung cancer3. It is the fifth most common cancer in Australia, accounting for 9% of all cancers diagnosed and is responsible for almost one in five cancer deaths in the country.2
Lung cancers are highly mutated, with >100,000 mutations found in some cases4. In the 1990s, conventional chemotherapy was relatively ineffective, leading to few treatment options for those in whom the cancer was no longer curable.
The development of tumour genomic profiling combined with new treatments has transformed treatment options for patients with lung cancer.
By 2021, we have identified more than 11 different drug targets in lung cancer. The use of the right drug in the right patient has transformed outcomes, leading to extension of survival by years in many cases. More than half of all patients with lung cancer will carry one of these 11 drug targets. A single comprehensive genomic panel can now identify all 11 drug targets at one go, rather than gene by gene. The challenge in Australia today is to transition from single gene tests to comprehensive genomic panels.
The question then is how can genomics and precision oncology play a vital role in the shift towards value-based healthcare?
Precision oncology and value-based healthcare
With these advances in genomics and matched therapies, and also a deeper understanding of the molecular biology of cancers, we can now deliver better value by moving away from a one-size-fits-all model for cancer treatment.
In the example of lung cancer, moving towards testing all drug targets at one go in order to find out what is present in a patient’s tumour, enables the use of that information as early as possible in the patient's journey to guide the choice of best treatment. To show the potential benefits of this approach in Australia, we have developed a large-scale genomic screening program focused on lung cancer called ‘ASPiRATION’.
In a partnership between Roche Australia, the Thoracis Oncology Group of Australia, and the Australian Government, ASPiRATION aims to assess the impact of personalised health care in lung cancer — potentially transforming the way cancer care is administered in this country. A first-of-its-kind in Australia, ASPiRATION will generate high quality, real-world clinical and medical data about the impact and value of comprehensive genomic profiling (CGP), precision medicine and personalised health care (PHC).
We hope to show that comprehensive genomic profiling — when implemented at scale along with tools and processes to support personalised care plans, rapid access to innovative medicines and systematic tracking of clinico-genomic data — enables the promise of truly personalised health care by identifying the right treatment for the right patient, at the right time.
The 11 approved drug targets are present in almost 50% of all lung cancer patients today. By 2023, assuming the current success rates in clinical trials, we expect that number to go up to 25 druggable targets. Lung cancer is a poster child for the ongoing success of precision oncology, but the principles of precision apply to all cancers.
Given that cancer is now the leading cause of death in high income countries, it is critical for health systems to understand the value proposition of precision oncology, to affordably and equitably introduce these into the care of cancer patients.
I also predict that genomics-based precision medicine will be implemented earlier in the cancer journey, moving from the incurable setting to adjuvant treatment, diagnosis, and even to the pre-diagnostics space — where we might be able to identify people at differential risk and screen for them.
Prevention, early detection, accurate diagnosis, curative therapy and personalised treatment of advanced cancers will all be influenced and affected by genomics and targeted therapies. I cannot think of an area of cancer care which will not be changed by the use of genomics, in Australia and beyond. The future is coming: we should be preparing for it today.
1About | Garvan Institute of Medical Research. (2019). Garvan Institute of Medical Research. Retrieved from https://www.garvan.org.au/research/genomic-cancer-medicine-program/about
2About | Garvan Institute of Medical Research. (2019). Garvan Institute of Medical Research. Retrieved from https://www.garvan.org.au/research/genomic-cancer-medicine-program/about
3Australian Institute of Health and Welfare (AIHW). Cancer Data in Australia, AIHW, Canberra. (2020). Retrived from https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/about
4Strachan, T., Goodship, J., & Chinnery, P. (2015). Genetics and Genomics in Medicine. European Journal of Human Genetics, 23(5). https://doi.org/10.1038/ejhg.2015.18
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