Precision cancer medicine - close at hand or just out of reach?
2 June 2016
We recently hosted a four week internship for Andy Graham, a medical student at the University of Cambridge. Andy has a particular passion for all things genomics and cancer related so we asked him, as a doctor of the future, whether he could imagine precision medicine being available to NHS clinicians in the near future. This is what he said...
I perch on the desk, coffee in hand, nex t to my tutor (who is a GP). We have a shared interest in cancer, a fascinating disease, and my enthusiasm bubbles over. "Precision medicine" I venture, trying to impress, "that's the future of cancer therapy. Patients will stroll in, have their tumour biopsied and sequenced, and walk out with a targeted drug just for them". "Maybe" is the reply, as she types out the referral to send to her secretary who will print it, fax it over to the consultant’s secretary, who then scans it, prints it again and passes it on to the consultant with a thick wodge of notes dating back to the 40s.
As a child I'd heard of fax machines, but didn't think I'd ever see one. The UK, despite its position at the forefront of biomedical research, has a national health service that seems to be struggling to keep up with the times – and this is where my dreams for precision medicine hit their first roadblock. A technological overhaul is clearly necessary to allow such a huge undertaking as introducing precision cancer medicine into the NHS.
The French have already laid the groundwork, introducing 28 regional centres across the country to give patients access to sequencing technology and allowing all cancers to be sequenced and reported on. This was achieved four years ago and proved cost effective. Surely a similar initiative in the UK is possible?
A second roadblock is the current state of the research. As often occurs with things ‘just round the corner’, expectation might outstrips reality. Cancer precision medicine has been hailed as a ‘sure thing’ and, that as research progresses, the evidence will arrive to back it up. We already have numerous trials supporting targeted therapy, with many n of 1 trials and observational or retrospective trials suggesting clinical benefit.
However, the first prospective randomised control trial (the gold standard of trial design) provided a first glimpse of reality, and many did not like what they saw. The SHIVA trial, published in September 2015, has been dominating recent discussions around cancer precision medicine, its ‘disappointing’ results leading some to fundamentally question the concept of precision medicine for treating cancer. Others have since disregarded the paper, arguing it was poorly designed and the results are meaningless.
As such all the SHIVA trial stated was that off-label use of therapy should be discouraged, but that more research is necessary to show the safety and efficacy of cancer precision medicine
A more balanced approach – and one that I take – recognises that the trial’s shortcomings are openly acknowledged in the paper: it couldn't use combination therapies, it did use off-label drugs with limited evidence base, tumour tissue of origin wasn't restricted, it's patients had extremely advanced cancer and the patients had received varying numbers of pre-treatments. As such all the SHIVA trial stated was that off-label use of therapy should be discouraged, but that more research is necessary to show the safety and efficacy of cancer precision medicine - something which hopefully all will agree on. Looking to the future there are a several well designed randomised control trials, again looking at pre-treated individuals, which should better determine the value of precision cancer medicine.
Assuming targeted cancer therapy does prove beneficial, we then hit the third roadblock - the large task of convincing every professional in the NHS that precision medicine is the way forward and the era of standard cytotoxic therapy is over.
In the admittedly short time I have known the NHS and its employees I'm not too sure how you would go about revolutionising one of its departments. Walking through hospitals and visiting general practices I was struck by what to me looked like a hodge-podge approach to innovation in the NHS, with bits added here and there as need or opportunity arise. My first interpretation was that it suggested an unwillingness to change, but after experiencing work life in these buildings I see that it may well be the opposite. Medical revolutions don't all come at once, as such they're drip fed into the system and the NHS absorbs them when it can, adding them to its arsenal to combat disease. Surely precision medicine would be no different. It would be the genomics laboratories turn to be the shiny new building, attracting the likes of me to spearhead the initiative going forward, only to feel the pangs of envy as the next revolution gets built next door.
So maybe precision medicine will be ready in a few years for a big roll out, maybe the NHS will get the investment necessary for its introduction, maybe healthcare professionals will seize the day and maybe the will of enough people will be garnered to force it into fruition.
But first things first, let's introduce the National Health Service to email.