From "Magic Bullets" to Precision Medicine—Ensuring More Patient-Centered Cancer Care

IN 1998, THE ESTEEMED JOURNALIST,

Seymour Hersh, wrote about a new, revolutionary anticancer technology (now known as antiangiogenic agents):

Within a year, if all goes well, the first cancer patient will be injected with two new drugs that can eradicate any type of cancer, with no obvious side effects and no drug resistance…in mice.¹

Although the article was quick to point out that many promising discoveries are tempered by the reality of more limited activity when used to actually treat people with cancer, in the article, Hersh went so far as to quote a Nobel laureate who gushed that “Judah (the leading scientist in studying the new technology) is going to cure cancer in two years.”¹ However, over the past 2 decades, the impact of antiangiogenic agents on cancer survival outcomes has been far more limited than what the initial enthusiasm suggested.

For decades, the popular press has oversold the transformational nature of new, anticancer therapeutics. Interferons and other drugs have been lauded on the cover of Time magazine and other popular publications as the “magic bullets” that would end the devastating impact of a cancer diagnosis. While the pace of anticancer drug discovery and innovation has accelerated beyond anyone’s wildest dreams, we have yet to discover “magic.” There is not a single drug that is the cure for all cancers, and in all likelihood, there will never be. The search for a cure has instead focused upon better understanding the genomic, molecular, proteomic, and transcriptomic mutations/variations that form the biological underpinnings of the breadth of cancers. Instead of finding cures by identifying an underlying simplicity, we have instead embraced the mind-numbing mechanistic complexity of navigating cancer biology.

This era of “precision medicine” feels decidedly different than prior eras in cancer discovery. The hubris of talking about “magic bullets” has given way to a humility about understanding that a set of diseases like non—small cell lung cancer may represent a dozen or more genomic variants that present distinct opportunities for targeted therapeutic interventions. The work of deciphering the human genome and proteome have finally provided us with a set of tools that make cancer, in its many avatars, knowable and more potentially curable.

Inasmuch as the opportunities presented by the “precision medicine” paradigm are countless, the challenges posed to our patients and our healthcare delivery system, by this paradigm shift, are numerous. How can patients effectively grasp their healthcare choices when the pace of innovation creates changes in the standard of care at a rate nearly impossible to process? How can medical oncologists and hematologists outside of academic “innovation” centers become effective stewards of an increasingly complex armamentarium of anticancer drugs and the molecular diagnostic tools required to use them effectively? How do we create a value-based, economically sustainable system of delivering these care solutions to patients on a population basis? Given the extraordinary cost of the new, targeted anticancer agents, how can we deliver these care solutions without bankrupting either our patients or our healthcare system?

Beyond the extraordinary scientific challenges of understanding the molecular underpinnings of cancer, we are at a time when we need to create a better system for delivering these therapeutics that more effectively engages the multitude of healthcare stakeholders (patients, physicians, government, healthcare payers, medical groups, pharmacy benefits managers, and pharma) in the sustainable pursuit of value-centric care.

In this edition of Evidence-Based Oncology™, we begin what promises to be the long process of bringing these challenges and their solutions to life. Michael A. Thompson, MD, PhD, and colleagues explore the challenges and opportunities of implementing an oncology precision medicine clinic in a large community health setting. Joy Larsen Haidle, MS, and colleagues describe the value-enhancements that genetic counselors can bring to the genetic testing of cancer patients. Bonnie J. Addario and Daryl Pritchard, PhD, explore the importance of patient engagement in ensuring the relevance and sustainability of precision medicine solutions for patients with cancer.

In the shift from the search for “magic bullets” to the precision medicine model of cancer care, it is finally possible to foresee a growing, highly targeted, highly complex armamentarium of anticancer agents that will change patients’ lives for the better. It is essential, however, to develop a scalable system that can deliver these (undoubtedly expensive) care solutions in a patient-centered, economically sustainable way.REFERENCE

1. Kolata G. Hope in the lab: a special report.; a cautious awe greets drugs that eradicate tumors in mice. The New York Times website. nytimes.com/1998/05/03/us/hope-lab-special-report-cautious-awe-greets-drugs-that-eradicate-tumors-mice.html. Published May 3, 1998. Accessed July 27, 2017.

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