Dr. Akhil Chopra: Genomic characterization of cancer has brought major transformation
Economic Times HealthWorld, 3 November 2017
In an interview with ETHealthworld, Dr. Akhil Chopra, Specialist, Medical Oncology, OncoCare, Singapore, talks about the developments in cancer research. Edited excerpts:
What are the recent pivotal developments in oncology that excite you as an oncologist?
Well it’s a great time to be an oncologist, due to exponential growth in cancer research, availability of new treatments that benefits our patients, and largely due to availability of next gen sequencing of cancer that characterize cancers based on the genetics- which has led this growth. We’ve always known that cancer is a genomic disease. It is a disease of genomic alteration but due to several technological limitations, we could never use that to target cancer. Since the initial human genome project was completed, and the next generation sequencing technologies were available- there has been rapid progress in terms of targeted therapy for various cancer spheres. In the last 5 years we have seen molecular characterization of cancer, something that we had never seen before. We have witnessed treatment decisions based on individual genomic profiles of cancer- which is very unique. As technology gets cheaper and more available to oncologists all over the world- I think it’s only going to improve in the next 5 years.
How in your opinion has precision medicine for cancer care evolved in the last 5 years and what are your predictions for the future?
A lot has happened in the last 5 years. In fact, most oncologists, like myself, are struggling to keep up with the development. Again, the major transformation has been genomic characterization or molecular characterization of cancer and the availability of targeted therapy unique to the genomic alteration with the aim to improve the efficacy of the treatment. Also, reduce the toxicity of the treatment and essentially benefiting our patients to live longer and live a good quality of life – which is particularly true in some cancers like lung cancer and melanoma. Not all cancers, but we are getting there and in the next 5 years there is going to be real progress. Unfortunately even today, despite all the technology, only a few mutations are target able. But there are a lot of drugs in development – and that is what we will see in the next five years- more drugs getting approved for treatment of cancer.
How critical a role does genomic profiling play while making precision medicine for cancer patients?
Genomic profiling is an integral part of precision medicine. There are certain genomic alterations against which drugs have been designed. One example is EGFR mutation in lung adenocarcinoma – where we have specific drugs that target this mutation that lead to inhibition of the growth of cancer and of course improvement in the symptoms as regards to the patients and prolonging their life. In fact, now we know of resistance mechanism to these drugs. We have 2nd and 3rd generation drugs that are available in the market. It is very gratifying for oncologists to be able to give these options to our patients which were not available before. There’s still a lot of work to be done. Not every mutation is targetable. Not every drug is accessible – lot of drugs are in clinical development, lot of drugs that are only available through clinical trials, lot of drugs that are still out of the reach for our patients because of cost issues. We will have to see in the next 5 years how this comes about.
Do you have cases where you have changed your treatment decision on the basis of genomic profiling? What was the impact on the patient?
Yes, in many cases, especially in lung cancer and some rare cancers where these tumors are relatively infrequently seen in the clinic, and there are not a lot of treatment options because not a lot of research has been done. It is easier to do research in a cancer that is very common like breast cancer. But how do you do research in a cancer that is uncommon because there are just not enough patients? In those situations, genomic profiling gives clues in terms of unique mutations that are targetable and I’ve had that experience myself over the past 5-10 years. And those patients would not have had any other option for treatment otherwise. In addition there’s a new, exciting treatment in oncology called immunotherapy that I’m sure you’ve heard about. It is unclear at this time, to ask us clinicians, who are the right patients to be treated by immunotherapy. It doesn’t work for everyone and it is expensive. Ideally, as a doctor, I would like to know beforehand if my treatment is going to benefit the patient or not, for a multitude of reasons. Tumor genomic profiling can sometimes help answer that question. Recently there have been evidence and publications suggesting that the total mutational burden of a cancer can help predict its response to immunotherapy. That is something I have used to help guide my treatment decision in patients.
There are so many steps and profiling services available in the market. As a practicing oncologist, how do you decide which step to use for a situation?
One disadvantage of the rapid technological progress is that now doctors have too many options. There are a lot of commercial vendors who are available, and it becomes hard to choose. One clear mechanism to decide is cost. Very expensive tests are difficult to use routinely. The other more important aspect that I use is validity. You want a platform which has been proven in terms of analytical validity. It is impractical to expect every hospital to have a multiple pathology lab- it is too expensive. As doctors we need a partner in commercial vendors, who are able to give us high quality information with high analytics validity that we can use on a routine, daily basis in clinics to help guide our decision making. In addition, it is probably not that difficult to generate genomic data. Most of it is done by machines-it is automated. But how to interpret that data is very important. Not everything is clinically relevant- a lot of it is noise and you need a vendor or a team that is competent enough to be able to exclude the non relevant information and present to the clinician, clinically relevant genomic data in a concise manner – something that I can understand and act upon. I think FoundationOne® is one example of a commercially available platform which is very useful.
Roche partnership with Foundation Medicine is one of the first – where a global pharmaceutical company is bringing genomic profiling services. What is your opinion on this partnership?
I think it’s an excellent partnership. Roche partnering with FoundationOne® is really a win-win situation. They are using their expertise in the clinical field of oncology with the scientific expertise of next gen sequencing molecular pathology – combining them together to give what the clinician wants. So I think that partnership is great and successful and is like to become more successful.