Practicing Clinical Oncologists to the Rescue

Cancer patients and their physicians can find themselves at the wrong end of many scientific discoveries. For example, the drug capecitabine, sold commercially as Xeloda, was originally marketed at a daily dose of 2500 mg/m2 given for two weeks.

This schedule developed by the pharmaceutical investigators, is known as the maximum tolerated dose (MTD) and it performed well against other regimens for breast and colon cancer. With an FDA approval in hand, oncologists began administering the drug on the recommended schedule.

MTD2It did not take long before physicians and their patients realized that 2500 mg/m2/day was more than many patients could tolerate. Hand-foot Syndrome (an inflammation of the skin of palms and soles), mucositis (oral ulcers) myelosuppression (lowered blood counts) and diarrhea were all observed. Immediately clinical physicians began to dose de-escalate. Soon these astute practitioners established more appropriate dose schedules and the drug found its rightful place as a useful therapeutic in many diseases.

What was interesting was that activity continued to be observed. It appeared that the high dose schedule was simply toxic and that lower doses worked fine, with fewer side effects.

Modern targeted agents have been introduced over recent years with dose schedules reminiscent of capecitabine. The drug sunitinib, approved for the treatment of renal cell carcinoma, is given at 50 mg daily for four weeks in a row, followed by a two week rest. Despite good activity, toxicities like mucositis and skin rash often set in by the third week. What remained unclear was whether these schedules were warranted. A recent report in the Annals of Oncology examined this very question. In a retrospective analysis of patients with kidney cancer the physicians found that lowering the dose of sunitinib preserved activity but reduced toxicity.

As a practitioner, I have long reduced my patient’s schedule of sunitinib to two weeks on, one week off or even 11 days on, 10 days off. In one patient that I treated for a gastrointestinal stromal tumor (GIST), I achieved a durable complete remission with just 25 mg/day, given seven days each month, a remission that persists to this day, seven years on.

We are in a new world of targeted therapy, one in which very few people understand the kinetics, pharmacodynamics and response profiles of patients for novel drugs. In our laboratory, favorable dose response curves often suggest that many agents could be administered at lower doses. More interestingly, some patients who do not carry the “targets” for these drugs nonetheless respond. This has broad implications for multi-targeted inhibitors like sunitinib that can influence multiple targets simultaneously.

As so often happens, it is the nimble clinical physicians with their feet on the ground, confronting the very real needs of their patients who can outmaneuver and outthink their academic colleagues. The trend toward consolidation in medicine and the absorption of clinical practices into hospital groups all using standardized algorithms has the risk of stifling the very independence and creativity of practicing oncologists that has proven both effective and cost-effective for our patients and our medical system at large.

Of Cells, Proteins and Cancer Drug Development

Our recent presentation at the American Association for Cancer Research meeting reported our work with a novel class of compounds known as the HSP90 inhibitors. AACR 2015-HSP90 Abstract

The field began decades earlier when it was found that certain proteins in cells were required to protect the function of other newly formed proteins hormone receptors and signaling molecules. Estrogen and androgen receptors, among others, require careful attention following their manufacture or they will find themselves in the cellular waste bin.

230px-Geldanamycin.svgAs each new protein is formed it risks digestion at the hands of a garbage disposal-like device known as a proteasome (named for its protein digesting capabilities). To the rescue comes HSP90 that chaperones these newly created proteins through the cell and protects them until they can assume their important roles in cell function and survival.

Recognizing that these proteins were critical for cell viability, investigators at Sloan-Kettering and others developed a number of molecules to block HSP90. The original compounds known as ansamycins underwent clinical trials with evidence of activity in some breast cancers. The next generation of compounds was tested in other diseases. Though the clinical results have been mixed, the concept remains attractive.

We compared two drugs of this type and showed that they shared similar function but had different chemical properties and that the concentrations required to kill cells differed. What is interesting is the activity of these drugs seems to be patient-specific. That is, each patient, whether they had breast or lung cancer, showed a unique profile that was not directly connected to the type of cancer they had. This has important implications.

Today, pharmaceutical companies develop drugs by disease type. Compounds enter Phase II trials with 30 to 50 lung cancer patients treated, then 30 to 50 breast cancer patients treated and so on. This continues until (it is hoped) one of the diseases provides a favorable profile and the data is submitted to the FDA for a disease-specific approval. As home runs are rare, most drugs never see the light of day failing to provide sufficient response in any disease to warrant the enormous expense of bringing them to market.

What we found with the HSP90 inhibitors is that some breast cancers are extremely sensitive while others are not. Similarly some lung cancers are extremely sensitive while others are resistant. This forces us once again to confront the fact that cancer patients are unique.

Pharmaceutical companies exploring the role of targeted agents like the HSP90 inhibitors must learn to incorporate patient individuality into the drug development process. Failing to do so not only risks the loss of billions of dollars but more importantly denies patients access to active novel agents.

The future of drug development can be bright if the pharmaceutical industry embraces the concept that each patient’s profile of response is unique and that these responses reflect patient-specific, not diagnosis-based drivers. Clinical trials must incorporate individual patient profiles. Drugs could be made more available once Phase I studies were complete by using biomarkers for response, such as the EVA-PCD assay, which has the capacity to enhance access and streamline drug development.

Cancer Research Moves Forward by Fits and Starts

AACR logoI recently returned from the American Association for Cancer Research (AACR) meeting held in Philadelphia. AACR is attended by basic researchers focused on the molecular basis of oncology. Many of the concepts reported will percolate to the clinical literature over the coming years.

There were many themes including the revolution in immunologic therapy that took center stage, as James Allison, PhD, received the Pezcoller Prize for his groundbreaking work in targeting immune checkpoints. The Princess Takamatsu Award given to Dr. Lewis Cantley, recognized his seminal contribution to our understanding of signal transduction at the level of PI3K. A series of very informative lectures were provided on “liquid biopsies” that examine blood, serum and other bodily fluids to characterize the process of carcinogenesis. These technologies have the potential to revolutionize the diagnosis and monitoring of cancers.

The first symposium I attended described the phenomenon of chromothripsis. This represents a catastrophic cellular trauma that results in the simultaneous fragmentation of chromosomal regions, allowing for rejoining of disparate chromosome components, often leading to malignancy and other diseases. I find the concept intriguing, as it reflects the intersection of oncology with evolutionary developmental biology, reminiscent of the outstanding work of Stephen Jay Gould. His theory of punctuated equilibrium, from 1972, challenged many long held beliefs in the study of evolution.

Since the time of Charles Darwin, we believed that evolution was slow and continual.  New attributes were selected under environmental pressure and the population carried those characteristics forward toward higher complexity. Gould and his associate, Niles Eldredge, stated that evolution was anything but gradual. Indeed, according to their hypothesis, evolution occurred as a state of relative stability, followed by brief episodes of disruption. This came to mind as I contemplated the implications of chromothripsis.

Licensed under CC BY-SA 3.0 via Wikimedia Commons

Licensed under CC BY-SA 3.0 via Wikimedia Commons

According to the new thinking (chromothripsis and its related fields), cancer may arise as a single cell forced to recover from what would otherwise be catastrophic injury. The reconfiguring of genetic elements scrambled together to avoid apoptosis (programmed cell death) provides an entirely new biology that can progress to full-blown malignancy.

By this reasoning, each patient’s cancer is unique. The results of damage control whereby chromosomal material is rejoined haphazardly would be largely unpredictable. These cancers would have a fingerprint all their own, depending on which chromosome was disrupted.

As high throughput technologies and next generation sequences continue to unravel the complexity of human cancer, we seem to be more and more like those who practice stone rubbing to create facsimiles of reality from the “surface” of our genetic information. Like stone rubbing, practitioners do not create the images, but simply borrow from them.

With each symposium, we learn that cancer biology does not come to be, but is. Grasping the complexity of cancer requires the next level of depth. That level of depth is slowly being recognized by investigators from Harvard University to Vanderbilt as the measurement of humor tumor phenotypes.

Cancer is phenotypic and human biology is phenotypic. Laboratory analyses that allow us to measure, grasp, and manipulate phenotypes are those that will provide the best outcomes for patients. Laboratory analyses like the EVA-PCD.

Is There a Role for PI3k Inhibitors in Breast Cancer? Maybe.

Over the past decades oncologists have learned that cancer is driven by circuits known as signal transduction pathways. Signal_transduction_pathways.svgThe first breakthroughs were in chronic myelogenous leukemia (CML) where a short circuit in the gene as c-Abl caused the overgrowth of malignant blasts. The development of Imatinib (Gleevec) a c-Abl inhibitor yielded brilliant responses and durable remissions with a pill a day.

The next breakthrough came with the epidermal growth factor pathway and the development of Gefitinib (Iressa) and shortly thereafter Erlotinib (Tarceva). Good responses in lung cancers, many durable were observed and the field of targeted therapy seemed to be upon us.

220px-PI3kinaseAmong the other signal pathways that captured the imagination of the pharmaceutical industry as a potential target was phospho-inositol-kinase (PI3K). Following experimental work by Lew Cantley, PhD, who first described this pathway in 1992, more than a dozen small molecules were developed to inhibit this cell signal system.

The PI3K pathway is important for cell survival and regulates metabolic activities like glucose uptake and protein synthesis. It is associated with insulin signaling and many bio-energetic phenomena. The earliest inhibitors functioned downstream at a protein known as mTOR, and two have been approved for breast, neuroendocrine and kidney cancers. Based on these early successes, PI3K, which functions upstream and seemed to have much broader appeal, became a favored target for developmental clinical trials.

The San Antonio Breast Cancer Symposium is one of the most important forums for breast cancer research. The December 2014 meeting featured a study that combined one of the most potent PI3K inhibitors, known as Pictilisib, with a standard anti-estrogen drug, Fulvestrant, in women with recurrent breast cancer. The FERGI Trial only included ER positive patients who had failed prior treatment with an aromatase inhibitor (Aromasin, Arimidex or Femara). The patients were randomized to receive the ER blocker Fulvestrant with or without Pictilisib.

With seventeen months of follow-up there was some improvement in time to progressive disease, but this was not large enough to achieve significance and the benefit remains unproven. A subset analysis did find that for patients who were both ER (+) and PR (+) a significant improvement did occur. The ER & PR (+) patients benefitted for 7.4 months on the combination while those on single agent Fulvestrant for only for 3.7 months.

The FERGI trial is more interesting for what it did not show. And that is that patients who carried the PI3K mutation, the target of Pictilisib, did not do better than those without mutation (known as wild type). To the dismay of those who tout the use of genomic biomarkers like PI3K mutation for patient drug selection, the stunning failure to identify responders at a genetic level should send a chill down the spine of every investor who has lavished money upon the current generation of genetic testing companies.

It should also raise concerns for the new federal programs that have designated hundreds of millions of dollars on the new “Personalized Cancer Therapy Initiatives” based entirely on genomic analyses. The contemporary concept of personalized cancer care is explicitly predicated upon the belief that genomic patient selection will improve response rates, reduce costs and limit exposure to toxic drugs in patients unlikely to respond.

This unanticipated failure is only the most recent reminder that genomic analyses can only suggest the likelihood of response and are not determinants of clinical outcome even in the most enriched and carefully selected individuals. It is evident from these findings that PI3K mutation alone doesn’t define the many bioenergetic pathways associated with the phenotype. This strongly supports phenotypic analyses like EVA-PCD as better predictors of response to agents of this type, as we have shown in preclinical and clinical analyses.

Investigators in Boston Re-Invent the Wheel

A report published in Cell from Dana-Farber Cancer Institute describes a technique to measure drug cov150hinduced cell death in cell lines and human cancer cells. The method “Dynamic BH3 profiling” uses an oligopeptidic BIM to gauge the degree to which cancer cells are “primed” to die following exposure to drugs and signal transduction inhibitors. The results are provocative and suggest that in cell lines and some human primary tissues, the method may select for sensitivity and resistance.

We applaud these investigators’ recognition of the importance of phenotypic measures in drug discovery and drug selection and agree with the points that they raise regarding the superiority of functional platforms over static (omic) measures performed on paraffin fixed tissues. It is heartening that scientists from so august an institution as Dana-Farber should come to the same understanding of human cancer biology that many dedicated researchers had pioneered over the preceding five decades.

Several points bear consideration. The first, as these investigators so correctly point out: “DBP should only be predictive if the mitochondrial apoptosis pathway is being engaged.” This underscores the limitation of this methodology in that it only measures one form of programmed cell death – apoptosis. It well known that apoptosis is but one of many pathways of programmed cell death, which include necroptosis, autophagy and others.

While leukemias are highly apoptosis driven, the same cannot so easily be said of many solid tumors like colon, pancreas and lung. That is, apoptosis may be a great predictor of response except when it is not. The limited results with ovarian cancers (also apoptosis driven) are far from definitive and may better reflect unique features of epithelial ovarian cancers among solid tumors than the broad generalizability of the technique.

A second point is that these “single cell suspensions” do not recreate the microenvironment of human tumors replete with stroma, vasculature, effector immune cells and cytokines. As Rakesh Jain, a member of the same faculty, and others have so eloquently shown, cancer is not a cell but a system. Gauging the system by only one component may grossly underestimate the systems’ complexity, bringing to mind the allegory of elephant and the blind man. Continuing this line of reasoning, how might these investigators apply their technique to newer classes of drugs that influence vasculature, fibroblasts or stroma as their principal modes of action? It is now recognized that micro environmental factors may contribute greatly to cell survival in many solid tumors. Assay systems must be capable of capturing human tumors in their “native state” to accurately measure these complex contributions.

Thirdly, the ROC analyses consistently show that this 16-hour endpoint highly correlates with 72- and 96-hour measures of cell death. The authors state, “that there is a significant correlation between ∆% priming and ∆% cell death” and return to this finding repeatedly. Given that existing short term (72 – 96 hour) assays that measure global drug induced cell death (apoptotic and non-apoptotic) in human tumor primary cultures have already established high degrees of predictive validity with an ROC of 0.89, a 2.04 fold higher objective response rate (p =0.0015) and a 1.44 fold higher one-year survival (p = 0.02) are we to assume that the key contribution of this technique is 56 hour time advantage? If so, is this of any clinical relevance? The report further notes that 7/24 (29%) of ovarian cancer and 5/30 (16%) CML samples could not be evaluated, rendering the efficiency of this platform demonstrably lower than that of many existing techniques that provide actionable results in over 90% of samples.

Most concerning however, is the authors’ lack of recognition of the seminal influence of previous investigators in this arena. One is left with the impression that this entire field of investigation began in 2008. It may be instructive for these researchers to read the first paper of this type in the literature published in in the JNCI in 1954 by Black and Spear. They might also benefit by examining the contributions of dedicated scientists like Larry Weisenthal, Andrew Bosanquet and Ian Cree, all of whom published similar studies with similar predictive validities many years earlier.

If this paper serves to finally alert the academic community of the importance of human tumor primary culture analyses for drug discovery and individual patient drug selection then it will have served an important purpose for a field that has been grossly underappreciated and underutilized for decades. Mankind’s earliest use of the wheel dates to Mesopotamia in 3500 BC. No one today would argue with the utility of this tool. Claiming to have invented it anew however is something quite different.

Cancer Patients Need Answers Now!

I read a sad editorial in the Los Angeles Times written by Laurie Becklund, former LA Times journalist. It is, in essence, a self-written obituary as the patient describes her saga beginning almost 19 years earlier, when she detected a lump in her breast. With stage I breast cancer she underwent standard therapy and remained well for 13 years until recurrence was heralded by disease in bone, liver, lung and brain. Given a dire prognosis she became a self-made expert, conducting research, attending conferences, and joining on-line forums under the name “Won’t Die of Ignorance.” Despite her heroic effort Ms. Becklund succumbed to her illness on February 8. She was 66.

Ms. Becklunla-laurie-becklund-cropp-jpg-20150209d experienced the anguish that every patient feels when his or her own individual and highly personal needs simply aren’t being addressed. She opines that entities like the Susan G. Komen Fund, which has raised over $2.5 billion in the last 20 years, “channels only a fraction of those funds into research or assistance to help those who are already seriously sick.” She continues, “We need people, patients, doctors, scientists, politicians, industry and families to make a fresh start.” Her frustration is palpable as she states her outcome seemed to be based on the roll of the dice, like playing “Chutes and Ladders.”

The author’s plight is shared by the millions of patients who are confronting advanced cancers. They are not interested in “why” or “how” their cancers came to be. They can no longer benefit from early detection or cancer awareness campaigns. They need practical, actionable, clinical answers today.

Ms. Becklund’s commentary resonates with me and with everyone who has cOutliving Cancerancer or knows someone who does. As an oncology fellow at Georgetown, I found myself losing patient after patient to toxic and largely ineffective treatments, all despite my best efforts. I described this in my book “Outliving Cancer.” It was then that I decided that I would dedicate myself to meeting the individual needs of each of my patients and I have used a laboratory platform (EVA-PCD) to do so. I have encountered surprising resistance from clinicians and researchers who seem to prefer the glacial pace of incremental advancement found in population studies over individual solutions found in the study of each patient’s unique biology. Ms. Becklund correctly points out that every treatment must meet each individual’s need.

The role of the scientist is to answer a question (treatment A vs. treatment B) while that of the clinical physician must be to save a life. Every patient is an experiment in real time. It may well be that no two cancer patients are the same. Indeed, the complexity of carcinogenesis makes it very possible that every patient’s cancer is an entirely new disease, never before encountered. Although cancers may look alike, they may be biologically quite distinct. Meaningful advances in cancer will only occur when we learn to apply all available technologies to treat patients as the individuals that they are. Let us hope that Ms. Becklund’ s final essay does not fall upon deaf ears.

A New Use for One of the Oldest “New” Drugs

With the profusion of new targeted agents entering the clinical arena, a report from the American Society of Hematology bears consideration.

The trial known as the SORAML trial enrolled 276 patients with newly diagnosed acute myelogenous leukemia. The patients were between the ages of 18 and 60. All patients received a standard chemotherapy regimen. The patients were then randomized to receive Sorafenib or placebo. Patients on the Sorafenib arm then remained on a maintenance therapy for twelve months.

While the achievement of complete remission was almost identical between the two arms at 59% and 60%, the event free survival demonstrably favored the Sorafenib group at 20.5 months versus 9.2 months. At three years of follow-up 40% of the Sorafenib group were well with only 22% of the placebo group still in remission. This corresponds to a three-year relapse free survival of 38% for placebo and 56% for Sorafenib (P=0.017).

The results are of interest on several levels.
1.    Sorafenib a multitargeted tyrosine kinase inhibitor was approved in December 2005 for the treatment of renal cell carcinoma. This makes Sorafenib one of the first targeted agents to achieve FDA approval.

2.     Sorafenib has many modes of action and it is not entirely clear which of its functions were responsible for the superior survival in this AML study.

3.    Sorafenib’s approval reflects a rather convoluted and interesting history. When first developed the drug was designed to target the oncogene B-Raf. As a result the drug was introduced into early clinical trials for the treatment of advanced melanoma, a disease known to be associated with B-Raf mutation. As the drug proved ineffective, it appeared unlikely to gain FDA approval. That is, until it showed cross reactivity with VEGF pathway associated with tumor cell vascularity. A successful trial published in the New England Journal of Medicine then led to the approval.

Now, nine years later this old new drug has gained new life. This time in acute myelogenous leukemia.

The term “dirty drug” refers to agents that target many kinases at the same time. Sorafenib is an example of a “dirty drug.” However it is Sorafenib’s “dirty drug” quality that led first to its approval and most likely now leads to its application in AML. This reflects the fact that Sorafenib may be inhibiting B-Raf signaling associated with the common mutation in Ras upstream of B-Raf or it may reflect Flt3 a secondary activity associated with Sorafenib.

Indeed B-Raf and Flt3 may not be upregulated in every patient, but could serve a function of permissive activity granting an additional survival signal to the AML cells as they go through induction therapy. These subtleties of drug effect may escape genomic analysis as the true “target” may not be mutated, upregulated or amplified. No doubt the investigators in this study will conduct gene sequencing to determine whether there is a driver mutation associated with the advantage reported in this clinical study. What will be intriguing is to determine whether that advantage is an abnormal gene functioning within these cancerous cells or possibly a normal gene functioning abnormally in these cancer cells. More to come.

The Cost of Chemotherapy Comes Home to Roost

NY TImes rotatedMedical care in the United States is a $2.7 trillion industry. That translates into almost $8,000 per person per year. One of the most expensive aspects is cancer care. This has caught the attention of the medical oncology community. A highly touted editorial in the October, 2012 New York Times described the unwillingness of physicians at Memorial Sloan Kettering Cancer Center to add a new and expensive drug to their formulary. The authors opined that the new drug provided outcomes similar to those for an existing drug, yet cost twice the price.

A subsequent editorial in the Journal of Clinical Oncology from MD Anderson (Cancer Drugs in the United States: Justum Pretium – The Just Price) further examined the cost of cancer therapy, profit margins and some of the drivers. Among the points raised was the fact that the monthly cost of chemotherapy had more than doubled from $4,500 to $10,000 in just one decade. Furthermore, of twelve anticancer drugs approved in 2012, only three prolonged survival and for 2 of 3 by less than two months. Despite these marginal benefits, nine of the twelve drugs were priced at more than $10,000 a month.
60 Minutes
This caught the attention of the media with 60 Minutes recently conducting an interview with the authors of the New York Times editorial. While Lesley Stahl pointedly decried the rather marginal 4 – 6% markups that many physicians apply to cover their costs of chemotherapy drug administration, there are in fact much darker forces at work.

The cost of cancer drug development reflects the expense of human subject trials, cost of R & D, the regulatory burden, as well as an extraordinary new drug failure rate. Fully 50% of new agents fail at Phase III (the last and most expensive type of study). Phase III trials cost tens to hundreds of millions of dollars. An article in Forbes magazine stated that the average drug approved by the FDA now costs, not the one billion dollars often cited but instead five billion dollars when one factors in the failures against the rare successes.

Drug development begins with a novel idea, a small molecule and a few preliminary results. At this point the expenses are low but the drug is of little commercial value. As one moves from cell lines to animal models, the price goes up but the value remains low. The cost of formulation, toxicology and animal studies continue to add up but doesn’t influence interest in the agent. Then come human studies as the Phase I trials begin. Specialized institutions across the United States accept contracts with the pharmaceutical industry to examine the tolerability of the drug. I use that term advisably as the intent of Phase I trials is only to determine safety not efficacy. If the drug proves tolerable, it then moves to Phase II to explore it’s activity against cancer. This is where the money starts flowing.

Phase II clinical trials are conducted by university medical centers. Each patient accrued costs the pharmaceutical sponsors from $25,000 to more than $50,000 per patient. As drugs are tested in many schedules against many diseases it can take hundreds or even thousands of patients for statistical analysis. Nonetheless, a successful Phase II trial showing meaningful benefit in a cancer population generates a buzz and the drug’s value begins to gain traction. With hundreds of millions already expended, the final testing pits the new drug against an existing standard in one or more Phase III trials. Endpoints like progression-free-survival must then fold into overall survival if the drug has any hope to gain full approval by the FDA. These registration triaus-money-with-black-backdrop-1024x640ls at the national or international Phase III level cost up to $100,000 per patient and most of the participating institutions are university-based medical centers or their affiliates.

So, why do chemotherapy drugs cost so much? While it may be convenient to point fingers at the pharmaceutical industry, private practitioners or the smaller institutions, the university medical centers and their affiliates have added greatly to the costs of drug development as have the increasingly byzantine regulatory standards that have so encumbered the process that it is now increasingly only a rich man’s game.

We applaud the investigators at Memorial Sloan-Kettering for focusing attention upon this important matter. We applaud 60 Minutes and the authors of the Journal of Clinical Oncology editorial for their exploration of the same. While the willingness of these physicians to raise the issue is laudable, the solution may be somewhat more complex than these authors have been willing to admit. Before we vilify private practitioners who have time and again proven to be more efficient and less expensive purveyors of cancer care than their university brethren we should examine other drivers.

To wit, a review of one of the NY Times editorial author’s conflicts of interest statement listed in the 2012 American Society of Clinical Oncology proceedings revealed that his co-presenters at this national meeting disclosed fully 16 separate pharmaceutical affiliations for employment or leadership positions, consultant or advisory roles, stock ownership, honoraria, research funds, expert testimony, or other remuneration. With the research community enjoying these levels of compensation, it must be surmised that the costs of clinical trials reflect in part these expenditures. When one adds to this, the increasingly burdensome regulatory environment, the cost of cancer chemotherapy development appears to have plenty of blame to go around.

With Cancer, Don’t Ask the Experts

I was recently provided a video link to a December 2013 TEDx conference presentation entitled, “Big Data Meets Cancer” by Neil Hunt, product manager for Netflix. Mr. Hunt’s background has nothing to do with cancer or cancer research. His expertise is in technology, product development, leadership and strategy and has personally shepherded Netflix to its current market dominance. With his background and lack of expertise in cancer, he is an ideal person to examine cancer research from a fresh perspective.

The Long Tail of CancerMr. Hunt begins with a (admittedly) simplistic look at cancer research today. Because he is a data guy, naïve to all of the reasons why cancer cannot be cured, he can look anew at how it might be cured. Using a graphic, he defines cancer as “a long-tail disease” made up of outliers. He points out that most 20th century medical successes have been in the common diseases that fall close to the thick end of the curve. As one moves to the less common illnesses data becomes more scant. Echoing a new conceptual thinking, he points out that cancer is not a single disease but many, possibly thousands.  His concept is to accumulate all of the individual patient data to allow investigators to explore patterns and trends: a bottom up model of cancer biology. Many of his points bear consideration.

For those of you who have read these blogs, you know that I am an adherent to the concept of personalized cancer care. I have articulated repeatedly that cancer patients must be treated as individuals. Each tumor must be profiled using available platforms so that time and resources will not be wasted. We have used the same term “N-of-1” (a clinical trial for one patient) that Mr. Hunt uses in his discussion. He provides two anecdotes regarding patients who benefitted dramatically from unexpected treatment choices. His rallying cry is that contemporary clinical trials are failing. Again, this is an issue that I have addressed many times. He then describes broad-brush clinical protocols as the “tyranny of the average.”

The remainder of the discussion focuses upon possible solutions. Among the obvious hurdles:
1.    Cancer centers are hesitant to share data.
2.    The publication process is slow.
3.    Few are willing to publish negative trials.

To counter these challenges, he points out that small organizations are more incentivized to share and that successes in long-tail diseases can resurrect failed drugs, thereby repaying the costs. Several points were particularly resonant as he pointed out that early adopters face outsized resistance but their perseverance against adversity ultimately evolves the field. He sees this as a win-win-win scenario with patients receiving better care, physicians witnessing better outcomes, and pharmaceutical companies gaining more rapid approval of drugs.

As I watched, it occurred to me that Mr. Hunt was articulating many points that we have raised for over the last decade. As an outsider, he can see, only too clearly, the shortcomings of current methods. His clear perceptions reflect the luxury of distance from the field he is describing. Mr. Hunt’s grasp of cancer research is direct and open-minded. Many problems need fresh eyes. Indeed as we confront problems as complex as cancer it may be best not to ask the experts.

Truly Personalized Cancer Care

In the mid 1980s, it became apparent to me that cancer did not result from uncontrolled cell proliferation, but instead from the lack of cell death. Yet, cancer research labored for almost a century under the erroneous belief that cancer represented dysregulation of cell proliferation. Today, we confront another falsehood: the complexities and redundancies of human tumor biology can be easily characterized based on genomic analyses.

The process of carcinogenesis reflects the accumulation of cellular changes that provide a selective survival advantage to transformed cells.  However, the intricate circuitry that provide these survival advantages, reflect harmonic osolations between DNA, RNA and protein. Put simply, Genotype does not equal Phenotype. It is the phenotype that determines biological behavior and clinical response in cancer. Thus, it is overly simplistic to imagine that a DNA profile by itself can provide more than a fraction of the information required to make individual patient treatment decisions.

Colon cancer

Colon cancer

When therapies are based on genomic analysis, only a portion of the patient’s profile is taken into consideration. These analyses disregard the environmental, epigenetic and proteomic factors that make each of us individuals. Though useful prognostically and applicable in select circumstances where a unique genetic perturbation leads to a clinical response (c-ABL and Imatinib response in CML), genomic analyses provide only a veneer of information.

The Rational Therapeutics Ex Vivo Analysis – Programmed Cell Death™ (EVA-PCD) assay focuses upon the complexity of human tumors by measuring cell death, the end result of all cellular mechanisms of response and resistance acting in concert. By incorporating cell-cell, vascular, stromal and inflammatory elements into the tumor response assessment, the EVA-PCD platform provides a robust surrogate for human tumor response. While much of modern cancer research pursues the question of “Why” cancer arises, the clinical oncologist must confront the more practical question of “How” the best outcome can be achieved.

Assay-directed therapy is truly personalized cancer care providing treatments unique to the individual.


Reblogged from February 2010.