Navigating the complexities of precision medicine through testing, education, and hope.
“How did you get to this Star Wars analogy?” I was recently asked, after I presented a talk titled, “Precision Medicine, A New Hope: The approach will not be easy. The target area is only two meters wide.” In this talk, I discussed how precision medicine has evolved over the last twenty years and what we have to look forward to as groundbreaking technologies move this field forward. The answer was pretty simple: it was a great way to explain to my nerdy friends what I did and why it was important, as some never heard the term “precision medicine” and some have only heard it in passing. Star Wars lends itself really well to explaining this field.
The term precision medicine is used ubiquitously across the industry, and can have a myriad of meanings depending on who the audience is. The idea is about finding a way to treat patients that is pecific to what is driving their cancer—whether it’s genetic, genomic, or protein expression. This has been a significant clinical pivot over using a “one size fits all” approach. In a pivotal scene in Star Wars, the Resistance is struggling to stop the Death Star by shooting across it. They ultimately succeed by identifying what its weakness is, and start a chain reaction that ultimately destroys it. As an example, we can think of cancer in the same way: we understand the underlying science of what’s driving the disease—its mechanism of action—and build therapies that are uniquely targeted for these drivers.
A Galaxy of Possibilities
The current state of precision medicine is exciting in both breadth and scope, because there are countless possibilities available to target the mechanism of action. Pipelines across the industry show that targeted therapies are expected to represent approximately a third of market share in the coming years. With this high ramp up in the development of new treatments, it has become significantly more complex to understand and identify the best first treatment option, based on the testing results.
Gaps in practice—such as delays in turnaround time, tissue processing, report delivery and interpretation, treatment urgency, access issues, and other steps in the diagnostic journey—can significantly impact how a patient is ultimately treated. With so many critical steps involved, understanding each step of the process has become a hot discussion topic across the field. Greater understanding of treatment drivers, in light of the influx of newly released products, has led to rapid guideline updates. The result has created an environment where healthcare practitioners are looking for education to better understand the rapidly changing and expanding landscape. Greater adoption of targeted therapies has demonstrated the value in taking a personalized approach, rather than relying on “one size fits all.”
The Role of Education in a Complex Landscape
In the same way that fostering disease state awareness (DSA) is a critical component of marketing any newly developed therapy, education around testing state awareness (TSA), is a critical component of the testing landscape. As the space expands, TSA is becoming an increasingly crucial part of educating stakeholders on the decision-making progress of therapy selection. Field teams are now routinely hired by companies whose sole focus is unbranded education around the testing landscape. This is a much-needed answer to healthcare practitioners’ requests for educational content. Currently, precision medicine education is available through a wide variety of channels, and as a result, healthcare practitioners must rely on a variety of sources to stay informed in their daily practice. With an overwhelming number of therapies and information available, the broader adoption of precision medicine will depend on the development of decision support tools that can assist with navigating this complex galaxy of information.
“ This has been a significant clinical pivot over using a ‘one size fitsa ll’ approach. In a pivotal scene in Star Wars, the Resistance is struggling to stop the Death Star by shooting across it. They ultimately succeed by identifying what its weakness is, and start a chain reaction that ultimately destroys it.”
These tools can take many forms as we evolve current practices. HCPs need to journey through the various steps in a guided flow, in contrast to the disconnected and often isolated processes that are continuously practiced today. At the beginning of the process, there would be a clear understanding of how to test—including protocols around what modality is needed, from IHC, FISH, NGS, PCR, or other methods. This would also involve a detailed understanding of what tests are needed, and how to optimize tissue and liquid samples in order to get the maximum amount of information from what’s available.
Depending on the size of what was biopsied, there may be tissue scarcity, resulting in a need for a combination of tissue and bloodbased testing. Clear communication between stakeholders within a multidisciplinary team (MDT) is critical in the early stages. In order to establish protocol between the medical oncologist, pathologist, interventional surgeon, and other staff members, ensuring direct visibility around what is being looked for and needed from each stakeholder.
“…Education around testing state awareness (TSA), is a critical component of the testing landscape. As the space expands, TSA is becoming an increasingly crucial part of educating stakeholders on the decision-making progress of therapy selection.”
Access and Equity in the Era of Personalization
Varying access to technologies and testing modalities also presents a high level of complexity. Access can vary based on insurance coverage, state, and test availability. Some tests are not covered by insurance providers, and there are varied interpretations of what should be covered, and as a result, patient care can be impacted.
Without a complete understanding of the patient’s clinical picture, those who treat have to make decisions based on the incomplete information available to them, and ultimately, this may lead to less efficacious treatment. As we shift toward the future of precision medicine-based care, this critical step would need to have standardization to ensure every patient is receiving equal consideration before therapy selection is made.
Timing Is Everything
The therapy selection step also can be influenced by test result availability at the time of clinical decision-making. The pressure can be a significant obstacle for clinicians, as some newly diagnosed patients may expect to receive treatment immediately. These patients may not receive information explaining that delaying treatment can be critical to their overall survival, as it gives their care team time to understand their full clinical story and determine which treatment would offer the greatest benefit. While there have been strides in making patientfacing education widely available, an ideal future state would ensure this education is available at diagnosis, to allow for shared decision-making, with educational materials tailored for patients and available in the languages they speak.
The future of precision medicine is heavily focused on our ever-expanding understanding of disease mechanics and the many ways we can approach those underlying mechanisms with a myriad of technologies. It will continue to evolve and lead to improved therapy selection.
To circle back to the Star Wars analogy, the target area that Luke was shooting at was only two meters wide, and the result was more significant than a fleet of ships. The journey for precision medicine treatments to become the standard of care is progressing at a breakneck speed, and while the therapies are available, the journey is in many ways still being built. With greater adoption of and access to precision medicine in our future, there is a great level of hope and the force is with us.
