Genetics, genomics, targeted therapy, and the costs of care

A new paper in a new journal argues that all men diagnosed with advanced forms of prostate cancer should now, routinely, be undergoing tumor and germline DNA profiling so as to guide enrollment into targeted clinical trials and ensure appropriate counseling of families at increased risk of malignancy.

This is the sort of guidance that companies like Foundation Medicine, which carry out these types of DNA profiling studies on clinical specimens, will, naturally, be delighted to hear. But one has to wonder just how practical this really is unless there is going to be a further massive reduction in the costs associated with these types of test (and potentially a significant decrease in the costs associated with treatment using targeted therapies).

There is no doubt, based on the findings of the team from Memorial Sloan-Kettering Cancer Cancer and published in the new journal (JCO Precision Oncology), that the recommendation is justifiable. Knowledge is power. Your sitemaster is a patient advocacy representative who regularly participates in case reviews associated with applications to enroll patients in the TAPUR trial, which is investigating just how effective genetic and genomic data can be in helping to determine whether specific patients with specific mutations should be treated with targeted therapies known (or at least believed) to be effective in treating such patients. So from that perspective he is familiar with and understands the concept of this type of “precision oncology”. But …

We are still early in the process, even though the field is certainly “hotting up” fast. As reported in these columns, just this year, we have seen the first drug actually approved in America to treat a set of patients with a set of genetic mutations regardless of where the cancer actually originated, biologically. And we have seen a second, as yet investigational, new drug demonstrate a high degree of efficacy in a subset of patients with another set of genetic and genomic characteristics.

But new drugs like these, which may only be effective in very small subsets of patients with cancer, and which (at least to date) have shown no sign that they are going to be able to eliminate and “cure” the cancers they target, are going to be very expensive and will add to the “financial toxicity” of modern cancer therapy.

Are we really ready to deal with the implications of genetic/genomic testing of pretty much every patient who gets diagnosed with any form of cancer? I’d love to think so, but I am far from certain.

2 Responses

  1. For the time being Foundation Medicine is absorbing all costs in most cases.

    There is anecdotal evidence that certain precision drugs are effective against prostate cancer … for example olaparib with a BRCA mutation and pembrolizumab with mutations associated with Lynch syndrome that also have high MSI counts.

    It is too early to say cure, albeit I personally am aware of men treated at NCCN facilities whose tumors have melted away.

    I agree the number is not only small, but the population likely to benefit is also small right now. However, each day we learn about new mutations; moreover, each day the somatic tumors change. Knowledge allows us to treat where we can.

  2. I think that developing a genomic database of prostate cancers is the proper province of a governmental project. Until, the database is accumulated, it won’t be clear to pharmaceutical companies how they can make money in developing pharmaceuticals targeted to various abnormalities. The NCI-MATCH study is such a database, although its prostate cancer component is small.

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