Precision Medicine Picks up Pace Across Oncology

Matching the right treatment with the right patient resides at the heart of precision medicine, but with continued interest in pursuing the molecular milieu of cancers, precision medicine has the potential to better inform pre- and post-cancer interventions as well, explained Andre Goy, MD, MS.

“The goal of precision medicine is to give the right intervention at the right time to the right patient. Although this is something that physicians do naturally, we’ve seen an acceleration [in that regard] given the better understanding of cancer biology and the unbelievably rich pipeline,” said Goy, chair of the 2nd Annual Precision Medicine Symposium, a program developed by Physicians’ Education Resource® LLC, and physician-in-chief of the Hackensack Meridian Health Oncology Care Transformation Service, in an interview with OncLive.

In the interview, Goy, who is also chairman and executive director of John Theurer Cancer Center at Hackensack University Medical Center, Lydia Pfund chair for Lymphoma, chief of the Division of Lymphoma, professor of medicine at Georgetown University, and professor and chair of oncology at Seton Hall–Hackensack Meridian School of Medicine, discussed current and future applications of precision medicine in oncology.

OncLive: How has precision medicine impacted the field of oncology, and how can this year’s Precision Medicine Symposium help practicing oncologists make sense of all these advances?

Goy: Precision medicine has created a complex landscape in oncology. For example, last year, 59 drugs were approved by the FDA. We’re seeing pressure on the sustainability of health care and the costs of cancer drugs. At the same time, we hear a lot about precision medicine as a buzz word, but we also hear some critics saying it has not [been] delivered. I would argue that we already have started precision medicine. When you look at TKIs and resistance in chronic myeloid leukemia, [we apply precision medicine to subsequent therapy]. Now we know that many other drugs are approved with a companion diagnostic. 

We understand better that some subsets of patients respond better to a drug or something else. This increasing pressure for oncologists given the complexity of the landscape and the number of options makes it difficult for them to find the best option for a given patient, which is the goal [of precision medicine]. That’s the rationale for this conference. When you go to a large meeting, such as the ASH Annual Meeting or the ASCO Annual Meeting, you [are inundated] with tons of information. We want to try to filter out what is important and impactful for the practicing clinician. This is the second annual [Precision Medicine Symposium], and we’re seeing that [precision medicine] applies to all cancers.

What presentations were you most excited to hear?

Although I’m a lymphoma specialist, I very much looked forward to reviewing the panoply of options that we have across oncology. I am struck by the fact that [precision medicine] applies in all cancers, ones [we would never imagine] like gastrointestinal cancers. A few years ago, we couldn’t have had a conference like this on precision medicine, because it was not really feasible. That shows you the rapid acceleration [we’re seeing]. We are only scratching the surface of immune resistance. How do we understand the patient who really benefits from immunotherapy, and also [better understand] the emerging role of the microbiome?

How can medical oncologists and pathologists collaborate to develop a better understanding of molecular oncology and optimal treatment decisions?

It’s really important to [collaborate] with a pathologist. When you get a report from a pathologist, it’s important to try to drill down and ask them [about] additional markers. In large cell lymphoma for example, you need [to understand what] markers [are present] to identify the subset. However, that’s not routinely done. In non–small cell lung cancer, approximately half of patients [don’t undergo mutational profiling]. The best way to start to treat a patient is to have the best workup. It’s really important to connect with your local specialists that can guide treatments, and also to refer patients for clinical trials. With the options that are made available, and with these novel combinations of targeted therapy and immunotherapy, we are seeing unprecedented [responses].

As a lymphoma specialist, what precision medicine therapies are we seeing in this space?

We know that the vast majority of patients do well with 6 cycles of rituximab (Rituxan)-CHOP (R-CHOP), but those who do poorly with R-CHOP [have really poor outcomes]. Can we focus on the 80% of patients who will relapse within the first 18 months [of treatment]? We are starting to do this, looking at genetic subtypes beyond the germinal center and non–germinal center subtypes—mostly double-hit, but also p53­-mutant, subtypes. All of these subsets of patients should be treated differently.

Research led by Jason Westin, MD, at The University of Texas MD Anderson Cancer Center, with rituximab and lenalidomide (Revlimid) plus ibrutinib (Imbruvica) combinations in non–germinal center lymphoma is really interesting. In older patients who have aggressive disease, very often non–germinal center disease presents with more events and more symptoms. Giving a non-chemotherapy option at the beginning and completing the shorter version of chemotherapy is very appealing.

In mantle cell lymphoma (MCL), there’s this whole spectrum [of patients who don’t have indolent or aggressive disease]. We can identify up to 25% patients who have high-risk features. Similarly, giving rituximab and ibrutinib as a combination and an abbreviated course of chemotherapy is very appealing. This is the first step for patients who are not candidates for high-dose therapy or dose-intensive therapy. [The treatment algorithm] is really shifting. In MCL, we’re [identifying] subset after subset that allows us to truly define a better treatment and a better option for our patients.

Are there any ongoing research efforts that you’re working on that you would like to highlight?

Clinical trials are often the best option you can offer a patient because it offers them access to care that they would not necessarily have otherwise. It’s important to understand that the future of cancer is going to be [understood in] 3 phases. Specifically, pre-cancer where genetic risk management and early detection is going to have a much broader impact; intervention for emerging cancers; and post-cancer, where minimal residual disease will apply across the board with cell-free DNA (cfDNA).

We already use cfDNA as part of routine practice in MCL and some other lymphomas. This is going to be very important across hematologic malignancies in particular. Can we take advantage of immune consolidation approaches post-cancer treatment to try to prevent recurrence? That will be sort of the third phase of cancer therapy, allowing patients to reduce [their risk of] relapse and [have] a better recovery in partnership. This is overall a really exciting time to be in oncology.