Technology Advances Aid Treatment Decisions for Community Oncologists

Lori Brisbin

Molecular testing has become an imperative step in the treatment decision-making process for oncologists, and new technologies and assays are emerging to further help identify tumor abnormalities and at the right time.

For example, Trapelo is a novel single-technology platform with the ability to automatically update with treatment guidelines from the National Comprehensive Cancer Network (NCCN) and more to assist community oncologists with deciding on the optimal therapeutic path for their patients, explained Lori Brisbin.

“Only 30% of patients are being tested for precision medicine. If we don't test…then that is not a treatment option for them,” said Brisbin, vice president of precision medicine at Texas Oncology. “[The goal of Trapelo] is to advise on whom to test.”

In an interview during the 2019 OncLive^® State of the Science Summit™ on Precision Medicine, Brisbin discussed using these types of technology platforms in precision medicine as well as the role of liquid biopsies.

OncLive: How is Trapelo used in precision medicine for oncology?

Brisbin: Trapelo is a clinical decision support tool. We have a lot of tools to help us with our treatment pathways, but we don't have a lot of tools in the marketplace to help us with choosing the right test, for the right patient, and the right tumor type. With this tool, we have built in our diagnostic pathways. The tool is updated every single day with guidelines, from the NCCN, ASCO, and the FDA. Every day, this tool looks at these guidelines and updates them automatically. Then, I can put in information on clinical trials. We added [this feature] because we're enrolling patients in clinical trials, and this helps us to identify eligible patients.

For breast cancer, we perform certain tests throughout the entire stage of disease. However, for lung cancer, we look at stage III and metastatic stage IV disease. Who can remember all those details? Community oncologists treat patients with every kind of tumor type and they need to keep up to date on everything. This automated tool [keeps physicians updated] and is guideline based.

Are there any studies using this platform to test its effectiveness?

Right now, we're in a beta trial with 50 different physicians. These physicians vary from super users with precision medicine to [those who are less familiar] with precision medicine. We didn't have a big reason to be testing for genetic targets in ovarian cancer until these PARP inhibitors came to light.

Also, it's complicated. Should we do germline or somatic testing? When should we do the testing? What phase of the disease and [in what setting of] disease management should we test? It's different from breast cancer; that's why we put ovarian cancer in this tool.

Now, we have a pilot with this tool. We've rolled it out to 50 physicians. We have key performance indicators at the end of our pilot, which will end at the end of 2019. From there, we're going to decide if we want to go ahead and roll this out to the entire practice or if we want to have each [practice] sign up for [Trapelo] on a case-by-case basis.

What is the financial cost of using this tool?

It's very expensive, actually; that is one of the reasons, if you're a small practice, that you're not going to purchase an enterprise-wide subscription. However, [Texas Oncology] is such a large practice and with every tool that we have, we need to think about whether this will work for 490 physicians spread across a huge geography. We have to train everybody on how to use this tool, so it has to be very easy to train them. We believe the return on investment in patient care is going to be well worth the spend.

What challenges currently exist with Trapelo?

The current platform is app-based. The good thing about that is we could put it on anybody's iPad and they could do this at home. Today, they have to be on the network and order it through electronic medical records. This is both positive and negative because [physicians] have to open the app and order [tests] from that. The physicians think this is great, but nurses like the workflow the most because the nurses have to execute the order. This takes something that is a manual paper requisition process and automates it from start to finish.

Are there other emerging platforms or tools that you are excited about?

Today, we looked at a clinical trial matching tool that will go right from the laboratory that's performing the result and match automatically to clinical trials. [The clinical trial matching tool] calls the clinical trial coordinators of Texas Oncology, look at all of the inclusion criteria, and match that patient with a trial.

There are a lot of physicians and patients spread all over the country. Usually, we just have trials in big cities; however, this [clinical trial matching tool] allows us to open a trial where the patient lives so they do not have to go to an institution in a city. Clinical trials are standard of care for cancer, according to the NCCN. They are important. Traditionally, patients would have to go to an academic center in order to enroll in the trial, and this will eliminate that need.

One of the tests Trapelo assists with is liquid biopsies. What are your thoughts on using liquid biopsies in patients with cancer?

For non—small cell lung cancer, the positive about liquid biopsy is that it provides results in 48 hours, At Texas Oncology, we draw an extra ethylenediaminetetraacetic acid tube every time the patient comes to visit, which is every 2 weeks. While we are running the EGFR mutation test, we're also trying to procure the tissue from wherever that might be, and then we might get a result. Often, when patients don't get treated with a targeted therapy, it's because the patient was progressing while we were waiting for the molecular profile. If [the EGFR test] is positive, that gives us the ability to go ahead and choose a targeted therapy for them.

Liquid biopsies are great, but they have to be used with caution and the results have to be used appropriately. I would like for every pharmaceutical company to develop a liquid biopsy while they're developing their investigative agents in clinical trials because [liquid biopsy] needs more validation, but it will absolutely help more patients be accessible