Education by Pharmacist May Help Oncologists Who Are “Drowning in Data”

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Lions and tigers and zebras oh my! Expert says precision medicine helps identify unique “zebras” (cancers), but it is increasingly difficult to keep up with new treatment indications across a broad range of cancers.

George W. Sledge Jr., MD, Executive Vice President and Chief Medical Officer at Caris Life Sciences, joins Pharmacy Times to discuss the future of technology on cancer research. Sledge stresses the importance of the pharmacist, better understanding what drugs work for what patients, and using precision medicine and genomics to revolutionize cancer therapy.

PT Staff: Technology has a broad range of functions. What technologies have you found to be instrumental to cancer (clinical) research, and why?

George W. Sledge Jr., MD: In terms of molecular diagnostics, I would say in the last 20 years, largely as a result of the Human Genome Project and what's followed on from it, we're now able (at a very precise level) to tell exactly which mutations are present in human cancers. We do that at the level of DNA, genomics, or we can do it at the level of RNA, transcriptomics. And our ability to do genomics and transcriptomics— through whole exome sequencing, and whole transcriptome sequencing— has revolutionized our ability to tell exactly which mutations are driving a patient's cancer. And that, in turn, has led to multiple novel therapeutics that target very specific mutational events in human cancer.

PT Staff: Does technology have an impact on precision medicine? Could it impact the treatment type?

George W. Sledge Jr., MD: Let me give you a really obscure example because I think it's one that might be of interest to your colleagues in the pharmacy industry. There's something called an indirect fusion gene, a neutrophic tyrosine receptor kinase (NTRK), and it's really, really rare. It's present in about 2 patients in 1000, [and] across a whole variety of human cancers. So it's something that, prior to the presence of genomics [and] prior to what's called next-generation sequencing, we never tested for it. In fact, I'd never heard of it until 5 years ago or so.

But it turns out that if you have this particular fusion gene, we've been able to figure out what drugs target it. There are 2 of these drugs that are now FDA-approved, and it's a pill. There's about an 80% response rate—80% of patients will have major shrinkage of their cancer, sometimes lasting for years, and next-generation sequencing have allowed us to find what I what I call the “zebras”, and target them.

There's, there's an old mantra in that's taught in medical schools, which is when you're when you hear hoofbeats, think of horses— common things occur commonly. So those are the things that you should know. But in oncology, as a result of genomics, we're now living in zebra land. Where there's now these rare hoof beats that we can find as a result of genomics, things like the NTRK fusion gene, that allow us to precisely identify which patients are going to benefit from a particular drug for a particular mutation. And that has revolutionized how cancer doctors approach cancer patients.

PT Staff: How can pharmacists optimize technology to help cancer patients and patients with less severe conditions?

George W. Sledge Jr., MD: Pharmacists pretty clearly play a crucial role in this oncology is dealing with a crisis right now, the crisis is what I call the 1 new indication a week crisis. If you go to the Food and Drug Administration's website for hematology and oncology drugs, and look over the last 5 years, roughly once a week there's a new drug indication over the last 5 years. Now, if you're a general medical oncologist, and trying to imagine learning one new indication per week, across a broad range of cancers, it's virtually impossible. And an important part of that learning curve, of course, is being able to instruct patients in terms of the side effects of therapy. And even how to take a drug.

And, you know, it's not if you're the if you're the poor oncologist and you're trying to learn 1/2 indications a week, well, you certainly need a good partner and your pharmacist. You know, a lot of patient education that occurs is education, that that's occurring at the pharmacy level. And I think, you know, if we're going to solve the 1/2 indication a week problem and oncology, part of that must be extensive education of patients and a large part of that is probably going to have to occur at a level of a pharmacist, we're drowning in data.

PT Staff: What direction do you see cancer (and your own) research going in the next decade?

George W. Sledge Jr., MD: First off, the 1 new indication a week thing is going to continue for all of oncology and that's going to continue for breast cancer as a as a subset of oncology as we learn more and more about human cancer, which in large part has been taking the pie and slicing it into ever finer pieces as we slice the pie ever more.

Finally, we're going to have more than more treatments that are specific to subgroups of patients with cancer. So I think that's that will be one thing that will occur. Another major thing that's going to occur, and I think this will again be because of genomics and our increasing ability to apply genomic technologies to cancers, is we're going to be able to predict increasingly who benefits from therapies for human cancer.

One of the problems we have is that even when we have these targeted therapies, these therapies that are designed around precision medicine, based on the genomics, many of these drugs still don't work for everyone. One of the big challenges going forward for us—and this is going to be important from a cost standpoint, from a toxicity standpoint, and from an efficacy standpoint—is trying to address which patients will benefit from which drug at which time. I'm hugely interested in being able to come up with predictive signatures for patients with cancer that will allow us to allow physicians to understand which patients should receive which drugs. I think that's going to be a major challenge for the field as a whole, but also particularly exciting for me and my colleagues at Caris and I'm sure throughout the entire industry.

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