The Future of Anti-Cancer Treatment:
Precision Medicine and Immunotherapy
Maurie Markman, M.D.President, CTCA Medicine & Science
Clinical Professor of Medicine, Drexel University College of Medicine
© 2015 Rising Tide
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Systemic Treatment
• “Non-specific cytotoxic effects” (“poison the cancer …..”)
• Moving to an era of “precision cancer medicine”
– PCM is a NOT an event
– Rather it is fundamental process whereby both investigative
efforts and subsequent “standard-of-care” therapy of an
individual patient’s cancer will be increasingly based on the
documented presence of:
– (a) particular germline variants (toxicity and efficacy) and
– (b) tumor-based molecular abnormalities (revealed through the
conduct of clinical research) to be relevant in the progression
[“driver”] of the cancer
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“Precision Cancer Medicine”
• Not a new concept in oncology !!
– Hormonal therapy of breast/prostate cancer – earliest systemic
anti-neoplastic strategy
– Her-2 over-expression in breast cancer
– CML/GIST (profoundly different pathology but similar molecular
abnormalities resulting in essentially identical highly effective
therapies
– Resulting in over-simplification of complex biology
– Example: “EGFR over-expression” in lung cancer - until it was
understood there was a specific mutation that was relevant ….
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Issues with “precision cancer” therapeutics
• Quality of evidence for clinical utility of molecular
markers
• Insurers willingness to pay for anti-neoplastic therapy
based on molecular test results
• Small subsets of patients (<5% of patients with a
particular uncommon malignancy)
– How does one prove clinical benefit?
– Is a phase 3 randomized trial always required?
– How doses a drug achieve FDA approval?
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But the “future” is here …..
• Now possible to sequence the entire genome of a tumor
and corresponding germline of an individual cancer
patient for < $5,000 (less than 20 years ago this would
have cost > $1,000,000,000)
• So, the issue not whether the data will be available to
patients, but rather how to optimally convert this massive
quantity of raw data into information of genuine value in
individual patient management
• Multiple “platforms” being investigated and currently
commercially available, including small and larger
“actionable” gene panels (200-500 genes)
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Options to test “precision medicine” strategy
• Increasing number of pharmaceutical company
sponsored “basket trials” with treatment assigned based
on identified molecular abnormalities rather than specific
site of tumor origin or morphology
• NCI-MATCH trial (anticipated 1,000 patients) – molecular
testing performed in central laboratory
• ASCO “TAPUR” trial (unknown total number of patients)
– accepts multiple molecular testing platforms
• “N-of-1” experiences - assuming available mechanism
for drug payment
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Reporting results of “precision cancer medicine” experiences
• Peer-reviewed publication of results of clinical trials
(anticipated slow process)
• Peer-reviewed publication of individual “N-of-1” case
reports
• Peer-reviewed abstract presentations at national
oncology meetings
• Public database of “N-of-1” experiences (e.g., planned
as a component of ASCO’s CancerLinQ effort)
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Potential Impact of Germline Variants
• Pharmacogenomics (toxicity and efficacy)
– 5-fluorouracil
– Irinotecan
– Thiotepa
– Methotrexate
– Tamoxifen (“poor metabolizers – 10% of population”)
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Potential Impact of Germline Variants (Efficacy)
• Risk of renal cell cancer recurrence
– Lancet Oncol 2013; 14:81
• Risk of breast cancer recurrence
– PLOS One 8(1):e53850.doi:10.1371/journal/pone.0053850
• Risk of childhood ALL recurrence
– Blood 2012; 120:4197
• Colorectal cancer survival
– Clin Cancer Res 2011; 17:6944
• Response to platinum-based therapy in NSCLC
– J Clin Oncol 2010; 28:4945
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Potential Impact of Germline Variants (Toxicity)
• Lung cancer patient-reported quality-of-life
– J Clin Oncol 2012; 30:1699
• “Hand-foot syndrome” after sorafenib
– Cancer 2013; 119:136
• Fatigue among breast cancer patients
– J Clin Oncol 2013; 31:1656
• Neurocognitive outcome in childhood lymphoblastic
leukemia
– J Clin Oncol 2013; 31:2182
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Potential Impact of Germline Variants Impacting Cancer Management
• Donor grant containing “functionally stronger natural-
killer cells” in pediatric allogeneic hematopoietic stem-
cell transplants
– J Clin Oncol 2013; 31:3782
• Risk of aspergillosis in stem-cell transplants
– N Engl Med 2014; 370:421
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Cancer Immunotherapy
• Relationship between infection and cancer regression noted by at least the 18th century
• Coley’s toxin (1891) – case studies
• Very limited success – but provocative data on the small number of long-term survivors (Rosenberg, NCI)
• Today, we are in the new era of “cancer immunotherapy” resulting from critical basic science discoveries followed by development of innovative anti-neoplastic agents (checkpoint inhibitors)
• But critical issue remains, determining which patients will benefit ….. precision cancer medicine
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Essential Requirement: Define “Value” in Cancer Care
• Our society (and individual patients/families) simply cannot
continue to pay the “charges” associated with novel and
clinically effective anti-neoplastic strategies
– Combination regimens
– Advanced/metastatic/recurrent cancer increasingly recognized as a
serious “chronic disease process” with survival of acceptable quality
(as defined by the patient) and possible treatment durations
measured in “years” rather than “months”
– We must find biomarkers to predict clinical activity/inactivity
– The entire “system” must be changed to (a) permit anti-neoplastic
drug access at affordable prices, but also to (b) continue to strongly
encourage development of novel strategies and innovation
– Next steps?
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EMERGING TECHNOLOGY
AND PROCEDURES
in
CANCER IMAGING
Christine B Capitan MBA
Capitan and Associates, INC.
DIFFERENCE BETWEEN
RADIOLOGY & DIAGNOSTIC
IMAGING
RADIOLOGY
DIAGNOSTIC IMAGING
21st CENTURY ADVANCEMENTS
TECHNOLOGICAL IMPROVEMENTS
X-ray tubes, software, computers
PACS
Elimination of film
Instantaneous multi-user availability of images
EFFICACY
More precise
Increased understanding of diagnostic information
INTEGRATION WITH COMPUTERS
Quality of images
Amount & orientation of diagnostic information
IMPROVED PATIENT EXPERIENCE
Speed of the exam
PROTECTION OF INITIAL INVESTMENT
Platform for future advancement
EMERGING TECHNOLOGY
PET/MRI
METABOLIC IMAGING
CONTINUAL CT, MRI & RADIATION THERAPY
ENHANCEMENTS
PET/MRI
ADVANTAGES
Combines anatomic and functional information
Simultaneous or sequential studies
Quicker availability of diagnostic information
50% less radiation compared to PET/CT
Women's health
Pediatric patients
DISADVANTAGES
Proven efficacy
Cost $5-7M
Space
Reimbursement
METABOLIC IMAGING RESEARCH AND CLINICAL TRIALS
COMBINES MOLECULAR BIOLOGY WITH IN VIVO IMAGING
Visualization of the cellular function and molecular process
CT, MRI, PET/CT, PET/MRI
Biomarkers
BIOLOGICAL BEHAVIOR OF TUMORS
Personalized medicine
DETECT PREDISEASE STATE, STAGE TUMORS, ASSESS
TREATMENT RESPONSE
EXPECTED ECONOMIC IMPACT DUE TO EARLIER AND MORE
PRECISE DIAGNOSIS
RADIATION ONCOLOGY RADIATION TREATMENT PLANNING
CT
MRI
PET/CT
PET/MRI
Treatment planning computers coupled to verification computers on linear accelerators
ADVANTAGE
More precise delivery of radiation
Reduced/eliminated adjacent normal tissue damage
DISADVANTAGE
Expense
Reimbursement
EMERGING CLINICAL PROCEDURES
SCREENING PROCEDURES
Low dose lung scanning
CT colonoscopy
Cardiac CT
DIAGNOSTIC PROCEDURES
Elastography
Ultrasound
MRI
LOW DOSE LUNG SCREENING
ADVANTAGES
Early detection
20% screening benefit
DISADVANTAGES
Screening cost
False positives
COST EFFECTIVENESS NOT YET RESOLVED
Varying opinions
COST EFFECTIVENESS STUDY
BENCHMARK
$50,000 per quality-adjusted life year (QALY)
100% screen rate
COST PER LUNG CANCER DEATH AVOIDED
$183,577
LIFE YEARS SAVED BY SCREENING
$120,792
COST PER LIFE SAVED
$28,497
COST PER QALY SAVED
$35,577
2015 May;25(2):205-15
THORACIC SURGERY CLINIICS
MAUCHLEY DC MITCHELL JD
CT COLONOSCOPY
ADVANTAGES
Improves patient experience
Eliminates sedation
Immediate resumption of daily activities
Effective screening tool
Improves population health
Reduces the cost per capita of healthcare (Medicare)
Conventional colonoscopy screening $1036
CT screening $439
DISADVANTAGES
Removal or biopsy requires 2nd patient prep and procedure
Small polyps (2-10 mm) may not be visualized
CARDIAC CT ADVANTAGES
Non-invasive
Calcium scoring predictor of adverse cardiovascular events
Less costly than cardiac-cath or exercise stress testing
Eliminates sedation
Allows cardiologists to focus on procedures rather than diagnosing
More access to cardiac cath capacity
DISADVANTAGES
Radiation exposure
Still may require catherization for diagnosed pathology
COST (MEDICARE)
Cardiac cath $2948
CTA $508
ELASTOGRAPHY
MEASURES THE STIFFNESS OF TISSUE
emulating the surgeons fingertips “touch”
MRI AND US
MRI more sensitive & costly
US less costly
DIFFUSE LIVER DISEASE
CANCER CARE
Breast lesions
Liver cancer
Radiation & Chemotherapy induced fibrosis
NON INVASIVE SURGICAL PROCEDURES “Surgery without a scalpel”
INTERVENTIONAL RADIOLOGY
Image-guided biopsies
Gene therapy
Delivery directly to the tumor
Tumor ablation
Chemo embolization
Directly into the tumor allowing lower dosses
RADIATION THERAPY
Stereotactic Radiosurgery
Accurate targeted radiation in large doses
GOOD, BAD, UGLY
Availability to quickly & easily diagnose medical
conditions allowing physicians to start treatment earlier
Is it better, worse or the same
Different technologies, different procedures, lead to
confusion of appropriate use and sequencing and often
overuse or inappropriate use
Rising costs of healthcare
DIAGNOSTIC IMAGING GOAL
RIGHT PROCEDURE, RIGHT TIME FOR THE RIGHT PATIENT
AT THE RIGHT COST
American College of Radiology (ACR)
Developing ordering guidelines in collaboration with other
subspecialties
Reduction of unnecessary imaging
Radiation Safety – ALARA
As low as reasonably achievable
Conducting outcomes based research-driven protocols
