How to Define Precision Cancer Medicine
"Disruptors" is a series sharing new and innovative ideas and viewpoints from Columbia Cancer researchers and clinicians that challenge conventional thinking about cancer care, research, and beyond.
When the concept of personalized medicine surfaced, more than 20 years ago, the message sent to the general public from the medical community was straightforward: patients could receive drugs or tailored treatments that are specific to their disease, essentially providing them with individualized care. The idea behind personalized medicine, also known as precision medicine, underscored one simple truth—there is no “one-size-fits-all” approach to treating patients.
For cancer, this is definitely the case.
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Over the last decade, more and more research, clinical trials, and interest have been generated around precision cancer medicine, communicating the idea that doctors can conduct genetic profiling on your tumor, unveil disease-causing mutations, identify the optimal drug to treat your specific cancer, and, at times, eradicate it. While this model of using the genome to find the “silver bullet” for each patient has transformed the care for some patients with cancer, this model requires new perspectives to fulfill its initial promise. Today, there is an evolving picture of what precision cancer medicine is and should be.
Precision cancer medicine needs to be envisioned as understanding how cancer works, which goes far beyond individual gene mutations, and using that information to guide therapy and prevention. Genetic sequencing is an important tool and the advances in that technology have been monumental in getting us to where we are today. Knowing the specific genes that are mutated, however, is just a piece of a complex puzzle intertwining the remarkable complexity of the fundamental biology of a cancer cell and of non-cancer cells, most specifically, the immune system. Moreover, the tools and approaches developed to treat advanced cancer can be applied to the critical problems of early detection and prevention of cancer.
Crystallizing the Ecosystem
In establishing the Center for Precision Cancer Medicine at the Herbert Irving Comprehensive Cancer Center at NewYork-Presbyterian/Columbia, we are cultivating an all-encompassing scientific hub that pulls from multiple expertise areas and disciplines across the university to tackle precision cancer medicine head-on and in a different way to the “silver bullet” concept.
Instead of looking at cancer like a target to hit with a certain drug or therapy (a traditional, one-mutation-one-drug approach to precision medicine), we are looking at cancer like a game of chess, working to predict the appropriate combinations of drugs that are needed, based on the nuances of cancer biology, including how cancer cells adapt to specific drugs and how to integrate different classes of therapies.
Precision cancer medicine is an ecosystem. Key to this ecosystem is laboratory research, working in the lab with not just cancer biologists, but computational biologists, systems biologists, biomedical engineers, and experts in many other fields to uncover how cancers work.
Working in the Lab With the Help of Real Patients
We can start by identifying the vulnerabilities in specific cancers; studies that are informed by patient data, but ultimately performed in the laboratory. And increasingly that laboratory work is about not just finding a good target in the cancer cell, but using the bigger view of the chess board where a drug against a promising target is a stepping stone to building the right combinatorial therapies, approaching cancer from multiple angles. This is really about dissecting how tumors adapt to particular therapies, thinking about new treatment combinations, learning how tumors become resistant to treatments that had been working and then using these data to prevent or at least delay resistance.
While the fundamental work to define precision cancer medicine is largely done in the laboratory using model systems such as cancer cells that researchers can grow in the lab, this process is now interwoven with studies in the patient. The most important model of cancer will always be that of real cancer in a real person. Thus, while laboratory work remains essential, our studies are increasingly looking at these critical questions in our patients. With the use of circulating markers of cancer that can be detected in blood, to studies we can do on biopsies of patients’ tumors during therapy or advanced new imaging techniques, we can define how cancers adapt and evolve during therapy. These observations from the patients then can be brought back to laboratory models so we can define the approaches to thwart cancer’s ability to defy our therapies.
Our job here is innovation. We need to innovate in our fields but, more important, is how to innovate across fields. With the immense complexity of cancer, these problems need teams that bring with them totally different tools and approaches. Moreover, one advantage of tackling this problem in a university such as Columbia is the remarkable diversity of expertise. It well could be that the most important advances to come in cancer research may originate from a scientist who has yet to realize they are a cancer researcher.
Adam Bass, MD, is the founding director of the Center for Precision Cancer Medicine at the Herbert Irving Comprehensive Cancer Center (HICCC) at NewYork-Presbyterian/Columbia, co-leader of the Precision Oncology and Systems Biology research program at the HICCC, and Irving Professor of Medicine at Columbia Vagelos College of Physicians & Surgeons.