Learning to Swim in the Pool of Genetic Data
Drug & Reference Information
I am Dr. Mark Kris from Memorial Sloan-Kettering Cancer Center, recapping discussions from a regional meeting of oncologists here in the Greater New York area.
I talked earlier about the importance of collaborating and working closely with your pathology department. The next important issue, and a change in practice over the last few years, is the use of molecular testing. If you go to the National Comprehensive Cancer Network (NCCN) guidelines, immediately after you make that accurate histologic diagnosis, there are specifications for molecular diagnostic testing.
Today we routinely test for epidermal growth factor receptor (EGFR) and rearrangements in the anaplastic lymphoma kinase (ALK) chain, but each passing month finds more and more targets. We are going to be testing for more targets. Technology has really helped us. It has allowed so-called "multiplex testing." Think of obtaining the complete blood count. The truth is, I don't think it's possible to order a white blood cell count or a platelet count. In ordering one of those tests, you get all the other ones with it. It is very efficient and has increased accuracy in doing these tests together in a multiplex fashion, and it's the same with these molecular tests as well.
I think that testing will increasingly become multiplexed. I also have to urge that the testing be done at the time of diagnosis. We know from our oncology training that the most critical regimen that we prescribe is the first one. Making the best recommendation and giving the most precise regimen makes the most sense. We need to do it at diagnosis, and we need to do it for all the different targets that we have.
Multiplex testing is definitely the way to go. I think that, more and more, pathology departments are doing these tests in parallel. It saves tissue resources. All the molecular tests can basically be done on one DNA specimen. Also, our patients cannot wait for us to do one test after another. We need to be very, very efficient.
This explosion in the ability to test and the number of test results that we receive is also another great change in our practice. I think it is fair to say that our testing capabilities now and in the years to come will clearly exceed our comfort level, and it will also exceed the clinical trial data we need to process the results. I think that individual oncologists are going to be given information that is not put in any sort of context, and we have to make the best decisions that we can.
When one of these multiplex test results comes to you -- 200 genes -- you can easily start with the critical genes; for example, EGFR and ALK. But then, as you find other ones, it is important to speak to your colleagues, look at the literature, and try to use that material as best as you can.
Frankly, I think we all have to be comfortable with being uncomfortable. We are going to have more data than we have ever had before. The data arriving on our desk are going to exceed our literature base to analyze them, and we are going to have to seek all the information we can to make the best decisions for our patients.
Where it is clear how to use the data -- ALK rearrangement, for example -- that's easy. But as other pieces of information come through, we are going to have to work hard together to make the best decisions and to try to marshal our resources as best as we can.
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