FEATURED , Opinion

Alan Stolier, MD/

GAZING OVER THE HORIZON AT CANCER TREATMENT

“The greatest curse is to be stuck in one’s own time; the greatest power is to see beyond its horizon.” Rachel Kadish, The Weight of Ink

Is it true that all cancers are in some way genetic whether by germline or sporadic mutation or by some epigenetic event? I certainly believe this to be the case. We initially saw the benefits of germline mutation testing as well as testing tumor genomics. Both assisted in risk assessment and the latter in treatment selection.  Much of the benefit of testing for these mutations come from a more accurate assessment of risk or in the reduction in the use of chemotherapy.  It is also undeniable that the identification of oncogenes such as Her2 has led to the development of new biologic treatment options. Unfortunately, biologic therapies for breast cancer have not been highly successful when given as monotherapy, all appearing to require more standard courses of multi-drug chemotherapy to maximize success. 

As these thoughts creep inexorably to gain a peek beyond the horizon, one might conclude that since all cancers are in one way or another genetic, then it should follow that eventually, treatment of cancer should proceed along a path that takes advantage of this genetic knowledge. It is only in recent months that we began to catch a glimpse of that distant light. Several labs, including Myriad, Ambry and Color have begun using single nucleotide polymorphisms, SNPs, (now beginning to be known as single-nucleotide sequence variants) to examine associations with various diseases including cancer. As noted in a previous post on this website on Genome-wide Association Studies (GWAS), over 250 SNPs are known to be associated with male-pattern baldness. Cancer has got to be, it just has to be more complex than male-pattern baldness!

SNP tests are now commercially available to assess cancer risk for this group of high-risk but germline mutation-negative patients. Both companies use near 100 SNPs plus the Tyrer-Cuzick risk model (TC) to arrive at their score. Equally exciting data was presented at the 2019 San Antonio Breast Cancer Symposium. Hughes et al, from Myriad Genetics Laboratory, presented validated data demonstrating the use of SNPs plus TC to assess risk in women testing positive for five of the more common germline mutations. Intuitively, we’ve always known that different mutations in high-risk genes carried different cancer risks. This data from Myriad finally confirms this.

But peering over the horizon, one has to believe that genetics has to carry us further than risk assessment and the treatment of one known oncogene. To me, the holy grail is the treatment of existing cancers. If all cancers are indeed genetic then it makes perfect sense to me that ultimately, the treatment should be genetic. The fact that for an overwhelming number of patients over-expressing the Her2 oncogene, multi-drug chemotherapy is required in addition to targeted biologics suggests that we have a long way to go. 

 

They gathered for the feast

They stab it with their steely knives

But they just can't kill the beast

(Hotel California...Don Henley, Glenn Frey…Performed by The Eagles)

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