Medicine is becoming more and more precise. Healthcare professionals have growing access to big data, computational power and genetic sequencing and testing. Advances such as genetic screenings that rule out ineffective chemotherapy treatments are already being used clinically. Many other diseases, from high cholesterol to depression, are also on the list to potentially benefit from getting more precise interventions.
Host Frank Stasio talks with Dr. Francis Collins, director of the National Institutes of Health, Dr. Geoffrey Ginsburg, director of the Duke Center for Applied Genomics and Precision Medicine, and Dr. Kimberly Blackwell, Professor of Medicine and Assistant Professor of Radiation Oncology at Duke University and Director of Strategic Relations at the Duke Cancer Institute, about precision medicine. The three are participants in the Precision Medicine 2017 World Conference, which takes place today and tomorrow at Duke University. It explores how precision medicine is changing healthcare in North Carolina and what individual doctors and patients should know about its use and its promise.
Francis on what’s happening now in precision medicine:
Well, it’s pretty exciting. What we are about to launch in the coming months would be an unprecedented program to invite one million Americans to join in an effort to understand what are all of the environmental and genetic factors that play out at the individual level in keeping people healthy. Or if they develop a disease, how best to manage it. This so-called “All of Us” initiative...That’s the data set that, I think, is going to drive a lot of where we want to go in terms of this individualized approach to health maintenance and to management of chronic disease.
Geoffrey on what role North Carolina is playing:
I would characterize our state as being both vibrant and innovative in the precision medicine space. We have a number of really great contributors to the field with our academic powerhouses at Duke, UNC, (NC) State, Wake (Forest), ECU and others. All of which have gotten incredible funding from NIH to participate as well as working with industry, contributing first-class research towards the field of precision medicine.
And with our community of biotech, pharma and data science companies...We’’re now, as I like to think about it, stringing all these North Carolina pearls into a precision medicine necklace to make North Carolina an even more powerful contributor to precision medicine.
Francis on translating precision medicine into patient care:
Clearly, what we need is the evidence to show how this kind of information can improve outcomes. And you’ve just heard about how in cancer that is already becoming very compelling. That is the leading edge of precision medicine: the ability to use information about the specific nature of a particular cancer to determine what ought to be the optimum treatment. Getting away from one-size-fits-all surgery, radiation and chemotherapy. And to target the drugs that are going to be right for that individual. That’s the direction things are going. And already in many leading academic centers anybody who has a diagnosis of cancer is having that kind of DNA analysis of their tumor carried out. And if I had cancer right now that’s what I’d want to do.
I think other aspects are going to take a little longer to come along. But some are coming fairly quickly and one of them is this whole idea about why people don’t always respond equivalently to a therapeutic intervention – a drug. We know that if you get sick and you get a prescription for a drug, hopefully it’s going to work, but sometimes it doesn’t seem to give you the benefit and sometimes you have a toxic effect. A lot of that is because of variations in DNA. And now for more than 100 drugs we kind of know what some of those variations are. And we ought to be able to begin to use that information to optimize the treatment. So you get the right drug, at the right dose, for the right person at the right time...That is still, for the most part, a research enterprise. But I would predict that’s going to break out into the general practice of medicine pretty soon, especially as more and more people begin to have their DNA analyzed and have that in their medical record where it can be quickly used to make those decisions.
Kimberly on the cultural shifts required by precision medicine:
I think we’re beginning to see that sea change. What we’re talking a lot about in the field I work in – cancer – is called de-escalation. For 20 years, my entire career, we’ve added drugs on top of drugs to try to see if one plus one equals three. Or even, we’re happy if one plus one equals two. The reality is we can’t continue to treat everybody as one-size-fits-all. In part because if you give two drugs you get twice as much toxicity and that patient sitting in front of you might have only needed one drug to begin with. So I think from a patient’s perspective, they’re very interested in this de-escalation. Why should I get two drugs when one drug will do what I need for my own health?
It’s in part the doctor’s uncomfortableness of it. We go to med school because we’re taught we’re going to help people by doing X, Y, and Z, and so I think the shift’s going to have to start from the earliest medical training. Which is two things might not be better than one, and starting to incorporate that precision aspect of it in helping us guide our patients. But our patients guide us back, which is, I want to know what caused my disease. I get asked that every day in clinic. And I think within the next 10 years we’ll probably have an answer to questions like that.