Dr. Wade placed precision medicine in the context of many different promising cancer treatments over the past few decades and described the participation of Heartland CORP in precision medicine trials.

Precision medicine is an exciting development in cancer, but it must be placed in a historical context. Over the past few decades, many waves of promising cancer treatments have waxed and waned. Each wave has come with great hope and enthusiasm, but has left us with some disappointment. This is not because people have failed, but because it is hard.

One such wave was interferon, which many experts thought would cure everything from small cell lung cancer to ovarian cancer. Interferon is still used, but its role is limited. Other waves have included multi-agent chemotherapy, non-cross resistant chemotherapy, bone marrow transplant for solid tumors, biotherapeutics such as IL-2, and antibodies such as bevacizumab for multiple cancers. Each wave has brought progress, but has not proven to be the final solution. For this reason, we need to rein in our enthusiasm for precision medicine. Some successful results have been reported, but these are often heavily influenced by patient variation (ethnicity, background, age, pharmacogenomics, immune response, metabolism, etc.).

Heartland NCORP is an Illinois-based alliance that serves 6 million people and treats 16,000 new cancer cases annually. We are currently involved in 6 molecular target driven studies: SWOG Lung-MAP, ECOG/ACRIN MATCH, NCI Exceptional Responders, SWOG 1403 (A Randomized Phase II/III Trial of Afatinib Plus Cetuximab versus Afatinib Alone in Treatment-Naïve Patients with Advanced, EGFR Mutation Positive Non Small Lung Cancer, and Alliance (Combination Chemotherapy With or Without Atezolizumab in Treating Patients With Stage III Colon Cancer and Deficient DNA Mismatch Repair).

My overall experience is that molecular trials hold promise, but for a few. Over the last 3 years, sequencing and identification of molecular subtypes has grown at a staggering rate. At the same time, payers such as Medicare have begun focusing on cost of care. Medicare is now evaluating cost of care (eg, sequencing, drug expenses, etc.) in their determinations of reimbursement.

Progress in cancer treatment will require many different solutions. One avenue for exploration is to search closed phase 3 trials of patients with metastatic disease to look for unexpected survivors (expanded, validated data set). Often cancerous tissue and germ line DNA were collected as part of the parent trials and they may produce important clues. Another avenue is to search prevention trials for those who subsequently developed cancer. Would we find early circulating DNA clues? The blood is already stored and the analytic technologies are far superior today than they were in the past.