Molecular Tumor Board Brings Precision Medicine to All Wisconsin Cancer Patients
Cancers are typically classified based on their tissue of origin, and that location typically determines treatment plans. While that practice is unlikely to end anytime soon, tumor classifications based on genetics are gaining traction and could lead to more effective, personalized treatments for cancer patients.
"In recent years, we have recognized that even within one organ type of cancer there are many different diseases that are pretty unique, and one way you can see these features is by looking at the genetics of the tumor," said Mark Burkard, MD, PhD, a medical oncologist and researcher at the UW Carbone Cancer Center. "We are hoping to ultimately use that information to customize people's treatment, and that concept is called precision medicine."
A Statewide Coalition to Benefit Patients
Before Vice President Biden announced precision medicine as a focus of the National Cancer Moonshot Initiative, doctors throughout Wisconsin were already starting to incorporate it into research and patient care. They went one step further by forming the Precision Medicine Molecular Tumor Board (PMMTB) in September 2015, a partnership between the Carbone Cancer Center and regional medical centers, including Gundersen Lutheran, Green Bay Oncology and Aurora Healthcare.
"The PMMTB is a group of physicians and scientists who can take the information about how each cancer is unique, make recommendations and try to figure out what that information means and how we can use it," said Burkard, one of the PMMTB's co-directors. "We are not the first molecular tumor board, but we are unique in that we are not just institutional, we are a resource for any patient in the state."
In order to be considered by the PMMTB, a patient's tumor must first be sequenced to identify its DNA mutations, then the case is submitted by the patient’s oncologists. Cases are reviewed via teleconference where board members, comprised of oncologists, pharmacists, researchers and pathologists at the Cancer Center and throughout Wisconsin, analyze the case with the referring physician.
"The tumor board meets, looks at the mutations, looks at the clinical trials and drugs that are available, and based on that we can make a recommendation for the patient," said Jill Kolesar, PharmD, professor of pharmacy at UW and co-director of the PMMTB. "If there is a drug that has been shown to target the same mutation in another cancer type, but it is not currently approved for their type of cancer, then we can make an 'off-label' recommendation because we think the patient may benefit from the drug."
Ben Parsons, DO, a medical oncologist with Gundersen Lutheran, said he participates on the PMMTB because of the benefits it offers him and his patients.
"As a clinician, it's really difficult to stay on top of what these changes mean at the genomic level, and you learn a lot more about whether a mutation may be significant or not from the Board's review than from the sequencing report," Parsons said. "Even if I walk away having presented a case and there isn't a clinical trial or off-label treatment option available, it is still a huge benefit to my patients because I leave with a better idea of the biological behaviors of their cancer and potential future treatment options."
Because of the complexity of interpreting the data, the molecular tumor board includes experts from across the state, including Dr. Paraic Kenny, director of the Kabara Cancer Research Laboratory in Lacrosse and Bill Rehrauer, Director of Molecular Diagnostics at UW-Madison. Other state-wide experts, such as molecular geneticists from the Blood Center of Wisconsin in Milwaukee, participate on an ad hoc basis.
Balancing Emerging Evidence with Best Evidence
PMMTB review is limited to patients with active, incurable cancer, as patients with potentially curable cancers should not forego better-studied treatments. The Board carefully balances emerging evidence with best evidence to date to offer customized recommendations, and tracks patient outcomes on a research registry.
"A physician can order a high-powered genomic test and get detailed information about the patient's tumor, but how to use that information is still a real challenge," Burkard said. "We are collecting information about how well the recommended treatment is working and use it to adjust our recommendations as we go forward, benefitting current – and future – patients."
The PMMTB reviews cases free of charge, but the patient or their health insurance company is responsible for the costs associated with the DNA sequencing and treatment drugs. As sequencing costs decline, more insurance companies are paying for the tests. Each test sequences 50-500 cancer-associated genes from one tumor sample and costs about the same as individually sequencing two genes and spares the patient from multiple biopsies. They are available at UW or from outside companies.
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Date Published: 10/06/2016