Last year Nature published an Outlook collection of viewpoints surrounding the progress and promise of precision oncology. The Perspective piece that particularly caught my attention was on “The precision-oncology illusion” authored by Vinay Prasad, assessing the success of genome sequencing programs and trials pairing individual patients with a targeted therapy matched to mutations and disease specificities. Whether one agrees or not with the arguments provided, one thing is true: we still have a long road to travel if we are to deliver on the promise and potential of precision medicine. That said, I believe that we have every reason to be optimistic.
Thanks to several major advances in genomic technologies, including the widespread implementation of gene panels to diagnose the molecular culprits of solid and haematological cancers, the advent of non-invasive liquid biopsies, and steady progress in precisely targeting drug therapies against individual patient tumours, we have made much progress in thwarting this hideous disease.
While these developments must be applauded, we need to get smarter and move faster. The two major challenges that continue to hamper our efforts in more precisely treating cancer are reversing cancer drug resistance and counteracting tumour cell spread factors.
Importantly, we are witnessing the extension of novel therapies – immune-based approaches in particular – to more tumour types, furthering our insights into the cancer genome and epigenome towards better tracking, detecting and treating disease, fine-tuning and tailoring cancer medicines matched to newly classified subtypes, and identifying new avenues for molecularly targeted therapy against metastatic disease.
At preclinical level, our translational efforts are marking important progress in empowering predictive cancer science towards the next generation of precise anti-cancer therapies. By developing and pioneering increasingly “intelligent” humanised cancer models, including patient-derived tumour xenografts (PDXs) as avatars for patient response to therapy as well as organoids as in vitro models of disease, we continue to discover the driving factors that influence tumour growth, more accurately predict cancer progression and response to certain treatments.
Continued focus aimed at advancing today´s array of modelling systems will help us to increasingly deliver the predictive data required to reliably inform the clinical development of innovative agents and evidence reproducibility before moving to the clinic – avoiding costly duplication as well as wasted opportunity in our collective quest to get the right treatment to the right patient, on time and at the right time.
In order to address the immense complexity and heterogeneity underlying cancer, innovative drug combinations will need to be developed in order to improve outcomes for our patients. In terms of combinatorial targeted therapy and the which, for whom, and for what, the possibilities are endless when considering which to move forward. As we up the tempo in accelerating and potentiating truly transformative therapies, we must continue to uncover the genetic basis of tumour-specific vulnerabilities, and base our clinical studies on strong scientific rationale. Future clinical trial design must be based on robust scientific hypothesis coupled with the co-development of biomarkers to facilitate patient selection – the empirical; trial and error approach to trial design is no longer acceptable or affordable.
To move us closer to the holy grail of personalised medicine in oncology, it´s not only a matter of driving the necessary scientific breakthroughs from bench, bedside and back; it´s also about access to and affordability of novel cancer treatments.
According to a recent study, in 2015 there were an estimated 17.5 million cancer cases globally and 8.7 million deaths. Furthermore, cancer burden is on the rise at an alarming rate, owing to a growing and ageing global population as well as risk factors including smoking, obesity and dietary patterns. As an example, estimates suggest that cancer incidence is expected to increase more in the GCC region than in any other region across the globe over the next 20 years. Considering the widely-documented issue of cancer medicines carrying disproportionate price tags – the major contributing factor to unacceptable disparities in access to current therapies, and the daunting prospect that one in two people will develop cancer at some point in their lives, healthcare systems are already buckling under the burden, with some at breaking point.
Global oncology costs soared to 107 billion US dollars in 2015, representing an increase of 11.5% over 2014. According to the alarming estimation, these costs are set to reach 150 billion US dollars by the year 2020. In the last five years, costs of cancer medicines increased by 72% over 2010 in the US, and by 50% in countries other than the US. Coping with escalating healthcare costs now and beyond is a problem faced by all countries and, if we don´t collectively work together to prepare and suitably plan for the future, the outcomes for countless cancer patients, now and in the future, will be catastrophic.
The key now will be to work together to prioritise and better guide informed decision making when it comes to the fair pricing and access to approved therapies. The shaping of oncopolicy towards facilitating equitable access to optimal, affordable care for patients quite literally begins ´at home´. Decision makers will need to balance efficacy and reimbursement of anti-cancer therapies with regional socio-economic realities. In this respect, major professional societies and organisations will play an essential role in road mapping these necessary directions.
To name but one, the European Society for Medical Oncology (ESMO), for which I am truly honoured to currently serve as President-Elect, represents an essential partner in this process. ESMO´s Cancer Medicines Working Group with its especially appointed expert task forces, Policy Committee and Regional Committees are working hard, in concert, to better guide policy makers, regulators, reimbursing bodies and pharma companies to increase cancer therapeutic access of both innovative drugs and essential drugs.
We all consequently need to take a hard look at current policies and priority setting on a region-per-region basis. Without this essential overhaul, today’s advances in predictive cancer science, treatment and care, as well as prevention strategies, cannot possibly hope to benefit an increasing number of our patients, across borders, now and in the future.
Some difficult choices will have to be made in terms of selecting which therapy, for whom, based on clearly demonstrated benefits across patient populations. A multi-stakeholder review of cost settings and the suitably adjusted pricing of cancer therapies to enable equitable access to the most effective therapies, is also as important as investing in the cancer research itself.
Only in unison, by engaging the entire oncology ecosystem and considering the views and the perspectives of all stakeholders in oncology, including patients and families, researchers, payers, regulators, the policymakers, and industry, will we be able to pursue our dedicated efforts aimed at solving cancer sooner for as many patients as possible.