Boston, MA—Delivering the keynote lecture at the 2015 Palliative Care in Oncology Symposium, Howard L. McLeod, PharmD, Medical Director of the DeBartolo Family Personalized Medicine Institute at Moffitt Cancer Center, Tampa, FL, discussed advances in personalized medicine as they relate to palliative care, as well as the continuing challenges in cancer care.
"The whole field of palliative care is personalized medicine," said Dr McLeod. "You're looking at patient attributes, and trying to understand how to intervene in order to help patients derive the best quality from their remaining years, months, or whatever it might be going forward."
Dr McLeod acknowledges that progress in the field is ongoing, but oncology has a long way to go before personalized medicine becomes a reality for every patient, he says.
Response to Treatment Still Unpredictable Despite Much Progress
Multiple active regimens now exist for the treatment of most cancers. However, with this choice comes variation in response to therapy and unpredictable toxicity.
"The clinical problem around therapeutics is quite a wonderful problem," said Dr McLeod. "There are now multiple treatment options for almost anything you're trying to do, which means there are some real decisions to be made."
"There is still a great variation in response to therapy," he said. "Many patients do not respond to certain therapies or do not have durable responses, much less curative responses, even with modern approaches to which others respond well."
Dr McLeod added that in practical terms, one's therapeutic choices are "amongst equals or apparent equals."
"We're all trained that if there's a clinical trial, there are a winner and a loser. The reality is that we can barely get a finger between the 2 curves, and we use the 'loser' as second-line therapy," he said.
Dr McLeod also elaborated on the issues of toxicity and cost. "Acceptability needs to be defined by the patient, not the prescriber," he said. "Patient-derived outcomes are going to be a key part of this, because what's acceptable to me is not necessarily acceptable to the patient we're trying to care for," Dr McLeod said.
"The idea that toxicity matters is a big deal," Dr McLeod added. "Grade 1 toxicity matters."
"Adverse drug reactions are also a big deal in this country," he emphasized. Not only are side effects important to the patient, but they also constitute a heavily litigated area. With new technology, many of these reactions are predictable, Dr McLeod said
Sadly, adverse drug events are the fifth leading cause of death in the United States, he added.
Addressing cost, Dr McLeod noted that although chemotherapy is expensive, physicians are seeing more opportunities to improve value for patients through more precisely tailored therapies. "We're now seeing real opportunities to make sure patients are getting the best options for them, not just for us and our health system," he said.
A Need for Further Discovery
Despite advances in precision medicine, prescribers still lack the means to use DNA-based markers to identify which patients will benefit, which will experience excess toxicity, which require dose adjustment, and which will have heightened sensitivity to a given agent. "There's still a need for discovery," Dr McLeod emphasized.
Hope versus Hype
He stressed the importance of further research in building on personalized medicine. "The concept of trying to separate out toxicity, efficacy and other elements is one that we can build on. And we can only build on it if we have the robust data sets with which to go forward."
"What needs to be done to determine hope versus hype?" Dr McLeod asked. "Find the 'right' biomarkers, validate them in robust data sets, and then apply them."
He added that patients should be able to make wise decisions that fit their values and desires, and that they should be able to learn from similar patients, " as opposed to this idea that they're one of a kind."
Dr McLeod emphasized the importance of considering benefit and risk in making preemptive assessments. Complex data need to be presented in a manner that helps patients and clinicians work together to make informed decisions.
"If we're going to make advances in patient care, we have to think about what patients are suffering from, and how we can help them," he noted.