Clinical OMICS

MAR-APR 2017

Healthcare magazine for research scientists, labs, pathologists, hospitals, cancer centers, physicians and biopharma companies providing news articles, expert interviews and videos about molecular diagnostics in precision medicine

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28 Clinical OMICs March/April 2017 become increasingly interested in the application of liquid biopsy in his practice and noted that presentation of the evidence for its use in NSCLC at last year 's ASCO Conference in June pushed him and his colleague, pulmonologist Mark Bowling, M . D . , to adopt a process similar to Dana Farber 's for their patients . (see sidebar) "We started the program in March [2016]," Dr. Walker noted, "But with ASCO, the validation of liquid biopsy really crystallized my thinking that we were going to use it on everybody at the same time as the bronchoscopy . We often get the liquid biopsy back quicker than we do the tissue qualita- tive analysis." To date, Dr . Bowling said the care team has employed liquid biopsy on 194 patients with NSCLC, and in 37% of those cases, liquid biopsy has sug- gested ways in which to change the treatment regimen to more precisely address those patients' disease . While application of liquid biopsy to inform patient care is leading the way, work to validate and prove its clinical utility as a diagnostic, and monitoring tool is still emerging . "There is the growing sense that in the years to come we will be doing more cancer types, looking for these mutations to see if this will predict not just molecular changes, but also cancer burden, which might mean you would be less reliant on things like CT scans or other ways of look- ing at cancer burden," noted Harold Burstein, M . D . , Ph . D . , associate pro- fessor of medicine at Harvard Med- ical School and chair of the ASCO communications committee . "Another story that is emerging— not routinely used in clinical practice, but is around the corner—is estrogen receptor mutations in ER-positive breast cancer," said Dr. Burstein, who (continued from previous page) Like many hospitals affiliated with med- ical schools and medical research, doc- tors at Vidant Health in Eastern North Carolina had been dabbling in the use of liquid biopsies, to both ease the burden of invasive tissue biopsy procedures, and to learn about how well it could provide relevant information to guide cancer treatment. Last March, Paul Walker, chief of hema- tology/oncology with the affiliated Brody School of Medicine at East Car- olina University, took the leap to have every patient that presented with non- small cell lung cancer (NSCLC) undergo a liquid biopsy as part of their treatment and diagnostic regimen. "Once we ended up getting it on everybody, it was one of those "wow" things," Dr. Walker said. "We were seeing things that we had never seen before, and once you see those things, you start thinking in a radically different way." For Dr. Walker, the benefits of turning to liquid biopsy for NSCLC were twofold: significantly shorter time to answer via liquid biopsy; and the ability to more narrowly define the appropriate treat- ment regimen for a significant subset of patients whose liquid biopsy results returned the presence of specific muta- tions in their cancer. "If you have an actionable mutation, a targeted therapy, by and large, is going to be better than slug-it-out, industri- al-strength, nontargeted chemotherapy," he said. But aside from the EGFR and KRAS mutational markers that have received significant attention since a publication by Dana Farber researchers last April con- firmed liquid biopsy's effectiveness at identifying these markers to inform can- cer care, Dr. Walker has found additional insight via his use of the technology. "For example, younger than the age of 40, the number one mutation in peo- ple with lung cancer is not EGFR, which everybody thought, but it is actually an ALK gene rearrangement and fusion, and ALK will tend to be platinum resistant," Dr. Walker pointed out. "So if I was going to give a young per- son an aggressive cisplatin-based che- motherapy—almost half of the patients end up having an ALK mutation—you are giving them the wrong treatment and you go down the wrong path and things can go bad very quickly," he said. In addition, he noted, more than 60% of patients with ALK-mutated lung cancer will eventually develop a brain metastases. Knowing this allows for the application of a targeted tyrosine kinase inhibitor, proven as effective central nervous system penetrants, which may obviate the need for a more aggressive treatment approach such as whole brain radiation treatment. n Vidant Health "All In" for NSCLC Liquid Biopsy KatarzynaBialasiewicz / Getty Images

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