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Thu, Aug 20 6:00am · Could population genetic screening improve public health?

Hereditary BRCA-related breast and ovarian cancer, Lynch syndrome and familial hypercholesterolemia are estimated to be relatively prevalent in the general population but poorly found using traditional risk screening. In a typical medical practice, genetic testing for these conditions is based on personal or family history, ethnic background or other demographic characteristics, that may not always be easily or accurately gathered by a physician.

Data from a population health study published in Nature Medicine show that population genetic screening efficiently identifies carriers of these genetic conditions, without requiring personal or physician knowledge about them.

“Our experience suggests that population genetic screening in patients will identify at-risk carriers who may not know they are at risk if they just followed routine medical care,” says Matthew J. Ferber, Ph.D., a Mayo Clinic contributing author. “Early detection and intervention could significantly reduce their morbidity and mortality.”

The population study, called the Healthy Nevada Project, targeted Nevada’s diverse demographics, with 23.8% of participants recruited from rural zip codes and 19% from minority groups, predominantly Hispanics and Native Americans. In all, a cohort of 26,906 participants was evaluated to determine whether population screening could efficiently identify carriers of these genetic conditions and the impact of genetic risk on health outcomes.

Researchers found:

  • 1.33% combined carrier rate for pathogenic and likely pathogenic genetic variants for BRCA related hereditary breast and ovarian cancer, Lynch syndrome and familial hypercholesterolemia.
  • 21.9% of participants had clinically relevant disease, among which 70% had been diagnosed with relevant disease before age 65.
  • 90% of the risk carriers had not been previously identified and less than 19.8% of these had documentation in their medical records of inherited genetic disease risk, including family history.
  • 25.2% of individuals reported a family history of relevant disease in a direct follow-up survey

Our results suggest that genetic screening for these conditions has the potential to identify the 90% of at-risk carriers who are not detected in current medical practice.

The findings are consistent with previous studies demonstrating that family history is an independent risk factor for breast and ovarian cancer.

However, their analysis of trends in familial hypercholesterolemia did not show that falling within or outside the guidelines changed the diagnostic pattern for hyperlipidemia or the use of antihyperlipidemic agents.

“Our results suggest that genetic screening for these conditions has the potential to identify the 90% of at-risk carriers who are not detected in current medical practice,” says Dr. Ferber. “This estimate comes from an already engaged cohort, typical of voluntary participation in population studies, and thus underestimates the potential impact of preventative screening in larger populations with diverse cohorts.”

The accelerated disease risk of carriers of these genetic conditions suggests average-risk screening protocols—such as mammography for breast cancer starting at age 50 in women, colonoscopy for colon cancer starting at age 50 in both sexes and lipid screening in individuals over 40 years of age who have a 10-year risk of atherosclerotic cardiovascular disease that is greater than 10%—may not adequately detect disease progression early enough for some at-risk individuals.

Studies have found predisposition genetic screening with a limited panel of genetic information to be cost effective in a population under the age of 45 when testing costs are in the low hundreds of dollars. However, a population health screening approach to genetic medicine requires scrutiny, given the potential for added costs, over interpretation of disease risk and ethical and social factors.

Additional implementation studies are essential before these approaches are ready for standard clinical practice. According to Dr. Ferber Mayo Clinic is running its own study to similarly characterize a cohort of 100,000 participants.

Dr. Ferber is the director of the Mayo Clinic GeneGuide laboratory focusing on improving health outcomes and accelerating research through population genomics.

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This article was originally published on the Individualizing Medicine blog.

Watch a related discussion with Sandhya Pruthi, M.D., on diagnosing and managing patients with BRCA mutations.

Tue, Mar 10 6:00am · Patient's premature aging symptoms tied to shorter DNA strands

At only 27-years-old, Morgan Cook recalls the days when she had an abundant amount of energy.

“I would lift weights. I would do cardio. I would – you name it, I would do it. I was a lot more active,” says Cook. “I felt like I was able to do more things with friends. I was able to keep up with anything and everything that was thrown at me, and I didn’t really have an issue with energy.”

Today, Cook is in the midst of accepting her new normal after being diagnosed with short telomeres syndrome.

According to her Mayo Clinic physician, Mrinal Patniak, M.B.B.S., short telomeres are regions present at the end of the DNA that help protect the DNA from premature shortening.

“Every time our cells divide, there is a potential for the DNA to shorten, and premature shortening could lead to cell death or defective repair,” says Dr. Patnaik. “This is most applicable to stem cells in the body. If they don’t have the telomerase apparatus, you’ll find that there is a premature shortening, cell death, and essentially, it leads to a premature aging symptoms.”

In Cook’s case, she had all of the classic symptoms of short telomeres ailments—decreased energy levels,  low blood counts, and hyperextensible joints (capacity to be stretched to a greater than normal degree).

Cook’s health journey started with a visit to her primary physician in Iowa who ran some tests and noticed her white blood cell counts were really low, even though Cook was feeling fine at the time. Her physician referred Cook to Mayo Clinic’s hematology department to uncover the cause of the low blood counts.

Dr. Patnaik, a specialist in blood disorders, invited Cook to participate in a study to examine several potential causes for her condition and to see multiple areas where it could be causing issues with her low blood count. As part of the study Cook underwent genetic testing, which revealed that she had short telomeres syndrome.

Diagnosis provides relief, plan for the future

Mrinal Patnaik, M.B.B.S.

“Once Mayo figured out the diagnosis it was a huge relief. It made me feel like this is real. It’s not just in my head,” says Cook. “It may take a while to explain it because it’s pretty rare, but it’s something tangible.”

Today she takes weekly shots that help build up her white blood cell counts so she doesn’t get as sick as easily. “Every day is kind of different. I don’t have a great predicting tool to see how I’m going to do. Sometimes my energy’s fantastic and other times I hit a low point,” says Cook.

With the diagnosis in hand Cook took a realistic look at her life and what she is able to do. Although physically she doesn’t have the energy to work full time she is able to continue her passion for physical fitness by coaching others with their fitness goals.  

Another area of concern with this diagnosis was family planning. Dr. Patnaik referred Cook to a fertility specialist who discovered that the genetic mutation that causes short telomeres syndrome is dominant, meaning her child would have a 50% chance of having short telomeres syndrome too. According to Cook having this information is critical for her and her husband as they plan for the future and decide whether or not to have children.

Patience, monitoring, and hope

Cook admits it’s still a hard game of patience as Dr. Patnaik continues to monitor her symptoms.

“It’s hard on the psyche. It’s hard to know what may happen in a year or two years or three years, but having the comfort and the knowledge from Mayo Clinic and knowing I’m taken care of at all times is very awesome,” says Cook.

According to Dr. Patnaik the ultimate fix for Cook’s immune system would be a bone marrow transplant. Dr. Patnaik acknowledges that Cook still has a lot to endure as she looks at her future in managing this disease— from the timing of a bone marrow transplant to finding the optimal donor. 

Hope sprung up quickly for Cook when her sister was tested for the same gene mutation. Her sister tested negative for the gene mutation and turned out to be a good match as a bone marrow donor.

“We are extremely blessed in that aspect and it gives us a ton of hope because my sister’s healthy. She’s here. She is willing,” says Cook. “So we kid around that after the transplant, I’m going to owe her because she gave me some pretty good bone marrow, but it’s just an inside joke with the family. She’d do it in a heartbeat because she cares.”

Dr. Patnaik is also optimistic about exciting clinical trials underway and drugs that may come up for short telomeres syndromes. “We hope to provide them to hundreds of people like her who are yearning for this kind of multidisciplinary care,” says Dr. Patnaik.

Dr. Patnaik also connected Cook with a nonprofit support group for others who have short telomeres syndrome.  “It’s amazing now that I can ask questions when I need to through that group as well.  And without that, I think it would be really hard,” says Cook.

Cook looks forward to a day when she will be much stronger, more active and able to get back to her former self. “I feel like I’m on that right path and then as the years go by, we’ll know how to handle each new thing that arises,” says Cook.

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This article was originally published on the Center for Individualized Medicine blog.

Feb 14, 2019 · Using brain organoids to uncover causes of neuropsychiatric disorders

Mayo Clinic and Yale University collaborated in a study published in Science to create a new model for studying neuropsychiatric disorders in early human brain development. This unique collaboration brought together Mayo Clinic’s team-based, patient-centered research with Yale researchers to discover and analyze the genetic mechanisms that may cause these disorders.

The Mayo Clinic team, led by biomedical scientist Alexej Abyzov, Ph.D., used the organoid model to analyze artificially grown cells that resemble the brain (brain organoids) to outline groups of developmental genes and regulatory elements related to the cause of autism.

Researchers know that genes implicated in neuropsychiatric disorders are active in the human fetal brain. However, systematic and comprehensive studies are hampered due to the difficulty in getting fetal brain tissue. According to Dr. Abyzov, the power of organoids is that they can be created from the skin cells of any individual.

“Using brain organoids helps to uncover the genetic underprints of these disorders and helps identify functional elements that may drive disease onset,” says Dr. Abyzov. “Our results suggest that organoids may reveal how noncoding mutations contribute to the cause of autism. By understanding the cause of autism this research may lead to assessing the personal risk for other neuropsychiatric disorders.”

The research team set out to discover gene-regulatory elements and chart their dynamic activity during prenatal human brain development, focusing on enhancers (the short region of DNA), which carry most of the weight upon regulation of gene expression.

“Over a period of time we modeled human brain development using human-derived brain organoids and compared those organoids to fetal brain tissue that had the same genotype,” says Dr. Abyzov. “This study validated that using brain organoids is a suitable model system for studying gene regulation in human embryonic brain development, evolution and disease.”

The research team is planning a larger study using organoids to compare regulation and expression during development for individuals with autism.

“This model has the potential to offer a personalized approach to each patient with autism,” says Dr. Abyzov.

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Dec 10, 2018 · Novel data-driven approach for precision medicine

Thousands of patients’ tumors have been sequenced in the past decade, yielding a rich source of data on the changes associated with the cancer development and treatment response. However, there are no validated methods that are used in the clinic to select the best therapy. Today, Mayo Clinic researchers report an omics-guided (comprehensive) drug prioritization method tailored to an individual cancer patient.

“To date, genomic sequencing data provided to clinicians includes information on a small set of gene alterations. Recommendations for therapy do not account for many other genomic and clinical factors that might dictate tumor response,” says Mayo researcher Krishna Rani Kalari, Ph.D. “Therefore, there is an urgent need for a comprehensive approach to integrate an individual’s clinical, germline and tumor genomic data to identify and select the best treatment for a patient.”

Dr. Rani Kalari, a computational biologist, and lead author of a Mayo Clinic led study, published in JCO Clinical Cancer Informatics showed that combining multiple sources of data to predict the most effective drug choices for patients with cancer is feasible.

“We developed PANOPLY- Precision cancer genomics report: single sample inventory, an open-source computational framework to analyze complex multidimensional data to determine the most appropriate drug to target an individual’s tumor,” says Dr. Kalari. “PANOPLY approach is more comprehensive and efficient than existing single-sample analyses methods,” says Dr. Kalari.

PANOPLY includes existing FDA-approved drugs and prioritizes the drugs for patients with cancer-based on their omics profile and reports the results for oncologists to guide treatment decisions. In this study, PANOPLY was applied to in-house breast cancer datasets, and the findings were confirmed with patient-derived xenograft (PDX) models Tissues or cells from a patient’s tumor are implanted into an immuno-deficient mouse. These mouse models are used to create an environment that resembles the natural growth of cancer, for the study of cancer progression and treatment. In addition, the researchers demonstrated the flexibility of the PANOPLY framework by applying it to colon, breast, ovarian and glioblastoma datasets from The Cancer Genome Atlas.

Dr. Rani Kalari is using high-throughput tumor sequence data and teaming up with basic scientists such as Liewei Wang, Ph.D., M.D. director of the Mayo Clinic Pharmacogenomics Program, to determine whether PANOPLY can identify novel drug targets. After successful testing and benchmarking of the method using PDX repositories, they plan to work towards the ability to merge PANOPLY reports into the electronic medical records so the information is available to oncologists.

“Currently, the vast majority of patients with cancer continue to receive treatments that are minimally informed by omics data. Working with Mayo Clinic surgeon Judy Boughey, M.D. and oncologist Matthew Goetz, M.D., we anticipate that the proposed work will open new research and clinical vistas to allow a more individualized approach for the better treatment of patients,” says Drs. Kalari.

Mayo Clinic authors are:

Krishna R. Kalari, Ph.D.

Jason P. Sinnwell

Kevin J. Thompson, Ph.D.

Xiaojia Tang, Ph.D.

Erin E. Carlson

Jia Yu, Ph.D.

Peter T. Vedell, Ph.D.

James N. Ingle, M.D.

Richard M. Weinshilboum, M.D.

Judy C. Boughey, M.D.

Liewei Wang, Ph.D., M.D.

Matthew P. Goetz, M.D.

Vera Suman, Ph.D.

This study is funded in part by the Mayo Clinic Center for Individualized Medicine; Nadia’s Gift Foundation; John P. Guider; the Eveleigh Family; George M. Eisenberg Foundation for Charities; generous support from Afaf Al-Bahar; and the Pharmacogenomics Research Network (PGRN).  Other contributing groups include the U54 GM114838, Mayo Clinic Cancer Center (P30CA 15083-43) and the Mayo Clinic Breast Specialized Program of Research Excellence (SPORE- P50CA116201).

Oct 18, 2018 · What is the impact on health care of genome editing?

Although Mayo Clinic does not use genome editing as part of any treatment in the medical practice, genome editing has promise for treating and even curing previously intractable disorders, such as Duchenne muscular dystrophy.

Genome editing, via methods like CRISPR-Cas9 (clustered regularly interspaced short palindromic repeats and CRISPR-associated protein) can be used to facilitate the targeted modification of specific genes in living cells from the body and germline (inherited) sources. However, there are uncertain and potentially undesirable side effects to genome editing and regulatory oversight of genome editing is also unclear.

Genomic experts discussed the technological basis for genome editing, its current and potential research and clinical applications, and ethical and regulatory concerns at the Individualizing Medicine Conference: Advancing Care through Genomics. The Mayo Clinic Center for Individualized Medicine (CIM) hosted the conference at the Mayo Civic Center in Rochester, Minnesota.

What is gene editing?

Shondra Pruett-Miller, Ph.D.

Shondra Pruett-Miller, Ph.D., Assistant Member of Cell and Molecular Biology, St. Jude Children’s Research Hospital, spoke about the molecular biology behind gene editing and how it works, in addition to its advantages and limitations. Dr. Pruett-Miller explained gene knockout, which is a genetic technique in which one of a cell’s or organism’s genes is “knocked out” of the respective genome for the purpose of understanding the function of the gene.

“Using this technology in agriculture has huge implications from creating heat-resistant cattle to drought-resistant crops,” says Dr. Pruett-Miller.

However, there are still limitations to genome editing.  According to Dr. Pruett-Miller in order for this technology, and specifically CRISPR-Cas9, to reach its full therapeutic potential, every effort must be made to ensure that the genome edits are made with minimal chance of off-target effects on the structure of the gene.

From gene therapy to genome surgery

Stephen Tsang, M.D., Ph.D.

Stephen Tsang, M.D., Ph.D., Laszlo Z. Bito Associate Professor of Ophthalmology and Associate Professor of Pathology and Cell Biology, Ophthalmology, Columbia University, spoke about the current and potential research and clinical applications of genome editing. Dr. Tsang explored the beginnings of gene therapy and the path that led to genome surgery.

“Gene therapy is not the same as gene surgery, also known as gene-editing,” says Dr. Tsang. “CRISPR-Cas9 opened a new chapter in medicine.”

Gene therapy uses genes as a “drug” to treat or prevent disease by modifying, supplying or blocking gene expression or gene products that cause a condition either by their presence or absence.

CRISPR-Cas9 is a method of genome surgery that enables geneticists and medical researchers to edit parts of the genome by removing, adding or altering sections of the DNA sequence. Dr. Tsang used the example of juvenile macular degeneration as a perfect target for CRISPR-Cas9.

“The eye is the ideal system for genome surgery as well as stem cell transplantation: its relative immune privilege and accessibility, and the effects of treatment can be precisely monitored at the resolution of a single cells with non-invasive imaging allowing physicians to monitor what is happening in real time as they put the cell in and interact with eye,” says Dr. Tsang. “The eye is a self-contained area preventing CRISPR off-targeting from going to other parts of the body. As a pair organ, the eye provides the ideal treatment-control conditions and distinguishes itself as the ideal system for Individualized Medicine due to the low risk of off-targeting of genome surgery and stem cell therapies.”

The science has to advance first

Megan Allyse, Ph.D.

Megan Allyse, Ph.D., Assistant Professor of Biomedical ethics at Mayo Clinic closed the session discussing ethical and regulatory concerns related to genome editing and how they may impact clinical decision-making.

According to Dr. Allyse with the advent of gene therapy and gene surgery the National Academy of Sciences laid out clear guidelines relating to responsible science.  The National Academy of Sciences covers all facets of responsible science from transparency, respect of the person, fairness, to due care (proceeding carefully and deliberately and only when supported by sufficient and robust evidence).

“Although we have a lot of structures in place to monitor gene editing there are many unresolved dilemmas,” says Dr. Allyse.

Dr. Allyse posed several thought provoking questions to the audience concerning the ethical and regulatory issues such as:

  • “Who defines what a serious condition or disease is?”
  • “How do you handle illegitimate stem cell therapies and the exploitation of people who are desperate to solve a health issue?”
  • “Is the human genome sacred?”

The questions set up a hard conversation with those in attendance and the answers were as varied and individual as each person.

“As much as we want to get into humans, the science has to come first,” says Dr. Allyse. “Our goal is to bring people up to health as opposed to pushing them to enhancement.”

Keep the conversations going

For more information on the Mayo Clinic Center for Individualized Medicine, visit our blogFacebookLinkedIn or Twitter at @MayoClinicCIM.

Apr 19, 2018 · Direct-to-consumer genetic testing-a rapidly shifting landscape

Direct-to-consumer genetic or over the counter testing emerged in the early 2000s as a means of allowing consumers to access information about their genetics without the involvement of a physician. While early models were popular with consumers, they were controversial in medical and regulatory circles.

In the January 2018 issue of Mayo Clinic Proceedings authors Megan Allyse Ph.D., David Robinson, Matthew Ferber Ph.D. and Richard Sharp Ph.D. trace the history of direct-to-consumer genetic testing, discuss its regulatory implications, and describe the emergence of a new hybrid model.

Direct-to-consumer testing — the early days

Megan Allyse, Ph.D.

In 2007 the journal Science named human genetic variation the “breakthrough of the year” and direct-to-consumer companies were offering microarray panels for $1,000. Fast forward five years and the curious consumer could get a microarray panel for $99. Microarray refers to a microchip-based testing platform that allows high-volume, automated analysis of many pieces of DNA at once.

“Consumers liked the convenience of direct-to-consumer testing, the appeal of gaining access to their personal genetic information, and its promotion of preventive and individualized medicine,” says Dr. Allyse, a Mayo Clinic bioethicist, and lead-author of the paper.

However, critics quickly raised concerns about direct-to-consumer testing.

  • Risk of misinterpreting genetic test results
  • Making health decisions on inaccurate or incomplete information
  • Lack of consideration for ethnic and racial differences across human populations
  • Potential for unnecessary, expensive, or time-consuming downstream medical testing
  • No clear regulatory mechanisms in place to assess the analytical and clinical validity, and clinical utility
  • Poor procedures in place to ensure informed consent for the testing process
  • Consumers may not understand the health implications of the information they received
  • Companies could sell aggregate data to third parties or use consumer’s data for research without their awareness

By 2011 the government began cracking down on the practices of direct-to-consumer testing companies. In 2013, the U.S. Food and Drug Administration (FDA) ordered 23andMe to immediately discontinue marketing and sales of its health-related testing services until they received FDA authorization for these devices.

A new model emerges — direct-to-consumer 2.0

In 2015, 23andMe received FDA device approval for its carrier screen for hereditary Bloom syndrome. The FDA confirmed that 23andMe had submitted evidence demonstrating that members of the public were capable of correctly interpreting the test report at a 90 percent comprehension level.

“At the same time the FDA announced that it would classify direct-to-consumer genetic carrier screens as lower risk devices. This opened the way to testing for additional autosomal recessive conditions and signaled the FDA’s willingness to consider at least some forms of direct-to-consumer medical testing under the regulations,” says Dr. Allyse.

That same year Illumina one of the largest providers of genomic sequencing in the U.S. launched Helix, a personal genomics platform that utilizes a “sequence-once-query-often” model. Helix stores genomic information in a central database and allows its partners to develop various testing strategies that interrogate portions of genomic datasets for its customers. In 2017, the FDA approved the marketing of the first direct-to-consumer test for genetic health risk, 23andMe’s Personal Genome Service, which tests for 10 diseases or conditions, including Alzheimer’s risk, Parkinson’s disease, and hereditary thrombophilia.

“These emerging models of direct-to-consumer genetic testing attempt to strike a balance between the need to ensure consumer safety and the knowledge that personal genomic information is both highly desirable and potentially beneficial to some consumers,” says Dr. Allyse.

The future of direct-to-consumer testing 

Dr. Allyse and colleagues speculate on several promising strategies to align the interests of the direct-to-consumer market and the practice of medicine:

  • Improve pre-test education to facilitate the kind of informed consent expected in a medical setting
  • Separate consent to receive testing by purchasing a product from agreeing to the storage, use or sale of samples for research
  • Create clearer pathways into the medical system in the event of high-risk results by partnering with licensed medical providers to ensure information integrity
  • Provide a supportive environment for consumers acknowledging the entertaining nature of genetic information and provide for counseling and follow-up

The Mayo Clinic Center for Individualized Medicine continues to seek ways to apply the latest genomic, molecular and clinical science to personalized care for every individual, so patients receive the exact care they need — when they need it — and to address unmet needs of the patient.

Disclosure: The authors have no personal financial relationships to disclose. Mayo Clinic holds a commercial interest in Helix. There was no relationship between Helix and the contents of this paper.

Mayo Clinic Proceedings Symposium on Precision Medicine 

This paper is part of the Mayo Clinic Proceedings Symposium on Precision Medicine, a series of articles that cover a wide range of topics in personalized medicine. Watch for an upcoming article in the symposium focusing on how personalized medicine and genomics are impacting patient care in the area of heritable cancers.

Read more about the ethical issues of home DNA kits

Learn more about biomedical ethics

Apr 10, 2018 · New international practice guidelines for using tamoxifen to treat breast cancer

An international group of clinicians and scientists representing the Clinical Pharmacogenetics Implementation Consortium (CPIC) published the first-ever clinical practice guideline for using CYP2D6 genotype to guide tamoxifen therapy in Clinical Pharmacology and Therapeutics.

Tamoxifen is a hormonal agent used for the prevention and treatment of premenopausal and postmenopausal breast cancer that is estrogen receptor positive. CYP2D6 genotype is an inherited factor that alters the metabolism of tamoxifen.

“The goal of the CPIC Guideline for CYP2D6 and tamoxifen therapy is to provide clinicians information that will allow the interpretation of clinical CYP2D6 genotype tests so that the results can be used to guide prescribing of tamoxifen when genotype information is available,” says Matthew Goetz, M.D., a Mayo Clinic medical oncologist, who is the lead author. “The consensus of the consortium tamoxifen group was that there was sufficient evidence to use CYP2D6 genotype to assist with clinical recommendations for women who are being considered for tamoxifen for early stage estrogen receptor positive breast cancer.”

Matthew Goetz, M.D.

Tamoxifen is converted through the process of liver metabolism into forms that result in greater anti-estrogenic potency and anti-tumor activity than the parent drug. Antiestrogens are a class of drugs which prevent estrogens from mediating their biological effects in the body.

“The work of the consortium is an example of Mayo’s commitment to taking a comprehensive, collaborative team science approach to deliver advanced genomic medicine to our patients. We work with other academic medical centers, hospitals, and clinics to bring the latest discoveries to improve the practice of medicine.” – Matthew Goetz, M.D.

“The work of the consortium is an example of Mayo’s commitment to taking a comprehensive, collaborative team science approach to deliver advanced genomic medicine to our patients. We work with other academic medical centers, hospitals, and clinics to bring the latest discoveries to improve the practice of medicine,” says Dr. Goetz.

Jan 30, 2018 · How does a genomic tumor board impact patient care?

The outcomes from a Mayo Clinic study published in Oncotarget found value in having an established genomic tumor board, and using genomics for certain patients.

The experience of the Genomic Tumor Board has promoted an evolution in the practice according to Alan Bryce, M.D., a Mayo Clinic oncologist, and co-first author on the study.

“There is an emerging consensus to begin genomic analysis early in the treatment course due to many driver mutations presenting early in the disease course. This allows time for potential therapies in a clinically useful timeframe,” says Dr. Bryce.

Alan Bryce, M.D.

Mayo researchers looked at initial results from their efforts in establishing the Mayo Clinic Genomic Tumor Board. The board brings together physicians, research scientists, cancer biologists, ethicists, pathologists, bioinformaticians and genetic counselors from Mayo Clinic campuses in Arizona, Florida, and Minnesota. This “A” team reviews and discusses each case, bringing their unique expertise to the table. Through consensus they conclude if findings are deemed actionable, lead to treatment recommendations, and are deemed informative.

According to Jan Egan, Ph.D., a Mayo Clinic research scientist and co-first author, the Genomic Tumor Board provided a translational platform to transform the practice.

“We brought together the unique perspectives of clinicians and laboratory scientists to drive treatment decisions and create patient focused research questions,” says Dr. Egan.

Jan Egan, Ph.D.

The Mayo Clinic Genomic Tumor Board engaged in patient case review to address limitations by considering genomic testing results, in addition to treatment options such as: surgery, ablation, radiation, new chemotherapy, or observation. Other benefits included facilitating collaboration between physicians and scientists to assist with target prioritization or consideration of alternate targets. It also provided a forum for teaching and consideration of alternative treatment options in complex cases. The Genomic Tumor Board contributed to the ongoing revolution of tumor genomic-based treatment in cancer, along with innovations in clinical trial design, technological innovations in big data management, and regulatory changes promoting data.

What are the barriers to delivery?

The study revealed these barriers to implementing genomics into cancer care:

  • Knowledge. Fewer than half of Mayo oncology faculty, fellows and advanced practitioners surveyed felt confident enough in their understanding of genomics to make treatment recommendations and explain it to patients. The majority sought input from colleagues or conducted a literature search when uncertain.
  • Access. Patients struggle with gaining access to the recommended therapy, pointing to drug access barriers that prevent optimal use of tumor genomic testing.
  • Cost. Out of pocket expenses and reimbursement varies by insurance company.

Looking ahead, researchers identified the importance of rapidly sharing insights gained from successful treatment to other clinicians and investigators. In addition, cross-institutional databases linking genomic profiles and treatment outcomes are needed given the rarity of specific abnormality/tumor combinations. Lastly, cost of tumor sequencing should be compared to the cost of treating with unselected therapies or enrolling in non-biomarker based clinical trials.

“We demonstrated treatment decisions driven by tumor genomic analysis can lead to significant clinical benefit in a minority of patients,” says Dr. Bryce.

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