Cancer care is changing rapidly, and the pace of change is accelerating. In 2019, major advances in precision medicine, gene-based therapy, immunotherapy and many other areas brought new hope to countless patients. City of Hope clinicians and researchers are brimming with optimism as 2020 begins. Here are some of their predictions:
So-called “liquid” biopsies can detect tumor DNA in the blood, making for a much less invasive method for detecting cancer. As our DNA knowledge base and knowhow continue to grow, liquid biopsies are becoming ever more accurate, at ever earlier stages. While it’s unlikely they’ll replace conventional biopsy — where physical tumor tissue is extracted — anytime soon, the prospects are exciting.
“Our crystal ball is very clearly showing an increased trend for patients to be monitored with liquid biopsies,” said Stephen Gruber, M.D., M.P.H., Ph.D., director of the Center for Precision Medicine. “Liquid biopsies detect early progression or resistant disease faster than other methods. And this is likely to be increasingly used in the U.S. for measuring residual disease and recurrence.”
“A simple blood test can now detect disease recurrence up to one year before it can be detected by imaging or other routine tumor markers,” said colorectal cancer specialist Marwan G. Fakih, M.D., “allowing not only tumor detection at an early stage but also helping track tumor evolution and allowing physicians to adapt and modify their treatments based on tumor molecular changes.”
“These methods,” added stomach cancer surgeon Yanghee Woo, M.D., “will identify patients who have stomach cancer through super-sensitive and accurate blood-testing methods. These will be especially important in early detection of stomach cancer in high-risk patients.”
Theranostics: The All-in-One Solution
The relatively new field of theranostics — a combination of “therapeutics” and “diagnostics” — makes it possible to diagnose and treat cancer at the same time. One example is to use a radioactive agent in the imaging process to “light up” cancer cells, then immediately deploy a second agent to attack those cells.
“We will see a further role of image-guided management in diseases including prostate cancer,” predicted radiation oncologist Arya Amini, M.D., “where we can utilize imaging to detect microscopic disease that routine scans would not be able to identify. This work will likely grow from prostate cancer into other areas including colorectal cancer.”
“I believe the theranostics approach, and more broadly the use of radioactive-targeted compounds, will make a big impact in prostate cancer beginning soon,” agreed prostate cancer specialist Tanya Dorff, M.D. She calls theranostics a “big breakthrough” and predicts “the use of imaging to show a phenotype of a cancer that could be targeted with a radioactive compound, i.e. Lu177-PSMA (lutetium-based prostate-specific membrane antigen therapy, often used in advanced cases). Further radioisotopes and targeting antibodies are being explored.”
There’s also great interest in “radioimmunotherapy,” said diagnostic radiologist Ammar Ahmed Chaudry, M.D., explaining that clinicians “will combine theranostics agents with immunotherapy to deliver optimal high-powered treatment to aggressive forms of cancer that are generally resistant to conventional therapies.”
GENE THERAPY: “Off the Shelf” and Into the Future
Perhaps no recent advance has created more excitement than CAR T cell therapy — when a patient’s own immune cells are reengineered to seek out and attack cancer. The Food and Drug Administration has approved two CAR T cell products for treating blood cancers, and clinical trials continue for a broad array of solid tumors. More will follow, along with new ideas; Woo predicts we’ll see “CAR T therapy in combination with other immune therapies targeting specific stomach cancer biomarkers.”
Because each CAR T cell treatment originates from a patient’s own cells, the process is slow and very expensive. But efforts are underway to develop “off-the-shelf” CAR T treatments created with donor cells that are specially treated to eliminate the possibility of rejection. Gene therapy pioneer John A. Zaia, M.D., the Aaron D. Miller and Edith Miller Chair in Gene Therapy, predicts “an off-the-shelf CAR T cell will show promise in early studies” in 2020. Zaia also predicts at least three more gene therapy products will receive FDA approval in 2020, and he expects to see the first human clinical trials for gene therapy to combat sickle cell disease.
Clinical geneticist Thomas P. Slavin, M.D., believes we’ve barely scratched the surface in genetic research and treatment, and yet a major shift is already taking place. Together with City of Hope affiliate TGen, researchers are taking a critical step beyond analyzing a tumor’s genetic makeup. They are pairing that information with each patient’s “germline” — the inherited genetic characteristics that make each individual unique. “This will be a very important step toward driving the use of genomics in oncology to help patients and their families,” predicted Slavin, because of all the added data it will provide, especially regarding a person’s risk of developing future tumors.
"We are right on the cusp of this being very obvious,” he added. “City of Hope will be among the first to roll out ‘paired tumor germline sequencing,’ and it will quickly become the standard of care."
Artificial Intelligence. Real Cures.
More and more elements of the patient experience are now being converted into digital information. This opens the door to using big data and artificial intelligence to mine that treasure trove of material for insights few could have imagined only a few years ago.
“The digitization of electronic medical records, radiology and pathology will allow application of artificial intelligence in precision medicine,” said diagnostic radiologist Chaudry. “AI can help find a needle in a haystack. Synthesis of this information will allow for early detection and patient-specific treatment optimization.”
“Mathematics and computational biology will continue to increase its influence and role in basic and translational research in cancer,” said mathematical oncologist Russell Rockne, Ph.D., who recently authored a paper about cancer and Einstein’s theory of relativity. “I also predict that mathematical modeling and machine learning will continue to merge together.”
Bottom line, it’s an exciting time for all, and City of Hope scientists and clinicians are on the front lines.
“Technology is advancing at such a rapid pace,” said Woo. “We pioneer the translating of these tools to ensure the safety, efficacy and oncologic benefit to our patients.”