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Cambrosio A, Campbell J, Drilon AE, Keating P, Polk JB. Decision-making as discovery: Vetting clinical research in a leading precision oncology service. SOCIOLOGY OF HEALTH & ILLNESS 2024; 46:495-513. [PMID: 37796533 DOI: 10.1111/1467-9566.13719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023]
Abstract
Based on fieldwork carried out at the Early Drug Development Service of a world-leading cancer institution, our study sheds lights on decision-making processes at the stage where decisions are made about which clinical trial to pursue and thus which experimental drugs will feed the growing pipeline of molecularly guided therapies and therapeutic strategies available to treating physicians. The paper shows how such collective decision-making practices by a translational research unit employ formal tools and ad hoc valuation strategies that interweave technical-scientific matters of concern with patient-oriented clinical ones, as part of the institutional assetization of biomedical knowledge production. In the process, decision-making practices in part define the conditions of possibility for the provision of care in what is increasingly becoming a 'clinic of variants.' They do so by reconfiguring on an evolving basis the socio-material ecosystem through which precision oncology is enacted as a rapidly evolving assemblage of patients, physicians, research and support staff, protocols, molecular markers, drugs and administrative components.
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Affiliation(s)
- Alberto Cambrosio
- Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada
| | - Jonah Campbell
- Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada
| | - Alexander E Drilon
- Early Drug Development Service and Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Peter Keating
- Department of History, Université du Québec à Montréal, Montreal, Quebec, Canada
| | - Jess B Polk
- Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada
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2
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Hauge AM. Regulating diagnosis-Molecular and regulatory sub-stratifications of lung cancer treatment. SOCIOLOGY OF HEALTH & ILLNESS 2024; 46:56-75. [PMID: 37553761 DOI: 10.1111/1467-9566.13693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 06/06/2023] [Indexed: 08/10/2023]
Abstract
The sociology of diagnosis has shown that diagnosis not only serves to label the underlying cause of disease but also to provide access to services and resources. Elaborating on this double-affordance of diagnosis, this article examines how precision medicine reconfigures diagnosis as a label and as a process in regulatory and clinical settings. Reporting from an ethnographic case study of the introduction of immunotherapy for lung cancer, the paper unfolds the uncertainties involved in dissecting diagnosis into layers and examines the efforts and negotiations it takes to enable these layers to work both as clinical entities and regulative entities with the purpose of delineating access to treatment. I suggest that the work of subdividing diseases into molecularly defined categories for the purpose of delineating treatment-eligible populations can be labelled 'diagnostic sub-stratification' and argue that it is pertinent to understand the political capacity of this strategy. Diagnostic sub-stratification involves a push of diagnosis from the clinic 'up' into the regulatory system and 'out' into the laboratories, obscuring who is accountable for the diagnostic categories employed to define patients' treatment access.
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Pillayre H, Besle S. What rare cancers have in common. The making of lists of (very) rare cancers and the coordination of medical work. FRONTIERS IN SOCIOLOGY 2023; 8:1148639. [PMID: 37727367 PMCID: PMC10505805 DOI: 10.3389/fsoc.2023.1148639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/12/2023] [Indexed: 09/21/2023]
Abstract
This article aims to understand why medical actors recently published lists of rare and very rare cancers. It studies four lists of rare and very rare cancers based on interviews with the main actors on these lists and an analysis of medical articles in which these lists were published. It argues that these lists constitute boundary objects whose aim is to deal with the organizational challenges raised by precision medicine, which imply increasing the coordination work between various types of actors. Our work therefore allows a better understanding of the functioning of the recursive standardization process of a boundary object and, by analyzing how the category of rarity is built at the intersection of both professional and nosographic principles, shows the intertwining of the biomedical, organizational, and political aspects on which rests the practice of contemporary precision medicine.
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Affiliation(s)
- Héloïse Pillayre
- Centre Léon Bérard, Département SHS, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Sylvain Besle
- Centre Léon Bérard, Département SHS, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
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Froger-Lefebvre J, Lade Q, Vallier E, Bourgain C. E-prescription and invisible work in genomics in France. FRONTIERS IN SOCIOLOGY 2023; 8:1152364. [PMID: 37456272 PMCID: PMC10349168 DOI: 10.3389/fsoc.2023.1152364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
This article aims to analyze the transformations in medical prescription work and infrastructures brought by digitalization. Our fieldwork takes place in the context of precision medicine development based on genomics High Throughput Sequencing (HTS) in France, through the Plan France Médecine Génomique (PFMG 2025). The Plan aims at industrializing the production of genomic testing in clinical context at a national scale, particularly in oncology. To ensure the intensified flow of information between hospitals and HTS platforms required, a centralized process has been organized around two sequencing platforms and the introduction of a new e-prescription software (E-PRES). We start by analyzing how the e-prescription software changes the practices of health professionals by imposing new technological and professional standards. We show that, more than a mere prescription tool, this software is also a monitoring tool for the platforms and prescribers' work, and a support tool for the logistical and work organization. Secondly, we question the division of labor among the different professionals involved in the organizational or technical tasks required. We show that the feasibility of this new form of digitalized prescription relies on an important datawork performed by "small hands" to select, translate and process a vast amount of heterogeneous data.
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Affiliation(s)
- Juliette Froger-Lefebvre
- Groupe d'Etude des Méthodes de l'Analyse Sociologique de la Sorbonne, Centre National de la Recherche Scientifique, Paris, France
- Département SHS du Centre Léon Bérard, Lyon, France
| | - Quentin Lade
- Département SHS du Centre Léon Bérard, Lyon, France
- Centre de Recherche en Cancérologie de Lyon, Université Lyon 1, Lyon, France
| | - Estelle Vallier
- Département SHS du Centre Léon Bérard, Lyon, France
- Institut Gustave Roussy, Villejuif, France
| | - Catherine Bourgain
- Université Paris Cité, Centre National de la Recherche Scientifique, INSERM, Ecole des Hautes Etudes en Sciences Sociale, Centre de recherche médecine, sciences, santé, santé mentale, société, Villejuif, France
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5
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Ross E, Kerr A, Swallow J, Chekar CK, Cunningham‐Burley S. Unsettling the treatment imperative? Chemotherapy decision-making in the wake of genomic techniques. SOCIOLOGY OF HEALTH & ILLNESS 2023; 45:1063-1081. [PMID: 36965058 PMCID: PMC10946787 DOI: 10.1111/1467-9566.13637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Abstract
Social scientists have argued that a treatment imperative shapes experiences of biomedicine. This is evident within oncology, where discourses of hope are tempered by persistent fears surrounding cancer. It is within this context that genomic decision-making tools are entering routine care. These may indicate that a treatment is not appropriate for a particular disease profile. We draw on qualitative interviews and observations centred on gene expression profiling to consider the implications of this technique for the treatment imperative in early breast cancer. Influenced by sociological perspectives on medical technologies, we discuss how fallibilities of established tools have forged a space for the introduction of genomic testing into chemotherapy decision-making. We demonstrate how high expectations shaped patients' interpretations of this tool as facilitating the 'right' treatment choice. We then unpick these accounts, highlighting the complex relationship between gene expression profiling and treatment decision-making. We argue that anticipations for genomic testing to provide certainty in treatment choice must account for the sociocultural and organisational contexts in which it is used, including the powerful entwinement of chemotherapy and cancer. Our research has implications for sociological perspectives on treatment decision-making and clinical expectations for genomic medicine to resolve the 'problem' of overtreatment.
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Affiliation(s)
- Emily Ross
- Department of Sociological StudiesUniversity of SheffieldSheffieldUK
| | - Anne Kerr
- School of Social and Political SciencesUniversity of GlasgowGlasgowUK
| | - Julia Swallow
- Centre for Biomedicine, Self, and SocietyUsher InstituteUniversity of EdinburghEdinburghUK
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Abstract
Drawing from interviews with women with metastatic breast cancer in the UK and France, in this article I analyze uncertainties linked to this condition. In particular, I show how the impossibility of foreseeing the evolution of the condition, also as an indirect consequence of medical innovation, initiates an irreparable disruption of life after diagnosis. I further show how the lives of the patients are not only limited by the illness, but also by the difficulty of finding a place in society. I argue that such experiences are best understood through the concept of the crisis of the presence.
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Affiliation(s)
- Cinzia Greco
- Wellcome Trust Research Fellow, Centre for the History of Science, Technology and Medicine, University of Manchester, Manchester, UK
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Ross E, Swallow J, Kerr A, Chekar CK, Cunningham-Burley S. Diagnostic layering: Patient accounts of breast cancer classification in the molecular era. Soc Sci Med 2021; 278:113965. [PMID: 33940433 PMCID: PMC8146724 DOI: 10.1016/j.socscimed.2021.113965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/06/2021] [Accepted: 04/22/2021] [Indexed: 12/22/2022]
Abstract
Social scientific work has considered the promise of genomic medicine to transform healthcare by personalising treatment. However, little qualitative research attends to already well-established molecular techniques in routine care. In this article we consider women's experiences of routine breast cancer diagnosis in the UK NHS. We attend to patient accounts of the techniques used to subtype breast cancer and guide individual treatment. We introduce the concept of 'diagnostic layering' to make sense of how the range of clinical techniques used to classify breast cancer shape patient experiences of diagnosis. The process of diagnostic layering, whereby various levels of diagnostic information are received by patients over time, can render diagnosis as incomplete and subject to change. In the example of early breast cancer, progressive layers of diagnostic information are closely tied to chemotherapy recommendations. In recent years a genomic test, gene expression profiling, has become introduced into routine care. Because gene expression profiling could indicate a treatment recommendation where standard tools had failed, the technique could represent a 'final layer' of diagnosis for some patients. However, the test could also invalidate previous understandings of the cancer, require additional interpretation and further prolong the diagnostic process. This research contributes to the sociology of diagnosis by outlining how practices of cancer subtyping shape patient experiences of breast cancer. We add to social scientific work attending to the complexities of molecular and genomic techniques by considering the blurring of diagnostic and therapeutic activities from a patient perspective.
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Affiliation(s)
- Emily Ross
- Usher Institute, Old Medical School, University of Edinburgh, Edinburgh, Scotland, EH8 9AG, UK; Department of Sociological Studies, University of Sheffield, Elmfield Building, Northumberland Road, Sheffield, S10 2TU, UK.
| | - Julia Swallow
- Centre for Biomedicine, Self and Society, Usher Institute, Old Medical School, University of Edinburgh, Edinburgh, Scotland, EH8 9AG, UK
| | - Anne Kerr
- School of Social and Political Sciences, University of Glasgow, Glasgow, Scotland, G12 8QQ, UK
| | - Choon Key Chekar
- Division of Health Research, Faculty of Health & Medicine, Lancaster University, Lancaster, LA1 4YG, UK
| | - Sarah Cunningham-Burley
- Centre for Biomedicine, Self and Society, Usher Institute, Old Medical School, University of Edinburgh, Edinburgh, Scotland, EH8 9AG, UK
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Imperfect biomarkers for adjuvant chemotherapy in early stage breast cancer with good prognosis. Soc Sci Med 2019; 246:112735. [PMID: 31869667 DOI: 10.1016/j.socscimed.2019.112735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 12/09/2019] [Accepted: 12/12/2019] [Indexed: 12/19/2022]
Abstract
The proliferation of biomarkers has raised concerns regarding the possibility for clinical judgment to be improperly removed from clinician's jurisdiction and included in laboratory tests. To evaluate the ways in which the diffusion of biomarkers questions the autonomy of clinicians, we consider the case of chemotherapy prescription to women with early stage breast cancer and a good prognosis. Drawing on a qualitative study of clinicians working in a diversity of institutional contexts, we follow three biomarkers available to guide this routinely made decision. We show that, biomarkers able to reduce all the uncertainties associated with, what we analyse as an uncomfortable decision, are sought more than dreaded by clinicians. If such ideal tools are unavailable, the fact is well acknowledged by the profession. Rather than precluding their usage, the imperfection of existing biomarkers is controlled by the profession, through their integration as additional tools in the decision process. The fact that the biomarkers are recognized as imperfect biomedical entities reinforces the importance of local material, organizational and financial constraints over that of international science, technology and clinical data, in their diffusion. The regulation of the uncertainties associated with these imperfections is organized at the professional level. Through an important work, relying on guidelines and enforced in collective bodies, the series of heterogeneous bioclinical evidences available are articulated. Biomarkers tend to be subordinated to the clinic. While maintaining the professional autonomy, the process also strengthens the internal professional hierarchy. When the most expert clinicians manage to inhabit a space for clinical autonomy, the nonexpert are torn between stronger professional rules and patient preferences. In this alliance between biomarkers and experts, their clinical autonomy tends to be the price for the professional autonomy.
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Cambrosio A, Campbell J, Keating P, Bourret P. Multi-polar scripts: Techno-regulatory environments and the rise of precision oncology diagnostic tests. Soc Sci Med 2019; 304:112317. [PMID: 31133442 DOI: 10.1016/j.socscimed.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 01/08/2023]
Abstract
The paper examines the development and marketing of five multi-gene tests, a.k.a. as tumor signatures, designed to aid clinicians and cancer patients in therapeutic decision-making, and, in particular, to avoid overtreatment. We build on a 2011 paper that investigated the emergence of this new domain by opening the 'black box' of two pioneering tests and analyzing the hybrid, scientific-regulatory 'scripts' that were built into them. In subsequent years, second-generation tests, produced by a diverse blend of academic and commercial initiatives, have become available, and they all built into their scripts the lessons learned from their predecessors. The present paper confirms the heuristic value of the initial script-analysis but expands it to consider the multi-polar nature of the space within which multigene tests mutually position themselves. We examine how the tests were first problematized - i.e. how they described and prescribed the kind of world in which they would operate - and how their initial problematization was re-specified following the emergence of a comparative arena and their resulting informational enrichment. In parallel, we explore valuation processes, i.e. the evolving definition of the set of referents against which the assays are mutually compared, and the debates about the appropriate criteria for doing so. We note that the cancer diagnostic industry is involved in the reconfiguration of the multi-polar environment defined by socio-technical, techno-scientific, and regulatory matters of concern that seamlessly blend commercial and scientific considerations.
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Affiliation(s)
- Alberto Cambrosio
- Social Studies of Medicine, McGill University, 3647 Peel St., Montreal, QC, H3A 1X1, Canada.
| | - Jonah Campbell
- Social Studies of Medicine, McGill University, 3647 Peel St., Montreal, QC, H3A 1X1, Canada.
| | - Peter Keating
- Département d'histoire, Université du Québec à Montréal, Case Postale 8888, succursale centre-ville, Montreal, QC, H3C 3P8, Canada.
| | - Pascale Bourret
- Aix-Marseille Univ, INSERM, IRD, SESSTIM, Institut Paoli-Calmettes, 232 Bd Sainte-Marguerite, 13273, Marseille CEDEX 9, France.
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Plastic diagnostics: The remaking of disease and evidence in personalized medicine. Soc Sci Med 2019; 304:112318. [PMID: 31130237 PMCID: PMC9218799 DOI: 10.1016/j.socscimed.2019.05.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022]
Abstract
Politically authorized reports on personalized and precision medicine stress an urgent need for finer-grained disease categories and faster taxonomic revision, through integration of genomic and phenotypic data. Developing a data-driven taxonomy is, however, not as simple as it sounds. It is often assumed that an integrated data infrastructure is relatively easy to implement in countries that already have highly centralized and digitalized health care systems. Our analysis of initiatives associated with the Danish National Genome Center, recently launched to bring Denmark to the forefront of personalized medicine, tells a different story. Through a “meta-taxonomy” of taxonomic revisions, we discuss what a genomics-based disease taxonomy entails, epistemically as well as organizationally. Whereas policy reports promote a vision of seamless data integration and standardization, we highlight how the envisioned strategy imposes significant changes on the organization of health care systems. Our analysis shows how persistent tensions in medicine between variation and standardization, and between change and continuity, remain obstacles for the production as well as the evaluation of genomics-based taxonomies of difference. We identify inherent conflicts between the ideal of dynamic revision and existing regulatory functions of disease categories in, for example, the organization and management of health care systems. Moreover, we raise concerns about shifts in the regulatory regime of evidence standards, where clinical care increasingly becomes a vehicle for biomedical research. Personalized medicine has led to calls for speedy revisions of disease taxonomies. A “meta-taxonomy” of disease taxonomic revisions is presented and discussed. Fine-graining disease categories has regulatory implications for healthcare systems. A Danish case illustrates difficulties in aligning multiple functions of disease codes. We argue that the political call for speed should be treated with caution.
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Vignola-Gagné E, Keating P, Cambrosio A. Informing materials: drugs as tools for exploring cancer mechanisms and pathways. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2017; 39:10. [PMID: 28523636 DOI: 10.1007/s40656-017-0135-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/07/2017] [Indexed: 06/07/2023]
Abstract
This paper builds on previous work that investigated anticancer drugs as 'informed materials', i.e., substances that undergo an informational enrichment that situates them in a dense relational web of qualifications and measurements generated by clinical experiments and clinical trials. The paper analyzes the recent transformation of anticancer drugs from 'informed' to 'informing material'. Briefly put: in the post-genomic era, anti-cancer drugs have become instruments for the production of new biological, pathological, and therapeutic insights into the underlying etiology and evolution of cancer. Genomic platforms characterize individual patients' tumors based on their mutational landscapes. As part of this new approach, drugs targeting specific mutations transcend informational enrichment to become tools for informing (and destabilizing) their targets, while also problematizing the very notion of a 'target'. In other words, they have become tools for the exploration of cancer pathways and mechanisms. While several studies in the philosophy and history of biomedicine have called attention to the heuristic relevance and experimental use of drugs, few have investigated concrete instances of this role of drugs in clinical research.
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Affiliation(s)
- Etienne Vignola-Gagné
- Department of Social Studies of Medicine, McGill University, 3647 Peel, Montreal, QC, H3A 1X1, Canada.
| | - Peter Keating
- Department of History, University of Quebec at Montreal, Case Postale 8888, Succursale Centre-Ville, Montreal, QC, H3C 3P8, Canada
| | - Alberto Cambrosio
- Department of Social Studies of Medicine, McGill University, 3647 Peel, Montreal, QC, H3A 1X1, Canada
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