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Liu R, Wang L, Rizzo S, Garmhausen MR, Pal N, Waliany S, McGough S, Lin YG, Huang Z, Neal J, Copping R, Zou J. Systematic analysis of off-label and off-guideline cancer therapy usage in a real-world cohort of 165,912 US patients. Cell Rep Med 2024; 5:101444. [PMID: 38428426 PMCID: PMC10983036 DOI: 10.1016/j.xcrm.2024.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/28/2023] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
Patients with cancer may be given treatments that are not officially approved (off-label) or recommended by guidelines (off-guideline). Here we present a data science framework to systematically characterize off-label and off-guideline usages using real-world data from de-identified electronic health records (EHR). We analyze treatment patterns in 165,912 US patients with 14 common cancer types. We find that 18.6% and 4.4% of patients have received at least one line of off-label and off-guideline cancer drugs, respectively. Patients with worse performance status, in later lines, or treated at academic hospitals are significantly more likely to receive off-label and off-guideline drugs. To quantify how predictable off-guideline usage is, we developed machine learning models to predict which drug a patient is likely to receive based on their clinical characteristics and previous treatments. Finally, we demonstrate that our systematic analyses generate hypotheses about patients' response to treatments.
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Affiliation(s)
- Ruishan Liu
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA; Department of Computer Science, University of Southern California, Los Angeles, CA, USA
| | - Lisa Wang
- Genentech, South San Francisco, CA, USA
| | | | | | | | - Sarah Waliany
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | | | - Zhi Huang
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Joel Neal
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | - James Zou
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA; Department of Biomedical Data Science, Stanford University, Stanford, CA, USA.
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Zhang Y, Chen D, Cheng S, Liang Z, Yang L, Li Q, Bai L, Li H, Liu W, Shi L, Guan X. Use of suboptimal control arms in randomized clinical trials of investigational cancer drugs in China, 2016-2021: An observational study. PLoS Med 2023; 20:e1004319. [PMID: 38085706 PMCID: PMC10715645 DOI: 10.1371/journal.pmed.1004319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The use of suboptimal controls in randomized trials of new cancer drugs can produce potentially unreliable clinical efficacy results over the current standard of care and expose patients to substandard therapy. We aim to investigate the proportion of randomized trials of investigational cancer drugs that used a suboptimal control arm and the number of trial participants at risk of exposure to suboptimal treatments in China. The association between the use of a suboptimal control and concluding statistical significance on the primary endpoint was also examined. METHODS AND FINDINGS This observational study included randomized controlled trials (RCTs) of cancer drugs that were authorized by specific Chinese institutional review boards between 2016 and 2021, supporting investigational new drug applications of these drugs in China. The proportion of trials that used a suboptimal control arm and the total number of trial participants at risk of exposure to suboptimal treatments were calculated. In a randomized trial for a specific condition, a comparator was deemed suboptimal if it was not recommended by clinical guidelines published in priori or if there existed a regimen with a higher level of recommendation for the indication. The final sample included 453 Phase II/III and Phase III randomized oncology trials. Overall, 60 trials (13.2%) adopted a suboptimal control arm. Among them, 58.3% (35/60) used comparators that were not recommended by a prior guideline for the indication. The cumulative number of trial participants at risk of exposure to suboptimal treatments totaled 18,610 by the end of 2021, contributing 15.1% to the total number of enrollees of all sampled RCTs in this study. After adjusting for the year of ethical approval, region of participant recruitment, line of therapy, and cancer site, second-line therapies (adjusted odds ratio [aOR] = 2.7, 95%CI [1.2, 5.9]), adjuvant therapies (aOR = 8.9, 95% CI [3.4, 23.1]), maintenance therapies (aOR = 5.2, 95% CI [1.6, 17.0]), and trials recruiting participants in China only (aOR = 4.1, 95% CI [2.1, 8.0]) were more likely to adopt a suboptimal control. For the 105 trials with publicly available results, no statistically significant difference was observed between the use of a suboptimal control and concluding positive on the primary endpoint (100.0% [12/12] versus 83.9% [78/93], p = 0.208). The main limitation of this study is its reliance on clinical guidelines that could vary across cancer types and time in assessing the quality of the control groups. CONCLUSIONS In this study, over one-eighth of randomized trials of cancer drugs registered to apply for regulatory approval in China used a suboptimal comparator. Our results highlight the necessity to refine the design of randomized trials to generate optimal clinical evidence for new cancer therapies.
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Affiliation(s)
- Yichen Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Dingyi Chen
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Siyuan Cheng
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, China
| | - Zhizhou Liang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Lu Yang
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, China
| | - Qian Li
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing, China
| | - Lin Bai
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
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Matsuo M, Hashimoto K, Kogo R, Jiromaru R, Hongo T, Manako T, Nakagawa T. Utility of Precision Oncology Using Cancer Genomic Profiling for Head and Neck Malignancies. In Vivo 2023; 37:2147-2154. [PMID: 37652518 PMCID: PMC10500534 DOI: 10.21873/invivo.13312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND/AIM In recent years, individual patient cancer genomic profiling (CGP) has become more accessible, allowing determination of therapeutic strategies using driver gene mutations in cancer therapy. However, this precision oncology approach, tailored to specific patients, remains experimental. In this study, we verified the feasibility and benefit of using CGP to guide treatment of malignant head and neck tumors. We aimed to evaluate the profiling and clinical courses of patients with head and neck malignancies who underwent CGP and determine the extent to which CGP for head and neck malignancies has resulted in beneficial drug administration. PATIENTS AND METHODS We analyzed CGP results, prognosis, and drug administration status in 27 patients. These patients had completed (or were expected to complete) standard therapy or had rare cancers without standard therapy. RESULTS At least one somatic actionable gene alteration was seen in 25 (92.6%) patients, with a median number of actionable alterations per patient of 4 (range=0-11). Drugs in clinical trials were recommended to 22 (81.5%) patients, but none could participate. However, 3 patients (11.1%) could use approved drugs off-label based on CGP results. The most common genetic abnormality was TP53 (66.7%), with TP53 mutations leading to poor prognosis. CONCLUSION CGP is clinically useful and serves as a bridge to increase the number of therapeutic options. However, candidate drugs confirmed using CGP may be ineffective when administered. Therefore, oncologists should not blindly accept CGP therapeutic recommendations but should make recommendations that lead to optimal therapies after proper verification.
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Affiliation(s)
- Mioko Matsuo
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuki Hashimoto
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryunosuke Kogo
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Rina Jiromaru
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiro Hongo
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomomi Manako
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Nakagawa
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Jorge S, Goff BA, Gray HJ, Enquobahrie DA, Doll KM. Characterization of the Early Years of Bevacizumab Use for First-Line Treatment of Ovarian Cancer in the United States. JCO Oncol Pract 2021; 17:e1698-e1710. [PMID: 33844592 PMCID: PMC9810132 DOI: 10.1200/op.20.00918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To quantify early dissemination patterns, factors influencing use, and costs of bevacizumab (BEV) for the treatment of newly diagnosed ovarian cancer (OC) in the United States before its regulatory approval for this indication (off-label use). METHODS We identified women 18-65 years of age with newly diagnosed OC treated with surgery and platinum-based chemotherapy from 2008 to 2016 through the MarketScan database (N = 8,109). The proportion of women receiving BEV over time was calculated, multivariate logistic regression used to determine factors associated with BEV use, and total costs per cycle of chemotherapy with and without BEV abstracted. RESULTS BEV utilization rose 1.8-fold during the study period, from 4.1% (2008) to 7.4 % (2016). BEV was used with non-platinum/taxane regimens over a third of the time (37.2%). Physician specialty (medical oncology v gyn oncology) and geography (southeast region) were significantly associated with higher rates of use. Clinical factors associated with BEV use were metastatic disease and presence of ascites. The median cost of one cycle of platinum/taxane chemotherapy plus BEV was $10,897 in US dollars (USD) (interquartile range $7,573-$18,133 USD), compared with $1,629 USD (interquartile range, $683.0-$4,461 USD) for platinum/taxane alone. CONCLUSION Off-label use of BEV for newly diagnosed OC was rare (< 10%), but doubled following presentation of phase II and III data at international meetings. Both clinical (ascites, metastatic disease, and age) and nonclinical (specialty and region) factors were associated with BEV use, and its use was accompanied by a six-fold increase in the cost of one cycle of treatment.
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Affiliation(s)
- Soledad Jorge
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA,Soledad Jorge, MD, MPH, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA 98195; e-mail:
| | - Barbara A. Goff
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Heidi J. Gray
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Kemi M. Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
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Maeda H, Fukuda Y, Uchida M. Assessment of Drugs Approved by Public Knowledge-Based Applications (Kouchi-shinsei) During the Last Two Decades in Japan. Clin Pharmacol Ther 2021; 110:1127-1135. [PMID: 34110632 PMCID: PMC8518418 DOI: 10.1002/cpt.2332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/26/2021] [Indexed: 11/15/2022]
Abstract
Public knowledge‐based application (“Kouchi‐shinsei” in Japanese) is unique to Japan, implemented to eliminate the off‐label use of unapproved indications, dosages, and administrations because of drug lag. The guidance for public knowledge‐based application was issued in 1999. This study comprehensively investigated the trends of items approved by public knowledge‐based application in Japan during the last 2 decades. Prescription drugs approved from January 2000 to December 2019 were surveyed. In Japan, 1,855 drugs were approved within the target survey period. Among them, 219 (11.8%) were approved by public knowledge‐based application. Considering the changes in the number of items approved by public knowledge‐based application over the years, the number of items approved in 2000 was 7, reaching a maximum of 34 items in 2011, and decreased after that, 8 items were approved in 2019. The regulatory characteristics of drugs approved by public knowledge‐based application and those of other drugs were compared. By public knowledge‐based application, more anticancer and pediatric drugs were approved (P < 0.001), and only one drug for orphan diseases was approved (P < 0.001). In addition, the review time of public knowledge‐based applications was significantly shorter than that of normal applications regardless of time point. The approval system using public knowledge‐based application began in 2000, following issuance of the “Guidance for off‐label use of prescription drugs.” Furthermore, the approved items were mostly drugs for cancer, infectious diseases, and pediatric drugs. We anticipate the promotion of public knowledge‐based application to accommodate the approval of drugs for orphan diseases.
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Affiliation(s)
- Hideki Maeda
- Department of Regulatory ScienceFaculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
| | - Yuka Fukuda
- Department of Regulatory ScienceFaculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
| | - Marika Uchida
- Department of Regulatory ScienceFaculty of PharmacyMeiji Pharmaceutical UniversityTokyoJapan
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National comprehensive cancer network recommendations for drugs without US food and drug administration approval in metastatic breast cancer: A cross-sectional study. Cancer Treat Rev 2020; 91:102113. [PMID: 33128993 DOI: 10.1016/j.ctrv.2020.102113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/04/2020] [Accepted: 10/07/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND National Comprehensive Cancer Network (NCCN) guidelines can include recommendations for off-label use of anti-cancer drugs. Here, we evaluate NCCN recommendations not supported by US Food and Drug Administration (FDA) approval and explore associations with such recommendations. METHODS All NCCN recommendations for MBC and their supporting data were identified. Drug labels were reviewed to determine whether recommendations are FDA approved. Logistic regression was used to compare FDA approved and off-label recommendations for pre-specified categories, including drug type, tumor subtype, level of recommendation and line of therapy. RESULTS Of 124 recommendations identified, 68 (55%) were off-label. Chemotherapy and human epidermal growth factor receptor 2 (HER2) targeted drugs were associated with lower odds of FDA approval (OR = 0.28, p = 0.001 and OR = 0.29, 95% p = 0.005, respectively). Recommendations for endocrine therapy (OR = 3.44, p = 0.009) and non-HER2 targeted treatment (OR = 10.0, p < 0.001) were more commonly FDA approved indications. Compared to combination therapies, monotherapies were more likely to be FDA approved (OR = 3.45, p = 0.001) as were category 1 (OR = 7.63, p = 0.001) and preferred NCCN recommendations (OR = 4.07, p < 0.001). Compared to off-label recommendations, NCCN recommendations of approved drugs were based on significantly higher sample size (mean 477 vs. 342 patients, p = 0.02) and were non-significantly associated with availability of randomized data (OR = 2.0, 95% CI 0.89-4.49, p = 0.09). CONCLUSION More than half of all NCCN recommendations for MBC are off-label, mostly involving chemotherapy containing regimes for HER2 negative disease and combinations which include HER2-targeted drugs. Improved transparency of NCCN guidelines may result from reporting of the strength of the evidence supporting recommendations for MBC.
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Bun S, Yonemori K, Sunadoi H, Nishigaki R, Noguchi E, Okusaka T, Nishida T, Fujiwara Y. Safety and Evidence of Off-Label Use of Approved Drugs at the National Cancer Center Hospital in Japan. JCO Oncol Pract 2020; 17:e416-e425. [PMID: 32956004 DOI: 10.1200/op.20.00131] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In Japan, for pharmaceutical products to be covered by public medical insurance, their efficacy and safety must first be confirmed in clinical trials. To our knowledge, this study is the first investigation into the off-label use of pharmaceutical products at a high-volume cancer treatment center in Japan. The objective of this study is to explore the framework necessary for future pharmaceutical development and regulatory approval in the field of oncology by surveying the frequency of and indications for off-label use of pharmaceutical products at the National Cancer Center Hospital in Tokyo, Japan. MATERIALS AND METHODS The pharmaceutical products used off-label in daily practice from 2003 to 2015 at the National Cancer Center Hospital were retrospectively examined based on applications that had been submitted to an internal review committee requesting off-label use. RESULTS A total of 1,390 applications were submitted during the study period. The most frequently used supporting documents were the results of phase II trials, followed by case series and phase III trials. The cancer most frequently treated with off-label drugs was sarcoma (15.1%), followed by urologic cancer (9.2%) and GI cancer (7.6%). CONCLUSION As reported in previous studies, pharmaceutical products were generally used off-label for the treatment of rare cancers, for which large-scale clinical trials are difficult to conduct. Continued discussion of the types of frameworks that are needed to guide pharmaceutical development is necessary.
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Affiliation(s)
- Seiko Bun
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan.,Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Kan Yonemori
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroko Sunadoi
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Rena Nishigaki
- Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Emi Noguchi
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toshirou Nishida
- National Cancer Center Hospital, Tokyo, Japan.,Japan Community Health Care Organization, Osaka Hospital, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan.,Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
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Alexandru O, Horescu C, Sevastre AS, Cioc CE, Baloi C, Oprita A, Dricu A. Receptor tyrosine kinase targeting in glioblastoma: performance, limitations and future approaches. Contemp Oncol (Pozn) 2020; 24:55-66. [PMID: 32514239 PMCID: PMC7265959 DOI: 10.5114/wo.2020.94726] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/24/2020] [Indexed: 01/08/2023] Open
Abstract
From all central nervous system tumors, gliomas are the most common. Nowadays, researchers are looking for more efficient treatments for these tumors, as well as ways for early diagnosis. Receptor tyrosine kinases (RTKs) are major targets for oncology and the development of small-molecule RTK inhibitors has been proven successful in cancer treatment. Mutations or aberrant activation of the RTKs and their intracellular signaling pathways are linked to several malignant diseases, including glioblastoma. The progress in the understanding of malignant glioma evolution has led to RTK targeted therapies with high capacity to improve the therapeutic response while reducing toxicity. In this review, we present the most important RTKs (i.e. EGFR, IGFR, PDGFR and VEGFR) currently used for developing cancer therapeutics together with the potential of RTK-related drugs in glioblastoma treatment. Also, we focus on some therapeutic agents that are currently at different stages of research or even in clinical phases and proved to be suitable as re-purposing candidates for glioblastoma treatment.
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Affiliation(s)
- Oana Alexandru
- Department of Neurology, University of Medicine and Pharmacy of Craiova and Clinical Hospital of Neuropsychiatry Craiova, Craiova, Romania
| | - Cristina Horescu
- Unit of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Ani-Simona Sevastre
- Unit of Pharmaceutical Technology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Catalina Elena Cioc
- Unit of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Carina Baloi
- Unit of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Alexandru Oprita
- Unit of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Anica Dricu
- Unit of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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Marchevsky AM, Walts AE, Wick MR. Pathology in the era of "Personalized Medicine": The need to learn how to integrate multivariate immunohistochemical and "omics" data with clinicopathologic information in a clinically relevant way". Ann Diagn Pathol 2019; 43:151410. [PMID: 31689574 DOI: 10.1016/j.anndiagpath.2019.151410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/11/2019] [Indexed: 11/30/2022]
Abstract
"Personalized medicine" has been proposed as a new paradigm for patient care that, based on the integration of genomics and other "omics" data with clinical and other multidisciplinary information, promises early disease detection, improved outcomes and reduced side effects to therapies. Pathologists have become important participants in this new approach as the guardians of tissues and experts in the performance of molecular and other laboratory tests. Large amounts of new laboratory data in multiple neoplasms and other entities are being reported but there has been limited discussion about how best to evaluate the clinical significance of this information and how to integrate it into currently available diagnostic and therapeutic modalities. This article introduces a variety of epistemological problems presented by the "personalized medicine" paradigm and briefly discusses various topics that will be evaluated in further detail in future articles of this new series on Evidence-Based Pathology.
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Affiliation(s)
- Alberto M Marchevsky
- Departments of Pathology & Laboratory Medicine Cedars-Sinai Medical Center, Los Angeles CA, United States of America.
| | - Ann E Walts
- Departments of Pathology & Laboratory Medicine Cedars-Sinai Medical Center, Los Angeles CA, United States of America
| | - Mark R Wick
- University of Virginia, Charlottesville, VA, United States of America
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Affiliation(s)
- E G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - N I Cherny
- Department of Medical Oncology, Cancer Pain and Palliative Medicine Service, Shaare Zedek Medical Center, Jerusalem, Israel
| | - E E Voest
- Division of Molecular Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Oncode Institute, Amsterdam, The Netherlands
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