A sociology of precision-in-practice: The affective and temporal complexities of everyday clinical care

Precision medicine in primary care: How GPs envision "old" and "new" forms of personalization

Visions of precision or personalized medicine (PM) are gaining currency around the globe. While the potential of PM in specialist medicine has been in focus, primary care is also considered to be a fruitful area for the application of PM. "Low-tech" forms of personalization and attention to individual patients are already central features of primary care practice, and primary care thus constitutes an area in which "old" and "new" forms of personalization (may) come together. Against this backdrop, we explore general practitioners' (GPs) views on PM and how they envision the future of personalization in primary care. We draw on 45 qualitative interviews with GPs from Austria, Denmark, and the United States. Along the lines of major "promises" of PM-tailoring treatment decisions, improving disease prevention, empowering patients-we show that in some areas GPs consider PM to be a continuation or extension of existing practices of personalization, while in other cases, GPs envision that PM may negatively disrupt current forms of personalization in primary care. We suggest that this ambivalent stance towards PM can be understood through the lens of GPs' views on core values and practices of primary care.

Sociotechnical imaginaries in academic medicine strategic planning: a document analysis

Purpose Along with other industries, healthcare is becoming increasingly digitized. Our study explores how the field of academic medicine is preparing for this digital future. Method Active strategic plans available in English were collected from faculties of medicine in Canada (n = 14), departments in medical schools (n = 17), academic health science centres (n = 23) and associated research institutes (n = 5). In total, 59 strategic plans were subjected to a practice-oriented form of document analysis, informed by the concept of sociotechnical imaginaries. Results On the one hand, digital health is discursively treated as a continuation of the academic medicine vision, with expansions of physician competencies and of research institutes contributions. These imaginaries do not necessarily disrupt the field of academic medicine as currently configured. On the other hand, there is a vision of digital health pursuing a robust sociotechnical future with transformative implications for how care is conducted, what forms of knowledge are prioritized, how patients and patienthood will be understood, and how data work will be distributed. This imaginary may destabilize existing distributions of knowledge and power. Conclusions Looking through the lens of sociotechnical imaginaries, this study illuminates strategic plans as framing desirable futures, directing attention towards specific ways of understanding problems of healthcare, and mobilizing the resources to knit together social and technical systems in ways that bring these visions to fruition. There are bound to be tensions as these sociotechnical imaginaries are translated into material realities. Many of those tensions and their attempted resolutions will have direct implications for the expectations of health professional graduates, the nature of clinical learning environments, and future relationships with patients. Sociology of digital health and science and technology studies can provide useful insights to guide leaders in academic medicine shaping these digital futures.

Understanding communication between patients and healthcare professionals regarding comprehensive biomarker testing in precision oncology: A scoping review

BACKGROUND

Precision oncology, using comprehensive biomarker testing (cBT) to inform individual cancer diagnosis, prognosis and treatment, includes increasingly complex technology and clinical data sets. People impacted by cancer (patients and caregivers) and healthcare professionals (HCPs) face distinct challenges in navigating the cBT and personalized treatment landscape. This review summarizes evidence regarding cBT-related communication between people impacted by cancer and HCPs and identifies important avenues for future research in precision oncology.

METHODS

A scoping review was conducted using records published in PubMed during January 2017-August 2022, focusing on the breadth of topics on patient-HCP communication and knowledge resources used by HCPs as guidance in cBT-related communication. Data were extracted from records meeting inclusion criteria, and findings were summarized according to main topics.

RESULTS

The search identified 287 unique records and data were extracted from 42 records, including nine from expert input. Most records originated from the United States included patients with different types of cancer, and oncologists were the main HCPs. Patients' motivation for undergoing cBT and receiving results was generally high in different settings. However, patients' understanding of cBT-related concepts was limited, and their knowledge and information preferences changed based on cBT implications and significance to family members. HCPs were valued by patients as a trusted source of information. Limited evidence was available on HCPs' information-seeking behavior and factors influencing cBT-related knowledge and confidence, often self-reported as insufficient.

CONCLUSIONS

Patient education by knowledgeable and confident HCPs, information management and a caring patient-HCP relationship communicating continuity of care regardless of cBT results are crucial to empower patients and shared decision-making in precision oncology. More data on the process and structure of cBT-related communication, distinction between and characterization of different timepoints of patient-HCP interactions are needed.

Hopes, concerns, satisfaction and regret in a precision medicine trial for childhood cancer: a mixed-methods study of parent and patient perspectives

BACKGROUND

Paediatric precision oncology aims to match therapeutic agents to driver gene targets. We investigated whether parents and patients regret participation in precision medicine trials, particularly when their hopes are unfulfilled.

METHODS

Parents and adolescent patients completed questionnaires at trial enrolment (T0) and after receiving results (T1). Parents opted-in to an interview at T1. Bereaved parents completed a questionnaire 6-months post-bereavement (T1B). We analysed quantitative data with R and qualitative data thematically with NVivo, before integrating all data for interpretation.

RESULTS

182 parents and 23 patients completed T0; 108/182 parents and 8/23 patients completed T1; 27/98 bereaved parents completed T1B; and 45/108 parents were interviewed. At enrolment, participants held concurrent hopes that precision medicine would benefit future children and their child. Participants expressed concern regarding wait-times for receipt of results. Most participants found the trial beneficial and not burdensome, including bereaved parents. Participants reported high trial satisfaction (median scores: parents: 93/100; patients: 80/100). Participants expressed few regrets (parent median scores: parents: 10/100; bereaved parents: 15/100; patient regret: 2/8 expressed minimal regret).

CONCLUSIONS

Even when trial outcomes did not match their hopes, parents and patients rarely regretted participating in a childhood cancer precision medicine trial. These data are critical for integrating participants' views into future precision medicine delivery.

Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care

Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.

Determinants of targeted cancer therapy use in community oncology practice: a qualitative study using the Theoretical Domains Framework and Rummler-Brache process mapping

BACKGROUND

Precision medicine holds enormous potential to improve outcomes for cancer patients, offering improved rates of cancer control and quality of life. Not all patients who could benefit from targeted cancer therapy receive it, and some who may not benefit do receive targeted therapy. We sought to comprehensively identify determinants of targeted therapy use among community oncology programs, where most cancer patients receive their care.

METHODS

Guided by the Theoretical Domains Framework, we conducted semi-structured interviews with 24 community cancer care providers and mapped targeted therapy delivery across 11 cancer care delivery teams using a Rummler-Brache diagram. Transcripts were coded to the framework using template analysis, and inductive coding was used to identify key behaviors. Coding was revised until a consensus was reached.

RESULTS

Intention to deliver precision medicine was high across all participants interviewed, who also reported untenable knowledge demands. We identified distinctly different teams, processes, and determinants for (1) genomic test ordering and (2) delivery of targeted therapies. A key determinant of molecular testing was role alignment. The dominant expectation for oncologists to order and interpret genomic tests is at odds with their role as treatment decision-makers' and pathologists' typical role to stage tumors. Programs in which pathologists considered genomic test ordering as part of their staging responsibilities reported high and timely testing rates. Determinants of treatment delivery were contingent on resources and ability to offset delivery costs, which low- volume programs could not do. Rural programs faced additional treatment delivery challenges.

CONCLUSIONS

We identified novel determinants of targeted therapy delivery that potentially could be addressed through role re-alignment. Standardized, pathology-initiated genomic testing may prove fruitful in ensuring patients eligible for targeted therapy are identified, even if the care they need cannot be delivered at small and rural sites which may have distinct challenges in treatment delivery. Incorporating behavior specification and Rummler-Brache process mapping with determinant analysis may extend its usefulness beyond the identification of the need for contextual adaptation.

Hope in the era of precision oncology: a qualitative study of informal caregivers' experiences

OBJECTIVES

To explore informal caregivers' perspectives on precision medicine in cancer care.

DESIGN

Semi-structured interviews with the informal caregivers of people living with cancer and receiving targeted/immunotherapies. Interview transcripts were analysed thematically using a framework approach.

SETTING

Recruitment was facilitated by two hospitals and five Australian cancer community groups.

PARTICIPANTS

Informal caregivers (n=28; 16 men, 12 women; aged 18-80) of people living with cancer and receiving targeted/immunotherapies.

RESULTS

Thematic analysis identified three findings, centred largely on the pervasive theme of hope in relation to precision therapies including: (1) precision as a key component of caregivers' hope; (2) hope as a collective practice between patients, caregivers, clinicians and others, which entailed work and obligation for caregivers; and (3) hope as linked to expectations of further scientific progress, even if there may be no personal, immediate benefit.

CONCLUSIONS

Innovation and change in precision oncology are rapidly reconfiguring the parameters of hope for patients and caregivers, creating new and difficult relational moments and experiences in everyday life and in clinical encounters. In the context of a shifting therapeutic landscape, caregivers' experiences illustrate the need to understand hope as collectively produced, as emotional and moral labour, and as entangled in broader cultural expectations of medical advances. Such understandings may help clinicians as they guide patients and caregivers through the complexities of diagnosis, treatment, emerging evidence and possible futures in the precision era. Developing a better understanding of informal caregivers' experiences of caring for patients receiving precision therapies is important for improving support to patients and their caregivers.

Organizing precision medicine: A case study of Memorial Sloan Kettering Cancer Center's engagement in/with genomics

Recent decades have seen a dramatic rise of in the number of initiatives designed to promote precision oncology, a domain that has played a pioneering role in the implementation of post-genomic approaches and technologies such as innovative clinical trial designs and molecular profiling. In this paper, based on fieldwork carried out at the Memorial Sloan-Kettering Cancer Center from 2019 onwards, we analyze how a world-leading cancer center has adapted, responded, and contributed to the challenge of "doing" precision oncology by developing new programs and services, and building an infrastructure that has created the conditions for genomic practices. We do so by attending to the "organizing" side of precision oncology and to the nexus between these activities and epistemic issues. We situate the work that goes into making results actionable and accessing targeted drugs within the larger process of creating a precision medicine ecosystem that includes purpose-built institutional settings, thus simultaneously experimenting with bioclinical matters and, reflexively, with organizing practices. The constitution and articulation of innovative sociotechnical arrangements at MSK provides a unique case study of the production of a large and complex clinical research ecosystem designed to implement rapidly evolving therapeutic strategies embedded in a renewed and dynamic understanding of cancer biology.

Approaches in Post-Experimental Science. The Case of Precision Medicine

In the introduction to his Spalt und Fuge, Hans-Jörg Rheinberger points to the possibility that we are currently experiencing a new turning point regarding forms of experimentation, which is characterized by the growing importance of high-throughput methods and big data analytics. This essay will explore the thesis that data-intensive research indeed constitutes a form of post-experimental research by interrogating research practices in precision medicine. Section 1 will introduce this thesis and highlight salient features of precision medicine as an example of post-experimental research. Section 2 suggests approach as a category that is broader than experimental system, as discussed by Rheinberger, and can serve to analyze and compare diverse forms of research, including experimental and post-experimental practices. The essay concludes with a reflection on how categories developed for the historiography of recent science might require an update when the science or its context changes (section 3).

"Doing Good" in U.S. Cancer Genomics? Valuation practices across the boundaries of research and care in rural community oncology

Genomic Tumour Testing (GTT) is an emerging site of "experimental care" in oncology [Cambrosio, Alberto, Peter Keating, Etienne Vignola-Gagné, Sylvain Besle, and Pascale Bourret. 2018a. "Extending Experimentation: Oncology's Fading Boundary Bbetween Research and Care." New Genetics and Society 37 (3): 207-226. doi: 10.1080/14636778.2018.1487281]. Few efforts to implement GTT have reached community oncology practices or patients living in rural communities within the US. Drawing on interdisciplinary research on a state-wide cancer genomics initiative in the rural US state of Maine, this paper explores the valuation practices within community oncologist and cancer stakeholders accounts of "doing good" within genomic science and care. We contribute to STS literatures on the bio-economy by highlighting the affective dimensions of strategies for managing economic and non-economic values. Clinician and stakeholders negotiated de-economizing and capitalizing modes of doing good as they built local genomic platforms "for Maine." These situated modes of doing good and feeling good via cancer genomics shaped how they navigated the ethical ambiguities of US biomedical markets across the boundaries of research and care.

Personalising clinical pathways in a London breast cancer service

Using interview and observational data from a busy and research-intensive breast cancer service in the United Kingdom, we discuss recent developments in personalised medicine. Specifically, we show how clinical and research practices meet in clinical pathways that are reconfigured in response to changing approaches of diagnosing, monitoring, treating and understanding cancers. Clinical pathways are increasingly sensitive to changes in evidence deduced through new technologies and therapies as well as decisions based on intensive, iterative analysis of data collected across a range of platforms. We contribute to existing research by showing how the organisation of clinical pathways both maintains established clinical practices and responds to new research evidence, managing a threshold between evidence-based and experimental medicine. Finally, we invite comparisons with other forms of personalisation to understand how they depend on the 'real time' collection, analysis and application of data.

Desafios atuais e futuros do uso da medicina de precisão no acesso ao diagnóstico e tratamento de câncer no Brasil

Este artigo busca refletir, cultural e eticamente, sobre os desafios atuais e futuros da incorporação de novas biotecnologias de diagnóstico e tratamento de câncer no Brasil, bem como seu impacto no acesso e no controle do câncer no país. Para tanto, esta pesquisa parte da problematização da literatura sobre o tema e dos resultados de um estudo, que realizou uma websurvey com especialistas médicos dos setores público e privado brasileiros, associados às dez sociedades oncológicas mais representativas do país, atuantes nas áreas da clínica, cirurgia, radioterapia, patologia e diagnóstico. A discussão do estudo desenvolve-se em torno de três eixos temáticos: conhecimento e expectativas sobre o advento das novas tecnologias para o diagnóstico e tratamento do câncer; considerações estruturais e éticas envolvidas no uso atual e futuro das novas tecnologias; e possíveis cenários associados ao uso e aplicação das novas tecnologias para o diagnóstico e tratamento do câncer. Foram suscitadas algumas questões: novos paradigmas tecnológicos beneficiarão todos os usuários do Sistema Único de Saúde (SUS) ou serão privilégios de poucos? Diminuirão as discrepâncias em termos de oferta de distribuição de serviços, de recursos tecnológicos e de acesso ao diagnóstico e tratamento do câncer? Como diversos segmentos da sociedade poderão participar e influir nesse processo? Que tipos de cenários poderão ainda compor esse quadro? Visando contribuir com o planejamento da atenção ao câncer no Brasil, o artigo finaliza propondo o desenvolvimento de futuras ações a partir de cinco dimensões estratégicas: dimensão econômica; dimensão científica, de inovação e tecnológica; dimensão estrutural; dimensão cultural; e dimensão reguladora.