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Pot M, Spalletta O, Green S. Precision medicine in primary care: How GPs envision "old" and "new" forms of personalization. Soc Sci Med 2024; 358:117259. [PMID: 39181083 DOI: 10.1016/j.socscimed.2024.117259] [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: 04/22/2024] [Revised: 07/13/2024] [Accepted: 08/15/2024] [Indexed: 08/27/2024]
Abstract
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.
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Affiliation(s)
- Mirjam Pot
- University of Vienna, Department of Political Science, Austria; European Centre for Social Welfare Policy and Research, Austria.
| | - Olivia Spalletta
- University of Copenhagen, Department of Science Education, Section for History and Philosophy of Science, Denmark; University of Copenhagen, Department of Public Health, Centre for Medical Science and Technology Studies, Denmark
| | - Sara Green
- University of Copenhagen, Department of Science Education, Section for History and Philosophy of Science, Denmark; University of Copenhagen, Department of Public Health, Centre for Medical Science and Technology Studies, Denmark
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Gjødsbøl IM, Knox JBL, Skovgaard L, Svendsen MN. Population curation: The construction of mutual obligation between individual and state in Danish precision medicine. SOCIAL STUDIES OF SCIENCE 2024:3063127241255971. [PMID: 38819129 DOI: 10.1177/03063127241255971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
How do precision medicine initiatives (re)organize relations between individuals and populations? In this article, we investigate how the curation of national genomic populations enacts communities and, in so doing, constructs mutual obligation between individuals and the state. Drawing on ethnographic fieldwork in the Danish National Genome Center (DNGC), we show how members of advisory bodies negotiated the inclusion criteria for two different genomic populations: a patient genome population and an envisioned 'Danish' reference genome population. The patient genome population was curated through a politics of inclusion, of as many genomes as possible, whereas the reference genome was to be curated through a politics of exclusion, to include only the genomes of 'ethnic' Danes. These two data populations configure differently the community of 'Danish patients' who might benefit from precision medicine, and thereby prescribe different moral continuities between person, state, and territory. We argue that the DNGC's patient genome population reinforces reciprocal relations of obligations and responsibility between the Danish welfare state and all individuals, while the proposed Danish reference genome population privileges the state's commitment to individuals with biographical-territorial belonging to the nation-state. Drawing on scholarship on social and health citizenship, as well as data solidarity in the Nordics, the discussion shows how population curation in national precision medicine initiatives might both construct and stratify political obligation. Whereas STS scholarship has previously deconstructed the concept of 'population', in the context of the troubling and violent effects of the management of human populations, we point to the importance of population curation as a vehicle for making the individual legible as part of a community to which the state is responsible and for which it is committed to care.
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Affiliation(s)
- Iben M Gjødsbøl
- Centre for Medical Science and Technology Studies, University of Copenhagen, Denmark
| | | | - Lea Skovgaard
- Centre for Medical Science and Technology Studies, University of Copenhagen, Denmark
| | - Mette N Svendsen
- Centre for Medical Science and Technology Studies, University of Copenhagen, Denmark
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Campbell J, Cambrosio A, Basik M. Histology agnosticism: Infra-molecularizing disease? STUDIES IN HISTORY AND PHILOSOPHY OF SCIENCE 2024; 104:14-22. [PMID: 38377771 DOI: 10.1016/j.shpsa.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 11/22/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
The term "molecularization" has been used by historians and sociologists of science to describe the transition from an anatomic view of the body to a submicroscopic one, where health and illness, indeed life itself, are increasingly defined in terms of an individual's "genetic landscape." Here we introduce the notion of the infra-molecular as a way of extending and nuancing the molecularization trope as it applies to the domain of (post)genomic oncology. In particular we look at how infra-molecularity is enacted in practice as part of the so-called "histology-agnostic" turn in clinical cancer research and care. Drawing on fieldwork in North American oncology settings, we analyze how histology agnosticism partially reconfigures knowledge and practice across the linked domains of drug development and clinical trials, therapeutic decision making, and regulation, and the implications of this for an ongoing revision of how we understand the biopathology and temporality of cancer. We show how, in practice, the inframolecular gaze entails a "return" of histology as a modulator of histology-agnostic drugs and background for interpretation of mutational complexity.
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Affiliation(s)
- Jonah Campbell
- Department of Social Studies of Medicine, McGill University, Montreal, QC, Canada.
| | - Alberto Cambrosio
- Department of Social Studies of Medicine, McGill University, Montreal, QC, Canada.
| | - Mark Basik
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada.
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Knox JBL, Svendsen MN. The fertility of moral ambiguity in precision medicine. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:465-476. [PMID: 37280471 PMCID: PMC10243698 DOI: 10.1007/s11019-023-10160-0] [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] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
Although precision medicine cuts across a large spectrum of professions, interdisciplinary and cross-sectorial moral deliberation has yet to be widely enacted, let alone formalized in this field. In a recent research project on precision medicine, we designed a dialogical forum (i.e. 'the Ethics Laboratory') giving interdisciplinary and cross-sectorial stakeholders an opportunity to discuss their moral conundrums in concert. We organized and carried out four Ethics Laboratories. In this article, we use Simone de Beauvoir's concept of moral ambiguity as a lens to frame the participants' experience with fluid moral boundaries. By framing our approach through this concept we are able to elucidate irremediable moral issues that are collectively underexplored in the practice of precision medicine. Moral ambiguity accentuates an open and free space where different types of perspectives converge and can inform each other. Based on our study, we identified two dilemmas, or thematic interfaces, in the interdisciplinary moral deliberations which unfolded in the Ethics Laboratories: (1) the dilemma between the individual and the collective good; and (2) the dilemma between care and choice. Through our investigation of these dilemmas, we show how Beauvoir's concept of moral ambiquity not only serves as a fertile catalyst for greater moral awareness but, furthermore, how the concept can become an indispensable part of the practices of and the discourse about precision medicine.
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Affiliation(s)
- Jeanette Bresson Ladegaard Knox
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building, 1014 Copenhagen, Denmark
- University Hospital of Copenhagen, Copenhagen, Denmark
| | - Mette Nordahl Svendsen
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building, 1014 Copenhagen, Denmark
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Green S, Prainsack B, Sabatello M. Precision medicine and the problem of structural injustice. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:433-450. [PMID: 37231234 PMCID: PMC10212228 DOI: 10.1007/s11019-023-10158-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023]
Abstract
Many countries currently invest in technologies and data infrastructures to foster precision medicine (PM), which is hoped to better tailor disease treatment and prevention to individual patients. But who can expect to benefit from PM? The answer depends not only on scientific developments but also on the willingness to address the problem of structural injustice. One important step is to confront the problem of underrepresentation of certain populations in PM cohorts via improved research inclusivity. Yet, we argue that the perspective needs to be broadened because the (in)equitable effects of PM are also strongly contingent on wider structural factors and prioritization of healthcare strategies and resources. When (and before) implementing PM, it is crucial to attend to how the organisation of healthcare systems influences who will benefit, as well as whether PM may present challenges for a solidaristic sharing of costs and risks. We discuss these issues through a comparative lens of healthcare models and PM-initiatives in the United States, Austria, and Denmark. The analysis draws attention to how PM hinges on-and simultaneously affects-access to healthcare services, public trust in data handling, and prioritization of healthcare resources. Finally, we provide suggestions for how to mitigate foreseeable negative effects.
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Affiliation(s)
- Sara Green
- Section for History and Philosophy of Science, Department of Science Education, University of Copenhagen, Niels Bohr Building (NBB), Universitetsparken 5, 2100 Copenhagen Ø, Denmark
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Oester Farimagsgade 5, 1014 Copengagen, Denmark
| | - Barbara Prainsack
- Department of Political Science, University of Vienna, Universitätsstraße 7, 1010 Vienna, Austria
- School of Social and Political Sciences, Faculty of Arts and Social Sciences, University of Sydney, Camperdown, NSW 2006 Australia
| | - Maya Sabatello
- Center for Precision Medicine and Genomics, Department of Medicine, Columbia University, New York, USA
- Division of Ethics, Department of Medical Humanities and Ethics, Columbia University, New York, USA
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Kenny K, Williams Veazey L, Broom A, Peterie M, Page A, Prainsack B, Wakefield CE, Itchins M, Khasraw M, Lwin Z. Hope in the era of precision oncology: a qualitative study of informal caregivers' experiences. BMJ Open 2023; 13:e065753. [PMID: 37130677 PMCID: PMC10163471 DOI: 10.1136/bmjopen-2022-065753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
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.
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Affiliation(s)
- Katherine Kenny
- Sydney Centre for Healthy Societies; School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Leah Williams Veazey
- Sydney Centre for Healthy Societies; School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Alex Broom
- Sydney Centre for Healthy Societies; School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Michelle Peterie
- Sydney Centre for Healthy Societies; School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexander Page
- Sydney Centre for Healthy Societies; School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Barbara Prainsack
- Department of Political Science, University of Vienna, Wien, Austria
| | - Claire E Wakefield
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine and Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW, Sydney, New South Wales, Australia
| | - Malinda Itchins
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Mustafa Khasraw
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Zarnie Lwin
- Department of Medical Oncology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
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Polk JB, Campbell J, Drilon AE, Keating P, Cambrosio A. Organizing precision medicine: A case study of Memorial Sloan Kettering Cancer Center's engagement in/with genomics. Soc Sci Med 2023; 324:115789. [PMID: 36996726 PMCID: PMC10961966 DOI: 10.1016/j.socscimed.2023.115789] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/03/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023]
Abstract
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.
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Affiliation(s)
- Jess B Polk
- Department of Social Studies of Medicine, McGill University, Montreal, Canada.
| | - Jonah Campbell
- Department of Social Studies of Medicine, McGill University, Montreal, Canada
| | | | - Peter Keating
- Department of History, Université du Québec à Montréal, Montreal, Canada
| | - Alberto Cambrosio
- Department of Social Studies of Medicine, McGill University, Montreal, Canada
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