EONS 2012

Personalised medicine and nursing

Paula Reiger – Oncology Nursing Society, USA


We live in an era of personalised medicine and very much so because drugs these days can target in on a particular molecule. How is this affecting things and what are the points you’d like to emphasise about this whole era, especially with the genes, the genetics and what’s called the genome as well?

It’s a very exciting time in cancer care because as we’ve learned from being able to unlock the secrets of the genome and to determine what kind of genetic changes a person has in their tumour, we can then begin to have therapy that’s more specifically targeted to precisely what’s gone wrong in any individual cell. For example, you can find certain markers that drugs are then targeted to, to a specific genetic change, and can hopefully more effectively treat someone’s tumour.

And there are a whole battery of new targeted agents, aren’t there?

Exactly. Almost all of the new drugs coming out in today’s world are what we would call targeted therapies, monoclonal antibodies is a whole class of agents that can selectively target molecules, receptors, and we also have a whole class of drugs that inhibit signals in a cell, different signalling pathways that are related to a tumour.

Now we’re here at a conference on oncology nursing in Geneva, how does this era of personalised medicine, individualised by molecular means, affect nursing care?

It’s so important because nurses are really the ones that implement and treat patients with cancer and so they’re the ones giving the chemotherapy, the targeted therapy. So they have an incredibly important role in educating patients and families about their therapy and how to manage side effects and so forth. So one of the key points when you think about targeted therapies, as compared to traditional chemotherapy, is they tend to be given for much longer periods of time and they also are primarily given in the outpatient setting and they’re also oral. So patients are more responsible for adhering to their therapy and so the nursing support and education is critical to keeping patients on therapy and helping them manage side effects.

What sorts of things on a day to day basis do you need to do that are different from the old days?

In the old days therapy was given more in specific time frames, for example six months, and patients would either come into the hospital or into the clinic and they’d receive an infusion and then they’d go home and they’d have side effects sometimes following that. But in today’s world they actually may be taking the therapy in the home, especially if it’s an oral agent. So patients are responsible for remembering to take their medication, self-managing side effects, reporting back to the healthcare team if they’re having problems or something like that. That’s probably the easiest way to put it.

And there’s an issue about disease understanding, the understanding of actually the disease processes being more individualised. What’s that all about?

Traditionally when someone had cancer and they had a biopsy, for example a breast cancer, they would be given a tissue diagnosis they had a cancer of the breast. But in today’s world we can actually look even a step deeper and through molecular analysis look at what we’d call the molecular signature, which is what are the specific genetic changes that have occurred in that particular person’s tumour. So that tells you a lot about what led to the development of cancer. Then as they try to figure out which of the mutations are key or critical, most critical to that process, you can begin to then develop drugs and target drugs to combat that specific genetic change. So it’s a much more precise form of therapy.

And how much of an improvement in the overall outcomes can you make if you conduct the care of the patient, including the nursing care, with a full view to understanding all of these processes and all of the targeted therapies that are now being used?

In some cases it can be dramatic. We’re not there yet because, as with any new methodology, there are lots of barriers sometimes and challenges you have to overcome. But several striking examples in the last, say, ten to fifteen years would be the treatment of chronic myelogenous leukaemia with imatinib is a targeted therapy and in the vast majority of patients their cancer comes under control. So in the old days we used to look and saying that we cured cancer, increasingly with targeted therapies patients will often receive their therapies for longer periods of time and the disease will be managed or controlled. They may or may not necessarily use the word cured.

But imatinib has been a mixed blessing because it does great things for CML but it’s lit a light that almost everybody is trying to follow and it doesn’t always work in other diseases and you do get lots of side effects as well. How does all of this affect nursing?

It does, the targeted therapies often have a very different side effect profile than traditional chemotherapy so whatever the side effects may be that are associated with a particular agent, nurses are often key in trying to help patients manage those and stay on their therapy. But you just hit the nail on the head because imatinib works in CML because it’s specifically targeted towards the genetic change that occurs in that disease, it’s a translocation between the arms of two chromosomes and so it sets up signalling that just continues and doesn’t stop. So imatinib actually blocks the receptor and stops the signalling so it’s not going to work in every disease because it’s targeted towards the specific change that occurs in CML.

But other targeted therapies will work or may work very well but we can’t expect them all to work as well as imatinib.

They may or may not, it’s hard to say and that’s part of trying to figure out which are the key or the critical mutations in a given cancer cell. For example, it’s not always as simple as one genetic change, most cancer cells will have anywhere to five, seven, nine genetic changes that occur and can actually even lead to the development of cancer. So you have to figure out which one is the most critical and important, the Achilles’ heel if you will, and then try to target an agent towards that driver mutation.

But even if you don’t do as well as you do with CML, which is almost like maintaining a diabetic person, you can still get huge gains and presumably if you handle it well then those gains are even more worthwhile?

Hopefully so in the future. What they say oftentimes about these discoveries and their application to clinical medicine is that our approaches will become more personalised and proactive which gets into the whole realm of prevention versus generalised and reactive. We used to apply the same kind of a therapy to a broad group of patients that, say, had breast cancer or lung cancer or something like that. Increasingly in the future you’ll see smaller segments, subsets of patients, with a particular kind of cancer receiving a particular kind of therapy based on the genetic change that’s a part of their cancer.

So what are the few points that you would like people to remember from all of this that they need to bear in mind?

The exciting thing about it is cancer is a disease that occurs over time so there’s a long time frame over which cancer develops. So hopefully in the future we’ll be able to actually assess for key genetic changes through different kinds of technology, maybe the blood, other mechanisms, to actually find cancer at earlier points where we can intercede earlier and treat and maybe stop the development of cancer. So that’s really the preventive piece of it. In the long run, though, cancer will probably become more of a chronic disease that’s managed effectively over time, hopefully with oral agents that are targeted towards the specific defect that someone has in their tumour and we’ll have better response rates than we see sometimes with the chemotherapies or the current kinds of therapies that we have. And I think less morbidity, toxicity or problems associated with the therapy that patients receive so they ultimately hopefully will have better quality of life. But there’s a lot to sort out between now and then.

Yes, and I want to guard against over-optimism as well because you shouldn’t be put off all of this just because you don’t immediately score a home run on first attempt.

We have some exciting home runs but I think the real thing is it’s a huge amount of information when you think of all of the information that they’ll be able to gain about someone’s disease. Then how do we bring that into the clinical setting so that it’s easily available for clinicians and they can access that information and then which particular drugs are going to be best suited to treating that particular patient’s tumour. But even outside of cancer this will apply to other diseases and conditions as well, so that’s what makes it so exciting.

Thank you very much, Paula.

You’re very welcome.