Redefining Cancer Treatment With Personalized Medicine and Early Intervention

Geoffrey D. Moorer, MD

Trends in the treatment for patients with cancer are shifting towards earlier intervention, with effective therapies like immunotherapy moving into neoadjuvant stages for improved outcomes. However, Geoffrey D. Moorer, MD, believes that challenges remain in ensuring wider access to sequencing and overcoming data complexity.

While the future holds immense potential for artificial intelligence to revolutionize treatment planning, for now, the focus lies on maximizing access to existing advancements and prioritizing comprehensive diagnostics for all patients with advanced cancer.

In an interview with Targeted Oncology^TM, Geoffrey D. Moorer, MD, medical oncologist at Virginia Cancer Specialists, discussed recent trending topics in the field of oncology among hospital tumor boards and committees.

Targeted Oncology: Can you share some insights into the latest advancements between tumor boards and committees that have been discussed?

Moorer: Some of the emerging topics in cancer care that tumor boards and tumor committees are discussing are our continuing efforts to find the right treatment for the right patient at the right time, which essentially is involving personalized medicine. This usually incorporates getting patients next-generation sequencing , either on their tumor specimen or from the serum of the patient. Ideally, that will allow us to find the right treatment for the right patient, whether that is a small molecule inhibitor, whether that is immunotherapy, whether it is endocrine therapy, whether it is good old-fashioned chemotherapy, or some combination of those things.

What emerging therapies or treatments have been hot topics in the oncology space?

While immunotherapy with checkpoint inhibitors has been a very hot topic for the past 5 to 10 years, there continue to be earlier approvals with a variety of the checkpoint inhibitors. I think a trend is that we are moving those treatments up earlier in our management of patients with cancer. There is more emerging data on neoadjuvant therapy, primarily in the lung space, but as well as in the breast cancer space. There continue to be many approvals for patients with advanced disease, which are extending their life and improving their symptoms. Essentially, these medications work very well, so that has been 1 of the major hot topics over the past 5 to 10 years.

I would also include small molecule inhibitors, which are things that can be picked up on next-generation sequencing or molecular testing. They continue to be used in a variety of tumor types, again, in our well-known breast cancers, and in lung cancer as well. Small molecule inhibitors also have the benefit of being oral for the most part. That provides not only efficacy for patients but also some convenience in terms of being able to take those medications at home and not having the added burden of coming into our infusion clinics and requiring infusions.

Have there been notable changes in multidisciplinary approaches to cancer treatment?

We are moving up systemic therapies earlier in our patients' treatments. There's a lot of data emerging now that new adjuvant therapy, with immunotherapy, checkpoint inhibitors and chemotherapy combinations, leads to better outcomes for patients in the lung cancer space. There is some more data in the breast cancer space as well. Also, other areas, such as [genitourinary] tumors. I think those would be the 3 biggest where we have some emerging data on moving those treatments up earlier in the neoadjuvant space before surgery, but also in the adjuvant space as well, improving their chances of care, or patients who have advanced disease getting those treatments earlier has been shown to extend overall survival, which is the goal in patients who have metastatic stage IV disease which is in general not curable but treatable.

What challenges are being addressed in terms of personalized medicine and targeted therapies?

This is a recurring theme that patients need to be the right patient [and get] the right treatment at the right time. All patients should be receiving next-generation sequencing testing either on their tumor specimen or serum. There are many different companies, many different players in that space, so I think the biggest challenge is making sure the patients get the right diagnostic workup and the right pathology workup with next-generation sequencing.

There are studies now that are looking at the rates of patients who are receiving next-generation sequencing and those should be 100%. Any patient who has metastatic disease that is on treatment should have next-generation sequencing. Many patients who have early disease, as I mentioned, because we are finding more utilizations for these medications in the neoadjuvant space and a curative with curative intent. I think we are fast approaching a space where almost all patients who are diagnosed with cancer will be getting some type of molecular testing and next-generation sequencing. I am sure there will be data to support that patients who do get that testing have better outcomes than those who do not.

A lot of times that may be financial. In my experience, our partners in that diagnostic space have been filling the gap for patients who may have some shortcomings in terms of their insurance coverage. But it is paramount that as physicians and as providers, we are ordering those tests.

Have there been discussions on incorporating genomics and precision medicine into cancer care?

Absolutely. Genomics and precision medicine are getting the right patient the right treatment at the right time. By getting that next-generation sequencing testing, we are able to find approved therapies that they are eligible for, but also clinical trials. Many of these clinical trials that we are doing now are tumor-agnostic. They are not for lung cancer, or for breast cancer, or colon cancer, but for patients with certain mutations, a KRAS mutation, MET amplifications. The only way you are going to pick those up is with next-generation sequencing. That is a recurring theme, and I think that is going to be sort of the bread and butter of all cancer treatment moving forward.

Are there any collaborative research projects or clinical trials that you could discuss in this space?

In my practice here at Virginia Cancer Specialists, our goal is to have a trial for every patient that is healthy enough to go on clinical trials. But we certainly have clinical trials and [of] all of our major tumor types, our largest portfolio[s are] probably in lung and breast. For instance, right now we have a lung cancer trial in patients with MET amplifications where they get neoadjuvant MET inhibitors, like capmatinib [Tabrecta], and then they go on to surgery, and then they get adjuvant treatment with capmatinib as well. That is a mutation that is only going to be picked up with next-generation sequencing, so that is a perfect example.

Otherwise, in the past, that patient would have just gone straight to surgery, and maybe have gotten adjuvant systemic therapy in the form of chemotherapy or immunotherapy. Now we know with that mutation, most likely those patients are going to do better. Research has shown that they do better in advanced space. We are hopeful and early. The preliminary results are that they do better in the neoadjuvant space, as expected.

In what ways are artificial intelligence and machine learning being utilized in cancer diagnostics or treatment planning?

AI is a hot topic across everything, from medicine to finance to city planning and everything in between. I have not seen any examples in my own practice of the direct impact of artificial intelligence. What I would predict is that as all these massive amounts of data are coming in, patients are getting next-generation sequencing, we are going to find more targets, more mutations, other biomarkers that tell us what treatments may work for what patient but then you also have the added complexity of the sequencing of those treatments, as well as what comorbidities that patients may have. So certain patients may not be eligible for certain treatments due to toxicities, or risk of toxicities or interactions with other drugs.

I see that as a space where artificial intelligence is sort of compiling all of those different factors, patient factors, disease factors, etc. and predicting what treatments will be most efficacious for what patient at what time. I think that is certainly on the horizon, but it has not entered clinical practice as of yet. To my knowledge, it is not even at the advanced or mature research space yet, but certainly, I think there will be more to come very rapidly over the next several months to years.

What are the key points a community oncologist should get from this discussion?

The take home is that all patients who have been diagnosed with cancer, especially advanced disease, should be getting next-generation sequencing from either their serum or from near tissue. As a cancer treatment community, our goal should be 100% and making sure all those patients are getting the right pathology and diagnostic workup.