Cancer Care: Redefining the Best We Can Do

Sometimes it seems like in cancer care the lag between bench science breakthroughs and clinical care is painfully long.  In addition information on the latest therapeutic modalities is fragmented and proprietary between competing research and clinical centers of excellence.  It can seem nearly impossible for a patient or a practicing oncologist to both be informed of the latest and best options and have access to this care.

Tony Blau MD director of the Center for Cancer Innovation, is trying to change all of this.  The Center is a new initiative from UW Medicine that brings together physicians and scientists from across many different organizations in a consortium dedicated to using state-of-the-art modalities of cancer tissue analysis and storage, information technology and open communication and sharing to allow cancer patients to get the best available cancer treatment.  I know Tony through his wife Sibel Blau MD who is a top oncologist in my Puyallup, WA medical community. Dr. Tony Blau has agreed to answer questions about his work towards allowing patients to get the best available care for their specific cancer.  Here are some questions I asked him to share answers to:

Dr. Pullen:  Thanks for agreeing to the interview.  I’ve heard great things about you from my wife, a cancer patient that your wife has helped, as well as enjoying your talk to our Rotary club a couple of years ago.  Please introduce yourself to readers by telling us briefly about your training and experiences that led you up to your current research passions:

Dr. Blau: Thank you Ed.  I grew up and went to medical school in Ohio, did my internal medicine residency at Duke, before coming to Seattle to do my fellowship in hematology and oncology in 1989.  Back then I was drawn to Seattle because of the bone marrow transplant program at the Fred Hutchinson Cancer Research Center.  The environment was thrilling – patients with leukemia or other life threatening blood diseases would come to Seattle to have the kitchen sink thrown at them in the form of very high doses of chemotherapy and radiation, and then would be “rescued” by receiving an infusion of a donor’s bone marrow.  It was incredibly intense and uncompromising – win or lose, live or die, no middle ground – and back in 1989 it epitomized what it meant to “do our best”.

Since then I’ve spent most of my time in the lab, where its been extremely impressive to witness just how fast technology is advancing – it’s breathtaking really – especially advances in computation and DNA sequencing.  On the clinical side, the care of cancer patients is also improving, but much more slowly.   Sibel and I had many discussions about the dramatic contrast between what is possible in the lab versus what is available for cancer patients today.  It seemed that we needed a profoundly different approach to tackling the cancer problem.  We needed to re-define what it means to “do our best” for patients with cancer.  For that reason I founded UW Medicine’s Center for Cancer Innovation.

Dr. Pullen:   I’ve heard you mention how the definition of the “best available care today” is evolving.  How do you see the Center for Cancer Innovation and your work pushing envelope of defining the best available care today?

Dr Blau:  We think that the dramatic improvements in technology that have taken place over the past decade have changed the definition of what it means to do our best for patients with cancer.  The biggest lesson that genomics has taught us is that on a molecular level, every cancer is unique.  We think that for patients with cancer that is incurable with conventional therapies, today’s definition of “doing our best” involves trying to understand a patient’s tumor on a molecular level, and then using that knowledge to look for a vulnerability that can be targeted with a drug.  Advances in sequencing and other technologies allow us to generate millions of data points from an individual patient’s tumor, converting a individual patient’s cancer into a “big data” problem.  Attempting to solve an individual patient’s cancer is an immensely difficult task that requires the cooperative effort of teams of scientists, physicians, computational biologists and, most notably, patients themselves.  That’s today’s definition of “doing our best.”

Dr. Pullen:   What do you see as the major advances in basic science and tumor analysis that bring the possibility of targeting therapy to an individual patient’s cancer?

Dr. Blau:  One huge advance is in the area of omics.  Omic technologies include genomics, which uses DNA sequencing to assemble and analyze genomes; transcriptomics, which uses sequencing to study RNA molecules; proteomics, which studies arrays of proteins; and metabolomics, which characterizes small-molecule metabolites.  Other crucial advances are in computation, the Internet, and a relatively new area of science called systems biology.

Dr. Pullen:  Why does it seem that most of the advances in the science of tumor marker analysis, genetic analysis and other technical innovations are not making their way to patient care?

Dr. Blau:  A firewall separates research and clinical care. This firewall serves the important purpose of protecting patients from tests and treatments that haven’t been extensively validated, but can also prevent cancer patients from accessing the very latest advances that technology has to offer.  Clinical trials supported by the Center for Cancer Innovation remove that firewall – leaving no gap between what a research lab can offer and what’s placed at the disposal of a cancer patient.

Dr. Pullen:   You seem to be getting many talented and competitive individuals to cooperate in sharing information and pooling talents. If you can pull this off it could greatly speed up innovation and benefit patients.  How are you pulling this off in the intensely competitive worlds of medical research and oncology patient care?

Dr. Blau:  Most researchers are really attracted to the idea of being able to use their knowledge to directly help a patient with cancer.  No single institution has the wherewithal to cure cancer, and we therefore needed to find ways to transcend institutional boundaries.  With nearly 100 members from more than half a dozen organizations, the Center for Cancer Innovation is a “coalition of the willing,” in which investigators from many different disciplines focus their expertise on the problems of a relatively small number of patients with cancer.  Researchers, physicians, and others who have joined the Center for Cancer Innovation are self-selecting.  We attract people who are interested in joining forces toward a grand goal, aspiring to accomplish what no single individual or lab could ever accomplish alone. Researchers who are interested only in advancing their own careers aren’t interested in joining us.

Dr. Pullen:  So you see care being provided by Oncologists and other specialists of the patient’s choice while your organization provides high-tech support and direction. Please give an example of how this might work for a non-Seattle based patient.

Dr. Blau:  Members of the Center for Cancer Innovation come from many different institutions, including hospital systems that compete with one another to attract patients.  To circumvent these competitive pressures, the Center for Cancer Innovation fosters the transfer of tissue and information, rather than a transfer of patients, between different institutions.  To illustrate how this works, our first clinical trial enrolls patients with a form of advanced breast cancer called metastatic “triple-negative” breast cancer.  Patients are enrolled from two sites that have no formal affiliation – the Seattle Cancer Care Alliance and Northwest Medical Specialties, which has offices in Tacoma and Puyallup.  Patients are seen by their own oncologist locally, biopsies are performed locally, and then tissues and clinical information flow into the Center for Cancer Innovation and information about what we’ve found flows back out to the oncologist and patient, allowing oncologists to bring world class advice and expertise at the point of care.

Dr. Pullen:  Can you explain how by participating in your program a patient can potentially benefit individually while at the same time contributing to the advancement of cancer treatment for other now and in the future?

Dr. Blau:  Our clinical trials enroll patients with advanced cancer who are eager to be the subjects of an unprecedented scientific investigation, in which we biopsy their tumors at multiple different sites of disease, subject multiple different bits of tumor to an extensive omic analysis, collect millions of datapoints, and place the information on the cloud, making it accessible to computational biologists from many different institutions.  These researchers interpret the information to the best of their abilities using the latest technologies, looking for a vulnerability that can be targeted with a drug.  Then we test their prediction by treating the patient with the drug that is predicted to work, and use the patient’s outcome to create a “learning loop” back to the researchers.  If the tumor doesn’t respond we repeat the process of biopsies, testing, analysis, and go onto the next prediction.  Through this process of “intensive longitudinal monitoring,” we aim to create is a massive database which will eventually constitute an “instruction manual” for how cancer works.  We summarize this approach as “all for one and one for all.”

Dr. Pullen:  I like that phrase, “All for one. One for all.”    Can you clarify just how a patient both benefits individually and contributes to oncologic care advancement.

Dr. Blau:  “All for one” – bringing the world’s expertise to bear in understanding and treating an individual cancer patient, and “one for all” – using that individual patient’s experience to add to the world’s understanding of how cancer works for the benefit of future patients.

Dr. Pullen:  Walk me through how an individual patient is managed in this model?

Dr. Blau:  Patients see their local oncologist and undergo an extensive informed consent process before they enroll on the trial.  A key point here is that even though we are trying our best to help the patients who enroll in our trials, the state of our knowledge is still very primitive, and in many cases even our best wont be good enough to benefit the patients who enroll in our trials.  Additionally, the patients who enroll in our trial are undergoing many more biopsies than they would normally, and these biopsies have a risk of complications.  After enrollment, patients are asked to complete a set of questionnaires detailing their medical histories and seeking their opinions.  Then they undergo a set of biopsies before starting treatment.  In our clinical trial in metastatic triple negative breast cancer, patients begin a chemotherapy drug called Cisplatin immediately after the first round of biopsies.  We perform testing on these tumors and aim to have recommendations ready for the patient and her oncologist by the time that the tumor becomes resistant to Cisplatin.  Then our protocol has provisions for additional biopsies prior to and following whatever subsequent treatments the patient receives.

Dr. Pullen:  How many patients are currently participating in this program?

Dr. Blau:  We have enrolled two patients with metastatic triple negative breast cancer.

Dr. Pullen:  What are the primary roadblocks to this program’s growth?

Dr. Blau: That’s easy – the main roadblock is funding.  Our budget for enrolling one patient is $125,000, so this is an extremely expensive trial for which we are seeking funding from many different sources.

DrP: How can readers help support your important work:

Dr. Blau:  We need champions who will tell their friends and family about us and help to build a grass roots network of support for our program.

Dr. Pullen:  Tony, thanks so much for taking the time to tell us about your work and vision. I for one hope you are successful beyond even your hopes and dreams.  Anyone interested in contacting the Center for Cancer Innovation can call their office at 206 685-6873 or contact Dr. Blau directly by e-mail   tblau – at – uw.edu    I’m sure they would love your financial or other support.

 

 

 

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