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  • Imaging at the Forefront of Precision Medicine

    Precision medicine continues to evolve at a rapid pace and the role of imaging is closely linked with that progress. By Mike Bassett

    June 1, 2017

    Two years after former President Obama launched the $215 million Precision Medicine Initiative, the movement continues to evolve at a rapid pace and the role of imaging is closely linked with that evolution.

    The 2015 initiative, which was developed to pioneer a new model of research to spur biomedical advances and provide clinicians with the tools and therapies needed to target treatments to individual patients, allocated $70 million from the 2016 federal budget to the National Cancer Institute (NCI) to advance the field of precision oncology.

    According to the NCI, the pairing is a natural choice considering that precision medicine uses the genetics of a disease to identify appropriate treatments and that cancer is a disease of the genome.

    Similarly, imaging is intrinsically tied to precision medicine as the primary method for observing — or phenotyping — the unexplored regions of the genome, according to Janet F. Eary, MD, deputy associate director of the NCI’s Cancer Imaging Program.

    “Imaging makes an important contribution in helping understand the phenotype of the patient and the expression of the genomics, proteomics and other aspects of tumors,” Dr. Eary said. “So imaging fits well into the notion that we can select therapies that are really aimed at individual patients.”

    Targeting Treatment to Individual Patients

    The growth of precision medicine has been fueled by the increased capability to gather information on each patient and define disease on a more granular level.

    While precision medicine has no single definition, the National Institutes of Health defines it as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment and lifestyle for each person.”

    From his perspective as an oncologist with expertise in immunotherapy, Elad Sharon, MD, MPH, medical officer for NCI’s Cancer Therapy Evaluation Program, described precision medicine as the use of a drug or agent that has been developed as a result of a molecular study of a particular target or gene mutation, as opposed to a treatment like chemotherapy which tends to be more nonspecific.

    “These kinds of therapies fall under the rubric of precision medicine because we are able to discern that someone lacking the gene or mutation in question should not be treated with a particular agent because it’s unlikely they will get any benefit,” Dr. Sharon said.

    One example: The U.S. Food and Drug Administration (FDA) recently modified the indication for the drug erlotinib for the treatment of non-small cell lung cancer, by limiting its use to patients whose tumors have specific epidermal growth factor receptor (EGFR) mutations that are present in a small percentage of lung cancer patients in the U.S.

    Because original studies of erlotinib involved the overall non-small cell lung cancer population in a relapsed setting, approval was granted to relapsed patients as a whole. However, the benefit that was seen was likely only a subset of patients. Further studies pointed to the benefits of limiting the use of the drug.

    Dr. Sharon says this is a good example of how precision medicine is moving patients toward targeted treatment.

    “Prior to this we would have given this drug to the entire population of patients with non-small cell lung cancer,” he said. “Now, with better techniques, we are able to underline the concept that patients are only going to benefit from the therapy if they have the (EGFR) mutation in question.”

    Such personalized treatments and therapies would not be possible without imaging, said Luis E. Selva, PhD, health science specialist and biomedical physicist at the VA Boston Healthcare System and the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC).

    “We can use imaging modalities to find the best possible treatment plan based on some extraction of information from the modality itself, whether it be CT, MRI or PET,” Dr. Selva said.

    Data Rich Programs Lead to Personalized Care

    Dr. Selva is a member of the Precision Oncology Program (POP) founded in 2015 by the VA’s New England Healthcare System and MAVERIC, which is a clinical care program with a research component intended to bring personalized healthcare and cutting-edge cancer treatment to veterans. The program is initially focusing on lung cancer but will likely expand to other forms of cancer.

    Imaging is critical to the POP, which maintains a public de-identified data set that describes the types of cancers, cancer mutations, stages and treatments that can be used to foster research and cutting-edge therapies.

    The POP is a precursor to the Applied Proteogenomics Organizational, Learning and Outcomes (APOLLO) consortium, a nationwide system to routinely screen patients for genomic abnormalities and proteomic information in order to match their tumor types to specific targeted therapies. APOLLO was founded in 2016 by the U.S. Department of Veterans Affairs, the Department of Defense and the NCI under the umbrella of the NCI’s Cancer Moonshot initiative (Read more in Look Ahead, page 5).

    To facilitate APOLLO, the New England VA created a research component of the POP — Research-POP (RePOP) — comprising veterans who agreed to share their medical data including clinical, imaging and genomic information, as well as pathology reports, radiotherapy images and treatment plans, inside and outside of the VA, Dr. Selva said.

    “The idea is to make all of this data available to researchers and clinicians at the time of diagnosis so we know the previous history of results for patients treated for a certain type of cancer,” Dr. Selva said.

    He pointed out that clinicians will be able to better target treatments based on information extracted from these different data streams.

    “This is where the frontier of precision medicine is heading,” Dr. Selva said. “Having all of these data streams available for clinicians so they can put their patients in the best and most suitable treatment plans is the goal.”

    Editor’s Note: This is the first in a series of articles on the role of imaging in precision medicine. The next two articles will cover case-specific prediction of therapeutic outcomes and the role of cross-disciplinary science alliances.

    NCI Perception Lab Returns at RSNA 2017

    Launched at RSNA 2016, the National Cancer Institute’s (NCI) Perception Lab will continue its research at RSNA 2017. Researchers supported by NCI will conduct studies on radiologic image perception in an open lab environment in the Learning Center. Additionally, the NCI Cancer Imaging Archive will conduct a new image annotation crowdsourcing activity at RSNA 2017.





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