Working together to integrate research directly into clinical cancer care

As a medical oncologist, I have seen a steady increase in the number of genomic tests incorporated into the standard of care for cancer medicine. The integration of genomic information into clinical care has allowed us to greatly improve outcomes for a small number of highly selected patients, and these successes have established the importance of genomic profiling as a powerful tool to personalize cancer treatments through precision medicine.  

Genomic or molecular tests currently used in the clinic most often consist of targeted panels that profile a few genes of known interest, and their findings are directly linked to approved and funded treatments for specific stages and types of cancer. Unfortunately, in most cases these tests are not sufficient to identify targetable abnormalities, and even when they are identified, the linked therapeutics are not always funded by healthcare systems.  

To address these limitations, ongoing research efforts are looking at more comprehensive genomic profiling and working to define which specific testing technologies are most effective and efficient for different tumour types and clinical settings. When oncology research is integrated into clinical care, it becomes possible for individual patients to benefit from discoveries in real time while researchers learn how to best implement cutting-edge technologies and treatments. As a co-founder and clinical lead of the Personalized OncoGenomics (POG) program at BC Cancer and Canada’s Michael Smith Genome Sciences Centre, I have seen first-hand how beneficial integrated cancer research can be for individual patients and how even small cohorts of patients can change standard practice; we have seen the promise of collaborative translational research. 

POG is a prospective research program that studies how more comprehensive genomic data – specifically whole-genome and transcriptome analysis (WGTA) – can be integrated into treatment decisions and used to select patients for clinical trials and catalyze new trials. The data we get from looking at the whole genome and transcriptome has enabled us to identify many more cancer-driving abnormalities, including genetic alterations, and has helped us to identify potential targets for therapy far more often than targeted panel tests. Panel testing typically identifies a potentially clinically actionable therapy in roughly 30 per cent of cases, but with WGTA we have found something actionable over 80 per cent of the time. This wealth of data also enables us to align patients to novel targeted therapies, clinical trials, and off-label treatments (those that are standard for other cancers or diseases), thus greatly increasing the potential for treatments. In addition, WGTA has enabled us to identify specific markers for the use of standard cytotoxic chemotherapies, thereby expanding treatment options to more commonplace and often inexpensive treatments.  

Research programs like POG are demonstrating the potential impact of precision medicine enabled by comprehensive genomic profiling. To implement this on a wider scale, however, we need to re-imagine how we do cancer research and care in Canada.  

First, we need to broaden our approach to clinical trials and to what kinds of data are considered sufficient and significant. Today, healthcare system decisions about which treatments to approve and fund are typically based on randomized controlled trials, which are resource-intensive, rely on large sample sizes and often use placebo controls to provide the type of evidence needed to displace existing standard of care by demonstrating safety, efficacy and cost-effectiveness. This has been a safe and thoughtful approach. However, if the premise of precision medicine is that all cancers are, by definition, unique, these types of trials become increasingly difficult to implement. Indeed, it is difficult to effectively or even ethically implement a randomized study when a drug target is only identified in a niche population.  

This understanding has led to the emergence of a new clinical trial paradigm that emphasizes smaller, targeted cohorts and the use of evidence gathered in actual treatment settings – approaches sometimes referred to as “N of 1” studies or "real-world evidence".  This is one area in which large collaborative projects like the national Marathon of Hope Cancer Centres Network (MOHCCN), led by the Terry Fox Research Institute and the Terry Fox Foundation, can make a significant impact by enabling cross-country studies that can enroll enough patients needed to generate the type of high-quality evidence needed to inform funding and implementation decisions. By facilitating and promoting collaborations between investigators in diverse communities and at cancer centres across the country, the Network is supporting nation-wide research and precision oncology trials, leading to higher quality research and promoting more equitable access to research-based care. 

To facilitate this evolution in our approach to clinical trials, the MOHCCN is bringing together researchers, clinicians, patients, administrators, funders, volunteers, and other key stakeholders across the country to build consensus, share data and knowledge and establish a common vision across its diverse membership. Importantly, this includes trainees and young investigators, including clinician-scientists, whose education and involvement are particularly critical to the future of precision oncology in Canada and beyond. This unified, future-facing approach is helping to create sustainable and equitable improvements in cancer research and care. 

Perhaps most importantly, the MOHCCN and POG (which the Network helps to fund) are implementing a patient-centric approach to cancer research and care and are guided by patient values and preferences. Meaningful patient involvement and engagement in research activities is essential to ensure that advances in care respond to genuine patient needs. This complex but vital work will help ensure the successful implementation of precision medicine and personalized care while also empowering patients in their own care journeys. 

As a practicing medical oncologist who has been involved in research throughout my career, I firmly believe that the integration of research into clinical care improves the quality of both activities. I strongly believe that good clinical care includes research and that every patient should have the opportunity to participate in research both for their own benefit and to contribute to our knowledge of how to do better. Large-scale collaborative efforts like the MOHCCN are essential to make this possible on a national scale and, crucially, enable us to unite our efforts for the benefit of all people with cancer.

*Dr. Janessa Laskin is a medical oncologist at BC Cancer and the co-founder and clinical lead of the Personalized OncoGenomics (POG) program at BC Cancer, Canada's Michael Smith Genome Sciences Centre and the University of British Columbia (UBC). She is also a member of the Marathon of Hope Cancer Centres Network's Steering Committee and co-chair of the Network's Return of Results Working Group.