Tuesday, March 03, 2009

MGH To Mutation-Type All Cancer Patients

Today's Boston Globe carried a front page item that Massachusetts General Hospital is planning to screen all cancer patients for a battery of about 110 common cancer mutations in 13 genes. MGH is apparently the first hospital to go this in depth on every patient.

This is an exciting push forward into personalized medicine, and it makes sense for a teaching hospital such as MGH to leap into the void. This sort of typing makes intuitive sense, but (as the article states) its clinical value remains to be proven. A few patients, such as one profiled in the piece, will have radical changes in treatment which benefit the patient -- in the example a woman had a relatively rare kinase fusion (to EML4-ALK) for which an investigational drug was available -- and she responded spectacularly. But for many patients, the mutations found won't change care because there isn't a known way to target their mutation spectrum.

But, the huge value will be longer term as MGH builds a database of mutations and responses to treatment -- such a database will almost certainly provide new ideas for treatment, ideas which a research-focused hospital will be willing & able to try out. As more mutations are linked to cancer outcomes and screening costs come down, surely the panel will be expanded. MGH is also presumably planning to screen patients on both initial diagnosis and after relapses, so an increasingly rich database of mutations appearing during cancer progression will emerge.

It will be interesting to see how many other hospitals here -- and elsewhere -- follow. Boston has a small herd of top-notch hospitals and most (if not all) have significant cancer centers (with one, Dana Farber, completely focused on the subject). Ideally the results of many such screens could be pooled into one or more common databases, with of course the need to protect patient confidentiality.

One barrier may be cost. The Globe article pegs it at $2000, and states it is unclear if insurers will pay -- in the past they have demanded proof of clinical value. While that isn't an indefensible position, it would be in their self-interest to chip in -- perhaps a prorated amount. First, it's lousy PR to not pay for diagnostics that are likely to work (and the drumbeat for single-payer is pretty much constant in the same paper). Second, the tests are likely to provide useful information some fraction of the time -- and in those cases may provide cost savings. MGH is apparently considering eating the cost or asking the patients to kick some in.

MGH may also be setting the price point for such services. $2K isn't far from the $4K that Complete Genomics claims it will be able to run a complete genome in the not-too-distant-future. $2K probably is in the ballpark already for sequencing off capture arrays.

Of course, budgets for diagnostics aren't infinite. Will such initiatives be knocking elbows with other genomics-driven diagnostics, such as the existing array-based assays (e.g. OncotypeDX, CupPrint)? Will greater value come from methylation profiling or other assays which evaluate markers not available to current sequencing technologies? Time will tell.

No comments: