Scenes from the Cancer Personalized Medicine Wilderness

I'm going to attempt to synthesize a number of thoughts which I've long pondered along with a bunch of news items I came across today. With luck, the result will be coherent and I'll not make a fool of myself.

There was a very interesting article last week in the New York Times on a serious ethical dilemma in melanoma and how different specialists in the field are voicing opinions on both sides of the divide. Even better, today I came across an excellent blog post reviewing that article which also added a lot of expert background. I'll summarize the two very quickly.

Metastatic melanoma is an awful diagnosis; the disease is very aggressive. Furthermore, the standard-of-care chemotherapy drug is a very ugly cytotoxic, with nasty side effects and very poor efficacy (more on that later). Sequencing studies have revealed that well over half of metastatic melanomas have a mutant form of the kinase B-RAF (gene: BRAF), most commonly the mutation V600E (which, alas, due to some sequencing error was for a while known as V599E). That's the substitution of an acidic residue (glutamate) for a hydrophobic one (valine), and it is right in the kinase active site.

Now, a biotech called Plexxikon, in conjunction with Roche, has developed an inhibitor of B-RAF called PLX4032. In Phase I trial results reported this summer in the New England Journal of Medicine, very promising tumor regressions were seen. Now remember, this was a single-arm Phase I trial for safety, meaning we don't have an objective comparison to make.

And there begins the rub. To some doctors (and many patients), the combination of great preclinical results, the theoretical and experimental underpinnings for targeting B-RAF in melanoma and the observed regression means we have a winner on our hands and it is now unethical to have a randomized trial comparing the new compound against the standard-of-care.

At the other pole are doctors who worry that we have been fooled before.
My standard example to trot out for such cases is a famous CAST cardiovascular trial to which a placebo arm was grudgingly added -- a sound theory had been advanced that
suppressing arrythmias in certain patients would prevent death. CAST was stopped early when it was clear the placebo arm fared far better; the toxicities of the drugs overwhelmed any benefits. Even closer to our current story is the drug sorafenib, which was originally developed as a B-RAF antagonist. Now, there are many in the field who argued that it really wasn't, but Bayer and Onyx got it to market (probably based on its inhibition of numerous other kinases) and the "raf" syllable in the generic name points to their belief in the B-RAF theory. Unfortunately, in randomized clinical trials it failed to work in V600E melanomas.

One idea that was apparently floated by at least one oncologist working in the trials, but rejected by the corporate sponsors, was to try to win approval based on nearly miraculous recoveries seen in some patients on death's door. What the NYT article failed to discuss is whether the FDA would buy that argument; there are many reasons to think they wouldn't -- they really do not like single arm trials, because all too often spurious results occur do to random chance (or rarely, to manipulation of the trial).

An important idea discussed in all this is the concept that once we have established a therapy as efficacious, it is generally unethical to withhold that therapy from patients. But, we are often not on such solid ground even in this area. Clinical trials represent a horrible case of multiple testing; more than a few drugs that squeaked through their trial would not if you ran the trial again; they just got lucky. Don't believe me? Think back to Iressa, which received accelerated approval for lung cancer and then had it withdrawn (only to later be reintroduced). We now know a key piece of that particular puzzle: Iressa works in patients whose tumors have mutant forms of the EGFR. The first trial, by chance, was enriched for such patients and the second trial (also by chance) was not as enriched. Given that the EGFR hypothesis wasn't known, neither trial could have been manipulated.

But another recent item, covered in a different post on the same blog, reminds us that even well-established clinical approaches may not hold true over time. Screening mammography is a hot potato issue in cancer: can you save lives by screening healthy women for breast cancer. Various studies have tried to ask this question not just for women overall, but by age groups since the incidence of breast cancer and the quality of mammograms changes with patient age. The newest fuel on this fire is a very clever Norwegian study, which I won't attempt to summarize, that suggests that much (but perhaps not all) of the benefit of screening mammography has been eroded by improvements in cancer care. In other words, the advantage of early detection has been blunted by better treatments. Now, I'm not qualified to really review that study, but certainly this is a concept we should keep in mind: the utility of medical strategies may change over time, and not always for the better.

In my mail tonight was a thick magazine-sized volume from Scientific American, which I confess I am not a subscriber of (it's a fine magazine; I just already subscribe to too many fine magazines). This special edition, titled "Pathways: The changing science, business & experience of health", focuses on healthcare with a mix of articles. Some appear to be written by professional writers, while others are thinly-veiled advertisements for various companies.

In scanning the table of contents, I was caught by "Pioneering Personalized Cancer Care", though unfortunately this turns out to be one of the puffier pieces. Written by two principles in the company, it mostly describes N-of-one, a company which has as its customers cancer patients. N-of-one tries to distill the available knowledge on a person's tumor and help them navigate to the most appropriate tests. It's a business model I've sometimes wondered about for myself, since playing an oncologic Sherlock Holmes could be both fascinating and rewarding. On the other hand, the regulatory environment is fraught with uncertainty and most likely this sort of organization will have to rely on wealthy customers willing to pay their own way.

Now, the article did set my teeth on edge early on with the statement "Recently, projects such as the Cancer Genome Atlas have documented thousands of mutations in cancer cells that can lead to unregulated cell growth and prevent apoptosis (cell death), the hallmarks of malignancy". Any regular reader of this space knows that I am a gung-ho proponent of sequencing tumors, but with that comes an obligation to be honest. And the honest truth is that sequencing has yielded thousands of candidates, but only a handful of those have actually been shown to have transforming ability -- there's just no high-throughput way to do that en masse.

But, what N-of-one and others are doing is where I strongly believe the future of oncology lies. But, it will be a complicated place. Getting back to B-RAF, I've heard noise that it has been found in a number of additional tumor types, albeit at low frequency. So, supposes it occurs at 1 in 1000 frequency in some awful tumor type. With routine whole-genome sequencing of tumors, we could detect that. Such sequencing is starting to be used to good effect, as reported recently in Nature. That leads to a conundrum for everyone. For a patient or clinician, do you go with PLX4032, given that we know it targets BRAF -- but knowing that we don't know whether BRAF is really driving your tumor (especially if the mutation is not V600E)? For those wanting to design clinical trials, could you really find enough patients to stock a trial -- or are you willing to have a trial with "any cancer, as long as it has a BRAF mutation"?

This is the challenge that personalized medicine presents us. With genome sequencing (and eventually also routine whole methylome profiling), we can find what makes cancers different -- but how will we ever actually sort through all those differences? Should we move away from randomized trials to going where the science seems to lead us, even knowing that more than a few times there have been dead ends?

I can find only one easy answer to all this: don't trust anyone who offers an easy answer to all this.

Review: The $1000 Genome

Kevin Davies' "The $1000 Genome" deserves to be widely read. Readers of this space will not be surprised that there are a few changes I might have imposed had I been its editor, but on the whole it presents a careful and I think entertaining view of the past and possible future of personal genomics.

The book is intended for a far wider audience than geeky genomics bloggers, so the emphasis is not on the science. Rather, it is on some of the key movers-and-shakers in the field and some of the companies which have been dominating this space, ranging from the first personal genetic mapping companies (23 and Me, Navigenics, Pathway Genomics and deCodeMe) to the instrument makers (such as Solexa/Illumina, Helicos, Pacific Biosciences, ABI and Oxford Nanopore) to those working on various aspects of human genome sequencing services (such as Knome and Complete Genomics. Various ups and downs of these companies -- and the debates they have engendered -- are covered as well as the possible impacts on society. Along the way, we see a few glimpses of Davies exploring his own genome and some of the biological history which he seeks to enlighten through these expeditions.

It is not a trivial task to try to explain this field to an educated lay public, but I think in general Davies does a good job. The overviews of the technologies are limited but give the gist of things. Anyone writing in this space is faced with the dilemma of trying to explain too much and losing the main thread or failing to explain and preventing the reader from finding it. Mostly I think he has succeeded in threading this needle, perhaps because only rarely did I feel he had missed. One example I did note was in explaining PacBio's technology; hardly anyone in science will know what a zeptoliter is, let alone someone outside of it. On the other hand, what analogy or refactoring of that term could remove it from the edges of science fiction? Not an easy challenge!

For better or worse, once I've decided I generally like a book like this my next thoughts are what could be removed and what could be added. I really could find little to remove. But, there are a few things I wish were either expanded or had made it in altogether.

It would be dreary to enumerate every company which has ever thrown its hat in the DNA sequencing ring. It is valuable that Davies covers a few of the abject failures, such as Manteia (which did yield some key technology to Illumina when sold for assets) and US Genomics. There is scant coverage, other than by mention, of most of the companies which have but nascent attempts to enter the arena. However, the one story I really did miss was anything about the Polonator. It's not that I really think this system will conquer the others (though perhaps I hope it will hold its own), it just represents a very different tack in corporate strategy that would have been interesting to contrast with the other players.

Davies has been in the thick of the field as editor of Bio IT World, so this is no stitching together of secondary sources. I also appreciated that he includes both the ups and the downs for these companies, emphasizing that this has not been easy for any of them. But, that added to my surprise at several incidents which were left out (believe me, many were left in I had never heard before). Davies describes how Helicos delivered an instrument to the CRO Expression Analysis, but not that it was very publicly returned for failing to perform to spec. Nor is Helicos' failed attempt to sell themselves mentioned. An interesting anecdote on Complete Genomics is how a wildfire nearly disrupted one of their first human genome runs; left out is the near-death experience of that company when it was forced to either lay off or defer salaries for nearly all of its staff. The section on Complete's founder Rade Drmanac mentioned Hyseq, but not the company (or was it two) which he ran between Hyseq and Complete to try to commercialize sequencing-by-hybridization. This would have added to this portrait of determination -- and the travails of the corporate arena. I was also surprised that the short profile of Sydney Brenner as a personal genomics skeptic didn't include the fact he invented the technology behind Lynx, which was another early attempt in non-electrophoretic sequencing. Some would see that as irony.

Another area I would like to have seen expanded was the exploration of groups such as Patients Like Me, which are windows on how much people are willing to chance disclosing sensitive medical information. One section explores the fact that several prominent persons interested in this field became so when their children were diagnosed with rare recessive disorders, leading them to ponder whether they would have made the same marriage had they known in advance of this danger. I was surprised that little of the existing experience in this area was explored; I believe the Ashkenazi population has dealt with this in screening for Tay-Sachs and other horrific disorders which are prevalent there.

The book is stunningly up-to-date for something published the beginning of September; some incidents as late as June are reported. Despite this, I found little evidence of haste. I'm still trying to figure out what a "nature capitalist" is, but that's the only case I spotted of a likely mis-wording.

Davies briefly explores possible uses of these sequencing technologies beyond our germline sequences, but only very briefly. Personally, I think that cancer genomics will have a more immediate and perhaps greater overall impact on human medicine, and wish it had gotten a bit more in depth treatment.

Davies in a expatriot Brit, living not very far from me. The sections on the possible impact of widespread genome sequencing on medicine are written almost entirely from a U.S. perspective, with our hybrid public-private healthcare system. I suspect European readers would hunger for more discussion of how personal genomics might be handled within their socialized medical systems and different histories of handling the ethical issues (Germany, I believe, has pretty much banned personal genomics services). On this side of the pond, he does a nice job of showing how different state agencies have charged into the breach left, until recently, by the FDA.

Okay, too many quibbles. Well, maybe one last one -- it would have been nice to see more on some of the academic bioinformaticians who have created such wonderful and amazing open-source tools as Bowtie and BWA.

As I mentioned above, Davies injects a good amount of himself into all this. I've encountered books (indeed, on recently on moon walkers), in which this becomes a tedious over-exposure to the author's ego. This is not such a book. The personal bits either link pieces of the story or make them more approachable. We find out that he has already attained a greater age than his father did (due to testicular cancer, one of the few cancers in which overwhelming progress has been made), leading to questions he hopes his genome can answer. Hence, his trying out of pretty much all of the array-based personal genetic services. But, he does not address one question that the book raised in my mind: will the royalties from this project fund a complete Davies genome?

ARID1A A Fertile Ground for Mutations in Ovarian Clear Cell Carcinoma

Although ovarian clear cell carcinoma does not respond
well to conventional platinum–taxane chemotherapy
for ovarian carcinoma, this remains
the adjuvant treatment of choice, because effective
alternatives have not been identified.

This sentence is a depressing reminder of the status of medical treatment of far too many tumor types. Present in roughly 12% of U.S. ovarian cancer cases, ovarian clear cell carcinoma (OCCC) is a dreadful diagnosis.

Two papers this week made a significant step forward in understanding the molecular basis -- and heterogeneity -- of this horror. Seemingly the finale of an old-fashioned race to publish, groups centered at the British Columbia Cancer Center (in New England Journal of Medicine) and Johns Hopkins University (in Science) published papers with the same headline finding: inactivating mutations in the chromatin regulating gene ARID1A (whose gene product is known as BAF250) are a key step in many -- but not all -- OCCC. I'll use the shorthand Vancouver and Baltimore to refer to the respective groups.

Both papers got here by the largest applications of second generation sequencing to cancer so far published. The Vancouver work relied on transcriptome sequencing (RNA-Seq) of a discovery cohort of 18 patients; the Baltimore group used hybridization targeted exome sequencing on just 8 patients. Both used Illumina paired-end sequencing for the discovery phase; Vancouver also used the same platform for validation on a larger cohort.

Whole genome sequencing is likely the future for cancer genomics. A non-cancer paper just published 20 genomes in one shot, underscoring how this is becoming routine with easy samples & a work which is apparently in press (I have no inside knowledge; it has been discussed at several public meetings) will have perhaps a dozen human genomes in it. But, there are still cost advantages to focusing on expressed genetic regions (and perhaps a bit more) and perhaps further information to be gleaned from actually looking a gene expression. These two papers give an opportunity, albeit a bit constrained, to compare the two approaches.

One interesting note comes straight out of the Vancouver data. After finding ARID1A mutations in 6/18 discovery samples, they re-screened those samples plus 211 additional samples. In total this set included 1 OCCC cell line, 119 OCCC, 33 endometrioid carcinomas and 76 high-grade serous carcinomas. The validation screen was by long-range PCR (mean product size 2067 bp) products sheared and sequenced on the Illumina. One exon proved troublesome and required further PCR and sequencing by Sanger. In any case, the key bit here is in the discovery cohort this approach found ARID1A mutations which had been missed by the original RNA-Seq. As the authors state, a likely culprit is nonsense mediated decay (NMD). It would be interesting to go into their dataset to see if these samples had a markedly lower expression of ARID1A, though I don't have easy access to it (it has been deposited, but with protections that should be the subject of a future post).

One interesting contrast between the two studies is the haul of genes. The Vancouver group found ARID1A as a recurrently mutated gene; the Hopkins group not only bagged ARID1A but also KRAS, PIK3CA and PPP2R1A. KRAS and PIK3CA are well-known oncogenes in multiple tumor types and had previously been implicated in OCCC, but PP2R1A is a novel find. The Vancouver group did specifically search for KRAS and PIK3CA mutants in their cohorts by PCR assays and found one patient sample and one cell line with KRAS mutations. Again, it would be interesting to review the RNA-Seq data to generate hypotheses as to why these were not found in the Vancouver set. On the other hand, the RNA-Seq data did identify one case of a rearranged ARID1A. While it is possible to use hybridization capture to identify gene fusions, this cannot be practically done in a hypothesis-free manner. In other words, without advance interest in ARID1A that approach would not work. In addition, CTTNB1 (beta catenin) mutations had been found previously in OCCC and were specifically checked (and found) by the Vancouver group, but none were reported by the Baltimore group. One final small discrepancy: both groups looked at cell line TOV21G for their mutations of interest and both found the same activating KRAS and PIK3CA alleles. However, Vancouver found one ARID1A allele but Baltimore found that one and a second one (actually, the two mutations I am calling the same [1645insC and 1650dupC] aren't described precisely the same, though I'm guessing it is a difference in an ambiguous alignment).

One other surprise is that TP53 (p53) and PTEN mutants had apparently been reported either for OCCC or endometriosis-associated tumors, yet neither group reported any.

An analysis that is not explicitly found in either paper but I feel is valuable is to look at the co-occurrence of these mutations. If we look only at patient samples, then the big take-home is that neither group saw co-occurrence of KRAS and ARID1A (the TOV21G cell line is at odds with this conclusion). Mutually-exclusive mutations have been seen in many tumors. For example, KRAS mutations are generally mutually-exclusive with other mutations in the RTK-RAS-RAF-MAPK pathway. In contrast, ARID1A mutations are found in conjunction with mutations in CTTNB1, PIK3CA and PPP2R1A -- one patient sample in the Baltimore data was even triple mutant for ARID1A, PIK3CA and PPP2R1A. About 30-40% of sample are mutated for none of these genes as far as this data can tell; the hunt for further causes will continue. Will they be epigenetic? Mutations in regulatory elements?

Another interesting comparison is simply the number of mutations per sample. The Hopkins exome data typically has very small numbers of mutations (after filtering out germ line variants); as few as 13 in a sample and as many as 125 -- and the high number was from a tumor which had previously been treated with DNA-damaging agents (all of the other tumors in the Hopkins study were treatment naive). In contrast, the Vancouver data often found more than 1000 non-synonymous variants per tumor. Unfortunately, no clinical history information is available for the Vancouver cohort, so we don't know if this is from DNA-damaging therapeutics or differences in the sequencing or variant filtering. In an ideal world, we could filter each data set with the other group's filtering scheme to see how much of an effect that would have.

The Vancouver group went beyond sequencing to examine samples by immunohistochemistry (IHC) for expression of the ARID1A gene product, BAF250. There is a strong, but imperfect, negative correlation between mutations and BAF250 expression. Some mutated but BAF250-expressing samples may be explained by the target of the antibody; the truncated forms may still express the correct epitope. Alternatively, ovarian cells may be very sensitive to the dosage of this gene product (in some samples both wt and mutant alleles were clearly found in the RNA-Seq data). Also of interest will be samples lacking expression but unmutated; these may be the places to identify further mechanisms for tumors to eliminate BAF250 expression.

The Vancouver study illustrates one additional bonus from RNA-Seq data: a list (in the supplemental data) of genes differentially expressed between ARID1A mutant and ARID1A wild-type cells.

Another interesting bit from the Vancouver paper is looking at two cases in which the tumor was adjacent to endometrial tissue. In one of these, the same truncating mutation was found in the adjacent lesion and tumor -- but not in a distant endrometriosis. Hence, the mutation was not driving the endometriosis but occurred afterwards.

I'm sure I'm short-shrifting further details from the paper; there's a lot of data packed in these two reports. But, what will it all mean for ovarian cancer patients? Alas, none of the genes save PIK3CA are obvious druggable targets. PIK3CA encodes the alpha isoform of PI3 kinase, a target many companies are working on. But that wasn't novel to these papers. PP2R1A is a regulatory subunit of a protein phosphatase and the mutations are concentrated on a single amino acid, suggesting these are activating mutations (as seen in ARID1A, inactivating mutations can sprawl all over a gene). Phosphatases have not been a productive source of drugs in the past, but perhaps that can be changed in the future. Chromatin regulation is a hot topic, but ARID1A is deficient here, not active. Given that tumors can apparently live with two mutated copies, the idea of further inactivating complexes with ARID1A mutations is probably not a profitable one. But, perhaps there is a ying-yang relationship with another chromatin regulator which can be leveraged. In other words, perhaps inhibiting an opposing complex could restore balance to the cell's chromatin regulation and inhibit the tumor. That's the sort of work which can build off of the foundation these two cancer genomics papers have provided.




Kimberly C. Wiegand, Sohrab P. Shah, Osama M. Al-Agha, Yongjun Zhao, Kane Tse, Thomas Zeng, Janine Senz, Melissa K. McConechy, Michael S. Anglesio, Steve E. Kalloger, Winnie Yang, Alireza Heravi-Moussavi, Ryan Giuliany,Christine Chow, John Fee, Abdalnas (2010). ARID1A Mutations in Endometriosis-Associated Ovarian Carcinomas New England Journal of Medicine : 10.1056/NEJMoa1008433

Jones S, Wang TL, Shih IM, Mao TL, Nakayama K, Roden R, Glas R, Slamon D, Diaz LA Jr, Vogelstein B, Kinzler KW, Velculescu VE, & Papadopoulos N (2010). Frequent Mutations of Chromatin Remodeling Gene ARID1A in Ovarian Clear Cell Carcinoma. Science (New York, N.Y.) PMID: 20826764