As dire a disease as it may seem, there are actually a lot of treatment options available for cancer.
These options can be divided into surgical and medical, with the latter including old stalwarts like chemotherapy and radiotherapy, and the newer hormone therapies, immunotherapies and targeted therapies.
In fact, sometimes, the choices can be quite overwhelming, especially for the oncologist who needs to not only decide on the type of therapy to prescribe their patient, but often also the best drug for that particular patient within that type of therapy.
Shares consultant clinical oncologist Dr Kua Voon Fong: “Cancer treatment has evolved very fast over the last few years.
“We have a lot of choices now for cancer treatment, and these choices depend on the stage and type of cancer, the patient’s age, and also their wellbeing.
“So, it’s quite overwhelming for doctors and patients to decide what is the best treatment available.”
She explains: “What we do usually is we gather a combination of treatments, we go through a first round of treatment for the patient, and based on their response, we decide whether to continue or change.
“So if the patient does not respond, we will go on to the second choice, and this will repeat until the patient responds.”
However, she notes that not all patients will benefit from this approach, especially those for whom time is of the essence because of the advanced stage of their cancer or the aggressiveness of the cancer.
“In terms of cancer treatment, there is no one-size-fits-all,” she says.
What it does
One way to help narrow down the treatment options is to do tumour, or molecular, profiling.
This is where a sample of the cancer cells is taken from the patient and analysed for their genetic and molecular characteristics.
As certain drugs are targeted at certain tumour characteristics, the confirmed presence or absence of these characteristics will let doctors know which drugs are likely to work or not.
Explains Caris Life Sciences International medical director international Dr Klaus Schuster: “Molecular profiling means that we are looking at the genes, what is happening in different parts of the genes, to ensure that we can treat cancer with more precision.
“We want to find drugs that have the highest likelihood of success for the patient.
“For that, we are looking at different parts of the genes – the DNA, RNA and proteins – to have a very comprehensive understanding of what is happening with the cancerous tissue.”
He says that many other companies only analyse the DNA of the tumour, which, while being the most important part of the tumour’s genes, is still only “a part of the iceberg”.
The patient’s cancer sample is not only analysed on a molecular level, but it is also entered into the US biotechnology company’s database.
According to Dr Schuster, this database not only currently contains the analysis of around 25,000 anonymised patient samples, but also the treatment each of those patients underwent and the outcome of each treatment.
This data, combined with relevant scientific evidence from clinical trials around the world, is used to come up with the best treatment options for each new patient.
“We offer meaningful information to the physicians, because on the one hand, we can highlight the drug or drugs that have the best likelihood of success, the best outcome.
“And on the other, we can also inform the physician which therapies – by looking at the markers, looking at the genes – that have a decreased likelihood of success,” he says.
He adds that their recommendations not only include both the standard and newer therapies, but also a list of relevant clinical trials the patient can potentially participate in.
In addition, Dr Schuster says that Caris offers clinical consultations with physicians via email or phone, with their own team of pathologists, geneticists and oncologists.
One reason is to ensure that the physician understands the information in the tumour profile report.
Shares Dr Kua: “As an oncologist, I will say, when I received the first molecular profiling report, I was overwhelmed with all the information provided.
“It took me a long time to understand what it all meant. I’m glad that we could interact and that Dr Schuster could teach me and I could learn – it is a steep learning curve.”
Another reason for the consultation is to enable the oncologist to discuss whether their patient is suitable for molecular profiling in the first place, and technical matters, like the best site to obtain the tumour sample.
The consultation can also be an avenue for the oncologist and Caris team to discuss the best treatment for the patient, as the tumour profile report does not take into account each individual patient’s situation and preferences.
Who should do it
While it can be argued that tumour profiling is potentially useful for all cancer patients, there are certain types of patients who will benefit from it more.
One group is those patients with rare or aggressive tumours.
“The reason for that is, in those patients, there is not a lot of evidence or clinical practice guidelines available,” explains Dr Schuster.
In those cases, he notes that the tumour profiling report can help provide the information needed to help the oncologist decide on the best treatment.
Dr Kua adds that this is especially so in patients with aggressive tumours because time is of the essence.
“The chances of them responding to the standard-of-care treatment is low. Because of the time shortage, they will have confidence if the tumour profile comes back and tells them which drug has a higher chance of working and which doesn’t.”
Another group, according to Dr Schuster, is those patients who have undergone multiple treatments, which have not worked, but are still in a relatively good condition.
“We want to offer something meaningful to these patients,” he says, i.e. an option for more targeted therapy based on their tumour profile.
“And the last ones are cancer patients who have multiple treatment options available.
“Tumour profiling can help the physician to find not only the best treatment for that time, but also the best sequence of treatments.”
He notes: “We try to find the best treatment for a specific patient at a specific timing because the cancer is evolving over the time.”
Dr Kua adds that another group of patients that would benefit from tumour profiling are those with an unknown primary, or original, tumour.
“There is a group of patients who come in not knowing what is their primary cancer, and the cancer has already spread throughout the whole body.
“With this kind of patient, we really don’t have a standard guideline to follow, and they will absolutely benefit from having tumour profiling.”
In terms of actual results, Dr Schuster says: “Normally, looking at the results, if we profile a patient, more than half of these patients will have a significant benefit.
“‘Significant’ means their survival time not only becomes longer, but also the quality of this time is improved.”
He adds that, based on their database, on average, patients who used tumour profiling services had their progression-free survival increased by more than 30%.
Progression-free survival means that the cancer has stopped growing or advancing, although it is still present in the patient.
In Malaysia, Caris has partnered exclusively with Mundipharma Pharmaceuticals since 2016 to deliver their services to local patients and oncologists.
Mundipharma helps to collect and send the tumour samples from local patients to Caris’ laboratory in the United States to be analysed.
Dr Schuster notes that it takes around two to three weeks from the time the sample is collected for it to be analysed and the report produced and sent to the oncologist.
According to Mundipharma South-East Asia medical head and Malaysia & Singapore medical director Dr Murtaza Qasuri, around 10%-15% of oncologists in Malaysia have used their tumour profiling service.
“There are various reasons for that. One is the price, which, of course, needs to be justified,” he says.
“But I see that as we go forward and more evidence comes in, more doctors are going to trust and develop confidence in this tool as their partner in informed treatment decision-making.”
He shares that the price for testing and analysing one tumour sample is currently RM25,000, but anticipates that this price will reduce if the demand for tumour profiling increases.