Precision oncology: tests are missing and who can interpret them
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Over the last few years, oncology has made great strides, especially in the field of precision medicine, and above all thanks to genetics. Yet, as often happens when it comes to healthcare, without a strategy there is the risk that each region will make its own story, with the result that the benefits of innovative therapies, born thanks to precision medicine, are not the same for everyone the patients. This is what is happening: there are no tests and no one who can interpret them. Not all specialized centers for oncological therapies, in fact, have the possibility of accessing extensive genomic sequencing, nor are there everywhere the teams of multidisciplinary experts who guide the choice of therapies on the basis of these tests. The directors of the medical oncology departments of the regions themselves denounced it, reached in a survey conducted by the experts of Cipomo (Italian College of Primary Oncologists and Hospital Doctors) and published in The Oncologist. And they do so the day after the draft establishing the Molecular Tumor Boards and identifying the specialist centers for carrying out NGS tests was sent to the State-Regions Conference: 129 managers were consulted, from 19 regions.
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NGS: each center makes its own story
The main results emerging from the survey show that the use of new generation genomic tests is still scarce nationwide. In fact, for NGS, i.e. extended genetic sequencing techniques that allow for the analysis of large quantities of DNA, the types used are different: in some cases specific for tumours, in others not, with a very variable number of biomarkers. Only 10% of respondents admit to using it as a routine for most patients, although almost 30% believe it would be the appropriate strategy to use from the first diagnosis of the disease. To date, however, the experts recall, the recommendations of the Esmo (European Society for Medical Oncology) advise the use of these tests only for some tumors. Overall, for the centers questioned, NGS techniques are used only in half of the cases, and in the vast majority of these (over 80%) relying on internal or regional laboratories.
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But what should an NGS exam report contain? For more than half of the department heads it should report all the biomarkers analyzed and for 20%, however, only the markers approved by the guidelines. Furthermore, for 25% the reports should have two versions: an in-depth one for clinicians and a simplified and reduced one for patients. Patients who are not always aware of the molecular analyzes conducted on their samples (more than in a third of cases), raising the problem of standardizing informed consent policies as well.
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The presence of Molecular Tumor Boards
In terms of the Molecular Tumor Boards (MTB) – present in 13 regions – about a third of the interviewees declare that they do not have access to this team and, in cases where there is, only about 24% declared that they consulted it for advice . For a third, the current MTB organization is not optimized to meet the needs of specialists. There is also no agreement on how opinions should be organised: for 38.6% they should be regional, for 43.6% intra-regional and about 18% imagine that the ideal condition would be to have a local MTB and one regional. The majority of respondents believe that oncologists, molecular biologists, pathologists, geneticists, hospital pharmacists and case managers should be present within the group. All this suggests, the experts comment, that MTBs in the vision of managers should be devoted more to the analysis of clinical cases than to bureaucratic and political issues.
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On when to ask them, experts believe MTBs should deal with the most difficult cases, those of patients who have run out of treatment options, with rare mutations or with rare and orphan cancers. The information coming from this survey will be invaluable in helping CIPOMO now put together a consensus document to be shared with scientific societies, in the hope of being able to unify and optimize the benefits of precision oncology throughout the national territory.
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