“A New Renaissance for Medicine.”
Dr. Virgilio Sacchini is a surgeon who specializes in the treatment of breast cancer. He will be attending a meeting in Florence on October 15 and 16, 2015, at the Gabinetto Scientifico Letterario G.P. Vieusseux. The meeting will be on “Evidence Based Medicine.” He will talk about “Precision Medicine in Oncology – An Experience in the USA.”
What is this meeting in Florence about precision medicine, and why is it taking place in Italy?
In Florence there will be a panel of experts discussing the state of the art and future application of precision medicine. These experts will discuss the possible transformation of the current way to treat disease into a more precise and individualised mechanism, to have better results and less side-effects. It takes place in Florence because it is like a new Renaissance for medicine, and Florence as we all know represents this very well in a symbolic way. Professor Gianfranco Gensini, Dean of the University of Florence, is organising the meeting.
Can you tell me in what way is precision medicine different from previous medicine?
We know now that each disease, especially cancers, are very different diseases from the genomic point of view, with modified genes with respect to the DNA of the normal cells. The mutations in the genes can modify the metabolic processes of the cell, and in this other world the cancer cell is able to live and replicate, using different systems with respect to the normal cell.
And so what does this mean?
It means that to destroy the cancer cells we need to switch off the specific metabolic process the cell is utilizing to survive and replicate, and just by knowing the new metabolic process we can find the specific medication to interrupt the process. The medication can be more selective and only directed to the cancer cells.
Will you talk in Florence about the Memorial Sloan Kettering Cancer Center of New York experience in specific medicine that you are experimenting now?
We have at the Sloan Kettering a powerful technology that we did not have before for sequencing the DNA of the cancer cell. We created a special task force on precision medicine coordinated by José Baselga, Joan Massagué and John Petrini. We launched a genomic test called MSK-IMPACT™ that allows pathologists to screen more than 410 genes for mutations. Every year more than 10,000 MSK patients will have their cancer profiled using this test. This information will help physicians select personalized approaches that improve the safety and efficacy of each patient’s treatment. We are studying the ability to find cancer DNA in the blood and study the mutation in this DNA. Sometimes under cancer therapy the cancer cell can develop new mutations, bypassing the blocking of the metabolic process induced by the medication. This is the reason why a medication may become no longer effective. Looking at the cancer DNA in the blood we can quickly identify the new mutations and switch to a different drug specific to these new mutations.
In this way do you think that shortly you will be able to cure cancer for good?
This completely new approach can really increase, in an important way, the curability of cancer. By studying the DNA in the blood we can also detect a very early cancer, and this will also improve curability.
Isn’t this precision medicine very expensive at the moment?
It is becoming less and less expensive. In 2001 to decode the entire human DNA cost $100 million dollars. Now it would cost $5,000 dollars. Technology will allow this precision medicine to become less expensive, and the target treatment will also avoid empiric treatments that sometimes are not effective and are also expensive. In the end this medicine will be more effective, with better curability and less cost.
How much do you already use precision medicine?
At the moment only 10% of medicine in cancer treatments is genomic based. We would like precision medicine to be more and more diffused. For 2016 the US Government has invested $215 million dollars in precision medicine, because they realise that this will be the way to obtain a more effective cost/benefit medicine.
Is this medicine only for cancer therapy or does it also apply to other diseases?
It is also important for other diseases, like cardiovascular, autoimmune, neurology and the identification of mutations that can better benefit from specific medication.
How can the pharmaceutical industry keep up with this progress?
They are investing a lot into the research of new medications specific for the different mutations. Some medications are already in use, like Trastuzumab for HER-2 mutated breast cancers, and others are under investigation and may be available soon. Some simple medications that we have had available for years may have a more specific application in some patients. A good example is the simple aspirin, which was found to decrease the risk of colon cancer, but it can also cause potentially serious bleeding in the stomach, small intestine, or even the brain. So it would be great to have more precise ways to predict whether the benefits of aspirin are likely to outweigh the risks in an individual patient. We now know that an individual with a mutation (SNPs) at chromosomes 12 and 15 has great risk reduction, outweighing the bleeding risks.
From all that you say, is it the case that because of this new technology medicine is really making enormous progress? Am I right?
Yes, because the way of treating diseases may completely change with this concept of different diseases inside one disease. It’s like Chinese boxes: by only opening the right one we can cure the disease. The patient will go to the doctor, the doctor will take his/her blood sample and the DNA in the blood will be sequenced; and the next day you will have your specific medication, or none if it is not necessary.
You are a surgeon. Will the system of surgical operation also change?
We may avoid some surgeries in the future. We know that some cancers never progress and kill the patient. Identifying these cancers by DNA study would avoid surgery. There is debate now, for example, about prostate and breast cancers that we may not need to remove surgically because they are indolent. The DNA sequence and determination of the mutations may better select these cancers and avoid surgery.
What are you expecting to come from the meeting in Florence?
New ideas on how to apply this precision medicine, and an idea on how to combine this precision medicine with ethics. Sequencing the DNA and knowing the possible risks of an individual would complicate important ethical issues and also will touch the person’s privacy. This new precise medicine is almost at its beginning, therefore the process to clearly show that it will be much better than empiric medicine will take some time. But I really hope that the meeting in Florence will help to shorten the time from the research to the clinical application. The scientific community is analysing the results and will ultimately decide for the change.
Are you personally very active in this new medicine?
Like never before precision medicine requires a strong interaction among different specialists and scientists. Even surgeons, radiologists, internists and all the clinicians that may not yet be familiar with the biological engineers will need to become more and more familiar and interactive with researchers. For this reason, at the Memorial Sloan Kettering the clinicians and the surgeons are, and I am myself, very much involved in translating as quickly as possible the biological researches into treatment of the patient.
How is the situation in Italy?
In Italy there are excellent scientists and researchers, but unfortunately with limited resources, and sometimes they are obliged to emigrate to the States or other countries, because often they struggle with the economic situation of the country.
1st October, 2015.
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