Last week, Health Affairs published three interviews [one-week free access] that I conducted with leading cancer oncologists. As Donald Kennedy, editor-in-chief of Science, and I wrote in an introduction to these interviews:

“An intellectual chasm exists between those who do innovative research and those who deliver it. Researchers and physician-scientists read different journals than their counterparts in health policy or economics; they attend different meetings; they speak different professional languages…. The moment to create a powerful new dialogue among these separate but mutually dependent communities could not be more propitious. Successful sequencing of the human genome has opened avenues of research that will be ripe for discovery for decades to come. New therapies, ranging from genetically targeted drugs for cancer to the use of nanoparticles in medicine, are gradually changing the medical landscape. And inevitably, better care through better technology comes with a high price tag, especially at the beginning.”

Here are some excerpts from my conversation with Victor Velculescu of the Johns Hopkins University Kimmel Cancer Center, who has been a major player in the analysis of genes associated with cancer and their mutations in different forms of cancer and different individual patients. I also interviewed financial analyst Thomas Roberts, an oncologist formerly with Harvard, and Lee Newcomer, an oncologist who heads UnitedHealthcare’s cancer division.

Role Of Basic Research In Health Policy

Barbara Culliton: What role do you think that academic researchers, such as yourself, who function as both basic researchers and physician-scientists can or ought to play in health policy?

Victor Velculescu: We are at the brink of so-called individualized medicine, at least for cancer. People are different; if you think about genetics and the environment, it makes sense that in important ways their susceptibility or response to disease will be different, too.

I explained why policymakers [in the Maryland state government] should know about our work and know how the money the state has invested in us is being used. I think that people were excited to hear what we have achieved. But it was surprising to me that a lot of what I was saying was brand-new to this audience, even though it is familiar to the cancer research community. It highlighted the importance of informing legislators about the discoveries that result from research and what implications these discoveries will have for the future in medicine….

Basic scientists could help shed light as to whether certain assumptions used in economic models generated in policy circles are realistic regarding the pace of science–the likelihood that something will move from research to the bedside in two years, or five, or ten. That sort of thing. But we generally are not asked. I think this kind of “best guess” projection is probably helpful to legislators on the national level as well. The “dialogue” Health Affairs is creating is important as well.

Exciting Areas Of Cancer Research

Culliton: Let’s talk about research. What do you think the most exciting areas are in cancer research right now?

Velculescu: Certainly one of the most exciting areas in cancer research is the recent analyses of cancer genomes that we at Hopkins and others have begun….Just in our laboratory, we have identified, in breast and colon cancer, more than 200 genes that are mutated in tumors. The vast majority of these genes had never been previously implicated in human cancer….

One really interesting part of this is that we’ve learned that breast and colon cancers are very different in terms of the genes that they affect…. All the knowledge we have acquired recently explains why, when you go into the clinic and you see two patients, they might be the same age, their tumors might be the same size and look the same under the microscope, but they respond very differently to the same treatment. There are some genetic differences between them, and the exciting thing about this in terms of actually helping patients is that although there now are a lot of different targets that one can think about in terms of cancer therapies, it also brings up the possibility that at one point in the future, you can imagine a scenario where a patient comes into the clinic, and his or her tumor is either diagnosed by a DNA test or removed and analyzed for DNA mutations. Then, based on the mutation spectrum that exists in the individual’s tumor, the person would receive a combination of therapies–a cocktail of different therapies that are specifically suited to the different genes that mutated in that individual’s tumor….

Culliton: What about the new so-called targeted biologics that are on the market or in the pipeline for tumor therapy? Can you imagine that if you found one of these tumors through a DNA test, you could treat the cancer without surgery?

Velculescu: It’s a very good question. That scenario flashed in my mind as I was just discussing the previous scenario. It almost wouldn’t matter where the tumor is physically located in the body if you could just treat it with a drug. The current problem with that scenario, which I do think is realizable in the future, is that there are several steps that we need to fulfill in order to get there. One, we need to develop drugs against different and even more precise targets for cancer, or else this whole discussion is moot. We have good evidence that we can do that eventually. Two, we need a better way of looking at lots of different genes, and for that we need new technology to sequence genes for less cost. The good news is that there is technology in the pipeline that will allow us to do that. Several companies are currently working on new sequencing methods, with the goal of getting the cost of sequencing all of the genes in the genome down to $1,000 from about $300,000 today.

The full interview with Dr. Velculescu is available online [one-week free access].

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