Is Targeted Therapy Treatment the Same as Personalized Medicine? It Depends

My task: teach the residents about oncology.  I attempted to impart my newly found knowledge about hematology and oncology to this group of wonderful (even more neophyte than myself), physicians. 

This is a routine part of medical training where trainees often learn practical/hands-on knowledge about medicine from the physician a few years ahead in training.  It is a very fun part of training.  In a certain kind of a dance, the resident's fire off questions at me about management decisions in clinical care and I respond; this is the dance that we are taught to do starting in medical school in order to do well on exams.

We don’t always do the dance to soak up other forms of knowledge--knowledge that perhaps was not taught as proficiently in medical school.  It is always striking to witness a change in the question-answer dance once the residents realize that I am interested in their experiences in treating patients in terms of communication, their own feelings, and how their patients are adapting, coping, and surviving.  Sometimes their eyes go down or to the side; the tempo slows somewhat, but then often the eyes rise up, with even more vigor, to ask important and serious questions for these physicians who are learning their skill:

• “So how do you talk to patients about how their disease is going?” 
• “What do you do when patients don’t seem to understand that their treatments have not worked?” 
• “How do you explain how chemotherapy and targeted biologic therapies work? 

The answer epitomizes what it means to apply "personalization."  The answer is always, “it depends." This is exactly what throws off our little question-firing dance.   I’m not sure that anyone ever really wants to hear, "it depends."  It’s not an entirely satisfactory answer.  Now, "it doesn’t depend," has a nice finality to it, and can be used to answer a question on an exam. 

The "it depends" answer has been passed down to generations of physicians by putting the question in a real-life experiential context at the bedside.  This experience is where you learn the lesson: "it depends." Students receive non-verbal education on how it truly depends when it comes to using science to help the patient that sits in front of them.   Issues that we face with patients in oncology are challenging in unique ways. 

The application of science to a patient’s life is truly an art form that requires unique communicative and empathic skills to really understand what patients need, and how they hear what you are saying.   For example, the physician may want to offer important pieces of information in a nonthreatening and easy to understand way that may help foster more questions.

The "it depends" model that we use when it comes to psychosocial treatment is actually much further along scientifically than targeted biological therapies--the personalization of molecular biology is still in its infancy. 

I didn’t realize how much of an infant it really was until I was reading and writing about thyroid cancers.  In medical school, we were always tested on hereditary thyroid cancer syndromes and their associations proto-oncogenes, like the RET proto-oncogene.  Yet, just because the mutation exists, or is even a driver of the cancer, does not mean that we have achieved personalization of medicine. 

In its purest form, personalized medicine means that treatment choice and response to therapy would depend directly on the mutation.  Even in thyroid cancer, where the RET proto-oncogene is one of the very first oncogenes discovered, the three most recently approved targeted agents, sorafenib, vandetinib, and cabozantinib are not used solely when mutations are present.   In fact, each one of these drugs targets multiple tyrosine kinases and their efficacies are not tied directly to the mutation.  Their efficacy is actually not individualized to the multitude of kinases they inhibit.  That is, even if we had a printout of all the somatic mutations present in a thyroid cancer, we still would not be able to predict whether one of the FDA-approved agents would actually work.  It’s still actually a "wait and see" process. 

That level of precise scientific personalization is present in relatively few cancers and treatments, but the science is moving steadily in that direction.  We just shouldn’t substitute scientific personalization for the humanistic art of medical personalization.   Hopefully, its teaching will continue to be passed down for generation after generation among medical providers.  It takes advantage of that genetically honed skill of humanistic personalization.  It is an invaluable instrument that is of huge interest to patients and young doctors alike. 

Disclosures:

Daniel McFarland is a clinical fellow in hematology and medical oncology at Mount Sinai Medical Center in New York City and a member of the American Psychosocial Oncology Society. He is dually trained in internal medicine and psychiatry. As part of the American Psychosocial Oncology Society, Dr. McFarland is currently collaborating with Dr. Jimmie Holland at Memorial Sloan Kettering Cancer Center in an effort to bring psychosocial issues to the attention of oncologists as they treat patients in the new era of personalized medicine. The views expressed are his own.