I can think of nothing better than Yogi Berra quotes to organize a brief discussion of how molecular oncology is impacting cancer medicine.
“It’s tough to make predictions, especially about the future.”
When I was growing up in New York, if you had asked me which was more likely – for me to spend my career as a cancer center director in Iowa, or to own a flying car, I most definitely would have predicted the flying car. So much for predicting the future.
“If you don’t know where you are going, you might end up someplace else.”
Nevertheless, we need to plan based on what we know. With this in mind, this week we held the first meeting of a new conference called the “Molecular Tumor Board,” where we discussed how molecular findings, more specifically mutations found in cancer DNA, should be used to select the best treatment for a given patient. My prediction, which I hope is more accurate than the flying car, is that the initiation of this conference will be viewed as a landmark in our ability to apply molecular advances to the care of cancer patients.
“We have deep depth.”
Participants in the molecular tumor board included pathologists, molecular biologists, informatics experts, clinical oncologists, pharmacists and many others with diverse backgrounds, who have a common interest in working together to use recent advances in cancer research, and molecular biology to provide the best possible care for individual patients.
“Little things are big.”
At the center of the discussion will be interpretation of the clinical significance of individual mutations in DNA. In some cases these mutations are known to be associated with cancer, and with response to a treatment. More commonly, we don’t yet know what such mutations mean.
“Pair up in threes.”
This was the situation for the first case we discussed. If you recall basic biology, DNA is in two strands, and can be divided into “codons,” each of which is composed of three DNA bases. In some cases, we know that a mutation in a particular codon is associated with a certain cancer. During the tumor board meeting, we discussed a case of cancer where the mutation occurred in a nearby area but a different codon. What does this mutation mean for the patient? We don’t know.
“It ain’t over till it’s over.”
But we definitely want to know. One of the plans we made this week was to develop a good way to track results over time, and collaborate with other cancer centers, so we can understand the clinical importance of new findings as quickly as possible.
“The future ain’t what it used to be.”
There is no question the technology is changing very rapidly. We focused this first Molecular Tumor Board meeting on looking for point mutations in DNA. Other technologies are available or being developed to detect other changes in DNA, such as deletions of large sections of DNA, movement of pieces of DNA from one position to another, duplication of sections of DNA, and changes in how the DNA is interpreted within the cell (also known as epigenetics). Each of these can have a major impact on response to cancer therapy. The Molecular Tumor Board will work as a team to identify ways to incorporate these new technologies into research collaborations and eventually clinical care. We are also ready for other surprises that will provide us with opportunities we cannot even imagine today.
“When you come to a fork in the road, take it.”
I could try to use this quote to talk about molecular oncology (DNA synthesis takes place at what is called “replications forks”), but instead will simply say we will continue to keep our eyes open and seize unexpected opportunities and discoveries. That way, we can do our best for our patients today, while planning and learning as we travel down the unpredictable road so we can do even more for the patients of tomorrow.