Tailoring Cancer Treatment via Molecular Tumor Boards

Mark Burkard, MD, PhD

Today, we are speaking with Mark Burkard, MD, PhD, an associate professor of oncology and hematology at the University of Wisconsin School of Medicine in Madison. Dr. Burkard and his colleagues have launched a Molecular Tumor Board, as of September 2015 that brings together oncologists, pathologists, pharmacologists, and cancer researchers to review cancer patient cases based on pathology and molecular information to decide on the best clinical trial for those patients and here is Dr. Burkard to talk to us about that.

-Interviewed by Anna Azvolinsky, PhD

OncoTherapy Network: First, can you describe what a molecular tumor board is and the goal of the program at your center?

Dr. Burkard: A molecular tumor board is a tumor board that is attempting to vet out information that could be useful for precision medicine in cancer. Often, tumor boards are focused on a particular type of cancer whether breast or lung, but often we are finding that many of the genetic abnormalities of the cancer are across different types of cancer. So what we are doing as a molecular tumor board is providing the information to physicians about how to interpret genomic information about tumors and how to use that in clinical practice. 

OncoTherapy Network: What are the characteristics of the patients that you evaluate through the tumor board? Have most of these patients already undergone genetic analysis of their tumors?

Dr. Burkard: Most of these patients are being referred to us with incurable cancer and so they are looking for treatment options that are better than standard of care. Most of the standard-of-care medications are still chemotherapies and what the oncologists are doing, and this is being done widely, is doing genomic analyses and there are many ways to do that. But what the oncologists get is a report back which has many genes listed that are abnormal in that patient and then they have another set of genes listed that may be abnormal in that patient. And most oncologists, most of us are not well-trained in genetics nor are we familiar with every of the hundreds of possible genes that we are discovering are related to cancer. And so, what we have done is assembled a team of experts from pathologists to geneticists to oncologists to pharmacists to go through that information in great detail to actually research both the information regarding the genes and mutations, and the information regarding possible drugs that could be used to target these mutations. And then we are meeting and discussing that information and generating some recommendations to the doctor who refers the case to us and those recommendations often are to consider a clinical trial that the patient is eligible for, that includes targeted therapies rather than chemotherapies, based on the genetics of that patient’s tumor. Sometimes the recommendation is to use off-label treatment. There are some FDA approved drugs for one disease that match a mutation and when we find that mutation in another disease, we might recommend that drug and we register that patient in a registry where we can track what happens to that patient. Then the third thing we do is sometimes, we say, gee, we have all of this genomic information but unfortunately, because of where we are in 2016, we don't know how to use that information to improve the outcomes for that patient and then we look for opportunities to development research trials and lab investigations based on that tumor’s abnormalities for which we don't have a treatment recommendation immediately.

OncoTherapy Network: Can you provide an example of a patient case evaluated by a molecular tumor board and the treatment that patient received or a trial?

Dr. Burkard: Yes, we can do that because we had one patient who came forward and was willing to share her information publically. That was actually reported. So there was a woman with metastatic lung cancer that had spread to the brain and she also had cancer elsewhere in the body. She had had radiation therapy to the brain and she knew her mother had had chemotherapy for another type of cancer. So she was looking for another opportunity for treatment. So her case was referred to the molecular tumor board and she happened to have a mutation in a gene called BRAF which is commonly found to be mutated in skin cancer, melanoma. Based on that, we and her cancer doctor were able to find a clinical trial that included two targeted drugs that turned off that gene signal and what happened to her was that her tumor shrank. What it practically did for her was that there was a problem with her being able to speak because of a metastasized tumor that had gone near her voice box and so she noticed her ability to speak went from a whisper to a normal voice. So that is one example of the type of thing we are trying to help make happen. I would like to say that we are doing this not just at the university hospital where I see patients, but we are offering our molecular tumor board as a free service for all of the cancer patients in the state of Wisconsin. So we have engaged many of the cancer doctors across the state and invited them to submit their cases, and we will make some recommendations for their patients.

OncoTherapy Network: Is this also a trend that is happening in other cancer centers, in other states. How common are molecular tumor boards becoming now?

Dr. Burkard: We are all grappling with how to use genomic information. It is really changing how we think about and deal with cancer and many different groups have different approaches. But molecular tumor boards are becoming more common. The University of California, San Diego had one of the earliest molecular tumor boards that was reported. At the time they launched there were not that many targeted drugs as there are today. So, actually I think we can do better today. Today, actually, I am meeting with the leader of the molecular tumor board at Johns Hopkins who we invited to give a talk here, Dr. Joshua Lauring. I know there are molecular tumor boards at several other universities. Other groups, instead of setting up molecular tumor boards, are setting up master clinical trials and this is a challenge because you have to have a number of targeted drugs and you are limited by the targeted drugs that you can coordinate in your clinical trial. But I do know that other groups around the country are creating these large clinical trials where they include a molecular tumor board as part of the adjudication of what treatment the particular patient should receive. And then all of those treatments are done under the perview of a clinical trial. So there are many ways to do this. What, I think is unique about what we are doing is that we view this as both a service to our partners around the state so we can help doctors make good decisions about medical treatments for their patients and for clinical trials. And we are offering this without any strings attached.

OncoTherapy Network: Thank you so much for speaking with us today.

Dr. Burkard: Okay, thanks!