What is precision medicine and how has it evolved over time? Sara Van Driest, MD, PhD Vanderbilt University Medical Center March 2, 2016

Transcription

1 What is precision medicine and how has it evolved over time? Sara Van Driest, MD, PhD Vanderbilt University Medical Center March 2, 2016

2 What is Precision Medicine Precision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person. diseases.

3 Nothing New Under the Sun It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. Sir William Osler

4 Francis Collins on getting his genes Politico, Q&A: Francis Collins on high hopes and a made schedule for precision medicine by Arthur Allen, 12/27/2015. analyzed Did it do anything for you personally? Well it did in an odd way I was at higher risk than the average person for Type 2 diabetes... This was six years ago, I was 30 pounds heavier at that point and pretty much having no exercise and a pretty awful diet. That all changed

5 Francis Collins on getting his genes Politico, Q&A: Francis Collins on high hopes and a made schedule for precision medicine by Arthur Allen, 12/27/2015. analyzed Kathy Hudson: He used to live on these really disgusting honeybuns that they sell from the vending machines in Building 31. They were like 700 calories. They were so good... Never again. In other words, getting your SNPs ruined your life? Yes, it made me live a longer and miserable life.

6 Overview Precision Therapeutics Precision Diagnostics Precision Prognostics Looking Ahead

7 Which treatment is best for this disease? Intended Effect No Effect Side Effect Severe Adverse Event

8 Which treatment is best for this patient? Some reasons for variable drug effects: Age, sex Ancestry Drug interactions Environment Diagnosis Genetics Variable drug levels Altered responsiveness

9 Secondary Prevention in Heart Attack

10 Population Benefit of Clopidogrel 30 Days after Stent N Engl J Med. 2005; 352:

11 Individual Benefit of Clopidogrel 30 Days after Stent CYP2C19 Matters High Risk Genotype Lancet October 16; 376(9749):

12 Point of Care Decision Support

13 Percent of Patients What is the impact of genotyping? 100 Percent Treated with Alternative to Clopidogrel Nonactionable Intermediate Metabolizer CYP2C19 Result Poor Metabolizer Clin Pharm Ther Dec 22. doi: /cpt.331.

14 Overview Precision Therapeutics Precision Diagnostics Precision Prognostics Looking Ahead

15 Classifying Malignant Melanoma Historically Microscopic Features UV Exposure Genetic changes BRAF 38% Unknown 40% NRAS 15% GNAq/GNA11 4% KIT 2% CTTNB1 1%

16 Therapeutic BRAF Inhibition pre-treatment post-treatment relapse J Clin Oncol Aug 1;29(22):

17 Overview Precision Therapeutics Precision Diagnostics Precision Prognostics Looking Ahead

18 A Famous Case of BRCA1 Variation and Cancer Prevention New York Times May , A25 Image by Foreign and Commonwealth Office

19 Two Arrhythmia Genes Sequenced from 2,022 Individuals 122 rare variants Variants classified by 3 expert labs The labs don t agree JAMA Jan 5;315(1): JAMA Jan 5;315(1):33-5.

20 Two Arrhythmia Genes Sequenced from 2,022 Individuals Until more is known about the true clinical validity of such pathogenic variants in unselected 122 populations, rare non-synonymous returning results seems variants problematic, at least for these 2 genes and perhaps for others. At a minimum, the language for describing variations Variants predictive classified ability should by be carefully 3 expert calibrated sites to convey, when appropriate, a probabilistic, rather than deterministic, nature. EMR Phenotyping 63 with --William pathogenic Gregory Feero, variants MD, PhD ECG (44) QTc > 500ms (2) < 5% are affected JAMA Jan 5;315(1): JAMA Jan 5;315(1):33-5.

21 Overview Precision Therapeutics Precision Diagnostics Precision Prognostics Looking Ahead

22 A Geographer s View of the World

23 The Precision Medicine View of the World Genomics Health records Microbiome Metabolomics Proteomics mhealth Food deserts Patient Preferences Poverty

24 Precision Medicine Integrates Data Preferences -omics EHRs mhealth Sociocultural determinants of health Comprehensive Recommendation

25 Thank You Many slides courtesy of Dan Roden