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Episode 5  |  54:43 min

S1E5 | Pharmacogenomics: The gene’s role in cancer treatment

Episode 5  |  54:43 min  |  09.21.2020

S1E5 | Pharmacogenomics: The gene’s role in cancer treatment

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This is a podcast episode titled, S1E5 | Pharmacogenomics: The gene’s role in cancer treatment. The summary for this episode is: Ever since scientists sequenced the first DNA strand as part of the Human Genomic Project in the early part of the 21st century, our understanding of the role genes play in our health, and disease, has revolutionized the field of medicine. This is especially true of cancer care. In this episode of Focus on Cancer, the first in a two-part series, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), and his guest, Maurie Markman, MD, President of Medicine & Science at CTCA®, discuss pharmacogenomics, a burgeoning field that studies the role genetic variants play in how the body responds to medication.
Ever since scientists sequenced the first DNA strand as part of the Human Genomic Project in the early part of the 21st century, our understanding of the role genes play in our health, and disease, has revolutionized the field of medicine. This is especially true of cancer care. In this episode of Focus on Cancer, the first in a two-part series, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), and his guest, Maurie Markman, MD, President of Medicine & Science at CTCA®, discuss pharmacogenomics, a burgeoning field that studies the role genetic variants play in how the body responds to medication.
Guest Thumbnail
Maurie Markman, MD
President of Medicine & Science, Cancer Treatment Centers of America®
Early in his career, a mentor reminded Dr. Maurie Markman to approach the practice of medicine as a “people’s doctor.” This advice resonated with Dr. Markman, and he continues to carry it with him as he treats patients today. A nationally renowned oncologist, Dr. Markman is President of Medicine & Science at Cancer Treatment Centers of America® (CTCA). Previously, he was Senior Vice President of Clinical Affairs and National Director of Medical Oncology. “From the beginning of my career, I recognized the importance of practicing medicine as a ‘people’s’ doctor,’” says Dr. Markman. “All of my research and work has been motivated by the thought of giving patients every option to beat their disease.” Dr. Markman has decades of experience in cancer treatment and gynecologic research at some of the country’s most recognized facilities. In June 2011, he received the esteemed American Society of Clinical Oncology (ASCO) Statesman Award. Presented annually, the Statesman Award recognizes individual ASCO members who have shown extraordinary volunteer service, dedication and commitment to ASCO, their hospital community and the patients they serve for at least 20 years. Most recently, Dr. Markman served as the Vice President for Clinical Research and Chairman of the Department of Gynecologic Medical Oncology at M.D. Anderson Cancer Center in Houston, Texas, where he also served as a Professor of Medicine. Prior to that, Dr. Markman spent 11 years as Chairman of the Department of Hematology/Oncology and Director of the Taussig Cancer Center at the Cleveland Clinic Foundation. He also spent five years as Vice Chairman of the Department of Medicine at Memorial Sloan-Kettering Cancer Center in New York. A Diplomate of the American Board of Internal Medicine, Dr. Markman is board certified in internal medicine, medical oncology and hematology. He also holds a Graduate Certificate of Advanced Study in Bioethics from the Department of Philosophy at Cleveland State University. Dr. Markman began his undergraduate education at the University of Southern California, where he earned a bachelor’s degree in Biology and graduated summa cum laude. He went on to earn a medical degree from New York University School of Medicine. Following medical school, Dr. Markman completed an internship and residency in internal medicine at Bellevue Hospital-New York University Medical Center, where he was named Chief Resident in his final year. He then completed fellowship training in hematology and oncology at both the National Cancer Institute and Johns Hopkins University (Sidney Kimmel Comprehensive Cancer Center) in Maryland. Dr. Markman also holds a master’s degree in health policy and management from New York University Graduate School of Public Administration. Dedicated to finding new and innovative ways to treat cancer, Dr. Markman has published more than 1400 articles, editorials, peer-reviewed manuscripts, book chapters, reviews, letters and abstracts. Dr. Markman has written or co-edited 10 books and served as an editorial board member on over 40 journals. He is currently Editor-in-Chief of numerous oncology journals, including Oncology Digest and Current Oncology Reports. He is also a Fellow of the American College of Physicians and the American Society of Clinical Oncology. Dr. Markman is regularly listed as one of the “Best Doctors in America” by Best Doctors, Inc., one of “America’s Top Doctors” by Castle Connelly Medical Ltd., and one of “America’s Top Oncologists” by Consumer’s Research Council of America. In 1999 he was recognized as the Lee and Jerome Burkons Research Chair in Oncology by the Cleveland Clinic. He is widely regarded for his knowledge and expertise as a practicing clinical oncologist and is frequently asked to be a visiting professor and guest lecturer at universities and medical schools across the country. He has served as a member of hundreds of national and regional oncology committees. Dr. Markman joined CTCA® in September 2010. He currently serves as the National Director of Medical Oncology and Senior Vice President for Clinical Affairs at our hospital in Philadelphia. He says he was drawn to CTCA by the hospital’s patient-centered approach to cancer care and philosophy of treating the whole person, not just the disease. Dr. Markman is a member of numerous professional organizations, including, but not limited to: the American College of Physicians, the American Society of Clinical Oncology, the American Association for Cancer Research, the American Society of Hematology and the Society of Gynecologic Oncology.
Learn more about Dr. Markman

Hi, I'm past to present CEO of Cancer Treatment Centers of America and the host of focus on cancer it right here webcast and answers everyday questions cancer patient about the treatment and delivery of their care answered my expert I am particularly delighted to welcome a colleague and friend on the show today who is an absolute Pioneer and one of the most premier oncologists in the world at somebody who has a band of the the knowledge to treatment the care and cancer at every corner eye. Dr. Markman. The Morrie Martin is the president of Medicine Science GPA and he's joining us from the hospital in Philadelphia. Welcome to the show. Thank you, and I look forward to our conversation about this incredibly important topic of pharmacogenetics.

Today Show is is one that I'm really looking forward to us about pharmacogenomics a very exciting, you know area in medicine incredible by Future even do it before you came to see a which is now been there by ten years. I've been a wonderful experience. So I was the vice president for clinical research at the MD Anderson Cancer Center front of that. I was the director of the cancer center at the Cleveland Clinic in Cleveland, Ohio fire that I was the vice chair for the Department of Medicine at Memorial Sloan-Kettering Cancer Center, New York City starting my academic career at the University of California, San Diego and Demonte Colony training at the national cancer has to Dan. Johns Hopkins oncology center.

Well it incredible incredible at background you made a difference in how many different places in your career. You're making a huge difference in what you do. Now. What what made you go into ontology def to care for cancer patients before I did my medical school at New York University and did my internal medicine training at Bellevue Hospital at one of the Steal one of the Premier hospitals in America credible a public institution and I have the opportunity Spade end up in the private practice setting at New York University Hospital the time reason I say that is that at that point it became very clear to me that there was no other area of medicine and I was an internal medicine more complex.

Then the care of a cancer patient within the realm of medicine nor was there any part of medicine that was in my perspective more satisfying than the patients their families were so grateful for whatever we could do in in the cancer space and I even saw that as up as a general internist and of course that was decades ago and I said, but the complexity be able to have an impact and in the feeling of just really doing something for repair and her has family. There was no other area of medicine that was more interesting or exciting I fell off professionally gratifying than that you personally gratifying and I have not looked back for one moment to think I made a mistake. This has been an incredible journey both at the scientific and if that personal level dealing with cancer and cancer

We certainly don't think you made a mistake either you've had an incredible impact on that on the field. I have oncology in the Battle of Cancer Care near patient by referring to Patient. You are truly amazing at both the human and compassionate side as well as the the scientific and again Happy on the show. Marvin is excited to get into a really bad the focus of today's episode which is a big word area of Cancer Care but medicine and general and then so what what kind of break this down a little bit but just started, you know, 50000 foot point of view. What is pharmacokinetics

Obamacare genomics is a really important incredibly complex area the brief description which makes it sound not so complicated though is simply what is the impact of our genes on the drugs that we take during our lifetime. She goes from the magaria all the way to your the geriatric area. And that's it. It's it's a question of what in fact there are genes have on on on those drugs to take important but complex topic sentence and really break them down into into those simple component. So I appreciate you doing that. So let's break it down even further. I mean you look at the word pharmacogenomics send, you know farmaco in a meeting that the drugs and the effects on the body and we'll get to that in a moment and

Foundation of who we are and in terms of James of the Venom part right there. What is a gene and what is a gender role in our health? And and and the on answer you just ask some really incredibly important questions. I I will start a sort of almost at the at the opposite end of the spectrum but specifically because this is what I'm going to mention now is what we're not going to talk about it later, but it's really important at least in this conversation, but it is really important in cancer and cancer management and that is the genes within the cancer itself. And that's a very important conversation is genes bribe the cancers that drive their growth.

They drive the resistance to therapies. So I'm going to put that aside. So it's again the specific parts of the DNA of cancer cells that relate to that cancer. So turning to the much broader topic of what are genes within all of us jeans are really described as the basic functional unit that determine our hereditary and what it is that makes us who we are is estimated that there somewhere between twenty twenty five thousand of these units within our DNA and they control proteins that we make that control normal functions, but they also control regulatory factors that determine how proteins work.

They are very important. They again as I said, they're they're the foundation of the of the biology of what makes a living organism all living organisms very much agree with you. I often tell patients that the genes are sort of be in a foundation or that the blueprint if you will be at 7 structions that tells your body, you know, what the produces proteins you described and kind of you know, what what to do next. And and and that's why do at the break the scription of you know, how you start it in the role of

Cancer Gene is a blueprint of you know, our DNA and Adventures telling ourselves what to do. Next. What what is the role of a board game in in cancer? Does that developing cancer? Is it in talked about that a little bit more clearly, you know that you have the Gene and and their potential role in pack to cancer patients Journey with us so that the three basic strategies are approaches you might say and thinking about how these normal jeans again. These are these are genes that are with us from the time of conception to death when I say normal jeans. I mean something has happened to these normal James there in are germ-line.

And a can influence that cancer Journey to the first is being able to recognize that an abnormality is present before someone develops cancer. And that might be have an impact on the recommendations of members of the family for additional screening that they should have for example of breast cancer additional more frequent screening what different kinds of screening or in colon cancer if there's a risk because of a genetic abnormality again emphasizing they don't have the cancer yet, but they may have been your recommendation for more frequent colonoscopies, for example, so the one is simply to know there's a tree and then to potentially screen for that risk in someone who has the abnormality. Can you take

The second. Emphasizes the potential to do something about this Beyond screening and increasingly there's evidence that there are certain prophylactic procedures that can be undertaken generally a surgical but they're also potential medications that give it to reduce risk, but for example in in breast cancer ovarian cancer with the presence of a gene that many of the listeners and viewers will know is braca the trends of that mutation may lead to the recommendation and certain individuals for removal of the breast removal of the ovaries again, very carefully consider because there's data that demonstrates the back can substantially reduce the risk of those Cancers and basically improve survival of those individuals. This is again prevention of cancer.

And the third reason why this information can be very important and this is relatively new strategy is that those mutations within the germ have now been able to be shown to be relevant for certain medications one can give to treat the cancer guys again emphasizing when I mentioned your line it was in the germline. It's also in the cancer, but the presence of those mutations those abnormalities can in fact be targeted with specific medications and that includes now in cancers of the ovary cancers of the of the breast prostate cancer.

Pancreas cancer example to very effectively treat those lug nuts. These These are strategies that are increasingly being used and certainly being used by our colleagues at CTCA. Basically. The first area is to do is to help predict the future that one might have based on These Blueprints that one might have to develop cancer at the second would be to inform whether there's some action for Bend today of that should be taken based on that and on the third that you mentioned there would be specifically to look for ways to Target the therapy within that you mention something that is unimportant term that you refer to a couple times the germline. Can you per hour?

What you mean by that germline and then talk about the difference between genetic mutations on the difference between eyes mutation with other Drumline, very important Turman really what it what it needs is what is Ennis from the moment of conception in the DNA as we all know the wagon the sperm come together half of our inheritance comes from the mail and 1/2 comes from the female and that's really that the DNA that comes from half male half female then from that moment of the mixing together of the DNA Megamix firm through to the end of life.

That's the germline now it turns out that in some of us and it's a various numbers and it depends on the particular condition were talking about there are major abnormalities within that DNA that we call mutations that lead to the potential risk for medical conditions occurring later in life. And this is not exclusive to cancer. But of course, we're talking about cancer here and for example, the Bracken mutation, which we talked about briefly that can lead to risk of breast cancer ovarian cancer pancreas cancer prostate cancer month later in life. And those are you take major abnormalities within that Ramon. There are other differences between individuals which are called very

They're not your case. And there are actually millions of these variations that can occur from one individual to the next within the germline. Let me emphasize. These are not mutations. They don't cause major problems, but that is in fact the differences that occur in all of us make it why some of us have lighter colored hair than others big impact enormous number things within our lives within our normal biology and Physiology that are small and saddle and their millions of these that occur within us that occur within the germline the doctor Mario and I sometimes tell patients I use the analogy of I mentioned before of of genes being the plans of the blueprints.

Sometimes I say that a variant is your house is very different than my house staircase is over here in the bedrooms are on the right side vs. Left side. Those are normal variants. Where is a a mutation or something that could put us at risk might be something where something isn't up to code right or something might predispose door Rick and risk of fire. If you're in your stove is not appropriately connected or is in the wrong location. So I sometimes use that is as kind as an example and that is is not a guarantee, but there's going to be a fire but it is a increased risk due to do something being out of code and that being a genetic mutation that the last thing that I think I just wanted to clarify for our audience.

I think sometimes people think of mutation that is as may be something bad that can happen to you and it can wait later in life. But I just want to be clear what you're referring to hear is a is an inherited mutation in that germ line represents a greater risk in in future life as opposed to something before okay, if I'm exposed to a chemical that causes a mutation in the cell later it can you help really clarify for audience and about those two are two differences in the complexity of the discussion jeans can within a cancer. I've see cells become abnormal at some point. That's of course would have the cancer.

So there will be normal jeans still within the cancer of course, but there's some jeans that will become abnormal later and they become unique to that camper. So we call them tumor-associated jeans, but when I'm referring to are the genes that are present at the base line within the germline, it will always be with us. So if there's a mutation at Birth or again before birth in this Gene that has a susceptibility to cancer that will be with us throughout can there be mutations that occur later and jeans because of exposure to as you noted sign or carcinogens, absolutely. That's that's terrific. Yeah. I think it's really important to clarify for for audience because I definitely had patients to sort of think about those two terms that you know one with the sun is something that happens later.

And we should think about is an alteration that occurs later due to some sort of action or or exposure. What what doctor Marksman is is focused on in Tire descriptions, really something that you begin with witches and intrinsic, you know, like I said before the blueprint prevents a a likelihood not a guarantee by likelihood that the patient might not make it all cancel it. So I think it was really important for us to establish a genomics.

What's this briefly talked about the farm of Hell part of that before we dive deeper into pharmacogenomics. What is what is pharmacology generally speaking just kind of laid out foundation for a liquor that when we when we get into pharmacogenomics, we know we understand each and the winners and pharmacology and we can count on them together. Yes. This is now we're switching topics to come back to the jeans. So what is pharmacology? It is really the study of what happens to a drug any kind of drug is diversity a foreign substance that we take it has a purpose this foreign substance to have a favorable impact on some bodily function then again, I'm talking in general terms because pharmacology is a very general science. So you take a drug for the purpose of having a positive effect and the study of

Where that drug goes the impact of the drug on the body the concentration of the drug that needs to be present for a positive affect the concentration of the drive Gallup reduce the negative effects. All of that is under the the science of pharmacology a very basic example, you know Tylenol the average dose for most people might be unsafe 200 mg of Tylenol, but you really think about it in your body different from you and me to somebody else based on a number of things our are we our metabolism liver processes that Tylenol or kidneys are excreting it from her body and for any given person

That can be that can lead to different doses or a bioavailability within the body for barium barium outside. There's a concept that we've been reported that you off and refer to the idea that there is a a window or sometimes called the Goldilocks zone where in order to get the intended effect of the drug. If you have too little than your outside of that window and you're not going to achieve what you're looking to do and if you have too much to do you turn your damn it. So people who are taking an antibiotic before if the dose has been high enough, you're not going to kill the bacteria to cause an infection of course of the dosage too high. You can have another side effects.

And so basically, dr. Markman the universe idea of a therapeutic window and in Pharmacology, I think a couple accounts for audience of us has a different therapeutic window for a given amount of drug, but there are some drugs that have a wide enough window that given those differences the same dose NBA but there might be a neural therapy window. We're giving those for you and given those for me might actually not have the same intended effect that right. That's exactly right and again it sort of emphasizes the the science and to some extent the art of pharmacology because we are, you know, making reasonably educated guesses for a population of individuals who are receiving a drug and you give a wonderful example of Tylenol. I mean, I don't think the problem

Are too many people in the United States who haven't taken her Tylenol or the generic version of it and the vast majority of individuals tolerated very well. And the reason is because there's a very large therapeutic window, meaning of that. We are effective seen vs. Toxicity. It's it's a large large range, but that is necessary true for all drugs and particularly. We talked about anti-cancer drugs which a potentially very toxic because by definition the goal is to kill cells for cancer cells that therapeutic therapeutic window can be quite narrow. And so that's what we get into those concerns. That's right. You don't answer drives are absolutely example of a therapeutic window in general that that difference that margin for error is much thinner in terms of

Too much. Join the cancer. And so that's where we have to be much more precise pharmacogenomics really comes in right as those underlying blueprint predisposed already has a certain narrow therapeutic window, but on top of that the effects of your jeans and in my jeans hook on the the Burien without even specifically talking about, you know, specific mutations that generally speaking can really make an impact on the way that one body is responding to medication. If if you agreed with that give us give us an example if I think that is laid out very clearly and it cuz I would I was even thinking as you're describing the you know, he's

Verona field of radiology the importance of if you give a lot of drugs to Medicare give medications to patients prior to during the procedure and you have to be very aware of course of the potential in back of that an invitation sister or receiving these these procedures, you know, clearly we talked about the variation from patient patient. And so the idea of the pharmacokinetic genetics concept is wouldn't it be wonderful if we could potentially predict prior to giving a drug that this individual may have the same or toxicity because they metabolize the drug slower than another and conversely we might say that this individual may not have as good a therapeutic effect of a of a drug because this

Drive it needs to be activated when it's given to a patient. It's not acting as normal form. Another race is given to the drug is metabolized become active. But if we know that a patient has a particular variant that says she they'll be a lower amount of activation than the drug. Maybe we need to get more of it. Wouldn't it be wonderful if we could predict that knowing before we even give the therapy through this concept of pharmacogenomics remember? This is Germany its present from the time of conception. So you could have this information this blueprint for each individual patient in theory, of course, and then use that information.

So are there been lots of examples in oncology where this concept has been explored and perhaps the I might say the example that is most discussed within the call and called your community is that of the drug tamoxifen tamoxifen is a very widely used anti-cancer agent an oral drug for the treatment of breast cancer.

And it's been down for well over a decade that this drug is actually when it's taken it is not an act and active anti cancellation. In fact, it needs to be activated in the body to become active and it turns out that there are variants of the genes that are responsible for this metabolism that do it particularly slowly and as a result, there's some evidence that suggests that patients who have their wash lower metabolizers. In fact do not have it as favorable effect on their cancer when they take this truck.

And that is been ongoing research. Now for many years looking at this particular question. It is really very very fascinating. I think our audience and see the power of this which is the idea that we can predict in advance whether a certain drug in Frankfurt to what extent might impact them differently. Is it really power is not just as we said before the pharmacology but underlying premise of those BMWs were friends at 2 to predict will work to what extent and in the dosing and nnn. Where are we in are in are in the advancement of a pharmacogenomics? Dr. Markman? Maybe just give us store.

I don't know what timeline or are we are? We are kind of upset at the top of being able to really predict this for a vast majority of patients. Ambassador of drugs. Are we more at the beginning Donovan bed in the sort of theoretical phase where we are in Hell clickable.

Well, I think God first of all you got is a towel. I'm a proponent of this approach and and it is in it as I am a size earlier and I'll say again now because it is really relevant. We are talking about cancer but this concept is applicable for any medication that any visual takes potentially for the lifetime. So and it could relate to cardiac medications that could take medications that are people are taking for anxiety or for a Ford and antibiotics as you mentioned earlier and so cancer is a component of it a critically important component of it's still a component. So the ant direct answer your question. Is there ongoing research by investigators by Franklin all over the world in a large consorcia that are looking at very large databases of of

Individuals who are getting medications for a variety of reasons also studying the variance that they may have and and many of these variants are 1% of the population are 2% of the population. So you need lots of experience to be able to see if a particular variant with maybe hypothesized to impact an effect on a drug, but you needed that follow this and you need to follow a large numbers of individuals to see if in fact that a hypothesis is correct. So my prediction is over the next five years, maybe a little sooner maybe later. We are going to be see this this concept while you threw out medicine including in a kansas-based routinely using this information to potentially determine whether it be

Major drug or arrangement with might be a combination of drugs is more likely to be beneficial for an individual patient. Then another group of drugs based upon this information that is present again in all of us is variance in our German. It's incredibly incredibly excited and I I definitely share your passion for this with this field in genetics and in general genomics pharmacogenomics in particular moving Moore's Law computer processing speed eventually, you know how fast that process and MW?

Donald Ray look at how fast we have moved in in medicine in terms of unlocking our understanding of the human genome and being able to then act on it at dr. Markham to talk about it on taxes in 1998 for 13 years and 31 billion dollar to a gene now we can do that or a couple hundred dollars and it takes about a day. So the progress we've made is just a rapid and an incredibly Dynamic and years from now what might a cancer patient entry be today or maybe even a patient without cancer if it's the day go in and

And then have their their their Gene sequence and then be told that this given drug at this given doses is much more likely to potentially save your life. And then another one hit maybe calendar for this down the road. Absolutely before I respond to this question is that at 8 a moment that I obviously need to distinguish again, the the cancer Janome vs. The germline the issue of the cancer genome. Is that A Change Is So rapidly as so many differences individual cancers a patient with a cancer may have their Janome the changes. So that is a very complex in a very different discussion the Hat

But back to the question, you've asked the germline. I absolutely see a time and not that distant future where each individual will have that information up there germline the various variance. It'll be theirs. It'll be completely secure her it'll be private whether it's in the cloud or sign up in drive or something new that will have in the future that information will Define partially any medication we receive I can see that patient going into an emergency room for some condition and immediately before any medication is given the information regarding those variants will be known to the emergency room. Even though that emergency room doctor will never seen that face before and that information will help determine take the drugs that a patient perhaps should receive in preference doing

What medications they should not receive it all that will become routine of the common will be in the Pediatric the adulterers the geriatrics having that in your own your area, but I can see a patient you're going into to get a a procedure and their variety medications at the radiologist. They want to give they'll use that information know what what are the drugs we should give up and that's not you'll have that available at your fingertips as well to help that dacian knowledge of that variation will be very important in Radiology for them. Thank you for making that distinction between that patient blueprint their germline that what is with them versus thing that can be changing rapidly in a in a given answer. I'm so so exciting exciting future. What what kind of

Futurescape feed the present events that were 10. She talking about that individual patient get it at individual drug is relatively uncommon a member of society walking around is not going to know that they might need this particular drug at this point in time. Why would one care about that but I didn't care about it and maybe one out of a hundred individuals who may be affected by a particular drug. However, when you take all of the possible Barrett's that again are fixed from conception and you take all of the possible drugs that individual may have in their lifetime and you have that information in a single database that is secure for that individual.

Then the opportunity for that individual benefit from this information at some point in their lifetime. Will you add the hundreds of different drugs and individuals make a maybe thousands you develop a concept where one can say with in a health system. You know what this information is, very valuable. We oughta get it without a painted somebody out of paper. We got to figure out a place where we can keep it securely for that individual. So it's not that single patient rare mutation a drug. You'll never know if the patient will ever get its entire universe of drugs that a patient may receive during their lifetime potentially the potential variants that may impact lots of different drugs. I just a single drug that will make this book cost effective for society, but also cost effective for an individual insurance plan or employers who will

Craigslist again the key is this will always be secure. The only person that is relevant to have this war is that individual patient? That's where the information we will shift from this idea of this individual rare event for that individual patients to a composite. This is valuable information across a lifetime for individuals and will have a major positive impact on society awesome study for Adverse Events. For example, improving outcomes that will make this an imperative as part of our Healthcare System.

The great the great the great way framing it and this is such an exciting field scientifically in progress. But one of these challenges in the Arts of medicine is of course housing translate communication decision-making involving the patient and knows this is an area where everything from you know from us tetrick, you know, what what genetics around that your patient risk to obviously we're we're focused on talking about cancer. These are complex subject with a fair amount of sort of statistical analysis.

The not only does the doctor need to have a grasp of but then needs to be able to explain that to the patient in a way that they can come to sort of a shared decision-making and obstetrics due to cancer. So you know, how are we how are we changing and evolving as a society in in translating these complex studies statistics to the bedside MN in communicating with a patient that the really Drive effective I could change and in greater state of you guys are really a critically important a point. Our knowledge may be escalating at a revolutionary you mention Moore's Law.

What are ability to communicate complex ideas is not changed much humans or humans. They have their hopes. They have their fears. They have individual needs in terms of how that information be needs to be provided to them. The fact that we have this massive amount of information doesn't change the complexities of communication. One of the terms that has been used at that I I like because it I think it up size. The point is we need that is we being listened to community and I've see work so I can hear something about oncologist, but you can generalize bad to off position and patients their families. We need to come up with a better strategies of war decision support.

because ultimately that you highlighted it is a decision of a patient generally with her or his advisor and other family and of course that's going to include the position but we need to figure out ways of of supporting that decision whether that is in terms of a simplification not over-simplification because you know, you can make something so simple that you're not providing adequate information to make the decision but tools to do this obviously

We've talked a lot about about decision support and artificial intelligence strategies to help make things that are very complex simpler than ever be simple. But I'm hoping in the future we will come up with strategies that I can take these very complex Concepts this very complex information and provided in a way that does allow that patient with again her or his advisers after asking questions that are Central to be able to make up those informed decisions.

Yeah, I agree with you, you know you and I you and I get a lot of questions even position asking about you know, what is maybe if we go back a few example, you know, what is the risk in a patient who has this? You know this mutation let alone what that at risk is 1 and 10. Okay. Well, what does that mean in the context of a patient there one in ten to one patient might mean something that they don't want to do or that we should recommend doing versus to another patient that we shouldn't and then throw the balance of of benefit analysis in the context of a bit complex calculations and protest Texas largest medicating I think is is an equal importance as other than that the science of communication.

Play with you I think technology in making that more accurate, but also also good good communication with our patients as well, which is a kind of into the final a part. We got a question for patient to email us asking a question then and would love to just share a few of them with you and get your get your responses on today's topic the patient asks aside from studying How We Are Scientists far enough along that they're using pharmacogenomics to develop new drug. What would you say that we are increasingly when I say we I is this this this this large weenie cuz I am personally not a drug developer.

Visual two are really focusing on drug development are increasingly using a unbelievably sophisticated models that ain't you again going back to this area of artificial intelligence knowing the structure of drugs knowing the structure of the cancer knowing the molecular abnormalities down to the unbelievable detail. Yes the tank. It would certainly has two male dogs to quit drugs to use this kind of incredible design strategy to impact in a positive way potential issues of the variance of the present within some individuals in a pharmacogenomic area. So yes, that is a topic for the future it is it is not today what has been done, but after

I See This Bar or something happening for the future. Absolutely break. Here's another one this one is it from patient with a lot of colorectal cancer in our family and I've been doing some research and I wonder if I have Lynch syndrome find out an area that is of course precancerous until there is a cancer. I was Shirley suggests consultation with gastroenterologist. There are genetic tests that can be done and that will add the new user of effective against effected in R&R Drumline and that information can be determined with the other cats and another one somewhere similar from a patient at my mother died of breast cancer. Very very

Hear that. My mother died of breast cancer. Does that mean that I'll I will inherit the camper from very common question. The fact is I need to fax. This is not something that I wish you would happen. I was back the exact opposite one out of date women in this country will develop breast cancer during the life. Now that doesn't mean in any way shape or form that one out of eight women will die of breast cancer. Will it available breast cancer reason I say that is because a breast cancer has come in very common in women get their lifetime. And so the say that again the individuals asking about their mother and affect their mother had breast cancer that doesn't mean that they will have breast cancer. Obviously. There's that potential but simply because

Turn that breast cancer is that is a cancer of the Aging like many other cancers are that is certainly not a given that that individual will have a family history. Now the specifics of that, of course one would ask who suggested that this individuals ask me a question talk their own oncologist shooting me there since their mothers on, they didn't know that primary primary care physician and you know, I detailed history might be taking them out. The other members of the family who have had that cancers that would raise the concern about a potential hereditary risk answer the question. The fact that this individual is mother had breast cancer does not mean that they in fact will inherit or have inherited the gene pool. That's a reason Gene in that picture family that we can identify that increase the risk of breast cancer.

thank you and final question, obviously, you know, we as a as a nation that he still continues the battle raging covid-19 and you know about covid-19 19 trial vaccines in the future husband cancer patients approached decisions about which back pain would be

Wow, what a question. I think that we're going to have done a lot of information over the next several months that is simply not available today to answer this question. It it's no actual extraordinary as someone who's been involved in a conical investigated Madison. Now for almost four decades the speed at which the pharmaceutical Community investigators around the world that are working on developing effective vaccines is truly extraordinary their least a half-dozen. Not a good night a dozen potential candidates for vaccines that made quite frankly revolutionize our view of the management of this horrible virus. All that being said, we simply don't know today any information that can tell us either the most effective vaccines the safety profile.

Maxine wish vaccines might be most relevant for a population that up nipples elderly versus Pratt's younger. What about the the cancer survivor? Is there again, this is a rhetorical question is what are the answer, you know population of individuals who had cancer recovered from cancer might have been treated for cancer with drugs. Is there one vaccine and might be better that information is critical hopefully and I have no direct knowledge of this cancer survivors. Not necessarily individuals were receiving anti-cancer therapy because it is unlikely that they would be included in trials that is active cancer individuals lack of receiving at anti-cancer therapy, but individuals who have a prior history of cancer, hopefully they are being included in some of these trial so we can get some information that's relevant to that population. But the bottom line is hopefully over the next several months will have a lot of information.

With a number of vaccines to directly address the question critical question is just been addressed or Bank you this has been a very enlightening dive into the impact that it has on answer. I think a really exciting lens into the world of demons and and and what's a pencil holes in terms of unlocking the secrets we can talk for hours and some other other topics that are related to this for sure. I love it. It's been cleared by asking you any any advice do you have for for patient for a final things you'd like to share for car audio visual to act answer her while receiving cancer treatment of the advances that are occurring on all fronts from Modern Surgical.

Techniques to radiation strategies that improve efficacy and decrease taxes need to of course my area of interest in f a cancer therapies. The changes are are just incredible advances leading to Improvement in the survival and critically important quality life her cancer and cancer therapy for patients improvements are accelerating and the future holds great promise for individuals who are diagnosed with cancer. And of course, we want to find much better ways of buying diagnose make a diagnosis early and very importantly in preventing cancer.

Dr. Markman, thank you again for taking time from your very very busy schedule to come on the show incredibly fascinating topic. Thank you for sharing all of that the latest and greatest update and I'm really looking forward to doing a deeper dive with you on the next episode. We were talking about advances in Precision medicine. So thank you so much for coming up. Thank you. And I really enjoyed it. Very important. The changes. We are so excited for our patients and I look forward to our next conversation.

Outstanding well, thanks again, and I will see you within the next Shell.

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