RSNA: New era of image-guided personalized cancer care dawns
CHICAGO—The opportunities for imaging have never been greater, offered RSNA President Hedvig Hricak, MD, PhD, chair of radiology at Memorial Sloan-Kettering Cancer Center in New York City, during today's opening session of the annual conference of the Radiological Society of North America (RSNA).

During the president’s address—Oncologic Imaging: A Guiding Hand of Personalized Cancer Care--Hricak stated that the ultimate goal of personalized medicine is preemptive medicine. With cancer incidence projected to increase 45 to 50 percent in the next 20 years, the need to expand personalized medicine is significant.

The good news is that the tools that facilitate personalized medicine, genetics and molecular imaging, continue to emerge and develop. “Imaging has continuously  advanced cancer care and paved the road to personalized medicine. The pace at which medicine is transformed will be guided not only by the pace of discovery, but also by the pace at which we educate new physicians, ourselves and our co-workers,” said Hricak

The RSNA president divided the impact of imaging on personalized medicine into several categories: treatment decision-making, treatment planning and treatment followup. Hricak reminded the audience that imaging has nearly replaced the exploratory laporotomy with the non-invasive virtual laporotomy. What’s more, imaging serves as the GPS of medicine, a navigation tool to guide treatment. Finally, quantitative imaging and volumetric displays are not only assessing response to treatment and but also are changing the landscape of clinical trials anatomy, continued Hricak.

The era of molecular medicine will facilitate individualized, evidence-based medicine and help deliver the right care to right patient at right time, explained Hricak, who concluded with four areas of opportunity for imaging in the era of personalized medicine. These are:
  • Molecular imaging, specifically a new subspecialty within radiology;
  • Integration of imaging and pathology;
  • Biology-driven intervention for diagnosis and treatment with gene-expression holding the potential to reduce ‘blind’ biopsies; and
  • Theranostics, which combines targeted imaging and targeted therapy and may better determine mixed responses to therapy within tumors.

“As we develop targeted therapies,” summed Hricak, “we need targeted imaging.”

The need for collaboration
University of Texas MD Anderson Cancer Center President John Mendelsohn, MD, expanded on the themes of collaboration and personalization during the lecture, "Personalized Cancer Care," also delivered Sunday during the RSNA 2010 opening session.

"Treatment depends on the particular genetic and molecular abnormalities in the patient's cancer, as well as the tissue type and the stage," Mendelsohn said. "Biomarkers—laboratory and imaging—are critical for identifying patients likely to respond to new targeted therapies."

Mendelsohn reviewed multiple studies of colorectal, prostate, nonsmall cell lung cancer and breast cancers, which demonstrated his point. Tumors with specific mutations or genetic profiles respond differently to therapy. For example, the targeted therapy cetuximab is not effective for patients with metastatic colorectal cancer with the k-ras mutation. Other studies have preselected patients for targeted treatment based on genetic characteristics and biomarkers such as the BRCA 1 or BRCA2 mutation and demonstrated promising results.

The promise of targeted therapy is multi-faceted, said Mendelsohn, who declared a victory for the idea of targeting abnormal genes. “If we begin to apply new targeted therapies, we may expect more rapid [patient] responses and [accelerated] movement into clinical trials.”

The cancer paradigm in evolution
Mendelsohn offered an overview of the cancer paradigm in 2010. The human cancer genome project has demonstrated that most cancers accumulate multiple genetic and molecular abnormalities, a plasticity of expression can alter cancer cell behavior and response to therapies and physicians can expect non-uniformity in patients due to multiple variables including the cancer, the patient’s response to cancer and the patient’s response to therapy.

The calculus of cancer may be turning a corner. More than 800 drugs designed to inactivate various targets are in the development pipeline; however, research indicates that the number of targets in each patient is finite. Biomarkers enable physicians to detect genetic abnormalities and molecular pathways to select the appropriate targets and therapies.

The new paradigm hinges on complex and collaborative clinical arrangements. Planning cancer treatment today is a multimodality, collaborative process, said Mendelsohn. The team is wholly multidisciplinary and requires biomarker researchers; clinical investigators; biostatisticians; interventional radiologists, surgeons and internists; pathologists and bioinformaticians.

Mendelsohn concluded with the final piece of the puzzle. Personalized cancer treatment is not just about genes, he said. It’s also about patient relationships and partnerships between the patient and the physician.