Dodging cancer: Wishful thinking now, a reality one day

By Dr. Ng Huck Hui, Executive Director, Genome Institute of Singapore, A*STAR

Doctors and researchers are working on delivering targeted treatments, thanks to advances in medicine, science and technology.

When actress Angelina Jolie announced in 2013 that she had undergone an elective double mastectomy to prevent breast cancer, critics questioned the need for such a radical pre-emptive move.

But the actress argued in an op-ed in the New York Times that her life was at stake. A genetic test had revealed she had a mutation in the BRCA1 gene, which raised her risk of breast cancer to 87 per cent.

Many, however, looked past the Hollywood drama and hailed her decision for its scientific significance: that rapid advancements in science might one day allow people to dodge the cancer bullet. 

Such a possibility - however far off - is the result of advancements not just in medicine, but also in science and technology. In fact, it is the convergence of these fields that has shaped the vision of a future in which precision, targeted medicine might overcome cancer effectively.

No longer will surgeons and oncologists be racing against time to find the best method of treatment after cancer strikes, testing drugs on a patient one by one until they find the one that works.

Instead, the future could see patients having their DNA sequenced before treatment, and tumour "avatars" created and modelled for the- rapeutic vulnerabilities outside their bodies, so that doctors know exactly which drugs to prescribe.

There is also the possibility of having newer, more specialised drugs that will attack cancer at its core.

NEW STRATEGIES FOR TREATMENT

This hopeful vision is the result of disruptive technology in various fields.

On the biomedical front, the completion of the Human Genome Project to map human DNA has radically deepened our understanding of man's basic blueprint.

On the technology front, DNA sequencing costs have gone down significantly and data processing has acquired such speeds that collection and analysis of genetic data are now practicable.

As for imaging, advancements like MRI and PET-CT scans mean that the human body can be probed at increasingly higher resolutions.

What will the convergence of these advancements mean?

A new paradigm of smart medicine will emerge. Armed with advances in DNA and cell engineering, oncologists will have an increasingly wide array of powerful tools to treat certain cancers.

One example is immunotherapy, which involves programming a patient's own immune system to attack cancer cells. Already being tested, this form of treatment is believed to be more effective than some forms of chemotherapy, especially in advanced melanoma and lung cancers.

All these tools of the future promise to transform the treatment of diseases such as cancer radically. Genetic profiling could become an essential part of healthcare and screening, allowing doctors to tailor treatment and ensure that it is precise and specific to each patient.

Instead of the current approach of empirical treatment where information is incomplete, precision oncology represents a guided paradigm of treatment strategies tailored to the individual patient which increases the chances of doctors administering the most effective drug the first time round, saving precious time.

We, as a team of doctors and researchers, are actively developing this framework. The first step involves genetic profiling of a tumour to find out how a patient is likely to respond to certain drugs, while the second step evaluates the efficacy of the selected drug in a patient tumour model outside the body, which retains the characteristics of the original cancer.

Doctors will be able to find out precisely how a tumour responds to each drug, as well as discover combinations that may work better. To date, we have developed patient avatar models for colon, breast, head and neck, liver, lung as well as pancreatic cancers.

Humanity's battle against cancer is a continuous arms race. Cancer always tries to outsmart the treatments we develop, so we need better strategies to treat it. The paradigm of medicine will evolve from curing to pre-empting it.

This vision, however, requires time to realise. The human body is incredibly complex, and so are diseases. The challenge of developing precision treatment is so large that it needs to be broken down into smaller parts and solved from different angles - a task that could take several more decades before this utopian vision of biomedical research becomes a reality.

SINGAPORE: A WELL-PLACED RESEARCH HUB

A great dose of patience and perseverance is the key ingredient in our efforts to take laboratory breakthroughs to clinics and hospitals.

In Singapore, this long-term commitment to R&D in a wide range of fields has been supported by the Research, Innovation and Enterprise Plan. Since the early 2000s, a spectrum of world-class biomedical institutes has been built within the Agency for Science, Technology and Research (A*Star), universities and hospitals. Such institutes - and their progress - reflect the wisdom of a long-term approach to R&D.

It has helped Singapore train a critical mass of talent and attracted investments dedicated to diverse research efforts. There are now hundreds of publicly funded research labs, start-up companies and multinational corporations pursuing the latest in bio-computing, bio-imaging, human immunology, cell engineering, and so on.

The convergence of science, technology and medicine requires a carefully orchestrated strategy to synergise the intellectual output from different sectors, to impact healthcare and society.

Establishing R&D hubs and deliberately co-locating research clusters within Buona Vista's one-north and in close proximity to the universities and medical centres maximises meaningful and productive interactions.

For example, the Personalised Omic Lattice for Advanced Research and Improving Stratification (Polaris) was established by A*Star's Genome Institute of Singapore (GIS) in 2013 to enable the routine use of genomic technologies in patient care.

The Polaris network includes the Singapore Eye Research Institute, the National University of Singapore (NUS) Saw Swee Hock School of Public Health, NUS Centre for Biomedical Ethics, Duke-NUS, as well as clinical partners SingHealth, the Singapore National Eye Centre, National Cancer Centre Singapore, Singapore General Hospital, National University Hospital and Tan Tock Seng Hospital. Last year, the Polaris Laboratory obtained accreditation by the College of American Pathologists.

More recently, GIS obtained the Ministry of Health's licensing for its Polaris laboratories to provide clinical molecular tests. This programme will drive innovations in the clinic.

Polaris' Somatic Solid Tumour Panel has now been run in more than 100 patients, mainly for colorectal cancer, and will be rolled out to more solid tumours soon. This is a 29-gene panel that covers all of the current clinical targets that drugs can be used on.

All these examples demonstrate that Singapore is in a strong position to play a significant role in the global effort to develop precise, targeted treatment for the future.

A "One-Singapore" R&D effort is critical for a small country like ours to punch above its weight. The challenge is to maintain this commitment, with each generation building on the efforts of the previous one.

Policymakers, investors, management and researchers need to keep in mind that R&D requires the right mindset and timing - as well as a dose of luck. In the context of the global R&D scene, our R&D effort is still in its infancy. We need to hold firmly to the belief that diseases like cancer can be overcome.

As Jolie said in her 2013 article: "Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of."

About the writer

Dr Ng Huck Hui, 45, is executive director of the Genome Institute of Singapore (GIS) and adjunct professor at the National University of Singapore (Departments of Biochemistry and Biological Sciences), and the Nanyang Technological University (School of Biological Sciences).

He is well known for stem cell research and has published research pieces. Before joining GIS in 2003, he was a post-doctoral fellow with Harvard Medical School under the Damon Runyon-Walter Winchell Post-doctoral Fellowship.

He has won many awards, including the Chen New Investigator Award from the Human Genome Organisation in 2010. Earlier this year, he was elected an associate member of the European Molecular Biology Organisation, making him the only associate member to be based in Singapore.

This article is also available in The Straits Times on November 25, 2016, with the headline 'Dodging cancer: Wishful thinking now, a reality one day'.