A precision medicine fight is brewing between clinicians, public health
BOSTON -- Trying to apply new precision medicine methodologies when there are no precedents can be scary for physicians and patients alike. And the practice of genome sequencing and population screening are on the verge of getting more contentious.
“Genomic sequencing is an artisanal process if you want to be at the standard of care,” said Robert Green, MD, a medical geneticist and physician-scientist at Brigham and Women’s Hospital and Harvard Medical School. “Genomic medicine is outside, knocking on the door trying to get in.”
Green pointed to the BabySeq Project, which offers free genome sequencing for newborns, and said that 93 percent of parents turn that down as a current example of how hard it can be to convince people to share their data and participate in precision medicine programs.
“In the near term I think we will have a lot of skirmishes — and maybe even a war — about population screening, pitting clinical perspective of those who want to know everything against the public health perspective which says ‘be careful what you screen for because you might have unforeseen consequences and costs downstream,’” Green said.
It’s a matter of trust, but Vik Bakhru, chief operating officer of ConsejoSano, said precision medicine trust is only in its early stages.
“How do we inspire trust that the data is actionable and they can benefit from treatments out there?” Bakhru said.
One way is to educate prospective participants about the upsides. Penn Medicine, for instance, has changed the treatment plans on 80 percent of the patient it has sequenced, according to associate vice president Brian Wells.
Green said there are three big questions that have to be answered to earn that trust: Is genetic information toxic? Will participants and their providers misunderstand genomic information? Will benefits outweigh harms and justify the cost?
It’s not that doctors don’t know what to do with or how to interpret the data, and it isn’t even about the cost, Green said. Instead, it’s the lack of clinical utility data that’s the major obstacle of genomic medicine. Without that, precision medicine proponents can’t get insurance companies to reimburse for genomic sequencing so it’s not a standard of care.
Green said that answering those questions and overcoming that clinical data utility obstacle will happen because the benefits ultimately outweigh the risk. Early evidence, in fact, suggests that using genome sequencing can pinpoint molecular diagnoses in about 25 percent of cases.
“This is well established in the armamentarium of genomics,” Green said. “We have to work decision support into the process but we are going to get there.”