Scripps physicians call for change in cancer tissue handling

SAN DIEGO – Genetic sequencing technology is altering the way cancer is diagnosed and treated, but traditional specimen handling methods threaten to slow that progress.

That's the message delivered this week in a column appearing in the Journal of the American Medical Association (JAMA) by Scripps Clinic physicians Eric Topol, Kelly Bethel and Laura Goetz.

Dr. Topol is a cardiologist who serves as chief academic officer of Scripps Health and director of the Scripps Translational Science Institute (STSI), leading Scripps' genomic medicine research efforts. Dr. Bethel is a pathologist, and Dr. Goetz is a general surgeon and a researcher at STSI.

"Deciding how best to obtain (tumor) samples and how best to process them for whole genome or exome sequencing is a pivotal yet unresolved issue with several layers of complexity," the doctors wrote. "As the new clinical applicability of genomics emerges at a fairly rapid rate, the field of pathology will arrive at a tipping point for a fundamental change in how cancer specimens are handled."

Currently, tumor tissue obtained through a biopsy is fixed in formalin, a mixture of formaldehyde and water, and embedded in paraffin for microscopic viewing. However, because the chemical mixture damages DNA, sequencing tissue processed in this way can be difficult, if not impossible.

A better alternative is to also routinely freeze a portion of the specimen, which retains the tissue's genetic coding while preserving it for future analysis. In order to have enough tissue to freeze, larger or additional biopsy samples may be required, especially when using minimally invasive needle biopsy procedures.

"We need to completely rethink the way we have collected and stored cancer tissue samples for decades," said Dr. Topol, "It's becoming increasingly clear that obtaining an accurate map of a tumor's DNA can be the key to determining the specific mutations that are driving a person's cancer, how best to treat it and how likely it is to recur."

Even though complete genetic evaluations of tumors might require higher sample-storage costs and a more invasive biopsy procedure, most patients would likely agree to that option if it translates into a better diagnosis and possible treatment, the authors wrote.

Evidence of such benefit must come from randomized clinical trials that compare detailed genetic evaluation of tumor tissue with the current standard of care for cancer patients, they said.

"Drs. Goetz, Bethel and Topol's editorial acknowledges kindly the critical role pathologists play in patient care," said Dr. Stanley Robboy, president of the College of American Pathologists. "This type of change will require discussion about new operative standards, which will need the cooperation of surgeons, pathologists, ethicists and, of course, appropriate patient consents. It's these types of implications we will need to consider and incorporate as a progressive healthcare agenda is moved forward."

Patients and their advocates have a direct role to play in this transformation and should raise questions about tumor specimen storage and genetic testing with their doctor, said Dr. Topol, who outlines a consumer-led digital health revolution in his book "The Creative Destruction of Medicine."

Part of San Diego, Calif.-based Scripps Health, the Scripps Translational Science Institute (STSI) is a unique community collaboration that initiates research that moves basic science from the lab to the patient bedside. STSI is supported by the NIH flagship program, Clinical and Translational Science Award (CTSA). Collaborators in the STSI consortium include Scripps Health, The Scripps Research Institute, the Burnham Institute for Medical Research, Children's Hospital of Philadelphia, Genomics Institute of the Novartis Research Foundation, The J. Craig Venter Institute, Salk Institute for Biological Studies, San Diego State University, San Diego Supercomputer Center and The Neurosciences Institute.

Founded in 1924 by philanthropist Ellen Browning Scripps, Scripps Health is a $2.6 billion nonprofit integrated health system based in San Diego, Calif. Scripps treats a half-million patients annually through the dedication of 2,600 affiliated physicians and 13,500 employees among its five acute-care hospital campuses, home health care services, and an ambulatory care network of physician offices and 23 outpatient centers and clinics.

Recognized as a leader in the prevention, diagnosis, and treatment of disease, Scripps is also at the forefront of clinical research, genomic medicine, wireless health care and graduate medical education. With three highly respected graduate medical education programs, Scripps is a longstanding member of the Association of American Medical Colleges and is recognized by Thomson Reuters for having one of the top teaching hospitals in the nation. Scripps is also the region's only cardiovascular program recognized by U.S. News & World Report as one of the best in the country. Scripps has been consistently recognized by Fortune, Working Mother magazine and AARP as one of the best places in the nation to work. More information can be found at www.scripps.org.