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Personalising cancer: the future of research

Research updates

Issue 8, October 2011

As we move away from the traditional tissue-based model of cancer to one based on the genetic behaviour of disease, Dr Alex Swarbrik sees a future where biology and technology intersect to personalise care.

Dr Alex Swarbrick, senior research officer at the Garvan Institute of Medical Research, has some interesting views about the current state of play of research into a cure for cancer and what the more promising of these efforts hold for future directions in cancer research. We talked to him to find out more.

Cancer's scrambled genome

He began by addressing the difficulties about research into cancer and what sets it apart from other diseases.

"Normal cells play by the rules that define their cell type," says Alex. "For example, different kinds of cells each have their own chapter in the genetic library, which basically define what they can and can't do.

"Cancerous cells seem to able to bypass that completely and go rummaging through this library into whatever chapters they like, picking and choosing at will. For instance, in order to replicate they may take on the characteristics of embryonic stem cells."

the ability of cancer to scramble its own genome... enables cancerous cells to 'duck and weave' in response to whatever medical science might throw at it.

Alex describes this as the ability of cancer to scramble its own genome, or genetic code. It is this scrambling that enables cancerous cells to 'duck and weave' in response to whatever medical science might throw at it.

Understanding the unpredictable nature of how cancer cells divide and multiply is something that has driven Alex's research for several years.

Recently, Alex was awarded the 2011 Premier's Awards for Outstanding Cancer Research Fellow for his work identifying the role of microRNA (ribonucleic acid) genes in the behaviour of neuroblastoma.  A childhood cancer, neuroblastoma has been notoriously difficult to treat and his work will hopefully lead to the development of drugs to better target the disease.

With such credentials, Alex has a sound understanding of the complexity of cancer, how elusive the disease can be and the work needed to find a cure.

He highlights how essential collaboration and teamwork is to the cancer research effort.

"Medical research has been compared to a football.

"Cancer research is a good example of this.  No one can do it alone. Some researchers hold the ball for a while, doing their bit to gain ground. They will then pass the ball on to someone else, whoever can take it further upfield."

A heteregenous disease

Alex believes the impetus toward targeted therapies reflects the growing understanding of cancer as a heterogenous disease. There are not only many different types of cancer, but even the same cancer can manifest very differently depending on the individual.

Cancer ain't cancer... think of it as a collection of a thousand different diseases which outwardly present the same way.

"In a very real sense, 'cancer ain't cancer'," he says.

"Think of it as a collection of a thousand different diseases which outwardly present the same way. We are rapidly moving away from the traditional tissue-based model of cancer, to one based on the genetic behaviour of cancer cells wherever they are in the body. You might have, perhaps, 25 different types of breast cancer or 40 types of pancreatic cancer.

"Treatment will vary, therefore, from individual to individual depending on which particular variant of that type of cancer an individual has."

It is a scary thought to think that a disease can be so advanced, so what does this mean for finding a cure; and, realistically how far away are we from realising this goal?

"The poster-child, if you will, for targeted drugs is Herceptin, which was introduced about 10 years ago as a treatment for HER2+ breast cancer. Approximately 25 per cent of women with this form of breast cancer are completely cured," Alex observes.

"Twenty years ago, the childhood cancer acute lymphoblastic leukaemia, or ALL, had only had a 10 per cent survival rate … these days that stat has almost reversed, with only 10 per cent fatality. The discovery of Gardasil as a drug for cervical cancer is another breakthrough."

Alex agrees that cancer research can be viewed from both a glass half full and a glass half empty perspective. We cure cancer now, in an increasing number of cases. But the complex nature of the disease qualifies the success rate.

"You have to realise that even the ground-breaking discoveries I've mentioned have only been beneficial for a minority of cancer sufferers in a particular sub-group."

An optimistic future

Alex's vision for the future of cancer research is one of optimism. He acknowledges the widespread view of health professionals like oncologist Lisa Horvath (Royal Prince Alfred Hospital), projecting that over the next 20 years, with improved medical management, cancer - like heart disease - will increasingly be managed as a chronic disease, allowing people to have a normal life expectancy.

He expects we will continue to improve our ability to cure some cancers and that the effectiveness of targeted drugs will also improve; some cancers will simply be managed better while a proportion will remain a challenge.

Aside from more advanced drugs, an increased understanding of the immune system will be pivotal to future strategies in curing or managing cancer.

Perhaps in the future we will walk into a clinic and the very first thing we will have done is the sequencing of our cancer's genome.

"I think the personalisation of cancer that's driving the field now and supported by organisations such as the Cancer Institute NSW and the Cancer Council is, to a large extent, enabled by the intersection of biology and technology.

"Perhaps in the future we will walk into a clinic and the very first thing we will have done is the sequencing of our cancer's genome. This only costs a few hundred dollars now, whereas the initial worldwide collaborative effort to achieve this cost over a billion dollars."

Alex expresses the hope of the scientific community, that through this painstaking process of articulating how cancer manifests differently across different individuals, we will eventually identify classes of cancer.

"There is evidence already that we can achieve this, but I expect there will still be cancers that can't be classified. These will be the main challenge for future generations' researchers."

For the moment, Alex acknowledges the positives of having his work recognised at the Premier's Awards.

He has had contact with many colleagues, past and present, and staying in touch with the wider scientific community is something he believes is extremely important.

"To stay at the edge of research is the only way to remain relevant.

"Breakthroughs can only come from team efforts, where different expertise is brought together to create something bigger than the sum of its parts."