THIS WEEK EDITORIALS of the long-anticipated changes to cancer care work their way from as-yet-unexplained genetic variants. Such studies would also help bench to bedside — ones that would allow precision oncology to be researchers to unpick the effects of combinations of genetic variants, scaled up. In the past year, the US Food and Drug Administration has a consideration that is likely to become more important as clinicians issued its first approval of a genetic test that can detect mutations in sequence larger sets of a tumour’s genes. Also useful is the growing hundreds of cancer-associated genes. Also a first, the agency approved emphasis in cancer research on testing targeted therapies in com- a drug for the treatment of any solid tumour bearing a particular bination with one another, and together with drugs that provoke genetic signature, regardless of what tissue the tumour originated in. immune responses to cancer. From a clinical perspective, better and Health services around the world are talking up the role of DNA more-thorough screening should identify “Clinicians are and genomics in a new era of personalized medicine. But the utility the people most likely to benefit. left facing ill of increasingly expensive cancer tests and medications that will help Precision oncology increases the range patients and only a minority of patients is also being fiercely debated. Some 30 or of treatment options — but so far for only a trying to work so cancer drugs have so far been linked to a specific genetic signa- relatively small number of people. Yet clini- out what to do.” ture. Many people have benefited, but some will relapse later as their cians say that media reports of miracle cures tumours become resistant to the therapy. have painted a much rosier picture, fuelled Against this backdrop, clinicians are left facing ill people and by anecdotes about exceptional responders who experience dramatic, trying to work out what to do. Whose tumours should be sequenced, but highly unusual, responses to treatment. In the United States, the and when? How often should one patient’s tumour be sequenced? problem is compounded by advertisements — from pharmaceutical What kind of sequencing should be done — 50 genes, 400 genes, a companies and treatment centres — aimed directly at people with full genome? How should physicians interpret genetic variants and cancer. Enthusiasm for the possibilities of precision oncology has led conflicting data? too many involved to present the option with too much optimism. By And over it all hangs the painful question that health-care systems its very nature, each precision cancer drug is destined to help only everywhere must grapple with: at what point does the potential for a fraction of people. Everyone with cancer wants, understandably, benefit outweigh the cost of sequencing and the treatment that follows? to be in that fraction. Hope is important. But all parties need to be Researchers can help to pave precision oncology’s path to the sensitive to how the promise of precision medicine is communicated clinic. More research on cancer genetics might reveal roles for to patients — and to their physicians. ■ differences in agricultural practice that need to be built into models that assess risk. It calls for more systematic updates to the assessment Food chain of active substances when new data become available. It supports more monitoring and analysis of how pesticides and herbicides European advisers set out a path to a accumulate in the environment and in wildlife. And it suggests that mandatory pre-registration of the lab studies that companies will sustainable future for food production. rely on to show their chemical is safe (including the lab location, the types of test planned and what will be learnt from them) would hen Europe scrapped its chief scientific adviser role and help to address concerns about the independence and objectivity of instead installed a committee of experts in 2016, there were industry-sponsored studies. Wquestions about how well the system would function. Very More fundamentally, the report suggests some structural and well indeed, is the answer — at least if a report released by the expert systemic changes to the approval process. These range from clarify- group on 4 June is anything to go by. ing levels of acceptable risk (current regulations invoke the precau- Ostensibly, the opinion document from the European Union’s tionary principle to demand no harm to health or the environment, Group of Chief Scientific Advisors discusses how the EU authorizes which is unachievable in practice), to recognizing that taking no plant protection products (chiefly insecticides and herbicides). But it action (for example, not applying a pesticide) also carries risks. goes further, offering sound advice on how to reform aspects of the Furthermore, the report recommends bringing the risk-assessment EU’s infamous bureaucracy and convoluted decision-making mecha- process within the control of the EC (it is currently outsourced to nisms for agriculture. And written between the lines is a clear and member states). simple message, which Europe needs to take on board sooner rather These types of change are more difficult to implement — not least than later: that the region’s approach to food production is fragmented because, at present, nations have control over the process (and, in the and hopelessly unsuited to future needs. GM case, a de facto veto). National politicians will not surrender that The report is the latest in a series of papers by the group, all control lightly, particularly in countries such as Germany, where anti- “from a scientific point of view”. It will feed into specific discus- GM feeling has huge influence. sions about, for example, how the commission can better integrate The particular wisdom of the latest report is in its recognition that, the functions of its agriculture, food, environment and research for such political changes to become possible, the focus of the public directorates. That is important if Europe is to set out a coherent debate must shift from single issues in agriculture to the bigger ques- plan for a sustainable future. At present, it is too easy for policy- tion for society — how do we want to create sustainable agriculture making on a continent-wide level to be paralysed, as seen with in Europe and ensure quality food production, and how much are research into and applications for genetically modified (GM) we prepared to pay for it? Pesticides and herbicides have a part to organisms. And, as shown by a controversy late last year over the play, but so do complex and sometimes conflicting issues that have a approval of the herbicide glyphosate by the EU, there is insufficient relationship to agriculture: fertilizers, food chains and environmental public trust in the process. protection in general. Tighter controls of pesticides, for example, will The committee was tasked by the European Commission (EC) to affect these other aspects and have costs and benefits to society. Such work out whether the current system for approval of these products a discussion will go beyond a strictly scientific point of view, and must could be more effective, efficient and transparent. The report makes account for values and human judgements. some sensible suggestions for improving transparency, some of which A good start would be for the commission to arrange a high-profile can and should be implemented quickly in the existing approval workshop for all relevant parties — including the public, non-govern- process. It recommends a new public IT platform to store the rel- mental organizations, scientists and companies — to kick-start the evant data, case studies and information on cultural and historical process. Good advice alone is not enough. ■ 6 | N A T U R E | V O L 558 | 7 J U N E 2018 © 201 8 Mac m ill an Publi shers Li m it ed, part of Spri nger Nat ur e. A ll ri ghts r eser ved.
Nature – Springer Journals
Published: Jun 5, 2018
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