Andrew Hertler: The Future of Genomics and Clinical Pathways

 

Journal of Clinical Pathways spoke with Andrew Hertler, MD, about the role of genomics influencing clinical pathways in the near future (September 8-10, 2017; Washington, DC).

My name is Andrew Hertler. I am the chief medical officer at New Century Health.

In your opinion, what role do genomics play in clinical pathways?

They are going to play an increasingly important role in clinical pathways. I believe genomics will make clinical pathways even more useful than they already are to physicians. Genomics adds an exceedingly complex element, with multiple genes, multiple mutations, some being actionable, some not. There are certain drugs associated with certain mutations. I think it defies an oncologist’s ability to keep them all at the top of mind. With that degree of complexity, a decision support tool (ie a clinical pathway) which can rapidly guide them to the appropriate therapy is absolutely critical.

You say it is “going to happen.” How soon down the horizon do you see genomics influencing clinical pathways?

It is happening already. It’s very early right now and it’s certainly exceedingly complex. There are multiple genes, multiple mutations, but any one tumor can have more than one mutation. Therefore, the number of permutations is enormous. If you look at a simple disease like chronic myelogenous leukemia, where there is one gene and essentially one driver mutation and a number of secondary mutations, it is fairly simple to put in pathways. It also depends on what level you take the pathways to. If you just say “Is there an ALK mutation in non-small cell lung cancer,” that’s in most pathways already. But, some ALK mutations will sensitize a tumor to crizotinib, others will not. There can be secondary mutations. So clearly, the degree of complexity built into the pathways needs to increase.

Have you seen any of the other sessions in the Clinical Pathways Congress this weekend?

I have.

Which session was the most meaningful for you?

The mock pathway. It was interesting listening to it. After listening to the panel, what really struck me was the need for pathways. You had these verging viewpoints, many of which were based on personal experience. The point I walked away with is that clinical pathways really has to be driven by the evidence and the data. Personal experience is great, but you’ve got to drive the pathways by the evidence and by the data. I think that’s what pathways bring – what they are doing is codifying clinical evidence in a very concise, easily accessible form. For a clinician to have a trusted, easy to use, and regularly updated tool that can rapidly guide them to those evidence-based decisions is wonderful. I heard a whole lot of time this morning with physicians talking about liking abraxane or liking taxol, but let’s talk a little bit about the evidence and which should be used. It was interesting to hear the perspective, but in my own mind, when the data is there, ultimately the data and the evidence has to drive it.