Dr. Huey-En Tzeng shares her experience setting up a Molecular Tumour Board (MTB) at Taichung Veterans General Hospital (VGH), and the advantages of using digital solutions to faciliate the MTB meetings

Introduction

My name is Dr. Huey-En Tzeng and I am a medical oncologist at Taichung Veterans General Hospital. I also serve as the CEO of the Precision Medicine Center, where I oversee precision oncology and lead the MTB. My journey with the MTB started in 2017 at Taipei Medical University Hospital, where Professor Yen Yun established Taiwan’s first MTB, and I was a key member. In 2022, I moved to Taichung Veterans General Hospital. With the support of the superintendent Professor Shih-Ann Chen, I established the MTB at this hospital as well.

What is the vision of cancer care at Taichung VGH?

Taichung Veterans General Hospital is the National Medical Center in Taiwan, treating five to six thousand newly diagnosed cancer patients each year. In 2019, the hospital established the Precision Medicine Center, which integrates clinical practice, tumor biology and bioinformatics to offer the latest in cancer NGS testing. In 2022, we joined the National Health Research Institutes’ Precision Oncology Demonstration Project, providing comprehensive genomic profiling (CGP) testing for 2,000 cancers patients across Taiwan. As of April 2024, we have already enrolled 440 cases. We have also assembled a team of molecule experts and hold MTB meetings every two weeks to explore and discuss the optimal treatment plan which can benefit the most to our patients. Additionally, we aim to build a robust database to accumulate real-world data and establish a large-scale precision medicine repository.

What are the challenges encountered in precision oncology diagnosis, treatment decision making and progression monitoring in your country/your institution?

Starting in May this year, the government began to reimburse NGS testing, including CGP. Additionally, hospitals are now required to establish MTB and have to submit relevant data reports to national health insurance database. CGP provides a comprehensive analysis of cancer genes, but it brings significant challenges because of the large and complicated number of the mutation variants. These different mutation variants need input from multidisciplinary experts. However, for hospitals without experts, this is a new and difficult area. Especially in terms of data management, there is an urgent need to use standard data formats and build systems that can effectively use cancer database for clinical decisions and patient outcome monitoring.

Why were MTBs important in your institution? What were the challenges you encountered in conducting oncology MTBs in your institution?

There are four objectives to set up MTB in our hospital. First, it provides consultations, including testing options, hereditary cancer tests, and report interpretation. Second, it discusses the treatment plans. Third, it refers patients to clinical trials. Lastly, the MTB plays an educational role. However, traditional MTBs rely heavily on manual effort to collect data from various sources. When we review cases, we need to look at both the genetic test mutation variants and the patient’s clinical data. This data is stored in different HIS systems, making it difficult to keep everyone on the same page. As a result, we spend a lot of time organizing discussion materials, and the conclusions from these discussions are hard to store in the HIS for the attending physicians to refer at any time. In addition, we follow up with patients every six months, so managing the MTB patient list is also very important to us.

How have digital MTBs been implemented into your institution for cancer management?

After adopting MTB digital platforms, both genetic and clinical data can be stored in the same platform. In terms of workflow, physicians just simply need to fill in the patient’s medical record number and submit it, and I will receive the submission. At the same time, the platform will initiate automated data entry. Therefore, I can quickly review the cases that need to be discussed in the MTB on the digital platform and further schedule dates for MTB discussion. Even if the MTB members are in different locations, they can edit discussion data on the platform at any time before the MTB. In the discussions of the MTB clinical trials are important information. The platform integrates external clinical trial information and can match possible clinical trials and the latest journal literature based on the patient’s genomic profiling. In addition, the decision-making process of the discussions can also be stored completely on the platform, assisting us in cancer patients management and follow up.

What is your experience using digital MTB platforms? How have digital MTB platforms streamline your process?

Using a digital MTB platform, the biggest benefit is that it automates the collection of genetic and clinical data. MTB members can look at patient level data simultaneously, making preparation faster. It also improves patient management and follow –up across specialties. In the past, the information for each step, from physicians requesting case discussions, to reviewing cases, to preparing slides, and writing discussion records – was scattered. The digital MTB platform not only helps us digitize the process but also streamlines it. I can say it saves us a lot of time and workload.

What advice would you give your fellow colleagues to incorporate digital MTB platforms into their clinical or institutional practice?

Implementing the digital MTB platform requires effective change management and the ability to endure initial challenges. I would say it requires top-down decision support to sustain it. Once we overcome this phase, we can fully appreciate the value the MTB platform brings. Additionally, during the implementation phase, integrating clinical and IT capabilities is crucial. While IT skills are fundamental, understanding clinical processes and needs is indispensable. Last but not the least, automating data integration isn’t something that happens overnight; it should align with clinical milestones and be completed by phases.

Prof Chao-Hua Chiu shares insights on the application & clinical implementation of NGS for lung cancer treatment decision-making

Interview transcript:

Introduction

I’m a pulmonologist as well as a medical oncologist. I work in the Taipei Cancer Centre, Taipei Medical University in Taiwan. I work on lung cancer for 20+ years, and mostly I’m more interested in lung cancer screening and treatment in late stage lung cancer in early phase novel drug development clinical trials.

In the current healthcare situation in Taiwan, what are the most urgent needs for managing patients with lung cancer?

The first one is to identify the patient as early as possible. Lung cancer screening is a very important part in the control of cancer. Especially in Taiwan, about half of the newly diagnosed lung cancer are never-smokers. In Taiwan since about 1 year ago, last July, our government decided to initiate a national lung cancer screening program that include not only heavy smokers, but also non-smokers for those who have first-degree lung cancer family, as far as I know that is the first in the world in national lung cancer screening, that enrolled never-smokers with risk. Based on a recent study that will be published soon, showing that low dose CT lung cancer screening will be helpful for those with never-smokers, but with lung cancer risk. To find the patient in the early stage, and for those early stage lung cancer, surgery alone will be enough. The more challenging part of the management of lung cancer is when the disease goes to the 2nd or 3rd or the 4th stage. For those with locally advanced lung cancer, the recurrence rate after surgery is high, so we have to give neo-adjuvant and adjuvant treatment. We have EGFR-TKI in adjuvant setting, that is proven to give survival benefit after surgery. We also have neo-adjuvant or adjuvant immunotherapy, that also prove to provide survival benefit to the patient after or before surgery.  For those with stage 4 disease, it is complicated. In non-small cell lung cancer (NSCLC), the most important one is to find the driver mutation. So it is a most critical step in the management of late stage NSCLC.  We need a panel of testing to find out the driver mutations. So NGS, next-generation sequencing, it will be a must do testing in the near future.

How has the lung cancer screening in Taiwan helped to improve early diagnosis of lung cancer and improve patient outcomes?

The distribution of stages in NSCLC is roughly about 20% stage 1, 10% stage 2, another 10% stage 3, and more than 50% of the newly diagnosed cases are stage 4. But after the implementation of low-dose CT screening in Taiwan, in some medical centres, stage 1 lung cancer is reaching to 30 to 40%. We believe we will see lung cancer mortality will significantly improve after 5 or 10 years that is simply because we find more early stage lung cancer and less stage 4 lung cancer. It’s just because of the screening, result in stage shift, that will give a significant reduction of lung cancer mortality.

In your opinion, what are the key benefits of precision oncology in real-world clinical practice, especially for patients with lung cancer?

NSCLC is probably the [cancer to] most benefit from NGS. Driver mutations caused the lung cancer, And these driver mutations are usually mutually exclusive. NSCLC is no longer to be classified according to histology.  Nowadays NSCLC may be classified according to the underlying mutation because we treat the patient according to the underlying driver mutation. So if we want to check these 10 driver mutations one by one, it not only takes time but also takes money to do all these tests. More importantly, it takes tissue, and tissue is more precious than money or time. So we need a platform that can do multiple gene mutations simultaneously.

What are some of the challenges you currently face for precision oncology realisation in your clinical practice?

We know the benefit and the importance of NGS testing, but to be honest, only very few patients can get NGS testing at the beginning in Taiwan. The testing is expensive, and it is not yet reimbursed by the health system in Taiwan. So luckily, just a few weeks ago our government, they decide to reimburse NGS testing in the coming year. If it comes true, our patient will benefit a lot from this reimbursement policy change. From the scientific point of view, some diagnostics or treatment are certainly beneficial to the patient, but because of the budget impact of our health system, very few countries can fully reimburse all these treatment or diagnostics, so that’s a major hurdle of the management of NSCLC at this moment.

What are some solutions which may help address these challenges?

If we know how to treat the patient but the patient cannot afford it, that is a tragedy to the patient and his family. If the government and the Pharma industry can get some agreement to get the new drugs to be on the market as soon as possible, it will be a critical step to improve the overall patient outcome. For example, in UK, there is a system called Cancer Fund. The new drug can be in the market as soon as the drug gets approved and the government will re-evaluate the treatment efficacy, or the cost-effectiveness of the treatment. And then they can decide to get the drug so-called fully reimbursed or not. In Taiwan, our government also considers this so-called alternative reimbursement pathway, so that the patient can get the drugs. The doctor knows which drug is a treatment of choice but just just cannot get the drug. So how to get the drug as early as possible is very important, especially to a stage 4 lung cancer patient.

With new advancements in lung cancer and precision oncology, what are your future expectations for patient management in lung cancer? How do you see this field evolving over the next few years?

The precision medicine is not only at the treatment, but also at the management of health. So technology wise, I believe the AI technology will certainly play some role in the diagnosis as well as the treatment. And the other technology that we expect is the liquid biopsy, because not all patients can get enough tissue to do NGS testing. I believe in the very near future we just take 1 or 2 millilitres of blood, and then we can check mutations, and not only at the beginning, but also during the treatment, we can serially check the mutation status to decide whether the treatment can continue or the treatment should be changed. I think this technology will come in soon.

The views and opinions expressed by Prof. Chao-Hua Chiu are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.

Quick Summary

Tumour genomic sequencing is becoming increasingly prevelant in today’s oncology landscape, with more and more patients undergoing multigene sequencing of their cancer, in the hope of finding genomic alterations that could effectively be targeted with matched cancer treatments. Unfortunately, most multigene sequencing reporting systems do not prioritise alterations or use a standardised clinical utility-based ranking system. This poses a major challenge for oncologists when it comes to treatment decision making.

In order to facilitate implementation of precision medicine in clinical management of cancer, there is a need to harmonise and standardise the reporting and interpretation of clinically relevant genomics data. This can help prevent patients from potentially being recommended ineffective drugs matched to clinically unproven targets, and alternations with proved clinical value from being missed.

In this study, a unified framework to classify targets for precision cancer medicine based on clinical evidence of utility is proposed. The primary aim for developing this framework is to aid oncologists in prioritising potential targets for clinical use when receiving reports of broad gene sequencing panels. With this classification system, a common language can be adpoted by all cancer medicine and drug development stakeholders to place targets within their clinical context.

Quick Summary

The integration of next-generation sequencing (NGS) comprehensive gene profiling (CGP) into clinical practice is playing an increasingly important role in oncology. NGS CGPs have been incorporated into clinical practice to improve patient outcomes by identifying actionable drug targets. To integrate NGS CGPs and faciliate the implementation of precision medicine into clinical practice, multi-disciplinary Molecular Tumour Boards (MTBs) have been established, and enable the timely referral of patients to genomically stratified clinical trials

In 2018, the University of Hong Kong (HKU) and Hong Kong Sanatorium & Hospital (HKSH) established the HKU-HKSH Multi-disciplinary MTB to advance precision oncology in Hong Kong. A multicenter retrospective clinical outcome analysis was conducted for patients with advanced solid cancers presented at the HKU-HKSH-MTB for review and treatment recommendations. The primary objective of the study was to demonstrate the survival impact of a comprehensively curated real-world retrospective MTB dataset to facilitate the management of patients with cancer in the era of precision oncology.