Jonathan D. Grinstein, PhD, the North American Editor of Inside Precision Medicine, hosts a new series called Behind the Breakthroughs that features the people shaping the future of medicine. With each episode, Jonathan gives listeners access to their motivational tales and visions for this emerging, game-changing field.

In the premiere episode of Behind the Breakthroughs, Geoff Oxnard, MD, VP of Clinical Development at Lilly and a Thoracic Oncologist at Boston Medical Center, shares his journey in precision medicine with Inside Precision Medicine’s Jonathan D. Grinstein, PhD, beginning with his introduction to genetic testing as a Medical Oncology Fellow at Memorial Sloan-Kettering Cancer Center.

Oxnard discusses how differences in impact and reach drove his decision to transition from academia to industry. He also explains how perspective, not access, differentiates the adoption of precision testing in the United States. This episode also covers the topics of flexible enrollment in clinical trials, adapting to patient perspectives on clinical research as care, and the current state of precision medicine, specifically precision oncology, in the United States and elsewhere.

Highlights of this interview have been edited for length and clarity.

Grinstein: You are based in Boston, where many precision medicine tools are developed. How does location in the United States affect the implementation of precision medicine?

Oxnard: I don’t think they need to be only in Boston. Liquid biopsy, a blood test, is now FDA-approved, which means you can order it anywhere. Medicare pays for it. I don’t want us to see this as something that’s only in Boston.

Nearly all insurers offer coverage for these tests and they are available all over the country. So, I do not think access is the primary factor determining who adopts precision testing and precision oncology. It partly is the belief [in molecular testing]. I’ve done enough of it that I believe in it and apply it to all my patients. However, they do not take advantage of the availability if the belief is not yet present, whether from the oncologist or the patient. I think we are at a point where we could all adopt this if we only knew how accessible the tools are and how powerful they are in changing the story of the patient in front of us. We’re really at a tipping point to make that change.

Grinstein: What advantages do working in the industry have over academia for advancing and applying precision medicine?

Oxnard: One of the most frustrating aspects of being an investigator at a cancer center trying to enroll a patient in a trial is receiving a “no” response from a sponsor, even though this patient is an ideal candidate for the trial.

A specific example that we identified at Lilly is that lung cancer patients want to start targeted therapies early in the first-line setting but do not always have genetic testing results. In fact, the results might come back a week or two into their first-line therapy. So you have started chemotherapy, and then you get the test results and decide to switch from a therapy with some toxicity and unreliability to a precision therapy with possibly more reliability and less toxicity. But a clinical trial doesn’t allow that shift.

In some of our clinical trials, we have implemented the ability to enroll in this first-line trial not only before beginning therapy but also after one cycle of therapy. So, if you have only done one cycle and the results are back, you can act on them. Regulators have approved this flexible enrollment option, which is now part of our registrational trials.

It is very satisfying to be in an environment where we can implement something creative that’s good for the trial, good for investigators, and good for patients. We are saying that this is a new approach to our first-line trials, so why don’t other pharma partners join us in doing their trials like this to make clinical trials more acceptable and enrollable?

Grinstein: How do your patients view clinical research as care, and what can be done to improve this relationship?

Oxnard: We are observing an attitude among cancer patients that regards clinical research and clinical trials as something to do later down the line, saying, “I’m going to do standard now, and when I’ve run out of standard options, I can access clinical trials later.” One of the things we are trying to change in that narrative is awareness—that clinical trials are now available to you as a cancer patient.

We want to propagate the belief in clinical trials and research, including the belief that accessing research as part of your first cancer experience can improve your outcomes even further. That’s a shift.

If precision oncology continues to thrive, we must advocate for clinical trials as a critical, high-quality component of our healthcare and cancer care ecosystem. Certainly, that belief exists in many countries outside of the U.S., but it’s a little less prevalent in the U.S. because of how our healthcare system is designed.

All of us are stakeholders in that. As [pharmaceutical companies], we need to design more enrollable trials. Patients need to buy into this and trust that this will be part of high-quality care. We need to collaborate with investigators to build the ecosystem so that clinical trials do not just go to Boston and other places with a lot of infrastructure. Still, we have built networks across the United States to ensure these patients participate in clinical research. I am hopeful about it.

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