Making a difference for rural cancer patients
By Joyce Dall'Acqua Peterson
Oncologist Rachit Kumar, M.D., is deep in discussion about his patient with stage 4 pancreatic cancer that had metastasized to multiple organs. Around the conference room table and on the speakerphone, fellow oncologists and experts in cancer genomics and clinical trials discuss the genetic profile of the patient’s cancer, weighing in on advanced treatment options, as a genetic counselor and two student interns take notes.
If you’re picturing this scene at a big-city university medical center, think again. This tumor board meeting is taking place at the Maine General Medical Center’s Harold Alfond Center for Cancer Care in Augusta, the capital of Maine, the state with the lowest population density on the East Coast. And when it comes to cancer, Mainers are at a particular disadvantage: They are not only older (with the nation’s highest median age of 44.5 years), but also have a higher-than-average cancer rate even after adjusting for age and smoking.
The Jackson Laboratory (JAX), a nonprofit biomedical research institution headquartered in Bar Harbor, Maine, designed the to provide access to the latest advances in precision cancer care to the state’s cancer patients, most of whom are treated at small community hospitals. Founded in 2016 with a grant from the Harold Alfond Foundation, MCGI has already enrolled every oncology practice in Maine, and most of its oncologists, including Kumar.
Participating oncologists submit patient tumor samples to be sequenced and profiled for genes known to be associated with various cancers, and with response or resistance to FDA-approved targeted therapies or new drugs in development. The MCGI team takes advantage of JAX’s Clinical Genomics capabilities, including complex tumor profiling assays from the JAX CLIA Lab and the JAX Clinical Knowledgebase, an interactive online encyclopedia that allows both researchers and clinicians to interpret complex cancer genomic profiles.
Several tumor profiles, and the most appropriate treatment options for them, are reviewed at each monthly tumor board meeting in Augusta. Seated next to Kumar and directing the patient discussion is the founding medical director of MCGI, Jens Rueter, M.D.
Kumar reads the first case summary aloud: “The patient was started first line with three cycles of FOLFIRINOX”—the combination chemotherapy that is the current standard for advanced pancreatic cancer—"but tolerated treatment poorly even with dose reduction. The patient and I, he says, were interested in genomic testing for further treatment options.”
The patient’s cancer shows a genetic variant that is rare in pancreatic cancer: unusually high levels of PD-L1, a protein that protects cancer cells from immune attack. On speakerphone, the external clinical advisor comments, “Due to the high PD-L1 expression, a clinical trial investigating a PD-L1 therapy would be a good option for this patient, and off-label use of PD-L1 therapy may be an option as well.”
Based on the discussion, Kumar says he will continue to treat the patient using a standard of care but will consider immunotherapy on a clinical trial or off-label basis based on the test results discussed at the tumor board for future therapy.
Rueter steers the meeting to focus on the case of a patient with lung cancer and a history of smoking, and then that of a man with metastatic carcinoma of the bile ducts.
To date the MCGI enrolls mostly patients with stage 4 cancer, meaning that their tumors have metastasized to other organs of the body and that their mortality rate is higher than that of patients with stage 1, 2 or 3 cancer.
“We already have a number of success stories of patients’ therapies being guided by genomic profiling,” Rueter says. “In some cases, the clinician has prescribed a new medication based on the genomic information of the tumor; in others, the patient is enrolled in a clinical trial.”
Born and raised in Germany, Rueter received his undergraduate and medical degrees from Humboldt University in Berlin, but he speaks English with barely a trace of a foreign accent.
Rueter completed his residency in internal medicine at Tulane University and fellowship training in hematology and oncology at the University of Pennsylvania. In 2010 he joined the medical staff Eastern Maine Medical Center (now known as Northern Light) Cancer Care in Brewer, and St. Joseph’s Hospital in Bangor, and has courtesy staff privileges at Mount Desert Island Hospital in Bar Harbor. He became an adjunct member of the JAX faculty in 2012.
MCGI program director Andrey Antov, Ph.D., M.B.A. works with Rueter in developing the initiative, liaising with the Maine oncology community and overseeing the clinical design and implementation of the study protocols. “We were very fortunate to find Jens as our medical director. We were looking for someone who really understands the molecular aspects of cancer. And he has been in Maine for nine years and really knows the Maine medical community.”
Kumar adds, “Jens is a great leader, and I think his role is very important in connecting the experts. He has a background as a clinician and also as a researcher, so he brings both sides to the table. Connecting the two is where he really shines.”
With the early success of the MCGI in Maine, JAX is taking the first steps to explore expanding community genomic medicine initiatives in New England. JAX has a National Cancer Institute-designated Cancer Center, and in 2016 Rueter was appointed the Cancer Center’s associate director for regional translational research partnerships, leading outreach and partnerships with community hospitals in the region.
The MCGI, Kumar says, “is the sort of project that should be available in every state and every country. It's already helped improve outcomes for a few of my patients. That's why we do what we do, to help our patients. That's why I became a doctor. And if I'm able to make a difference along with the Jackson Lab, that's all that I can ask for.”
Kumar notes that while the tumor board meetings provide guidance for new approaches to treating individual cancer patients, “the most important thing is how this program can help to change how cancer care is done, for all patients.”
“Now that I have been an oncologist for almost a decade,” Rueter says, “the fact that I can help cancer patients deal with a devastating disease means a lot. I have found it most gratifying that patients are thankful even if I can’t cure their cancer.”
He recounts attending a JAX event at the Jesup Memorial Library in Bar Harbor last summer. “A number of patients, and relatives of deceased patients, came up to me to thank me. It’s so humbling. It also helps me put my own life in perspective, be more thankful for what I have, that I’m healthy at the moment.”
With your support, we can make a difference in the lives of Maine cancer patients. Learn more about the Maine Cancer Genomics Initiative and how you can contribute to this life-changing work.