Tumor Sequencing Test Brings Personalized Treatment Options to More Patients

Pictured: Michael Berger

Genomics researcher Michael Berger

A new genome-sequencing test developed at Memorial Sloan Kettering allows our doctors to quickly find out whether a patient’s tumor carries clinically useful mutations — including aberrations that make cancers vulnerable to particular drugs — and to match individual patients with available therapies or clinical trials that will most benefit them.

Until now, genomic testing of tumors has been done routinely only in certain cancers. For most cancers, the available tests have been limited to analyzing one or a handful of genes at a time, and within each gene, only the most common mutations could be detected.

The new test, called MSK-IMPACT™, makes the analysis far more comprehensive and can be used on any type of solid tumor, irrespective of where in the body the cancer is thought to have arisen. (A similar genomic test for blood cancers was recently co-developed by Memorial Sloan Kettering scientists and Foundation Medicine, a biotech company.)

“It’s an incredibly powerful test,” Memorial Sloan Kettering’s Department of Pathology Chair David S. Klimstra says of the MSK-IMPACT technology. He expects it will enable our physicians to rapidly extend the promise of precision medicine to many patients with difficult-to-treat cancers, including both common and rare tumor types.

Intensified Tumor Testing

“We are able to look at hundreds of genes in multiple patients simultaneously and collect an enormous amount of information about each of these genes,” adds genomics researcher Michael Berger, who developed MSK-IMPACT in the Department of Pathology. Marc Ladanyi, Chief of the Molecular Diagnostics Service, led the clinical validation of the test together with molecular pathologist Marcia Arcila, and bioinformatician Donovan Cheng.

The bulk of the tests will be done for patients with advanced disease, for whom results can help guide treatment choices. The assay will also be offered on a research basis in the newly launched Marie-Josée and Henry R. Kravis Center for Molecular Oncology.

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Effective Sequencing

The MSK-IMPACT test is based on next-generation sequencing — cutting-edge technology that allows cancer genomes to be profiled very quickly and with great sensitivity. Next-generation sequencing makes it possible to analyze more types of genetic abnormalities than conventional DNA sequencing technologies. “For example, we can tell if a gene has been mutated or deleted, or if there are additional copies of it,” Dr. Berger says.

Until recently, this technology had mainly been used in the context of research studies, in which tumor samples of the highest quality are chosen. “The samples we deal with in the clinic are different and much more difficult to analyze,” Dr. Berger explains. “They may contain a mix of various tumor cells and noncancerous cells, and the cells’ DNA might be degraded.”

In developing MSK-IMPACT, Dr. Berger and his co-workers, with support from the Farmer Family Foundation, meticulously enhanced the next-generation sequencing protocols and computational methods for the clinical diagnostic laboratory setting, where many tissue samples need to be processed and analyzed simultaneously.

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Actionable Targets

Rather than sequencing a tumor’s whole genome, or the entire part of the genome that codes for proteins, MSK-IMPACT analyzes 341 of the most important cancer genes, which are captured and sequenced on an instrument called Illumina HiSeqTM. This targeted sequencing approach makes the analysis of tumor tissue more feasible and effective and increases the chance of finding clinically relevant gene changes.

“All important regions of these 341 genes are sequenced, rather than the more focused analysis of only the most frequently altered regions, or mutational ‘hot spots,’ allowed by earlier technology,” explains Dr. Klimstra. “This gives us a much more comprehensive picture of the full spectrum of genetic changes in a person’s cancer.”

The 341 genes covered by the test are ones that have been shown to play a role in the development or behavior of tumors. They represent all “actionable targets” — genes that can either be targeted with drugs or provide clinically relevant information about the disease if they are altered. Dr. Berger says the test will be updated periodically as new actionable targets are discovered.

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A Wealth of Information

So what can the MSK-IMPACT test tell doctors about their patients’ diseases? A lot, according to Dr. Klimstra. “In fact,” he says, “the test will likely generate more molecular information about tumors than we will know what to do with initially.”

The 341 genes were selected by drawing connections between the genomic profiles and clinical data of past patients. For example, changes in some of the genes have been shown to indicate that a tumor is more likely to respond to a particular drug, while other gene changes may predict that a certain therapy will be of little or no benefit.

“The interaction of different altered genes can also be important in predicting the behavior of the tumor,” Dr. Klimstra says, “which is another reason why we needed a test to evaluate many genes simultaneously.”

In some cases, finding a specific mutation in a tumor can lead to a new clinical trial in which a patient is offered an experimental drug that may be the best treatment option for his or her disease, but that would not have been considered if the mutation had not been found. Other times doctors may spare a patient intensive treatment with standard drugs such as chemotherapy, if test results show that the therapy is likely not to be beneficial.

But Dr. Klimstra emphasizes that many gene changes detected by the test will not be immediately actionable. “If a mutation has rarely been observed in a disease and has not been studied, we may suspect it’s important, but we don’t know what would happen if we were to target it,” he says. “That’s why an important aspect of MSK-IMPACT is to gather data for research to help future patients.”

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Basket Trials

Patients with an actionable mutation that has not yet been studied in their tumor type may be eligible for treatment in a new type of clinical study called a basket trial. Traditional clinical trials focus on a particular cancer type, which is typically defined based on where in the body the cancer originated. Basket trials, however, focus on specific gene changes and may enroll patients with many different types of cancer whose tumors carry similar mutations.

Memorial Sloan Kettering investigators are currently undertaking an intensive research effort to learn what kinds of mutations different tumors have, and how these mutations impact patients’ responses to various kinds of treatment. Dr. Berger and his colleagues are working to develop genomic tests for research on banked tumor samples, as well as other clinical tests to detect mutations MSK-IMPACT might miss.

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any target yet for stage 4 adenocarcinoma nclc KRAS 12D non wild; nothing has helped so no treatment for three years now....I will be in Manhattan month of July staying on E 66 St and First Ave; should I make an appointment?

Carole, we are looking into this and hope to provide a response to you before long. Thank you for your comment.

Carole, we consulted with our physician who suggest that you call the Physician Referral Service for this cancer type at 646-497-9163 to speak with them about this information and determine if a visit is in order. Thanks for your comment.

alimpta and carbo did nothing

I mant to type nsclc stage 4

Are these tests any different to the tests offered by Caris Molecular Intelligence in the USA? Any chance that biopsy samples can be sent from the UK for testing?

Steve, we consulted with Dr. Berger, who responds:

“Caris is a diagnostic company that runs tests to molecularly characterize tumors from patients. I believe they provide a number of services. They have a panel to identify mutations in important cancer genes using next-generation DNA sequencing technology like MSK-IMPACT. MSK-IMPACT examines more genes and is capable of identifying additional types of mutations, but both tests include all genes where there are widely accepted guidelines for altering treatment based on the presence or absence of mutations. Caris also offers other tests that measure the abundance of particular proteins important for cancer diagnosis and treatment.”

If you are interested in learning about having a biopsy sample examined, we suggest you contact our International Center at (1-212-639-4900) or go to http://www.mskcc.org/cancer-care/international-patients

How do I order the MSK-IMPACT test?

Dear AJRen, in order to take advantage of this type of molecular testing at Memorial Sloan Kettering you need to make an appointment with one of our specialists. To do so, please call our Physician Referral Service at 800-525-2225.

Thank you for your comment.

Excellent development in the management of malignancy .Can you send the information in the form of article so that I , as an editor , of " BIHAR AND JHARKHAND JOURNAL OF OTOLARYNGOLOGY ' can publish in the journal . Thanks . Dr.Chandra Shekhar , Editor .

Dr. Shekhar, we sent an email about this to the email address that you provided. Thank you for your comment.

Is it possible to have more information on this test? It does not seem to take tumor heterogeneity into account, i.e., you could take 10 biopsies from the same solid tumor and see different mutations in each. Deciding which 'clone' is then most clinically relevant is difficult.

Kevin Blighe, Ph.D.

Hello Kevin, thanks for bringing up the important question about tumor heterogeneity. We forwarded your comment to Dr. Berger and here’s what he says:

“Tumor heterogeneity does indeed complicate both the sensitivity of the test and the interpretation of the results. Knowing that important mutations may only be present in a fraction of tumor cells in a given biopsy, we have designed our test to be as sensitive as possible. We sequence each tumor to very ’deep’ coverage, meaning that each gene is captured and sequenced several hundred times. This allows us to confidently detect mutations that are present in as few as 5-10% of cells.

“However, some mutations may not be present at all in one biopsy but present at high levels in a different biopsy. Rather than subjecting patients to multiple biopsies, we are exploring the potential of less invasive technologies involving tumor cells and DNA found in blood to see if they may more accurately represent the heterogeneity of a patient’s cancer.”

Also, you can read more about tumor heterogeneity in a recent post on this blog: http://www.mskcc.org/blog/what-tumor-heterogeneity

Is there a way to access the list of genes included on the MSK-IMPACT panel?

NicoleA, thank you for your question. The list of genes included is growing over time. As we start to publish studies based on the MSK-IMPACT technology, more information on the genes we are testing for will become available.

Is the MSK-Impact test relevant to my stage 3 colon cancer? Have had successful surgery; one of 3 regional lymph nodes was positive for cancer.

My regional center--Geisinger Medical Center--offers an NCI trial of FOLFOX (3 vs 6 months) plus celebrex (or placebo)
celebrex (or placebo)

Richard, we forwarded your question to medical oncologist Rona Yaeger, who is one of our colon cancer experts. She says currently MSK-IMPACT testing is being done to guide therapies in advanced, stage 4 colon cancer. For stage 3 tumors, we are not using the IMPACT test and targeted therapies are currently not part of treatment. In patients with more advanced, stage 4, colorectal cancers, targeted therapies have been approved and are being tested in clinical trials. For people with stage 4 tumors, results from the IMPACT test can guide the use of these therapies.

Hope this is helpful, and thank you for your comment.

My father-in-law is just diagnosed with kidney cancer a few days ago, and it is Stage IV. It seems like only one kidney has cancer, but cancer cells have been found also in distant lymph nodes. Is cancer immunotherapy available in your hospital? Such as cell-based therapy using tumor cells (live or lysate) to activate patient’s own immune cells. Please advice where we can find such treatment if your hospital does not have such treatment. Next Monday, the cancerous kidney will be removed by surgery. How should the tumor be preserved for MSK-IMPACT testing and cell-based immunotherapy.

Dear Cindy, we are sorry to hear about your father’s diagnosis. We do offer immunotherapy as treatment for certain types of cancer. We also offer clinical trials to evaluate immune therapies for some people with kidney cancer: http://www.mskcc.org/cancer-care/adult/kidney/clinical-trials?keys=immu…

Unfortunately, we are unable to offer personal medical advice for him on the blog. If he would like to make an appointment with one of our specialists to see what treatment options he may be eligible for, please call our Physician Referral Service at 800-525-2225.

Thank you for reaching out to us.

I have breast cancer that has metastasized to the bones as well as a bladder cancer (which makes me ineligible for many clinical trials). I am interested in the Tumor Sequencing if my situation would fit within the guidelines.

Dear Charlotte,
Thank you for your question. At Memorial Sloan Kettering, genomic tumor testing is done for all patients who could potentially benefit from it, and our doctors determine on a case by case basis whether testing is medically useful. So if you are a patient here, we encourage you to speak to your physician. If you are being treated elsewhere and would like to take advantage of the MSK-IMPACT test, you need to make an appointment with one of our specialists. To do so, call our Physician Referral Service at 800-525-2225.

My husband has stage 4 pancreatic cancer and he has an opportunity to have his tumor biopsied before starting the 3rd line of treatment. How can we get tumor cells to you for this testing? (we live in san francisco) Thanks

Jean, in order to take advantage of the MSK-IMPACT test, you must be one of our patients. To make an appointment for your husband with one of our specialists in New York, you can call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

Hi, My wife has a stage four cancer which has mutated into triple negative cancer. She is on chemo in UK and we are trying to gain as much intelligence about the cancer as we can. There are no real tumours as its just in her lymp nodes and a small spec in her neck. Would this test help as she is so early on in stage four? Can we send samples from UKA or should be fly to you?

I took this gene sequence test at Sloan Kettering......it took at least six to eight weeks to get the results.....finally, when it was ready, doctor explained it was too low to be helpful.....explaining the biopsy was too little tissue....the needle only takes a certain amount.....can you take samples from ...saliva....? I also gave blood .....It was very discouraging to wait all those weeks... with stage 4 lung cancer....what next...I am a liver transplant patient on the drug Rapamune......and can't take chemo....I almost died because of platelet problems and transfusion problems......what next?

Linda, we’re sorry you had this experience. We recommend you speak with your treating physician about what options you have. If you’d like to discuss concerns about your care, you can also call our Office of Patient Representatives at 212-639-7202. Thank you for your comment.

I have epithetical ovarian cancer stage IIIC, high grade serous papillary. My story is: I have had surgery three times, thus there are tumor slides in three different hospitals. Original surgery in 2010, 1st recurrence in 2011 and 2nd recurrence in 2014. Should I have these three tumors genetically tested for mutations and changes in recurrences? I do not want to miss an opportunity or miss a chance to help research.

Thank you,
Raylene Bastacky

Dear Reylene, we are sorry to hear about your diagnoses. We sent your inquiry to Dr. Ross Levine, and he responded:
“We can do sequencing on archival tissue. Whether it is clinically indicated is another question for the patient to discuss with her doctor. We are always appreciative of patients who want to help us with our research, but do not have a need for these tissues at present.”

Thank you so much for reaching out in an effort to help with our research. We wish you all our best.

I had a total thyroidectomy at Brigham and Women's Hostpital in July 2013 for PTC tall cell, BRAF+ determined from frozen sample a month post-op. Undetectable Tg since post-op RAI therapy, two non-suspicious lymph nodes seen in subsequent US(s). Do you recommend that I pursue with you having my BRAF subset (viz. Giordano et al) studied further? Is it likely that the TT sample will provide sufficient material?

Dear Susan, thanks for your interest in the MSK-IMPACT test. You must be an MSK patient in order to have the sample tested. To learn more about your options and the information our doctors would need from you, the best thing to do is to call our Patient Access line at 800-525-2225. Wishing you all the best.

I am a patient at memorial Sloan Kettering. I am about to have this test. How long will
It take to get the results?

Dear Theresa, once the tumor and blood samples are received in the lab, it usually takes 2 to 3 weeks for the MSK-IMPACT test to be complete. Thanks for your question.

My husband is a stage 4 brain cancer (GBM) patient and we chose to have his tumor evaluated by Foundation One ... is MSK-IMPACT comparable to Foundation One? Is your testing more sensitive? Or yield more information? What's the difference? Thanks.

Dear Dianne, we are so sorry to hear about your husband’s illness. We forwarded your question to genomics researcher Michael Berger, who led the development of the MSK-IMPACT test. He says MSK-IMPACT and Foundation One are similar assays. Both are equally sensitive and yield comparable information about the genomic alterations that are most important for diagnosing and treating cancer.

The most significant difference is that MSK-IMPACT involves the analysis of DNA from both a patient’s tumor and blood, where the blood is used to distinguish mutations that are inherited from those that arise spontaneously in the tumor. Foundation One utilizes only DNA from a patient’s tumor, which can make it challenging to make this distinction in certain circumstances. We suggest that you speak to your doctor to find out if this makes any difference in your husband’s case.

My husband has grade IV glioblastoma - he is currently on avastin- but adding irinotecan to this regimen. Will the MSK - impact test be of help during treatment? Several years ago my husband was put on gleevec and did really well- would the vemurafenib be a good choice? He has had this for 11 years- I would love to come to MSKCC and get another opinion!!

VIcki, if your husband would like to come to MSK to get another opinion and learn about which of our clinical trials might be right for him, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information on making an appointment. Thank you for your comment.

I am curious how MSK-Impact compares to the Foundation Medicine group of tests (the Foundation One and the Foundation Heme)? Are there mutations tested for in the MSK-Impact that are relevant to lung cancers beyond the usual (EGFR, KRAS, and ALK)?

Dear Mike, thanks for reaching out! You are right that MSK-IMPACT tests for mutations in many genes other than EGFR, KRAS, and ALK that can have important implications for choosing treatment. In fact, the test looks for mutations in more than 340 genes. These are all mutations that can either be targeted with drugs or can provide clinically-relevant information about a person’s disease.

You can learn more about how our doctors use the test to optimize treatment for lung cancer patients here: http://www.mskcc.org/blog/genomic-analysis-brings-personalized-treatmen…

Also, the Foundation One test is similar to MSK-IMAPCT. Both tests are equally sensitive and yield comparable information about the genomic alterations that are most important for diagnosing and treating cancer. There are some differences between the tests, though, that you can read about in the March 23 comment above.

Regina, we’re so sorry to hear about your husband’s illness. The UW-OncoPlex test is developed and used by the Seattle Cancer Care Alliance. Our experts here at Memorial Sloan Kettering don’t know enough about its specifics to provide helpful information, so we suggest you reach out to Seattle Cancer Care Alliance directly. As for your last question, we recommend you research clinical trials on www.clinicaltrials.gov. Thank you for your comment.

Is there applicability of your testing to adrenocortical carcinoma (ACC)? My 17 year old son is fighting this rare cancer and has had his primary tumor removed but has metastases in his lungs. Did well with Cisplatin-Etoposide-Doxorubicin regimen (7 cycles), but is about to start a different chemo protocol along with targeted radiation. Oncologist has mentioned tumor sequencing to us. Just curious what your take is on it for this type of cancer. Much obliged.

Gary, thank you for reaching out. Memorial Sloan Kettering does offer the IMPACT diagnostic test for ACC. If you are interested in being seen by an MSK physician, you can contact 646-497-9053 for an appointment to be assessed.

Have there been any studies with Adenoid Cystic Carcenoma? I've been treated with radiation and cysplatin, but it metastasized.

Dear Zachary, thanks so much for reaching out to us. We do have one study going on currently that might be a fit for you. You can read more here: https://www.mskcc.org/cancer-care/clinical-trials/13-244. Please do give our Patient Access Service a call at 800-525-2225 if you’d like to learn more. You can read about recent work our researchers have done to map the genome of adenoid cystic carcinoma here: https://www.mskcc.org/blog/investigators-sequence-genome-rare-head-and-…. Thank you for your question, and we wish you the best,

I am currently diagnosed with stageIIIC primary mediastinal germ cell nonseminomatous germ cell tumor, choriocarcinoma. Is there any applicability with the MSK-IMPACT testing for this type of cancer?

What a great test!
Are PD-1 and PD-L1 also tested? Are these possible in intrahepatic cholangiocarcinoma?
Thank you in advance!

Charlotte, The genes encoding PD-1 and PD-L1 are both included in MSK-IMPACT testing. They are considered to be biomarkers to predict response to immunotherapy, and it is not yet fully understood what role these mutations play. Thank you for your comment.

I am patient of MSK, stage IV colon cancer.
Had 3 liver resections. Last surgery September 2014.
I am wondering if I will benefit from MSK-IMPACT test.

Maria, we recommend that you discuss this with your MSK healthcare team. Thank you for your comment.