Incorporating genomics into breast cancer clinical trials and care

Advances in DNA sequencing provide the potential for clinical assays that are timely and affordable and use small amounts of clinical material. The hypothesis has therefore been raised that marked improvements in patient outcomes will result when DNA diagnostics are matched to an armamentarium of targeted agents. While this may be partially true, much of the novel biology uncovered by recent sequencing analysis is poorly understood and not druggable with existing agents. Significant other challenges remain before these technologies can be successfully implemented in the clinic, including the predictive accuracy of pathway-based models, distinguishing drivers from passenger mutations, development of rational combinations, addressing genomic heterogeneity, and molecular evolution/resistance mechanisms. Developments in regulatory science will also need to proceed in parallel to scientific advances so that targeted treatment approaches can be delivered to small subsets of patients with defined biology and drug reimbursement is available for individuals whose tumor carries a mutation that has been successfully targeted in another malignancy, as long as they agree to participate in an outcome registry.