India – In step with world-class healthcare technology
Thank you for reading our latest myStrand issue on all things cancer and genetics as seen through an Indian lens. his month we are pleased to bring you news about the latest development in cancer testing: liquid biopsy! At Strand, we have worked hard for the last couple of years to ensure Indians will have access to this latest advancement in healthcare technology in step with American and European citizens. And this week, all the hard work has paid off with the launch of Strand’s very own portfolio of liquid biopsy tests. Liquid biopsy in cancer enables earlier diagnosis, tumor profiling, as well as early detection of therapy resistance or relapse through a simple and relatively affordable blood test. No repeated surgeries to get tumor tissues or other invasive procedures that are not only uncomfortable or painful but also hugely expensive. In this issue, we’ll give you a chance to learn more about liquid biopsy without the doctor jargon and a little history on how India came to be at the forefront of this technology bringing truly personalized medicine to patients across India and the world.
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The myStrand team!
Let’s talk about liquid biopsy!
What is a liquid biopsy?
If you have been following the headlines recently, you might have come across some stories about something called ‘liquid biopsy’ and how it can help with diagnosing and treating cancer. In fact, some of those stories would even have been about Strand Life Sciences recently launching a liquid biopsy test in the Indian market. Surely, you might have wondered, what exactly is a ‘liquid biopsy’? What is all the fuss really about? Now, many of you will have come across the word ‘biopsy’ in your lives and you know it means that a doctor takes a tissue sample of an organ in order to investigate whether an unusual growth or lump is made of cancerous tissue or not. So what is a ‘liquid biopsy’ then? As the word ‘liquid’ indicates, this biopsy consists not of some form of solid bodily tissue, like skin, liver, breast, etc., but of a bodily fluid, for example, saliva, urine, or blood.
Why liquid biopsy is important
I hear you say: “What’s so special about that? I’ve been giving urine and blood samples for years for diagnostic tests and monitoring of my blood sugar or lipids.” Some of you might even have given a saliva sample to test for hereditary cancer risk or another hereditary condition. However, the crucial difference here is, that the type of ‘liquid biopsy’ science and medicine have been so excited about over the last few years is the one that is set to revolutionize the way we diagnose, treat and monitor cancer. This is important because according to the Indian Medical Research Council (ICMR), the burden of cancer in India is only going to increase with an estimated 17.3 lakh new cancer diagnoses and over 8.8 lakh cancer deaths by the year 2020.
The kinds of liquid biopsy that have been making the headlines in India and abroad recently, are the ones that allow a doctor to not only accurately diagnose cancer but also monitor how the tumor responds to treatment, whether resistance has set in and in what form and make a prognosis on how likely the cancer is to relapse after surgery or initial treatment. While doctors have been able to use genetic testing to accurately diagnose cancer and the mutations that caused it to personalize treatment for several years now, this process so far has always required a tumor tissue sample. However, in some cancers, getting a tissue sample is not straightforward and sometimes even requires specialist surgery that cannot be performed in every hospital. This puts patients at an additional risk from surgery as well as accessibility and affordability for those living in smaller towns and villages, not to mention the financial and emotional costs caused by the cancer diagnosis alone. Being able to provide the same accurate diagnosis from a much simpler method, like a blood sample, would make a huge difference to doctors and patients alike. And getting the additional tools for monitoring response and adjusting treatment accordingly, as well as being able to detect relapse early, well that would just be a huge bonus.
How does it work?
Enter liquid biopsy for cancer!! Scientists have known for many years that tumor cells detach from the original site of the tumor and travel along the blood stream to other sites, where metastases form. At this stage, cancer is usually quite advanced and very difficult to treat. However, more recently, scientists discovered that tumors start shedding cells much earlier than expected and that is possible to detect tumor cells as well as cell-free tumor DNA (that’s the genetic material in the tumor that a lab would analyze in a tumor biopsy as well and where we would normally expect to find the mutations that caused the cancer). This discovery has opened the door for science, governments, and many diagnostics companies to invest large amounts of money in developing cost-effective methods to detect so-called circulating tumor cells (CTCs) and extract their DNA as well as detecting any cell-free tumor DNA (cfDNA) in the blood and establish beyond a doubt that the information gained from that DNA can indeed be used to make the same diagnoses and treatment recommendations as tumor tissue analysis.
The ‘Holy Grail’ at the heart of these research efforts is, of course, the early detection of cancer through a simple blood test, before the cancer causes too much damage and becomes very difficult to treat. Science is still some way away from this landmark, but in the meantime, a handful of tests around the world have been established and used for a number of patients to show that the blood test is as effective as the tissue biopsy when it comes to detecting the genetic mutation that caused the tumor (this process is known as clinical validation), therefore enabling a doctor to choose the most effective medicine for that patient. Some of these tests also include a monitoring option that identifies so-called resistance mutations. This means, that while the tumor was being treated with a particular medication, the cancer evolved and developed other mutations that allowed it to resist the treatment and continue to grow. Being able to identify that resistance mutation and then target the tumor with another medication specific for that new mutation is an important tool in our fight against cancer and liquid biopsy applied as a monitoring tool has made that possible.
Does liquid biopsy work for all cancer types?
Most of these early tests are for lung cancer (including the first tests launched in India this week by Strand Life Sciences and other tests available in Europe and the US) and there is a good reason why. Lung cancer is one of the top 5 cancers globally and one of the most deadly. With recent advances in personalized medicine and the identification of specific mutation and effective drug combinations, doctors have been able to make significant inroads in the treatment of lung cancer. However, there IS one caveat: In lung cancer, it is not possible to get a tissue sample from up to 30% of patients. That means that personalized medicine is out of reach for 1 in 3 patients! Now, with the availability of validated liquid biopsy tests, no patient needs to be left behind in this precision medicine revolution! And liquid biopsy brings the added benefits of being non-invasive (no surgery required), available at any hospital (or even the patients’ home), as well as providing the additional benefit to all patients for monitoring treatment success and cancer recurrence, which buys valuable time to respond with new medicines before the cancer can once again cause too much damage for further treatments to work.
The story does not end here. Liquid biopsy for lung cancer is just the beginning! Laboratories across the globe, including our scientists at Strand Life Sciences’ lab in Bangalore, are working feverishly towards validating and offering the same liquid biopsy advantages for other cancers, including breast, colon, and bladder cancer. In fact, at Strand, validation is already under way for a number of these cancer types and liquid biopsy tests have been available to doctors since February 2017 to build the foundation and trust for the next set of tests to bring minimally-invasive, blood-based genetic testing to cancer patients across India to deliver on the promise of truly personalized precision medicine!
Disclaimer: The information provided in this article is in no way intended to replace expert medical advice. Always discuss the best possible course of action for your situation with your doctor.
What is a liquid biopsy?
A liquid biopsy is a test that is used to find evidence of cancer in a blood sample. Traces of tumor DNA are released into the blood from dying cancer cells and can be detected by sensitive technologies. This DNA can give valuable and accurate information about changes in cancer-specific genes (also known as mutations). Since the sample that we collect from the patient is blood (a bodily fluid rather than a solid tissue sample) the technique is known as a liquid biopsy.
India at the forefront of medical science and technology
Gone are the days when Indians would look towards the West for new technology with baited breath and anticipation for the same products to become available here, often at a steep premium. Or in the healthcare context, waiting for medical devices or getting treatment abroad (affordable obviously only for the super rich) or sending diagnostic samples abroad for a lack of the required services at home. However, serious investment over the last couple of decades by individuals, corporates, and the government have turned a nation of importers and let’s face it ‘copy-cats’ into a nation of innovators with the potential to change the world. Yes, you read correctly: “Change the World”.
With a focus on quality as well as affordability, independence from electrical supply and suitability for various climates, Indian scientists, engineers, and entrepreneurs have taken the bull of rising healthcare costs across the globe by its horns. Now, home-grown Indian companies are able to offer the same or even superior technological advances as in Europe or the US and at a cheaper cost too, delivering first class medical care to patients in India, and believe it or not, foreigners travelling to India for cheaper treatment. How the tables have turned! These days, many western countries, as well as other emerging economies, even look towards India and Indian medical innovations to reduce runaway healthcare costs, especially in hospitals.
One particular medical innovation that is transforming cancer care across the globe is ‘precision medicine’, also known as ‘personalized medicine’. In an age, where pharmaceutical companies have moved on from small molecule drugs to so-called biologicals in search of better cures, this branch of medicine has become even more important. What sets biologicals and other new generation medicines apart from your acetaminophen or ibuprofen is that they interact very closely with the genes and proteins that make our bodies tick. Needless to say, biologicals are also more expensive. Now, one thing pharmaceutical companies and scientists had not factored in was the variability of human genes and how this variability impacts the effectiveness of biological drugs. The cat was out of the bag quickly though, with some people benefiting tremendously from a new drug while the same drug would fail miserably in other patients or in some cases even endanger their lives (a story that is repeating itself in the even more recent development of immunotherapies). The race was on to find out what turned a promising drug into a failure or danger for some. The answer, it turns out, lay in part in people’s genes and the minute differences between all of us: Precision Medicine was born. And with it a new conundrum: How do we ensure the right person gets the right drug at the right time?
The discovery that genetic mutations lay at the heart of some drug responses has led to a shift in pharmaceutical development, especially in the field of oncology, that has seen the emergence of so-called ‘targeted therapies’. Targeted therapies work by interfering with the biological processes happening in our bodies or tumor tissue in a specific way. Choosing which drug works best for a particular patient now relies on genetic testing of tumor tissue and sometimes even the presence of hereditary mutations. Hereditary mutations are present in all cells of our body (not just in a tumor), like some mutations in the BRCA1/BRCA2 genes, and are passed down in families and significantly increase the likelihood of a woman developing breast or ovarian cancer in her lifetime. We’ve looked at this process in previous issues of myStrand and one patient’s story we shared in Issue 3, where the presence of a hereditary mutation in BRCA2 meant that a PARP inhibitor drug could be prescribed to an ovarian cancer patient where all other treatments had failed after her cancer had returned.
So what is India’s contribution to precision medicine in India and abroad? The answer lies in its abundant intelligent and highly-skilled science, engineering, and bioinformatics workforce. In a recent article, Raymond McCauley, chair Digital Biology at Singularity University—a Silicon Valley think tank devoted to training leaders in exponential technologies said: “India has more trained bioinformaticians than any other country on earth. These people, who are trained to use computers in the life sciences, and systems biologists, and biostatisticians, are the heroes of the coming biotech revolution. They keep it moving forward.” And he knows what he is talking about! He is part of the team that developed next generation DNA sequencing at Illumina, where he worked in bioinformatics, cancer sequencing, and personal genomics.
Next-generation sequencing (or NGS) technology and more importantly the ability and capability to analyze all the data generated from it lie at the heart of personalized medicine. While the continuous reduction in the cost of sequencing due to technological advances at the engineering and chemistry level has made NGS more affordable for diagnostics and lifestyle testing, the bottleneck of analysis capabilities still remains. This is where Indian companies like Strand Life Sciences come into the picture. We don’t just use analysis workflows developed by others and trust they have done whatever was possible. On one end of the spectrum, our bioinformaticians constantly work at the boundaries of what is possible, working on new computer algorithms to speed up data analysis or make analysis more efficient so that less IT infrastructure is required to run the algorithms. These constant improvements make analysis both faster and cheaper. Then some more bioinformaticians work with our scientists to establish the most accurate and efficient ways to interpret the analysis results so we can give the most up-to-date, reliable, and actionable advice to the doctors who have turned to us for answers for their patients’ treatment.
However, in order to be truly in control and able to deliver the highest quality of diagnostics, we also took on the laboratory aspect and excelled at that, too. Today we are one of only a few diagnostics labs in India accredited by the College of American Pathologists (CAP) as well as the National Accreditation Board for Testing and Calibration Laboratories (NABL). Both certifications ensure that the results we report back to doctors and patients are as accurate as possible and minimize errors that could otherwise be introduced throughout any part of the testing process.
We didn’t stop there. We are also a part of the latest revolution in cancer diagnostics and treatment planning with the launch of our very own liquid biopsy portfolio of tests to make sure no patient is left behind in this precision medicine wave. Thanks to our pioneering engineers, bioinformaticians, and scientists we are able to offer one of the shortest test turnaround times of just 5 days, empowering physicians across India to make better, more personalized treatment decisions within weeks of a cancer diagnosis with minimal discomfort to the patient. Liquid biopsy is set to transform the way we deal with an ever-increasing number of cancer diagnoses and disproportionately high mortality rate in India and Indian companies like Strand Life Sciences are at the forefront of making this latest advance in medical science and technology available and affordable in India.
For more information about Strand Life Sciences and our tests, call 1-800-1022-695 (toll-free in India) or write to us at firstname.lastname@example.org.
Strand LB test portfolio launched in India
We are proud to bring to you a truly affordable and minimally invasive cancer test with the launch of our Strand LB test portfolio on 11 April 2017. Watch excerpts of the press conference organized to launch these new path-breaking liquid biopsy tests, developed in collaboration with Mazumdar Shaw Center for Translational Research. Watch now!