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Welcome to the September 2023 journal club.
Jeff has kindly offered to lead this month. He chose a really interesting topic, liquid biopsies. I have to admit I wasn’t sure what this entailed until I read the articles.
I look forward to reading your comments and discussions. Thanks in advance for your participation.
Here are the links to the articles:
Liquid biopsy: a step closer to transform diagnosis, prognosis and future of cancer treatments – Molecular Cancer
Next-generation sequencing in liquid biopsy: cancer screening and early detection – Human GenomicsHello- as Renee said I am Jeff and I am one of the nurses in the ambulatory float pool. I picked these articles because my time working in the thoracic clinic I saw an increase in liquid biopsies and thought it was an interesting discovery (and one in which is only going to continue to revolutionize oncology treatment).
1. What was the knowledge gained from the article?
The gold standard of obtaining specimens for biopsies has been invasive surgical procedures. These articles are interesting because it gives insight into an alternative method to obtaining biopsy samples. The technology associated with liquid biopsies is advancing and making their use even more beneficial for patients. The articles mentioned how cancer cells can adapt and change over time- liquid biopsies (whether blood/ urine/ csf/ or other fluids) are infinitely easier to obtain than repeated invasive surgical biopsies. The articles also go into detail about how results are often faster and give a wider array of tumor diagnostic information for the medical oncology team to make better decision, and more individualized for that specific patient. I found the images provided in the first article to be incredibly helpful and showing a plethora of information (mostly emphasizing what liquid biopsies can do). We hear about circulating tumor cells but oftentimes don’t think too much of them- but these articles broke down what exactly circulating tumor cells are doing in relation to liquid biopsies; the liquid biopsies provide “real-time” information and show how tumor cells are changing.2. Will the research/information in this article change or influence your practice? If so how?
These articles won’t really impact my practice- yet. We aren’t able to order biopsies/ decipher the results. As a float nurse we typically are not working that close with a doctor to help in the diagnosis phase of the patient’s oncology journey. The only way it would change my practice (currently) was if patients got a more personalized report of their oncological diagnosis and it changed our practice model.3. What other questions does the article raise about current practice?
What needs to be done to increase the sensitivity/ accuracy of liquid biopsies?
What types of cancers do liquid biopsies show more accurate results with?
Are diagnostic clinics going to start using liquid biopsies more since they have been proven beneficial earlier in the process?
Will the amount of blood needed in the future decrease once technology is more accurate for liquid biopsies?4. Do you agree/disagree with the conclusions of the author, why?
I agree with the authors of both articles- that liquid biopsies have a time and place where they are incredibly beneficial. The technology is advancing to where liquid biopsies will become more relevant, but it is not there yet. Liquid biopsies, once more accurate, will be great in getting a more genomic profile for a cancer cell and therefore making each cancer treatment individualized to the patient. I would like to see more information and research done with liquid biopsies to help improve their efficacy going forward.I look forward to a good discussion about liquid biopsies and want to hear what you all think about them!
1. What was the knowledge gained from the article?
I didn’t know anything about liquid biopsies before reading these articles, so everything was gained knowledge. Liquid biopsies sound very usefully by being minimally invasive/non-invasive and providing real-time information on cancer cells and their response to treatment and changes over time. Some of these tests, such as branched-chain amino acids, might assist in earlier diagnosis than current methods.2. Will the research/information in this article change or influence your practice? If so how?
I won’t be able to directly change my practice based on liquid biopsies, but I believe this practice will change oncology nursing practice by allowing us to administer more targeted treatments that can be changed and updated real-time based on disease response or progression. I also like how liquid biopsies can provide information about tumor resistance or response to certain therapies, especially when a particular trait or mutation makes it resistance to traditional treatment. This could save our patients’ time, money, and health on treatments that would be ineffective against their particular form of cancer.3. What other questions does the article raise about current practice?
These tests are very detailed and specific to certain types of cancer cells. I’m guessing the current process is very expensive. Hopefully, as further tests are developed and refined in the future, the costs of testing will decrease to the point that we will be able to use these tests regularly for diagnosis and at routine intervals during treatment. I would also hope that false positive/negative tests would be decreased to a clinically acceptable level, hopefully less than current testing methods. One of the articles mentioned certain genetic mutations can be detected up to a year before cancer diagnosis, and is more sensitive than current protein marker and antigen detection methods. These could prove to be life-saving screening methods in the future. This is especially important in lung cancer, since there currently is no early detection screening method.4. Do you agree/disagree with the conclusions of the author, why?
The authors fully supported their opinions of liquid biopsies with detailed discussions of strengths and weaknesses. I agree with their conclusion that liquid biopsies are an emerging and useful technique that needs further standardization, refinement., and cost reduction.1. What information did I learn?
I have to admit the term liquid biopsy is new to me and pretty interesting. After reading this article I learned a liquid biopsy utilizes blood sampling to identify cancer cells from a tumor that are circulating in the blood or for pieces of DNA from tumor cells located in the blood.
2. How will the information gained change my practice?
It is clear after reading this article that liquid biopsies are continuing to improve in accuracy and have potential to help change diagnostic standards in testing . Going forward I will seek out new information regarding liquid biopsies to better my knowledge. More specific how are the providers at the James currently using this information towards treatment. I understand there are reliability concerns, as pointed out in the article, but the more information that is studied the more we are able to utilize these tests in a less invasive way to help our patients. In the future I would like to pay closer attention to the ” why” and “how” we are currently using the test results.
3. What questions does the article raise about current practice?
Currently we check CEA 19, 125 ect from my understanding to see response to treatments. I would like to know are these labs considered liquid biopsies? More so what labs am I already checking that are liquid biopsies?4. Do you agree or disagree with the conclusions of the author, why?
Considering I have limited knowledge (outside of what was gained through this journal club) regarding liquid biopsies, I would have to agree liquid biopsies will make future impact in the oncology world. Anytime we are able to study cell breakdowns in other areas of the body the more knowledge and better treatments we can offer to patients. This is one more tool to help.
Jeff thanks for leading this journal club and thanks for picking an interesting topic. I agree and am also looking forward to more research in this area. When discussing this with another nurse they mentioned a patient who was recently diagnosed with colon cancer after a home colon cancer screening. Although she still had to have a colonoscopy and biopsy, she was able to identify a problem earlier and in an less invasive way. I do not know if that kit is considered a liquid biopsy but it seems to correlate with how this article describes a liquid biopsy.
Katie- You pose a good question about the labs (Ca 19-9/ 125/ etc)- I did a quick delve into what those tests are actually monitoring and it sounds similar to liquid biopsies but different enough where I don’t think they would be classified as liquid biopsies. These tests are already being used for certain GU cancers and gynocological cancers so how can we further develop these tests to work with a broader spectrum.
Greg-When I worked in thoracic I remember filing out the paperwork and I think insurance covered most of the cost but if it didn’t I don’t think patients were to pay more than $250 for the liquid biopsy (it has been a few years since I filled out the paperwork so I could be off on the total cost)- which if that is the case that is infinitely cheaper than an invasive biopsy.
Greg you mentioned saving our patient’s time and money with liquid biopsies. I found it interesting that certain mutations like KRAS was detected in patient’s sputum up to 2 years prior. With that in mind, could you imagine how much better early detection and prescreening could be with our patients?
Jeff- The only lab draw I remember filling paperwork out for is the NavDx in rad onc. I was told that was genetic marker testing to see the response to treatment. That got me curious, so I went to the NavDx website and it says this:
NavDx is the first and only clinically validated circulating tumor-tissue–modified HPV (TTMV®) DNA blood test that aids in the detection of HPV-driven cancer.
NavDx uses proprietary technology to quantify fragments of circulating TTMV HPV DNA, a unique HPV-driven cancer biomarker that cancer cells shed into the blood. This highly accurate blood test reliably uncovers the presence of HPV+ head and neck cancer across the care continuum. (from: https://naveris.com/what-is-navdx/)Based on this statement, it sounds like this is indeed a liquid biopsy test. So it ends up we have been using liquid biopsies and didn’t know it!
Katie-
Think of the “worst” cancers: lung, ovarian, pancreas. They have poor prognosis and survival because there currently is no early, reliable screening process, so they are usually advanced stage when they are diagnosed. I would love to see advances in liquid biopsies for these cancers to improve treatment and survival rates. I remember the James starting a program where people with a certain amount of smoking history could get a low-dose CT at certain intervals to check for lung cancer. A liquid biopsy would be faster, easier, and avoid exposing patients to radiation.
Greg- that is interesting about us using liquid biopsies and not even knowing it. It makes sense what exactly Nav-DX is when you list it from the website.
I also believe that survivorship still does screening using the low dose CT scans for lung patients. A lot of those patients as you said have a smoking history or have a random nodule that was discovered as a pre-surgery x-ray. It would be great for these patients to have less radiation and even fairly accurate results to detect lung cancers.
It poses the question why don’t these “worst” types of cancer have early screening tests that are reliable? I’m not expecting a scientific answer but a hypothetical of sorts.
Thanks Jeff for the interesting articles!
1. Knowledge gained: I too was unfamiliar with liquid biopsies. I am definitely interested in learning more about them, but must admit it reads to be pretty complicated. Seems like this could be the future of cancer screeing and I had no idea how many different methods that can be used.
2. Influence on practice: I can’t see it infuencing my practice currently (with the exception of drawing labs such as CA 125 and the like- From the “Next generation” article, I interpreted those assays as being liquid biopsies, but maybe not?), although I can envision a future where we, as nurses, could be involved in collecting liquid tumor samples as this becomes more streamline.
3. Questions raised: How involved is the James in researching this? I realize that there can be a great expense (example dPCR) with liquid biopsies, but would using liquid biopsies be cheaper in the long run if you are detecting cancer earlier and preventing multiple surgeries etc? As Katie mentioned, are we already drawing blood for liquid biopsies and dont’ even know it?
4. Agree/disagree with authors: I agree that great strides have been made with liquid biopsies and they will definitely be impactful once some of the kinks can be worked out, such as sensitivity, specificity, and expense to name a few. It could be a game changer once figured out.Katie- I am questioning like you…what are we doing in our practice that may involve liquid biopsies? We draw a lot of labs that I have no idea what they are. It would be nice to clarify if the CA 125 etc are considered liquid biopsies.
Greg-We draw a lot of genetics labs at various clinics (Ambry, to name one). I too have filled out paperwork for NavDx. I wonder if some of those are just for RNA and DNA or if they are looking for liquid tumors too. Clearly a good topic to look in to. I feel like this is a big black void in my nursing knowledge.
Holly good questions and insight. This is not the 1st time I have questioned what exactly we are drawing with Ambry/ Ca 19-9/ etc. Whenever I try to find answers it always just says it is a cancer biomarker. I feel like it is a “black hole” of knowledge for most of us since it is recently new and really only in certain clinics.
Jeff-The articles you chose were very interesting and informative. I had only thought of liquid biopsies being something like a FNA for melanoma or blood samples being evaluated only for blood cancers. Having the ability to utilize blood samples for other tumor markers that may circulate is amazing for early screening and prevention. My wonder is if these early screening results would allow for implementation of cancer treatment in smaller doses.
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