The Future Digital Health Consumer Here Today –Toward Personalized Preventive Medicine
Personalized Preventive Care for Cancer -...
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Transcript of Personalized Preventive Care for Cancer -...
Seoul National University College of Medicine, Korea
Daehee Kang, MD, PhD
Personalized Preventive Carefor Cancer
Bukchon Hanok Village
SeoulNationalUniversityCollegeofMedicineAlumniAssociationofNorthAmerica,Inc.
Contents∗ Increased importance of personalized preventive care∗ Aging and health∗ Paradigm shift in medicine∗ Precision medicine
∗ Evidence of personalized preventive research on cancer∗ Past efforts∗ Current interests on cancer
∗ Preparation for future needs∗ Collaboration is key∗ The next cohort for cancer in epidemiology
Increasedimportanceofpersonalizedpreventivecare
PartI.
3
WeliveLONGER!
Data from United Nations, World Population Prospects, the 2015 Revision
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.0019
50 -1
955
1955
-19
6019
60 -1
965
1965
-197
019
70 -1
975
1975
-198
019
80 -1
985
1985
-199
019
90 -1
995
1995
-200
020
00 -2
005
2005
-201
020
10 -2
015
2015
-202
020
20 -2
025
2025
-203
020
30 -2
035
2035
-204
020
40 -2
045
2045
-20
5020
50 -2
055
2055
-206
020
60 -2
065
2065
-207
020
70 -2
075
2075
-208
020
80 -2
085
2085
-209
020
90 -2
095
2095
-210
0
Life
Exp
ecta
ncy
at B
irth
(yea
rs)
Years
Female Male
Female:72.74Male:68.29
∗ Extendedlifeexpectancy∗ Averageincreaseof20yearsduringthepastfewdecades(world)
∗ Percentageofolderpopulationgrowing
AgingPopulation
Source: Petsko, Genome Biology, 2008
6
Theviciouscyclewillcontinue,Increasingproportionofelderlypopulation(65+):1950-2050
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
World OECD EU27 USA Korea Japan
Source: OECD.Stat
KoreaJapan
PopulationPyramid:Korea2010-2060
Population Pyramid, from KOSIS.kr/statPpulation/main.jsp#
male female
13% of population age>65 in yr 201540% of population age>65 by yr 2060
BUT…doweliveHEALTHIERLife?
∗ Healthylifeexpectancy(HALE)∗ Averagenumberofyearsthataperson
canexpecttolivein“full”health
Salomon et al. Lancet. 2012
Men
Women
Korea
Korea
Sex YearLife
Expectancy(LE)
Healthy Life Expectancy
(HALE)
Increase in LE
Increase in HALE
Men1990 68.1 60.6
8.4 7.32010 76.5 67.9
Women1990 76.2 67.1
6.5 5.52010 82.7 72.6
Wesufferfromchronicdiseases!
Data from GBD 2013 @ http://viz.healthmetricsandevaluation.org/gbd-compare/
GlobalBurdenofDiseases(GBD)In1990
GlobalBurdenofDiseases(GBD)In2013
Source: OECD Health Data
Korea
Japan
10
Andthatcomeswithit…- Increasedhealthcarespending -
The Global Economic Cost of Cancer. American Cancer Society. 2011
• Impactofprematuredeathanddisabilityfromcancerworldwidewas$895billionin2008
• Represents1.5%oftheworld’sgrossdomesticproduct(GDP)
• Theeconomictollfromcancerisnearly19%higherthanheartdisease
• Theanalysisdidnotincludedirectmedicalcosts
Better,moreexpensiveDiagnostictoolsTreatmentmodalities
Unraveltheproblem- Atitscausalorigin-
Dans et al. Lancet. 2011
∗ Importanceofpreventivecare∗ “Anounceofpreventionisworthapoundofcure”
- BenjaminFranklin
Leftshiftofnaturalcourseofdisease
ExposurePathologicChanges Symptoms
Diagnosis
StageofClinicalDisease
StageofSubclinicalDisease
StageofSusceptibility
StageofRecovery,DisabilityorDeath
Therapy
Newparadigm:Leftshiftofdiseaseprogressiontoimprovedhealth
Naturalhistoryofdiseaseprogression
Pathtofuturemedicine
Ordinary medicinePersonalized medicine and prevention
via precision and prediction
GovernmentsinAction!- UnitedStates-
http://news.yahoo.com/obama-calls-major-personalized-medicine-initiative-030325518.htmlhttp://news.yahoo.com/nih-taking-first-steps-huge-precision-medicine-project-111203692--politics.html
15
the right treatment at the right time
- Launchofanewprecisionmedicineinitiative,a$215millionprojecttocollectdataongenomes
January,2015
Dr.FrancisCollins,NIHDirector:
“…empoweranyperson,anywhereintheU.S.”inwhat’scalledthePMICohortProgram
“NIHwillprovide fundingtoVanderbiltU.[foracollaborativepilotproject]withVerily(formerGoogleLifeSciences)”
- ObamatoaskCongress for$309million[in2017fortheinitiativescaleup]- Amassivedatabasewilltrackat least1millionvolunteersby2019
February,2016
Dr.FrancisCollinsatSNUH
PrecisionmedicineinKorea- MinistryofHealthandWelfare-
Source: Korea Health Industry Development Institute
Core area Project Department
Infrastructure establishment for precision medicine cohort
New precision medicine cohortCohort
Enhance existing cohort and biobanks
Prepare systemic coordination for precision medicine-based big data
Standardization and linkage of genomic-medical data
Medical record and public health based big data
Establishment of open data hub Information security and standardization
Develop precision medicine based health services
Development of precision medicine based artificial intelligence Public health big data
Precision medicine based clinical experiment system Omics
Development of precision medicine based healthcare service model Mobile health care
Improve policies and laws related to precision medicine and developmanpower
Improvement of laws, policies, and regulations Law/Policy
Train professionals in the field of precision medicine -
Theuseof“KoreanChip”will helprealizeprecisionmedicineinKorea:∗ Genomicinformationon100,000Koreans∗ Linkagewithcoreinfrastructuresuchascohort,healthcareindustry, electronichealthrecords,andbigdata
∗ NationalCancerCenter(NCC): Large-scalecancerprecisionmedicinecohort∗ Geneticdataof1million cancerpatients∗ Providebasis fordevelopment of
chemotherapeuticagents∗ Bigdatadrivenpreventionofcancer
recurrence
PrecisionmedicineinAcademia- SeoulNationalUniversityBundang Hospital-
Healthcare Innovation Park (HIP) & Seoul National University Bundang Hospital (SNUBH)
- SeoulNationalUniversityBundang Hospital (SNUBH)toleadBigData-basedprecisionmedicineinKorea,anewleapsinceitsembarkasthenation’sfirstfullydigitalized,paperlesshospital
- Establishedtaskforceforcollaborative researchonprecisionmedicine
18
Chul-Hee Lee,SNUBHPresident&CEO:
“Therealizationofprecisionmedicineforeachandeverypatientmaybeadvancedthrough theintegrateduseofhospitaldatabasesystemandgenomic information.”
October,2015
Evidenceofpersonalizedpreventiveresearchoncancer
PartII.
19
Today,it’sallaboutprediction
Newparadigmshift:AJCC’sprognostic,statisticallybasedriskcalculatorsin2016
• Cancerstobeevaluated:• breast,colon,prostate,lung,melanoma,head
&neck• Foreachcancertype,riskmodelsmust:
• Predictoverallsurvival ordeath• Passall16criteria(13inclusion +3exclusion)
Riskpredictionusingbiomarkers
Song, Lee and Kang , JJCO, 2014
SeoulBreastCancerStudy(SeBCS)
Discriminativevaluesofbreastcancerriskmodelsusinggeneticandnon-geneticfactorsfromSeoulBreastCancerStudy(SeBCS)
SNUH AMC Borame hospital EUMC Community-based
• NumberofSubjects(2001-2007)• Cases:4040• Controls:3946
• Originalpapers(2003~2012)• SeBCS:51papers• Collaboration:24papers
Anexampleofbreastcancersurvivalprediction
Song, Kang et al., PLoS One, 2015.
A.Tumorsubtype: rs166870 B.Tumorsubtype:rs10825036
Comparisonofthepredictivepowersofdisease-freesurvival(DFS)forbreastcancer:§ Modelwithcombinedclinical(age,TNMstage,tumorsubtype)andgeneticvariables tendedto
havebetterpredictivepowersoverall§ Geneticfactorsplayedroleindistinguishing highandlowriskgroupswhenusingcombined
prognosticmarkers
• Overall:• Harrell’sCclinical model =70.92%• Harrell’sCcombined model =71.37%• p =0.03
• HR+HER2-:• Harrell’sCclinical model =65.08%• Harrell’s Ccombined model =66.69%• p<0.01
• HR- HER2-:• Harrell’sCclinical model =63.26%• Harrell’sCcombined model =65.88%• p<0.01
PreparationforfutureneedsPartIII.
24
Thespeedofknowledgeaccumulation
Smallerworld,biggerdata
Source: IBM 2013 @ https://www-304.ibm.com/connections/blogs/ibmx86/entry/biginsights_for_big_data?lang=ko
Wiredworld(theInternet)
Globaltransportationnetwork
Infiniteaccumulationofdatawithdatabasetechnology
Moreknowledgeandinsight
Collaborativeworkisimportantinthefuture
∗ Theartofcommunicationandteamwork∗ Withprofessionalsfromvarioussectors∗ Withinaglobalsetting
IdentificationCard
NextGenerationCohort• Needmorepower• Outcomeheterogeneity• Gene-environmentinteraction• Widerdistributionofexposurevariables
AnextgenerationlargegenomiccohortinKorea
InNeedofaNextGenerationCohort
TakingAdvantageofKorea’sUniqueEnvironment
• Biennial HealthExaminationbyLaw(NationalHealthInsuranceCorporation)• NationalPersonalIdentification System(13-digitresidence registrationnumber)
Birthday(6)YYMMDD
Registration(7)Sex-Birthplace-Order-Hidden
Driver’slicense Passport
ExamplesofPreviousCohorts
è AutomaticRepeatedFollow-up&PossibleIntegrationtoSecondaryData
HEXA(HealthExamineesStudy)since2004CentralizedDatabaseStorage
&Biobanking
• Men:Women=2:1
• Meanageatrecruitment (years)§ Men:women=53.7(±8.2):52.6(±7.6)
DiseaseGroup 2018 2023
All-sitecancer 11,749 17,800
Ischemicheartdisease 2,663 4,034
CVA 6,308 9,556
• Totalnumberofquestionnaires n=1,303§ SES,Pastmedicalhistory,lifestylehabits,socio-
psychologicalfactors,reproductivefactors,dietaryhabits(including106SQ-FFQ)
§ Clinical&physicalexamination
HEXAsubjects recruit2004-2012(n=162,142)
EstimatedNumberofIncidentCasesofSelectedDiseasesComposition ofHEXAQuestionnaire &Labdata
HEXAresearchactivities
WhyAsia?
∗ 2/3ofworld’spopulation∗ 4/5ofnewcanceroccurrenceby2020
∗ Widerdistributionofexposurevariablesinrelativelyhomogenousethnicbackgrounds∗ smoking,diet,environment
∗ Rapidchangesincertainpersonalhabits∗ reproductivefactors,urbanization,
etc.
AsiaCohortConsortium(ACC)
Asia CohortConsortium
China
Malaysia
Japan
Singapore
Korea
NCI Cohort ConsortiumBPC3
EPICUK Biobank
8~10 countries, over 1,000,000 participants
IndiaBangladesh
AsiaCohortConsortium- Challengesforcollaborativeresearch-
Song, Kang et al, J Epidemiol 2012
Challenges:
• dataharmonization• resolutionofethicalandlegalissues• establishmentofprotocolsforbiologic
samplesandtransferagreements• fundingprocurement• preciseexposureassessment
MGEL(Molecular&GenomicEpidemiologyLaboratory)
Personalized
Predictive Preventive
Participatory
Prospective Precise
“P4 medicine will transform the healthcare industry”- Hood Leroy
Building Evidence through “6 P” Research!