Genomic expertise in action: molecular tumour boards and decision‐making in precision oncology

Abstract

The recent development of cancer precision medicine is associated with the emergence of ‘molecular tumour boards’ (MTBs). Attended by a heterogenous set of practitioners, MTBs link genomic platforms to clinical practices by establishing ‘actionable’ connections between drugs and molecular alterations. Their activities rely on a number of evidential resources – for example databases, clinical trial results, basic knowledge about mutations and pathways – that need to be associated with the clinical trajectory of individual patients. Experts from various domains are required to master and align diverse kinds of information. However, rather than examining MTBs as an institution interfacing different kinds of expertise embedded in individual experts, we argue that expertise is the emergent outcome of MTBs, which can be conceptualised as networks or ‘agencements’ of humans and devices. Based on the ethnographic analysis of the activities of four clinical trial MTBs (three in France and an international one) and of two French routine‐care MTBs, the paper analyses how MTBs produce therapeutic decisions, centring on the new kind of expertise they engender. The development and activities of MTBs signal a profound transformation of the evidentiary basis and processes upon which biomedical expertise and decision‐making in oncology are predicated and, in particular, the emergence of a clinic of variants.

“Balancing Expectations with Actual Realities”: Conversations with Clinicians and Scientists in the First Year of a High-Risk Childhood Cancer Precision Medicine Trial

“…Childhood cancer care is emotionally demanding for the healthcare team due to the young age of the patient and the potential for widespread impact on the family, especially if the child dies [5]. Precision medicine has the potential to compound these emotional pressures by demanding new ways of working for non-genetics trained clinicians, including a heightened level of interdisciplinary engagement and increased familiarity with genomic medicine [2,[6][7][8][9][10]. Despite growing evidence that clinicians are hopeful about the clinical utility of precision medicine [11], they may not feel adequately skilled to interpret and communicate the results of advanced genomic sequencing to patients and their families [12,13].…”

“…If cancer predisposing germline variants are identified, family implications need to be considered [23]. Molecular tumour boards (MTB), which bring together various clinical and scientific specialties to facilitate knowledge exchange and enhance clinical decision-making, have emerged in response to the complexities of precision medicine [7,24]. The discussion of individual patient outcomes in the MTB is likely to be a particularly novel experience for scientists.…”

Beyond nosology? Molecular tumor boards, singularization, and the conflation of diagnosis and therapy

“…In the present article, we focus on MTBs as a distinctive component of precision oncology. A twin paper (Bourret and Cambrosio 2019, 1571-1572 provides a description of the ethnographic material we collected (in short, observation of over 100 MTB meetings, hundreds of related documents, and over 40 interviews with MTB participants) and of our analytical approach. For the specific purpose of the present paper we performed a number of additional investigations, namely ongoing fieldwork on an international harmonization initiative of knowledgebases and MTBs, a close examination of articles on MTBs, and unstructured, open-ended interviews with 10 of their authors from the US and European countries.…”

“…We initially ran into a few situations where the MTB was in fact a meeting of genomic scientists interpreting molecular data prior to the more traditional TB staffed by clinical oncologists. More recently, however, the predominant MTB configuration includes both scientists and clinicians who jointly enact new, hybrid forms of expertise (Bourret and Cambrosio 2019). Identities are shifting: while some clinicians define themselves as "translational oncologists," highlighting their experimental orientation, others qualify themselves as "disease specialists," emphasizing the continued relevance of organ-based categories in spite of the histology-agnostic nature of MTBs.…”

“…In a previous article we provided a detailed ethnographic investigation of MTB activities, focusing, among other things, on the peculiar kind of expertise they engender (Bourret and Cambrosio 2019). In the present article we examine a different, albeit related aspect, namely the diagnostic work accomplished by MTBs, broadly defined to encompass both the heterogeneous elements that make this kind of work possible, and the workflow within which they are embedded.…”