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Intermountain and Stanford Medicine: Taking Precision Medicine from the Bench to the Bedside

May 16, 2016
by Heather Landi
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Lincoln Nadauld, M.D., Ph.D., executive director of precision medicine and precision genomics at Intermountain Healthcare, and Hanlee Ji, M.D., the senior associate director of Stanford Genome Technology Center discuss their clinical genomics partnership.
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Last month, Intermountain Healthcare and the Stanford Genome Technology Center (SGTC) announced a new collaborative research program with the aim of providing scientific advances in precision health and medicine.

The joint research team consists of members of Intermountain’s Precision Genomics Core Laboratory, based in St. George, Utah, and SGTC, based in Palo Alto, California. The team of researchers and clinicians are working to identify novel biomarkers using an advanced array of technologies developed at SGTC. The focus of the research will be on solving clinical issues for patients using cutting-edge technologies that enable delivery of precision health, or, essentially, taking genomics from the “bench to the bedside.”

Intermountain Health is a 22-hospital integrated health system based in Salt Lake City. And, Intermountain Precision Genomics is a service of Intermountain Healthcare, which offers genetic sequencing of solid tumors. This in-depth sequencing identifies individual mutations within a person’s cancer cells to identify specific DNA targets for personalized drugs. SGTC is a research center at the Stanford University School of Medicine that integrates personnel and expertise from the Stanford departments of Medicine, Genetics, Biochemistry and Electrical Engineering. SGTC’s mission is to develop innovative biomedical technologies that reduce the costs of health care.

Healthcare Informatics Assistant Editor Heather Landi recently caught up with Lincoln Nadauld, M.D., Ph.D., executive director of precision medicine and precision genomics at Intermountain Healthcare, and Hanlee Ji, M.D., the senior associate director of SGTC and an associate professor at the Stanford School of Medicine in the Division of Oncology, to discuss the clinical genomics partnership and how the research teams are moving beyond just talking about the promise of precision medicine to actual clinical application of precision medicine principles.

Can you tell me more about the work that you’re doing with the Intermountain Precision Genomics program?

Nadauld: About three years ago, we launched Intermountain Precision Genomics with the thought that we would take some of the emerging technologies and apply to cancer patients with advanced disease who were running out of options and see if we couldn’t make better determinations about which treatments might benefit them. So we wanted to apply a precision medicine approach where we identify molecular changes in their tumor and then give them the appropriate targeted therapy.

Lincoln Nadauld, M.D., Ph.D.

And that’s what we’ve done. We’ve been monitoring outcomes, and we’re pleased with what we’re seeing. We think patients benefit from this. It doesn’t mean we’re suddenly curing a bunch of incurable cancer cases, but we have seen patients live longer and feel better and have a higher quality of life with this approach. And so, as that has progressed and been beneficial for our patients, we recognize that one of the real opportunities here is to continue this effort around translational medicine, where we take emerging technologies, evaluate them for clinical application and then do what we do really well at Intermountain Healthcare,  which is provide excellent care to patients.

So we wanted to partner with entities and institutions that have world-class, cutting-edge research and help bridge that gap from the bench to the bedside. And that’s what this partnership with Stanford is really trying to get at.

What will this collaborative initiative enable you do accomplish that perhaps you could not accomplish separately?

Nadauld: It will allow us to evaluate new, cutting-edge, world-class technologies and apply them clinically. So, previously, we haven’t had access to cutting edge technologies. Our own institution, while innovative, is not fundamentally a technology company or a research institution that develops its own findings. We are an institution focused on care delivery and iterative improvements in that care delivery process, and that’s what we’ve exceled at for 40 years. We think to make real progress that sometimes requires a clinical implementation of novel technologies and we think marrying our really good clinical delivery with really excellent technology is a way to make changes and dramatic improvements in patient care.

Ji: A central part of this project is that we have a variety of methods, technologies and other approaches, including computational ones, that have a lot of potential to be informative in biomedical research and in studies of populations with specific diseases like cancer. Stanford generally is able to capture a swath of the population but it’s only one medical center. And, at some point, it becomes important to verify and validate what you discover and what you can develop on much larger clinical populations. And that’s where our project with Intermountain is so critical, and that’s the big advantage, is we now have access towards identifying common goals that both institutions and both research groups want to achieve and use all these advances that we have available at Stanford, particularly at Stanford Genome Technology Center, and apply that to address this question.

Hanlee Ji, M.D.

Can you give me an example of what you think you can accomplish?

Nadauld: A good example is liquid biopsy technology. So, the precision oncology effort that I alluded to before really was an effort to look at the molecular changes, or gene mutations, in the patient’s tumor and then provide targeted therapy. The challenge there is that requires a biopsy or some tissue from the patient, and that’s not always feasible. It’s risky to do a biopsy, not all patients are good candidates, and sometimes it doesn’t yield enough tissue.

We have just begun to recognize that cancers will shed their DNA into the peripheral blood, so we can take someone’s blood and look at the DNA that’s flowing freely, its cell-free DNA. So we can look at someone’s peripheral blood and analyze their tumor DNA without having to take a biopsy of the actual tumor itself, so it’s a “liquid biopsy.” And, Stanford has that technology, they have the ability to perform a molecular analysis on cell-free DNA and we have, we think, the appropriate clinical models for implementing. So we’re going to be working with them on taking some of their cell-free DNA technology, their liquid biopsy technology, and clinically implementing it to the benefit of our cancer patients.

And, frankly, asking the question, does liquid biopsy improve outcomes or not? That’s the other area where we really excel—monitoring patient outcomes, and the cost of the technologies as well. We did that with our first effort where we were using this precision medicine approach for advanced cancer patients; we asked ‘What are their clinical outcomes like?’ And, we also asked, ‘What is the impact economically, and what is the cost of care?’ We believe implementing technology can help patient outcomes, but if it dramatically increases the cost of care, we really have to be careful about which technologies we implement. Because we’re in an era of static healthcare resources, and if we constantly increase the cost of care, that’s not good stewardship. So we want to partner with Stanford to implement technology and then ask the question “Do we improve patient outcomes,” and number two, “What is the overall cost of care look like when we add these new technologies?’

Ji: That’s something where we’ve definitely already made a lot of progress. So we developed a highly efficient, very rapid method of doing liquid biopsy that is immediately clinically informative; and we’re working with Intermountain so that we can take that approach and implement it in a way that we can do large scale, translational clinical studies on patients in Utah and adjacent states. So that represents an approach that can easily and readily be scaled. We’re certainly going to try to push that up with the optimal intent of number one, determining its clinical benefits, and number two, if it does show benefits, how to scale the platform where it can be potentially be applied to every cancer patient throughout the system at some point.

Will you be able to implement some of these technologies with resources you already have?

Nadauld: The good news is that we’ve set up the collaborative in a way to try to take advantage of some of the resources already available. We have an integrated electronic medical record (EMR), and we have some genomics platforms and software and things in place, and Stanford knows what they are, we’ve talked about implementing solutions that lean on some of the processes already in place.

How is it advantageous for your team to partner with Intermountain in particular?

Ji: Intermountain has demonstrated its commitment to a high level of clinical excellence, by vetting and adopting methods, procedures and clinical practices that have been shown to be best practices by rigorous research. I can’t imagine a better partner for these types of precision medicine studies. Much of that is based on the fact that they are very forward-thinking on their outlook, and that’s something that seems to permeate the entire organization, from the top and all throughout all levels. So I see an organization that’s really dedicated to improving the health and welfare of their patients by adopting the best in precision medicine.

Precision medicine is gaining increased attention at a national level due to President Barack Obama’s Precision Medicine Initiative and Vice President Joe Biden’s Cancer MoonShot 2020 initiative. How does the work of this collaboration play into this larger effort?

Nadauld: It dovetails very nicely. It’s completely complimentary to and synergistic with this entire enthusiasm around precision medicine. In fact, at Intermountain, we’re part of that PMI sponsored by the White House. We were at the White House event in February around the PMI and Stanford has been involved with this whole PMI paradigm shift as well. I think one thing that Biden’s MoonShot for Cancer team really wants to see is inter-institutional collaboration and cooperation. I think our effort with Stanford is an ideal example of what they are helping to promote. Here are two institutions that separately are excellent in their own spheres. Stanford has world-class technology development, unparalleled scientific capabilities, Nobel Prize winners and Intermountain Healthcare has spent nearly a half century focusing on excellence in clinical care delivery. Now we are going to marry those two strong capabilities for the benefit of patients, and I think that’s exactly what Biden and the MoonShot team want to see; that’s what they are trying to promote.

Do you think this kind of partnership is replicable?

Nadauld: I think so. I actually think this could be a bit of a paradigm for others to follow; this notion of working together and applying each other’s strengths, and specifically, I think the idea of an academic institution, with all of their rigor and scientific capabilities working closely with an integrated care delivery network, to implement some of their scientific discoveries, I think that is a recipe for success that could be patterned over and over again. Gone are the days of a single institution trying to take something from bench to bedside all by itself.

Ji: I think Stanford has already made a major commitment to establish a relationship with intermountain; I would say that is already pretty ambitious given that if we develop something that has an impact on Intermountain patients and improves their clinical welfare, you’re impacting patients that cover at least four or five states. So I’m pretty happy just to get up to that point. Whether other organizations, other integrated healthcare providers, see that as a model, that would be great, but we’re not going to wait around for other people to adopt it. I feel that it’s going to prove to be enormously productive and lead to improved clinical outcomes, and also have the potential to reduce healthcare costs.


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