We focused on myeloid blood cancers, a growing issue with our aging population, that cause debilitating and life-threatening complications. When we started our project, diagnosis was often at a late stage and heavily reliant on subjective microscopic findings, with limited genetic testing. Thus, myeloid cancer patients were lumped into broad diagnostic and treatment categories.

We applied next-generation DNA sequencing (NGS) to uncover a wealth of genetic information about myeloid cancers. Our successful experience enabled the adoption of clinical NGS testing for patients at Kingston Health Sciences Centre (KHSC) and several others across Ontario. We then tracked clinical utility, revealing how personalized NGS testing helped to detect cancer earlier, refine classification and provide more accurate information about patient risk and treatment options. Along the way, Dr. Rauh advised Ontario Health/Cancer Care Ontario and advocated for patients, leading to new diagnostic guidelines and equitable funding/access for NGS testing for myeloid cancer across Ontario.

GOALS and INNOVATIONS of our project:

Cancer diagnosis.  Myeloid cancer diagnosis has relied on subjective morphological criteria, laborious low-resolution cytogenetics, and a limited number of molecular-genetic tests.  The revised WHO classification includes many new molecular features, leaving Ontarians with sub-standard tools for diagnosis. Path2MyDx incorporated personalized, objective, molecular criteria, with rapid turnaround, using a high-throughput, multiplexed NGS assay.

Prevention.  We demonstrated the utility of NGS for earlier detection of myeloid cancers.  As deeper understanding of the drivers of myeloid cancer emerges, we may be better positioned for earlier and targeted interventions that eradicate mutant clones before they cause de novo or therapy-related myeloid cancers. Path2MyDx is a step towards surveillance and prevention.

Clinical management.  Information obtained from Path2MyDx will better inform clinical risk stratification, the identification of actionable mutations and selection of most appropriate treatments and trials.  In the near future, targeted NGS will enable the monitoring of treatment responses, and fine-tuning therapy in real-time, to address the changing landscape of mutant myeloid clones.

OUTCOMES including TRANSFORMATION OF HEALTH CARE DELIVERY:

We met and exceeded our specific objectives. We:

1. Implemented and validated a myeloid NGS cancer assay at Kingston Health Sciences Centre.
2. Demonstrated its “actionability” for Clinicians and Patients, and advised and enabled assay development and/or adoption at other Hospitals (i.e. Horizon Health, NB, Osler Health and Sunnybrook, ON).

Moreover, TWELVE PAPERS (see Publications list below) and TWO GUIDELINES were published around this project. Briefly, we also identified the earliest drivers and stages of myeloid cancers, called clonal hematopoiesis or CH; this included the observation that CH mutations alter the immune functions of myeloid cells and contribute as a new risk factor to other diseases of aging (such as heart, lung, kidney and infectious diseases). Dr. Rauh also served on two expert advisory panels for Ontario Health/Cancer Care Ontario, 1. creating guidelines for complex malignant hematology testing and NGS funding for acute myeloid leukemia (see: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/43061 ); 2. expanding guidelines and accessible NGS funding for patients suffering from other types of myeloid cancers (i.e. MPN and MDS) (“Consensus Diagnostic and Prognostic Testing for MDS, MPN and MDS/MPN: Recommendations Report – 2022”).

Twelve (12) related papers, where funding was acknowledged, resulted from this project:

Ferrone CK, McNaughton AJM, Rashedi I, Ring B, Buckstein R, Tsui A Lower Frequency of Spliceosome Mutations Distinguishes Clonal Cytopenias of Undetermined Significance From Low-Risk Myelodysplastic Syndromes, Despite Inherent Similarities in Genomic, Laboratory, and Clinical FeaturesH, Rauh MJ. Mod Pathol. 2023 Mar;36(3):100068. doi: 10.1016/j.modpat.2022.100068.10.1016

Ferrone CK, McNaughton AJM, Vincelli F, Zuzarte P, Lee D, Feilotter HE, Rauh MJ.

U2AF1 S34/Q157 Variants Detected in cis Arise Sequentially in an MDS Patient With Serial Sequencing Spanning 18 Years. Hemasphere. 2022 Sep 22;6(10):e779. doi: 10.1097/HS9.0000000000000779.

Ferrone CK, Wong H, Semenuk L, Werunga B, Snetsinger B, Zhang X et al.

Validation, Implementation, and Clinical Impact of the Oncomine Myeloid Targeted-Amplicon DNA and RNA Ion Semiconductor Sequencing Assay. J Mol Diagn. 2021 Oct;23(10):1292-1305. doi: 10.1016/j.jmoldx.2021.07.010.

Ferrone CK, Blydt-Hansen M, Rauh MJ. Age-Associated TET2 Mutations: Common Drivers of Myeloid Dysfunction, Cancer and Cardiovascular Disease. Int J Mol Sci. 2020 Jan 17;21(2):626. doi: 10.3390/ijms21020626.

Cook EK, Izukawa T, Young S, Rosen G, Jamali M, Zhang L, et al.

Comorbid and inflammatory characteristics of genetic subtypes of clonal hematopoiesis.

Blood Adv. 2019 Aug 27;3(16):2482-2486. doi: 10.1182/bloodadvances.2018024729.

Snetsinger B, Ferrone CK, Rauh MJ. Targeted, Amplicon-Based, Next-Generation Sequencing to Detect Age-Related Clonal Hematopoiesis. Methods Mol Biol. 2019;2045:167-180. doi: 10.1007/7651_2019_216.

Nazha A, Sekeres MA, Bejar R, Rauh MJ, Othus M, Komrokji RS, et al. Genomic Biomarkers to Predict Resistance to Hypomethylating Agents in Patients With Myelodysplastic Syndromes Using Artificial Intelligence. JCO Precis Oncol. 2019;3:PO.19.00119. doi: 10.1200/po.19.00119.

Sekeres MA, Othus M, List AF, Odenike O, Stone RM, Gore SD et al. Randomized Phase II Study of Azacitidine Alone or in Combination With Lenalidomide or With Vorinostat in Higher-Risk Myelodysplastic Syndromes and Chronic Myelomonocytic Leukemia: North American Intergroup Study SWOG S1117. J Clin Oncol. 2017 Aug 20;35(24):2745-2753. doi: 10.1200/JCO.2015.66.2510.

Duarte BKL, Yamaguti-Hayakawa GG, Medina SS, Siqueira LH, Snetsinger B, Costa FFet al.

Longitudinal sequencing of RUNX1 familial platelet disorder: new insights into genetic mechanisms of transformation to myeloid malignancies. Br J Haematol. 2019 Sep;186(5):724-734. doi: 10.1111/bjh.15990.

Abegunde SO, Buckstein R, Wells RA, Rauh MJ.  An inflammatory environment containing TNFα favors Tet2-mutant clonal hematopoiesis. Exp Hematol. 2018 Mar;59:60-65. doi: 10.1016/j.exphem.2017.11.002.

Cull AH, Snetsinger B, Buckstein R, Wells RA, Rauh MJ. Tet2 restrains inflammatory gene expression in macrophages. Exp Hematol. 2017 Nov;55:56-70.e13. doi:10.1016/j.exphem.2017.08.001.

Cull AH, Rauh MJ. Success in bone marrow failure? Novel therapeutic directions based on the immune environment of myelodysplastic syndromes. J Leukoc Biol. 2017 Aug;102(2):209-219. doi: 10.1189/jlb.5RI0317-083R.