Beyond the Cancer Diagnosis: Dialogue with Svetlana Nikic, Hosted by Adrian Pogacian

In the current episode of ‘Beyond the Cancer Diagnosis’, Adrian Pogacian debates the psychosocial dimension of Precision Oncology in dialogue with Svetlana Nikic, the founder of Precision Oncology Consulting.

Svetlana Nikic 

Adrian Pogacian, MS Psychology, clinical psychologist with executive education in Psycho-oncology, holding a degree in Global Health Diplomacy from Geneva Graduate Institute. Currently, researcher and associate lecturer with focus on Impact of Cancer Diagnosis on Couples and Families, Communication in Cancer Care and Posttraumatic Growth. His expertise is on Coping with Cancer and managing Fear of Recurrence.

Additionally, Founder of INCKA Psycho-oncology Center, Host of Beyond the Cancer Diagnosis Interview Series as well as Writer and Host Content in Psycho-oncology at OncoDaily.com, co-author of the first Romanian Multimodal Care Guideline in Pediatric Onco-hematology, active contributor to the International Psycho-oncology Society, presently IPOS Fear of Cancer Recurrence SIG member and IPOS Early Career Professionals in Psycho-Oncology Committee founder member.

Hello everyone, welcome again to a new edition of Beyond the Cancer Diagnosis interview series. Today we’ll have an interesting discussions about precision oncology and the outcome from a psychology point of view with Svetlana Nikic, the founder of precision oncology consultancy. Svetlana, welcome and thank you for accepting my invitation.

Speaker 1
Thank you Adrian, it’s a pleasure to be here.

Speaker 2
As I always do for the first question I will ask you to make like an overview or to develop this concept of precision oncology and if this concept is regarded like a positive outcome for the oncological patient.

Speaker 1
Yes, absolutely. So thank you. So obviously the term of precision oncology is fairly broad.
Before I give you my vision in terms of how I perceive that, I would just want to make a short disclaimer. I’m not a treating physician nor psycho-oncologist, so these are really my personal views. I’m a scientist, I’m a molecular biologist by degree.

Speaker 2
So precision oncology, it’s even better because when you look outside from the field you see things differently that I see, so it’s more important.

Speaker 1
Okay, yes, yes, yes, yes. So I have been working in the space of molecular diagnostic for a little bit under 20 years and the way how I see precision oncology is really a field that evolves around the patient, right? So that means from the first moment when we identify a suspicious feature in a specific patient, right, through the diagnosis, then through the treatment, treatment administration, follow-up, all of these aspects for me should be centred around the patient.

So I see that sort of as precision oncology definition. In terms of the evolution that we’ve seen, right, we’ve seen huge progress in terms of, you know, identifying novel biomarkers that help us to identify patients who will benefit or not from these very effective and expensive treatments. But again, I also think that there’s a lot of space for further improvements, right?

We need to make sure that those solutions are scalable and that they do not cause actually more inequalities, right? So we want more patients to benefit and I always say I would like to bring precision oncology closer to as many patients as possible. So I think there’s a huge progress done so far, but again, we have also a lot of work ahead.

Speaker 2
And just a question from what you said for our audience to understand, is precision oncology, let’s say, part of personalised cancer care?

Speaker 1
Yes, so I do believe that these things go hand in hand, personalised medicine, precision oncology, right? So today what is happening still in many institutions and many hospitals, right? Patients are treated, all patients are treated more or less in a standard way, are given treatment, not necessarily based on the molecular profile of their tumour, right?

So what we are seeing in certain places and for certain cancer patients that, you know, they get a molecular profiling of their tumour and based on these results, they are given a treatment that will be most effective in that context. So what I would like to see that we have many patients, hopefully eventually we will have each cancer patient being analysed molecularly in addition to other methods before they’re administered the right therapy.

Because there are many studies out there that have shown that patients who are treated based on molecular findings, so who are assigned these molecularly matched therapies, that their outcomes, so progression, pre-survival, overall survival and ultimately also quality of life of these patients is better than when they are administered treatment based on non-molecularly matched findings.

Speaker 2
It is very important because the COVID-19, as I always said, put the society in front of great and important decisions. And within oncology field, especially for us, for psychologists, we noticed that there are many and many cases which, as you mentioned, are not standard, like breast cancer or I don’t know which one, they are more within the body, like viruses, bacterias. So it’s very, very difficult from the first symptom to do not have a gap till you have a diagnosis.
And we see on patients their decision making or this process of what should I do, it’s very difficult.

Speaker 1
I agree, I agree. But I do think this is a very kind of complex issue, right? Because we also, you know, it’s very subjective on whether you’re feeling fine or not.

But what I do think that we will see hopefully that change with all of these sort of AI-based tools, all these variable tools, watches, smartwatches that we carry that are measuring our specific features 24 hours a day. And I think in future, we will see that, you know, through these wearables, we can potentially detect some symptoms that will hopefully, you know, suggest to us to see the, you know, the physician while we are officially still healthy, but maybe we have some symptoms that are suggesting there might be something wrong.

So I think those sort of developments in the, you know, digital tools will also hopefully help in detecting these cancers earlier than what we are seeing today, right?

Speaker 2
Yeah, this is the most important thing because statistics, as I always said, show that we are living longer generation by generation, but we are also exposed to higher risk. And the risk to have cancer in your life, it’s getting higher as the life expectancy is increasing. So it is a need in the future to be precise, also from precision oncology, to try to make a bridge on this gap from the symptom to the diagnosis and then to treatment.

This is very important. And we notice this on the patients because they are, they don’t know what is happening with them between diagnosis and treatment. And it’s very, very difficult to work with them because I don’t know what he has, he knows, but he knows something.
So we also need specialist tools to increase our efficiency.

Speaker 1
Absolutely, absolutely. And I know that the whole space of the startups in the field of precision oncology is really booming and there’s a lot of exciting tools being developed. And I think some of them will be really very, very helpful.

So again, I’m not a specialized in digital health, but for example, I know that some of these tools who are helping patients to treat, to track their symptoms during the treatment, right, that will help us to sort of look into these patient reported outcomes, which are very relevant, you know, also for the, you know, drug approval processes where we can track what’s the actual impact on the quality of life of that specific treatment. So I think these sort of tools will help both the patients to potentially identify some, maybe adverse events, right?

So the patients can go and see their nurse early on that they would have done without those tools. And then as well, I think treating physicians and nurses, they will benefit from these tools, right? They will help them to sort of identify some of those patients who potentially are not benefiting from a therapy or maybe are having some serious side effects.

So if they act upon those sooner, the patient will not be affected as much. So I think these are areas that we will see a lot of development in over the few years, over the next years. And then also what we were mentioning earlier, right, about identifying these symptoms early.

Also, there are obviously screening programs out there. This is something I just wanted to mention in this context, right? For example, in the context of the colorectal cancer, obviously these are health individuals, but I believe in Europe today, if I’m not mistaken, there are only three countries that have national programs for screening individuals that are between I think 50 and 74 years old for potential early symptoms of colorectal cancer.

And the uptake is fairly poor. It’s around 20%. So, right?
So I think we also need to do more in terms of education and awareness amongst the healthy population, right? What does the screening program mean? How does it, you know, happen?

What does it involve? What are the benefits? We, I think within this community, we know what it means detecting stage one colorectal cancer and impact on your outcomes and what it means if it’s stage three and four.
But I think non-clinicians, non-scientists are not aware of this. So I think we need to do more in educating healthy population.

Speaker 2
You are right because our work is on healthy population, not on a diagnosed, let’s say, population. Unfortunately in Europe, there are few countries with not national programs on colorectal cancer, but with national programs on oncology. Also in Romania, it was, I guess, last year that was a national big plan for oncology or cancer treatment, but it’s only on the paper.

So it’s very, very difficult. Also for us from the other part of the problem to try to convince patients to make screening. We try to educate them to give them this psychosocial education in oncology, which is very, very important for them.
But the feedback is not what we expect from the patient because our world today is very chaotic, so they don’t have time. When they are healthy, they don’t have time. After the diagnosis, they don’t have time because they are ill, so they want to make better soon.

So it’s like continuing running after a diagnosis, after an information. So it is very important, and you mentioned a lot of opportunities that this field of precision oncology show, proved, and could help us in the future. But I would like to ask you about the challenges, because it’s a field within oncology, and to develop something in an oncology field is not an easy thing.
So what are the challenges?

Speaker 1
Agreed, agreed. So there are many opportunities, as we said, and equally, I would say there are also many challenges, right? So let me maybe mention just a few, and then we can elaborate some of those.
So we were speaking about molecular testing, right? So identifying these predictive and prognostic biomarkers who can identify the patients who will respond or not from specific therapies or who would fall in sort of a high-risk group. So many of these approaches require sort of a significant investment, right, in terms of infrastructure.

So next-generation sequencing technology is a very powerful tool, but to make this infrastructure available within a hospital poses a significant cost burden. So obviously, certain countries with high income, they don’t have as big challenges as low- and mid-income countries, so I think that’s one of the challenges. But I know that the manufacturers of these technologies are also thinking about developing sort of alternative solutions, smaller instruments that potentially could deliver the similar results.

So hopefully, thinking about these different settings that we are facing across the globe, right, low- and mid-income countries and high-income countries, my worry is that, you know, whether precision oncology will make, you know, a bigger gap or smaller gap between, you know, these regions. Another big challenge that we have, and even within Europe, so even if you just compare Eastern Europe and Central Europe in terms of drug approval times. So you probably know that once the drug is approved by EMA in Europe, right, typically, for example, it takes around 100 days for the same drug to be approved by the national agency in Germany, whereas I believe in Romania it’s around 900 days.

And low- and mid-income countries, they don’t even have that approval. So if you don’t have access to the innovative drug, then you can also question whether you need to be tested for an innovative biomarker if you cannot, right, give access to this therapy to your patients. So my worry is, you know, not to create more inequality, and I think the time will tell, but I would like to, you know, and I know at the European level, there are certain efforts aimed towards standardizing and harmonizing these processes related to the drug approval and hopefully joint approval of the companion diagnostic test.

So there are some efforts, the society is aware of these sort of misalignments, so the good thing is there are certain efforts that are working towards harmonizing that. But yes, so inequality and sort of that market access issues are one of my biggest fears when we think about the future of the precision oncology.

Speaker 2
Inequalities, this is inequality, inequity in cancer care access, this is a major issue, and not only from a precision oncology point of view, but also from access to cancer care or healthcare system. And for, as you mentioned, low- and medium-income countries, it’s very, very difficult because the patients are increasing and there are no specialists. So it is very important to educate both the specialists and the patients about every technology that could be in the advantage of the patient, because this is our purpose, to to help the patient.

And in this regard, I want to ask you, are there any risks for patients with regard to precision oncology? I don’t know, maybe they don’t want to try this new technology, maybe they are fear, do not find out something more because there is this right to know. So it’s not like so easy to convince a patient to do such a thing.

Speaker 1
Yes, yes. So, yeah, I think this is interesting question. So we will probably also see, and there are already some data that show you differences in this perception among different nationalities, right?

There are also cultural aspects, certain nations are more sort of risk-averse than others. And I agree, you know, when we speak about genomic testing, we think about what’s, you know, somatic aberrations that come, for example, you know, these inherited mutations typically found in tumours, but then there’s also this inherited part, right, that can give you predisposition to certain other diseases. And we always speak about these variants of unknown significance that sometimes pop up when you do these genetic tests.

And I think also there, there’s a lot of discussion in the field, even between the clinicians, not to mention the, you know, non-scientifically savvy individuals, but I think as long as everyone is, you know, very transparent from the clinician’s perspective, you know, they have to describe what their rights are and what their duties are, right? And I know there are also some nationally, national differences, you know, certain, in certain countries, I think you have to report on any incidental findings, whereas in others you don’t. So I think there needs to be as well some alignment.

But again, we are going back to the education, right? Predisposition to breast cancer, ovarian cancers, right? There are certain preventive measures that you can do, right?
Colorectal cancer. So for certain cancers, if we know we have a high predisposition and if there’s a preventive solution out there, right, it’s a kind of a something that patients or potential future patients should know. But I don’t think there’s a sort of a simple answer to that question.

I think these are sort of very ethical questions that we need as a society just to be aware of and address them.

Speaker 2
So to understand now your focus is on, let’s say, a big network of hospitals, public, private hospitals, and then hopefully in the future to go to local centers, local communities, because as you mentioned, education is a very important cultural background. It is another important factor. And I notice every day because sometimes it’s very difficult also to talk with a patient.

And as I see the things we are going through, very, let’s say, digital intervention, both medical and I see in my field both psycho-oncological intervention, because we are talking in our field about holograms, digital twins. So it will come the times when a patient will come, make the precision oncology, and then just move into the room and have like a hologram. And then you start thinking, where is the human touch?

Where is the meaning of life? So these are the questions in the future that we have to put, because technology can’t replace. Human touch can’t replace emotion.
So this is, I guess, another challenge also for you, but for everyone involved in oncology.

Speaker 1
I agree. I would say it’s a challenge and opportunity, right? So I do see, you know, the fact that we are moving into this digital era and thinking about elderly population, right?

So hopefully, you know, once all of these digital tools become part of sort of a routine day for all of us, right, we will, you know, hopefully already be up to date with those developments, right? I think, for example, today’s elderly generation is a little bit struggling because, right, you know, we’ve seen this emerge of digital tools within the last potentially 10, 15 years. But, you know, I do not see actually these digital tools replacing human touch in future.

I see them really as a way to alleviate some of these, you know, administrative tasks from treating physicians, from nurses, and hopefully leaving more time for them to see and treat and talk to their cancer patients, right? So what is, you know, worrying me that, you know, there’s certain predictions that by 2030 in Europe, I believe it’s 44 million and globally 10 million healthcare workers that will be missing, right? Shortage of staff, very impressive numbers.

So what I’m hoping that we will have these digital tools that will, right, alleviate this, you know, administrative tasks that will hopefully help clinicians to write up their notes after they’ve seen a patient that, you know, I see these tools more as a sort of a support, supportive tools for the treating clinicians, where treating clinicians can really then, you know, dedicate their time to what they’re best at, right? Patient-clinician interaction, giving the right treatment, and also maybe, you know, having even more time for those patients, which today is really challenging.

Speaker 2
Yeah, you mentioned about the lack of social worker, of personal, there are also nowadays lack of psychologist everywhere, of clinician everywhere, because everyone is going on the research part, which is, let’s say, not easier, but you don’t have the contact with the cancer patient. So let’s say 65% of them are going to research. And in time, it is a huge gap.

And you mentioned the age category, and a lot of digital instruments. I would like to ask, like, the final question. How about adolescents and young adults between 15-39 years?
They are generations that already use technology since they were born. How are they receiving this information in comparing with, I don’t know, generations like 80s or maybe 70s?

Speaker 1
Yes, it’s an interesting question. You know, I’ll be honest, I didn’t really give it a lot of thought. For sure, I would imagine that, you know, these individuals, young individuals, I’m probably here referring mostly to young adults, right, AI patients.
So I would imagine that, you know, when they are going to see their treating physician, they go very well informed, right? They probably know even better than you and I, how to use these tools. So I would imagine that they would go very well prepared, because they have access to all of these digital tools, they know how to use them.

I would wonder, you know, from that psychological, right, perspective, you know, how do they cover those needs? Because there’s this other sort of side, right, that, you know, maybe the digital tools, obviously, they cannot provide them that psychological support that they need. So maybe we will see in future.
And again, I think this is really your expertise, maybe those younger generations, even though they’re more informed, they might actually require even more human touch, right? Because initially, they will be sort of so independent in finding those answers online and through these digital tools. So I think it’s going to be interesting to see how that group involves in terms of those needs.

And in terms of elderly, obviously, today, I think it’s a totally opposite situation, right? So they are the ones who are benefiting mostly from this type of psychological support. So yeah, we’re going to probably see a lot of a shift over the next 30 to 40 years.
Sorry that I can’t be more specific.

Speaker 2
No, it’s okay. And it was very important because you said that this is true, they are very well prepared, you know, with smartwatches, I know the pulse, I know everything, the sleep problems, everything. But when it comes to talk about, yeah, to express their emotion, here is a problem.

And even though I would like to end the interview in a positive note, I have to mention that as technologies advance, and as we go by this thing of the right not to know, it’s used more and more by many patients, because you start talking with them, not me as a psychologist, but the doctors and they say, okay, stop. I don’t know to know further. And this stops everything.

So it’s very difficult to work with these kinds of patients. So this is even more important to make education, to make awareness and to try to prevent and to try to, let’s say, catch the cancer diagnosis as soon as we can. So thank you very much, Tetrana, for this interesting discussion for joining me today.
It was a really, really interesting debate about the future of oncology, which is a very broad subject and concept and we’ll see what future will bring us. Thank you very much. And good luck on your activity.