A Piece of a Puzzle – The All of Us Research Program and Cancer

A recent article discusses the promise of precision medicine research for cancer prevention and control in the National Institutes of Health (NIH)’s All of Us research program.

In 2015, then-President Barack Obama announced the precision medicine initiative to “bring us closer to curing diseases, such as cancer and diabetes — and to give all of us access to the personalized information we need to keep ourselves and our families healthier.” Precision medicine is a personalized approach to medical care where a person’s own genes or proteins are used to prevent, diagnose, or treat disease.  The initiative has two main components: a near-term focus on cancers and a longer-term aim to generate knowledge applicable to the whole range of health and disease.

In 2016, the National Cancer Institute launched the “Cancer Moonshot”, a program that aims to reduce cancer-related deaths by 50% over the next 25 years. To achieve this, Congress authorized, through the 21^st Century Cures Act, $1.8 billion toward cancer research with a focus on precision medicine. Included among the seven priorities of “Cancer Moonshot” is precision medicine, i.e. targeting the right treatments to the right cancer patients.

In 2018, the National Institutes of Health launched the All of Us research program, which aims to enroll 1 million or more participants to advance the science and application of precision medicine. All of Us collects information on personal medical history (family health history, genetics), healthcare access, electronic health records (EHRs), biospecimens, and survey data. This program will create a large nation-wide database that links environmental and lifestyle factors, and genome-wide sequencing with electronic medical records, ushering in a new opportunity for researchers to use genome-wide association, phenome-wide association studies, and whole genome sequencing. The goal of this research program is to help identify individualized prevention and treatment strategies for the diverse American population and to better address the unequal burden of cancer.

Studying Cancer in the All of Us Research Program

The All of Us database allows precision medicine research for all diseases, including cancer. The program strives to include individuals from diverse backgrounds, and this inclusiveness is described as one of its major strengths. The article by Aschebrook-Kilfoy et al. reports that 21.2% of the All of Us population identifies as African American/Black and 18.8% identifies as Hispanic. Aschebrook-Kilfoy et al. also report that the All of Us research program has a higher prevalence of cancer patients and survivors represented (in part due to the recruitment strategy of participants) than the estimated national prevalence as reported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program’s 26-year limited duration prevalence, which estimates 4.43% of Americans have a cancer diagnosis. This high prevalence of breast, prostate, and colon cancer patients and survivors may allow researchers to stratify by important characteristics, such as specific genetic mutations or race and ethnicity, and still have meaningful results.

While the combination of EHRs and self-reported survey data is another strength of the dataset, there are potential biases that should be carefully considered in making inferences about the generalizability of findings from the All of Us database.

A Piece of the Puzzle: Using Family History in Cancer Prevention and Control

Asking patients about their family health histories is an important question physicians use to ascertain cancer risk. The CDC’s Division of Cancer Prevention and Control and the Office of Genomics and Precision Public Health have resources on how family health history can be used for cancer prevention. For example, about 5% to 10% of breast and about 10% to 15% of ovarian cancers are hereditary. Knowledge of family health history can help healthcare providers facilitate genetic counseling and testing that may affect prevention and treatment.

The All of Us research program has vast potential for making an impact on population health using the new tools of precision medicine. Pairing genomic data with family health history will be critical for clinical utility. The genetic and environmental data that the All of Us research program promises are all important pieces of the puzzle in the progress towards cancer prevention and control.

Please share your input and thoughts on the role of precision medicine in cancer prevention and control.