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.
Highlights
The therapeutic management of cancer patients is generally based on standardized treatment plans which are in turn embedded in clinical guidelines
We suggest that only a focus on the actual content of Molecular Tumour Boards’ (MTBs) activities can lead to an understanding of the peculiar kind of expertise they deploy, and that in order to pursue this line of inquiry we need to examine MTBs, rather than its individual members, as the source of the bio-clinical expertise that underlies the clinic of variants
The collective, sequential form of reasoning displayed by MTB members rests decisively on the triangulation of results provided by different kinds of equipment (NGS, CGH) with the information about pathogenic variants derived from dedicated knowledgebases or, is some cases, elicited from ad hoc searches in publication databases such as PubMed
Summary
As mentioned in the previous section, MTB activities, while defined by their common goal of enacting actionable interpretations, are characterized by the presence of a number of different specialists, namely clinicians (medical oncologists, surgeons, radiologists and radiotherapists, pathologists), biologists (geneticists, molecular biologists), biostatisticians, and information technology specialists (computational biologists, bioinformaticians). MTB activities, while defined by their common goal of enacting actionable interpretations, are characterized by the presence of a number of different specialists, namely clinicians (medical oncologists, surgeons, radiologists and radiotherapists, pathologists), biologists (geneticists, molecular biologists), biostatisticians, and information technology specialists (computational biologists, bioinformaticians). Each of these practitioners can be said to possess peculiar skills, i.e. distinctive forms of expertise that require the mastery of specific tools, a shared language, and shared assessment criteria. MTBs, from this perspective, qualify as assemblages (or better: agencements, a term that denotes both the process and the result) that in addition of being composed of heterogeneous elements, display immanent, emergent properties and downward causality, for once in place they act on their components (DeLanda 2016)
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