IMPROVING THE EFFICIENCY
AND EFFECTIVENESS OF
GENOMIC SCIENCE TRANSLATION

WORKSHOP SUMMARY

Sarah H. Beachy, Samuel G. Johnson, Steve Olson, and
Adam C. Berger, Rapporteurs

Roundtable on Translating Genomic-Based Research for Health

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Sarah H. Beachy, Samuel G. Johnson, Steve Olson, and Adam C. Berger, Rapporteurs Roundtable on Translating Genomic-Based Research for Health Board on Health Sciences Policy

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THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the coun- cils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was supported by contracts between the National Academy of Sciences and American Academy of Nursing (unnumbered contract); American College of Medical Genetics ­ and Genomics (unnumbered contract); American Heart Association (unnumbered contract); American Medical Association (unnumbered contract); American Society of Human Genetics ­ (unnumbered contract); Association for Molecular Pathology (unnumbered contract); Blue Cross and Blue Shield Association (unnumbered contract); Centers for Disease Control and Prevention (Contract No. 200-2011-38807); College of American Pathologists (unnumbered contract); Department of the Air Force (Contract No. FA7014-10-P-0072); Eli Lilly and Company (unnumbered contract); Genetic Alliance (unnumbered contract); Health Resources and Services Administration (Contract No. HHSH250201100119P); International Society ­ for Cardiovascular Translational Research (unnumbered contract); Johnson & Johnson (unnumbered contract); The Kaiser Permanente Program Offices Community Benefit II at the East Bay Community Foundation (Contract No. 20121257); Life Technologies (unnum- bered contract); National Cancer Institute (Contract No. N01-OD-4-2139, TO#189 and Contract No. HHSN2632012-000741, TO#5); National Coalition for Health Professional Education in Genetics (unnumbered contract); National Heart, Lung, and Blood Institute (Contract No. N01-OD-4-2139, TO#275); National Human Genome Research Institute (Contract No. N01-OD-4-2139, TO#264 and Contract No. HHSN2632012-000741, TO#5); National Institute of Mental Health (Contract No. N01-OD-4-2139, TO#275 and Contract No. HHSN2632012-000741, TO#5); National Institute of Nursing Research (Contract No. HHSN2632012-000741, TO#5); National Institute on Aging (Contract No. N01-OD-4-2139, TO#275 and Contract No. HHSN2632012-000741, TO#5); National Society of Genetic Counselors (unnumbered contract); Northrop Grumman Health IT (unnumbered contract); Office of Rare Diseases Research (Contract No. N01-OD-4-2139, TO#275); Pfizer Inc. (unnumbered contract); PhRMA (unnumbered contract); and U.S. Department of Veterans Affairs (Contract No. VA248-P-1528). Any opinions, findings, conclusions, or recommenda- tions expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13:  978-0-309-29453-9 International Standard Book Number-10:  0-309-29453-3 Additional copies of this workshop summary are available for sale from the National A ­ cademies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Improving the efficiency and effective- ness of genomic science translation: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE1 Wylie Burke (Co-Chair2), Professor and Chair, Department of Bioethics and Humanities, University of Washington, Seattle Geoffrey Ginsburg (Co-Chair3), Director, Center for Genomic Medicine, Institute for Genomic Sciences and Policy, Duke University, Durham, NC Sharon Terry (Co-Chair), President and Chief Executive Officer, Genetic Alliance, Washington, DC Muin Khoury, Director, National Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA Thomas Lehner, Director, Office of Genomics Research Coordination, National Institute of Mental Health, Bethesda, MD Robert L. Nussbaum, Chief, Division of Medical Genetics, Department of Medicine and Institute of Human Genetics, University of California, San Francisco, School of Medicine DEREK T. SCHOLES, Chief, Policy and Program Analysis Branch, National Human Genome Research Institute, Bethesda, MD IOM Staff ADAM C. BERGER, Project Director Sean P. david, James C. Puffer, M.D./American Board of Family Medicine Fellow Claire F. Giammaria, Research Associate (until July 2012) TONIA E. DICKERSON, Senior Program Assistant 1  Institute of Medicine planning committees are solely responsible for organizing the work- shop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. 2Until June 2013. 3From June 2013. v

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ROUNDTABLE ON TRANSLATING GENOMIC-BASED RESEARCH FOR HEALTH1 Wylie Burke (Co-Chair2), Professor and Chair, Department of Bioethics and Humanities, University of Washington, Seattle Geoffrey Ginsburg (Co-Chair3), Director, Center for Genomic Medicine, Institute for Genomic Sciences and Policy, Duke University, Durham, NC Sharon Terry (Co-Chair), President and Chief Executive Officer, Genetic Alliance, Washington, DC NAOMI ARONSON, Executive Director, Technology Evaluation Center, Blue Cross and Blue Shield Association, Chicago, IL EUAN ANGUS ASHLEY, Representative of the American Heart Association; Director, Center for Inherited Cardiovascular Disease, Stanford University School of Medicine, Palo Alto, CA PAUL R. BILLINGS, Chief Medical Officer, Life Technologies, Carlsbad, CA BRUCE BLUMBERG, Institutional Director of Graduate Medical Education, Northern California Kaiser Permanente, The Permanente Medical Group, Oakland DENISE E. BONDS, Medical Officer, Division of Prevention and Population Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD JOANN A. BOUGHMAN, Formerly Executive Vice President, American Society of Human Genetics, Bethesda, MD PAMELA BRADLEY, Staff Fellow, Personalized Medicine Staff, Office of In Vitro Diagnostics and Radiological Health, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD PHILIP J. BROOKS, Health Scientist Administrator, Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD ANN CASHION, Acting Scientific Director, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD C. THOMAS CASKEY, Professor, Baylor College of Medicine, Houston, TX SARA COPELAND, Formerly Acting Chief, Genetic Services Branch, Health Resources and Services Administration, Rockville, MD 1  Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. 2Until June 2013. 3From June 2013. vii

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ROBERT B. DARNELL, President and Scientific Director, New York Genome Center; Investigator, Howard Hughes Medical Institute, Heilbrunn Cancer Professor and Senior Physician, Head, Laboratory of Molecular Neuro-Oncology, The Rockefeller University, New York, NY MICHAEL J. DOUGHERTY, Director of Education, American Society of Human Genetics, Bethesda, MD VICTOR DZAU, President and Chief Executive Officer, Duke University Health System; Chancellor for Health Affairs, Duke University, Durham, NC W. GREGORY FEERO, Contributing Editor, Journal of the American Medical Association, Chicago, IL ANDREW N. FREEDMAN, Branch Chief, Clinical and Translational Epidemiology Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD jennifer L. Hall, Representative of the International Society for Cardiovascular Translational Research; Associate Professor of Medicine, University of Minnesota, Minneapolis Richard J. Hodes, Director, National Institute on Aging, Bethesda, MD Sharon Kardia, Professor and Chair of Epidemiology; Director, Public Health Genetics Program; Director, Life Science and Society Program; Co-Director, Center for Public Health and Community Genomics, University of Michigan School of Public Health, Ann Arbor Mohamed Khan, Representative of the American Medical Association; Leader of Radiation Oncology, Vancouver Cancer Centre, BC Cancer Agency, Vancouver, British Columbia, Canada Muin Khoury, Director, National Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA GABRIELA LAVEZZARI, Assistant Vice President, Scientific Affairs, PhRMA, Washington, DC Thomas Lehner, Director, Office of Genomics Research Coordination, National Institute of Mental Health, Bethesda, MD Debra Leonard, Representative of the College of American Pathologists; Professor and Chair of Pathology and Physician Leader of Pathology and Laboratory Medicine at Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington MICHELE A. LLOYD-PURYEAR, Representative of the Office of Rare Diseases Research; Formerly Senior Medical and Scientific Advisor, National Institute of Child Health & Human Development, Bethesda, MD TERI A. MANOLIO, Director, Division of Genomic Medicine, National Human Genome Research Institute, Rockville, MD viii

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ELIZABETH MANSFIELD, Director of the Personalized Medicine Staff, Office of In Vitro Diagnostics and Radiological Health, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD KATHRYN McLAUGHLIN, Program Officer, National Hemophilia Program, Genetic Services Branch, Health Resources and Services Administration, Rockville, MD KELLY McVEARRY, Former Senior Scientific Advisor, Health Solutions, Northrop Grumman Information Systems, Rockville, MD GARRY NEIL, Former Corporate Vice President, Corporate Office of Science and Technology, Johnson & Johnson, New Brunswick, NJ Robert L. Nussbaum, Chief, Division of Medical Genetics, Department of Medicine and Institute of Human Genetics, University of California, San Francisco, School of Medicine Olufunmilayo F. olopade, Walter L. Palmer Distinguished Service Professor of Medicine; Director, Center for Clinical Cancer Genetics; Associate Dean for Global Health, The University of Chicago, IL MICHELLE A. PENNY, Senior Director, Translational Medicine Group, Eli Lilly and Company, Indianapolis, IN AIDAN POWER, Vice President and Head PharmaTx Precision Medicine, Pfizer Inc., Groton, CT VICTORIA M. PRATT, Representative of the Association for Molecular Pathology; Associate Professor of Clinical Medical and Molecular Genetics and Director, Pharmacogenomics Diagnostic Laboratory, Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis ronald przygodzki, Associate Director for Genomic Medicine and Acting Director of Biomedical Laboratory Research and Development, Department of Veterans Affairs, Washington, DC Allen D. Roses, President and Chief Operating Officer, Cabernet, Shiraz and Zinfandel Pharmaceuticals; and Jefferson-Pilot Professor of Neurobiology and Genetics, Professor of Medicine (Neurology); Director, Deane Drug Discovery Institute; Senior Scholar, Fuqua School of Business, R. David Thomas Executive Training Center, Duke University, Durham, NC Kevin A. Schulman, Professor of Medicine and Business Administration; Director, Center for Clinical and Genetic Economics; Associate Director, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC JOAN A. SCOTT, Chief, Genetic Services Branch, Division of Services for Children with Special Health Needs, Maternal and Child Health Bureau, Rockville, MD ix

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SAM SHEKAR, Chief Medical Officer, Health IT Program, Northrop Grumman Information Systems, McLean, VA KATHERINE JOHANSEN TABER, Senior Scientist, Genetics and Molecular Medicine, American Medical Association, Chicago, IL David Veenstra, Professor, Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle Michael S. Watson, Executive Director, American College of Medical Genetics and Genomics, Bethesda, MD Daniel Wattendorf, Deputy Chief, Medical Innovations, Department of the Air Force; Program Manager, Defense Advanced Research Projects Agency/Defense Sciences Office, Arlington, VA Catherine A. Wicklund, Past President, National Society of Genetic Counselors; Director, Graduate Program in Genetic Counseling; Associate Professor, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL JANET K. WILLIAMS, Representative of the American Academy of Nursing; Professor of Nursing, University of Iowa College of Nursing, Iowa City Fellows Sean P. david, James C. Puffer, M.D./American Board of Family Medicine Fellow SAMUEL G. JOHNSON, American Association of Colleges of Pharmacy/ American College of Clinical Pharmacy Anniversary Fellow IOM Staff ADAM C. BERGER, Project Director SARAH H. BEACHY, Associate Program Officer Claire F. Giammaria, Research Associate (until July 2012) TONIA E. DICKERSON, Senior Program Assistant (until January 2014) Board on Health Sciences Policy Staff Andrew M. Pope, Director DONNA RANDALL, Administrative Assistant x

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Reviewers This workshop summary has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and respon- siveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: Atul Butte, Stanford University and Lucile Packard Children’s Hospital Corey Goodman, venBio Partners, LLC Todd Sherer, The Michael J. Fox Foundation for Parkinson’s Research Eric J. Topol, Scripps Translational Science Institute Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Melvin Worth. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional pro- cedures and that all review comments were carefully considered. Responsi­ bility for the final content of this workshop summary rests entirely with the rapporteurs and the institution. xi

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Acknowledgments The support of the sponsors of the Institute of Medicine Roundtable on Translating Genomic-Based Research for Health was crucial to the planning and conduct of the workshop, Improving the Efficiency and Effectiveness of Genomic Science Translation, and the development of the workshop sum- mary. Federal sponsors are the Centers for Disease Control and Prevention; Department of the Air Force; Health Resources and Services Administra- tion; National Cancer Institute; National Heart, Lung, and Blood Institute; National Human Genome Research Institute; National Institute of Mental ­ Health; National Institute of Nursing Research; National Institute on Aging; Office of Rare Diseases Research; and U.S. Department of Veterans Affairs. Nonfederal sponsorship was provided by the American Academy of Nursing; American College of Medical Genetics and Genomics; Ameri- can Heart Association; American Medical Association; American Society of Human Genetics; Association for Molecular Pathology; Blue Cross and Blue Shield Association; College of American Pathologists; Eli Lilly and Company; Genetic Alliance; International Society for Cardiovascular Trans- lational Research; Johnson & Johnson; The Kaiser Permanente Program Offices Community Benefit II at the East Bay Community Foundation; Life Technologies; National Coalition for Health Professional Education in Genetics; National Society of Genetic Counselors; Northrop Grumman Health IT; Pfizer Inc.; and PhRMA. The Roundtable expresses its gratitude to the expert speakers whose presentations helped outline the challenges to, as well as the opportunities for, improving genomic science translation. The Roundtable also thanks xiii

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xiv ACKNOWLEDGMENTS the members of the planning committee for their work in developing an excellent workshop agenda. The project director thanks the project staff, who worked diligently to develop both the workshop and the resulting summary.

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Contents ABBREVIATIONS AND ACRONYMS xix 1 INTRODUCTION 1 Workshop Goals, 2 2 CONNECTING BASIC RESEARCH AND HEALTH CARE NEEDS 5  Improving Translation Efficiency with a Mission-Oriented Mindset: Milestone- and Outcome-Focused Research, 6 Genomics and Personalized Cancer Treatment, 8 Implementing Change for the Future, 10 3 MOVING BASIC SCIENCE FORWARD 13  Discovering New Drugs and Diagnostics from 300 Billion Points of Data, 14 Lessons for Translation from Autism Research, 18 Changing the Research Culture, 20 4 INDUSTRY AND VENTURE CAPITAL 23 The High Cost of Uncertainty for Venture Capital, 24 A Model for Translational Medicine in Genomics, 28 xv

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xvi CONTENTS 5 ROLE OF ADVOCACY IN FACILITATING TRANSLATION OF BASIC SCIENTIFIC RESEARCH 31 Accelerating Translation for Those Who Need It Now, 32 Risk Sharing as a Path to Progress, 34 A Drug Development Ecosystem, 37 6 STRATEGIES FOR CHANGE 39 Aligning Incentives for Change, 39 A Better Model for Industry–Academia Collaboration, 43 Final Words, 44 REFERENCES 45 APPENDIXES A WORKSHOP AGENDA 47 B SPEAKER BIOGRAPHICAL SKETCHES 53 C STATEMENT OF TASK 63 D REGISTERED ATTENDEES 65

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Boxes and Figure BOXES 1-1 Workshop Objectives, 3 6-1 Pathways to Improving Genomic Science Translation, 40 FIGURE 4-1 Health care spending as a percent of GDP by country, 25 xvii

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Abbreviations and Acronyms AGRE Autism Genetic Resource Exchange ASD autism spectrum disorder CNTNAP2 contactin-associated protein-like 2 CRO contract research organization DMD Duchenne muscular dystrophy EMR electronic medical record FDA U.S. Food and Drug Administration GDP gross domestic product HHMI Howard Hughes Medical Institute MJFF The Michael J. Fox Foundation for Parkinson’s Research NIH National Institutes of Health PPMD Parent Project Muscular Dystrophy RADD Review of Approved Drugs for Duchenne xix

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xx ABBREVIATIONS AND ACRONYMS TACT TREAT-NMD Advisory Committee for Therapeutics TREAT-NMD Translational Research in Europe–Assessment and Treatment of Neuromuscular Diseases UCLA University of California, Los Angeles