Tremendous efforts to appreciate the complexity of cancer and the specific threats and vulnerabilities of individual malignant tumors are underway, involving large-scale and high-resolution DNA, RNA and protein characterization. Results of these investigations may shape the kinds of tissue-based analytical tools that anatomic pathology will be called upon to develop and deploy. Increasingly, these often-multiplexed panels of molecular assays prove to be complex, expensive, proprietary, and hard to independently validate. But what if, in addition, these tests turn out to be focused on the trees and in fact are missing the forest? The interaction between cancers (highly mutable in their geno- and phenotypes) and their tissue environment (more stereotyped) has proven to be complex and informative. Recent data from multiple investigators suggest that host factors rather than specific tumor characteristics may determine clinical outcomes. How should these perspectives be reflected in research and clinical practice, particularly with respect to pathology-based tools? Perhaps a new focus on “stromics” is in order.
In addition, much of contemporary tumor profiling is undertaken in the context of current conventional or targeted therapies. What will happen if and when more general cancer treatments (equally applicable to tumors with differing tissue backgrounds and molecular phenotypes) become reality? Such developments may lead to simpler and lower-cost assays with improved impact on prognostic accuracy, treatment selection and outcome.