The Gene Editing Revolution

this evening where we're going to have a very interesting speaker talking to you about very interesting things my friend and colleague dr. Eric Quebec and rather than read through a very extensive CV about him he and I just discussed how I'm simply going to say that he's the director of the gene editing Institute here at Christiana Care he's affiliated faculty College of Health Sciences at the University of Delaware a professor and chairman of chemistry department at Delaware State University in the past and also in the past co-founder and chief scientific officer and board member or of Orpha genex he went to he went to he did go to the Southern Illinois University Edwardsville for an MS in cell biology Rutgers University for BA in biology and where did she do your PhD in Florida alright so anyway my friend Eric that wasn't as bad as I thought it was going to be so I thought that supposed to be short so I begged him to do that anyway so thanks for having me I'm going to give you two short talks tonight and then hopefully we can engage in a good conversation about CRISPR and gene editing we have been at this for a long time and our lab has contributed to some of the CRISPR work directly and indirectly and we are certainly heavily involved in that here at Christiana so the first talk I'm going to give you is really going to be kind of how this all began and how we got here and tell you a little bit about some of the work that had gone on to make us think about our ability to actually edit genes and then in the second part I'm going to talk about some specific things we're doing on the campus here and they go all the way from developing new tools for research working on a cancer diagnostic which has been launched and then tell you about a really complicated and difficult trial for lung cancer that we're we're working on and then at the end tell you a little bit about where we stand with the ethics of gene editing I've been back and forth to Boston in the last couple weeks and we have obviously some very interesting problems since the Chinese apparently have gone ahead and edited a child and now the twins are supposedly prospering although I heard a rumor in Boston that it's all fake so we'll see where we all come out on it so all kinds of wild things so I'm sure Netflix will have a movie or two on there there was a rumor a couple years ago that Jennifer Lopez was going to star in a I think it was for NBC a series called CRISPR and that never came about we're all we're hoping to be in that believe me but so far the phone has not rung so so I'm gonna start um oh great does this can you see the great so this is a very famous picture this is how gene therapy began these are a group of people who are at the National Institute of Health in the mid 70s early 80s and the objective here was to treat an immunodeficiency disease known as a da and the people who are in this picture including Ken Culver Mike Blais and French Anderson are considered to be kind of the founders of genetic medicine and IH started working in this area quite some time ago and their primary goal was to augment the gene deficiency so in fact if you had an inherited disease it was usually because you had a gene or two that were not functioning properly and that's actually the sill is the same story there are a lot of diseases that we face that have a dis fun Jean and there's many reasons why it's dysfunctional and unlike today although I can tell you with dealing with the FDA it's not far differently gene editing than this this was a patient trial of an N of one this young woman Ashanti D'Silva was actually the only patient ever injected with this I think this is her mother here and it kind of worked so she got better for about three months and people hailed this as a real successful demonstration but what had happened to this child is actually a big problem that we still worry about because genes are basically biological material even though they're chemicals there's a chance that they have you can have an immune response to the treatment and she did and so after about three months she developed an immune response and they ceased the treatment now so this is not a morbid story there is actually a number and was actually a number of different treatments for her so she didn't die she just didn't get a lot better but at least there was a boost in that enzyme and and these guys were pretty happy actually ended up training with Mike Blaise myself for a few years and he's a great guy he was really a very very forward-thinking guy he's a pediatrician at NIH and ended up the head of gene therapy so really really good guide they were all very very concerned about this child and then in 1999 the world kind of woke up a little bit about the power of genes well we had known a lot about genes and we understood how they functioned suddenly the human genome was sequenced so we knew every base we can probably put it all together now we know most of the DNA sequence of humans and most other animals the pig who looks pretty happy in that picture is actually one of the earliest mammalian type eukaryotic animals that was were actually sequence and there's a reason for that we can talk about later pigs are very important medical especially with CRISPR there they're going to play a major role that may not be a comforting thought to you but pigs are going to enter into your lives at some point so here's just some some basics and and I pilfered this slide from a colleague of mine because I actually didn't have it which sounds kind of dumb but they're about three billion base pairs of your DNA the average chromosome is 120 million base pairs the average gene is two to three to two thousand two hundred thousand base pairs to strophe and for examples very large CTF R is very large other genes like insulin or tiny three thousand bases or so and within all of that at three billion base pairs if you have a single base wrong in the wrong spot you get a genetic disease so it's it's an astonishing thing now where do these arise from so most human genetic diseases are wrote arose through evolution under what we call selective pressure so sickle-cell disease for example emerged out of the Congo with people who had been infected with malaria and survived because malaria requires the incorporation of parasites into blood cells and those who had sickle-cell actually weren't infected so the rest of the folks passed away and sickle-cell proliferated and it started to grow the same thing is true for cystic fibrosis and dysentery in India so these these mutations actually arise somewhat spontaneously I mean there's lots of ways to argue that but in fact most of them are caused by a single base pair so how do you think about this think about each base being a letter in a spelling of a word and if you have a book and I'll show you an example I think in the next next couple slides about how hard this is if you have a single misspelled word in the Encyclopedia Britannica which maybe some of you probably remember I say that and I'm thinking cheese my kids don't even I don't know the last time they ever mailed a letter actually so so and you have one base pair wrong in there that's about what we're talking about here and so how do you find it and how do you deal with it so why didn't Mike blaze and Culver and French Anderson's gene-therapy work well we just if you have a bad gene would give you a good gene okay and the reason for that was it was really hard to deliver that good gene into your body by injection or by some sort of inhalation the physics of diffusion is that it's hard to get even viruses to penetrate a lot of cells especially in a tissue tissues are not just one cell layer they're packed so that challenge still faces us today and it's one of the biggest challenges that we face in lung cancer over in the Cancer Center important genes are pretty tough to get squinched into a virus that can be then infected into the person and and delivered a lot of times viruses like to integrate what we don't want them to there are a couple of very famous French gene therapy trials where these male babies were had also an immunodeficiency disease and they were placed into a trial where they used the virus to integrate a good copy of the gene and everything went really well I was actually at the meeting in Colorado years ago when the French group presented this and then suddenly three of the children died and the reason was is because the virus infected into a tumor suppressor gene caused the tumor suppressor gene not to suppress any more but the activated tumor and the kids died of leukemia so the danger of where these things go inside your body is still challenging and that has not been solved as of yet and then there's the problem of unregulated gene expression now we know in children and in teenagers unregulated movement and activity is pretty common that is nothing to do with unregulated gene expression but in fact genes are expressed at a certain time in your body the biggest one is is hemoglobin before you were born you're primarily getting your blood delivered by something called fetal globin which is an alpha globin type of molecule when you're born that gets turned off and you get beta globin from a different gene a whole different set of things so when you start to muck around with this stuff back and forward and you tip the balance and change things it makes a big difference and the body does not respond well so these are the real challenges and I mentioned the immune system that had happened with Ashanti still plagues some of the work that was here the most famous problem of this actually was at the University of Pennsylvania in 1999 when a young man named Jesse Gelsinger and this is kind of the you know the major case that cited all the time was treated with the gene therapy vector and he died because his immune response was so great they couldn't get couldn't get the corrective measures to him in time so in 1999 that were a whole series of papers published in the Journal of Clinical Investigation and to tell you how old I am there I am here and at the time this was the entire field most of us were in the witness protection program as they say we we were very few of us actually believing this would ever work and I'm still not sure it's going to work but I think we're closer so we've been at this a long time and even though it doesn't seem like that we there's actually a lot of good science that's gone on for for a number of years so currently at Christiana we have excellent doctors doing this and here we are at the Cancer Center trying to fix a chromosome so when this transition will take place we're not really sure there are clinical trials in humans with CRISPR today and there are three patients cured of sickle-cell disease as of this afternoon so it works it's just a question of what else is it doing and and we'll talk more about that so this is where we are now with excellent care and service and patients get a lot better here but eventually probably in your lifetime it's certainly true in the lifetime the majority of diseases will be treat with genetic tools because then it's a 1 it's 1 or 2 times it's not a constant thing that you've seen this already with car t-cells if any of you have unfortunately had experience with cancer and you're treated with t-cell immuno therapy car t-cell therapy is one time and so far all the patients have been treated Carty are completely cancer-free so is it miraculous yes and that makes us all very nervous because we don't know what else has happened there to be perfectly honest and then as we began to advance along and this is kind of getting into the the time in which a lot of us are dealing with things a lot of the popular press began to pick up on the process of CRISPR and I'm gonna tell you in a while what CRISPR stands for but you won't like it it's complicated and it's very good that it has an excellent acronym it does sound like a part of your refrigerator where your lettuce is kept or a breakfast cereal so either one of the hoses is worth it but CRISPR is a great acronym and it's it actually is represents a series of repeated DNA sequences that some people who were interested in milk fermentation noticed and they decided that that was pretty interesting but it took two women scientists Jennifer Doudna from University of California Berkeley and Emanuel chiffon ta who is now at the Max Planck Institute in Germany to democratize it and transfer it into human cells so CRISPR has been around since the beginning of time because it supplies how bacteria work and we'll talk about that a little later in defending themselves against their own viral infections it just happens to work really well in humans and those two women and fen John from MIT are likely Nobel laureates in the next three to five years should this continue unquestionably we moving along and National Geographic has now begun to pick up on this and the DNA revolution really involves CRISPR that's kind of what they're talking about DNA sequencing is great almost all of you who go get a blood test have a panel of genes looked at have DNA sequence made that's pretty commonplace but that's the technology that is just telling you something about the sequencing it's really gene editing this is gonna transform people's lives in a lot of ways and not always in the in the best ways and again that gets to the ethics and the use of this in society and and we as a group take that very seriously so essentially we are now on the new frontier and I have to tell you Christiana Care is swinging behind us very nicely in this but I think it's because we are rational and logical and very careful and cautious about using this and and reducing this to practice so eventually as I said gene editing is going to become a commonplace tool that already is in genetics there are very few model animals whether they're mice monkeys rats bacterial cells that are not created with CRISPR now everybody switched to it because it's pretty straightforward to do so these are some very cool names and I'm really happy to be in a field that works on mega nucleases that sounds like something that the rock would star in in fact he did star in a movie called rampage that was about CRISPR I don't know how many people saw a rampage with the rock is CRISPR falls out of the sky from a satellite and hits two animals and a wolf has wings and grows and this gorilla gets gigantic so if you go outside and you see one of those things walking around you know where it came from so Megan nucleate zinc finger nucleases talons and CRISPR it's a very warlike field we're we're always fighting these are the four tools that people use and they do one thing they cut DNA very specifically so keep in mind what I told you that your DNA as a series of letters or bases pretty unique women have a more fine-tuned genome men are different my wife reminds me that is no surprise and men have a odd chromosome the Y chromosome there's not much on there and my wife says there's a reason for that so all of this is making since as I grow older with her but in general the sequence of you is fairly unique but there are regions that are kind of common among all of us and so we can design each of these tools these are naturally occurring and partially synthetic tools that we design in the lab routinely to cut DNA in a very specific spot so the world started with mega nucleases they're huge they're ugly difficult to make we move to zinc finger nucleases which are a little smaller than two talents which grab the DNA like talons literally and then CRISPR cast nine and I'm gonna go through these in the second talk in more detail and why it why they're slightly different but I didn't want to just present the tools that are currently available to geneticists and they here's a double double helix of DNA and here's kind of the structures that these tools get on the DNA that CRISPR casts nine complex is absolutely the coolest and that's because it's the simplest so these tools are working great so even with these new tools we still face the problem of delivery so people in this field have chosen to approach some of the early trials and what we call the ex vivo approach which means that we take your stem cells out of your bone marrow we treat them with a genetic tool to fix a disease or to knock out a gene that's causing you trouble and then we put them back in in that way it's more like a bone marrow transplantation or bone marrow effect now I can tell you from experience it ain't that easy it turns out that the progenitor cells and stem cells in your bone marrow don't like to come out of where they are they're pretty comfortable in there it's warm lots of fluid lots of you know it's like watching TV it's just it's lovely in there and here we rip them out we put him out in the dish and we mock him up with a CRISPR or something and we ask them to go back in there it's still a big problem it's really really challenging and then of course trying to deliver this to a specific site inside an organ that's suffering from cancer lung liver pancreas how do you get it only to that Oregon and how do you only to the tumor self of that organ because not the entire organ is not is not in encased in cancer so those are the problems that we face and you might have imagined that from 1999 when I kind of entered this field that somebody might have figured this out but they have not and it tells you the magnitude of the problem because the quality of people who've worked on delivering biomolecules to cells is been pretty good very very bright folks so I want to talk just for a couple minutes about what they actually look like so this circular diagram here really talks about how people package CRISPR cast nine into a ball and then deliver it and we can use viral vectors so these are a bunch of viruses that you get and probably have in your body right now and so add no associated virus what's known as the Lenti virus which is a complex set of viruses and add no virus the viruses are very very evolved and they actually have incredibly beautiful geometry but they're also extremely efficient of infecting you anybody who has just lived through a cold you probably have part of that caused by Rhino virus and adenovirus add no associated virus usually comes along for the ride so these two guys are in your body all the time they don't usually by themselves cause any problems and so they're often used to deliver CRISPR Castine so what happens is the DNA of this virus is extracted the genes for crisper and cassadine are put in there it's sealed back up and away it goes and it goes very efficiently into yourself does it discriminate between cancer and normal cells not yet but that's a big area of work so these other things here which are horrible looking things lipids polymers calcium phosphate all these kind of things I like the DNA nano cludes it's sometimes called ena Nana clock these little ball looking structures these guys actually are used almost exclusively and what I just told you when people take cells out of the body because these things don't require any sort of penetration you can just add them and mix them with the cells and they tend to merge to the self so that's called physical or chemical delivery in this is Cal viral delivery I put this light in here I have a colleague of mine at the University of Minnesota cliff steer who has worked on this for a long time and I think he's more depressed than ever he has not been able to really break this code of how to get this to work really efficiently it might be the long winters up in Minnesota too that he's depressed okay so beyond the fact that people are now sort of oscillating a little bit toward using viruses to deliver CRISPR and genetic engineering tools I wanted to point out a couple of a couple of problems you can ignore the size and the genome size that's not that important for tonight but people are thinking about effectively using adeno-associated virus to deliver to the eye liver and muscle and central nervous system anti virus is mostly for tumors and the ex vivo approach and lentiviruses are very hot right now in t-cell immunotherapy so if you've heard about t-cell therapy and we actually have a project in that too with pen actually that one seems to do well when it's infected with lentivirus immunogenicity is an extremely important part of this adeno-associated virus was thought to be completely immuno genetic deficiency it didn't cause an immune response but now it kind of does aDNA virus was always known to be very immuno genic and Lenti virus is extremely low so you have a whole series of these problems that keep arising making it where they're gonna go in the body immunogenicity but they're the best we have right now and so people are trying to do this improve this all the time but so far it's been it's been a real challenge this is a kind of a picture of what's known as a lipid nanoparticle this is a hot item right now for a lot of folks it's pretty ugly I'm not sure I want that stuck in me somewhere but if you use your imagination a little bit it kind of looks like a virus actually and so we're trying to do build things so there's just lipid it's like fat droplets nanoparticles are tiny little solid beads that DNA likes to wrap around and it's attracted like static electricity it sticks on there and then they're engineered with lipids and amino acids and cholesterol and nucleic acid and they're all kind of packaged and very very sophisticated multi-layer complex and they're delivered into carry CRISPR so anything that's very complex is the readouts pretty complex and so it's kind of hard to to understand how these are going to work but a lot of work is being done here at University of Delaware on these type of projects they have an incredibly good engineering department we kind of feel the virus is the best way to go because of our work in in vivo rather than in in vitro way okay so this is a it looks complex but it but believe me it's not so here I've just illustrated three different genetic engineering tool zinc finger nucleases talons and CRISPR here's a helix of DNA along represented by these two lines all the big hollow Ballou about CRISPR is it breaks the DNA that's all it does it does so really efficiently and very precisely so you can see these little NNN bases and names in here this specific sequence we can engineer in the lab so we can build a CRISPR entirely synthetically in laboratory and tell it where to bind on the double helix in your chromosomes we can send that little payload exactly to that site and it works all the time it always goes there and what it does is it causes a break in the DNA it's job is to break DNA now two things can happen and this happens to you every day when you walk outside your DNA is being broken in your chromosome and the body has evolved this remarkable ability to repair the chromosome it just slams the ends back together again you go to the beach you lay on the beach you have x-rays and UV light that damages your chromosomes that's why we still have a lot more melanoma in the state frankly because of the great beaches nick Petrelli had the Cancer Center always gives a lecture about how great the beaches are then he puts on suntan in front of everybody and he's trying to represent that you go to the beach you can really really damage yourself but we survived that stuff because where the ability is to slam the two things back together again in case for some reason and we don't know why human cells have evolved to do this inaccurately so it's like having these to the DNA broken like this and then for some reason some of the DNA gets resected or lost before something gets slammed back together again and that's a term a fancy term it called non-homologous end joining no idea where it came from but it's there and everybody uses it but if you think about this as the coding region of a gene remember the letters inside a word if we broke in the DNA and then we've lost some of those letters the word is now misspelled or non pronounceable and that we call a genetic knockout so when CRISPR breaks the DNA and the cell receptor sections it generates a dysfunctional gene and because we can engineer CRISPR to go exactly where it's supposed to go the knockout can be achieved and so we can knock genes out I don't think there's a gene that it hasn't been knocked out in humans in all there's only about maybe 3% of your genome is coding for genes and I think every gene has now been knocked out in different animals mice there it's almost all done because CRISPR is so efficient and there's thousands of these things done every day so here's kind of the platform's that we've we've been talking about and again not to really kind of get into any of these in detail but a lot of you see a lot of words on here unknown unknown unknown difficult difficult difficult here's the easy positional work word worries me a lot relatively easy it's always hysterical in science those new remedies or doctors at current science nothing is relatively easy it's usually not moderate difficulty relatively easily so the point is that we're up against something that is real a huge challenge and the tools we have are so new and we're still working with them in such a way but they are so powerful that people are moving ahead very dramatically so we're kind of at a crossroads we incredible tools now we have a responsibility to use them ethically but the potential for what these tools can do to human health is unheard of and an unmatched and so these kind of the things that do we have to deal with kind of on a regular basis it really CRISPR really jumped on the scene in 1987 and that was really when people started to recognize these repeated sequences and bacterial DNA and nobody knew what the hell they were all about well it turned out that the bacterial cell was capturing pieces of viruses and sticking it into its DNA repetitively and that's that's the repetitive part of Chris Berg and so as time has gone on there was sort of some activity and then in 2011 in 2012 that's when the conceptually from a bacterial system nobody knew or cared much about went into human genetic engineering and that was the start of things and from there on in everything has exploded and today there is just an unbelievable number of people doing it we are overwhelmed with requests for us making these tools and handing them over we work with a couple of major pharmaceutical companies that are knocking every gene out and their drug testing schemes to be able to find new drugs particularly for diabetes which is a excuse me a very hot area so we're building tools for them so it's been an explosion but really in the last sort of you know maybe five six years the CRISPR has moved into the clinic and I'll talk a little bit more about the clinical trials going on with CRISPR because they're actually pretty fascinating what are we using it for well we're very interested here in human health at Christiana Care but it's been used actually more aggressively in a lot of other different for other different applications I've talked a little bit tonight about ex vivo in vivo gene therapy ex vivo haemophilia in sickle cell anemia are being treated already in humans they're already clinical trials using CRISPR cure sickle-cell disease in hemophilia and the word from sickle cell is incredibly good the girls are cured there's they have no more in fact a couple of one was on 60 minutes I think not too long ago you might have seen her she's playing basketball she could barely walk in gym now she's playing basketball in vivo Duchene muscular to see HIV is very successfully treated with CRISPR HPV and cystic fibrosis a very aggressive activity in those areas synthetic biology rice wheat sorghum tobacco everything every type of plant has been modified by CRISPR for what reduced pesticide requirements prevent insect insect burdens Monsanto and DuPont Dow if they can grow an acre more of corn it's a huge advantage to them and a lot of times the weeds get between the corn stalks or the soybean and so they've used CRISPR to make those plants resistant to any sort of chemical so they can spray the fields and only the weeds die this is true for roundup but it wasn't quite quite true for crops in general this drug targets and phenotypes we do a lot of work in here inherited diseases cancer so we're heavily involved in cancer and I'll talk a lot about that and this is us lung cancer Ewing sarcoma lymphoma and acute myeloid leukemia of all being treated now openly with cancer so and there's a fair amount of press around this stuff which is good and bad frankly so I prefer not to do that we have people hovering a little bit so well we'll let them know when something good happens so this kind of gets you a little bit into the danger so everything I've talked about so far and everything that is legal in the United States is to treat people adults particular who are suffering from a genetic disease or cancer in what we call a somatic disease way so if you have a tumor in your lung that's called a somatic so that means if I modify that you're not going to pass that on to a progeny the problem is that the same tools can be used in fertilized eggs in sperm they're very effective in sperm knocking male it you know even haploid genomes out and so once you start to move backwards up to the ultimate stem cell that all of us were created by one fertilized egg now you start to get into questions about redesigning children and we'll talk about the Chinese case in here in a little while but nobody thought it was possible until he actually did it supposedly so in terms of that we call that reprogramming which means that we can reprogram genes and cells from your skin it becomes stem cells and that's the technology that's widely available now so if I were to take a skin cell off anyone here it would take us a couple weeks so we could reprogram it into a stem cell then we can edit it and make a copy of you this is twice as tall or spent twice as small or with blue eyes brown hair or whatever so characteristics can be altered and that's what we're finding out everybody used to think that was really hard and that's what I wouldn't do it it turns out unfortunately it's not hard oh there are key genes now and the area that that is becoming more interesting in for people is in pain relief so there are only a couple genes that are involved in pain now and so those are being knocked out this is just kind of a summary of disease modeling and precision therapy you'll hear the word precision medicine a lot in the literature now and it on the popular press so this is all stuff that goes on daily and is legal it's this stuff here that ends up to be illegal in the United States and also to be unethical so we'll get a little bit more into that in the future here are the trials the Deschenes haemophilia x-kid HIV hepatitis B these are all in motion now and as I mentioned the sickle cell anemia trial has actually been taken off this because it's been viewed as a success so these are all underway so when people say when is it going to reach the clinic it's in the clinic now it's a question of the bigger problem is that how do you get it out to the general public where are people going to be treated with it many people in any comfortable having that and will it reach the people who most need it and that's always a challenge in health care delivery we call that here Christiana health care delivering a very cool picture basically says we can do anything with a gene we can insert a replace DNA we can silence a gene so if a gene is out of control making too much of its own product we can knock it off we can activate genes this is actually being done for a sickle cell in a different way it turns out that if you have there are people who have sickle cell disease who don't show any symptoms and that's been puzzling for people for years they the genetic mutation is there and yet they're perfectly fine and the reason they're fine is their embryonic gene known as the fetal globin gene has never stopped making fetal globin so it turns out if you could make enough field globin in patients they'd be cured of sickle-cell disease so there are people in a company called CRISPR therapeutics what else would they be called is doing a major trial in Europe on this exact act and we can modify epigenetic modifications that's how your DNA looks and we can also label genes and find out where they move doing differentiation and when you develop so incredible amounts of CRISPR castes and applications we all want to know about the therapy side but it's the research and development side in which CRISPR has captivated the genetic world and an is used very efficiently so here's some of the challenges and things that that we're facing as I mentioned in most cases if you go into a if you have a certain kind of anemia they will normally take out your bone marrow they'll treat it somehow and put it back in so this is really no different than that except in this case what we're doing is modifying the gene so the gene behaves properly it makes normal hemoglobin as opposed to sickle globin and so that's really already in place the structures of doing bone marrow and transfusion are there so you're just adding this extra step this genetic correction sometimes called gene repair genetic correction gene correction so that's kind of how that whole thing is going and people are able to to do this because this is pretty straightforward so having said it straightforward now we start to enter into the world of is it ethical to do this and I've actually been involved in more panels on this question on on the science and I have a great colleague at Hopkins named Deb Matthews who's really a first-rate ethicist and she's she's really quite good on this she was involved a lot in the early stem cell work and she's actually hard we have she's the ethicist on our team and so she's constantly haranguing me with dumb questions I try to ignore her calls all the time but she won't give up and she's very interested if you listen to fresh air on NPR she's oftentimes on on there she's very very good and she's she's and she's also well balanced she realizes that but we think as being ethical of all us healthy people in this room I hope is unethical for people who are dying of cancer so there are many people who have stage 3 lung cancer who have no option and want to want to continue to live and see their daughter graduate from high school perhaps take a trip with their wife or girlfriend or partner doesn't matter that's the goal the goal here is to help those folks along who are willing to try this and try to avoid children so why is that because children are the most apt to have other mutations occur in this process we'll talk about off site mutations that's what The Economist is really talking about we can recreate this child to make it a better sprinter a great singer 20/20 vision high IQ no baldness maybe no a lower risk of Alzheimer's so MIT is trying a trial is very interesting it's a preventive CRISPR trial so they're actually giving patients who have have a history of Alzheimer's CRISPR to knock genes out in the brain that are more susceptible to developing the plaques or creating the plaques we'll see how that goes there's a big problem with that and and Matthews has talked a lot about this you're actually creating mutations and a normal patient you're not fixing and there's no problem with these people other than you know they there have a propensity to develop Alzheimer's or Parkinson's so there's a question of whether or not you'd actually want to try an experimental medicine to actually prevent yourself from getting into these really horrible long-term disease so incredible questions have arisen these questions have already been here I used to get these in early 2000s but nobody thought it was going to work to be honest it was a great tool we did a lot of I think really good science on how it works we figured out the mechanism but in terms of applications until CRISPR came along people thought this was just really cool science and for science geeks and people like that but not would affect anything everything changed in 2014 because of the efficiency with which CRISPR works that's why you see articles in The Economist talking about in kinetic - and there's actually big money around that so here's how people actually do it and re-engineer children in most cases people will say that if a an OA site or zygote which is basically a fertilized egg in all these cases you can isolate those so an in-vitro fertilization clinic can do this they'll take the egg they'll hold it with a suction tube I don't think I have a picture that it's on one end tube it sucked here and then the needle comes in as it is here and injects CRISPR cast nine so the CRISPR then changes all of the cells in there and the embryo begins to develop now the difference with this is that in every case where where I would treat a patient with cystic fibrosis or muscular dystrophy in the muscle which is already a muscle and can't go on that's the only place at that altered tissue or muscle would stay in this case every cell in your body including your egg or sperm or your germline that you pass on to your children is changed that's the problem so that's what we call germline editing and that's what a lot of publicity gets on because people are playing around with this but it's not funded by the National no application will be will be approved but interestingly it's not illegal so you are not going to be hauled off to jail for editing at jasny this is really hysterical you don't pay your parking tickets for two years they drag you into jail but if you re you know re-edit a human embryo long as you don't get any funding for it it's kind of okay so that's kind of that's kind of the way things are now interestingly in Britain the government is funding germline editing so they are far far down the road and China which has great science is very unregulated and so we don't really know what's happening there as we heard about not too long ago so germline editing is is actually occurring in the world and so our greatest fear about designer children is actually coming true now whether we can really make this work and design the kind of children and we want I don't know but but this is the tool CRISPR can do this and this is why this has arisen so engineering large animals cliff steer also talked to me the other day about a fascinating thing they did in minutes Minnesota so a bunch of geneticists took CRISPR knocked out the genes that give Kyle's horns how many people in this room know cows are born with horns I didn't either you know good I'm glad somebody verified that because I'm always afraid when I say something and it could be total because steer is I think it's funny his name is steer and he's talking about cows but the problem with them is that they can Gore each other and so there's a gene that they've knocked out in these in these cow embryos and they're making herds of cows without horns and it's a huge apparently this is a big economic boon and that's basically re-engineering large animals crop editing we've talked about those are the kind of things that basically people re restructuring food products and stuff like that so what are the real risks there's a lot of controversy in the field now and it swings all the way from moratoriums on gene-editing moratoriums on cancer therapy moratoriums on forward mutations that's the the when we call a forward mutation of something like the Alzheimer's trial where we're prevented we're causing a preventive measure so you don't you don't get it you know sadly we've read you know about I think it was Angelina Jolie who had a double mastectomy because her mother had a breast cancer mutation or so that's a serious preventive measure but that's the kind of thing that people might be willing to do to stop themselves from getting a genetic disease even if they have no signs of it and that's with CRISPR it's not possible to do that kind of thing to CRISPR not to CRISPR ethical debates of arising as I mentioned there are huge conferences all over the world about this and in particular the government is involved in bio safety training we have certain rules we have our laboratories if you any of you would like a tour just you can email me and we have a number of people in the lab that'll take you through there are hoods which are packed into the back of the room where no one has success the doors are closed and so you have to go through a series of doors to get in there not that there's anything that's infectious or anything it's just that the contamination that can come in there with people are is little much so there's lots of biosafety that goes in there on in here so people are being as careful as careful as they can and the US intelligence community it sounds like oxymoron but I guess it's there and I don't know if you remember who Jane well of course remember who James clapper she's in the news every day now so clapper gave this testimony and I think 2016 or so and he called CRISPR a weapon of mass destruction so the US intelligence committee believes that CRISPR could be used in the and a warlike setting how's that possible so they feel it could be dumped into the water system and could modify the bacteria and the algae in there which can then produce all kinds of toxins so that you can enter the United States water system so there are now tasks of most of the aquifer is going on to make sure there isn't CRISPR running around in there inside a bacterial cell so people are taking it pretty seriously who knows I mean it's it sounds sounds good safety is always good you can it's like you know you can't argue against safety it's important so the National Academies of science have focused expressly on this in the last several years and they have put together a series of rules and regulations which govern those of us who work with this panel and these these rules are pretty they're pretty fluid they tend to change a lot and sadly they change in kind of the wrong direction the people who make up these panels are really top-notch scientists and so they think science is really cool so if somebody does something that kind of bored us on the end they they tend not to pull them back they move the goalposts a little bit so there's some concern as to how far is this really going to go and now the ethicists around the country are stepping up this is not a religious question this is just fundamental ethics so dealing with with human cells they're starting to enter into the fray a little more so it's less science more ethics now here are some some basic things and I'm not going to go through them all so the one that's most interesting I think is the germ line heretical gene-editing about five years ago this was not allowed in the United States but last year to everyone's surprise they decided that if you know a child is going to suffer it is unborn child it's going to suffer with a particular genetic disease it is possible under very strict conditions that you would be able to do gene editing on a fertilized egg in the United States it's that's what I taught the goalposts shifted Jessel is kind of subtle and I don't know if this has happened yet but this is definitely a little troubling to a lot of us for sure here's all a somatic cell gene editing regulatory processes are in place clinical trials of therapies prevention of disability evaluate safety these are all standard things if you were to develop a new drug for headaches or something you'd go through these kind of things and and these are actually pretty good as I'm going to tell you about later the FDA is a little confused about how to how to go through this so and that's that's a little trouble there are a lot of reasons here's a great thing enhancement so when I was younger they would certainly been wouldn't have been opposed to any enhancement but you know athletic prowess looking like George Clooney changing the way that you your height your weight your abilities that's completely prohibited so what's prohibited is trying to make LeBron James here but here if you're treating a disease and I can tell you from my years of Science in this area that this is a very slippery slope the only way to not to do this is not to do this there should be no exceptions because as things go forward just slowly things will say well enhancement well not really and then suddenly we have normal children being born with the great skills of LeBron James or any sort of other incredible athletes so stay tuned on this this is a fascinating area that's that's morphing in a direction that a lot of us are uncomfortable with so I've been talking about this and I'm you know some of you may not know what actually happened here so I apologize but over the summer at a con as a conference in in the Far East I believe is either Singapore Hong Kong I'm blanking on where it was a scientist who is an entrepreneur who had no funding for this claim that he had taken twins from a fertilized clinic and knocked out the gene that causes HIV to infect people so it's a great idea by the way and it's actually being done somatically by a company called Sangamo in San Diego and he announced this and the shocking thing was that he nobody knew he was doing this now a number of US scientists actually knew of him he had spent some time in their labs that he went back and he created this and it was so unique and different that the entire scientific community condemned it immediately he was removed from his laboratory and put in isolation and when I understand in China that's not a great place to be for sure but strangely enough the girls I believe their twin girls according to research are doing pretty well and in fact are doing a lot better than normal children so the one Gini knocked out not only made them resistance to HIV forever they're healthier they appear to be smarter the everything seems to be enhanced which is the worst news in the world for people who oppose germline editing so the Chinese government developed now you saw the complexity of the United States rules they were inundated with bad press and the Chinese have excellent science there's no question but the regulations there are a little bit you know loose so even as I mentioned the slippery slope is here again mercy for families in need only for serious disease never vanity all true but the definitions of what that means are kind of lacking okay so this was a stunning piece of technology development and people are still kind of talking about about what it did was it launched the American and European bodies into following this much more tightly so ethical things are on the minds of a lot of people the fact is you can use CRISPR to change unborn children you can at the one or two cell stage which is really amazing and you can supposedly in the great news you could eliminate every genetic disease there is by changing the child before he or she is born so this is amazing okay so this is a this is a survey that I could edit my eyes would be great but this is a survey that the I believe this would be the Pew foundation or I think University of Wisconsin ran now the first question is how much do you agree with the use of a gene editing and children or adult secure threatening disease so I would imagine everybody in here would probably be on the strongly agree side here's the neutral tone oh here's a negative stuff children adults secure debilitating disease that's cancer okay all good embryos to prevent a life-threatening disease embryos there's no change so well some of you may be shocked at this but I just told you the vast majority of Americans agree that genetic manipulation in embryos is okay debilitating and here's the one that has shocked everybody embryos to alter any non disease characteristic this is the what we call the LeBron James syndrome we'd all like to play basketball like if I actually would like to be like LeBron it's a very bright guy look at this it's split 50-50 so this means that half the population United States find it okay to create designer children and that's something that really is is astonishing to a lot of us we don't know we don't know where this is going but it's now become kind of front and center I'm not always sure that people really understand the questions of surveys and the implications and a lot of people like me don't want to answer questions so we run down and they then we say yes or no just to get rid of people so maybe this is something to think about but it is astonishing that people in this country and half of us actually believe that restructuring non this means hair color I things like that if all the genes known we knew all those genes and changed them we could actually be able to gene out at them and about half the population thinks it's okay here's where I went wrong early on this was the 1980s I think right I wasn't born then so I my wife told me about this thing here so things can go very wrong but it certainly is everywhere so I'm gonna stop there and maybe take a few questions and then give you guys a break we're almost on time it's amazing and then when we come back I'll tell you a little bit more details about how we're using CRISPR and a little bit more about how it works so anyway so of any questions yes good yeah so the only challenge with neurodevelopment so far is that it's very hard to have CRISPR into neurons neurons tend to they don't take foreign things up very well other than small pharmaceuticals so incredible amount of work on there for sure and obviously the Alzheimer's Parkinson's advanced stuff people think and they're doing that by injecting it at the base of the brain stem you know it used to be when I was in college people thought nothing could ever cross the blood-brain barrier in fact a couple Nobel Prizes were given for that turns out to be entirely wrong things pass through there all the time and so I think there's a lot of hope now that at some point CRISPR will be able to use but it's still a challenge because neuronal tissue tends to be very refractory to the uptake of things from the outside so fingers crossed so yes yeah yes yeah but there's a better way so the second half I'll tell you the better way I'll give you a hint if they're growing them in pigs so that's not a good I know it's terrible you know I know people who are two-legged pigs but you know now we're gonna get them for no absolutely true so theoretically you can take a skin cell and de-differentiate it all the way back to the primordial cell now the primordial cell is a matter of great contention now nobody wants to admit they have it or not but they can get it to a point where if you now add a magic cocktail of hormones you can differentiate into lung tissue and to pancreas and you can rebuild organs that way absolutely the faster way to do it is to engineer a pig so it so a human doesn't reject it doesn't reject the organ and so that's tends to be where people are headed but you could absolutely do that mice mice have created all the time that way yes no I'm sorry I was unclear if you take it your skin cell and put it back in the body will not reject it but if you take an organ from a pig but the reason if biggest Chozen is this is not a comforting thought pig organs are about the same size as ours and so the spatial arrangement of your body you can't put an organ that's this big like from a rabbit or something in it even though it might work better you have to your body or you know you'll kind of sink in and stuff like that so the pig organ is chosen now the problem with the pig Oregon is a it would be rejected as as you said by human but pigs bring along with them a lot of viruses and so CRISPR is being used to generate pigs that are borne by the fertilized egg and they know what the virus is so they knock all 40 viruses out one at a time and then they breed these pigs and they grow and it's almost done there are others a herd of pigs is that a herd of pigs or a pot of pigs or a group of pigs I gotta be careful in these days and so they are available now and the first transplants should be in the next couple years probably this year so it's harvesting organs that way because actually it was done primarily because of the orc the lack of human organ donors and so this is solving solving that problem but the advantage of CRISPR is it's able to reduce all of the rejection and the viruses very efficiently which hadn't been possible in the past so it's a good question yes the virus can't distinguish between healthy cells by cancer or normal yeah so we're wearing we're very in soap adenovirus at AAV it's complex it has a series of serotypes which means that people in this room probably have up to 12 different kinds of Av because it's evolved based on the person it affects we call that serotype there are some serotypes which appear to be able to sort of tell between a normal tumors a tumor cell and a normal cell by the number of receptors that are on the cell surface so it's really not a clever way to do it it's like a mass action thing there's more here than there so it has a better chance of getting in getting in there we found out I'm gonna talk about lung cancer and what we're doing with that and a young graduate student I think she's 22 years old may have solved this problem and she showed it to me she's one of my grad she showed it to me in a matter-of-fact way with a piece of paper he said I think if we do this it'll work and I'll be damned if so far is work so I'll tell you about that in the second half so a lot of this stuff you might think is really smart but it really isn't it's just there's a lot more in this bucket and then in here and guess what there's more of this crap here that's where it's gonna go so that's the only way to sort of do it that I know of yeah yes we hope so we hope so yes there is I think the you know that's you see it in the grocery stores all the time Europe is very sensitive to this some countries won't allow the sale of those kinds of things we don't know of anything that's really caused a negative I tend to be neutral on this stuff I feel that's a personal decision so far there hasn't been any disease related to genetically modified food or organisms but we just don't know the rules but there is definitely a fair bit of pushback on that yeah yeah yes yeah Candice Nevin asked me that question all the time she's a CEO here she was in our lab on Friday and asked me that question we don't know the only the only guidance I can give is that the car to sell therapy which is currently being offered is half a million dollars a shot now that sounds terrible and of course it is and nobody's paying for it yeah but it's cancer treatment one time so if you take your cancer treatments over ten to twenty years it's a lot more than half a million dollars insurance companies are kind of coming around to it I've heard Aetna might start funding this so what's happened is Novartis has the treatment they're the main kartik therapy so we have them over and that we treat over the Cancer Center that I don't do it but very talented doctors do it over there and of artists is currently paying for it from what I understand it's almost completely perfect everyone who takes it is security so the question is who's gonna pay for it and will the costs go down Novartis did a funny thing and what's not funny it was ironic they came out with it and they priced at it seven or fifty thousand dollars and people just fell off the thing and I said okay okay half a million I thought you know what we want is ten thousand dollars you know so you just asked a question and hast those are asking for every kind of genetic medicine this is really cool science but when you transfer it into practical use it's very expensive I don't think there's anything else that's really going to be used for it the the edge of your question which is very good is in fact that making enough of this stuff so pharmaceuticals are basically a chemical reaction very effective drug companies are gonna make chemicals you know you see these these billions sell of pills coming out but this is a really a biological material because it involves a protein called cast 9 and how do you make enough of that and we don't know that yet so that's that's another barrier it's called scale up how do we scale up enough so we can actually make that I think CRISPR will probably go into practice in small numbers for about a year or two and then hopefully an insurance company will begin to pick up because the attraction is that you're not going to have to treat this patient or that patient score more remember as patients age with the genetic disease they get many more problems so you're not just treated for that genetic disease you're treated for punk sickle cell patients have a terrible time they're in constant pain it's a terrible disease it's an orphan disease only about 50,000 people the United States have it yet it's incredibly famous they have fungal infections viral infections so physicians have to treat those first as opposed to just going after the base treatment so stay tuned on that when that's that occu days a couple floors if you go down this building go up to the eighth floor there are people who spend all day thinking about that question so I keep trying to hurry it up you know and they're not thinking hard enough but it's it's a gray it's a problem for short I mean health care delivery in the country is changing very dramatic crystianna's really very progressive Janis Nevin is fabulous not just because she's my boss I'm being recording this Megan okay so dr. Navin is the finest now she really is she's actually very progressive and she's willing to listen to new things and she's moving Christiana care very forward which with better health care and patient focus but it's going to change yes like millions of dollars in real estate and then collapse oh yeah I have nothing and you've said it as good as I could the pharmaceutical companies have struggled with genetic medicine for a long time for a couple of reasons one they like this acute you to keep buying the pill so if you are cured with something you're not going to buy the pill anymore that's when of artists doing this was quite a shock to everybody I think they see the end of their patents coming on certain drugs generic drug our yard falling they're going off patent whatever you think of the Trump administration the right to try rule is fabulous that's new that's going to allow a lot of this kind of stuff to move forward that's the FDA's approve that the bad news for us and for you and me is that the FDA Commissioner who was fabulous and wanted to drive prices down and doing it just quit and we don't know why he's got that inevitable thing he wants spend more time with his family and in Connecticut so I just he's a young guy and he's great he's a huge fan of gene editing so hopefully that will continue they do invest in research a lot and they are actually investing in CRISPR so we'll see but their motives are unclear because they have purchased a lot of good technologies in the past and buried them meaning they buy them and license them and patent them they buy the patents and then they don't develop them and they prevent anyone else from developing them so it is a business and they you know they're great great commercials though I like them I like the ones that are looking up at the ceiling and pulling the string down those are those are great but again you know the the researchers in there are very very good and they they love science they do great science the business does crowded in a little bit and they do have to answer to shareholders so we actually see that a little bit in the CRISPR field to a lot of people that started biotechnology companies and a lot of times when they come to me as they can't talk about their latest data because they don't want to breach a patent or something like that so it can get a little challenging at times yep an age-old question none we're ever gonna get there but good to a OC maybe in ten years or five years we'll be there so okay well maybe you can take a five minute break and then hopefully you'll all come back because I think he'll get better I promise in the second half okay it's the second half now so looks like we actually have most people came back that's great so in in this in this section I'm gonna talk a little bit about the things that we're doing here and give you a little bit more insight into what it actually is and requires to edit a gene so this will be a little sort of not so vague but more specific this is a sampling of major popular magazines that have focused on CRISPR and the list continues to grow on a on a regular basis so it's not uncommon to see it published everywhere so the gene editing Institute is actually an independent department in the cancer center and and we do have to focus not only on technology development but also on patients the Christiana Care is very very forceful in thinking about the patient first in science is always a tendency to think about technology but here that I can tell you that isn't the case and we do not enter into a clinical trial or even a clinical research project without thinking about how we're going to deliver it that actually is not really a commercial but it actually makes Christiana care a little bit different than most places so so that's a good thing so we began the gene editing Institute with four missions the first was to focus on technology research and technology development translational research we have a fair bit of funding from the National Institutes of Health National Science Foundation we also have a mission to educate college students high school students community college students in in gene editing and so we've actually developed a curriculum that we are launching with our partners across the street Dell tech this fall and sending it out to four-year and two-year schools and even some high schools to be able to them to the laboratory exercise there are we hold workshops for people from around the country there's one tomorrow at Deltek excuse me with instructors coming from around the country to learn how to do this this is our tool making group we're actually a core facility and we make gene editing tools CRISPR for other researchers around the country and it actually turns out to be important that you actually develop some revenue and so for that that tool making we actually commercialize some of those things so these are the four and this is these are all the partners that we're currently involved in change this one down here we're going to talk a little bit about this one in the end because as I tried to convince you in the first hour this area what we call CRISPR gene editing 360 is a is a wide spanning circular look at the public policies legal issues community outreach and obviously the ethical implications so we are concerned about this it's not just about the science here at Christiana I'm going to tell you a lot about our lung cancer work we've launched a cancer diagnostic here's the education thing and these are the projects that we actually are working on right now and actively in the lab we've had a long term project in sickle cell disease this has not been as effective as we thought in our hands but but I'm glad to see other people are having it move a lot quicker but we are having some success in lung cancer which which is moving along pretty well so I've been using this term forever and what does it actually mean so you don't really have to learn many of the details about this but think about gene editing as if it were a word program and you can either cut paste or change a word or a letter and that's basically what we're doing with jeans jeans so jeans are a word the basis are the letters and so by cutting something you are basically removing a gene and paste sorry cutting a word in changing a letter pasting a letter and they're changing it and gene editing we use christopher to delete bases or genes insert genes and replace genes and all of these things are possible these guys right here the leptin gene is a gene that's involved in appetite so CRISPR has knocked that gene out and this here he is he's pretty happy he's a little larger than his litter mate but he actually lives as long this is very disappointing to the people who are interested in that here are some green fluorescent mice these are called nude mice they don't have any coat that's just their skin this is the same letter and half of them have had a Arctic fish green fluorescent protein gene included in them and if things don't work out I'll be selling these at the Christian amol later tonight and then here is a colleague of mine here in Nebraska dr. guru-murthy who's very very good at CRISPR actually was able to tag a green fluorescent protein gene on to a rhodopsin gene and knocked it into this Mouse it's only expressed in his eyes and you turn the lights off and this is probably the scariest thing I've ever seen in my life and he can see perfectly well so it's really quite amazing you know like cat's eyes and the darkness is it's different so these are much more expensive at the mall than these guys here so I often get asked why hasn't this happen before why haven't you been able to do something so here's here's the real problem imagine a book with a thousand pages each page contains 1000 words now imagine 3,000 of these books all those words represent all the genetic information in the animal body gene targeting allows scientists to pinpoint one word on page 91 and volume 1349 that's how big the challenge is and CRISPR can find that one word on page 91 and volume 1,300 49 so that's the problem and the challenge that we fed and until we had a series of these remarkable tools most notably CRISPR we couldn't find that word as efficiently as we can now so that's what everyone was up against here's our friends again zinc finger nucleases challenge and CRISPR now I'm going to show you the next couple slides why people use CRISPR but you can probably figure out from this picture this is these are zinc fingers they're actually two pieces they're two proteins this is a it looks like a cord of cable here is talon and here's CRISPR IP a single string and a big blob it's just easier to make and it works better these we we've spent a lot of time working with talons as well in our lab we still do them they're complicated they work pretty well they're just hard to make now this is a complete lie I do not believe I do not know if this is the evolution of the Swiss Army knife but I was able to kind of piece together a series of edges that go from a blunt instrument all the way up to the very complex was army knife here and we think about this as the evolution of gene editing in 1999 and before we were working in here and we've actually progressed a long work of you know some of my competitors think I still work down here which is which is okay I think they work down there too so it's equal but but inevitably this this kind of advancement really happened over five years and that's when a tool comes along that's a breakthrough technology like CRISPR it changes the entire field and that certainly has so I mentioned earlier was a great question over here what else will they have will you have to do and here's the answer so if someone comes into a clinical trial or we're going to use this patients we're going to need to design it correctly we're going to have to build it the speed at which we build it counts and can we scale it up you can get a lot of stuff to work in mice but in rats now there are plenty of two-legged rats to walking around but they tend to be bigger than the four-legged ones and so it's hard to scale everything up everything works in mice because Nick Petrelli says cancer has been cured in mice for 35 years the problem is you can't make enough of the of the vehicle or the tool to make it work in humans so in terms of designing a zinc fingers that complex talents are less complex and even I can draw this as a CRISPR building them pretty complex complex and even I could probably build that with some help speed six months to build a zinc finger nucleus one takes about a week to two weeks if you're good at it we do these in two hours so we can build a crisper and have it in it we can build a crisp it order it from a house in Iowa that actually does the chemistry we have it overnight we'll start the experiment the next morning and scalability is readily possible with CRISPR very difficult and only possible with talents so if someone here asked me kind of just a translation of this and while science is very exciting and good you have to think about does it end adjust good science and innovation of discovery or is it translatable everybody likes to talk about their in translational research but most people aren't really because they have to worry about this stuff here this kills a lot of really good science that is for knowledge sake and it helps in other things but in terms of getting into the patient these are the four things that we have to think about very carefully so here's an actual picture of the CRISPR here's little gold man carrying scissors this was photographed yesterday afternoon we caught him walking down the street so CRISPR takes to two parts it's in it and again I you know I know it's it's sometimes hard to relate to this but it really is simple it is a protein called cast 9 that is a molecular scissors that cuts DNA right like that it snaps it right in half and all it was waiting for was a CRISPR which is a piece of nucleic acid called RNA and that carries those guys marches along the chromosome literally attracted rolls along the chromosome until it finds that one site and it cuts the DNA at that site that's what's a miracle this happens in about 0.2 nanoseconds once that once it gets into the cell so it's diffusion controlled if those guys have spent some time in the industry know that that's about as fast as it goes so pretty amazing so where'd it come from so as I mentioned to you before it actually came from scientists studying the fermentation of milk and they noticed that this was happening so this is a bacterial cell itself and it is inundated with viral infections doesn't seem like you know bacteria would care about viruses but they get infected to become bacteria phages it's a it's a Greek or Latin word that that stands basically represents viruses so this little satellite like creature is a virus and it sits down on the bacterial cell and it injects its DNA and so the cell bacterial cell protects itself by chopping up the DNA as fast as it can now we used to think and when I was in graduate school that this DNA was just somehow spit out by the cell into the medium but it turns out that's not what happens it actually takes pete the bacterial cell takes pieces of DNA and sticks it in it's one chromosome bacterial have one chromosome and it arranges it in a way so that the next time that the virus infects here in Step five same virus that makes CRISPR so a little piece of RNA comes off the cast proteins sitting in there it makes this ugly little thing that looks like a little marshmallow and it goes flying up and it cuts the DNA very specifically why did what do we call this bacterial immunity it's the same thing you get infected with a virus you develop an antibody next time you get infected the antibody sole point of vaccination bacterial cells have been doing this forever but instead of an antibody they use CRISPR casts the nine number nine is one type excuse me of Casper and is the most common one but it's called crisper cast so that's where it's all come from and people had known about this reaction for a very long time but it took until about 9th at 2012 when people started to say I wonder if this guy right here the crisper cast molecule can actually go and edit human DNA and obviously the answer is yes okay so in essence what's happened here is that Jennifer Doudna and Emanuel chiffon ta both very good scientists decided to repurpose the bacterial gene of the bacterial vaccine and immunity and we've done this many times in our lives and repurposing is inventing a develop for one purpose but is later modified to be useful for another purpose does anyone know what Coke was originally intended to do so it was an alternative to morphine addiction and treat headaches and anxiety now we think it causes headaches and as I especially the price actually right what about Listerine this one is not good here's a cure for gonorrhea so next time you buy a bottle Listerine go a little slower and the most famous drug every purpose for anything was of course viagra which was originally designed to react reduce heart ailments and men and it actually was in a clinical trial in China and the Chinese nurses noticed something very unusual about people on this trial so yeah so anyway there's too many bad jokes and it's too late so I'm going to leave it there right so this is a three dimensional picture of CRISPR and the cast nine protein is this big blue blob and those of you who are old enough we'll make it look like a pacman which is about my level of gamesmanship still and right in here along this this is the little pink sequence with the pegs that's the the RNA that's going to grab on to the I'm gonna go back here and hold it so if you look down the left here this is the DNA would come in at an angle in a helix and what's happened is that the CRISPR RNA now binds on to this and grabs it in place and then this little thing right here where you see it elevated that's the shark's tooth and it goes on and cuts the DNA right there it's a magnificent machine it is could not be designed better it's it's stunning and it's in a simplicity and elegance from up from a spent crystallize it's been studied probably every amino acid encoded by a gene had been modified in here to make it work more it's a really beautiful diagram here's what it does it cuts DNA now remember I told you that when CRISPR cuts the double-stranded DNA basically here's an example of what I meant by resection here's the DNA being cut and those things are removed just by being broken and we may and you can make a deletion in there now let's say that you wanted to repair a mutation you'd cut the DNA again and then you add some excess DNA that had the corrected gene in it and through some magical stuff it would actually put itself into the gene corrected and so this kind of a thing here is extremely difficult we work on this problem all the time but all CRISPR does and this is a really this is what kind of shocks most people adhere this it just breaks DNA very specifically it does nothing else it doesn't remove DNA it breaks the DNA it sits there for a while and it goes away the cell does everything else okay so when we started thinking about lung cancer we started to form a team here and we've now evolved this much known as precision population health and I want to kind of talk now for a few slides about our approach to lung cancer so I'd like to tell you that CRISPR and the way we're going to treat cancer patients here is the solution to lung cancer but it's not stop smoking that's the solution to most lung cancer not all a lot of people get initiated to MERS so you cannot have a lung cancer program without having experts in smoking cessation there are all kinds of wild things going on there are people who have quit smoking who are who buy this app that goes on their watch and the app will go off if they enter a place that sells tobacco so if you're walking down the street and the and there's a convenience store that sells tobacco just to prevent you from being drawn to buy cigarettes it'll stop it'll it'll ping you here so incredibly wild stuff but that's really where you've got to stop the problem we we are very anxious and hopeful and stuff like that but frankly in any sort of population health program it really has to begin by behavior changes in lung cancer it's a terrible terrible disease but we think by combining population health that way and then using some some pretty sexy state-of-the-art kind of therapies we should be able to make a dent in lung cancer it's the number one killer in the state of Delaware by far it's a number one killer nationally there are more people killed by lung cancer than breast prostate and most other kind of solid tumors combined and yet there's very little treatment for lung cancer we do know that smoking definitely activates it and moves it forward very quickly so there is some help if you simply and you can do that at any time people have smoked for many years my father smoked after the war World War two for many years and then one day stopped and I was at he he died in 93 years old so he and he never had any lung cancer obviously that's some genetics so it can work I mean really can it can it can work if you if you change your behavior now here's the problem it's been around a long time and [Applause] I'm not sure I actually got this from a psychologist here in the upstairs named Scott Siegel who's very smart and when he showed this I thought this makes a lot of sense because the whole thing was to get covered up with ash and it's definitely from cigarettes so and there they are that's a rare photo is actually Gary Larson was the photographer and he was there and he took this picture so this is just challenged this is what we're up against just so you know this has been around for multiple millions of years so so here's our approach I don't think CRISPR is going to work by itself in just about any form of cancer and the reason that is is that cancer cell changes continuously it's called a forward mutator phenotype people have known this for years so as a cancer cell grows in your body it divides quickly and because it's dividing abnormally quickly the DNA replication machine at replicating ramose ohms makes mistakes and because it's forced to divide it leaves the mistakes behind in normal tissue it doesn't divide as fast kind of checks and as his balancing act so what we felt was when we started thinking about lung cancer especially after the medical director of cancer center said I want you to work on lung cancer we immediately thought we'd work on lung cancer we engaged oncologists from around the the cancer center and the first line of defense although it's changing a little bit and and I get pushback all the time on this but the majority of people who have lung cancer who present with lung cancer are treated with chemotherapy right away normally it's this platen carboplatin and these are drugs that were approved in 1976 and yet there's still the first line of defense they work they're just really hard to take so what we felt was that we might be able to help augment that that therapy by reducing the amount of tumor burden or chemotherapy patient has to take so the idea is pretty simple that we knock out a gene known as nrf2 and I'll show you that gene in a second that's the gene that's responsible for chemo resistance I don't know how many of you have friends I hope none hope no one has a friend like this who has long cancer or god forbid you've had it but what happens is that you're treated with chemotherapy for about two weeks on heavy dosages and you come back and you feel you know you're out it looks good then it comes back and it's it's you know a lung cancer is the worst because the tumor is growing in a perfect place oxygen nutrients blood flow it couldn't be a worse place to have a tumor and so what happens is that the the nrf2 gene is normally there to protect you from stressful conditions and it thinks that chemotherapy is pretty stressful so it stops the tumor cell from taking in chemotherapy so we have to knock that gene out so that now that the chemotherapy flows back into the tumor cells and that's basically the approach it's an augmentative therapy to help chemotherapy work better and it sounds like low-hanging fruit but it's about the only way that we can see to really get into this into this problem now here the team that I was currently working on it this is Pavel he is probably one of the top Christopher guys in the country he leads our design team and it's the only time I have ever seen him with a tie and I have to tell you I'm looking more it looks like it's photoshopped in here by one of his friends he does not dress like this at all if he has a t-shirt on I consider that to be a victory every day Greg masters is the head of the oncology program in lung cancer and really one of the top docs in the country in lung cancer he's supported very heavily by NCI Mike Jamil and HN Wong is a health economist experts actually works mostly on Wall Street now but she comes down two days a month to help us on this and Pat Swanson is the nurse navigator so a Pat is been terrific in helping us get going and Gerry Castellano is very funny he's the head of the internal review board so this is the group that reviews to whether to go into patients or not the look on Jerry's face is not when I told him what we were going to do even though he he kind of looks that way every tell him I'm gonna come with you to a protocol and I'm not sure what he's thinking there but it doesn't look like it's very positive why an RF to sew nrf2 is a very interesting gene and all you need to know is it's involved in cryo protection and detoxification defense system so it acted the miniature on chemotherapy this drip this gene kicks on to protect you against the bad side of chemotherapy the problem is is that you want the bad side of chemotherapy to kill the tumor cell so the ideas that we knock this guy out and now the chemotherapy will be more more efficient and and work better that's the hypothesis it's pretty straightforward and in every project in our lab with particularly with gene editing there is always hypothesis made and this is the type of science it really needs to be done in this call hypothesis-driven research make up offices and you spend the rest of your life trying to disprove it just for no other reason I stuck in it in case you guys have not seen what a real gene looks like this is the sequence of part of the nrf2 gene and these are all little types of proteins that are made from it so huge challenge undoubtedly and this gene is quite long you're only looking at that spot right there here's the whole gene and you're looking at the sequence right there so complicated gene and big now someone asked about at me up here asked me about how long just is the gene stay in there I was gonna try to turn these lights off but I don't know if anyone is back there anymore if not so let me tell you what we're doing here so Kelly Munoz who is a graduate student in the lab in University of Delaware was asking a very simple question if we introduced CRISPR into a lung tumor cell how long does it take to get in and how long does it stay inside the cell it seems like a pretty stupid question but it's the FDA has asked to see this information because they want to know what they're kind of dealing with so is that possible just for a couple minutes or a minute so what Kelly did was she did this is the murmur the design of the CRISPR but she put a fluorescent tag a group piece of green fluorescence on the protein and she put a red tag it was not a long Christmas but this actually works this way on the RNA the little gold man instead of gold it's red and that she introduced it into the cell and she took time points staying up most of the night all the way through and and looked at these lung cancer cells and we're CRISPR is inside the cell and here's what she found so if you just look over here the green is the protein and the RNA is the is the red so within an hour the protein sits on the outside of the nucleus Blue is nucleus is a nuclear staining and you can see that the CRISPR RNA is in then something is like the dark side of the moon here the green and the red seem to be in the nucleus together and then at eight hours things start to be moving out and by 12 hours Christopher's done its job and it's moved completely out of the cell and at 24 and 48 hours it's exiting so we've now believed the gene editing takes place in a cancer cell between one and four hours and then what we didn't know is that the CRISPR and the cast nine do not dissolve they come out of the nucleus and head off into the cell somewhere this is the cytoplasm of the cell and here's the nucleus so very cool data this is a second year graduate student in kelly vanassa and the pictures are very very exciting so we have an answer to how long Christopher is actually working okay I'm afraid you'll fall asleep so here's a picture what the protein looks like so proteins are made up of different domains they're just kind of you know some bye and some disrupt so this is a domain that Kelly knocked out it's called the nuclear entry signal inside the protein that controls chemo resistance so she knocked that gene out and then she looked at again the nucleus so here's what happens in normal cells everything is the nrf2 s in the gene when we knock it out the gene stays outside in this case you're looking at red to represent the protein the nrfu protein so again another question from the FDA was show us that the CRISPR actually changes the function of the protein and this is how we do it you can see it on the outside here here it's blended in here okay so again these are the kind of experiments that are ongoing to kind of convince convince you that we understand how CRISPR is working in a tumor cell this is a nude Mouse it's nude for obvious reasons it actually does have an immune system so what we did here was asked whether CRISPR could attack lung cancer cells so the lung cancer cells human lung cancer cells are injected into the back of the mouse and then CRISPR is introduced into the tail vein hanging right here the tail that CRISPR is in here and the CRISPR is so designed to only knock out the tumor in that particular location inside the mouse this is called the xenograph model i didn't bring much data this is the only slide this is how fast a tumor grows it at minus 13 days up to 14 days so this is the growth of a tumor in about 3 to 4 weeks 600 volume in your lung and in a month that's why when people walk in the door they're at stage three the tumor grows very quickly if we knock the nrf2 gene out we arrest the growth pretty well but if we then treat with chemotherapy plus the knockout we've completely arrests the tumor growth for two weeks so this is very exciting people are really excited about it but it's only two weeks in mice you might be wondering why didn't we let this go further the animal regulations are treating mice we have to stop the stop the experiment when the tumor gets to this side this is a pretty big tumor in the back of that Mouse so evidence looks pretty good I think we have a good opportunity here and and the data is starting to look forward so these are the two people that have joined us the Enlai is a FDA expert he's the one that will argue the case for us with the FDA and Lawrence of insky is actually a global regulatory writer she's extremely good and has worked on some very impressive portfolios why are they here they're here because we don't know how to do this anymore we have brought the the technology to a point where now regular regulatory affairs start to kick in and so these guys come in and they help right the clinical protocol and develop something known as a briefing package for the FDA we also have a project in melanoma in this case it's a little bit easier in the sense that we're reorganizing and re-engineering t-cells from a patient so if you have a a tumor a skin tumor and it's extracted you can take the tumor out and drop it on a plate and the t-cells come scrambling out just remove the tumor and you've got all the t-cells that when they're fighting the tumor the problem is that the tumor tells your your t-cells your immune cells to stop killing itself and so we've reengineering and continue to fight against the tumor that's this that's the project in melanoma as I mentioned in sickle cell disease it's a little bit different people who have sickle cell disease the idea is that you want to change a single base people have sickle cell disease have that letter or that base in this word the beta-globin word or the beta globin gene I hope everyone in this room has an a at that position people have a single T change so Bret Sainsbury who is a third-year student in the lab she's gone on to do something else but when she was a first-year student she actually converted made this change pretty readily the problem that Brett found with this was that in every single patient we had a different degree of change this is the percent change that has happened in patients here's a female african-american only 1% it's only 1% of her stem cells were changed another patient didn't work a Caucasian male 33 years old no smoking had some activity higher activity interestingly the 35 year old male Caucasian who smoked had the best level of gene editing I know what you're thinking somehow with me its lung cancer and sickle cell are connected so if you want to get a good treatment you have to smoke a pack of Marlboros before you come into the clinic that'll make the trailer very happy I can tell you so the point about all of this and it's pretty self-evident these are all different patient samples here's two of the same patient that's been done and in in this case it was done one week and then another week with these samples and we get answers all over the place okay so this address is one of the bigger problems that we're facing CRISPR works very efficiently the problem is it works very efficiently differently in different patients and until we have a capture of that fixing genetic diseases is going to be a big challenge with the lung cancer stuff we're disabling a gene and destroying it that's that's pretty straight for that's what CRISPR does normally we don't see that much variance but fixing a gene is much harder and the reason for this is you are all different as we talked about earlier it's in the first they talked about genetic diversity we talk a lot about genetic diversity in patients and how we want to treat individual patients but this is where it counts the most because while we'd like to treat all African Americans with sickle cell disease or Caucasians with cystic fibrosis the variants that we're seeing among patients is quite dramatic this is an amazing outcome the fact that you can fix this gene and people is one thing but we can't rely on the effectiveness for a patient and that's a big problem the other mission that I wanted to just point out is that we have transferred this gene editing curriculum to community college students this is Kristin pasar cheek who works in our lab she's a funded by the National Science Foundation and she's working with community college students across the street and not too long ago dr. Janice Nevin who is our CEO visited and she tried to break into this group I'm not sure they let her in there but she she's actually been very very supportive of this this is going on as I said across the street and will be launched nationally so that would be very cool we're also partnering with the Franklin Institute I've done a couple of community forums up there pretty packed houses on this topic as you might imagine with very varying degrees of interest and opinions and so the Franklin Institute is launching a program called editing our evolution and so let's check their websites it's a great place there'll be a lot of different speakers a lot of different topics and and they're kind of talking about this openly and this is more on the should we do this how should we do this and about the genetic diversity that we brought to the table and as I mentioned we've had a whole series of discussions and if you follow the the Christiana website we're going to do this again here's Deb Matthews down here she looks really smart you know I always tell her she looks she looks smart there and I'm as my wife said you're not on fresh air so okay you know but essentially this is a topic that will we're going to have a group of people come in to talk about it somebody asked also you get some really good questions and one of the questions was who's gonna pay for this so this is Ed pizzelle at Mozilla used to be the vice president and a vice chief executive officer of Aetna and he retired and asked and I heard him talk in Washington so inviting him to come up and I said Ed you look like you're about 45 years old he said I'm 47 and I said well why would you need Aetna he said well I left at nough because they could get more money consulting to Aetna than being at CEO with less pain so he's at least he's truthful okay Edie and Deb were fascinating they talked a lot about how insurance companies look at these kind of innovative therapies pizzelles the guy who is developing the program for Edna to cover car t-cells and he's a very engaging worm great speaker very very fascinating Bob Oaks who is a lawyer talked about the intellectual properties issues and patents that surround CRISPR we are not able to use CRISPR freely which means because we while we owned several patents on CRISPR we don't own what's called the master family that's owned by mass uses technology and by california-berkeley we have to license that technology in a Christian and we have done that the war is among who owns parts of CRISPR our store extraordinary and they're they're very very expensive so these topics it's about half the day it's about three or four hours but I can't encourage you enough if you're interested in this topic to keep this will be happening in the fall and and I learned so much there I probably just be the moderator this year and get out of the way and let these other people talk it was really enjoyable we're actually going to be reunited some degree at bio 2019 bio 2000 is about a twenty thousand person meeting at that's Philadelphia Convention Center and I put this slide in here for you to read the title only you know these criminals in here but can genome editing fulfill that's what people are interested in and not necessary and the science is cool and interesting but will it actually fulfill the promise this should be a very lively show Gregorio here Giorgio is actually a very very interesting guy the kind of people to deal with Chris Berg so he's the guy who's gone into the Congo and isolated blood samples from various folks and has shown incredible genetic diversity he's a wellcome trust scholar and he's at university of pennsylvania is a fascinating background so this should be great and Jonathan Marone from Harvard has written extensively on a big problem in science most medical breakthroughs never reached minority communities and he's been excuse me the leading light on that and it so it should be fun to listen to them now here I am standing nicely with our FDA review asagna now this is probably the last time that you'll be smiling because I'm going to be introducing things and arguing with her for a long time she's very good and Sheahan she's very receptive she's very soft-spoken but very very much in touch with things so this is how we're progressing the lung cancer stuff through to her but I have to tell you that on almost every meeting we have and the FDA is very open with it you can as long as you have a legitimate trial coming forward to have you talk to you they this is kind of how they are take a look at this sign no parking anytime turn off engines so this kind of represents where we are with this at the rate we we got one hand saying one thing and the other thing the other thing and the FT is actually asking investigators what to do nobody knows what to do they just know this is going to be really good but we don't know what's going to happen so this is from a sidewalk at the University of Minnesota Parkland then that was great and I just made about it's probably appropriate it's on University campus too right and again some of the dangers we have here as we mentioned or if things go wrong things can really happen ken Silverstein gave me this slide ken Silverstein is the chief medical officer at Christiana Care this is a series of portraits self-portraits by Picasso when he was 1825 and 90 years old and this is how he saw himself we started off in 2012 pretty clean were a little jagged now especially with the patient diversity and we're hoping that we just don't end up looking like this in the field but it's an unusual field normally this gets cleaned up but because of the big implications of CRISPR it has a chance to to go south these are the people in the lab who do all the work and I get a chance to talk here current lab members and I said we've been funded very well by the nationís of Health for for some time and here they are all this is let's see that soap eval bilk is here seasoned as normal clothes now probably rented that shirt this is Kelley Benassi and talked a lot about her work here she is a major rising star in this area Brett's Hansberry is kind of her mentor Brett's about a year ahead but Brett is also an incredibly talented person here's Kristin force our chick and this guy over here with the odd look on his face is Kevin Blau and he's actually the guy that's heading up the melanoma group and Here I am worrying about how to pay for all of them so anyway I'm happy to take questions but thank you again for paying attention you

Channel: ChristianaCare

Views: 4,146

Rating: 4.949367 out of 5

Keywords: Christiana Care Health System, Christiana Care, Gene Editing

Id: FoYdgAI7x2Y

Length: 113min 17sec (6797 seconds)

Published: Wed Apr 24 2019