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Interview with Dr. Katherine Rauen: Evolving Care for Ras Pathway Syndromes

Audio Interview

Listen to a Patient Power interview with Dr. Katherine Rauen, a medical geneticist and director of the NF/Ras Pathway Genetics Clinic at UCSF, which she founded in 2007. She is a leader in studying Ras/MAPK pathway genetics syndromes.

Interview Transcript

Andrew Schorr:

Hear from the leader of the first clinic in the world to offer groundbreaking treatment for specific genetic disorders and learn more about this novel genetic pathway-based approach to treatment that's now being emulated worldwide. It's all next on Patient Power.

Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr.

RASopathies: A Related Group of Genetic Syndromes

There are some conditions that you may develop during your lifetime, but there are some conditions that are in your genes, if you will, that you're born with, and it may be that one in a thousand people are born with a group of genetic conditions coming from what's called the Ras pathway.

Now, we need to understand that, and I can think of no one better to help us understand it than Dr. Kate Rauen. Dr. Rauen is a medical geneticist, and she is director of the Neurofibromatosis/Ras Pathway Genetics Clinic at the UCSF Medical Center in San Francisco.

Dr. Rauen, thank you for being with us on Patient Power.

Dr. Rauen:

Thank you so much, Andrew, for having me.

Andrew Schorr:

Dr. Rauen, so one in a thousand babies, if you will, what's going on — I mean, what's cockeyed, if you will, with the genes?

Dr. Rauen:

The group of medical genetic syndromes, which we've actually coined the term the RASopathies, are a group of medical genetic syndromes that are caused by small genetic mutations in a very important, very critical pathway that's present in every single one of our cells. It's known as the Ras pathway, and they are mutations that can just spontaneously happen. It's no one's fault, nothing is done during pregnancy, but they just happen. And about one in a thousand individuals are born with a genetic change in this very important pathway.

Andrew Schorr:

Now, I know you're a pediatrician. I understand there's no newborn screening test for this. So if someone is one of those one in a thousand, how does it show up in a newborn baby?

Dr. Rauen:

Well, sometimes these RASopathies can be detected right at birth. An individual might be born with some minor changes in craniofacial features or craniofacial structures. Individuals might be born with something very subtle as low set ears, or their eyes may be spaced a little wider apart than is commonly seen in the general population. Sometimes a baby might be born with a specific type of heart defect or a hole in the heart, or they might be born with a minor enlarged heart. Sometimes a child could be born and they have problems with feeding, more than is typical in the newborn stage.

And when you put these constellations of findings together, they can add up to what we call a recognizable pattern of a genetic syndrome. And this is commonly seen in children or kids who ultimately get diagnosed with a RASopathy, or a genetic alteration within the Ras pathway.

Andrew Schorr:

What are the names of some of these conditions? I mentioned neurofibromatosis. What's that, and what are some of the others?

Dr. Rauen:

Yes. Neurofibromatosis is actually one of the most common medical genetic syndromes in the human population. NF1, or neurofibromatosis type 1, affects about one in every 3,000 to one in every 3,500 individuals. And from a medical genetic standpoint, that's actually relatively common. But NF1 more recently has been identified with lots of cousin syndromes out there, in the sense that NF1 is due to a genetic mutation within the Ras pathway. It's due to a genetic alteration in the gene known as neurofibromin, but neurofibromin, which is one of the proteins that are really important in Ras signal transduction regulation — there are a lot of other cousin syndromes around that Ras pathway that can also have genetic alterations in them.

These syndromes include Noonan syndrome, which is also relatively common, affecting about one in 1,000 individuals. Another syndrome is Costello syndrome, which is due to genetic alteration in a very important gene called HRAS. Another syndrome is cardiofaciocutaneous syndrome, which we call CFC, and those individuals have genetic alterations in genes called BRAF, MEK1 and MEK2. Another syndrome, part of the RASopathies, is called capillary malformation-arteriovenous malformation syndrome (CM-AVM). Another syndrome includes legius or legius syndrome.

As you can see, I've got now a very long list of medical genetic syndromes that are due to genetic alteration within the Ras pathway. And NF1 was the genetic syndrome that kind of started all this. It was the original RASopathy, and just over the last few years, these other genetic syndromes have been identified to actually be part of the Ras pathway.

Ras Pathway Clinic: Specialized, Coordinated Care

Andrew Schorr:

You have a clinic that you started five years ago, first in the world, focused on this constellation that goes around this Ras pathway, to help patients understand what they have. I know you even help, let's say, people who are older, if they're going to have a baby, they wonder are they going to pass it on to their newborn. Lots of questions come up for people with this about their family. Tell us more about your devotion to that, and I know it's been emulated now around the world.

Dr. Rauen:

I'm happy to tell you more about the Ras Pathway Clinic. The Ras Clinic was something that we started over five years ago here at UCSF, and it was based on the fact that these RASopathies are all due to a common alteration in this very important pathway which causes dysregulation of the Ras pathway.

So the Ras clinic — we see patients with NF1, and like a traditional NF clinic, we see patients with NF2 and schwannomatosis. We also see patients with Noonan syndrome or who are suspected of having Noonan syndrome, CFC syndrome, Costello syndrome, capillary malformation-AV malformation syndrome and legius syndrome. So, a constellation of syndromes or even individuals who are suspected of having a Ras pathway alteration.

This is a genetic clinic that is very unique in the sense that it is a pathway based clinic. There are a lot of genetic clinics out there that focus on certain syndromes, like Down syndrome clinics, or Turner syndrome clinics or Marfan syndrome clinics, but this is the very first pathway based clinic where we've taken a group of syndromes that have a common pathogenetic mechanism. And because they have this common genetic alteration, their signs and symptoms, the care for these genetic syndromes, the care for these individuals who have these genetic syndromes, actually is very, very similar.

We have this clinic, whereby we see individuals — even before they're born or a pregnant individual who might be passing along this genetic alteration — we see kids, we see young adults, and we see adults. So, we see everybody. There is no age limit in a genetics clinic. But we see these individuals that have common features. They can have very similar cardiac issues. They can have very similar skin issues. They can have very similar neurocognitive delay issues. That's why this clinic made so much sense.

A lot of institutions have a traditional NF clinic whereby they see individuals with NF1, NF2 and schwannomatosis. What we did at UCSF was we built upon that great idea of having an NF clinic, but we now expanded it to the rest of the pathway to see all the RASopathy patients. In fact, this was such a novel, new idea that these RASopathy clinics have now popped up all around the world, and in fact a lot of individuals who have had a traditional NF clinic have now turned their NF clinic into a Ras clinic.

Andrew Schorr:

This sounds so cool. It sounds like it springs from the Human Genome Project that I think many of us have heard about.

So, for a patient with one of these conditions that follows this Ras pathway, is it your feeling this sort of specialized clinic, with the hope of newer targeted therapies or participating in trials that may lead to that, that this is something that people should really check out if they have one of these diagnoses?

Dr. Rauen:

Just as you had mentioned, the Human Genome Project has really revolutionized medical genetics. The medical genetics of today is so different than what it was even just 10 years ago. It's really an evolving field. And so with regards to a novel new clinic that is pathway based, we are looking and keeping in mind not just the genetic alteration in one gene that this individual may have, but we also keep in mind the 20 to 25,000 other genes that make up an individual and how those particular genes might interact with the one gene that has the genetic alteration.

What makes the Ras Clinic a little bit different than another clinic, just an NF clinic that you might go to, is that we transition individuals from the pediatric community and community care in pediatrics to adults, and we continue to see that patient throughout their lifetime.

We are so lucky to have such wonderful, talented physicians at UCSF, who are very interested in these RASopathies, that we have many subspecialists who can see patients in their pediatric years. And then as the child gets older we can transition care to adult specialists that also specialize in these RASopathies. So it's a seamless transition, which is actually something that, believe it or not, is very difficult to do in today's pediatric environment — that is, to transition care from the pediatric to the adult medicine world.

Hope for New Treatments Around the Corner

Another thing that we focus on in the Ras Clinic is we really push the boundary for the best medical practices for these individuals with RASopathies. As I mentioned, genetics is a very evolving field in medicine right now, and a lot of these syndromes are relatively new by medical standards. We've only known about something like CFC syndrome or Costello syndrome for a little over a decade or two. We're still learning about the natural history, and we're still putting in place the best practices for these individuals with RASopathies.

And, as you mentioned, because of the Human Genome Project, and because we're learning so much about medical genetics these days and we're implementing the best practices for individuals with genetic syndromes, the thought of moving toward clinical trials and moving toward treatment in medical genetic syndromes, including the RASopathies, is right around the corner.

What makes the RASopathies such prime candidates for treatment is the fact that the genetic alteration is part of a very well-studied Ras pathway that has been under investigation for decades now. And because of this, there are a lot of small molecule inhibitors that already exist that potentially could be used in individuals to help make them stronger, to help them feed better, to help perhaps decrease the hypertrophic cardiomyopathy. There's a lot of excitement in the RASopathy community about potentially using small molecule inhibitors to treat these conditions.

Andrew Schorr:

As I listen to you I think, well, if I were touched by one of these conditions or had a child who was, it would seem like your clinic is sort of action central. And that as medical science moves forward, you're kind of on the frontlines. So I would want to have a relationship with you, so that as news breaks or there's a trial that might open that might be promising, we'd want to be in touch, and I'm sure you welcome that.

Dr. Rauen:

Well, again, we are so fortunate at UCSF to have such a wonderful group of pediatric physicians and adult physicians who are cutting edge not only in the medical community, but also in the research arena as well.

Because of this, we at UCSF really move forward and think about the future of medicine and the best practices we have for our patients. We're not only thinking about today and what we can do for our patients today, but we're always looking forward and thinking about what are some items that are coming down the line that we can apply, medically speaking, to our patient population to give them a better quality of life. We'll always have our eye on future treatments, including future tretments for the RASopathies.

Andrew Schorr:

Well, Dr. Rauen, I hear the excitement in your voice, really, about the discoveries that have been made, the specialization you're offering in your Ras pathway clinic, the constellation of patients with that pathway, that can come together. They're really in partnership with you, these families, and I think at one of the most exciting times in medicine.

Dr. Rauen:

You're absolutely right. Again, with this Ras Pathway Clinic, it is cutting edge. It is something that we hope is really benefitting the patient population by not only providing them with the best medical care that we can, but also looking towards the future for medical practices that might be right around the corner.

At UCSF, again, we have just such a wonderful group of physicians that we have, just in our Ras pathway provider network, over 60 physicians who care for individuals with RASopathies, and that's why we've been so successful as well in transitioning the pediatric patient with a RASopathy into adult care at UCSF. In essence, we really are serving as a one-stop shop, which helps provide continuity of care and best practices for individuals with RASopathies.

Helping Patients from Around the World

Andrew Schorr:

One last question. Someone is listening who may say, well, I wish I lived in the Bay Area but I don't. Can people come from afar to take advantage of your expertise?

Dr. Rauen:

We're very fortunate to have a large catchment at UCSF where we see a lot of patients from northern California, a lot of patients from Oregon, Nevada. But we also see patients who have flown in from across the country, from Hawaii, from outside of the United States. We've had patients come from South America, from Singapore. We have a patient coming from Japan next month.

Again, the word is getting out about this clinic and how we specialize in patients that have RASopathies or suspected of having a RASopathy, and we are very happy to see patients coming from anywhere in the country, anywhere in the world, and from any walk of life.

Andrew Schorr:

Dr. Kate Rauen, thank you for what you started there, and really being on the leading edge of medicine. I know your work and the work of your colleagues is going to pay off for so many generations and I know lead to new treatments too. Thank you for your devotion and explaining this to us today.

Dr. Rauen:

Andrew, thank you very much for your time.

Andrew Schorr:

All right. Really an exciting area, and I know for people affected by these genetic mutations you want to listen to this again maybe and make sure that you're getting the expert care you and your family need and deserve.

I'm Andrew Schorr. Thank you for joining us. Remember, knowledge can be the best medicine of all.

Recorded October 2012

 

Reviewed by health care specialists at UCSF Medical Center.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

Related Information

UCSF Clinics & Centers

Medical Genetics

NF/Ras Pathway
400 Parnassus Ave., Second Floor
San Francisco, CA 94143
Phone: (415) 476-2757
Fax: (415) 476-9305