Precision Oncology

name: tooluniverse-precision-oncology description: Provide actionable treatment recommendations for cancer patients based on molecular profile. Interprets tumor mutations, identifies FDA-approved therapies, finds resistance mechanisms, matches clinical trials. Use when oncologist asks about treatment options for specific mutations (EGFR, KRAS, BRAF, etc.), therapy resistance, or clinical trial eligibility.

Precision Oncology Treatment Advisor

Provide actionable treatment recommendations for cancer patients based on their molecular profile using CIViC, ClinVar, OpenTargets, ClinicalTrials.gov, and structure-based analysis.

KEY PRINCIPLES:

1. Report-first - Create report file FIRST, update progressively
2. Evidence-graded - Every recommendation has evidence level
3. Actionable output - Prioritized treatment options, not data dumps
4. Clinical focus - Answer "what should we do?" not "what exists?"
5. English-first queries - Always use English terms in tool calls (mutations, drug names, cancer types), even if the user writes in another language. Only try original-language terms as a fallback. Respond in the user's language

When to Use

Apply when user asks:

• "Patient has [cancer] with [mutation] - what treatments?"
• "What are options for EGFR-mutant lung cancer?"
• "Patient failed [drug], what's next?"
• "Clinical trials for KRAS G12C?"
• "Why isn't [drug] working anymore?"

Phase 0: Tool Verification

CRITICAL: Verify tool parameters before first use.

Workflow Overview

Input: Cancer type + Molecular profile (mutations, fusions, amplifications)

Phase 1: Profile Validation
├── Validate variant nomenclature
├── Resolve gene identifiers
└── Confirm cancer type (EFO/ICD)

Phase 2: Variant Interpretation
├── CIViC → Evidence for each variant
├── ClinVar → Pathogenicity
├── COSMIC → Somatic mutation frequency
├── GDC/TCGA → Real tumor data
├── DepMap → Target essentiality
├── OncoKB → FDA actionability levels (NEW)
├── cBioPortal → Cross-study mutation data (NEW)
├── Human Protein Atlas → Expression validation (NEW)
├── OpenTargets → Target-disease evidence
└── OUTPUT: Variant significance table + target validation + expression

Phase 2.5: Tumor Expression Context (NEW)
├── CELLxGENE → Cell-type specific expression in tumor
├── ChIPAtlas → Regulatory context
├── Cancer-specific expression patterns
└── OUTPUT: Expression validation

Phase 3: Treatment Options
├── Approved therapies (FDA label)
├── NCCN-recommended (literature)
├── Off-label with evidence
└── OUTPUT: Prioritized treatment list

Phase 3.5: Pathway & Network Analysis (NEW)
├── KEGG/Reactome → Pathway context
├── IntAct → Protein interactions
├── Drug combination rationale
└── OUTPUT: Biological context for combinations

Phase 4: Resistance Analysis (if prior therapy)
├── Known resistance mechanisms
├── Structure-based analysis (NvidiaNIM)
├── Network-based bypass pathways (IntAct)
└── OUTPUT: Resistance explanation + strategies

Phase 5: Clinical Trial Matching
├── Active trials for indication + biomarker
├── Eligibility filtering
└── OUTPUT: Matched trials

Phase 5.5: Literature Evidence (NEW)
├── PubMed → Published evidence
├── BioRxiv/MedRxiv → Recent preprints
├── OpenAlex → Citation analysis
└── OUTPUT: Supporting literature

Phase 6: Report Synthesis
├── Executive summary
├── Treatment recommendations (prioritized)
└── Next steps

Phase 1: Profile Validation

1.1 Resolve Gene Identifiers

def resolve_gene(tu, gene_symbol):
    """Resolve gene to all needed IDs."""
    ids = {}
    
    # Ensembl ID (for OpenTargets)
    gene_info = tu.tools.MyGene_query_genes(q=gene_symbol, species="human")
    ids['ensembl'] = gene_info.get('ensembl', {}).get('gene')
    
    # UniProt (for structure)
    uniprot = tu.tools.UniProt_search(query=gene_symbol, organism="human")
    ids['uniprot'] = uniprot[0].get('primaryAccession') if uniprot else None
    
    # ChEMBL target
    target = tu.tools.ChEMBL_search_targets(query=gene_symbol, organism="Homo sapiens")
    ids['chembl_target'] = target[0].get('target_chembl_id') if target else None
    
    return ids

1.2 Validate Variant Nomenclature

• HGVS protein: p.L858R, p.V600E
• cDNA: c.2573T>G
• Common names: T790M, G12C

Phase 2: Variant Interpretation

2.1 CIViC Evidence Query

def get_civic_evidence(tu, gene_symbol, variant_name):
    """Get CIViC evidence for variant."""
    # Search for variant
    variants = tu.tools.civic_search_variants(query=f"{gene_symbol} {variant_name}")
    
    evidence_items = []
    for var in variants:
        # Get evidence items for this variant
        evi = tu.tools.civic_get_variant(id=var['id'])
        evidence_items.extend(evi.get('evidence_items', []))
    
    # Categorize by evidence type
    return {
        'predictive': [e for e in evidence_items if e['evidence_type'] == 'Predictive'],
        'prognostic': [e for e in evidence_items if e['evidence_type'] == 'Prognostic'],
        'diagnostic': [e for e in evidence_items if e['evidence_type'] == 'Diagnostic']
    }

2.2 COSMIC Somatic Mutation Analysis (NEW)

def get_cosmic_mutations(tu, gene_symbol, variant_name=None):
    """Get somatic mutation data from COSMIC database."""
    
    # Get all mutations for gene
    gene_mutations = tu.tools.COSMIC_get_mutations_by_gene(
        operation="get_by_gene",
        gene=gene_symbol,
        max_results=100,
        genome_build=38
    )
    
    # If specific variant, search for it
    if variant_name:
        specific = tu.tools.COSMIC_search_mutations(
            operation="search",
            terms=f"{gene_symbol} {variant_name}",
            max_results=20
        )
        return {
            'specific_variant': specific.get('results', []),
            'all_gene_mutations': gene_mutations.get('results', [])
        }
    
    return gene_mutations

def get_cosmic_hotspots(tu, gene_symbol):
    """Identify mutation hotspots in COSMIC."""
    mutations = tu.tools.COSMIC_get_mutations_by_gene(
        operation="get_by_gene",
        gene=gene_symbol,
        max_results=500
    )
    
    # Count by position
    position_counts = Counter(m['MutationAA'] for m in mutations.get('results', []))
    hotspots = position_counts.most_common(10)
    
    return hotspots

Why COSMIC matters:

• Gold standard for somatic cancer mutations
• Provides cancer type distribution (which cancers have this mutation)
• FATHMM pathogenicity prediction for novel variants
• Identifies hotspots vs. rare mutations

2.3 GDC/TCGA Pan-Cancer Analysis (NEW)

Access real patient tumor data from The Cancer Genome Atlas:

def get_tcga_mutation_data(tu, gene_symbol, cancer_type=None):
    """
    Get somatic mutations from TCGA via GDC.
    
    Answers: "How often is this mutation seen in real tumors?"
    """
    
    # Get mutation frequency across all TCGA
    frequency = tu.tools.GDC_get_mutation_frequency(
        gene_symbol=gene_symbol
    )
    
    # Get specific mutations
    mutations = tu.tools.GDC_get_ssm_by_gene(
        gene_symbol=gene_symbol,
        project_id=f"TCGA-{cancer_type}" if cancer_type else None,
        size=50
    )
    
    return {
        'frequency': frequency.get('data', {}),
        'mutations': mutations.get('data', {}),
        'note': 'Real patient tumor data from TCGA'
    }

def get_tcga_expression_profile(tu, gene_symbol, cancer_type):
    """Get gene expression data from TCGA."""
    
    # Map cancer type to TCGA project
    project_map = {
        'lung': 'TCGA-LUAD',
        'breast': 'TCGA-BRCA', 
        'colorectal': 'TCGA-COAD',
        'melanoma': 'TCGA-SKCM',
        'glioblastoma': 'TCGA-GBM'
    }
    project_id = project_map.get(cancer_type.lower(), f'TCGA-{cancer_type.upper()}')
    
    expression = tu.tools.GDC_get_gene_expression(
        project_id=project_id,
        size=20
    )
    
    return expression.get('data', {})

def get_tcga_cnv_status(tu, gene_symbol, cancer_type):
    """Get copy number status from TCGA."""
    
    project_map = {
        'lung': 'TCGA-LUAD',
        'breast': 'TCGA-BRCA'
    }
    project_id = project_map.get(cancer_type.lower(), f'TCGA-{cancer_type.upper()}')
    
    cnv = tu.tools.GDC_get_cnv_data(
        project_id=project_id,
        gene_symbol=gene_symbol,
        size=20
    )
    
    return cnv.get('data', {})

GDC Tools Summary:

Why TCGA/GDC matters:

• Real patient data - Not cell line or curated, actual tumor sequencing
• Pan-cancer view - Same gene across 33 cancer types
• Multi-omic - Mutations, expression, CNV together
• Clinical correlation - Survival data available

2.4 DepMap Target Validation (NEW)

Assess gene essentiality using CRISPR knockout data from cancer cell lines:

def assess_target_essentiality(tu, gene_symbol, cancer_type=None):
    """
    Is this gene essential in cancer cell lines?
    
    Essential genes have negative dependency scores.
    Answers: "If we target this gene, will cancer cells die?"
    """
    
    # Get gene dependency data
    dependencies = tu.tools.DepMap_get_gene_dependencies(
        gene_symbol=gene_symbol
    )
    
    # Get cell lines for specific cancer type
    if cancer_type:
        cell_lines = tu.tools.DepMap_get_cell_lines(
            cancer_type=cancer_type,
            page_size=20
        )
        return {
            'gene': gene_symbol,
            'dependencies': dependencies.get('data', {}),
            'cell_lines': cell_lines.get('data', {}),
            'interpretation': 'Negative scores = gene is essential for cell survival'
        }
    
    return dependencies

def get_depmap_drug_sensitivity(tu, drug_name, cancer_type=None):
    """Get drug sensitivity data from DepMap."""
    
    drugs = tu.tools.DepMap_get_drug_response(
        drug_name=drug_name
    )
    
    return drugs.get('data', {})

DepMap Tools Summary:

Why DepMap matters for Precision Oncology:

• Target validation - Proves gene is essential for cancer survival
• Cancer selectivity - Essential in cancer but not normal cells?
• Resistance prediction - What other genes become essential when you knockout target?
• Combination rationale - Identify synthetic lethal partners

Example Clinical Application:

### Target Essentiality Assessment (DepMap)

**KRAS dependency in pancreatic cancer cell lines**:
| Cell Line | KRAS Effect Score | Interpretation |
|-----------|-------------------|----------------|
| PANC-1 | -0.82 | Strongly essential |
| MIA PaCa-2 | -0.75 | Essential |
| BxPC-3 | -0.21 | Less dependent (KRAS WT) |

*Interpretation: KRAS-mutant pancreatic cancer lines are highly dependent on KRAS - validates targeting strategy.*

*Source: DepMap via `DepMap_get_gene_dependencies`*

2.5 OncoKB Actionability Assessment (NEW)

OncoKB provides FDA-approved therapeutic actionability annotations:

def get_oncokb_annotations(tu, gene_symbol, variant_name, tumor_type=None):
    """
    Get OncoKB actionability annotations.
    
    OncoKB Level of Evidence:
    - Level 1: FDA-approved
    - Level 2: Standard care
    - Level 3A: Compelling clinical evidence
    - Level 3B: Standard care in different tumor type
    - Level 4: Biological evidence
    - R1/R2: Resistance evidence
    """
    
    # Annotate the specific variant
    annotation = tu.tools.OncoKB_annotate_variant(
        operation="annotate_variant",
        gene=gene_symbol,
        variant=variant_name,  # e.g., "V600E"
        tumor_type=tumor_type  # OncoTree code e.g., "MEL", "LUAD"
    )
    
    result = {
        'oncogenic': annotation.get('data', {}).get('oncogenic'),
        'mutation_effect': annotation.get('data', {}).get('mutationEffect'),
        'highest_sensitive_level': annotation.get('data', {}).get('highestSensitiveLevel'),
        'treatments': annotation.get('data', {}).get('treatments', [])
    }
    
    # Get gene-level info
    gene_info = tu.tools.OncoKB_get_gene_info(
        operation="get_gene_info",
        gene=gene_symbol
    )
    
    result['is_oncogene'] = gene_info.get('data', {}).get('oncogene', False)
    result['is_tumor_suppressor'] = gene_info.get('data', {}).get('tsg', False)
    
    return result

def get_oncokb_cnv_annotation(tu, gene_symbol, alteration_type, tumor_type=None):
    """Get OncoKB annotation for copy number alterations."""
    
    annotation = tu.tools.OncoKB_annotate_copy_number(
        operation="annotate_copy_number",
        gene=gene_symbol,
        copy_number_type=alteration_type,  # "AMPLIFICATION" or "DELETION"
        tumor_type=tumor_type
    )
    
    return {
        'oncogenic': annotation.get('data', {}).get('oncogenic'),
        'treatments': annotation.get('data', {}).get('treatments', [])
    }

OncoKB Level Mapping:

2.6 cBioPortal Cross-Study Analysis (NEW)

Aggregate mutation data across multiple cancer studies:

def get_cbioportal_mutations(tu, gene_symbols, study_id="brca_tcga"):
    """
    Get mutation data from cBioPortal across cancer studies.
    
    Provides: Mutation types, protein changes, co-mutations.
    """
    
    # Get mutations for genes in study
    mutations = tu.tools.cBioPortal_get_mutations(
        study_id=study_id,
        gene_list=",".join(gene_symbols)  # e.g., "EGFR,KRAS"
    )
    
    # Parse results
    results = []
    for mut in mutations or []:
        results.append({
            'gene': mut.get('gene', {}).get('hugoGeneSymbol'),
            'protein_change': mut.get('proteinChange'),
            'mutation_type': mut.get('mutationType'),
            'sample_id': mut.get('sampleId'),
            'validation_status': mut.get('validationStatus')
        })
    
    return results

def get_cbioportal_cancer_studies(tu, cancer_type=None):
    """Get available cancer studies from cBioPortal."""
    
    studies = tu.tools.cBioPortal_get_cancer_studies(limit=50)
    
    if cancer_type:
        studies = [s for s in studies if cancer_type.lower() in s.get('cancerTypeId', '').lower()]
    
    return studies

def analyze_co_mutations(tu, gene_symbol, study_id):
    """Find frequently co-mutated genes."""
    
    # Get molecular profiles
    profiles = tu.tools.cBioPortal_get_molecular_profiles(study_id=study_id)
    
    # Get mutation data
    mutations = tu.tools.cBioPortal_get_mutations(
        study_id=study_id,
        gene_list=gene_symbol
    )
    
    return {
        'profiles': profiles,
        'mutations': mutations,
        'study_id': study_id
    }

cBioPortal Use Cases:

2.7 Human Protein Atlas Expression (NEW)

Validate target expression in tumor vs normal tissues:

def get_hpa_expression(tu, gene_symbol):
    """
    Get protein expression data from Human Protein Atlas.
    
    Critical for validating:
    - Target is expressed in tumor tissue
    - Target has differential tumor vs normal expression
    """
    
    # Search for gene
    gene_info = tu.tools.HPA_search_genes_by_query(search_query=gene_symbol)
    
    if not gene_info:
        return None
    
    # Get tissue expression data
    ensembl_id = gene_info[0].get('Ensembl') if gene_info else None
    
    # Comparative expression in cancer cell lines
    cell_line_data = tu.tools.HPA_get_comparative_expression_by_gene_and_cellline(
        gene_name=gene_symbol,
        cell_line="a549"  # Lung cancer cell line
    )
    
    return {
        'gene_info': gene_info,
        'cell_line_expression': cell_line_data
    }

def check_tumor_specific_expression(tu, gene_symbol, cancer_type):
    """Check if target has tumor-specific expression pattern."""
    
    # Map cancer type to cell line
    cancer_to_cellline = {
        'lung': 'a549',
        'breast': 'mcf7',
        'liver': 'hepg2',
        'cervical': 'hela',
        'prostate': 'pc3'
    }
    
    cell_line = cancer_to_cellline.get(cancer_type.lower(), 'a549')
    
    expression = tu.tools.HPA_get_comparative_expression_by_gene_and_cellline(
        gene_name=gene_symbol,
        cell_line=cell_line
    )
    
    return expression

HPA Expression Validation Output:

### Expression Validation (Human Protein Atlas)

| Gene | Tumor Cell Line | Expression | Normal Tissue | Differential |
|------|-----------------|------------|---------------|--------------|
| EGFR | A549 (lung) | High | Low-Medium | Tumor-elevated |
| ALK | H3122 (lung) | High | Not detected | Tumor-specific |
| HER2 | MCF7 (breast) | Medium | Low | Elevated |

*Source: Human Protein Atlas via `HPA_get_comparative_expression_by_gene_and_cellline`*

2.8 Evidence Level Mapping

2.4 Output Table

## Variant Interpretation

| Variant | Gene | Significance | Evidence Level | Clinical Implication |
|---------|------|--------------|----------------|---------------------|
| L858R | EGFR | Oncogenic driver | ★★★ (Level A) | Sensitive to EGFR TKIs |
| T790M | EGFR | Resistance | ★★★ (Level A) | Resistant to 1st/2nd gen TKIs |

### COSMIC Mutation Frequency

| Gene | Mutation | COSMIC Count | Primary Cancer Types | FATHMM Prediction |
|------|----------|--------------|---------------------|-------------------|
| EGFR | L858R | 15,234 | Lung (85%), Colorectal (5%) | Pathogenic |
| EGFR | T790M | 8,567 | Lung (95%) | Pathogenic |
| BRAF | V600E | 45,678 | Melanoma (50%), Colorectal (15%) | Pathogenic |

### TCGA/GDC Patient Tumor Data (NEW)

| Gene | TCGA Project | SSM Cases | CNV Amp | CNV Del | % Samples |
|------|-------------|-----------|---------|---------|-----------|
| EGFR | TCGA-LUAD | 156 | 89 | 5 | 28% |
| EGFR | TCGA-GBM | 45 | 312 | 2 | 57% |
| KRAS | TCGA-PAAD | 134 | 8 | 1 | 92% |

*Source: GDC via `GDC_get_mutation_frequency`, `GDC_get_cnv_data`*

### DepMap Target Essentiality (NEW)

| Gene | Mean Effect (All) | Mean Effect (Cancer Type) | Selectivity | Interpretation |
|------|-------------------|---------------------------|-------------|----------------|
| EGFR | -0.15 | -0.45 (lung) | Cancer-selective | Good target |
| KRAS | -0.82 | -0.91 (pancreatic) | Essential | Hard to target |
| MYC | -0.95 | -0.93 | Pan-essential | Challenging target |

*Effect score <-0.5 = strongly essential for cell survival*
*Source: DepMap via `DepMap_get_gene_dependencies`*

*Combined Sources: CIViC, ClinVar, COSMIC, GDC/TCGA, DepMap*

Phase 2.5: Tumor Expression Context (NEW)

2.5.1 Cell-Type Expression in Tumor (CELLxGENE)

def get_tumor_expression_context(tu, gene_symbol, cancer_type):
    """Get cell-type specific expression in tumor microenvironment."""
    
    # Get expression in tumor and normal cells
    expression = tu.tools.CELLxGENE_get_expression_data(
        gene=gene_symbol,
        tissue=cancer_type  # e.g., "lung", "breast"
    )
    
    # Cell metadata for context
    cell_metadata = tu.tools.CELLxGENE_get_cell_metadata(
        gene=gene_symbol
    )
    
    # Identify tumor vs normal expression
    tumor_expression = [c for c in expression if 'tumor' in c.get('cell_type', '').lower()]
    normal_expression = [c for c in expression if 'normal' in c.get('cell_type', '').lower()]
    
    return {
        'tumor_expression': tumor_expression,
        'normal_expression': normal_expression,
        'ratio': calculate_tumor_normal_ratio(tumor_expression, normal_expression)
    }

Why it matters:

• Confirms target is expressed in tumor cells (not just stroma)
• Identifies potential resistance from tumor heterogeneity
• Supports drug selection based on expression patterns

2.5.2 Output for Report

## 2.5 Tumor Expression Context

### Target Expression in Tumor Microenvironment (CELLxGENE)

| Gene | Tumor Cells | Normal Cells | Tumor/Normal Ratio | Interpretation |
|------|-------------|--------------|-------------------|----------------|
| EGFR | High (TPM=85) | Medium (TPM=25) | 3.4x | Good target |
| MET | Medium (TPM=35) | Low (TPM=8) | 4.4x | Potential bypass |
| AXL | High (TPM=120) | Low (TPM=15) | 8.0x | Resistance marker |

### Cell Type Distribution

- **EGFR-high cells**: Tumor epithelial (85%), CAFs (10%), immune (5%)
- **MET-high cells**: Tumor epithelial (70%), endothelial (20%), immune (10%)

**Clinical Relevance**: EGFR highly expressed in tumor epithelial cells. AXL overexpression in tumor suggests potential resistance mechanism.

*Source: CELLxGENE Census*

Phase 3: Treatment Options

3.1 Approved Therapies

Query order:

1. OpenTargets_get_associated_drugs_by_target_ensemblId → Approved drugs
2. DailyMed_search_spls → FDA label details
3. ChEMBL_get_drug_mechanisms_of_action_by_chemblId → Mechanism

3.2 Treatment Prioritization

3.3 Output Format

## Treatment Recommendations

### First-Line Options
**1. Osimertinib (Tagrisso)** ★★★
- FDA-approved for EGFR T790M+ NSCLC
- Evidence: AURA3 trial (ORR 71%, mPFS 10.1 mo)
- Source: FDA label, PMID:27959700

### Second-Line Options
**2. Combination: Osimertinib + [Agent]** ★★☆
- Evidence: Phase 2 data
- Source: NCT04487080

Phase 3.5: Pathway & Network Analysis (NEW)

3.5.1 Pathway Context (KEGG/Reactome)

def get_pathway_context(tu, gene_symbols, cancer_type):
    """Get pathway context for drug combinations and resistance."""
    
    pathway_map = {}
    for gene in gene_symbols:
        # KEGG pathways
        kegg_gene = tu.tools.kegg_find_genes(query=f"hsa:{gene}")
        if kegg_gene:
            pathways = tu.tools.kegg_get_gene_info(gene_id=kegg_gene[0]['id'])
            pathway_map[gene] = pathways.get('pathways', [])
        
        # Reactome disease score
        reactome = tu.tools.reactome_disease_target_score(
            disease=cancer_type,
            target=gene
        )
        pathway_map[f"{gene}_reactome"] = reactome
    
    return pathway_map

3.5.2 Protein Interaction Network (IntAct)

def get_resistance_network(tu, drug_target, bypass_candidates):
    """Find protein interactions that may mediate resistance."""
    
    # Get interaction network for drug target
    network = tu.tools.intact_get_interaction_network(
        gene=drug_target,
        depth=2  # Include 2nd degree connections
    )
    
    # Find bypass pathway candidates in network
    bypass_in_network = [
        node for node in network['nodes']
        if node['gene'] in bypass_candidates
    ]
    
    return {
        'network': network,
        'bypass_connections': bypass_in_network,
        'total_interactors': len(network['nodes'])
    }

3.5.3 Output for Report

## 3.5 Pathway & Network Analysis

### Signaling Pathway Context (KEGG)

| Pathway | Genes Involved | Relevance | Drug Targets |
|---------|---------------|-----------|--------------|
| EGFR signaling (hsa04012) | EGFR, MET, ERBB3 | Primary pathway | Osimertinib, Capmatinib |
| PI3K-AKT (hsa04151) | PIK3CA, AKT1 | Downstream | Alpelisib |
| RAS-MAPK (hsa04010) | KRAS, BRAF, MEK | Bypass potential | Sotorasib, Trametinib |

### Drug Combination Rationale

**Biological basis for combinations**:
- EGFR inhibition → compensatory MET activation (60% of cases)
- **Rationale for EGFR + MET inhibition**: Block primary and bypass pathways
- Network shows direct EGFR-MET interaction (IntAct: MI-score 0.75)

### Protein Interaction Network (IntAct)

| Target | Direct Interactors | Key Partners | Relevance |
|--------|-------------------|--------------|-----------|
| EGFR | 156 | MET, ERBB2, ERBB3, GRB2 | Bypass pathways |
| MET | 89 | EGFR, HGF, GAB1 | Resistance mediator |

*Source: KEGG, Reactome, IntAct*

Phase 4: Resistance Analysis

4.1 Known Mechanisms (Literature + CIViC)

def analyze_resistance(tu, drug_name, gene_symbol):
    """Find known resistance mechanisms."""
    # CIViC resistance evidence
    resistance = tu.tools.civic_search_evidence_items(
        drug=drug_name,
        evidence_type="Predictive",
        clinical_significance="Resistance"
    )
    
    # Literature search
    papers = tu.tools.PubMed_search_articles(
        query=f'"{drug_name}" AND "{gene_symbol}" AND resistance',
        limit=20
    )
    
    return {'civic': resistance, 'literature': papers}

4.2 Structure-Based Analysis (NvidiaNIM)

When mutation affects drug binding:

def model_resistance_mechanism(tu, gene_ids, mutation, drug_smiles):
    """Model structural impact of resistance mutation."""
    # Get/predict structure
    structure = tu.tools.NvidiaNIM_alphafold2(sequence=wild_type_sequence)
    
    # Dock drug to wild-type
    wt_docking = tu.tools.NvidiaNIM_diffdock(
        protein=structure['structure'],
        ligand=drug_smiles,
        num_poses=5
    )
    
    # Compare binding site changes
    # Report: "T790M introduces bulky methionine, steric clash with erlotinib"

Phase 5: Clinical Trial Matching

5.1 Search Strategy

def find_trials(tu, condition, biomarker, location=None):
    """Find matching clinical trials."""
    # Search with biomarker
    trials = tu.tools.search_clinical_trials(
        condition=condition,
        intervention=biomarker,  # e.g., "EGFR"
        status="Recruiting",
        pageSize=50
    )
    
    # Get eligibility for top matches
    nct_ids = [t['nct_id'] for t in trials[:20]]
    eligibility = tu.tools.get_clinical_trial_eligibility_criteria(nct_ids=nct_ids)
    
    return trials, eligibility

5.2 Output Format

## Clinical Trial Options

| NCT ID | Phase | Agent | Biomarker Required | Status | Location |
|--------|-------|-------|-------------------|--------|----------|
| NCT04487080 | 2 | Amivantamab + lazertinib | EGFR T790M | Recruiting | US, EU |
| NCT05388669 | 3 | Patritumab deruxtecan | Prior osimertinib | Recruiting | US |

*Source: ClinicalTrials.gov*

Phase 5.5: Literature Evidence (NEW)

5.5.1 Published Literature (PubMed)

def search_treatment_literature(tu, cancer_type, biomarker, drug_name):
    """Search for treatment evidence in literature."""
    
    # Drug + biomarker combination
    drug_papers = tu.tools.PubMed_search_articles(
        query=f'"{drug_name}" AND "{biomarker}" AND "{cancer_type}"',
        limit=20
    )
    
    # Resistance mechanisms
    resistance_papers = tu.tools.PubMed_search_articles(
        query=f'"{drug_name}" AND resistance AND mechanism',
        limit=15
    )
    
    return {
        'treatment_evidence': drug_papers,
        'resistance_literature': resistance_papers
    }

5.5.2 Preprints (BioRxiv/MedRxiv)

def search_preprints(tu, cancer_type, biomarker):
    """Search preprints for cutting-edge findings."""
    
    # BioRxiv cancer research
    biorxiv = tu.tools.BioRxiv_search_preprints(
        query=f"{cancer_type} {biomarker} treatment",
        limit=10
    )
    
    # MedRxiv clinical studies
    medrxiv = tu.tools.MedRxiv_search_preprints(
        query=f"{cancer_type} {biomarker}",
        limit=10
    )
    
    return {
        'biorxiv': biorxiv,
        'medrxiv': medrxiv
    }

5.5.3 Citation Analysis (OpenAlex)

def analyze_key_papers(tu, key_papers):
    """Get citation metrics for key evidence papers."""
    
    analyzed = []
    for paper in key_papers[:10]:
        work = tu.tools.openalex_search_works(
            query=paper['title'],
            limit=1
        )
        if work:
            analyzed.append({
                'title': paper['title'],
                'citations': work[0].get('cited_by_count', 0),
                'year': work[0].get('publication_year'),
                'open_access': work[0].get('is_oa', False)
            })
    
    return analyzed

5.5.4 Output for Report

## 5.5 Literature Evidence

### Key Clinical Studies

| PMID | Title | Year | Citations | Evidence Type |
|------|-------|------|-----------|---------------|
| 27959700 | AURA3: Osimertinib vs chemotherapy... | 2017 | 2,450 | Phase 3 trial |
| 30867819 | Mechanisms of osimertinib resistance... | 2019 | 680 | Review |
| 34125020 | Amivantamab + lazertinib Phase 1... | 2021 | 320 | Phase 1 trial |

### Recent Preprints (Not Peer-Reviewed)

| Source | Title | Posted | Key Finding |
|--------|-------|--------|-------------|
| MedRxiv | Novel C797S resistance strategy... | 2024-01 | Fourth-gen TKI |
| BioRxiv | scRNA-seq reveals resistance... | 2024-02 | Cell state switch |

**⚠️ Note**: Preprints have NOT undergone peer review. Interpret with caution.

### Evidence Summary

| Category | Papers Found | High-Impact (>100 citations) |
|----------|--------------|------------------------------|
| Treatment efficacy | 25 | 8 |
| Resistance mechanisms | 18 | 5 |
| Combinations | 12 | 3 |

*Source: PubMed, BioRxiv, MedRxiv, OpenAlex*

Report Template

File: [PATIENT_ID]_oncology_report.md

# Precision Oncology Report

**Patient ID**: [ID] | **Date**: [Date]

## Patient Profile
- **Diagnosis**: [Cancer type, stage]
- **Molecular Profile**: [Mutations, fusions]
- **Prior Therapy**: [Previous treatments]

---

## Executive Summary
[2-3 sentence summary of key findings and recommendation]

---

## 1. Variant Interpretation
[Table with variants, significance, evidence levels]

## 2. Treatment Recommendations
### First-Line Options
[Prioritized list with evidence]

### Second-Line Options
[Alternative approaches]

## 3. Resistance Analysis (if applicable)
[Mechanism explanation, strategies to overcome]

## 4. Clinical Trial Options
[Matched trials with eligibility]

## 5. Next Steps
1. [Specific actionable recommendation]
2. [Follow-up testing if needed]
3. [Referral if appropriate]

---

## Data Sources
| Source | Query | Data Retrieved |
|--------|-------|----------------|
| CIViC | [gene] [variant] | Evidence items |
| ClinicalTrials.gov | [condition] | Active trials |

Completeness Checklist

Before finalizing report:

• All variants interpreted with evidence levels
• ≥1 first-line recommendation with ★★★ evidence (or explain why none)
• Resistance mechanism addressed (if prior therapy failed)
• ≥3 clinical trials listed (or "no matching trials")
• Executive summary is actionable (says what to DO)
• All recommendations have source citations

Fallback Chains

Evidence Grading

Tool Reference

See TOOLS_REFERENCE.md for complete tool documentation.