

Topic
Cell and Gene Engineering
Anticipation Committee Chair:

Robin Lovell-Badge
Anticipation Committee:
Cell and Gene Engineering
The ultimate goal for gene editing is a one-shot wonder drug — a one-time injection that cures heritable or acquired disease for the rest of the patient’s life. However, it is becoming increasingly clear that the gene-editing tool that has underpinned most clinical and research breakthroughs will not be the main way forward. CRISPR, an editor that can snip DNA to alter its sequence, also creates dangerous and irreversible breaks in DNA.6 The future of gene editing will rely on new, more efficient, more accurate techniques now under investigation and in early trials, along with novel ideas about how to manipulate the genome indirectly, transiently and even perhaps reversibly.
They will also rely on improved delivery methods. Today, most gene editing is not applied to living embryos or directly done on patients, but is ex vivo: as, for example, in treatments for sickle-cell anaemia.7 But this limits the number of diseases that can be targeted. Targeted payload delivery is being developed to be more precise and less toxic, thereby creating fewer side effects and immune reactions. This could deliver the editor into tissues that are traditionally hard to reach. Better diagnostics, editors and delivery methods could be a result of advances in machine learning. AI could make it easier to diagnose and even predict heritable disorders.
It is generally agreed that future research needs to move forward with an eye to lowering the staggering costs of gene therapy. Currently, the biggest barriers to making gene editing a medical reality are not only technological: they also include public-health messaging, infrastructure and cost. Recently approved haemophilia and sickle-cell disease therapies cost $2 million to $3 million.8 The expense is multifactorial, but new initiatives are under way to make them cheaper and more accessible.9 Crucial to the future of scientific success will be public acceptance and understanding that this is not always led by the West.10 As this therapeutic modality moves into more medical interventions, more infrastructure needs to be developed to address the interpretability of the science (for example, genetic counsellors are needed to interpret genetic test results but are in short supply).
KEY TAKEAWAYS
Editing human genetics is a promising route towards disease prevention and reduction. Work to improve Diagnostics tools for reading and interpreting the genome has achieved fast identification of pathogens and promises to enable insight into the most suitable gene therapies for an individual. This will be complemented by developments in Next-generation editors and delivery, which will manipulate the genome in ways that avoid unwanted immune-system responses. A number of processes will benefit from Engineered organisms and AI-based tools, such as testing of proposed therapies on synthetic organisms and accelerated reading of whole genomes through the use of AI. Researchers are exploring Alternatives to direct gene editing, including epigenome editing, which might facilitate the fine-grained control of gene expression.
Anticipatory Impact:
Three fundamental questions guide GESDA’s mission and drive its work: Who are we, as humans? How can we all live together? How can we ensure the well-being of humankind and the sustainable future of our planet? We asked researchers from the field to anticipate what impact future breakthroughs could have on each of these dimensions. This wheel summarises their opinions when considering each of these questions, with a higher score indicating high anticipated impact, and vice versa.
- Anticipated impact on who we are as humans
- Anticipated impact on how we will all live together
- Anticipated impact on the well-being of humankind and sustainable future of our planet

Diagnostics
Future Horizons:
5-yearhorizon
Faster, cheaper, better diagnostics become available
10-yearhorizon
Genome-reading finds a broad range of applications
25-yearhorizon
Gene-reading goes mainstream
Faster, better and cheaper diagnostics coming into the mainstream will act as a fact-checker on the new generations of genome editors, detecting and preventing DNA-editing errors. These technologies need to be further refined to ensure every laboratory can easily adopt them when in vivo editing becomes mainstream.
Much progress will be thanks to the new ability to do long-read sequencing, more accurate than the previously more common usage of short-read sequencing. This could identify more clinically relevant gene variants and it could also provide epigenetic information that can bring epigenome editing to the clinic.15 Diagnostics will be able to tell patients what kind of gene therapy they are suited for, or even which interventions and lifestyle changes will most affect their chances of expressing a genetic disease. However, analysis and interpretation are a major bottleneck: a shortage of genetic counsellors is an increasing problem.16
Diagnostics - Anticipation Scores
The Anticipation Potential of a research field is determined by the capacity for impactful action in the present, considering possible future transformative breakthroughs in a field over a 25-year outlook. A field with a high Anticipation Potential, therefore, combines the potential range of future transformative possibilities engendered by a research area with a wide field of opportunities for action in the present. We asked researchers in the field to anticipate:
- The uncertainty related to future science breakthroughs in the field
- The transformative effect anticipated breakthroughs may have on research and society
- The scope for action in the present in relation to anticipated breakthroughs.
This chart represents a summary of their responses to each of these elements, which when combined, provide the Anticipation Potential for the topic. See methodology for more information.

Next-generation editors and delivery
Future Horizons:
5-yearhorizon
Ex vivo and in vivo therapies advance
10-yearhorizon
Safer germline editing blurs boundaries between therapy and prevention
25-yearhorizon
Polygenic editing erodes boundaries between therapy and enhancement
The two likeliest candidates are base and prime editing. Base editing is powerful against point mutations, which account for 80 per cent of human genetic diseases.21 It also enables mitochondrial gene editing, which is harder to achieve with CRISPR.22 Prime editing is also more specific and accurate, and new research continues to enhance its efficiency.23 Research is under way to replicate CRISPR successes in sickle-cell disease and beyond with base and prime editing.24,25,26 Prime editing can target multiple genes at the same time.27,28
Modified adeno-associated viruses (AAVs) can deliver gene editors, although the large quantities required can trigger dangerous immune responses. Efforts are under way to re-engineer AAV to be bigger and evade immune response. One alternative is more efficient lentiviral vectors, or viruses engineered to make them preferentially infect specific cell types, for example neural cells or airway cells.29
Non-viral delivery has become an increasingly viable alternative, thanks to rapid progress in the use of lipid nanoparticles and inorganic nanoparticle-based delivery systems.30,31
Next-generation editors and delivery - Anticipation Scores
The Anticipation Potential of a research field is determined by the capacity for impactful action in the present, considering possible future transformative breakthroughs in a field over a 25-year outlook. A field with a high Anticipation Potential, therefore, combines the potential range of future transformative possibilities engendered by a research area with a wide field of opportunities for action in the present. We asked researchers in the field to anticipate:
- The uncertainty related to future science breakthroughs in the field
- The transformative effect anticipated breakthroughs may have on research and society
- The scope for action in the present in relation to anticipated breakthroughs.
This chart represents a summary of their responses to each of these elements, which when combined, provide the Anticipation Potential for the topic. See methodology for more information.

Engineered organisms and AI-based tools
Future Horizons:
5-yearhorizon
Synthetic biology circuits go in vivo
10-yearhorizon
Chimeras, synthetic viruses and other models become mainstream
25-yearhorizon
Universal editors emerge
AI will help to quickly scan whole genomes and then design vectors that can be used more universally. Work is also under way in AI design of entirely new proteins and editors.41 However, human screeners are still needed to identify the small percentage that will work as they are meant to. This situation may improve with access to more training data. Generally, advances here will require more collaboration between mathematicians and biologists.
Furthermore, machine-learning algorithms may help identify the relationships among genes, gene networks and other variables (such as epigenetic factors) involved in disease, as well as the potential consequences of edits to these.42 AI-enabled searches through microbial data obtained from uncultivated samples may reveal more suitable enzymes — helicases, nucleases, transposases or recombinases — that solve the problems of currently available editors.
Recent rapid advances in stem-cell engineering, stem-cell-derived embryo models, organoids (artificial and simplified versions of an organ) and tissue engineering are helping research move towards providing experimental organisms based on human physiology that will help predict the functionalities of genome editors outside the human body and before clinical applications.43,44
Engineered organisms and AI-based tools - Anticipation Scores
The Anticipation Potential of a research field is determined by the capacity for impactful action in the present, considering possible future transformative breakthroughs in a field over a 25-year outlook. A field with a high Anticipation Potential, therefore, combines the potential range of future transformative possibilities engendered by a research area with a wide field of opportunities for action in the present. We asked researchers in the field to anticipate:
- The uncertainty related to future science breakthroughs in the field
- The transformative effect anticipated breakthroughs may have on research and society
- The scope for action in the present in relation to anticipated breakthroughs.
This chart represents a summary of their responses to each of these elements, which when combined, provide the Anticipation Potential for the topic. See methodology for more information.

Alternatives to direct gene editing
Future Horizons:
5-yearhorizon
Disease spread is monitored through metagenomics
10-yearhorizon
Epigenome editors are fine-tuned
25-yearhorizon
Cosmetic gene editing becomes possible
Alternatives to direct gene editing - Anticipation Scores
The Anticipation Potential of a research field is determined by the capacity for impactful action in the present, considering possible future transformative breakthroughs in a field over a 25-year outlook. A field with a high Anticipation Potential, therefore, combines the potential range of future transformative possibilities engendered by a research area with a wide field of opportunities for action in the present. We asked researchers in the field to anticipate:
- The uncertainty related to future science breakthroughs in the field
- The transformative effect anticipated breakthroughs may have on research and society
- The scope for action in the present in relation to anticipated breakthroughs.
This chart represents a summary of their responses to each of these elements, which when combined, provide the Anticipation Potential for the topic. See methodology for more information.

Citations
Topic brief
- National Cancer Institute. First Cancer TIL Therapy Gets FDA Approval for Advanced Melanoma https://www.cancer.gov/news-events/cancer-currents-blog/2024/fda-amtagvi-til-therapy-melanoma
- J. Couzin-Frankel. Cutting-Edge CRISPR Gene Editing Appears Safe in Three Cancer Patients https://www.science.org/content/article/cutting-edge-crispr-gene-editing-appears-safe-three-cancer-patients
- R. Stein. CRISPR Gene-Editing May Boost Cancer Immunotherapy () New Study Finds https://www.npr.org/sections/health-shots/2022/12/13/1140384354/crispr-improves-cancer-immunotherapy-car-t-cell
- EMA. New gene therapy for rare inherited disorder causing vision loss recommended for approval https://www.ema.europa.eu/en/news/new-gene-therapy-rare-inherited-disorder-causing-vision-loss-recommended-approval
- US Food and Drug Administration. FDA Approves First Gene Therapies to Treat Patients with Sickle Cell Disease https://www.fda.gov/news-events/press-announcements/fda-approves-first-gene-therapies-treat-patients-sickle-cell-disease
- J. Li et al. Precise large-fragment deletions in mammalian cells and mice generated by dCas9-controlled CRISPR/Cas3 https://doi.org/10.1126/sciadv.adk8052
- Vertex Pharmaceuticals Incorporated. A Phase 1/2/3 Study to Evaluate the Safety and Efficacy of a Single Dose of Autologous CRISPR-Cas9 Modified CD34+ Human Hematopoietic Stem and Progenitor Cells (CTX001) in Subjects With Severe Sickle Cell Disease https://clinicaltrials.gov/ct2/show/NCT03745287
- T. Hagen. Gene Therapy for Hemophilia Is Becoming a Reality. Who Will Write the Checks to Pay for It? https://www.managedhealthcareexecutive.com/view/gene-therapy-for-hemophilia-is-becoming-a-reality-who-will-write-the-check-to-pay-for-it-
- R. Leuty. Task force from Nobel-winner Jennifer Doudna's institute points way to cheaper, more accessible gene therapies https://www.bizjournals.com/bizwomen/news/profiles-strategies/2023/07/uc-berkeley-jennifer-doudna-cell-gene-therapy-igi.html
- M. Jibrilla M et al.. Survey of attitude to human genome modification in Nigeria httos://doi.org/10.1007/s12687-023-00689-1
2.2.1 Diagnostics
- G. Costain et al.. Genome Sequencing as a Diagnostic Test https://doi.org/10.1503/cmaj.210549
- R. Ding et al.. CRISPR/Cas12-Based Ultra-Sensitive and Specific Point-of-Care Detection of HBV https://doi.org/10.3390/ijms22094842
- M. Eisenstein. Streamlined workflows for DNA and RNA sequencing are helping clinicians to deliver prompt, targeted care to people in days — or even hours https://www.nature.com/articles/d41586-024-00483-0
- National Human Genome Research Institute. The Cost of Sequencing a Human Genome https://www.genome.gov/about-genomics/fact-sheets/Sequencing-Human-Genome-cost
- V. Marx. Method of the year: long-read sequencing https://doi.org/10.1038/s41592-022-01730-w
- M. Paneque et al. An European overview of genetic counselling supervision provision https://doi.org/10.1016/j.ejmg.2023.104710
- J. Wosen. Stanford Scientist Who Broke Genome Sequencing Record on What Faster Diagnoses Mean for Patients https://www.statnews.com/2023/03/22/euan-ashley-stanford-genome-sequencing/
2.2.2 Next-generation editors and delivery
- B. Bekaert et al. Retained chromosomal integrity following CRISPR-Cas9-based mutational correction in human embryos https://doi.org/:10.1016/j.ymthe.2023.06.013
- C. A. Tsuchida et al. Mitigation of chromosome loss in clinical CRISPR-Cas9-engineered T cells https://doi.org/10.1016/j.cell.2023.08.041
- L. Yang et al. Engineering APOBEC3A deaminase for highly accurate and efficient base editing https://doi.org/10.1038/s41589-024-01595-4
- S-I. Cho et al. Engineering TALE-linked deaminases to facilitate precision adenine base editing in mitochondrial DNA https://doi.org/10.1016/j.cell.2023.11.035
- S. Mu et al. Enhancing prime editor flexibility with coiled-coil heterodimers https://doi.org/10.1186/s13059-024-03257-z
- T. Mayuranathan et al. Potent and uniform fetal hemoglobin induction via base editing https://doi.org/10.1038/s41588-023-01434-7
- K. A. Everette et al.. Ex vivo prime editing of patient haematopoietic stem cells rescues sickle-cell disease phenotypes after engraftment in mice https://doi.org/10.1038/s41551-023-01026-0
- C. Li et al. In vivo HSC prime editing rescues sickle cell disease in a mouse model https://doi.org/10.1182/blood.2022018252
- M. Bulcaen et al. Prime editing functionally corrects cystic fibrosis-causing CFTR mutations in human organoids and airway epithelial cells https://doi.org/10.1016/j.xcrm.2024.101544
- R. Liang et al. Prime editing using CRISPR-Cas12a and circular RNAs in human cells https://doi.org/10.1038/s41587-023-02095-x
- A. Cooney et al.. Reciprocal mutations of lung-tropic AAV capsids lead to improved transduction properties https://doi.org/10.3389/fgeed.2023.1271813
- F. Sinclair et al.. Recent Advances in the Delivery and Applications of Nonviral CRISPR/Cas9 Gene Editing https://doi.org/10.1007/s13346-023-01320-z
- Y. Du et al. CRISPR/Cas9 systems, Delivery technologies and biomedical applications https://doi.org:10.1016/j.ajps.2023.100854
- L. Chen et al. Adenine transversion editors enable precise, efficient A•T-to-C•G base editing in mammalian cells and embryos https://doi.org/10.1038/s41587-023-01821-9
- A. Zamecnik. CRISPR Gene Therapies: Is 2023 a Milestone Year in the Making? https://www.pharmaceutical-technology.com/features/crispr-gene-therapies-is-2023-a-milestone-year-in-the-making/
- US Food and Drug Administration. Approval of roctavian to treat haemophilia https://www.fda.gov/vaccines-blood-biologics/roctavian
- Y. Ma et al.. Generation of an MESC Model with a Human Hemophilia B Nonsense Mutation via CRISPR/Cas9 Technology https://doi.org/10.1186/s13287-022-03036-2
- Mayo Clinic. Potential one-time gene therapy treatment for wet age-related macular degeneration https://www.mayoclinic.org/medical-professionals/ophthalmology/news/potential-one-time-gene-therapy-treatment-for-wet-age-related-macular-degeneration/mac-20551865
- M. Naddaf. First trial of ‘base editing’ in humans lowers cholesterol — but raises safety concerns https://www.nature.com/articles/d41586-023-03543-z
- E. Olson. Toward the correction of muscular dystrophy by gene editing https://doi.org/10.1073/pnas.2004840117
2.2.3 Engineered organisms and AI-based tools
- Genentech. Redefining Drug Discovery with AI https://www.gene.com/stories/redefining-drug-discovery-with-ai
- J. Kaiser. Better than CRISPR? Another way to fix gene problems may be safer and more versatile https://www.science.org/content/article/better-crispr-another-way-fix-gene-problems-may-be-safer-and-more-versatile
- D. M. Ichikawa et al.. A Universal Deep-Learning Model for Zinc Finger Design Enables Transcription Factor Reprogramming https://doi.org/10.1038/s41587-022-01624-4
- K. Mochida et al.. Statistical and Machine Learning Approaches to Predict Gene Regulatory Networks From Transcriptome Datasets https://doi.org/10.3389/fpls.2018.01770
- K. Saha et al.. The NIH Somatic Cell Genome Editing Program https://doi.org/10.1038/s41586-021-03191-1
- I. Sample. Scientists Create World’s First ‘Synthetic Embryos’ https://www.theguardian.com/science/2022/aug/03/scientists-create-worlds-first-synthetic-embryos
2.2.4 Alternatives to direct gene editing
- J. Kaiser. Better than CRISPR? Another Way to Fix Gene Problems May Be Safer and More Versatile https://www.science.org/content/article/better-crispr-another-way-fix-gene-problems-may-be-safer-and-more-versatile
- J.K. Nuñez. Genome-wide programmable transcriptional memory by CRISPR-based epigenome editing https://www.sciencedirect.com/science/article/pii/S0092867421003536
- J. Qian and S. X. Liu. CRISPR/dCas9-Tet1-Mediated DNA Methylation Editing https://doi.org/10.21769/BioProtoc.4976