Challenges & Solutions for NSCLC Molecular Testing

Jonathan W. Riess, MD, MS: I think there are several challenges to molecular testing. I think one of the key challenges is the time it takes to get the test back, particularly if the patient is having symptoms. Getting molecular testing in the appropriate turnaround time is critical. If you look at the guidelines for obtaining and getting back molecular testing, the recommendation is within 2 weeks or 10 business days. That’s something where the speed at which you get it back is very important. And, I think some of the challenges regarding the speed is also not just where the molecular testing is performed. If a tissue biopsy is needed, getting that schedule, having the procedure, having the pathologist look at that specimen, send out the appropriate specimen for testing, that all takes time as well. So, the more that could be accelerated through collaboration, multidisciplinary involvement, the better. Because, I think being able to obtain an accurate result in the shortest amount of time rapidly and quickly is a critical goal to get potential new targeted treatments to patients.

I think the payoff to patients when treatment is based on appropriate molecular testing is substantial. So, we have great new treatments for lung cancer patients, where we’re able to match the mutation or molecular aberration that’s really driving the tumor with many approved drugs that target that molecular aberration. Whether it be EGFR mutations, ALK translocations, ROS1 rearrangements, we have drugs that have high response rates and impressive progression-free survival that can really improve the quality of life and the duration of benefit in these patients. I think that it’s absolutely critical for molecular testing for these patients with advanced non—small cell lung cancer in order to match the patients with appropriately targeted therapies, which are either already approved or potentially can match new targets to clinical trials.

Communication for molecular testing among medical oncologists, thoracic surgeons, pulmonologists, radiologists, interventional radiologists, is all critical to obtain molecular testing from tissue in a quick amount of time in order to get the results to the patient that can impact treatment. So, for us in an academic medical center, we’re fortunate to have a clinic with our thoracic surgeons, pulmonologists, and other specialists that focus in lung cancer. We’re able to coordinate with them on a face-to-face basis in terms of moving this testing and these procedures forward rapidly. That’s not always the case at every institution. One of the things that I recommend is a multidisciplinary tumor board, where discussing these cases that need these biopsies with our pulmonologists, thoracic surgeons, radiologists, and interventional radiologists in a multidisciplinary setting, is critical. Everybody can be on the same page about where to biopsy, what to biopsy, and getting it done quickly in order to get the molecular testing results as soon as possible.

Riess case 4:

52-year-old man with relapsed metastatic NSCLC.

• 52-year-old man developed NSCLC, metastatic to the bone and brain
• Was found to have an EGFR activating mutation
• Started on erlotinib with a good response, received radiotherapy to hip and brain
• After 12 months he developed cough and dyspnea on exertion
• CT scan showed progression in the primary lesion and multiple other pulmonary nodules
• Tissue biopsy showed an EGFR T790M mutation
• Subsequent treatment with osimertinib resulted in tumor shrinkage as well as resolution of his symptoms.