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Molecular Testing for NSCLC in 2017

Panelists: Mark A. Socinski, MD, Florida Hospital Cancer Institute; Tracey L. Evans, MD, University of Pennsylvania; Alexander Drilon, MD, Memorial Sloan Kettering Cancer Center; Vali A. Papadimitrakopoulou, MD, The University of Texas MD Anderson Cancer Center; Jared Weiss, MD, UNC Lineberger Comprehensive Cancer Center
Published: Monday, Feb 20, 2017


Transcript:

Mark Socinski, MD:
Hello, and thank you for joining this OncLive Peer Exchange® titled “Metastatic Lung Adenocarcinoma: Treatment in 2017 and Beyond.” Research efforts in the field of lung cancer continue to yield important advances that impact the way we treat our patients. For patients with advanced lung adenocarcinoma, this translates to more options for precision treatment throughout the disease continuum. For oncologists, this requires an “art of medicine” approach as we interpret the new data to offer patients an optimal course of therapy through multiple lines. In this OncLive Peer Exchange®, I am joined by a panel of experts in lung cancer medical oncology. Together, we will highlight the latest studies, including those from the 2016 World Conference on Lung Cancer, and provide insight on how to apply the data to your clinical practice.

I am Dr. Mark Socinski, executive medical director at the Florida Hospital Cancer Institute in Orlando, Florida. Participating today on our distinguished panel are Dr. Alex Drilon, clinical director of the Developmental Therapeutics Clinic at Memorial Sloan Kettering Cancer Center in New York; Dr. Tracey Evans, associate professor of clinical medicine at the University of Pennsylvania in Philadelphia; Dr. Vali Papadimitrakopoulou, section chief of Thoracic Medical Oncology and professor of medicine at the University of Texas MD Anderson Cancer Center in Houston, Texas; and Dr. Jared Weiss, section chief of Thoracic and Head/Neck Oncology at the UNC Lineberger Comprehensive Cancer Center in Chapel Hill, North Carolina. Thank you for joining us. Let’s begin.

I’m going to start with Alex. Let’s kick it off by you giving us the stage of what should be the expectation, in terms of the standard of care, when it comes to molecular testing in 2017.

Alexander Drilon, MD: We’ve seen quite an evolution in the way we test for actionable targets in patients’ tumors. So, we’ve seen this go from a 1-test-1-gene type of approach, where you have sequencing for EGFR and FISH for ALK and ROS1 separately, to an intermediate stage, where you have 1 test with a few genes, like a Sequenom panel where you’re fishing for hotspot mutations. But more recently, we’ve adopted these much more comprehensive tests, called next-generation sequencing, where you have one big test that interrogates up to hundreds of genes. They’re commercial forms of next-generation sequencing testing and also internal tests.

We did a study, published in Clinical Cancer Research, where we actually looked at the value of the former algorithm, where you did piecemeal testing versus doing next-generation sequencing. And to qualify, this was in patients where nothing was picked up by doing things like FISH or sequencing for individual genes. We found that in 1 out of 4 cases, there was an actionable target that was missed and in another one-third of cases, there were other gene changes that made patients potentially candidates for a clinical trial. Now the biggest question here is what to do in the clinic, and there’s a push-and-pull between the sick patient and the well patient.

So, I’ll share with you our algorithm. We have, at our institution, rapid testing, where we do immunohistochemistry for EGFR and ALK—in addition, of course, to PD-L1—and then send the rest of the tissue for next-generation sequencing. That way, if you have an EGFR or ALK alteration, you’re able to come in with targeted therapy quickly.

Mark Socinski, MD: And what should be the expectation for turnaround in the clinic?

Alexander Drilon, MD: Our internal assay takes a substantial amount of time, so anywhere from 4 to 6 weeks. That amount of time is shorter with other assays, and this brings up the sick versus well, the push-and-pull.

Mark Socinski, MD: And when you don’t know, the message should be you’ve got to stick with chemotherapy until you know what the sequencing may show.

Alexander Drilon, MD: Exactly. I don’t wait around if someone needs therapy right away.

Mark Socinski, MD: Let me ask you one question. In terms of the options that we have available for targeted agents, do you have a list of actionable mutations or translocations you’d want to know about right now in every adenocarcinoma patient in your practice? What’s your thinking?

Alexander Drilon, MD: Oh, yes. So, beyond EGFR and ALK, there are, of course, ROS1, RET, and NTRK—granted, that’s very rare. And more recently for MET exon 14, you can potentially only really detect on NGS, or next-generation sequencing, because it’s so heterogeneous. Of course, there are other things that continue to be explored.

Mark Socinski, MD: BRAF.

Alexander Drilon, MD: BRAF V600E, yes. I missed that. That’s certainly actionable.

Transcript Edited for Clarity
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Transcript:

Mark Socinski, MD:
Hello, and thank you for joining this OncLive Peer Exchange® titled “Metastatic Lung Adenocarcinoma: Treatment in 2017 and Beyond.” Research efforts in the field of lung cancer continue to yield important advances that impact the way we treat our patients. For patients with advanced lung adenocarcinoma, this translates to more options for precision treatment throughout the disease continuum. For oncologists, this requires an “art of medicine” approach as we interpret the new data to offer patients an optimal course of therapy through multiple lines. In this OncLive Peer Exchange®, I am joined by a panel of experts in lung cancer medical oncology. Together, we will highlight the latest studies, including those from the 2016 World Conference on Lung Cancer, and provide insight on how to apply the data to your clinical practice.

I am Dr. Mark Socinski, executive medical director at the Florida Hospital Cancer Institute in Orlando, Florida. Participating today on our distinguished panel are Dr. Alex Drilon, clinical director of the Developmental Therapeutics Clinic at Memorial Sloan Kettering Cancer Center in New York; Dr. Tracey Evans, associate professor of clinical medicine at the University of Pennsylvania in Philadelphia; Dr. Vali Papadimitrakopoulou, section chief of Thoracic Medical Oncology and professor of medicine at the University of Texas MD Anderson Cancer Center in Houston, Texas; and Dr. Jared Weiss, section chief of Thoracic and Head/Neck Oncology at the UNC Lineberger Comprehensive Cancer Center in Chapel Hill, North Carolina. Thank you for joining us. Let’s begin.

I’m going to start with Alex. Let’s kick it off by you giving us the stage of what should be the expectation, in terms of the standard of care, when it comes to molecular testing in 2017.

Alexander Drilon, MD: We’ve seen quite an evolution in the way we test for actionable targets in patients’ tumors. So, we’ve seen this go from a 1-test-1-gene type of approach, where you have sequencing for EGFR and FISH for ALK and ROS1 separately, to an intermediate stage, where you have 1 test with a few genes, like a Sequenom panel where you’re fishing for hotspot mutations. But more recently, we’ve adopted these much more comprehensive tests, called next-generation sequencing, where you have one big test that interrogates up to hundreds of genes. They’re commercial forms of next-generation sequencing testing and also internal tests.

We did a study, published in Clinical Cancer Research, where we actually looked at the value of the former algorithm, where you did piecemeal testing versus doing next-generation sequencing. And to qualify, this was in patients where nothing was picked up by doing things like FISH or sequencing for individual genes. We found that in 1 out of 4 cases, there was an actionable target that was missed and in another one-third of cases, there were other gene changes that made patients potentially candidates for a clinical trial. Now the biggest question here is what to do in the clinic, and there’s a push-and-pull between the sick patient and the well patient.

So, I’ll share with you our algorithm. We have, at our institution, rapid testing, where we do immunohistochemistry for EGFR and ALK—in addition, of course, to PD-L1—and then send the rest of the tissue for next-generation sequencing. That way, if you have an EGFR or ALK alteration, you’re able to come in with targeted therapy quickly.

Mark Socinski, MD: And what should be the expectation for turnaround in the clinic?

Alexander Drilon, MD: Our internal assay takes a substantial amount of time, so anywhere from 4 to 6 weeks. That amount of time is shorter with other assays, and this brings up the sick versus well, the push-and-pull.

Mark Socinski, MD: And when you don’t know, the message should be you’ve got to stick with chemotherapy until you know what the sequencing may show.

Alexander Drilon, MD: Exactly. I don’t wait around if someone needs therapy right away.

Mark Socinski, MD: Let me ask you one question. In terms of the options that we have available for targeted agents, do you have a list of actionable mutations or translocations you’d want to know about right now in every adenocarcinoma patient in your practice? What’s your thinking?

Alexander Drilon, MD: Oh, yes. So, beyond EGFR and ALK, there are, of course, ROS1, RET, and NTRK—granted, that’s very rare. And more recently for MET exon 14, you can potentially only really detect on NGS, or next-generation sequencing, because it’s so heterogeneous. Of course, there are other things that continue to be explored.

Mark Socinski, MD: BRAF.

Alexander Drilon, MD: BRAF V600E, yes. I missed that. That’s certainly actionable.

Transcript Edited for Clarity
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