Select Topic:
Browse by Series:

Molecular Testing for NSCLC in 2019

Panelists: Mark A. Socinski, MD, Advent Health Cancer Institute; John V. Heymach, MD, PhD, MD Anderson Cancer Center; Leora Horn, MD, MSc, FRCPC, Vanderbilt University Medical Center; Mohammad Jahanzeb, MD, University of Miami Health System; Heather A. Wakelee, MD, Stanford University Medical Center; Jarushka Naidoo, MBBCh, Sidney Kimmel Cancer Center
Published: Tuesday, Apr 09, 2019



Transcript: 

Mark A. Socinski, MD: But we know in practice newly diagnosed adenocarcinoma, perhaps that she has, he or she has features that would suggest that the chance of an EGFR mutation is higher, or maybe some other driver. But when you see the patient on Monday and you get the PD-L1 back on Wednesday, and it’s 70%, but you still don’t have the testing results back. I want you to kind of tell us your opinion of that and just reinforce that. I’ve seen a number of patients who have come and ready to start pembrolizumab, and then we find out that they have an exon 19.

Heather A. Wakelee, MD: All right. I liked MJ’s comment before about the emotional emergency, because that’s really what it is. The patient now knows that they have a cancer, they’ve had it for a long time but they didn’t know about it. They want to start treatment yesterday. All their family wants them to start a treatment yesterday. And if it were me, of course, I’d want to start treatment yesterday. So I fully empathize with that. I get where that’s coming from.

It’s our job to make sure they understand rushing a treatment sometimes means going to the wrong treatments and can potentially be harmful, especially given the possibility of increasing the toxicity of TKIs [tyrosine kinase inhibitors] if there’s been immune therapy given first. And that’s been seen in multiple studies now, and I just presented my case earlier.

With those patients, talk through, it’s a long visit. We know you have this information. This is the data; why in this setting if you do have one of these driver mutations it could actually be harmful. Let’s just wait. And then I see them at least once a week, if not twice a week, until we’ve gotten them on treatment.

Mark A. Socinski, MD: Hand-holding.

Heather A. Wakelee, MD: Exactly. It’s helping them through that time, making sure we’ve got the backup plan ready to go in case it ends up being negative, have those approvals ready, then be able to move quickly. And again, with my practice, I mean over half of my patients have driver mutations. So this is the norm as opposed to the exception. And people are usually OK with that. But it does involve lots of time, lots of discussion, and lots of visits until you have that information.

Now what we do to get the information faster, we’re not waiting 3, 4 weeks, for full NGS [next-generation sequencing]. We’re doing a PCR [polymerase chain reaction]-based rapid EGFR test, as well as FISH [fluorescence in situ hybridization], for ALK and ROS. And I think IHC [immunohistochemistry] for ALK is also a reasonable option at many institutions. But we’re trying to get the more common ones done fast so we don’t have people wait quite as long. But if they’re symptomatic, physically symptomatic, then I don’t have a problem starting them on chemo,  potentially chemo plus immune therapy, because that’s, chemo alone isn’t necessarily a wrong choice. Not as good, but it’s not wrong. And adding immune therapy to hedge bets can be done.

Mark A. Socinski, MD: So the NCCN [National Comprehensive Cancer Network] calls out the EGFR, ALK, ROS1, and BRAF.

Heather A. Wakelee, MD: Um hmm.

Mark A. Socinski, MD: We also know there are things like RET and MET alterations and these sorts of things. So we need to, I think we need to think beyond those, the NCCN IV, because there are other things that are hard to get.

Heather A. Wakelee, MD: Absolutely, right. And so we’re doing NGS, but I feel like if you’ve got a patient, asking them to wait those four weeks can be really rough. I mean if they’re completely asymptomatic, then, yes, I have cases like that. But when they are symptomatic or they really seem like they’re probably going to be EGFR, and we can often get a pretty good sense of that given our patient population, we’ll just wait for that to come up.

Mohammad Jahanzeb, MD: I agree. It’s all about managing that wait. So I keep them busy by ordering a lot of things, for 4 weeks. I mean ranging from their scans that they need to our distress counselors’ visit, and dietician’s appointment, acupuncture, and so on and so forth.

Heather A. Wakelee, MD: And seeing them all the time. It’s just the same idea. They just need to feel cared for and not being ignored while they’re waiting.

Mohammad Jahanzeb, MD: Yes.

John V. Heymach, MD, PhD: If I may add, there’s recent data from The University of Texas MD Anderson Cancer Center about exercise for patients getting chemotherapy. And one of the things we sometimes underestimate is sarcopenia. So patients have a lot of muscle loss during treatment, and sometimes just inactivity contributes to it. So I actually try to get everybody on an exercise regimen. You know, like they’re training, especially for their girdle muscles, you know, things that get them out of the chair and up the stairs. So it’s something else you can add on to your preparations.

Mohammad Jahanzeb, MD: We have an exercise physiologist, too. So I get all those appointments for them for the 4 weeks. They feel they’re coming every other day, even if I’m not seeing them.

Transcript Edited for Clarity

SELECTED
LANGUAGE
Slider Left
Slider Right


Transcript: 

Mark A. Socinski, MD: But we know in practice newly diagnosed adenocarcinoma, perhaps that she has, he or she has features that would suggest that the chance of an EGFR mutation is higher, or maybe some other driver. But when you see the patient on Monday and you get the PD-L1 back on Wednesday, and it’s 70%, but you still don’t have the testing results back. I want you to kind of tell us your opinion of that and just reinforce that. I’ve seen a number of patients who have come and ready to start pembrolizumab, and then we find out that they have an exon 19.

Heather A. Wakelee, MD: All right. I liked MJ’s comment before about the emotional emergency, because that’s really what it is. The patient now knows that they have a cancer, they’ve had it for a long time but they didn’t know about it. They want to start treatment yesterday. All their family wants them to start a treatment yesterday. And if it were me, of course, I’d want to start treatment yesterday. So I fully empathize with that. I get where that’s coming from.

It’s our job to make sure they understand rushing a treatment sometimes means going to the wrong treatments and can potentially be harmful, especially given the possibility of increasing the toxicity of TKIs [tyrosine kinase inhibitors] if there’s been immune therapy given first. And that’s been seen in multiple studies now, and I just presented my case earlier.

With those patients, talk through, it’s a long visit. We know you have this information. This is the data; why in this setting if you do have one of these driver mutations it could actually be harmful. Let’s just wait. And then I see them at least once a week, if not twice a week, until we’ve gotten them on treatment.

Mark A. Socinski, MD: Hand-holding.

Heather A. Wakelee, MD: Exactly. It’s helping them through that time, making sure we’ve got the backup plan ready to go in case it ends up being negative, have those approvals ready, then be able to move quickly. And again, with my practice, I mean over half of my patients have driver mutations. So this is the norm as opposed to the exception. And people are usually OK with that. But it does involve lots of time, lots of discussion, and lots of visits until you have that information.

Now what we do to get the information faster, we’re not waiting 3, 4 weeks, for full NGS [next-generation sequencing]. We’re doing a PCR [polymerase chain reaction]-based rapid EGFR test, as well as FISH [fluorescence in situ hybridization], for ALK and ROS. And I think IHC [immunohistochemistry] for ALK is also a reasonable option at many institutions. But we’re trying to get the more common ones done fast so we don’t have people wait quite as long. But if they’re symptomatic, physically symptomatic, then I don’t have a problem starting them on chemo,  potentially chemo plus immune therapy, because that’s, chemo alone isn’t necessarily a wrong choice. Not as good, but it’s not wrong. And adding immune therapy to hedge bets can be done.

Mark A. Socinski, MD: So the NCCN [National Comprehensive Cancer Network] calls out the EGFR, ALK, ROS1, and BRAF.

Heather A. Wakelee, MD: Um hmm.

Mark A. Socinski, MD: We also know there are things like RET and MET alterations and these sorts of things. So we need to, I think we need to think beyond those, the NCCN IV, because there are other things that are hard to get.

Heather A. Wakelee, MD: Absolutely, right. And so we’re doing NGS, but I feel like if you’ve got a patient, asking them to wait those four weeks can be really rough. I mean if they’re completely asymptomatic, then, yes, I have cases like that. But when they are symptomatic or they really seem like they’re probably going to be EGFR, and we can often get a pretty good sense of that given our patient population, we’ll just wait for that to come up.

Mohammad Jahanzeb, MD: I agree. It’s all about managing that wait. So I keep them busy by ordering a lot of things, for 4 weeks. I mean ranging from their scans that they need to our distress counselors’ visit, and dietician’s appointment, acupuncture, and so on and so forth.

Heather A. Wakelee, MD: And seeing them all the time. It’s just the same idea. They just need to feel cared for and not being ignored while they’re waiting.

Mohammad Jahanzeb, MD: Yes.

John V. Heymach, MD, PhD: If I may add, there’s recent data from The University of Texas MD Anderson Cancer Center about exercise for patients getting chemotherapy. And one of the things we sometimes underestimate is sarcopenia. So patients have a lot of muscle loss during treatment, and sometimes just inactivity contributes to it. So I actually try to get everybody on an exercise regimen. You know, like they’re training, especially for their girdle muscles, you know, things that get them out of the chair and up the stairs. So it’s something else you can add on to your preparations.

Mohammad Jahanzeb, MD: We have an exercise physiologist, too. So I get all those appointments for them for the 4 weeks. They feel they’re coming every other day, even if I’m not seeing them.

Transcript Edited for Clarity
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Online Medical Crossfire®: 5th Annual Miami Lung Cancer ConferenceMay 30, 20196.5
Community Practice Connections™: Working Group for Changing Standards in EGFR-Mutated Lung Cancers: Real-World Applications of the Evidence for NursesJun 29, 20191.5
Publication Bottom Border
Border Publication
x