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Biopsy Considerations After Progression in ALK+ NSCLC

Panelists: Charu Aggarwal, MD, MPH, Hospital of the University of Pennsylvania; Hossein Borghaei, DO, Fox Chase Cancer Center; H. Jack West, MD, Swedish Cancer Institute
Published: Tuesday, Feb 26, 2019



Transcript:

H. Jack West, MD:
Hoss, you brought up the issue of biopsy at post progression. We have preclinical data to support this. Is this something that you think we should be doing, and particularly out in a community-based setting? Are there enough clinical data to support this, or is this a concept but not backed yet by enough clinical data to use it to guide or shape practice?

Charu Aggarwal, MD, MH: It’s a great academic concept. I would really like to do it at an academic setting to be able to learn to deliver personalized therapy. I think when we talk about mutation-positive patients or oncogene driver subsets, I do feel that there is so much to be learned with the posttreatment biopsies to be able to advance the field, overall. But, to your point, I don’t believe that we have enough validated clinical experience to guide management in the clinical setting yet.

H. Jack West, MD: You just published some very provocative work on liquid biopsies in the clinic for patients with advanced non–small cell lung cancer. Does the potential to do liquid biopsies easily and even serially lower the threshold for using this, or is this still too premature? And are we just going to be guessing anyway?

Charu Aggarwal, MD, MH: So I think what our study showed was that you could use a liquid biopsy to complement your ability to detect gene mutations in tissue and perhaps increase that ability to be able to deliver personalized therapy. However, we have to be very careful to adopt that approach to serially monitor patients or to generally say, “I will be able to use this liquid biopsy to guide the next line in therapy,” because we are limited by our panel size. We don’t really even know what we’re looking for as we are understanding the resistance mechanisms and what the resistance mechanisms may be as they emerge after treatment with a particular agent. So, although I love liquid biopsies because they increase the rate of detectable mutations, I don’t think we’re quite there yet to apply it to a resistance setting easily.

H. Jack West, MD: Hoss, what are your thoughts about how liquid biopsies change the landscape for repeat biopsies and informing subsequent treatments?

Hossein Borghaei, DO: Again, I look at the liquid biopsy as an option that has made life a lot easier in the clinic for a patient population that couldn’t get the biopsies done. I like Charu’s data. As we just pointed out, you can increase because sometimes a tumor is not accurate. We can pick it up in blood, and patients still respond, just as equally. So I like all those approaches with that. In the resistant and in the second-line setting and all of that, I think we still have a lot of work to do. These panels don’t have the specificity yet to give us exactly what we’re looking for. If and when we get there, and I’m very confident that we’re going to get there, I think it’s going to make life a heck of a lot easier, so we don’t have to go through the repeat biopsies on at least a majority of these patients that we’re dealing with. But we’re not quite there yet in that particular setting.

H. Jack West, MD: I feel like we’re all converging on that same concept. We can absolutely see how to get there from here, and the technology is only going to get better, as will the data to support it. But right now, having greater access to data we don’t know how to use is not a great incentive just yet.

Transcript edited for clarity.

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Transcript:

H. Jack West, MD:
Hoss, you brought up the issue of biopsy at post progression. We have preclinical data to support this. Is this something that you think we should be doing, and particularly out in a community-based setting? Are there enough clinical data to support this, or is this a concept but not backed yet by enough clinical data to use it to guide or shape practice?

Charu Aggarwal, MD, MH: It’s a great academic concept. I would really like to do it at an academic setting to be able to learn to deliver personalized therapy. I think when we talk about mutation-positive patients or oncogene driver subsets, I do feel that there is so much to be learned with the posttreatment biopsies to be able to advance the field, overall. But, to your point, I don’t believe that we have enough validated clinical experience to guide management in the clinical setting yet.

H. Jack West, MD: You just published some very provocative work on liquid biopsies in the clinic for patients with advanced non–small cell lung cancer. Does the potential to do liquid biopsies easily and even serially lower the threshold for using this, or is this still too premature? And are we just going to be guessing anyway?

Charu Aggarwal, MD, MH: So I think what our study showed was that you could use a liquid biopsy to complement your ability to detect gene mutations in tissue and perhaps increase that ability to be able to deliver personalized therapy. However, we have to be very careful to adopt that approach to serially monitor patients or to generally say, “I will be able to use this liquid biopsy to guide the next line in therapy,” because we are limited by our panel size. We don’t really even know what we’re looking for as we are understanding the resistance mechanisms and what the resistance mechanisms may be as they emerge after treatment with a particular agent. So, although I love liquid biopsies because they increase the rate of detectable mutations, I don’t think we’re quite there yet to apply it to a resistance setting easily.

H. Jack West, MD: Hoss, what are your thoughts about how liquid biopsies change the landscape for repeat biopsies and informing subsequent treatments?

Hossein Borghaei, DO: Again, I look at the liquid biopsy as an option that has made life a lot easier in the clinic for a patient population that couldn’t get the biopsies done. I like Charu’s data. As we just pointed out, you can increase because sometimes a tumor is not accurate. We can pick it up in blood, and patients still respond, just as equally. So I like all those approaches with that. In the resistant and in the second-line setting and all of that, I think we still have a lot of work to do. These panels don’t have the specificity yet to give us exactly what we’re looking for. If and when we get there, and I’m very confident that we’re going to get there, I think it’s going to make life a heck of a lot easier, so we don’t have to go through the repeat biopsies on at least a majority of these patients that we’re dealing with. But we’re not quite there yet in that particular setting.

H. Jack West, MD: I feel like we’re all converging on that same concept. We can absolutely see how to get there from here, and the technology is only going to get better, as will the data to support it. But right now, having greater access to data we don’t know how to use is not a great incentive just yet.

Transcript edited for clarity.
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