Optimizing Molecular Testing, Diagnosis, and Workflow in Early-Stage NSCLC Through Multidisciplinary Collaboration

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NGS Testing in NSCLC: Workflow Summary for Physicians

Testing Workflow and Team Collaboration

• Primary Test Orderers: Typically, pathologists, pulmonologists, thoracic surgeons, or medical oncologists order NGS testing, depending on institutional workflows
• Multidisciplinary Approach: Effective collaboration between pathology, pulmonology, thoracic surgery, and oncology ensures efficient testing
• Communication Strategies: Regular molecular tumor boards, integrated electronic medical record systems, and designated testing coordinators streamline result communication
• Critical Factors: Close collaboration between specimen handling teams and clinical teams prevents delays and ensures adequate tissue preservation

Optimal Timing for Molecular Testing

• Early-Stage NSCLC: NGS testing should be performed immediately after diagnosis/surgical resection
• Test Initiation: Ideally triggered automatically by pathology at diagnosis rather than requiring separate clinician orders
• Result Timeline: Results should be available before adjuvant therapy decisions (typically within 2-3 weeks post surgery)

Prioritized Biomarkers in Early-Stage NSCLC

• Essential Biomarkers: EGFR mutations (particularly exon 19 deletions and L858R), ALK rearrangements, ROS1 fusions
• Additional Important Markers: KRAS G12C, BRAF V600E, MET exon 14 skipping, RET fusions, NTRK fusions
• Emerging Markers: HER2 mutations, NRG1 fusions
• Immunotherapy-Related: PD-L1 expression (complementary to NGS testing)

Recommendations

• Implement reflex testing protocols where pathology automatically initiates NGS upon NSCLC diagnosis
• Utilize comprehensive NGS panels rather than sequential single-gene testing to preserve tissue

Consider liquid biopsy when tissue is insufficient or to complement tissue testing