The Evolving Landscape of Molecular Alterations in NSCLC: Optimizing Testing and Treatment to Improve Outcomes - Episode 8

Overcoming Barriers to Molecular Testing in NSCLC

After highlighting major barriers to molecular testing in advanced non–small cell lung cancer, Ticiana Leal, MD, provides advice on how to circumvent issues in this setting.


Ticiana A. Leal, MD: Importantly, there are still barriers in testing, particularly in the community setting. There was a study using real-world testing information and parameters looking at a retrospective study that showed that, although genomic testing is being performed, when you looked at key molecular targets that are actionable and that we have FDA-approved targeted therapies for, less than 50% of the patients had all of the 5 performed. I think we still need to improve molecular testing for patients with advanced non–small cell lung cancer with nonsquamous histology. We’ve also seen some of these real-world testing results showing that smokers are less likely to have genomic testing done. We’ve learned that, although some of the actionable mutations may be lower in nature, KRAS mutations are seen in patients who are smokers or former smokers. And now, we also have targeted therapy for patients with KRAS mutations. It is really important to test patients routinely, independent of clinical characteristics, and to do that up front and at initial diagnosis.

There are some potential barriers that we’ve seen in genetic testing.One of the things that IASLC [the International Association for the Study of Lung Cancer] did was a survey about barriers to molecular testing, using a survey of about 300 physicians. What they noted was that some of the barriers included inadequate tissue, issues with turnaround time, issues with not having enough information to do all the testing, or perhaps the interpretation of the testing, then certainly cost for some parts of the world. In the United States it is still a concern for patients and clinicians performing this kind of testing. Some of the strategies that we recommend for improving testing rates for molecular biomarkers in non–small cell lung cancer include creating a standardized approach and establishing multidisciplinary teams to try to overcome these biomarker testing barriers and challenges in the clinic. Some centers have done an approach with pathology called ROSE [rapid on-site evaluation], where pathologists and health care providers look at the sample in real time and confirm that it’s adequate for testing. This may be an approach that can be used by some centers that can perhaps reduce rebiopsy rates as well.

Another key method that can be used is to implement reflex testing, and again, there are some challenges in doing that. But doing reflex ordered testing for molecular biomarkers at the time of initial diagnosis can help speed the turnaround time for patients and clinicians, and get the patient on the correct therapy sooner. In addition, other important things include a discussion about which sites to biopsy and having the multidisciplinary team on board with the amount of tissue that we need, for example, getting core biopsies and fewer fine-needle aspirates, which sometimes can be inadequate or insufficient. Then certainly it’s important to incorporate a liquid biopsy, either as a complementary approach, where you do both up front, or you do a sequential approach where you do tissue and rely on liquid biopsy if there is insufficient tissue or inadequate tissue up front. I think one important thing is to think about getting these results back as quickly as possible and waiting for these results before we start treatment for patients because some of the alterations patients have will be important to guide the appropriate treatment options.

Transcript edited for clarity.