DR LOVE: The two things we were curious about was, one, BRCA testing because we had seen — I think it was at the last SGO meeting when we were polling people. We were shocked that not everybody was doing BRCA testing on ovarian patients. And here it is again. We had 25% of these patients were not BRCA tested, and they died of ovarian cancer.

DR BIRRER: Right.

DR LOVE: Any comment?

DR BIRRER: Well, completely unacceptable. It is something that comes up periodically. I think the data is very clear. It’s now through SGO, ESMO, all sorts of organizations, that every ovarian cancer patient should be tested for BRCA1 or 2 mutations. It’s simply not yet penetrated into the general oncologic community. So we need to keep banging the drum on that. And, yes, that was shocking.

And in fact we don’t even have specific guidelines when you have to test. It could be all the way up front in the diagnosis. It could be the first recurrence, the second recurrence, as long as the patient’s tested. We need to have that information. There are now specific treatments for it. And of course it has a lot of implications for the family.

DR LOVE: Right. And another biomarker issue that I was interested in — and we looked at this with all three of these cancers because we see this across oncology and cancer treatment in general — which is the use of multiplex testing, usually next-generation sequencing, of the tumor in patients who have gotten beyond — normally, in ovary, for example, a patient who’s gotten beyond approved therapies. And we saw a quarter of the patients had some kind of testing.

When a doc in practice asks you, “Is this worth doing in a patient with ovarian cancer,” how do you answer?

DR BIRRER: Yes. So in fact let me first react to the data you’ve collected, which is, I thought the next-gen usage was higher than I would have expected.

And to get back to your question, I usually instruct physicians who are asking me that at present most next-gen panels do not provide us with information to alter standard-of-care management of ovarian cancer patients. Now there may be mutations, rare mutations, and other things on those next-gen panels that allow a physician to triage a patient to a trial. But I have to argue — and I spend a lot of time on this — I do think that component of it is still experimental.

So it begs another question, which is, okay, why is the next-gen sequencing frequency rate higher than you would expect but the BRCA1 and 2 is lower than we want? Because the data is, for data, absolutely clear-cut. And I would assume part of it is communication. We have yet to communicate the proper way about BRCA1 and 2. And that’s why these exercises are very important, and videos like this are.

But, two, next-gen has gotten a lot of high-profile discussions, not in ovary but in other tumors. And I think that that’s penetrating into the community faster than BRCA1 and 2 issues. The solution may be to try to get next-gen panels that have BRCA1 and 2 on it. Then, of course, you get a twofer. You get all the information.

DR LOVE: In lung, we required that all the patients have nonsquamous cancers. And right now, if you think about it, next-gen sequencing, unless the patient has a mutation, tumor mutation, which we stipulated they didn’t, it’s standard of care. So actually, the lung rates being 27% are actually low compared to what the investigators are saying right now. It should be essentially 100%.

DR BIRRER: Correct.

DR LOVE: But in ovarian cancer, for example, do you, yourself, utilize some type of multiplex testing outside a trial?

DR BIRRER: That’s a great question. We’ve now gone from our original, what we call “snapshot” platform to a next-gen platform, which has about 150 cancer genes on it. To be perfectly honest, I would say in my own practice I’m probably in the range of between 25% and, at most, 50% of patients getting that because the mutation rates are so low in ovarian cancer. And we’re already testing for BRCA1 and 2 and, potentially, the Fanconi pathway, which we can target.

So you might ask, well, then why do I get it at all? Because as patients evolve through the natural history of ovarian cancer and they are on their second, third or fourth recurrence, obviously they’re concerned about their future. There’s a certain amount of expected desperation sets in. And we’re beginning to look for next trials, trials that may not be ovary specific. They may be a small molecule inhibitor of FGFR mutation. So even though that mutation is only 1% or 2% in ovarian cancer, in that setting it may be worth doing. So that’s why most of my patients end up getting it.

And I think you bring up a very good point. I certainly don’t want to send the message — what I was saying about ovary, I would extend to lung or other tumors. What I was saying in terms of I thought the next-gen rate is higher, that was specifically looking at the ovary data.

Metastatic wild-type nonsquamous non-small cell lung cancer (NSCLC)

Metastatic colorectal cancer (mCRC)

Metastatic epithelial ovarian cancer (OC)