Using the Morbidity and Mortality Conference Model to Explore and Improve Community-Based Oncology Care (Video Program)Optimal molecular testing algorithm for patients with metastatic nonsquamous lung cancer
3:53 minutes.
TRANSCRIPTION:
DR RODRIGUEZ: This lady was a 52-year-old, very independent professional woman. She was a paralegal who worked full time. She presented with shortness of breath and dyspnea that progressed to the point that she went to an emergency room and was found to have bilateral lung nodules. She was a never smoker. So when we met her, our first hope — everyone on the team was hoping that she had a mutation, that we could treat her with erlotinib or afatinib. And then the first challenge was getting the results of those mutation analyses. When she came in, we had a very difficult time with her biopsy because first we thought it was an infection, but then we realized it’s cancer. And then we had to wait some time to get the tissue sent out. DR LOVE: Could I just interrupt at that point? So Heather, a patient who’s a nonsmoker, she had a nonsquamous — what was the histology? DR RODRIGUEZ: She was adeno. DR LOVE: Adenocarcinoma, metastatic, who’s sick. Really leading into the question of appropriate up-front testing — tissue testing, nowadays, for non-small cell lung cancer. So how would you think through testing the tissue of a newly diagnosed patient with an adeno, nonsmoker who’s sick? DR WAKELEE: Well, I think it’s dependent upon how quickly you can get test results back. I think it’s always important to emphasize, chemotherapy is never a wrong choice. If you look at all of the trials of chemotherapy versus targeted drug, X, Y or Z, the chemotherapy always does relatively well. And if you compare it to outcomes of patients who don’t have a driver mutation, it’s still better than that. So if you’re not sure, chemotherapy is going to be the choice if they don’t have a driver mutation. And if they do have a driver mutation, if you don’t know the result or it’s going to take a couple of weeks to get that result, starting with chemotherapy is not going to harm them. We’ve not seen survival differences — overall survival differences — for patients in most of the randomized trials of EGFR TKI versus chemo, ALK drug versus chemo. And so you’re not harming the patient if you start them with chemo, if you don’t know. So if you don’t know, start with chemo. But we do want to get EGFR, ALK and ROS as fast as possible, ideally within a week. DR LOVE: And would you say the current algorithm is, in a patient with nonsquamous, regardless of smoking history, who is negative for EGFR, ALK and ROS1, that they need multiplex testing, next-generation sequencing at some point? DR WAKELEE: Absolutely. I mean we’ve identified patients with BRAF, with HER2 insertion mutations, with RET, and in those cases it provides us another line of therapy, which can be dramatically effective. Again, it’s not curing, but it can really change their outcome. DR LOVE: So just to tease out, though, a little bit in terms of, again, the sick patient, which is not necessarily typical, but at your place, how long would it take to get an EGFR and ALK? DR WAKELEE: We have a rapid EGFR panel that comes back within a week, if it’s PCR based. And then we have FISH testing for ALK and ROS. DR LOVE: And could this patient have waited a week? DR RODRIGUEZ: They could have waited a week. DR LOVE: And how long, at your place, does it take to get EGFR and ALK? DR RODRIGUEZ: If you’re Medicare age you will have to wait 14 days for the — DR LOVE: I’ve heard that. Is it really true? DR RODRIGUEZ: That’s happening. DR LOVE: Wow! DR PICTON: Yes. DR RODRIGUEZ: It has to do with billing, and not patient care, which is very unfortunate. But this lady was young, but even with that, there’s this, like, resistance to not send tissue until the patient gets discharged from the hospital. So we have to discharge the patient from the hospital, and then I have to make a phone call and say, “You don’t have to wait 14 days,” and the tissue will be released. And then some local companies will do EGFR relatively — within a week. And the PD-L1, you can have within 2 days. DR RODRIGUEZ: But the next-generation sequencing, that takes longer. It can take us 2 weeks to get the results. |