Integrating Molecular Testing into NSCLC Care

Announcer:
You’re listening to Project Oncology on ReachMD. On this episode, we’ll hear from Dr. Geoffrey Oxnard, who will be discussing strategies for effective molecular testing in non-small cell lung cancer. Dr. Oxnard is an Associate Professor of Hematology and Medical Oncology at Boston University Chobanian and Avedisian School of Medicine.

Let’s hear from him now.

Dr. Oxnard:
To achieve effective testing, we do need a system that works with us. And when I say a system, I acknowledge that lung cancer care is very much multidisciplinary and involves the diagnosis from the surgeon or pulmonologist, the specimen going to the pathology lab where it is comprehensively tested, and the results coming back in a reliable way to the oncologist's office to act on. And that multidisciplinary loop, I think, works better in some centers that have really worked on it, and can be more difficult than others.

In lung cancer, you can have a diagnosed and staged lung cancer that hasn't had molecular results. And I think that is a system barrier. So we need, as part of our own thinking as lung cancer oncologists, to see every lung cancer as not fully diagnosed until the molecular results are back, and until you have that fingerprint that says biomarker negative or KRAS-positive, et cetera.

Now we have to work on that. Certainly, it does require teamwork with your multidisciplinary team so that your pathologists and surgeons are as motivated and enthusiastic about molecular testing as you are: the oncologist who ends up getting the results. And through dialogue and multidisciplinary collaboration, I think that's very much achievable, and we've seen that at centers that have really made it work.

Now, let's acknowledge that some centers don't have that multidisciplinary collaboration as available. And I know there are many oncologists who don't see their pathologist on a weekly basis, or who get referrals from a surgeon at a different center. And if that's the case, there are steps, as an oncologist, you can take to dive in, roll up your sleeves, and take into your own hands.

And the simplest one is liquid biopsy. This is a kit that sits in your clinic that you can order and send out the door within a matter of minutes. It takes standard phlebotomy: two 10-cc tubes. You have to fill out a requisition either online or in paper.

But this means that molecular testing is now in the hands of the oncologist, and is something that you can incorporate early on in your first-line testing. Heck, I see patients in the door sometimes even before diagnosis, just with suspected lung cancer. And when I see what looks like a lung cancer, even if the pathology's not fully complete, I'm sending off liquid biopsy because I want to make sure that part of their diagnostic odyssey doesn't just include the PET scan and the brain MRI to get the staging. It doesn't just include the tissue and PD-L1 testing but also includes the next-generation sequencing. And that's, for me, upfront liquid biopsy.

The catch for the liquid biopsy is learning to interpret it. If it's positive for a biomarker that's convincingly there, great. Act on it. If it’s negative for a biomarker, it might be a low tumor content blood specimen. It might be a false negative, and so negative liquid biopsies should reflex to tumor testing to confirm that that negative is real. But the key message is that liquid testing is now accessible through multiple FDA-approved liquid biopsy profiling tests.