Sandy on the Practicalities of Molecular Testing in Newly Diagnosed Lung Cancer

Beth Sandy, MSN, CRNP

Biomarker testing in lung cancer has never been more important, according to Beth Sandy, MSN, CRNP. Targeted treatments are associated with better outcomes and fewer toxicities for patients with select mutations, and although there are multiple barriers to testing, she urges all oncology nurse practitioners to order molecular tests for all newly diagnosed patients with lung cancer.¹

“It is really important that we are doing the testing,” Sandy, who is a nurse practitioner at Abramson Cancer Center at the University of Pennsylvania, said in an interview with Oncology Nursing News®. “Recent studies have shown that we’re not testing at great rates—less than 50% of [individuals] are getting the full next-generation sequencing [NGS] panel, which is testing for all these things. We need to make sure we’re doing a good job.”

Current National Comprehensive Cancer Network recommendations for biomarker testing say that, whenever feasible, providers should recommend a broad panel-based, molecular test. NGS is the most common way to complete this. These can be performed either in-house or through a commercial company. If no biomarkers are uncovered, providers should consider an RNA sequencing panel to detect RNA fusions.

In addition, all patients with metastatic NSCLC with nonsquamous histologic subtypes and NSCLC not otherwise specified should be tested for biomarkers. Testing should be considered in any patients with squamous disease. Further, as of 2022, patients with IB-IIIA NSCLC should be tested for EGFR mutations when they are being considered for adjuvant therapy, and patients with II-III NSCLC being considered for adjuvant therapy should be tested for PD-L1.

In addition, patients with stage II-III NSCLC being considered for neoadjuvant therapy should be tested for EGFR mutations prior to receiving immunotherapy/chemotherapy, because the presence of the biomarker renders the treatment less effective, Sandy noted.²

Sandy recently presented on the value and practicalities of molecular testing in lung cancer as part of the 6th Annual School of Nursing Oncology meeting. In an interview with Oncology Nursing News® ahead of the conference, Sandy discusses some of the challenges for nurses to consider when ordering the tests.

“There are barriers,” she said. “First of all, you have to make sure that [the test] has been ordered and that the patient has quality tissue for it. For example, sometimes you will order an NGS panel, and it comes back as an “S,” which means quality or quantity is not sufficient to run the test. What do you do then? Do you retest [the patient]? There are a lot of [questions] there.”

“[Further], a lot of these reports are going to an outside company,” Sandy added. “So [you need to check] for a result. Did it go to a portal online that you have to look it up? Did it come across a fax machine, and it’s sitting on a fax machine, and no one’s looked it up? At the University of Pennsylvania, we do in-house testing and even I sometimes can’t find [the results] in our electronic medical records. If it’s embedded in the pathology report, it [may be] hard for me to find—I may overlook it—I [may] have an unconscious bias [and think] a patient isn’t going to have a mutation.”

It is key to ensure that all patients receive molecular testing and that the results find their way into the electronic medical report. Once this has been completed, the next barrier is understanding the results, Sandy said, adding that collaboration with the molecular pathologists is crucial.

“There’s a whole line of numbers and letters that don’t make any sense to me,” she admitted. “I recommend calling the molecular pathologist, whether it’s in your institution or an outside institution, they love to talk about this stuff. I call them and say: What does this mean? Is this targetable? Is there something approved? Is there something in clinical trials? Does it mean that that’s actually actionable?”

Moreover, Sandy noted that the oncology nurse plays a vital role in ensuring that these processes are completed and the test was done. Once it’s been ordered, the oncology nurse ensures the report has been received, deciphered, and explained to the patient. Then, once the report has been conducted, the team can see whether there are any approved targeted therapies that correlate with the mutations.

When it comes to ordering liquid vs tissue biopsies, Sandy noted that there are advantages and disadvantages associated with each.

“Everyone has lung tissue,” she said. “But sometimes tissue come back as QMS: quality not sufficient.”

Blood biopsies are less invasive, and results come back quicker; however, if the tumor did not shed DNA on the day the blood was drawn, the mutations might not show on the report. In addition, these tests cannot detect histology, and cannot therefore determine a “small cell transformation” from EGFR to NSCLC.

“[Individuals] who don’t have a big disease burden might not have [tumor] shedding that day. But if you [don’t] actually find a mutation [via liquid biopsy], that doesn’t mean they don’t have a mutation,” she said.

To address these concerns, Sandy recommended ordering both tests. “I would make an argument to do both from the beginning,” she said. “At my institution, the day the patient comes to see me, we do both [tests].”

Because the tissue biopsy takes longer but may be more accurate, by ordering both at the same time, you are providing you patient with the best chance to start treatment sooner, she explained.

“The blood [tests] comes back in less than 5 days. It’s really quick. In comparison, the tissue 2 to 3 weeks,” she said. Further, if something actionable is detected in the liquid biopsy, the patient can be treated right away. If nothing appears in the blood, by already having ordered the solid biopsy, the patient is still waiting for a shorter amount of time to received treatment.

‘By doing both together [liquid] and tissue, you’re going to find more results, and cover all the bases you can to try to find one of these actionable mutations” she concluded.

References

1. Sandy B. Molecular testing and targeted therapies in lung cancer. Presented at: 6th Annual School of Nursing Oncology®; July 29-30, 2022; San Diego, CA.
2. Ettinger DS, Wood DE, Aisner DL, et al. Non-small cell lung cancer, version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20(5):497-530. doi:10.6004/jnccn.2022.0025