Reflex Testing of Lung Cancer Tissue Needs to Be Improved

Zosia Chustecka

May 09, 2013

In an ideal world, the oncologist meeting a patient newly diagnosed with nonsmall-cell lung cancer (NSCLC) will already have information on genetic mutations in the tumor, so can initiate targeted therapy (where appropriate) from the very start. For instance, if the testing has shown EGFR mutations, then treatment with erlotinib (Tarceva) or gefinitib (Iressa) would be indicated, whereas the presence of an ALK rearrangement would indicate treatment with crizotinib (Xalkori).

For this to happen, however, there needs to be reflex (or automatic) testing of lung cancer tissue for genetic mutations and biomarkers. Findings from 2 recent surveys suggest that this is currently happening in less than half of cases.

One survey, conducted by Boehringer Ingelheim in collaboration with the American College of Chest Physicians, asked 100 pulmonologists about lung cancer testing; another survey, conducted by Boehringer Ingelheim alone, questioned 250 pathologists.

Typically, pulmonologists are the physicians who make the early diagnosis of lung cancer, and they are usually the ones who take a biopsy of lung tissue to send to the pathologist for testing. However, the surveys found that the majority of pulmonologists (85%) and pathologists (92%) said that they consulted with oncologists about the testing.

The surveys, conducted in November and December 2012, found that 43% of pulmonologists have implemented reflex testing of NSCLC patients in their practice, whereas only 33% of pathologists have.

This shows a need for "greater collaboration in incorporating biomarker testing into a patient's care early on, with the goal of initiating an appropriate lung cancer treatment plan as soon as possible," said Kevin Lokay, vice president of oncology at Boehringer Ingelheim, in a statement.

The company conducted the surveys to complement its Let's Test Initiative, which aims to educate healthcare professionals about the critical role of biomarker testing in NSCLC. This can be seen as laying the groundwork for future marketing of its new product, afatinib, which is destined for use in EGFR-positive NSCLC. Afatinib is awaiting approval in both the United States and Europe, and launches are expected before the end of this year.

In a previous survey of 100 community oncologists, 95 said that they plan treatment differently for lung cancer patients who are found to have a genetic mutation.

However, for oncologists to have this information, the testing of lung cancer tissue needs to be improved, the latest surveys conclude.

Both pulmonologists and pathologists said that the biggest challenge is obtaining tissue samples that are sufficient in both size and quality. Pulmonologists said that they were unable to obtain enough tissue in 60% of cases, and that the tissue sample was not of sufficient quality in 31% of cases; for pathologists, size was an issue in 73% of cases and quality in 39%.

The surveys also revealed a wide range of opinions on the best method for acquiring lung tissue for testing.

About half the pulmonologists (51%) said that endoscope biopsy provides the most appropriate balance between quantity and quality of tissue and risk to the patient, 44% said core biopsy does, and 33% said fine-needle aspiration does.

In contrast, the majority of pathologists (63%) said the best method is core biopsy, 15% said it is endoscope biopsy, and only 10% said it is fine-needle aspiration.

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