UK Lung Cancer Molecular Testing Rates 'Fantastic'

Tim Locke

February 03, 2020

DUBLIN — An audit found molecular testing has been successfully implemented in the NHS in England with "fantastic" testing rates, but quicker results are needed. 

The Royal College of Physicians (RCP)'s Spotlight report on molecular

testing in advanced lung cancer was released at the British Thoracic Oncology Group (BTOG) annual meeting in Dublin.

Audit Data

Currently, all patients with advanced lung adenocarcinoma (and other non-squamous subtypes) should have molecular testing at diagnosis for at least:

  • Epidermal growth factor receptor (EGFR) mutations

  • Anaplastic lymphoma kinase (ALK) and ROS-1 rearrangements

  • Assessment of expression of programmed death ligand 1 (PD-L1) on neoplastic cells

For the audit, 142 NHS trusts in England were invited to take part between June and December 2017. Of these, 60 provided data on 1157 patients.

  • 83% of patients with advanced adenocarcinoma underwent molecular testing for all three of the recommended predictive biomarkers

  • 96% of molecular tests were successful in providing adequate results

The audit also found that 11.5% of patients required second biopsies in order to obtain molecular results. This was more likely if the initial attempt was via pleural biopsy or aspiration.

In terms of results turnaround times, the median time from tissue acquisition to EGFR mutation result was 18 days.

First-line targeted therapies were received by 75% of patients following confirmation of an EGFR mutation and by 58% of patients with an ALK translocation.

How Is the UK Performing?

The results were presented at BTOG by Dr Neal Navani, consultant respiratory physician, and National Lung Cancer Audit clinical lead.

Dr Neal Navani

"The top line here is sensational news for UK lung cancer testing. Our testing rates are fantastic. They're over 90% and I think that's an enormous credit to the enthusiasm and expertise of everyone in the room, and the wider community as well."

However, there was an area "that requires urgent improvement”, he said.

"The median time from biopsy to the complete results was 18 days for an EGFR mutation. And similarly for ALK and PD-L1.

"So way above the recommended guidance."

He continued: "I think you need a considerable amount of work to reduce down to meet the targets within the optimal pathway."

With regard to the need to repeat biopsies in more than 1 in 10 cases, he said: "The community involved in tissue acquisition: we need to work on that to reduce that as much as possible."

When they delved into the repeat data they noted: "If those patients were having a pleural  aspiration as their initial diagnostic procedure for lung cancer, they were twice as likely to need another biopsy procedure than if they had an EBUS [endobronchial ultrasound] for example as their first procedure."

He continued with some "more sobering data".

"I said that the testing rates themselves are excellent. However, the proportion of patients that receive first-line targeted treatments, in my view is still low. It's down to 75%, and I can't help but think of us, intrinsically related to the turnaround times, and the need to start other systemic therapies in the meantime.

"Unfortunately the survival of the cohort was still poor with a median survival of just over 7 months, and even in those with an EGFR-sensitising mutation the median survival in this cohort was a year."

Overall though, he said: "I think molecular testing has been successfully implemented. And given the health care structure that we all work in, I think that's an incredible achievement, and congratulations to everyone on achieving that, because the pathways I know are complex. I know that there are centres in London, for example, that send samples to Birmingham. The fact that we achieve this is commendable.

"But I do think there are areas that need to be improved, particularly the timeliness."

Patient Consent

The next presentation by Dr Angela George, clinical director of genomics, Royal Marsden Hospital, London, raised another issue affecting progress – patient consent for genomic testing both for research and cancer diagnosis.

She said the national testing module will be called 'patient choice'. "This is a little bit controversial because as you all know, at the moment for somatic testing, patients are not routinely consented in the same way that they are for germline testing.

"But once this goes forward, they want all patients who will be potentially having any form of genomic testing undertaken on a sample to be consented either before the sample is taken or as soon as there is a confirmed cancer and malignancy is confirmed."

The current process was based on the 100,000 Genomes Project, which she said could take up to 45 minutes to complete.

"It is now being narrowed down and it is hopefully going to be a little bit more streamlined, but it still isn't really fit for purpose and something that can be instituted in a busy clinic, particularly with someone who has a long list of patients to get through biopsies on."

British Thoracic Oncology Group (BTOG),  18th Annual Conference 2020, Dublin, 29th to 31st January 2020.

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