Oncologists, Pathologists Need a 'Culture Change' on Biopsies

Mark G. Kris, MD


April 03, 2020

This transcript has been edited for clarity.

Hello. I'm Mark Kris from Memorial Sloan Kettering.

I would like to discuss a wait time that profoundly affects our lives: the time between when a cancer is diagnosed and when we get adequate information to start therapy.

This time period has only gotten longer and more critical in the era of targeted therapies, where we need very precise and complete molecular information to figure out what treatment to choose. This impacts patients, first and foremost, and it impacts their loved ones. But it also impacts us.

Many times, we are forced to give a treatment that is not as precise as we would like because it's inappropriate to wait any longer to start a therapy.

What are some ways to deal with this, and how can we implement them in our practices?

We need a culture change. Whenever lung cancer is suspected, at the time of the initial diagnostic biopsy, sufficient tissue for a complete interrogation should be obtained. That is, tissue for morphologic assessments; immunohistochemistry studies, particularly programmed death-ligand 1 (PD-L1); and molecular studies. I'm not suggesting that you do all these tests, only that you get sufficient tissue to do them if needed. Most people with suspected lung cancer need all these tests, however.

Remember that tests need to be ordered. This often falls to the treating physicians. It's not uncommon that the tissue is in the pathology department but specific tests have not been ordered. So it's incumbent upon us to make sure that there is enough tissue and to make sure that necessary tests have been ordered.

It gets a little more complicated at the next point because we don't perform the biopsies. We as medical oncologists are often not involved at the time that the diagnostic studies are being done. We should explain the need for a complete interrogation of tissue to those who do biopsies, including thoracic surgeons, interventional radiologists, pulmonologists, and interventional cytologists. They need to understand that we cannot treat people without exact knowledge of their cell type as well as their immunohistochemical test results—particularly PD-L1—and molecular results.

It is also critical that we understand how these specimens are dealt with in our pathology and cytology departments. The truth is that even when we want the tests done, we are not the ones performing the biopsy and the order is often placed by the person who performs the biopsy. There is a disconnect between what we need to treat a patient and what actually gets ordered when the biopsy is done. Once it gets to the pathology department, each test has its own flow.

For example, in our pathology department, when tissue is accessioned, it first goes to a team who morphologically assesses it for the presence of cancer. This is critical and must be done as the first step. The tissue resides in that area until a diagnosis is made. Very often, immunohistochemical tests are done, not to help guide therapy but to help make the diagnosis. There is a whole different process within pathology to make that histologic diagnosis and an estimation of the cell type.

The next step involves additional studies, such as PD-L1. Hospitals deal with that in different ways, but it doesn't necessarily follow that the PD-L1 test is done in every patient following a biopsy. Then there is molecular testing, which is usually a third step. So, after the interrogation is done morphologically, immunohistochemistry is done if necessary and then passed along for molecular analysis.

We need to continue to work with our pathology colleagues to try to speed up this process to facilitate better treatment for our patients.

Mark G. Kris, MD, is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York City. His research interests include targeted therapies for lung cancer, multimodality therapy, the development of new anticancer drugs, and symptom management with a focus on preventing emesis.

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