Tips to Reduce Treatment Downtime in Lung Cancer

Mark G. Kris, MD


November 29, 2021

This transcript has been edited for clarity.

This is Mark Kris from Memorial Sloan Kettering Cancer Center in New York, talking today about a persistent and extremely difficult problem in medical oncology: waiting.

I hate to wait. I grow more impatient with every passing day. Waiting just drives me nutty. What makes me even more concerned is what it does to our patients.

Nothing is more disconcerting for a person who has been told they have lung cancer, or that they have lung cancer that may have spread to an important organ like the brain or the liver, than to have their treatment team say, "Oh, the pathology test or the molecular test is not back. We're not sure when it will come back. We have to wait."

It's incumbent on all of us to do what we can to eliminate that waiting, both for our patients, first and foremost, and then for our own peace of mind because we also want to get on with treatment, particularly when we know a treatment can lead to a long-term benefit for that patient.

Getting Enough Tissue

The first issue is that it's incumbent on the medical oncologist to speak to their colleagues that perform the biopsies — the thoracic surgeons, interventional pulmonologists, and interventional radiologists — and explain to them why, when a lung cancer is suspected, we need sufficient material for a comprehensive pathologic evaluation of cell type; complete immunohistochemistry tests to help verify cell type and other characteristics — for example, PD-L1; and molecular testing.

Every biopsy for every patient with suspected lung cancer requires sufficient tissue for a comprehensive morphologic review, immunohistochemistry supporting that, and next-generation sequencing (NGS). When we explain to our colleagues how important these things are, it becomes much more in their interest to obtain the specimens required. They want to give patients the answers needed for the best care, and they need to know how important these things are. This is not a test for research but a critical test for care.

Not everybody understands at the moment. People say, "Oh, these mutations are rare. ROS is only 2% or RET is only 2%. Why do we really need to know that?" Well, number one, it's tremendously important for those people whose tumors have RET or ROS. Number two, when you add up all of the drivers for which we have a targeted therapy, it's just under 50% of lung adenocarcinoma. I think our colleagues need to understand that there's a very high likelihood that we're going to find an oncogenic driver with a matched targeted therapy and to please help us get that information right away.

It's super-critical, too, that we work with our pathologists, again, to help them understand all the information that we need. I can't say how important it is to get an accurate, histologic examination because in truth, NGS testing for small cell and squamous cell are of secondary importance in 2021. Perhaps they'll be more important as time goes on, but there isn't a likely driver in those cancers that would affect the initial therapy in somebody with metastatic disease. NGS testing for them is less important.

Knowing that it's small cell or squamous cell tells us what we need to know to go ahead with treatment. I really like the idea of doing NGS testing on these patients, but I don't think what we learn is sufficient to make them wait for the result because they're going to get a chemotherapy and checkpoint inhibitor regardless.

Adding Blood Tests

The other big innovation is the availability of blood tests. It allows us to get a quick answer in many patients, but not every patient. A positive result is great; you can go to the bank on it. What I do currently is push to get tissue studies and order the NGS testing and blood as well.

It's very important to explain this to patients. They're so disoriented by everything we throw at them. The diagnosis of lung cancer and facing an often incurable malignancy is very burdensome, and we need to explain why we're waiting and what's in it for them.

For adenocarcinoma, knowing that there's a 50/50 chance you'll find a target that can be used to help select therapy, it's worth doing. It also tells us some things that won't help; for example, you're very unlikely to get great benefit, if you have an ALK fusion, with a checkpoint inhibitor. So these results help select better treatments and [also clarify] treatments that aren't going to be helpful.

It's very important to keep working with patients and to keep seeing them to determine their symptom status and for their own peace of mind. Some people just cannot wait. That's okay if they start therapy because of symptoms or because the patient needs to start a standard chemotherapy plus a checkpoint inhibitor while the NGS testing is done.

Last, if you start a therapy and then a target becomes apparent, in the absence of toxicity, please continue that therapy until you see if it benefits the patient. If it's well tolerated and benefits the patient, it's very reasonable to continue the same treatment and not to stop their treatment. Don't automatically throw a treatment away until you know if it works and you can assess toxicity.

Let's try to lessen the important wait times by working with our colleagues and explain the reasons for waiting to our patients. It will clearly improve the quality of life for our patients and for us, as oncologists, by delivering the best therapy as quickly as we can.

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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