In review of molecular evaluation in non-squamous cases (Table 2), the majority of patients received appropriate testing. Most untested patients were either not candidates for treatment or elected not to receive treatment. Only 1 patient eligible for treatment did not undergo a request for EGFR, ALK, and PD-L1, and 2 patients did not have requests for ROS-1, after its addition to NCCN guideline recommendations. One patient who tested positive for EGFR mutation did not receive targeted treatment with erlotinib due to other clinical circumstances. Two patients had testing elsewhere, with incomplete information available for this study concerning EGFR testing. Two patients received PD-L1 directed treatment as initial therapy. Insufficient tissue for testing was not uncommon in the non-squamous cell cases. Discussion of the challenges to obtaining sufficient tissue is beyond the scope of the current study. The role of “liquid biopsies,” that is, testing for cell-free tumor DNA or RNA mutations circulating in the blood, is an ongoing area of research to supplement tissue biopsies for testing for molecular targets, and there is expected increased utilization of such testing in the near future. All initial treatments of Non-Squamous cell patients were consistent with NCCN guidelines. In review of the cases diagnosed at AH with squamous cell lung cancer (Table 4), PD-L1 expression testing was performed in 8 of 9 patients eligible for therapy, and 2 patients received PD-L1 directed checkpoint inhibition therapy as part of their initial regimen. Six of 9 eligible patients underwent ROS-1 molecular testing; 2 of the 3 patients who did not undergo testing were diagnosed prior to the addition of ROS-1 to recommendations by NCCN guidelines. The current study revealed that there may be opportunities to reduce cost of testing by avoiding molecular tests with low likelihood of benefit. Insufficient tissue was not seen as a problem in the cases of squamous cell histology. All initial treatments of Squamous cell patients were consistent with NCCN guidelines except one (pembrolizumab + gemcitabine). Recommendations The evaluation and management of patients with Stage IV Non-Small Cell cancer will likely continue to increase in complexity as new science expands treatment options in this most lethal of cancers. There will likely be further identification of important target mutations, and drugs to combat them; likewise, the optimal use of immune checkpoint inhibitors is in its infancy, and increasing use is expected. Assessment of patient function to select patients most able to benefit from therapy will remain paramount, as will the early utilization of palliative care services. In reviewing the results generated in this study of data from 2017, several recommendations for the future can be made in the evaluation and management of Stage IV Non-Small Cell Lung Cancer: 1. Expand discussion of the evaluation, pathology, molecular and immunologic markers and management of patients diagnosed with NSCLC at multispecialty tumor conferencess 2. Ensure clinicians have the tools needed to support direct communication between physicians in identifying the molecular and immunologic testing to be performed for individual patients with Stage IV lung cancer 3. Ensure that patient testing and evaluation is commensurate with the extent of the lung cancer and patient’s functional status 4. Evaluate challenges in the collection of tissue samples that cause samples to be inadequate for molecular/immunologic testing in appropriate cases 5. Avoid molecular tests in cases unlikely to be helpful and not in accordance with guidelines (ie, EGFR and ALK in pure squamous histology, unless minimal smoking history) 6. Consider additional means of testing for molecular markers or mutations, such as next generation sequencing of tumors Summary In summary, patients diagnosed with Stage IV Non-Small Cell Lung Cancer at Augusta Health in 2017 underwent initial evaluation, pre-treatment evaluation, and treatment in accordance with NCCN guidelines as deemed appropriate. Additionally, adherence to evolving recommendations concerning molecular and immunologic testing of lung cancer to better select therapy was appropriate. Date Presented to Cancer Committee: 11/01/2018 9 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT
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