Overcoming Barriers to Molecular Testing in NSCLC With Multidisciplinary Care

EP: 1.Evolving Field of Molecular Testing in Non–Small Cell Lung Cancer

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EP: 3.Overcoming Barriers to Molecular Testing in NSCLC With Multidisciplinary Care

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Transcript:

Estelamari Rodriguez, MD, MPH: Dr Levy, what are some of the barriers faced when conducting molecular testing in patients?

Benjamin Levy, MD: You beautifully outlined the basic issues. It sounds so easy: get the test, and make a decision based on the test. But it’s more complicated than that. The barriers include tissue procurement. Are we getting enough tissue? How can we refine that so we can talk to our interventional pulmonologist and our interventional radiologist about the right area to biopsy? Then you’re talking about what I call tissue stewardship: where does the tissue go? When it goes to the pathology department, is there tissue exhaustion? Are they doing a million immunostains? You’ve got to prioritize PD-L1 and clinical trials. Then it goes off to molecular testing. Is there enough tissue for molecular testing? Those are challenges.

Once the report is done, where does it go? Does it go in the EMR [electronic medical record]? Is it faxed to you? How [do we] interpret the test? Sometimes we’re getting a lot of noise in the background of what is potentially an actionable mutation, and it’s very difficult to interpret these tests. We need to do better with streamlining the information and making it easily palatable to community oncologists. There are a lot of strategies, and I’m glad to hear that you’re part of trying to work through these strategies to overcome these barriers.

It takes a village. We need a multidisciplinary team. It can’t just be the medical oncologist who has historically lived in a silo. We have to work together with our interventional pulmonologist, our thoracic surgeons, our radiologist, our interventional pulmonologist, and our interventional radiologist. They’re important. With our pathologists, we have to talk to them. This is where molecular tumor boards come in handy. This is where clinical tumor boards come in handy. We need to get ahead of the issue, talk to the pathologist, and hold off on the immunostains. Those are challenges that we need to make sure of.

Then there are small things, including ROSE, the rapid on-site evaluation. When the pulmonologist does the biopsy, [we need to] make sure they got enough tissue and that it’s done on-site. We mentioned liquid. Liquid has been a savior for me. Even at our institution [Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins], 15% of patients have Q and S, which is not enough tissue to perform molecular testing. Liquid has come in fold for us to identify actual alterations very quickly. Sometimes we don’t even need the tissue result. Every health system is going to have a different way to do this. There’s no right answer. Every health system has to come up with the best ways, best strategies, and best practices to pull this off in a meaningful way.

Estelamari Rodriguez, MD, MPH: Our patients depend on this. One thing we have to communicate with patients is how important it is to wait. Sometimes we understand all the challenges from the patient’s perspective, but they need treatment now. “Why are you making me wait?” It’s critical to communicate why this is important and what we’re doing to solve it.

Transcript edited for clarity.