The Lungevity blog features a video of Dr. Jack West from Swedish Cancer Institute in Seattle discussing his evolving views regarding molecular testing for actionable driver mutations in non-small-cell lung cancer (NSCLC). Dr. West is a thought-leader in lung oncology and I found this a tidy and brief summary of current issues and reasonable argument for expansion of such testing.
This is important for pathologists as we are often tasked with triaging testing as the time of diagnosis, managing results reporting, and driving testing. My own views as a pathologist with a concentration on lung cancer have changed over the last two years based on clinical practice, research meetings, recent publications, and listening to clinicians' views. Initially, it seemed to me that reflex testing of all advanced stage (stage 2B and up) lung adenocarcinomas and excluding tumors with squamous histology; since we generally are unaware of the smoking history, I ignored smoking history as a criterion for testing. I okayed this with the oncologists and off we went. Dr. West succinctly contrasts the two views concerning molecular testing in NSCLC: essentially testing all patients with advanced stage NSCLC versus testing focused on "enriched" populations, e.g. adenocarcinoma histology, never/light smokers.
My own views began to change as a result of one memorable lung cancer research meeting at Rush we had when one of the thoracic surgeons related how a patient grilled him on why he received an expensive bill for all this molecular testing without any discussion with the surgeon or oncologist and, moreover, when he had already expressed his preference to not receive any further treatment following biopsy and mediastinoscopy. These aren't cheap tests and someone (not the pathologist) must explain these results to the patient. I also reviewed our experience with molecular testing and found several instances where testing was sent on early-stage patients and squamous histology tumors, which I didn't think was appropriate. Based on another round of discussions with the oncologists, I decided that we should consult with the oncologist before ordering molecular testing.
But as Dr. West says, "Some patient's cancer don't read the books." He relates several recent experiences that have caused him to revise his views: squamous tumors that show driver mutations, including one tumor with both EGFR activating mutation and ALK rearrangement. He advocates broader, more expansive molecular testing as well as consideration of testing recurrences and re-biopsy of clinically stable lesions.
The bottom line is that this is still an evolving area--we must be aware of new data coming out and be prepared to modify our views and practices.