Mark A. Socinski, MD: I think it’s important to realize that cancer is a disease of your DNA. And in lung cancer, particularly non–small-cell lung cancer, the DNA needs to undergo interrogation because there may be changes in the DNA—either mutations, which are alterations of genes that create altered proteins, or translocations in genes that also create altered proteins. And many of these proteins can be important in driving the cancer to grow.
Typically, we test the biopsy material, so it’s important to get enough of the biopsy material to test. But technology is bringing us the ability to test many of these things in blood, nowadays. So that’s another option. The things that I would absolutely want to know, that my doctor would know about, is, do I have an EGFR mutation? An ALK, or a ROS1 translocation? A BRAF mutation? Are there alterations in the MET protein (either amplification or mutation in that setting)? RET? HER2?
So there are a number of things that I think patients should be asking about, because these can potentially change the course of your disease—not only from the prognosis (how well you’re going to do, and how long you may live), but also direct you to the right therapy. Lung cancer, in 2017, is not a one-size-fits-all. Every case is an individual case. And even though there may be similarities between cases, each patient’s lung cancer may be different than the next patient’s lung cancer. So the way to distinguish that is to look for these alterations in the DNA that may have a huge impact on prognosis and treatment approach.
Edward S. Kim, MD: If we’re staged, we have a diagnosis, and we’ve done our scans, we need to do biomarker testing. These biomarkers are these markers, that again, reflect what’s in the cancer and what potential therapy we can match with it. So, the ones we like to do are ones for EGFR mutation, that’s epidermal growth factor receptor mutation, and ALK, anaplastic lymphoma kinase, as well as ROS1. And those are reserved mostly for our nonsquamous diagnoses. But we may also look for PD-L1, programmed death-ligand 1, which tells us if immunotherapy is the appropriate choice for initial therapy.
So part of what we have to discuss is what, based on all of the information that we’ve gathered, or if we need other information, is the appropriate therapy? Is it going to be an intravenous drug? Is it going to be an oral drug? Is it going to be a targeted drug? Or is it going to be a non-targeted drug?
Mark A. Socinski, MD: The process of molecular testing does take some time, depending upon what or how you may be testing it. It can take anywhere, for some of the tests, from a week to 2 to 3 weeks. In certain situations, patients are well enough and they don’t have findings that are really threatening to them. You can wait, although we all understand that that’s very anxiety-provoking. In many instances, when you have a sick patient that needs to be treated, then the current paradigm really is to use standard chemotherapy until you know the results of the molecular testing.
Again, there are many patients who a doctor may feel uncomfortable in waiting 3 weeks for the results of tests. You can start with chemotherapy. It doesn’t mean you can’t alter the choice of therapy if you find out that there was something detected on the molecular testing aspect of it. So there’s complete flexibility depending on the results. But if you’re sick, you need to get treatment.