Listen to this podcast with advanced practice professionals providing an overview of the current biomarker testing landscape for patients with lung cancer, including their thoughts on overcoming key barriers to testing, education of patients and caregivers, and improving equity in the application of biomarker testing in patients with lung cancer.
Advanced practice providers discuss biomarker testing in patients with lung cancer. Listen in to learn from Beth Sandy, MSN, CRNP,FAPO, and Denise Rouse, MS, PA-C, about key biomarker testing in patients with lung cancer, including their thoughts on overcoming key barriers to testing, education of patients and caregivers, and improving equity in the application of biomarker testing in patients with lung cancer.
Presenters:
Beth Sandy, MSN, CRNP, FAPO
Thoracic Oncology Nurse Practitioner
Abramson Cancer Center
University of Pennsylvania
Philadelphia, Pennsylvania
Denise Rouse, MS, PA-C
Physician Assistant
Thoracic Medical Oncology
Department of Medicine, Section of Hematology/Oncology
The University of Chicago Medicine & Biological Sciences
Chicago, Illinois
Link to full program:
https://bit.ly/4rt1OCl
Get access to all our new podcasts by subscribing to the Decera Clinical Education Oncology Podcast on Apple Podcasts, YouTube Music, or Spotify.
This transcript was automatically generated from the audio recording and may contain inaccuracies, including errors or typographical mistakes.
Advanced Practice Professionals Discuss Biomarker Testing in Patients With Solid Tumors: Lung Cancer
Hello and welcome to this Decera Clinical Education Oncology podcast. I am your host, Jerfiz Constanzo. In today's episode, we are joined by Beth Sandy, who is a Thoracic Oncology Nurse Practitioner from the Abramson Cancer Center of the University of Pennsylvania in Philadelphia, Pennsylvania, and Denise Rouse, a Physician Associate in Thoracic Medical Oncology and Department of Medicine at the University of Chicago in Chicago, Illinois.
Together, they will be discussing the role of advanced practice professionals, APPs, regarding biomarker testing in patients with lung cancer. This episode is part of a larger educational program entitled the APP Guide to Actionable Biomarkers in Solid Tumors Reducing Barriers, Promoting confidence, and Leveraging Genetic Testing for Informed Treatment Decision Making. For more information on Beth and Denise, along with the link to the complete program including downloadable resources, clinical commentaries, and educational podcasts for colorectal and prostate cancer, please visit the show notes of this episode. Now, let us hear from the experts on the role of APPs and biomarker testing in patients with lung cancer.
Beth Sandy: Thank you, Jerfiz. I am happy to be here together with Denise today to cover this very important and exciting topic about biomarkers in non-small cell lung cancer that has really changed the way we treat lung cancer.
Beth Sandy (Abramson Cancer Center):
I should say for myself, I have been a thoracic oncology nurse practitioner for over 20 years.
Back 20 years ago, we did not have these biomarkers to test for. As a matter of fact, pretty much everyone that came through the door was getting paclitaxel and carboplatin. It was really the only thing that we had to treat lung cancer.
Now we have come so far. Particularly, what we are talking about today is identifying all these different biomarkers that are there in non-small cell lung cancer, and then how we can give the appropriate treatments to target these, and patients can live so much longer with a better quality of life that we have seen over and over with the different biomarkers that we find.
Sometimes Denise, it is even to the point that I look back, and I think about my young patients. Particularly, I feel like 20 years ago, I would have these young women who were never smokers coming in. They were 30, 35 years old, and we did not know that their lung cancer was probably very different from a lot of other lung cancers. Unfortunately, a lot of them died within nine months of treatment because all we had was chemotherapy back then. Now I think about them, and I think they probably had one of these mutations or biomarkers that we could have targeted, and we just did not know.
Sometimes that haunts me a little bit, but I am so happy now when we are able to find one in whoever it is, whether and - they affect all types of patients, these biomarkers. It is so exciting when we can find one and really personalize our therapy. How has this been for you, this biomarker testing experience over your journey as a physician associate?
Denise Rouse (University of Chicago):
I feel the same way. It was heartbreaking when earlier we would see patients, they would come in, they would not respond the same way, maybe if they were a younger, never-smoker. It was always really difficult to see these patients go through this process.
Now we have these biomarkers, which are changing really quickly. We are seeing new biomarkers every few months, six months. Now it is really exciting. It is what makes this fun and exciting. We have so much more to offer. It is so interesting. We have so much to learn.
But I think it is what also makes it overwhelming. It can be really hard to keep on top of all these biomarkers. I think about the people in the community who are seeing multiple types of cancer. I am just so amazed and impressed that they are able to manage so much. I have the privilege of being able to focus just on thoracic oncology. This must be really overwhelming at times for our partners.
Beth Sandy:
That has to be so hard if you are seeing multiple different tumor types.
Let us talk a bit about what biomarkers are we actually testing for in patients with lung cancer. It is just like you just said, Denise, this has changed so much in the past 5 to 10 years. I remember I was looking back at one of my long-term EGFR responders, and I saw the requisition that I had sent, which was handwritten, maybe, I do not know, 12 years ago.
The only thing I tested for was EGFR and ALK, and I thought, well, that is all I knew about back then. I did not know anything more, but now we know so much more.
I am interested to ask you, I am assuming you do a full next-gen sequencing panel in non-small cell lung cancer. You do not cherry-pick out different biomarkers. Would I be right to say that?
Denise Rouse: That is absolutely true. We definitely do full NGS, full next-generation sequencing. The part of the process that makes this more efficient for us it is reflex testing. To get that tissue, we see it is a lung cancer. We are going to have reflex testing that is performed. That way, we make sure people are not falling through the cracks.
Beth Sandy: Even at my institution, we have developed a smaller panel that we get quickly that has what we would consider the essential biomarkers. The ones that we have known established targeted therapies for, such as EGFR, ALK, ROS1, RET, MET, BRAF V600E, KRAS, and then the really outliers like NRG-1 and NTRK. But it will do, I think, a 30 gene panel, and we get that a little bit quicker than the full panel. Then we reflex to that of course. Timing is always an issue, and we are going to get into that in this podcast of how timing can be such a barrier and so difficult for patients.
Another thing I wanted to ask you is can you explain to our listening audience what the difference is between a germline mutation and a somatic mutation or a biomarker? Because I think those terms get thrown around a lot. In lung cancer, we see less germline. You may see that more in things like breast cancer or gynecologic-type cancers. Can you explain to our audience what the difference between those two terms are?
Denise Rouse: It is really important because often, the patient comes in, they find out they have cancer, and then they immediately think, what about my kids? Is my daughter, is my son going to inherit this? It is important to understand the difference between germline, something you are born with, it is inherited, that can be passed down to the next generation, and we need to be thinking about screening and how do we protect that next generation, versus somatic, which is what most of our lung cancers are, the vast majority, and those are acquired.
Those happen over time. You are not born with them. You pick them up as you go. There is a change in your cells that forms the cancer. You are not going to pass that on to your next generation, and it is not going to affect your family or those around you in terms of seeing it forward. I have actually had people also sometimes be worried could they give their cancer to their family member?
I do not know if you have ever seen that, but sometimes people are scared, worried.
Beth Sandy: They are. Parents will be like say, "Oh, you have an EGFR mutation," and like, "Oh my gosh. My children, are they going to get this too?" We can confidently say to them that no, EGFR, ALK, really most all of our biomarkers that we have targeted therapies for, these are somatic. These are not something that are hereditary and passed down to their children. I have seen patients in the clinic breathe a sigh of relief. Even sometimes their children that are sitting in the room with them, because that can be really a difficult thing to think about.
Denise Rouse: I do think that that can be a real challenge for families. Sometimes it allows the patient to - sometimes it allows them to shift the focus a little bit more to their cancer and what they are going through, because I do find that patients are often almost more worried about their children, about what is going on, how this could affect them. I do think it allows them to say, okay, this is just me, now we can work on this.
Beth Sandy:
The implications of this testing for our clinical practice and the way we develop treatment plans and certainly patient outcomes, all comes into play here. When we get one of these biomarker tests back, and it shows that there is an actionable mutation. Denise, maybe walk me through how that conversation might go between you and a patient? Let us just take, for example, maybe an ALK gene rearrangement, if that comes back. How does that look for you in your practice when you might be talking to a patient about that?
Denise Rouse:
Part of the role that we play is we do a lot of education as APPs at my site. I think that that is pretty common that APPs are educators, and we spend a little more time sometimes answering those questions that people have after their diagnosis. With the biomarker testing we talk about, let us say ALK, we talk about is that we have found what is driving your cancer. We talk about these targetable mutations, these driver mutations.
We have seen with this testing what in your cell is not working properly that is allowing your cancer to grow. The good news is that we have a drug, in this case, it would be an oral pill that you would take to target that very specific area that is causing the cancer to grow, and that we will be monitoring you. We find that people tend to respond better. We can manage the side effects, and they tend to have less time in the clinic and live longer.
I think one of the challenges, as we look at all these biomarkers, is also all of the different drugs that we have that target them, which we can talk about later, also have different side effects and different monitoring profiles. I will usually, in the very beginning, make sure that I go through what is our monitoring plan and what are some of the side affects you can anticipate? When do you call us?
Beth Sandy:
I think that was an awesome description of how you talk about this with a patient, because what I loved about what you said is how you took it down to a level that patients can understand. You are not sitting there using big words and saying, "The way that these genes are rearranged within your cell are going to cause driver growth."
You are not throwing these big words out. You are saying what it really is, is that "We have identified this thing this protein that is within your cancer that is helping drive your growth of your cancer, and we have a pill that we can target that with." Because most patients think about lung cancer, they think chemotherapy.
Thanks to television commercials, they think immunotherapy. Now they are thinking like, oh, why are not you giving me something IV in my arm? We get to say to them, "No, you can take this pill, and this has been studied. If you compare this to chemotherapy or immunotherapy, you do much better on these medications that are targeted towards this biomarker that we found." I think keeping it on that patient level is really great and reassuring them that the outcomes are better.
We know this based on clinical trial data, that these outcomes are going to be better than something IV we are going to put in your arm or something you may have seen on television, which works great. I remind patients, hey, that works great for a whole subset of patients who do not have your specific type. The pill thing too is big.
Denise Rouse: Yes. This is a real common thing we see, especially in this day and age. How do you handle patients who come in with doing their Dr. Google research and saying to you, "But wait a minute, I saw though that this immunotherapy that these drugs I should get this because I saw my PD-L1, it is high. I can see that it is really important. Why would you not give that to me along with this pill?
Beth Sandy:
I literally had a patient come in one time with the name of an immunotherapy drug on a napkin, and it still had a coffee stain on it. He said, I was meeting my friend, and he wrote this down on the napkin for me because he thinks I should be getting this. I said, well, that is a drug that works great sometimes for lung cancer, but you have this EGFR mutation, so you are in a better group because you get to take this pill that works even better than that. I know it is been advertised, and like I said, it works great for some people, but this is not for you. Yes, patients will certainly, I think gravitate toward that.
Denise Rouse:
I do find as well that when we get these tardy mutations, and I have these, what we call at our site sometimes the Dr. Google, who is weighing in on these things. We do have some really good organizations out there that people can get good, validated information. People who are really interested in more, I will sometimes refer them to LUNGevity or some of the targeted groups like an EGFR resisters, most of these have those different groups, where they can talk to people who have the same type of cancer, and they can get better information.
Beth Sandy:
The KRAS kickers, the ROS wonders. I love it with their names. They have come up with great patient advocacy groups. Let us dive into some of our themes that we have seen within biomarker testing. I will introduce this.
We did a survey because we wanted to survey some other advanced practice providers who are in oncology to see what they have experienced as far as biomarker testing, as far as barriers to testing, how we interpret testing, what our role in treatment decisions are, and so forth. We are going to walk through some of these and introduce some of the data that we saw. We did this basic survey. There were 39 people who responded. About 25 of those were nurse practitioners and physician associates.
We are going to stay on the data from that subgroup. Out of that subgroup about, I would say, a little over 50% of us saw the majority lung cancer patients, and then the other 50% saw a little bit of a mix of everything. I think we got a good representation of these barriers and different things that we experience in practice.
Let us talk first about some of our barriers with testing integration. I think, Denise, you and I could probably spend a half hour just on this topic. It seems so easy. It seems like, just test all of your patients for this broad molecular panel. Just do it, and then you will have the results and be able to start your treatment. At the end of the day, it is not that easy.
To be honest, in our testing results, only about 50% of our APPs said they are routinely doing the full NGS panel. Some of them were doing other piecemeal panels. The majority of people were doing some testing.
I think you and I were both taken aback by that number. We feel like it should be 95%, 100%.
What do you see, and what did you think from our data are some of the main barriers?
Denise Rouse:
I think one of the easiest ones to answer is identifying which patients to test.
In the guidelines, we test everyone, but stage IB for your metastatic stage 4 is everyone. We should not be using clinical pathological features to test. We do not just test nonsmokers. We do not just test a younger patient. Everyone should get testing because starting at stage IB, there are some mutations we find that are actionable even for those early-stage resectable patients. That should be the policy. That should be the standard that you have.
Beth Sandy:
Denise, do you guys do reflex testing at your institution?
Denise Rouse:
We do. I think that that is one of the things that can be very helpful to have reflex testing, so those people are not falling through the cracks.
Beth Sandy:
What that means for anyone listening is that reflex testing means that in your pathology department, as soon as the pathologist reads a specimen that is non-small cell lung cancer. Now, in my institution, we only reflex the non-squamous patients right now, whereas other institutions may do everybody with non-small cell lung cancer. Our institution we reflect on the patients that are not squamous. That is going to mainly be adenocarcinoma, but it would also fall a large cell or not otherwise specified.
Any patient that gets that pathology read, the pathologist is immediately going to send this for biomarker testing. They are not going to wait for an oncologist or a pulmonologist or someone else to order the test. They are going to automatically start the testing. I think that relieves a lot of barriers. One of which, like you said, is identifying who to test because we are just going to test everyone.
It also helps with the timing. I think we should probably go into turnaround time. 39% of our responders said turnaround time is a huge barrier for them. If you sit in front of someone, a patient in the office with stage 4 non-small cell lung cancer, and say, "Hey, listen, I am going to wait a couple of weeks until I start your therapy." That does not go over real well. How do patients respond when you say something like that, Denise?
Denise Rouse:
Oh, it is definitely true. Patients, they are like, "But you got to do something now. I have cancer in my liver. I have cancer in my lungs," and it is very panicking. Sometimes the family is even more panicked. That is pretty standard. It takes two or three weeks for us to get these next-generation sequencing results. That is going to happen across the country.
It is not like they are going to go to an institution across the street who can get it for them in three days. It does take time. It is really talking about we want to make sure we get the right medicine for your cancer. We want to make sure we are personalizing that treatment to make sure that you are getting a treatment that your cancer will respond to. If we wait, we will get all of the data to make those choices.
Beth Sandy:
Let us talk about some of the other barriers as well, because I feel like there are so many. I think we will spend a little more time on this topic. Have you run into cost or reimbursement issues?
Denise Rouse:
Yes, that is really interesting. I think this goes into disparity as well, because one of the studies that I have seen recently has mentioned that sometimes providers are not ordering the testing, because it is very expensive testing, because they are afraid that there is going to be a cost burden to the patient that they cannot manage.
In Illinois, I work in Illinois, and we are really fortunate here, we actually have had state legislation that Medicaid, and all of our state-funded insurance programs, are mandated to cover biomarker testing. It is really helpful. That is something that advocacy groups are trying to enact. There is other states across the country.
We know our patients that are on Medicaid, that are the patients maybe we are most concerned about coverage, it is going to be covered, so that is taken care of. A lot of the testing, they are covered by Medicare. A lot of the commercial carriers follow that. I do not think there is as much of an issue of coverage as they used to be. Copays are a different issue, but our social workers can sometimes help us with some additional resources to help if there is a large copay that needs to be paid, and most of the time, it is covered well. What about you?
Beth Sandy:
The testing companies that we use mainly do ours in-house, but the liquid biopsies we still send out, and within those liquid biopsy testing companies, they have a policy they are never going to balance bill someone more than $100. Even within that $100, they have said, if they cannot afford it, we are not sending anyone to collections. We are not doing any of that. They are just not aggressively going after this.
Those companies want to be paid too. They are going to do the legwork for you to fight the insurance company and say, this was appropriate, but that was one of our big respondent answers was the concern for cost. Then the last one I will touch on was our biggest one. This was the most common barrier identified in our survey, was insufficient tissue. What are you going to do? I know you get this result back.
I will say this sometimes with pleural fluid, if a patient has a pleural effusion. It is a quick, easy way to get a diagnosis. You drain the effusion. A lot of times, there might not be a lot of cellularity to that, and the ability to get a good DNA extraction is not great. You have insufficient tissue. What do you do in this situation? So hard.
Denise Rouse:
It is so hard. If we have a metastatic patient, this is where liquid biopsy can give us additional information, in that setting. Although, for our metastatic patients, liquid biopsy should be being run along with our tissue biopsies. It is really hard, and so we have to look at can we get another biopsy? Can we get better tissue?
Sometimes that is just institutional as well as our teams working with each other to try and maximize the tissue that they can get sent to pathology. What do you guys do?
Beth Sandy:
It all depends, it really does. If we have insufficient tissue and a patient is sick and they need to get started right away, we are probably going to honestly start them on chemotherapy, not immunotherapy. The immunotherapy is what we want to hold off on, because we wanted for sure no biomarker status before that. Maybe get some chemotherapy on board, find a new place to biopsy to get sufficient tissue, and get as much of a rapid turnaround. I think this is also a great place for liquid biopsy because you can send off the circulating tumor DNA within a liquid biopsy.
Now, the problem is if that comes back negative, that might be a false negative because sometimes there might have not been, if there is not a heavy disease burden, you might not have a lot of circulating DNA. I think it all depends. I think another thing that depends on it too, and the waiting part is what are their clinical features? Now we just said we want to test everyone, which is absolutely true. If I have a young, never-smoker in front of me, it is probably likely that they have some actionable biomarker. I may be more inclined to wait, if I can, to get that new biopsy. I certainly want to send the liquid biopsy right away on those patients, but I think this has been one of the biggest barriers that was certainly in our survey, identified as the biggest barrier to getting the testing done.
I think anytime somebody drains an effusion or gets a very small biopsy specimen, we have to rethink that and say, I need a good specimen here, because I know it is going to affect my treatment.
Denise Rouse:
You brought up a really good point that I think is so important. We have actually in the last month, we have had two patients come to us from outside institutions that were started immediately on chemotherapy and immunotherapy. Biomarker testing was done. Then we found that they had EGFR mutations. It is really important if a patient needs treatment, let us get them some chemotherapy. Let us get them some relief while we are waiting for that biopsy to cook and give us results, because if they do have some of these mutations, we could really be depriving them of their next best therapy, because they can have increased toxicity when we add on these targeted therapies. And immunotherapy often does not work as well in these patients.
Beth Sandy:
Absolutely. If you give the immunotherapy, you cannot take it back. It is like a six-month half-life. That is why I say do not give the immunotherapy. Just give the chemo. Because if the immunotherapy is on board, and then you have to switch to a targeted therapy, there is often a lot of toxicity.
Let us move on and just spend a couple of minutes on interpreting these results. Sometimes I think you need to be a rocket scientist. Denise, what do you think?
Beth Sandy:
Have you tried to read some of these? What is with the numbers and the letters, and the underscores and the stars?
Denise Rouse:
It is literally a different language. It is a foreign language. These are not terms that we understand, not things we usually do. I think one thing to realize is not no one has memorized all these mutations no one all has this all down. If you can just get comfortable with the most common mutations, at least with the list of targeted mutations that we have, that can really help you, and you can start there. It is also okay to say to someone, I am not sure what this means, but I am going to take it to my molecular board and make sure that we get the right interpretation and we get the best treatment for you, or to my multidisciplinary tumor board. It is okay to tell your patient that because they want you to do the right thing.
Beth Sandy:
When I get these reports, and I do not understand, I call my molecular pathologist. I have them like I know exactly how to get in touch with them, or I email them right away. This just happened recently. This says RET, but you have it under a DNA variant of uncertain significance. What is that? They said, well, remember, Beth, a RET is a fusion gene. This rep that we reported is not fused with another gene. It is actually some DNA mutation that is not the type of RET that would be actionable. I said, well, how would I know that? Then they went into some spiel about what a fusion looks like on their report.
Just ask, because usually on the report, it will say disease-associated variant, which is usually something actionable or associated with the disease. Then you will have a point that says VUS or variant of uncertain significance. When listed under there, that is your pathologist telling you, we are not sure what this means. It is uncertain if this has any disease associated implication, but it might not. That is one thing you can look out for immediately.
Denise Rouse:
Yes, for sure. This is where the devil really is in the details. It is not enough to know it is an EGFR mutation. You have to know which one. We have to know what the mutation is. EGFR amplification is not the same as mutation. The other one is like a KRAS G12C, and these are two most common, KRAS and EGFR. KRAS G12C, like Charlie, is not the same as KRAS G12V, like Victor. One is targetable. One currently has no FDA-approved treatment. It is not enough to just see that mutation.
You really have to understand the specific mutation it is. The College of American Pathologists, at the end of last year, put together some guidelines where they are working on a standard for reporting of NGS so that each company you go to everywhere you go, it is going to have a standard and more readable NGS. As that is rolled out, I think that may help, but yeah, you really have to look carefully.
Beth Sandy:
You would love that. I think to summarize that, just call the company, call the molecular pathologist, whatever it may be if you are not sure because you need to be sure on this, before you select therapy based on it, and it can be really confusing. Do not feel bad, guys. Denise and I do this every day for a living, and we still do not know every time. Do not feel bad if you do not understand it, because we do not always either.
Transition a little bit and talk about what our APP's role in treatment selection is. This one is a little bit harder I think. Denise, you and I have been doing this a long time, so I probably have a little bit more of a comfort level. I certainly didn’t in the beginning and would not, and that makes sense. I think it depends on the biomarker also. For example, if you have somebody who is ALK positive, who has a low PD-L1 expression, that is a slam dunk. We know what we are doing. As a matter of fact, it is a slam dunk, even if they have high PD-L1 expression, because the answer is still an ALK therapy. It is way better than immunotherapy or chemotherapy would be in these patients. The treatment decision really is up to the oncologist at the end of the day. I think we a lot of times, probably start the conversation when we see one of these reports, if we are the one that gets the report back, I would often call a patient and say, "There is a pill that we are likely to start you on”. What are your thoughts on how you - do you feel like you have a role in the treatment selection?"
Denise Rouse:
I definitely think medicine in general is a team sport, but especially oncology. What we do is our physicians are going to make that treatment selection. I think that is totally appropriate. As you said, we will often educate the patient as to what might be expected. Like you said, if we are seeing the report before that patient's back in to see the physician, certainly educating them after they are given that drug, monitoring them, helping monitor toxicity, helping them understand their disease, answering their questions. We talk about all of our patients every week.
Every patient is going to be seen the following week. We talked together as a team. Sometimes the physician will say, hey, you have seen this person quite a bit. How hardy do you think they are? How do you think they might tolerate whatever this treatment is? We work together as a team to understand what the best option is, but the physician makes the treatment decision always.
Beth Sandy:
Then that leads into our joint decision-making and shared decision-making, which is a big deal now in oncology. I think back, like I said, 20 years ago, we had like paclitaxel and carboplatin and not much more. There was not a ton of shared decision-making going on because we did not have really many options. It was like treatment, no treatment. Now there are a lot of options for patients. Even in particular, what did we just talk about ALK? There are now six drugs approved just within that setting. I do not know, we can talk with patients about what some of the toxicities are of different agents.
Our APP survey, and we asked them how confident are you in your ability to explain to patients the difference between something like a PD-L1 status, NGS results, and histology?
A lot of people said they were not all that confident. Actually, the majority and then the people who said they were really confident were probably the people that just do lung cancer for a living, I am guessing, I do not know, to that level. There were certainly people who said they do not feel really confident in explaining the differences of this and helping the patient make that shared decision-making. What are your feelings about that?
Denise Rouse:
I think if you understand this base level, the nice thing is you can learn this piece, and it applies to all of our targeted therapies.
These are the basics. This is the foundation for all of our targeted therapies. If you are able to talk to patients and explain the histology is that this is an adenocarcinoma. That is what it looks like underneath the microscope. That is what the pathologist is seeing, and it helps us identify where the cancer is originating from. That is that piece of it. Then that can be confusing for like but wait, you said I have EGFR or a PD-L1, how do you explain to them the difference between PD-L1 and NGS?
Beth Sandy:
I would certainly say to them a PD-L1 is an expression level. This is something that is looking at a percentage of protein on your cell that might predict for how you might respond to immunotherapy. NGS is different. These are actual driver mutations within your cells that we have targeted therapies that will absolutely change the outcome of how we treat you. That might be some way that I would explain it to a patient.
Denise Rouse:
They are all pieces of the puzzle, right?
Beth Sandy:
Yes.
Denise Rouse:
You need all those pieces to make the best decision.
Beth Sandy:
Then I think making the best decision with the patient also comes from our ability, as APPs, to communicate with the specialists.
My experience usually is that they are happy to talk to us about it and explain it to us, because it can be confusing. In our survey, the other APPs, the majority felt that they were either very confident or extremely confident in collaborating with their medical oncologist, with the rad onc, with the molecular pathologist, because I think we all are speaking the same language and we are all doing this. But I want to make sure that for all our listeners, you can talk with these other specialists.
Denise Rouse:
I have the same experience as you where most of the vast majority of the time, people are happy to give advice. They are happy to share their expertise. Just ask the question. If it is not an urgent question, send an email. If you can, get the answer tomorrow, if you are worried about interrupting someone, just send them an email. The worst that can happen is they can say, talk to your doctor, or I do not want to answer this question, but it is always worth asking because most people will share their expertise, and it is one of the best ways to learn more about this process is to actually get that insight from somebody who has some special knowledge.
Beth Sandy:
Agreed. Now, let us finish up by just talking about health and equity regarding biomarker testing. There is certainly literature out there. Among our overall respondents, all 39 of them, actually, this was not just the APPs, but physicians, nurses. Out of all of them, 82% said they definitely feel like they have noted health inequity regarding testing. Let us talk a little bit about that. I think for me, something I always worry about insurance and whether it is going to be covered. For patients who may be on a Medicaid plan or some plan that might not be as strong.
Again, this goes back to what you and I said earlier, that should not be a factor. This is covered by medical assistance. It is covered by Medicaid. It is covered by Medicare. That should not be a reason that we do not test patients. I think health literacy might come into play here. Our ability to make sure we are explaining this to patients, no matter what their education level is, we have to be able to explain this. You did a great job of giving an example of that earlier. What do you feel in your practice have you seen inequity within biomarker testing and lung cancer?
Denise Rouse:
You have hit on two of the major areas. One is if we do not test because we assume, either because of their socioeconomic status, the type of insurance they have, we assume they cannot afford this coverage, or if we say it is an 80-year-old smoker, they do not really need necessarily this biomarker testing. We know what is going on, it is unlikely. Those people then are going to have - we are just not going to know. People who can be treated, who can really have better outcomes, they are going to miss those opportunities.
The other thing that happens is I do think that this also leans into the fact that we have disparity in clinical trials. Many of our clinical trials are targeted, and if we have that information, then those same patients may be eligible for some clinical trials, and we will have more people that have access to those opportunities.
Beth Sandy:
That is a great example. I am going to just finish up with - I am just going to tell you one of my own personal stories about something very similar to this. This was years ago. I had this very elderly, African American male heavy smoker. I think he was still smoking at the time. He always came alone.
He and I developed a relationship over time because we had been treating him with chemotherapy and immunotherapy for over a year, he was really debilitated. He is one of those guys that, I said, can I get you a wheelchair? No, I do not need one, and he is walking with his walker, and I am walking behind him down the hallway, thinking, oh my goodness, I am going to catch you when you fall. He was so cute.
We just had this great relationship over the years. When he progressed on second-line therapy and I thought, well, I think this is it. This is for hospice, and I thought this guy has adenocarcinoma. Did we ever test him? I go back, and I look, and we did test him, but for whatever reason, and this was many years ago, it was like not in the EMR in a place that I could really find it. It was not a top on my radar. This is not an Asian female, a never-smoker, like somebody who I am thinking definitely is going to have a mutation.
I literally was ready to make the hospice call. I would already talked to the doctor, and we went back like, did we ever test him? Sure enough, he had a KRAS G12C, and we did not see it because I think in my own mind I was just thinking, well, he does not fit the picture of someone who is likely to have an actionable mutation. He had no one there supporting him or advocating for him. If you think about that, it was just him and his health literacy was not good. Here is me with my own unconscious bias, not thinking that this is someone likely to have a mutation. Sure enough, he had a KRAS G12C. We did put him then on targeted therapy because it is oral, did not have a lot of side effects, so we did not have a big downside to that.
I think that is a good, realistic case of someone who I had unconscious bias towards that I did not think that would be a candidate for this. This is something that you have to remember. All patients can have a targetable mutation, and we need to be looking and advocating for them, particularly when they do not have someone else there with them who is also saying, “hey, do your biomarker status? Did you look it up?”
Denise Rouse:
Your story illustrates a couple of really good points in there. One is that part of the reason we need to do broader testing is because, although that target is not available today, it does not mean that there is not going to be a treatment available for that target six months from now or a year from now when they progress. KRAS G12C, it is a common mutation, but there was no treatment for many years, and so it is easy to overlook that later on. You have to go back and you got to look. Some of those mutations, like KRAS G12C or the BRAF V600E we see those in smokers. We do see some of these mutations in different smokers.
The one other thing I wanted just to bring up is resources. I know that that was something that was asked by some of the people in our survey, and one of the things they asked for is, do you have a one-page list of the drugs and the biomarkers? We actually do. If you go to the NCCN, which is the National Comprehensive Cancer Network, which is the standards for cancer in the United States, you do have to have a subscription, but it is free.
In other words, you do have to put in a username and a password to get access, but there is no charge to that. They have great algorithms and flow sheets to tell you, by stage, what do you do next? You can follow that along, and there is a one-page biomarker-directed therapy that talks about our targetable mutations and the drugs that are approved for that. ASCO also has a - they call it a living document - it is an article that is out there that is continually updated, that gives you more detail.
If you see, like you said, it is an ALK fusion, and there is six therapies and you are like well, where do I go with this? If you go to ASCO, there is a nice little ALK. Here is the drugs, and there is a nice little maybe half page. It is not real onerous. Information that tells you here is the studies. This is what they resulted from. Here is what we got these drugs. These are some recommendations for how to sequence these drugs. There are some resources that are not really hard to work through that are going to help you get more information.
Jerfiz Constanzo: Thank you, Beth, and thank you, Denise, and thanks to you, the listeners, for joining us. As a reminder, to view the full program, the APP Guide to Actionable Biomarkers in Solid Tumors, Reducing Barriers, Promoting Confidence and Leveraging Genetic Testing for Informed Treatment Decision Making, and to access online resources associated with this discussion, please click the link in the show notes.
Thanks for listening.