Erin Gillaspie, MD, MPH, FACS, a faculty member of Vanderbilt University Medical Center’s Department of Thoracic Surgery, explained what testing needs to be done to identify the best treatment for patients with lung cancer.
Erin Gillaspie, MD, MPH, FACS, of Vanderbilt University Medical Center (VUMC), explained what testing must be done to identify the best treatment for lung cancer patients, noting that not every patient benefits from the same treatments. Gillaspie is a faculty member of VUMC’s Department of Thoracic Surgery and an assistant professor of thoracic surgery.
She also presented at The American Journal of Managed Care®’s Institute for Value-Based Medicine® held in Nashville, Tennessee, on August 17, 2023.
What testing is needed to identify the best patients for certain treatments?
This is actually adding a layer of complexity to how we think about taking care of these patients now. One of the old adages we like to say all the time is "tissue is the issue," but I think I mean that more than ever right now. Because now when we're thinking about making a new lung cancer diagnosis, not only do we want to know the histology—so we want a diagnosis, we want a histology—but we also want the opportunity to do things like PD-L1 (programmed cell death ligand 1) testing, molecular testing, because immunotherapy is not the right answer for everybody. We have other molecular alterations, targetable mutations, that have dedicated therapies for them.
I think about, in particular, a treatment like osimertinib for our patients who are eGFR (epidermal growth factor receptor) positive. There are 2 primary mutations that we use osimertinib for—that's the L858R mutation and the Exon 19 deletion. We already know that that's very, very efficacious in the adjuvant setting based on the ADAURA trial. We hardly ever have disease-free survival and overall survival curves like we did in that trial. In fact, the trial was stopped early because there was such a benefit in that treatment arm.
The NeoADAURA trial is actually ongoing to help establish the efficacy of that treatment in the neoadjuvant space. One of the things that's sort of unique about some of these mutations is some of them tend to be very immunologically cooled. So, what do I mean by that? Well, immunotherapy doesn't work particularly well for them.
One of the really common mutations that I think about for that is the Exon 19 deletion. If we're not testing for that ahead of time, if we don't know that ahead of time, and then we're putting this patient on immunotherapy, not only are we giving them potential risks without benefit, but we're also potentially affecting their ability to get the therapy that's really going to give them the best outcome, which is the osimertinib.
It's really important that we do 2 different things. One, we have to get enough tissue to make sure that we understand the right treatment regimens for that patient. If that's not something that we can get ahead of time with just a biopsy, that's where all of us are starting to say, “Okay, so maybe that's a patient we don't think about neoadjuvant therapy for; we get a good resection on them, and then we give them an adjuvant to make sure that we're getting them the right therapy.”
The other piece to this is making sure we get the testing in a timely fashion. To that end, working within our teams, working with our pathology colleagues to say, “Okay, we need to get this testing back as fast as possible. So ,as soon as you have that new lung cancer diagnosis, we need to get that PD-L1 testing, we need to get the molecular testing sent off.”
Most places aren't lucky enough to be able to do that in house, and it takes a few weeks to get it back. The more that we can automate that, the more that we can get those tests sent off very quickly, the better we can deliver care in a really timely fashion to our patients.