Dr Seetharamu on Current Platforms Utilized for Molecular Testing in Lung Cancer

Nagashree Seetharamu, MD, MBBS, associate professor, medicine, Division of Hematology, Medical Oncology, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, discusses currently utilized platforms and workflows for molecular testing in lung cancer at Northwell Health.

Northwell Health employs a reflexive testing pathway that initiates once the pathologists receive a sample, with different platforms used depending on whether the disease is early stage or advanced stage, Seetharamu begins. Communication between the pathologists and the clinicians is crucial, as it can be difficult for the pathologists to determine the stage of a patient’s disease based solely on the biopsy location, she states, adding that cases where the biopsy comes from a primary lung site or a metastatic spot can be particularly challenging. However, if a sample comes from a liver or adrenal biopsy, it may not require additional clinical information, she notes.

In early-stage lung cancer, Northwell Health focuses on detecting mutations in 

, as these are key biomarkers that guide treatment decisions, Seetharamu says. Although insurance may not always cover comprehensive molecular testing for early-stage disease, the goal is to expedite the identification of these mutations so that neoadjuvant therapy can be initiated without delay, she explains. Both 

 testing are now performed in-house for early-stage disease, allowing for rapid turnaround times, which are critical when starting treatment, Seetharamu states.

For advanced stages of disease, molecular testing is typically outsourced, although efforts are underway to bring this process in-house, Seetharamu continues. Currently, Northwell Health uses DNA-based methods for mutation detection. However, if there is a strong suspicion that a mutation may have been missed, the sample will be sent for RNA-based testing, she says. Additionally, Northwell Health conducts in-house testing for certain targetable proteins, depending on tissue availability, Seetharamu notes. Tissue quantity remains a key limiting factor, as comprehensive testing depends heavily on having enough tissue from the biopsy to run these necessary tests, Seetharamu concludes.

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Nagashree Seetharamu, MD, MBBS, discusses currently utilized platforms and workflows for molecular testing in lung cancer at Northwell Health.

Nagashree Seetharamu, MD, MBBS, associate program director, Hematology/Oncology Fellowship Program, Northwell Health; associate professor, medicine, Division of Hematology/Medical Oncology, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, discusses interpreting the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology and deciding when to initiate hospice care in patients with small cell lung cancer (SCLC).

Dr. Seetharamu on the NCCN Guidelines for SCLC

Although the NCCN guidelines provide recommendations for the second-line treatment of patients with SCLC, choosing to retreat patients with platinum-doublet chemotherapy or begin using lurbinectedin (Zepzelca) instead is a decision that depends on individual patient needs and characteristics, Seetharamu says. Many physicians may choose to retreat patients with platinum-doublet chemotherapy before giving lurbinectedin, however, administering lurbinectedin first and then using platinum-doublet chemotherapy in later settings is also an option, Seetharamu notes. If patients have recurred within 6 months of their initial treatment, moving on to another line of therapy with a different mechanism of action or retreating them with previous therapies if they still have a good ECOG performance status (PS) are both strategies that are supported by the NCCN guidelines, Seetharamu explains.

The NCCN guidelines for the management of SCLC, were revised in 2021 to include lurbinectedin as a frontline treatment, Seetharamu says. In contrast, the NCCN guidelines for non–small cell lung cancer are frequently updated to include new treatments, highlighting the need for further research and additional treatments in SCLC, Seetharamu emphasizes.

Dr. Seetharamu on Hospice Care vs Further Treatment in SCLC

ECOG PS is 1 of the most important factors to consider when determining whether patients should continue to receive treatment or begin hospice care, Seetharamu says. If a patient’s health has significantly declined and further treatment is not in their best interest, hospice care could be the next step, Seetharamu explains. However, patient preference also plays a crucial role in this decision, as some patients, upon learning the pros and cons of continuing vs discontinuing treatment, choose to decline further treatment. Patient decisions to start hospice care should be honored and take precedence over any available treatments they may be eligible to receive, Seetharamu emphasizes.

Availability of suitable treatments is also a contributing factor in this decision, Seetharamu notes. In the third and subsequent treatment lines, patient characteristics such as organ function and comorbidities affect the therapies patients are fit to receive, Seetharamu concludes.

Nagashree Seetharamu, MD, MBBS, discusses interpreting the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology and deciding when to initiate hospice care in patients with small cell lung cancer. 

Nagashree Seetharamu, MD, MBBS

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