Interim Management Strategies Could Aid Patients With Advanced NSCLC Awaiting Biomarker Test Results

Although biomarker testing is crucial for determining optimal targeted therapies for patients with advanced non–small cell lung cancer (NSCLC), the time between conducting these tests and receiving results poses challenges for both oncologists and patients, according to Stephen V. Liu, MD.

“There are cases where we need to act fairly quickly [if] someone is symptomatic, and [we] use symptoms and disease burden to guide that [decision],” Liu said in an interview with OncLive^® during the 18th Annual New York Lung Cancers Symposium^®.

In the interview, Liu shared his insights on optimal ways to care for patients with NSCLC who are awaiting biomarker test results, which he presented on at the meeting. He highlighted the importance of biomarker testing for identifying effective targeted therapies for patients with lung cancer, characteristics that would make patients ideal candidates for chemotherapy before they receive biomarker test results, and strategies for symptom management during the waiting period.

Liu is an associate professor of medicine of Georgetown University, as well as the director of Thoracic Oncology and head of Developmental Therapeutics at Georgetown Lombardi Comprehensive Cancer Center in Washington, DC.

OncLive: What is the importance of conducting biomarker testing for patients with advanced NSCLC and waiting for the results before selecting a treatment?

Liu: When we treat a patient with advanced NSCLC, we need biomarker results, but they’re not always available to us right away. We’ll get a diagnosis of lung cancer, but the next-generation sequencing may take a few weeks. What do we do in the meantime? It’s easy to say we just wait for those results, but the patients are often anxious to start therapy, which is understandable because the symptoms [they are experiencing have] probably been going on for a while. Additionally, there are often delays in diagnosis, [so patients have a] sense of urgency; they want to get started [on treatment] quickly.

However, we need to stress that we’re not looking for the fastest treatment; we’re looking for the right treatment. There are consequences with giving the wrong therapy or giving treatment in the wrong order. We know that when we give immunotherapy before a targeted agent, such as a TKI, it increases the toxicity of that TKI. We want to avoid putting ourselves and our patients in that situation.

What disease features might influence your decision to start a patient on chemotherapy before receiving definitive biomarker results?

When we get a [patient’s] diagnosis of metastatic lung cancer and we want to start systemic therapy, we need those biomarker results first. Those are going to point us toward targeted therapy or away from immunotherapy if we see an actionable driver. However, we have to wait for those results, which can be challenging to do.

If we need therapy quickly, it’s got to be chemotherapy. We can’t give targeted therapy without knowing the driver, because we’ll be giving an ineffective treatment. We can’t give immunotherapy without knowing the driver because it also could be ineffective if there’s an EGFR or ALK alteration. Also, [immunotherapy] can complicate subsequent targeted therapy, and it’s hard to walk back from that. Chemotherapy bridges that [period between testing and receiving results].

We can see modest responses [with chemotherapy; it] can work fairly quickly, and [it does not] alter the subsequent safety profile of other treatments. We can give chemotherapy safely, if needed, in the meantime. However, ideally, we are waiting for [biomarker] results when we can.

How do you address and manage symptoms in patients as they wait for biomarker test results?

If [patients] have a lot of symptoms while we’re waiting for those results, and we need to start therapy, [a treatment such as] chemotherapy can be effective. Sometimes, palliative radiation [can be effective as well]. Again, if it’s a short wait, then we’d rather just wait for those [test] results. Sometimes, we can do things to speed up [the testing process, such as] using liquid biopsy to try to get results quicker or making sure the tissue goes out [for testing] with some urgency.

We need to make sure we’re in constant contact with our patients, so they know we’re not forgetting about them. [We need to] provide that reassurance. Watching symptoms, [prescribing] pain medicine, [and conducting] symptom control are strong strategies to [use] until we can safely deliver the right treatment to patients with advanced lung cancer.

Reference

Liu SV. Managing patients while waiting for test results. Presented at: 18th Annual New York Lung Cancers Symposium®; November 11, 2023; New York, NY.