Clinical Cases in Lung Cancer - Episode 7

Case 2: 67-Year-Old Woman With EGFR+ Non–Small Cell Lung Cancer

Mark Socinski, MD: Let’s move on to case 2, this is a case of a patient with EGFR mutation-positive non–small cell lung cancer. It’s a 67-year-old woman who presents to her primary care physician complaining of visual disturbances, fatigue, and sporadic headaches. She does have a history of hypertension, hyperlipidemia, is a former smoker, pretty impressive 55-pack-year history. You can see her vital signs there. She does have some decreased breath sounds at the left lower lung base. Otherwise her examination is negative. Her CBC and chemistries are normal.

Her brain imaging demonstrates a 1-cm right parietal mass at the gray-white junction without significant vasogenic edema. Chest CT, abdomen, and pelvis shows a 3.4-cm mass in the left lower lobe and several small liver nodules there. She has a CT-guided transthoracic needle biopsy of the lung lesion showing a grade 2 adenocarcinoma acinar subtype, so she stages a T2aN0M1c. Her ECOG performance status is said to be 1. The initial laboratory results we get back show that she does have a higher expression of PD-L1, 70%, done by the 22C3 test, and the patient is anxious to start therapy, as most of them are. I guess the first discussion that I would have here, and I’ll let Dr. Kim to address this. What would you recommend for molecular testing? Then, what do you do with this PD-L1 status before you know the results of the molecular test?

Edward Kim, MD: Thanks, Mark. I still remember, just to digress, the first day when I was at Anderson Cancer Center, we converted from paper memos in the boxes to email, and it was a requirement that you had to check your email to get messages, and if you missed a meeting because you didn’t check your email, you were at fault. That’s the way you have to initiate change. As a medical oncologist out there you have to do these biomarkers and you must do all of them, and not just part of them. You can’t check your email once a week, it’s just not like that. The problem is out there, there’s no accountability to check on that, and we hear all kinds of excuses. For good or for worse, immunotherapy has been a great treatment initiative for many patients, but it doesn’t allow you to skirt the biomarkers.

The fact that we, even since May, we’ve had 7 different indications for lung cancer including 2 brand new biomarkers, RET and MET exon 14. You have to do these markers, you have to absolutely do them. You wait for the results, and then you make a decision on treatment. That’s like starting treatment without the biopsy results coming back, however you want to relate it. It’s one of the big no-no’s right now in treatment of non–small cell lung cancer to start therapy without having the molecular results. I ask people, I see this all the time when people are starting chemotherapy. When did chemotherapy get so good that that was going to be the therapy that we need to start? I don’t know what changed.

Transcript edited for clarity.