Molecular Results Interpretation and Subsequent Treatment Selection for EGFR Exon 20 Mutation-Positive mNSCLC

Dr Piotrowska and Lauren Welch offer insight into results interpretation and subsequent treatment decision-making for patients with mNSCLC who are found to harbor an EGFR exon 20 insertion mutation through biomarker testing.

Joel Neal, MD, PhD: Zosia, any additional insight on this?

Zosia Piotrowska, MD: This is just an incredibly confusing space now. And even just distinguishing between an Exon 19 deletion and an Exon 20 insertion, if that's not spelled out in the report if it just says A746(del) versus S 768-770 insertion. I think the standard thoracic oncologist, much less a community oncologist who's treating all different types of cancers, is not going to know what Exon that falls into or what type of insertion or deletion that is, nor should they. And it is really, really important that the reports at least be clear on the specific type of insertion or deletion that's being seen, what Exon and ideally the treatment implications as well. That's not even getting into many of the atypical EEGFR mutations, which can be really tricky to figure out what to do with. And I think that's where molecular tumor boards are important. But it is really incredibly helpful for all of us academic and community providers when the reports are clear and standardized in how these are reported, how these are spelled out. And not only the immune acid changes but also the specific category that these fall into.

Joel Neal, MD, PhD: Lauren, I know Sarah Cannon's part of a vast network of community oncologists, and it must be a challenge to standardize this not only the testing but the interpretation of the testing results across that. What are the efforts being done to make sure that all of the clinicians out there are acting on testing results in an appropriate way? And how much communication is there with the main providers that are affiliated with Sarah Cannon that we know well?

Lauren Welch, MSN, NP-C, AOCNP: You're right. It's been a tremendous undertaking, I think, trying to have consistency and have that level of breakdown for the different providers in the community. There's been several initiatives that I've really seen emerge these last couple of years, the more and more targeted therapies that have been approved. Sarah Cannon has its precision medicine team. We have geneticists and a molecular biologist in-house that run a Sarah Cannon Precision Medicine Tumor Board. And then Tennessee Oncology has its own molecular tumor board through one oncology. There are multiple avenues for the oncologists, for the providers to dial in and have cases reviewed with various teams. And that's been immensely helpful because we do talk about the more challenging or unique cases through our EHR system. We've also just in the last year, I would say, we have a new order set where you can request or order molecular help. And so, that request will go to the genetic team. They'll review the case and then reach out to the provider specifically. And then Sarah Cannon also has a platform that they developed called Genospace where all of the NGS results, when we get them back, they go into this system where we can interrogate it and search for what are the new KRAS G12C that have been identified this month and it's helped us with matching patients for trial within the whole Sarah Cannon network.

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