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As molecular drivers take a more prominent role in dictating courses of care, collaborations has become essential for ensuring that patients with non–small cell lung cancer (NSCLC) receive optimal treatment beginning at diagnosis. The rise of multidisciplinary care in this arena calls together thoracic oncologists, pathologists, interventional radiologists and pulmonologists, as well as a plethora of supportive staff to ensure that tissue samples and testing are executed within the parameters of a new standard—one that calls for larger sample sizes, next-generation sequencing (NGS) and other biomarker assays, and division of responsibilities across laboratories and institutions.

 program, Benjamin P. Levy, MD, discussed the challenges with tissue testing facing care teams. For a community perspective, he spoke with Bhuvana Ramkumar, MD; and Neil Morganstein, MD, who walked through the multilevel hurdles in procurement, analysis of results, and insurance.

Challenges With and Strategies for Tissue Procurement in NSCLC

: In my mind, lung cancer is the poster child for precision medicine. 

 are chapters 1 and 2 of the targeted therapy story that is still being written. We can start off there, but things have gotten incredibly complex. My running joke is that I went into lung cancer because it was incredibly easy 15 years ago, and this has certainly changed. The complexity [of the treatment landscape] has generated a tremendous amount of questions for patients, but also enthusiasm on behalf of both the oncologist and the patient. That has translated, fortunately, to include [improved outcomes].

We have now 10 biomarkers [with drug] approvals: 

 fusions. It’s getting exciting because can let these targets to specific therapies that can improve outcomes. But you can’t give the drug unless you identify the target.

How is tissue procured for patients with NSCLC within your practice?

: It depends on where the patient is coming from, what their status is. Most patients are already coming from [having received] a diagnosis of some sort. They are coming from their interventional radiologist, their plastic surgeon, [or] interventional [pulmonologist]. Sometimes when we see a patient we’re a little bit behind [knowing] whether the patients have had NGS sent off from pathology. Typically, when we see individuals, particularly those with metastatic disease, we’ll send for a liquid biopsy, and then try to procure the appropriate specimen from pathology and send it off to one of the companies of our choice [for NGS].

We are working on getting reflex testing, but it’s challenging, and it hasn’t worked perfectly. Some tests are being done in-house such as for 

 mutations, they are done easily with FISH [fluorescence in situ hybridization]. But sometimes there is a delay with tissue procurement and obtaining information.

: That is not just in the community practice. Even in the academic centers like mine, we’re having challenges of procurement and delays. Dr Ramkumar, what is your experience with tissue procurement and challenges in your practice?

: To add to some of the points Dr Morganstein spoke to, I see a lot of patients in the hospital, too. They are admitted and desperately sick. [These are patients who] are not screened and then they come with stage IV [disease] and are admitted quick. We try to get a biopsy when they are in the hospital and that gets technically challenging to move the patient or to get insurance reimbursements.

If the patient comes back and I see them in the clinic, in the community I [send the patient to an interventional] radiologist who does [tissue procurement] a lot. But if their disease [involves] the bronchi and needs tissue, I go with an interventional pulmonologist at the cancer center. [In this case] I have to arrange and [make sure they] know to get more tissue because [even though we have been] telling them that for a while, they do what they can do, and they try to get what they can and do their best. But then we are stuck when we get the results and realize it is not enough [tissue] and then we must do the entire thing again. That gets the patient frustrated. Now that we need more testing, we need more tissue.

: Dr Ramkumar, anecdotally, how often does that happen that, even in the best circumstances, you’re getting insufficient results?

: Right now, it is much better than it was 5 years ago because I know the radiologist I work with so I know they are going to get what I need. But approximately 10% to 15% of the time, I might be planning to do more [tests] on the tissue, that’s where it gets harder. We now have the liquid biopsy backup, and we know that once we can use what we can from the tissue, and we are all doing liquid [testing as well]. I am doing liquid biopsy for everyone I am seeing so I know I have that backup.

Enhancing Communication Among the Multidisciplinary Care Team

: Communication is key before the biopsy. Dr Morganstein, what is your experience with insufficient tissue and is there a way to overcome this challenge? Are you talking to the proceduralist as well as the pathologist? Or does that happen after the fact?

: Both and [the communication] is ongoing. This role of interventional pulmonary is new and we just started using this term in the past couple of years. The interventional pulmonologist, many of them are much younger [in age] and they’ve grown up with NGS and know they need [sufficient] tissue. If you read the reports you know they need 5 passes or 6 passes, they know they need tissue. With rapid on-site evaluation it’s become much less of an issue. They know getting 1 skinny needle biopsy that has a few cells isn’t adequate.

We do battle insurance issues, and it’s on ongoing battle to get tissue sent out immediately, there are [staffing issues], even when we request tissue it doesn’t get sent out. There are all kinds of hang ups along the way, physicians know what to do. There isn’t an educational [issue], it’s more of a logistical aspect, and a structural aspect to get the appropriate test run.

[We are in] communication and [we have] what we need [to do it], it just often does not happen.

: In small systems or large systems we’ve tried very hard to have this communication [with the] interventionalists and pathologists prior [to biopsy] but even under the best circumstances we are also struggling with reflex testing. Is reflex testing being done at your centers and then once that happens, what type of communication is going on between you, the pathologist, and the care team?

: I work in the community [clinic] and the community hospital pathologist are [hesitant to do] reflex testing right now because then it falls on them to do the authorization. In the cancer center, it’s not a problem, PD-L1 testing gets done. But for the other [tests], we have to do the paperwork for the prior authorization, or pull the paperwork for [NGS testing], and pathologists are not keen about sending [the samples].

If the patient is admitted to the hospital, and they have a chest tube [or other procedures], we can get the tissue, but we have to wait for [the patient] to be discharged for 24 hours to do the NGS. In the community setting it’s very hard, at the center we can still do the 

 [testing] and they get paid, but in the community setting it’s harder.

: You mentioned PD-L1 testing, and I’m curious from the community perspective, is the message out there that if you have a PD-L1 result you still need to wait for the testing or do you find that a lot of your colleagues are using [those results] and are not following up on the molecular report? We have a lot of data that suggest that if you have a PD-L1 that is high, then if they have an 

 mutation, single-agent immunotherapy doesn’t work that well nor does chemoimmunotherapy. Is that permeated in the community?

: As far as community oncologists are concerned, I think everybody knows to wait for the molecular results before acting on PD-L1 unless a patient needs to be treated right away. We do just chemotherapy to start with as we are waiting on the molecular or PD-L1 [results]. But I don’t think any community oncologist will just go by PD-L1 and get started.

: I think it is pretty well-documented, the lack of efficacy if their disease is 

-positive and PD-L1 and I think that has trickled down both to the pathologist and the community oncologist. They are well aware that you need the entire panel and it’s been repeated over and over again that you really need the full picture and panel before you can really treat [an individual].

Of course, if a patient needs urgent treatment, we have standard chemotherapy which is fine. But it’s harder to give the appropriate treatment. I always bring this back to the breast cancer oncologist who did much better than we have—they won’t treat somebody unless they have ER [estrogen receptor] or HER2 [results]. We haven’t gotten that good yet. We still see patients all the time without all the information. If you try to see a breast cancer clinician without ER, PR [progesterone receptor] or HER2, see what happens to the pathologist. We’re just not there, we’re getting there but we’re not close.

Best Practices for Accurate Tissue Genotyping in NSCLC

: I frequently say that we are learning a lot from the breast cancer world in terms of diagnostics [and] therapeutically [such as with] antibody-drug conjugates being used in breast cancer that we are just starting to learn about in lung cancer. I am leaning on my breast cancer colleagues quite frequently and, again, despite our best efforts, the nihilism of lung is in some ways preventing [reflex testing] from happening at a lot of institutions. This should be done ideally before we see the patient.

I’ll ask the unfair question, there is no right or wrong here, but what should be best practice if you look at the tissue journey from diagnosis to treatment?

: Once we do the biopsy and the pathologist knows it is NSCLC, [we have to have a preferred] panel which they can then reflex and send [the tissue] to. It’s a little complicated now because we have a few [panels available], but if we have a standard they can work with and if they are able to get that started, by the time [a patient] comes to see us, if the NGS is already started and we know it’s in the process we might have it by the time they see us. It is going to take time for that to happen especially for the community pathologist to come on board, I don’t know about the cancer centers, they may be ahead of us.

: If [pathologists] don’t run into any insurance issues and they get comfortable doing it will all fall in place and time will tell.

: That is good insight. Is there an opportunity to educate the proceduralist, whether that be the interventional pulmonologist or the interventional radiologist about the importance about how much tissue they get because that is a big thing? Or do you find that they are aware at this point that you need a lot of tissue?

: Both. In some ways they know that they need a lot of tissue, but I think that [we should] always be reminding them that we need more and that it is not adequate just to make a tissue diagnosis and overly repeat. Tissue by itself is no longer adequate to treat lung cancer. A diagnosis of adenocarcinoma gives us less than 50% of our information. We know [that the individual] has cancer but it leaves us hamstrung. They know it but repeating is always useful, it’s on us as the treating oncologist to throw fits until we get it. We just got our pathologists to send immediate NGS on all lung cancers whether they get paid or not because it is inadequate care. If you just keep saying it, it is a quality issue, eventually somebody will listen.

Average Turnaround Time for NSCLC Molecular Testing

: In a deeper dive into the evolution of molecular testing, what are some of the optimal NGS techniques? We’ve come a long way, we started with Sanger sequencing which was a hot spot of 3 or 4 genes. We move to this larger hot spot panel, what we used to call NGS, which was basically fishing out 50 genes and looking at just them. Then we moved to the NGS platforms, which can test over 300 genes and I think are the gold standard.

We also have other things which may still make a difference like IHC [immunohistochemistry], which we use for PD-L1, and FISH testing, which [Johns Hopkins] was using up until 2 years ago for all the rearrangements—

. When we look [at the landscape now] we have Sanger sequencing, we have the hot spot 50-gene panel, and then finally we culminate in this hybrid capture NGS, which we hear about with all the commercial assays.

[With that] we can discuss turnaround time. There are a lot of best practices for turnaround time and [Johns] Hopkins, is not emblematic of best practices, we are working on it, but we still have a lot of turnaround time issues. In your experience what is the average turnaround time from biopsy to getting the results?

: It’s a long time. It’s weeks, 2 weeks is early and if I get something from biopsy to all the information I need in 2 weeks, that is pretty good and unusual.

: Send out. I have to give the [NGS] companies credit, their turnaround time from when they get the block until we get the answers is [approximately] 1 week to 10 days. It’s [the time between] our request to getting it sent out to the company—this is a nebulous place now. Hopefully, the institution is going to get in-house NGS which would be great, but that is still a ways away.

: If we already have the biopsy and I send the NGS at that time, I say it’s 2 to 3 weeks combined with the insurance approval. But it depends on where the block is. In the community [setting], sometimes the clinician may be asking for another opinion if they are not comfortable.

If the block goes out somewhere and they have to track it through insurance approval and then track it again to get it to the place where it needs to go to have the NGS testing. I say 2 to 3 weeks, but it is usually much longer than that.

: We do the same thing, asking, “Where is the tissue in its journey right now? Is it in the pathologist’s office? Is it in our FISH, cytogenetics, or NGS laboratory?” It’s hard to track it.

 alone, like we used to do before because we know we can get something out of it, the sample could have gone somewhere else. [We] have to limit ourselves to PD-L1 and count on doing the NGS if it gets done at all.

: Is it a major hurdle there too, just getting it out to the company?

: Usually it is OK, but the pathologists are a little slow on [sending it out].

Receiving Molecular Testing Results for NSCLC

: Let’s talk about the actual results and this is where it gets tough for plasma and tissue results. Is there a best molecular report? Should there be a standard here?

: Some of it is [what you’re] used to. For example, I’ve been using [Foundation CDx] for years, so my eyes know exactly where to go on the report. I’m always afraid I’m going to miss something on some of the other reports. [What] I don’t love is that some companies will give you something that is “targetable,” but not necessarily targetable in lung cancer, such as 

 mutations or that you don’t know exactly what to do with the results.

: I would agree that some of these reports are structured better than others. How do you convey the results to the patient so that they are informed about what they need?

: When we run the NGS or liquid biopsy, we tell them, we are running more tests to see if they can go on an oral agent. That’s been 1 instance where patients are OK to wait because they have already gone through so much and [if they] wait for more testing, right there is a possibility they can go on an oral agent and don’t have to get a port and IV chemotherapy…. When we get the results, we can show them that they have this mutation, here is what is FDA approved, and we go over the results.

What are your thoughts on how patients received this information? Do they know about the NGS?

: Patients are usually overwhelmed. They have this hope for a pill, and they have a vague notion that there are some targetable mutations. But in all fairness, when I tell them that we’re going to run further testing on their tumor DNA, most individuals glaze over.

: It’s exceedingly difficult for patients to understand. We said in the beginning, there are 10 different mutations and we use them in different lines of therapy. I can speak for myself, I’m struggling to keep up with all the new mutations. For patients it’s just enough to say, we need more testing, and if there’s something targetable, we’ll be able to treat you with an oral medication. Do you have molecular tumor boards?

: We had a very successful molecular tumor board, prepandemic and postpandemic it fell apart a little bit. We present the vast majority of our cases in our thoracic tumor board and it tends to be the most molecularly valuable arena.

We would greatly benefit from a dedicated molecular board with a pathologist on site. It would be nice to have someone to bounce [these cases] off of monthly or bimonthly because sometimes you get weird mutations.

Benjamin P. Levy, MD, is the clinical director of Medical Oncology at Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital and an associate professor of Oncology at Johns Hopkins School of Medicine in Baltimore, Maryland. 

Bhuvana Ramkumar, MD, is a medical oncologist at Niagara Falls Memorial Medical Center at Roswell Park Comprehensive Cancer Center in Niagara Falls, New York.

Neil Morganstein, MD, is a medical oncologist at Overlook Medical Center at the Carol G. Simon Cancer Center in Summit, New Jersey. 

Articles

Benjamin P. Levy, MD; Bhuvana Ramkumar, MD; and Neil Morganstein, MD, discuss the challenges with tissue testing facing care teams, as well as multilevel hurdles in procurement, analysis of results, and insurance.

Perspectives From the Frontline: What Is Happening on the Ground With NGS Testing in NSCLC?

Patients with localized pancreatic adenocarcinoma who received care at a multidisciplinary clinic had significantly higher neoadjuvant therapy completion rates than those treated at a specialty-specific clinic, according to findings from a retrospective study presented at the 2022 Quality Care Symposium of the American Society of Clinical Oncology.

Patients whose treatment was coordinated through a multidisciplinary clinic (n = 157) completed their neoadjuvant treatment regimen per institutional standards at a rate of 71%, whereas the 83 treated at an individual clinic (surgical, medical, or radiation oncology) did so at a rate of 46.1% (P = .002). In addition, the rate of clinical trial enrollment was greater among the former (16.6%) than the latter (7.2%) (P = .043).

The adjusted odds ratio (aOR) for completion of neoadjuvant therapy per institutional standards for patients seen via multidisciplinary clinics vs standard oncology clinics was 3.35 (95% CI, 1.46-7.07; P =.004). In terms of clinical trial enrollment, the aOR in the multidisciplinary clinic cohort was 2.44 (95% CI, 0.94-6.35; P =.067).

Investigators used data from the Institutional Pancreatic Cancer Registry to compile a study population made up of patients who received a diagnosis of localized pancreatic adenocarcinoma between 2018 and 2020 at Johns Hopkins Hospital in Baltimore, Maryland. To be eligible for the study, patients needed to have disease for which resection was eventually undertaken and to have come to Johns Hopkins either via its pancreatic multidisciplinary clinic or through one of its surgical, medical, or radiation oncology clinics. 

The primary outcome of the study was the completion of neoadjuvant therapy as per stage-specific institutional standards. Clinical trial enrollment included only patients who had been admitted to an institutional clinical trial. Investigators noted that during the study period, it had been standard practice for patients with borderline resectable disease to be treated with neoadjuvant chemotherapy for a minimum of 4 months, with or without preoperative radiation, before transitioning to exploration. Patients with locally advanced disease received 4 to 6 months of chemotherapy, then radiation, followed by potential exploration.

Baseline patient characteristics were well-balanced between cohorts, with a median age of 67 years for both those treated at standard clinics (range, 58-73 years) and at multidisciplinary clinics (range, 61-73 years). Patients had a history of other cancers at a rate of 12% and 35.8%, respectively. Most patients in both arms had an ECOG performance status of 1 or less (63.9% vs 91.7%, respectively). 

Additional findings showed that patients who came to Johns Hopkins via a multidisciplinary clinic experienced a survival benefit. Death rates were 28.7% in the standard clinic and 20.5% in the multidisciplinary clinic (P =.157). 

More multidisciplinary clinic patients than standard clinic patients had neoadjuvant radiation therapy (59.7% vs 34.9%; P =.004). Patients in the standard clinic arm had a slightly lower rate of recurrence (38.5%) than those in the multidisciplinary clinic arm (40.1%; P = .421).

The median number of visits to the pancreatic multidisciplinary clinic was 1 (range, 1-6) and the authors noted that multiple visits to the clinic were not associated with the completion of neoadjuvant therapy. 

Following the outline set by the pancreatic multidisciplinary clinic at Johns Hopkins’ Skip Viragh Center for Pancreatic Cancer, the aim of the team should combine insights from medical and radiation oncologists, surgeons, radiologists, pathologists, and other clinicians to provide a complete comprehensive examination. The multidisciplinary clinic is also able to diagnose, educate, and create personalized treatment plans for patients.

Patients should meet with specialty clinicians based on their specific needs and then have their cases reviewed by an expert panel. The multidisciplinary clinic is best suited for patients with newly diagnosed disease that is treatment-naïve, those with locally advanced disease that is unresectable or borderline resectable, and those who have undergone surgery for pancreatic cancer but have not started chemotherapy and/or radiation therapy.

Oncology Live®

Patients with localized pancreatic adenocarcinoma who received care at a multidisciplinary clinic had significantly higher neoadjuvant therapy completion rates than those treated at a specialty-specific clinic.

Multidisciplinary Approach Leads  to Higher Rate of Neoadjuvant Treatment Completion in Pancreatic Cancer

Although cancer is the second leading cause of death in the United States, unprecedented progress in treatment has been made in recent years.

Precision oncology, artificial intelligence, breakthroughs in drug therapy, new digital health applications, and advanced detection strategies have revolutionized the field and significantly improved prognosis. There is, however, another factor that plays a major role in driving optimal outcomes: the patient experience. 

Patients with cancer face a great amount of mental and physical distress, which itself has been linked to increased health care usage, decreased survival, and suboptimal quality of life.

 Historically, overtaxed physicians may not have been adequately equipped to meet the vast needs and concerns of these patients,

 which makes the patient experience even more important. Ensuring a positive patient experience should be a top priority throughout the entire treatment journey, as higher patient satisfaction can drive improved health outcomes, treatment adherence, and quality of life.

However, creating a superb patient experience does not just happen. It takes careful planning and execution. There are numerous things providers can do to build the optimal patient experience that meets patient needs and cultivate the patient-provider bond and increase patient retention. A closer look at some of these activities may offer insight into how practices can approach this important task.

Best Practices For an Optimal Patient Experience 

The patient experience is not limited to just interactions with the direct care team, but goes well beyond that to include all encounters with the practice staff—from the receptionist, to the scheduler, to the pharmacy team, to billing, and all other key ancillary staff members.

 Each of these touchpoints and interactions play a role in building and sustaining a good relationship with the patient that can provide much needed support during treatment. To begin laying the foundation for a satisfactory patient experience and patient-provider relationship, practices should consider the following:

Trust is the cornerstone of every good relationship, and developing it begins with effective communication. Patients genuinely hope to have a close, collaborative relationship with their providers that will enable them to openly discuss their condition and concerns. Unfortunately, when it comes to the cancer journey, many of them report a one-sided relationship.

Practices should strive to establish a space that makes patients feel they are safe within the walls of the practice and in a supportive environment that allows them to be truthful and vulnerable. Because delivering comprehensive cancer care goes well beyond treating the patient’s disease, providers must take a more personal interest in what is happening in their patients’ lives, helping them manage and navigate through the complexities of this condition and the effect it has on their day-to-day experiences, not only physically but also emotionally. 

This may mean addressing patient needs outside of the provider’s primary area of responsibility, and successful providers are intentional with demonstrating compassion, listening to patients’ concerns, being respectful of their anxieties and fears, and doing whatever they can to assist the patient. This high level of support will go a long way in building trust and respect and in making the patient feel the care team is working in their best interest, an essential element in establishing a strong, positive patient experience.

Being transparent is important in delivering a good patient experience, as it helps patients stay informed throughout their treatment journey and have a better understanding of the various stages of their care plan. Thorough explanations should be delivered to patients to explain the rationale for a particular treatment recommendation to control or stabilize the disease, as well as the possibility of undesirable adverse effects (AEs) that come along with it. Providers need to be comprehensive in terms of teaching patients what the treatment involves and what they should expect when they receive therapy, providing patients with all the necessary educational materials so they thoroughly understand what is coming. 

Transparency also requires the care team to be candid, providing patients with truthful and accurate assessments of their condition. Patients appreciate and value frank and honest discussions of their situation, as this knowledge enables them to better prepare themselves and their loved ones for the future or meet specific goals they wish to achieve in a certain timeframe

Maintaining simplicity is an important aspect of building the optimal patient experience that is often overlooked. Locating and understanding educational material can be very difficult for a patient. This is especially true for patients during the early stages of their disease, as adjusting to the diagnosis can be distressing and overwhelming. Curating resources and leveraging digital health platforms that are easily understandable for patients and that meet them where they are can be very helpful in encouraging and supporting meaningful engagement.

Encourage patient involvement in decision-making 

A recent report by Accenture found that half of the respondents with cancer wanted more involvement in their treatment plan and decision-making process.

 By providing patients with autonomy and an opportunity to connect through open and candid conversations, patients will gain a voice in their treatment plan, collaborating with their care team and ultimately fostering a strong patient-provider relationship.

There are many opportunities for patients to be involved in deciding the care they receive. Today, clinicians have decision-support tools that identify several varying treatment options with similar efficacies that may have different AE profiles. Providers can seek patient involvement in deciding which treatment to select, explaining the various treatments to the patient and the possible AEs of each that can affect quality of life. The provider and the patient can then make a collaborative decision on which treatment path is clinically appropriate that also meets the patient’s lifestyle goals.

Creating an optimal patient experience requires patient involvement in the decision-making process during the entire cancer journey, including end-of-life care. Providing patients with the opportunity to determine and document the type of care they want during the final stages of their disease can ensure their end-of-life care goals and wishes are met. Advance care planning has become so critical that it is included as a quality metric in many value-based care models to make sure patients have a role in these important end-oflife decisions.

Incorporate a comprehensive, holistic approach 

To ensure patients have the best experience possible, providers must acknowledge that caring for the patient goes well beyond treatment plans and drug therapy, requiring a much more comprehensive, holistic approach. Cancer treatment is shifting away from being disease-focused to a more patient-centered method.7 This approach recognizes patients not only face physical challenges, but oftentimes emotional, social, spiritual, and financial issues as well. As such, more patients with cancer desire and seek out additional support and guidance. For instance, data shows 7 out of 10 patients believe having some sort of peer support would be valuable to them, so there is a need for more supportive care programs to address these issues.

In response to the additional needs of the patient, care plans now go well beyond simply managing the patient’s disease, focusing more broadly on managing and supporting the whole person. New care models, such as the integrative oncology model, have been developed to better address and treat the patient’s other needs through various mind-body practices, natural products, and lifestyle modifications.

 The model leverages evidence-based complementary therapies, in adjunct with conventional treatments. Some of these therapies include activities such as: support groups, mentorship, massage, yoga, music therapy, and many others that patients view as key components of their cancer experience. As 9 out of 10 patients want emotional support recommendations from their provider,

 addressing this need and other integrative care requests can help create a good patient experience and provide an excellent opportunity to enhance the patient-provider relationship through trust and collaboration.

As we live in an ever-growing digital world, digital health has come to the forefront of health care and goes hand-in-hand with the patient experience. The FDA’s definition of digital health covers a broad area of activity, including telehealth and telemedicine, mobile health, health information technology, wearable devices, and personalized medicine.

As digital health has empowered patients and made access to health information more readily available, it has also added some complexity and challenges to creating a positive patient experience. A diagnosis of cancer is a lifechanging event for patients and their families. Given the tremendous effect, there is often strong patient engagement and a desire to seek out knowledge to gain a more comprehensive understanding of their condition. 

However, with the plethora of medical information available online, patients often struggle to locate personalized, understandable, and reliable information they can trust. One out of every 3 patients in a recent survey reported being overwhelmed by the number of information sources when trying to learn more about their condition and symptoms.

 As a result, the patient’s care team is frequently sought out to help navigate these challenges to obtain clarity, providing yet another opportunity to enhance the patient-provider relationship.

Despite these difficulties, digital health and advanced technologies can still play a vital role in building a positive patient experience. A robust interactive online presence is essential for practices today, as patients have gotten used to experiencing a certain level of technical sophistication from the companies they interact with on a day-to-day basis. 

There are a few fundamentals practices should follow when building their digital presence that will help ensure a good digital experience for patients.

 For instance, practices should offer digital communication formats that are simple to use so patients at all skill levels can easily access them. This is especially important for older patients who might not be tech savvy. Educational needs may change as patients move through treatment and practices should provide easy access to a wide range of material to help them through various stages of their cancer journey. More personalized educational material can also be offered to patients with specific needs. Practices can also help patients by referring them to other online resources that are geared for their disease or therapies. 

Good Patient Experiences Cultivate Patient Retention 

Delivering the best possible patient experience brings a multitude of benefits to patients and providers, as well as the practice. Not only does it help patients achieve better outcomes, but it also strengthens the patient-provider relationship, fostering trust, loyalty and retention. In addition to producing the financial gains that come along with patient retention, positive patient experiences have also been associated with progressively shaping organizational culture through increased employee satisfaction.

Building the optimal patient experience can be challenging, but in today’s competitive world, it is essential for practices to make this activity a top priority. Often, patients have a multitude of choices when it comes to who will provide their care. Even if they are a current patient, it is relatively easy for them to slip away to another provider, and difficult, if not impossible, to win them back. As such, creating an optimal patient experience should be a core tenant of the practice, receiving the necessary investment of time, effort, and financial resources required to advance patient experiences.

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Partner Perspective

Ensuring a positive patient experience should be a top priority throughout the entire treatment journey, as higher patient satisfaction can drive improved health outcomes, treatment adherence, and quality of life.

Building the Optimal Patient Experience Takes Planning and Effort

Molecular and immune landscapes for solid tumors are constantly evolving as precision medicine techniques become more sensitive and next-generation sequencing methods (NGS) are taken up in clinical practice. 

Posters presented at the European Society for Medical Oncology Annual Congress 2022, showcased the results of the latest investigative efforts across institutions to better elucidate prevalent mutations across tumor types, some of which may inform next steps in drug development. 

fusions in solid tumors are most prevalent in non–small cell lung cancer (NSCLC) and well-differentiated thyroid cancer with 2 selective 

 tyrosine kinase inhibitors (TKIs)—selpercatinib (Retevmo) and pralsetinib (Gavreto)—approved for the treatment of patients with these indications.

 Additionally, in September 2022, an accelerated approval was granted to selpercatinib for the treatment of patients with locally advanced or metastatic solid tumors with a 

Investigators conducted a retrospective analysis using targeted RNA sequencing as well as whole transcriptome sequencing to identify the distribution of 

-positive solid tumors by cancer type and evaluate their molecular characteristics. 

Malignancies examined were NSCLC (n = 253), thyroid (n = 42), colorectal (n = 38), breast (n = 10), carcinoma of unknown primary (CUP; n = 10), and pancreatic (n = 8). Per cancer type, the distribution of 

-positive tumors were 66.9%, 11.1%, 10.1%, 2.6%, 2.6%, and 2.1%, respectively. Thyroid and breast 

-positive tumors were carcinomas whereas colorectal and pancreatic were adenocarcinomas.

-positive tumors examined included anaplastic thyroid carcinoma, cholangiocarcinoma, liver hepatocellular carcinoma, melanoma, neuroendocrine tumors, ovarian, soft tissue tumors, glioblastoma, and salivary gland tumors. 

Pathogenic/likely pathogenetic comutations occurring at a rate of more than 10% were NGS

Coamplifications with a copy number more than 6 were Can (copy number alteration)-

(13.8%). By malignancy, the most prevalent were 

(21%) in colorectal adenocarcinomas (Figure).

Investigators identified a total of 378 RET-positive solid malignancies in 15 different tumor types and CUP to undergo next-generation RNA sequencing. The most frequent single gene alterations in RET-positive tumors were TP53 (34.8%), ARID1A (10.8%) and RNF43 (6.7%). Additionally, colorectal cancer RET-positive tumors had a median tumor mutational burden (TMB) of 20 Mt/Mb with microsatellite instability high (MSI-H) seen in 63%.

 fusions across all solid tumors and the retrospective analysis used targeted RNA sequencing or whole transcriptome sequencing to identify the 

-positive tumors in NSCLC (n = 204), glioblastoma (n = 18), breast (n = 7), and others (n = 30). The other category included pancreatic adenocarcinoma, cancer of unknown primary, cholangiocarcinoma, gastric adeno, colorectal adeno, soft tissue, bladder, melanoma, neuroendocrine, ovarian, and thyroid. 

(9.03%), and 28 different partners occurred at a rate of under 2%.

exons was E6 (24.52%), E13 (11.94%), E10 (11.61%), E2 (10.97%), E9 (9.68%), E8 (7.74%), E4 (6.13%), intron 4 (4.19%), E7 (2.90%), E1 (2.58%), and 11 different exons occurred at a rate of under 2%. 

The mean TMB was 4.8 Mt/Mb (SD, 2.8) for all 

+ tumors. TMB was 5.7 Mt/Mb (SD, 3.4) in NSCLC, 3.6 Mt/Mb (SD, 1.5) in glioblastoma, and 5.7 Mt/Mb (SD, 3.6) in breast.

The most prevalent coalterations for NSCLC identified by NGS were LOH (7.3%) or mutations in 

 (7.3%). In glioblastoma the most common were 

(12.5%). The most frequent in breast cancer tumors were 

(28.6%). Using immunohistochemistry, estrogen receptor, progesterone receptor, and HER2 status was reported in 33.3% of tumors.

 fusions occurred at a low frequency in the 17 solid malignancies identified from 259 

-positive tumor samples out of 175,350 tumors that underwent sequencing. Of the 

-positive solid malignancies, 78.8% were in NSCLC, 6.9% in glioblastoma, 2.7% in breast. There are 2 

-positive in NSCLC—crizotinib (Xalkori) and entrectinib (Rozlytrek).

fusions occurred at an approximate frequency of 0.47% for NSCLC, 0.29% for glioblastoma and 0.04% for breast cancer. It was also noted that 

-positive in glioblastoma may represent a potential poor prognostic factor (HR, 0.56; 95% CI, 0.23-1.35; P = .19).

Response With Adjuvant Nivolumab in Recurrent HNSCC 

Although salvage therapies are advancing,outcomes for patients with head and neck squamous cell carcinoma (HNSCC) remain poor. Investigators retrospectively examined findings phase 2 trial (NCT03355560) of adjuvant nivolumab (Opdivo) after salvage resection to characterize the molecular and immune landscape of patients with HNSCC.

NGS, WTS, and whole-exome sequencing (WES) were performed on 37 tumors and the TMB cutoff was at least 10 Mt/Mb. Molecular alteration rates by sites, the larynx (n = 14), oral cavity (n = 10), and oropharynx (n = 7), were examined. Tumors with 

mutations occurred 86% in the larynx and 100% in the oral cavity and 

 mutations were solely found in the oropharynx at a rate of 57%. 

mutations occurred in the larynx (8%) and the oropharynx (86%). 

Gene expression for ABCA prior chemotherapy relative to no chemotherapy had a relative frequency (log) of –1.4 and a false discovery rate of 6.1. Gene expression for 

 for TMB-high vs TMB-low had a relative frequency (log) of 1.1 with a false discovery rate of 5.6. Further, gene expression for well differentiated vs not well differentiated had a relative frequency (log) of 1.4 for both the 

 genes and the false discovery rate was 2.0 and 2.7, respectively.

Distinct immune cell abundance and molecular alterations were not found in patients treated with nivolumab who developed a relapsed disease (n = 11) and those who did not (n = 26). In relation to immune cell abundance, gender, TMB-high status, and secondary disease had no significant findings. In relation to molecular alterations, the previous groups were not significant in addition to the following comparison groups: prior treatment of chemoradiation therapy vs radiation therapy alone, PD-L1 positivity, tumor differentiation, type of prior chemotherapy with cisplatin vs cetuximab, and secondary disease. 

The authors concluded that larger prospective trials are needed to further examine recurrent HNSCC cancers and analyze molecular and immune profiles on subgroups as they were unable to find a clear marker to predict responses to adjuvant nivolumab.

As RAS pathway alterations in NSCLC remain a difficult therapeutic target, investigators analyzed 29,767 NSCLC tumor tissue samples to examine the relationship between 

 gene mutations and the tumor microenvironment (TME). In head and neck tumors, 

 has been notably inactive because of indirect targeting with the farnesyltransferase inhibitor, tipifarnib. However, the role of 

has been associated with immune modulation.

Tumor tissue samples were molecularly profiled using NGS of DNA, RNA, and immunohistochemistry. Of the 29,767 samples, 0.4% (n = 128) had 

 mutations were linked to worse prognosis for patients who received pembrolizumab (Keytruda; HR, 1.667; 95% CI, 0.921-3.017; P = .088). Patients also displayed less B cell macrophage M2, natural killer cell, CD4-positive and CD8-positive T-cell infiltrates compared with a general cohort.

Moreover, pembrolizumab elicited a worse prognosis, aside from G12 or G13, in patients with 

Q61 (HR, 2.779; 95% CI, 1.04-7.423; P = .03) and displayed the highest MPAS score (P = .05), which previously demonstrated immune evasion.

Survival curves for patients treated with pembrolizumab comparing 

-mutant squamous cell carcinomas (SCC; all smokers) and a general cohort of patients with SCC, found a median difference of 246 days (HR, 1.72; 95% CI, 0.85-3.64; P = .126).

-mutated SCC demonstrated less infiltration with M1, B cells, and myeloid dendritic cells as well as a significantly higher MPAS score and

expression compared with the general cohort. Further, there were no similar trends in adenocarcinoma histology. 

Investigators concluded that compared with a general cohort, 

-mutated NSCLC displayed a relatively immune-cold pattern with fewer CD4-positive and CD8-positive T-cell infiltrates and a trend toward inferior overall survival for patients treated with pembrolizumab. The immune-cold TME demonstrated by 

-mutated SCC was associated with high MAP kinase pathway activation as well as high 

Next steps include further exploration of the 

-mutated SCC with combination therapies targeting the MAP kinase pathway or

With a goal of characterizing the genomic and clinical outcomes of patients with 

 mutations as potential prognostic and therapeutic biomarkers, investigators molecularly profiled 3426 urothelial bladder carcinoma (UBC) tissue samples with NGS of DNA and RNA.

 gene and a member of the RAS superfamily, is enhanced in high-grade UBC. HRAS mutations were detected in 107 patients with metastatic UBC and in those patients, point mutations were detected as follows: Q61 (47.6%), G12 (30.8%), G13 (19.6%), and other/likely pathogenic (1.9%). 

mutations had a tumor mutational burden of 5 Mt/Mb while those in a general cohort had a higher burden of8 Mt/Mb. PD-L1 expression was 55.3% vs 39.1%, respectively. 

Tumors with the Q61 mutation had higher MPAS scores (2.21 vs 0.6; q < .001) as well as enrichment in pathways and notch signaling. Additionally, when treated with checkpoint inhibitors, patients with 

Molecular and immune landscapes for solid tumors are constantly evolving as precision medicine techniques become more sensitive and next-generation sequencing methods are taken up in clinical practice.

Vol. 23/ No. 22 | Oncology Live®

Perspectives From the Frontline: What Is Happening on the Ground With NGS Testing in NSCLC?

Multidisciplinary Approach Leads to Higher Rate of Neoadjuvant Treatment Completion in Pancreatic Cancer

Building the Optimal Patient Experience Takes Planning and Effort

Tumor Profiling Studies Illuminate Nuances Across Malignancies

Rapid Developments Generate Waves of Excitement for Patients With RCC

CAR Therapy Era Moves Forward With Much Excitement, Lingering Questions

Multidisciplinary Workflow Benefits Patients With Newly Diagnosed Pancreatic Cancer

Defining Clinical Benefit in Oncology Trials Is Not as Simple as Some May Believe