Medical Policy: 02.04.79 

Original Effective Date: September 2019 

Reviewed: September 2020 

Revised: September 2020 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

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This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

  • This policy does not address circulating tumor DNA for the management of all other cancers, see medical policy 02.04.16 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy).

 

Lung cancer is the leading cause of cancer death in the United States. In 2020, an estimated 228,820 new cases (116,300 in men and 112,720 in women) of lung and bronchial cancer will be diagnosed, and 135,720 deaths (72,500 in men and 63,220 in women) are estimated to occur because of the disease. Only 19% of all patients with lung cancer are alive 5 years or more after diagnosis. However, much progress has been made recently for lung cancer such as screening, minimally invasive techniques for diagnosis and treatment, and advances in radiation therapy (RT) including stereotactic ablative radiotherapy (SABR), targeted therapies, and immunotherapies. Patients with metastatic lung cancer who are eligible for targeted therapies or immunotherapies are now surviving longer; 5-year survival rates range from 15% to 50%, depending on the biomarker. (NCCN Version 8.2020)

 

Treatment options for non-small-cell lung cancer (NSCLC) depend on disease stage and include various combinations of surgery, radiotherapy, systemic therapy, and best supportive care. Unfortunately, in up to 85% of cases, the cancer has spread locally beyond the lungs at diagnosis, precluding surgical eradication. Also, up to 40% of patients with NSCLC present with metastatic disease. When treated with standard platinum-based chemotherapy, patients with advanced NSCLC have a median survival of 8 to 11 months and a 1-year survival of 30% to 45%. The identification of specific, targetable oncogenic “driver mutations” in a subset of NSCLCs has resulted in a reclassification of lung tumors to include molecular subtypes, which are predominantly of adenocarcinoma histology. The NCCN NSCLC Panel recommends testing certain molecular and immune biomarkers in all appropriate patients with metastatic NSCLC to assess whether patients are eligible for targeted therapies or immunotherapies based on data showing improvement in overall survival (OS) for patients receiving targeted therapies or immunotherapies compared with traditional chemotherapy regimens. (NCCN Non-Small Cell Lung Cancer Version 8.2020).

 

Genetic testing of circulating tumor DNA (ctDNA) in peripheral blood (referred to as “liquid biopsy”) potentially offers a noninvasive alternative to tissue biopsy (standard of care) for therapeutic decisions and prognosis in patients with metastatic  non-small cell lung cancer (NSCLC) cancer when tissue biopsy is not available. The majority of patients present with advanced-stage disease and great strides have been made in the development of therapies for such patients, including targeted therapies and immunotherapy. For patients with metastatic non-small cell lung cancer (NSCLC), targeted therapies require identification of specific molecular alterations in the cancer which is important for selecting patients for targeted therapy.

 

Circulating tumor DNA (ctDNA) discussed herein are intended for use in patients with metastatic non-small-cell lung cancer (NSCLC), the plasma test has been and is being investigated in patients who do not have enough tissue for standard molecular testing using formalin-fixed paraffin-embedded tissue, do not have a biopsy-amenable lesion, cannot undergo biopsy, or have indeterminate histology (in whom an adenocarcinoma component cannot be excluded).

 

Predictive Biomarkers in Non-Small Cell Lung Cancer

Several predictive genetic biomarkers have been identified for non-small-cell lung cancer (NSCLC). Somatic genome alterations known as “driver mutations” are usually transformative variants arising in cancer cells in genes encoding for proteins important in cell growth and survival. Randomized controlled trials have demonstrated improved efficacy, often in conjunction with decreased toxicity, of matching targeted therapies to patients with specific driver mutations. Several such targeted therapies are approved by the Food and Drug Administration (FDA) for NSCLC. Guidelines generally suggest analysis of either the primary NSCLC tumor or of a metastasis for the presence of a set of driver mutations to select appropriate treatment.

 

A predictive biomarker is indicative of therapeutic efficacy because there is an interaction between the biomarker and therapy on patient outcome.

 

Predictive biomarkers in NSCLC  include the ALK fusion oncogene (fusion between ALK and other genes (e.g. echinoderm microtubule-associated protein-like 4), ROS1 gene fusions, sensitizing EGFR gene mutations, BRAF V600E point mutations, NTRK gene fusions, METex14 skipping mutations, RET rearrangements, and PD-L1 expression. The presence of EGFR exon 19 deletions or exon 21 L858R mutations is predictive of treatment benefit from EGFR tyrosine kinase inhibitor (EGFR TKI) therapy (e.g. osimertinib); therefore, these mutations are referred to as sensitizing EGFR mutations.

 

EGFR Variants

In patients with NSCLC, the most commonly found EGFR variants are deletions in exon 19 (Exon19del [with conserved deletion of the LREA sequence] in 45% of patients with EGFR variants) and a point mutation in exon 21 (L858R) in 40% of patients with EGFR variants. Both variants result in activation of the tyrosine kinase (TKI) domain, and both are associated with sensitivity to the small molecule EGFR TKIs, such as afatinib, erlotinib, dacomitinib, gefitinib, and osimertinib. These variants are referred to as sensitive EGFR variants. Other less common variants (10%) that are also sensitive to EGFR TKIs include exon 19 insertions, p.L861Q, p.G719X and p.S7681. Data suggest that patients harboring tumors without sensitizing EGFR variants should not be treated with EGFR TKIs in any line of therapy. These sensitizing EGFR variants are found in approximately 10% of Caucasian patients with NSCLC and up to 50% of Asian patients.

 

Most patients with sensitizing EGFR variants are nonsmokers or former light smokers with adenocarcinoma histology. Data suggest that EGFR mutations can occur in patients with adenosquamous carcinoma, which is harder to discriminate from squamous cell carcinoma in small specimens. Patients with pure squamous cell carcinoma are unlikely to have sensitizing EGFR mutations; those with adenosquamous carcinoma may have mutations. However, smoking status, ethnicity, and histology should not be used in selecting patients for testing. EGFR mutation testing is not usually recommended in patients who appear to have squamous cell carcinoma unless they are a former light or never smoker, if only a small biopsy specimen (i.e. not a surgical resection) was used to assess histology, or if the histology is mixed. The ESMO Guidelines specify that only patients with nonsquamous cell (e.g. adenocarcinoma) should be assessed for EGFR mutations. ASCO recommends that patients be tested for EGFR mutations. 

 

The predictive effects of the drug-sensitive EGFR mutations are well defined. Patients with these mutations have a significantly better response to erlotinib, gefitinib, afatinib, osimertinib or dacomitinib. Data show that EGFR TKI therapy should be used as first-line monotherapy in patients advanced NSCLC and sensitizing EGFR mutations documented before first-line systemic therapy (e.g. carboplatin/paclitaxel). Progression-free survival (PFS) is longer with use of EGFR TKI monotherapy in patients with sensitizing EGFR mutations when compared with cytotoxic systemic therapy, although overall survival is not statistically different.

 

Non-responsiveness to EGFR TKI therapy is associated with KRAS and BRAF mutations and ALK or ROS1 gene fusions. Patients with EGFR exon 20 insertion mutations are usually resistant to erlotinib, gefitinib, afatinib, or dacomitinib, although there are rare exceptions. Patients typically progress after first-line EGFR TKI monotherapy. EGFR p.Thr790Met (T790M) is a mutations associated with acquired resistance to EGFR TKI therapy and has been reported in about 60% of patients with disease progression after initial response to erlotinib, gefitinib or afatinib. Most patients with sensitizing EGFR mutations become resistant to erlotinib, gefitinib or afatinib; PFS is about 9.7 to 13 months. Studies suggest T790M may rarely occur in patients who have previously received erlotinib, gefitinib or afatinib. Genetic counseling is recommended for patients with pre-treatment p.T790M, because this suggest the possibility of germline mutations and is associated with predisposition to familial lung cancer. Acquired resistance to EGFR TKIs may also be associated with histologic transformation from NSCLC to SCLC and with epithelial to mesenchymal transition. For the 2020 updated (Version 1), the NCCN NSCLC Panel suggest that a biopsy can be considered at progression to rule out SCLC transformation, Acquired resistance an also be mediated by other molecular events, such as acquisition of ALK rearrangement, MET or ERBB2 amplification.

 

DNA mutational analysis is the preferred method to assess for EGFR status; IHC (immunohistochemistry) is not recommended for detecting EGFR mutations. Real-time PCR (polymerase chain reaction), Sanger sequencing (paired with tumor enrichment), and NGS (next generation sequencing) are the most commonly used methods to assess EGFR variant status. Direct sequencing of DNA corresponding to exons 18 to 21 (or just testing exons 19 and 21) is a reasonable approach; however, more sensitive methods are available. Mutation screening assays using multiplex PCR (e.g. Sequenom’s MassARRAY system, SnaPshot Multiplex System) can simultaneously detect more than 50- point mutations.

 

Osimertinib is a preferred first-line EGFR TKI option for patients with EGFR positive metastatic NSCLC. Erlotinib, gefitinib, afatinib or dacomitinib are “other recommended” EGFR TKI options for first-line therapy. Osimertinib is recommended (category 1) as second-line and beyond (subsequent) therapy for patients with EGFR T790M-positive metastatic NSCLC who have progressed on erlotinib, gefitinib, afatinib, or dacomitinib. Sensitizing EGFR mutations and ALK or ROS1 fusions are generally mutually exclusive. Thus, crizotinib, ceritinib, alectinib, brigatinib or lorlatinib are not recommended as subsequent therapy for patients with sensitizing EGFR mutations who relapse on EGFR TKI therapy.

 

ALK Rearrangements

About 5% of patients with NSCLC have ALK gene rearrangements. Patients with ALK rearrangements are resistant to EGFR TKIs but have similar clinical characteristics to those with EGFR mutations (i.e. adenocarcinoma histology, light or never smokers). ALK rearrangements are not routinely found in patients with squamous cell carcinoma. Patients with ALK gene rearrangements can have mixed squamous cell histology. It can be challenging to accurately determine histology in small biopsy specimens; thus, patients may have mixed squamous cell histology (or squamous components) instead of pure squamous cell.

 

First line therapy for ALK rearrangement positive is alectinib, brigatinib, ceritinib, crizotinib. Subsequent therapy includes alectinib, brigatinib, ceritinib and lorlatinib.

 

ROS1 Rearrangements

Although ROS1 proto-oncogene 1 (ROS1) is a distinct receptor tyrosine kinase, it is very similar to ALK and members of the insulin receptor family. It is estimated that ROS1 gene rearrangements occur in about 1% to 2% of patients with NSCLC; they occur more frequently in those who are negative for EGFR mutations, KRAS mutations, and ALK gene rearrangements.

 

ROS1 testing is recommended in patients with metastatic non-squamous NSCLC based on data showing the efficacy of crizotinib, ceritinib and entrectinib for patients with ROS1 rearrangements. ROS1 testing can be considered in patients with metastatic squamous cell carcinoma NSCLC if small biopsy specimens were used to asses histology or mixed histology was reported.

 

Crizotinib, ceritinib or entrectnib are the preferred first line therapy for patients with ROS1 positive metastatic NSCLC because they are better tolerated, have been assessed in more patients and are approved by the FDA. For ROS1 arrangements discovered during first line systemic therapy (e.g. chemotherapy), planned systemic therapy may be either completed or interrupted followed by crizotinib, ceritinib or entrectnib. Lorlatinib as a subsequent therapy option for select patients with ROS1 positive metastatic NSCLC that have progressed after treatment with crizotinib or ceritinib.

 

BRAF V600E Mutations

BRAF (v-RAF murine sarcoma viral oncogene homolog B) is a serine/threonine kinase that is part of the MAP/ERK signaling pathway. BRAF V600E is the most common of the BRAF point variants when considered across all tumor types; it occurs in 1% to 2% of patients with lung adenocarcinoma. Although other BRAF variants occur in patients with NSCLC at a rate approximately equal to p.V600E (unlike many other tumor types), specific targeted therapy is not available for these other variants. Patients with BRAF V600E variants are typically current or former smokers in contrast to those with EGFR variants or ALK rearrangements who are typically non-smokers. Variants in BRAF typically do not overlap with EGFR mutations, ALK rearrangements, or ROS1 rearrangements. Testing for BRAF V600E is recommended in patients with metastatic non-squamous NSCLC and may be considered in patients with squamous cell carcinoma NSCLC if small biopsy specimens were used to assess histology or mixed histology was reported.

 

Testing for BRAF variants is recommended based on data showing the efficacy of first line and subsequent therapy with dabrafenib/trametinib for patients with BRAF V600E variants and on the FDA approval.

 

NTRK Gene Fusions

NTRK gene fusions encode tropomyosin receptor kinase (TRK) fusion proteins (e.g. TRKA, TRKB, TRKC) that act as oncogenic drivers for solid tumors that includes lung. A diverse range of solid tumors in children and adults may be caused by NTRK gene fusion (e.g. NTRK1, NTRK2, NTRK3). It is estimated that NTRK fusions occur in 0.2% of patients with NSCLC and do not typically overlap with other oncogenic drivers such as EGFR, ALK or ROS1.

 

NTRK gene fusion testing is recommended in patients with metastatic NSCLC based on clinical data and the approval of larotrectinib for patients with NTRK gene fusion positive disease. Larotrectinib and entrectinib as either first line or subsequent therapy are options for patients with NTRK gene fusion positive metastatic NSCLC based on data and FDA approvals.

 

METex14 Skipping Mutations

C-MET, the hepatocyte growth factor (HGF) receptor is a tyrosine kinase receptor that is involved in cell survival and proliferation, oncogenic driver genomic alterations in MET include METex14 skipping mutations, MET gene copy number (GCN) gain or amplification, and MET protein overexpression. MET genomic alterations do not typically overlap with EGFR, ROS1, BRAF and ALK genetic variants. However, METex14 skipping mutations and MET amplification occur together. METex14 skipping mutations occur in 3% to 4% of patients with adenocarcinomas NSCLC and 1% to 2% of patients with other NSCLC histologies. METex14 skipping mutations are more frequent in older women who are nonsmokers.

 

Several different types of METex14 skipping mutations occur, such as mutations, base substitutions and deletions, which makes it difficult to test for all the mutations. Patients with METex14 skipping mutations have a modest response (16%) to immunotherapy, even those with high PD-L1 levels.

 

The NCCN NSCLC Panel (Non-Small Cell Lung Cancer Version 8.2020) recommends testing for METex14 skipping mutations (category 2A) in eligible patients with metastatic NSCLC (i.e. metastatic non-squamous NSCLC) based on data showing the efficacy of several agents for patients with METex14 skipping mutations and on the FDA approval for capmatinib.

 

RET Rearrangements

RET is a tyrosine kinase receptor that affects cell proliferation and differentiation. Rearrangement (fusions) may occur in NSCL between the RET gene and other domains, especially kideisn family 5B (KIF5B) and coiled coil domain containing-6 (CCDC6), which lead to overexpression and the RET protein. RET rearrangements occur in about 1% to 2% of patients with NSCLC and are more frequent in patients with adenocarcinoma histology. In European patients, RET rearrangements occur in both smokers and nonsmokers. RET rearrangements do not typically overlap with EGFR, ROS1, BRAF, METex14 skipping, and ALK genetic variants. However, a few studies suggest that RET rearrangements may infrequently overlap with EGFR and KRAS mutations. Patients with RET rearrangements have minimal response (6%) to immunotherapy.

 

The NCCN NSCLC Panel (Non-Small Cell Lung Cancer Version 8.2020) recommends testing for RET rearrangements (category 2A) in eligible patients with metastatic NSCLC based on data showing the efficacy of several agents for patients with RET rearrangements and on the FDA approval for selpercatinib.

 

Prognostic Biomarkers in Non-Small Cell Lung Cancer

A prognostic biomarker is indicative of patient survival independent of the treatment received, because the biomarker is an indicator of the innate tumor behavior.

 

KRAS

The KRAS oncogene is a prognostic biomarker. The presence of KRAS mutations is prognostic of poor survival for patients with NSCLC when compared to the absence of KRAS mutations, independent of therapy.  KRAS mutations are also predictive of lack of benefit from EGFR TKI therapy. 

 

KRAS is a G-protein with GTPase activity that is part of the MAP/ERK pathway; point mutations in KRAS most commonly occur at codon 12. Data suggest that approximately 25% of patients with adenocarcinomas a North American population have KRAS mutations; KRAS is the most common mutation in this population.

 

KRAS mutation prevalence is associated with cigarette smoking. Patients with KRAS mutations appear to have a shorter survival than patients with wild-type KRAS (when the KRAS gene is found in its natural non-mutated [unchanged form]); therefore, KRAS mutations are prognostic biomarkers.  KRAS mutational status is also predictive of lack of therapeutic efficacy with EGFR TKIs; it does not appear to affect chemotherapeutic efficacy. KRAS mutations do not generally overlap with EGFR mutations, ALK rearrangements, or ROS1 rearrangements. Therefore, KRAS testing may identify patients who may not benefit from further molecular testing. Targeted therapy is not currently available for patients with KRAS mutations, although immune checkpoint inhibitors (immunotherapy) appear to be effective; MEK inhibitors are in clinical trials.

 

Emerging Biomarkers to identify Targeted Therapies for Patients with Metastatic Non-Small Cell Lung Cancer

Emerging predictive biomarkers include ERBB2 mutations. High-level MET amplifications, and tumor mutational burden (TMB)

 

High-Level MET Amplification

In NSCLC, amplification of MET typically occurs in about 2%to 5% of newly diagnosed adenocarcinomas.

 

The current NCCN Guideline for Non-Small Cell Lung Cancer Version 8.2020 states the following:
“Other oncogenic driver variants are being identified such as high-level MET amplification, ERBB2 mutations and TMB. Targeted agents are available for patients with NSCLC who have these other genetic variants, although they are FDA approved for other indications. Thus, the NCCN NSCLC Panel recommends molecular testing but strongly advises broad molecular profiling to identify these other rare driver variants for which targeted therapies may be available to ensure that patients receive the most appropriate treatment; patients may be eligible for clinical trials for some of these targeted agents.”

 

ERBB2 (HER2)

ERBB2 (HER2) including both amplification and mutations, have been classified as oncogenic drivers that contribute to 2% to 6% of lung adenocarcinomas. ERBB2 (HER2) amplification is also an important mechanism for acquired resistance to EGFR tyrosine kinase inhibitors (TKI).

 

The current NCCN Guideline for Non-Small Cell Lung Cancer Version 8.2020 states the following:
“Other oncogenic driver variants are being identified such as high-level MET amplification, ERBB2 mutations and TMB. Targeted agents are available for patients with NSCLC who have these other genetic variants, although they are FDA approved for other indications. Thus, the NCCN NSCLC Panel recommends molecular testing but strongly advises broad molecular profiling to identify these other rare driver variants for which targeted therapies may be available to ensure that patients receive the most appropriate treatment; patients may be eligible for clinical trials for some of these targeted agents.”

 

Tumor Mutations Burden (TMB)

Tumor mutations burden (TMB) is an emerging biomarker that may be helpful for identifying patients with metastatic NSCLC who are eligible for first line therapy with nivolumab with or without ipilimumab. However, there is no consensus on how to measure TMB.  TMB is the number of somatic mutations in a tumor’s exome.

 

The current NCCN Guideline for Non-Small Cell Lung Cancer Version 8.2020 states the following:

“Other oncogenic driver variants are being identified such as high-level MET amplification, ERBB2 mutations and TMB. Targeted agents are available for patients with NSCLC who have these other genetic variants, although they are FDA approved for other indications. Thus, the NCCN NSCLC Panel recommends molecular testing but strongly advises broad molecular profiling to identify these other rare driver variants for which targeted therapies may be available to ensure that patients receive the most appropriate treatment; patients may be eligible for clinical trials for some of these targeted agents.”

 

Emerging Biomarkers to Identify Novel Therapies for Patients with Metastatic NSCLC (NCCN Version 8.2020)
Genetic Alterations (i.e. Driver Event)Available Targeted Agents with Activity Against Drive Event in Lung Cancer
High-level Met amplification Crizotinib
ERBB2 (HER2) mutations Ado-trastuzumab emtansine
Tumor mutations burden (TMB)* Nivolumab + ipiliumab
Nivolumab

 

*TMB is an evolving biomarker that may be helpful in selecting patients for immunotherapy. There is no consensus on how to measure TMB.

 

Treatment Selection

Tissue Biopsy as a Reference Standard

The standard of care (SOC) for treatment selection in NSCLC is biomarker analysis of tissue samples obtained by tissue biopsy.  Although tumor testing has been primarily focused on use of formalin-fixed paraffin-embedded (FFPE) tissues, increasingly, laboratories accept other specimen types, notably cytopathology preparations not processed by FFPE methods. Although testing on cell blocks is not included in the FDA approval for multiple companion diagnostic assays, testing on these specimen types is highly recommended when it is the only or best material.

 

While tissue biopsy is required to verify a cancer diagnosis and determine histology, there is often insufficient tissue for genotyping with expert centers reporting rates up to 25%, especially when a gene-by-gene sequential testing approach is utilized. Once tissue is exhausted options include a repeat biopsy or more often treating the patient empirically with standard chemotherapy when the patient may have benefited from targeted therapy. 

 

Testing for Molecular Biomarkers in Non-Small Cell Lung Cancer

Molecular testing is used to test for genomic variants associated with oncogenic driver events for which targeted therapies are available; these genomic variants (also known as molecular biomarkers) include gene mutations and fusions. The various molecular testing methods that may be used to assess for the different biomarkers are described below. Per NCCN guideline Non-Small Cell Lung Cancer Version 8.2020, broad molecular profiling systems may be used to simultaneously test for multiple biomarkers: 

  • Next-generation sequencing (NGS) is used in clinical laboratories. Not all types of alterations are detected by individual NGS assays or combination(s) of assays.
  •  It is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS). For patients who, in broad panel testing don’t have identifiable driver oncogenes (especially in never smokers), consider RNA-based NGS if not already performed, to maximize detection of fusion events.
  • Real-time polymerase chain reaction (PCR) can be used in a highly targeted fashion (specific mutations targeted). When this technology is deployed, only those specific alterations that are targeted by the assay are assessed.
  • Sanger sequencing requires the greatest degree of tumor enrichment. Unmodified Sanger sequencing is not appropriate for detection of mutations in tumor samples with less than 25% to 30% tumor after enrichment is not appropriate for assays in which identification of subclonal events (e.g. resistance mutations) is important. If Sanger sequencing is utilized, tumor enrichment methodologies are nearly always recommended.
  • Other methodologies may be utilized, including multiplex approaches not listed above (i.e SNaPshot, MassARRAY).
  • Fluorescence in situ hybridization (FISH) analysis is utilized for many assays examining copy number, amplifications, and structural alterations such as gene rearrangements.
  • Immunohistochemistry (IHC) is specifically utilized for some specific analytes and can be useful surrogate or screening assays for others.

 

Cell-free DNA in blood is derived from nonmalignant and malignant cell DNA. The small DNA fragments released into the blood by tumor cells are referred to as circulating tumor DNA (ctDNA). Most ctDNA is derived from apoptotic and necrotic cells, either from the primary tumor, metastases or circulating tumor cells. Unlike apoptosis, necrosis is considered a pathologic process, generating larger DNA fragments due to an incomplete and random digestion of genomic DNA. The length or integrity of the circulating DNA can potentially distinguish between apoptotic and necrotic origins. The ctDNA can be used for genomic characterization of the tumor and identification of the biomarkers of interest. Detection of ctDNA is challenging because cell-free DNA is diluted by nonmalignant circulating DNA and usually represents a small fraction (<1%) of total cell-free DNA. Testing methodology relies on the presence of ctDNA in circulation which is typically analyzed by one of the following methods:

  • Standard testing methodologies such as PCR or sequencing, are used to identify targeted mutations commonly present in tumors of a specific type.
  • Methodologies such as NGS-based sequencing or array-CGH are used to identify both novel and recurrent mutations. These approaches analyze single genes, panels of genes, exomes or genomes. Use of these approaches allows testing with no prior knowledge of genetic mutations that are present in the patient’s tumor.

 

The current NCCN guideline Non-Small Cell Lung Cancer Version 8.2020 states the following regarding principles of molecular and biomarker analysis regarding Plasma Cell-Free/Circulating Tumor DNA Testing:

  • Cell-free/circulating tumor DNA testing should not be used in lieu of a histologic tissue diagnosis.
  • Some laboratories offer testing for molecular alternations examining nucleic acids in peripheral circulation, most commonly in processed plasma (sometimes referred to as Ava
  • Studies have demonstrated cell-free tumor DNA testing to generally have very high specificity, but significantly compromised sensitivity, with up to 30% false-negative rate.
  • Standards for analytic performance characteristics of cell-free tumor DNA have not been established, and in contrast to tissue-based testing, no guidelines exist regarding the recommended performance characteristics of this type of testing.
  • Cell-free tumor DNA testing can identify alterations that are unrelated to a lesion of interest, for example, clonal hematopoiesis of indeterminate potential (CHIP).
  • The use of cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most notably:
    • If the patient is medically unfit for invasive tissue sampling
    • In the initial diagnostic setting, if following pathologic confirmation of NSCLC diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA should be used only if follow-up tissue-based analysis is planned for all patients in which an oncogenic driver is not identified. 

 

Selecting Targeted Therapy

Clinical Context and Test Purpose

The purpose of identifying targetable oncogenic “driver mutations” in patients who have metastatic non-small-cell lung cancer (NSCLC) is to inform a decision whether patients should receive a targeted therapy versus another systemic therapy. Patients have traditionally been tested for driver mutations using samples from tissue biopsies.

 

Patients

The target population consists of patients with metastatic NSCLC where tumor biomarker testing is indicated to select treatment. Patients may be treatment-naive or being considered for a treatment change due to progression, recurrence, or suspected treatment resistance.

 

Treatment recommendations for patients with advanced NSCLC are usually made in tertiary care setting ideally in consultation with a multidisciplinary team of pathologists, thoracic surgeons and oncologists.

 

Routine surveillance or periodic monitoring of treatment response as potential uses of liquid biopsy were not evaluated in this evidence review.

  

Interventions

The technology considered is an analysis of tumor genomic biomarkers in peripheral blood (liquid biopsy) to determine treatment selection. Several commercial tests are available and many more are in development. In contrast to tissue biopsy, no guidelines exist regarding the recommended performance characteristics of this type of testing. 

 

Studies have evaluated liquid biopsy for biomarkers that detect EGFR tyrosine kinase inhibitor (TKI) sensitization, concentrating on the EGFR exon 19 deletion and EGFR L858R variants. Studies have also evaluated separately biomarkers associated with TKI resistance, concentrating on the EGFR T790M variant.

 

Studies have also assessed a liquid biopsy for detection of the EML4-ALK fusion oncogene and its variants, translocation between ROS1 and other genes (most commonly CD74), BRAF variants occurring at the V600 position of exon 15, and other variants.

 

Patients with negative liquid biopsy results should be reflexed to tumor biopsy testing if they are able to undergo tissue biopsy.

 

Comparators

The relevant comparator of interest is testing for variants using tissue biopsy.

 

Some Guidelines have suggested that testing with a liquid biopsy should be used when testing with tissue biopsy is not feasible.

 

Outcomes

The outcomes of interest are overall survival (OS) and cancer-related survival. In the absence of direct evidence, the health outcomes of interest are observed indirectly as a consequence of the interventions taken based on the test results.

 

In patients who can undergo tissue biopsy, given that negative liquid biopsy results are reflexed to tissue biopsy, a negative liquid biopsy test (true or false) does not change outcomes compared with tissue biopsy.

 

Similarly, in patients who cannot undergo tissue biopsy, a negative liquid biopsy test (true or false) should result in the patient receiving the same treatment as he/she would have with no liquid biopsy test so a negative liquid biopsy test does not change outcomes.

 

The implications of positive liquid biopsy test results are described below.

 

Potential Beneficial Outcomes

For patients who can undergo tissue biopsy, the beneficial outcomes of a true-positive liquid biopsy result are avoidance of tissue biopsy and its associated complications. In the National Lung Screening Trial, which enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers, the percentage of patients having at least 1 complication following a diagnostic needle biopsy was approximately 11%.

 

For patients who cannot undergo tissue biopsy, the beneficial outcomes of a true-positive liquid biopsy result are receipt of a matched targeted therapy instead of chemotherapy and/or immunotherapy. The benefits of targeted therapy for patients with driver mutations in NSCLC using tissue biopsy are discussed in medical policy 02.04.78 Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer.

 

Potential Harmful Outcomes

The harmful outcome of a false-positive liquid biopsy result is incorrect treatment with a targeted therapy instead of immunotherapy and/or chemotherapy.  Studies have demonstrated cell-free tumor DNA (ctDNA) testing to generally have a high specificity, but significantly compromised sensitivity, with up to 30% false-negative rate. 

Timing

Due to the poor prognosis of advanced NSCLC, the duration of follow-up for the outcomes of interest are 6 months and 1 year.

 

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

 

The current NCCN guideline for Non-Small Cell Lung Cancer Version 8.2020 states the following: “To minimize tissue use and potential wastage, the NCCN NSCLC Panel recommends that broad molecular profiling be done as part of a biomarker testing using a validated test(s) that assess a minimum of the following potential genetic variants: EGFR mutations, BRAF mutations, METex14 skipping mutations, RET rearrangements, ALK fusions and ROS1 fusions. Broad molecular profiling is also recommended to identify rare driver mutations for which effective therapy may be available, such as NTRK gene fusions, high-level MET amplification, ERBB2 mutations and TMB. Although clinicopathologic features such as smoking status, ethnicity and histology are associated with specific genetic variants (e.g. EGFR mutations), these features should not be used to select patients for testing. Although the NCCN Guidelines for NSCLC provide recommendations for individual biomarkers that should be tested and recommended testing techniques, the guidelines do not endorse any specific commercially available biomarker assay.”

 

There are multiple commercially available liquid biopsy tests that detect EGFR and other variants using a variety of detection methods. Given the breadth of molecular diagnostic methodologies available and the lack of guidelines regarding the recommended performance characteristics of liquid biopsy, the clinical validity of each commercially available test must be established independently.   The market is changing rapidly and all available tests may not be represented below. The below table summarizes some commercially available liquid biopsy tests, and this list may not be comprehensive.

 

Commercial Circulating Tumor DNA (ctDNA) Liquid Biopsy Tests
TestManufacturerType of Liquid Biopsy
Circulogene’s Liquid Biopsy Test: Provides information on current FDA-approved treatment options for the tumor DNA identified. Doctor can monitor tumor responsiveness and adjust treatment protocols. Theranostics ctDNA

ClearID Biomarker Expression Assays: For PD-L1 and HER2.

Note: ClearID test results are summarized in an actionable genomic report containing clinical interpretations of the identified biomarkers and variants, their associations with drugs, related clinical trials, and experimental therapies that can help guide physicians, oncologists, and pathologists in making treatment decisions.

Cynvenio CTC plus ctDNA

ClearID Lung Cancer: Optimized for non-small cell lung cancer, also used for head and neck cancers, and other thoracic cancers.

Note: ClearID test results are summarized in an actionable genomic report containing clinical interpretations of the identified biomarkers and variants, their associations with drugs, related clinical trials, and experimental therapies that can help guide physicians, oncologists, and pathologists in making treatment decisions

Cynvenio CTC plus ctDNA
cobas EGFR Mutation Test v2: Real time PCR test that identifies 42 mutations in exons 18, 19, 20, 21 of the EGFR gene, including the T790M resistance mutation. Roche ctDNA and tissue

ctDX-Lung: Includes all actionable genes, genes with driver mutations targeted by a specific FDA approved through or therapies now in clinical trials. This liquid biopsy allows for serial, real time assessment of the tumor genotype as the tumor evolves.

 

ctDx Lung Panel includes 17 SNV/Indel; 7 fusion genes; and 12 CNV

Resolution Bio ctDNA

FoundationOne Liquid CDx: Analyzes 324 genes, plus it reports blood tumor mutational burden (bTMB),  microsatellite instability (MSI) and tumor fraction values. Results can help guide therapy selection and identify clinical trial options for patients with solid tumors.

 

FDA Approved Companion Diagnostic Test: Biomarkers detected EGFR exon 19 deletions and EGFR exon 21 L858R substitution. FDA approved therapy Iressa (geftinib), Tagrisso (osimertinib), or Tarceva (erlotinib)

Foundation Medicine ctDNA
Biodesix ddPCR (formerly known as GeneStrat): Delivers mutation results for EGFR, ALK, ROS1, RET, BRAF and KRAS. Drives treatment strategy and facilitates monitoring. Biodesix ctDNA
Guardant360: For advanced solid tumors, does not predict chemotherapy response but provides information on the genomic alterations known to respond to specific targeted therapies to the doctor the opportunity to tailor treatment to the individual cancer.

Point Mutations (SNVs) (73 genes)

Indels (23 genes)

Amplifications (18 genes)

Fusions (6 genes)

Note: Gauradant360 version updated to Guardant360 CDx

Guardant Health ctDNA
Guardant360 CDx: Is a qualitative next generation sequencing-based in virto diagnostic device that uses targeted high throughput hybridization-based capture technology for detection of single nucleotide variants (SNVs), insertions and deletions (indels) in 55 genes, copy number apmplifications (CNAs) in 2 genes and fusions in 4 genes. Guradant360 CDx utilizes circulating cell-free DNA (cfDNA) from plasma of peripheral whole blood collected in Streck Cell-Free DNA Blood Collection Tubes (BCTs).

 

The test in intended to be used as a companion diagnostic to identify non-small cell lung cancer (NSCLC) patients who may benefit from treatment with targeted therapy in accordance with approved therapeutic product labeling:

BiomarkerTherapy
EGFR exon 19 deletions, L858R and T790M Tagrisson (Osimertinib)

 

Guardant360 CDx was FDA approved August 2020

Guardant Health ctDNA
InvisionFirst-Lung: 37 gene panel that helps support the prognosis and therapeutic decisions in patients diagnosed with advance non-small cell lung cancer (NSCLC) using a proprietary enhanced tagged amplicon Next Generation Sequencing (eTAm-Seq) technology, this test can detect single nucleotide variants (SNVs), small insertions and deletions (InDels), copy number variants (CNVs), and structural variants (SV) such as fusions from plasma cell free DNA (cfDNA).

 

10 actionable genes relevant to advanced NSCLC in a panel of 37 genes: ALK, BRAF, EGFR, NTRK1, RET, ROS1, MET, ERBB2 (HER2), KRAS, STK11

Invita ctDNA
LiquidGx: Solid tumor therapies, monitoring for drug resistance markers. Admera Health ctDNA
OncoBEAM for Lung EGFR (Del 19, L858R, L861Q, T790M) and OncoBEAM Lung2 (EGFR, KRAS, BRAF V600E): to assist in the treatment decisions for non-small cell lung cancer Sysmex ctDNA
PlasmaSelect 64: Multiple cancer types, provides clinical explanation of all reported alterations, including FDA approved therapies, clinical trials and published literature. Personal Genome Diagnostics ctDNA

Signatera Lung:  is a custom-built circulating tumor DNA (ctDNA) test for treatment monitoring and molecular residual disease (MRD) assessment in patients previously diagnosed with cancer. It is not intended to match patients with any particular therapy. Rather, it is intended to detect and quantify how much cancer is left in the body, to detect recurrence earlier, and to help optimize treatment decisions.

Natera, Inc ctDNA
Target Selector: For breast, colorectal, gastric, prostate, lung, and melanoma to assist the doctor in understanding the status of the patient’s disease to make decisions about current and future therapy. Biocept ctDNA

 

Roche’s Cobas EGFR Mutation Test v2 is designed to identify 42 known mutations in exons 18 to 21, including the common in-frame deletions in exon 19, the L858R mutation in exon 21, and the T790M mutation in exon 20 that is associated with resistance to some tyrosine kinase inhibitors. Testing is FDA-approved for either formalin-fixed paraffin-embedded (FFPE) tissue specimens (cobas EGFR Mutation Test), or for specimens of circulating tumor DNA (ctDNA) prepared from a plasma sample (cobas EGFR Mutation Test v2).

 

The cobas EGFR Mutation Test is indicated as an FDA approved companion diagnostic to aid in selecting NSCLC patients for treatment with the targeted therapies listed in table below in accordance with the approved therapeutic product labeling:

 

DrugFFPETPlasma
TARCEVA® (erlotinib) Exon 19 deletions and L858R Exon 19 deletions and L858R
TAGRISSO® (osimertinib) Exon 19 deletions, L858R and T790M Exon 19 deletions, L858R and T790M*
IRESSA® (gefitinib) Exon 19 deletions and L858R Exon 19 deletions and L858R

 

The Ensure study was a multicenter, open label, randomized phase III study to evaluate the efficacy and safety of Tarceva versus gemcitabine/cisplatin as the first-line treatment for stage IIIB/IV non-small cell lung cancer (NSCLC) patients with exon 19 deletion or L858R mutations in the tyrosine kinase domain of epidermal growth receptor (EGFR) in their tumors. A total of 647 patients were screened, 601 patients had valid tissue EGFR results for exon 19 deletion and L858R mutation from the cobas EGFR test, and 217 patients were randomized in the study. Five hundred and seventeen patients (86.0%, 517/601) had matched plasma samples and 441 patients had a plasma sample volume > 2.0 mL, i.e. the sample volume for which the cobas EGFR Test in plasma was validated. The correlation of plasma and tissue samples by the cobas EGFR Test for detection of the exon 19 deletions and L858R mutation was evaluated both separately and in aggregate. A total of 431 samples with paired valid results from both tissue and plasma samples by cobas EGFR test were included in the agreement analysis. The positive percent (PPA) between plasma and tissue sample was 76.7% (95% CI: 70.5% to 81.9%), the negative percent agreement (NPA) was 98.2% (95% CI, 95.4% to 99.3%) for the detection of exon 19 deletion and L858R mutation. Positive predictive value (PPV) and negative predictive value (NPV) for detection of exon 19 deletion of L858R mutations in aggregate were also calculated using the bootstrap method based on the different population tissue prevalence. As expected the PPV increases and NPV decreases as the EGFR mutation prevalence increases. For a Caucasian patient population which assumes 10-15% tissue EGFR mutation prevalence, the PPV ranges from 82.8% to 88.6% while NPV ranges from 96.0% to 97.4%. The PPV ranges from 94.8% to 97.8% while NPV ranges from 80.8% to 90.9% if based on the prevalence in an Asian population assuming 30-50% tissue EGFR mutation prevalence.

 

In the Ensure trial, of the 217 patients enrolled (i.e. those with an exon 19 deletion or L858R mutation detection in tissue sample by cobas EGFR test v1), 214 (948.6%) had a plasma sample. Of the 180 plasma samples tested with cobas EGFR Test, 137 had a “Mutation Detected” result for an exon 19 deletion or an L858R mutation (68 patients in the erlotinib arm, 69 patients in the chemotherapy arm), 42 had a “No Mutation Detected” result (22 patients in the Tarceva arm, 20 patients in the chemotherapy arm), and one sample generated an invalid result. The patients in the Tarceva arm had a longer PFS compared to patients in the chemotherapy arm and the two curves were well separated over the course of the observation period (p value < 0.001) showing substantial benefit to therapy with Tarceva in patients with detectable EGFR activating mutation in plasma.    

 

The AURA2 clinical trial was a phase II, open-label, single-arm study, assessing the safety and efficacy of Tagrisso as second or third-line therapy in patients with advanced NSCLC, who had progressed following prior therapy with an approved EGFR TKI agent and were T790M positive as determined by the cobas EGFR test. A total of 472 patients were screening, 383 patients had a tissue sample tested and 371 patients had a valid tissue EGFR result for the T790M mutation from the cobas EGFR test, of which 233 patients were T790M positive and 210 patients were randomized in the study. Of the 383 eligible patients, 344 patients had plasma samples. A total of 334 samples were paired valid results from both tissue and plasma samples by the cobas EGFR Test were included in the analysis. The positive percent agreement (PPA) between plasma and tissue samples was 58.7% (95% CI: 52.2%, 65.0%) and the negative agreement (NPA) was 80.2% (95% CI: 71.8%, 86.5%) for the detection of the T790M mutation. The positive predictive value (PPV) as 85.6% (95% Ci: 79.2%, 90.3%) and the negative predictive value (NPV) was 49.2% (95% Ci: 42.0%, 56.4%) for the detection of the T790M mutation. The agreement between plasma and tissue samples in the detection of T790M resistance mutation is lower than for activating mutations. The PPA can be affected by tissue heterogeneity: unlike the activating mutations L858R and exon 19 deletions, T790M may be present in a small percentage of tumor calls as it is generally an acquired mutation; therefore T790M cfDNA may only be present in very low concentration in plasma and below the level of detection. The NPA can also be affected by tumor heterogeneity: because the T790M mutation may not present in all tumor cells, a tissue biopsy may be taken from a tumor in which T790M mutation is not present while other tumor sites may be T790M-positive.  

 

In the AURA2 trial the primary efficacy endpoint variable was the objective response rate (ORR) according to the RECIST 1.1 by BICR using the evaluable for response analysis set. The ORR was defined as the number (%) of patients with at least one visit and a result of complete response (CR) or partial response (PR) that was confirmed at least four week later (i.e. a best objective response [BOR] of CR or PR). In the tissue Evaluable Response Analysis Set (ERAS) population (T790M + patients by the cobas EGFR Test in tissue who received at least one dose of Tagrisso and had measurable disease at baseline according to BICR), 111 patients were plasma T790M positive by the cobas EGFR Test (i.e. T790M positive by both the tissue and plasma samples). The ORR for this subset was 64.9% (72/111, 95% CI: 52.1%, 70.4%) which is very similar to the 64.1% observed ORR in the tissue ERAS population. In the tissue Full Analysis Set (FAS) population 9 T790M positive patients by the cobas EGFR Test in tissue who received at least one dose of Tagrisso), 117 patients were plasma T790M positive by the cobas EGFR Test. The ORR for patients with T790M positive result by both tissue and plasma samples was 61.5% (72/117, 95% Ci: 55.2%, 73.7%) which is very similar to the 61% observed ORR in the tissue FAS population.   

 

In the FLAURA study a phase III trial for Tagrisso as first line therapy, a total of 994 patients were screened in this study where 556 patients were randomized into the clinical trial and 438 failed screening. Of the 556 FLAURA randomized patients, 537 were eligible for study analysis. Of the 537 study eligible patients, 276 were randomized by a central cobas EGFR tissue test, of which 254 had a plasma sample available for testing with 190 positive for cobas EGFR plasma test; 261 were randomized by a local tissue test, of which 242 had a plasma sample available for testing with 169 positive for cobas EGFR plasma test (136 cobas tEGFRm+, 1 cobas tEGFRm-, and 32 invalid/not tested by cobas tissue test). For the plasma primary population (tEGFRm+ and plasma EGFR mutation positive (pEGFRm+) by the cobas EGFR Test, N = 326, 190 centrally randomized and 136 locally randomized), the HR was 0.41 (95% CI: 0.31, 0.54) and the HR for the FLAURA FAS (tEGFRm+, N=556) was 0.46 (95% CI: 0.37, 0.58). Therefore, the drug efficacy for plasma primary population is consistent with the FLAURA FAS population. The superiority of Tagrisso over standard of care (SoC) was consistent across all plasma positive subgroups defined by local and central cobas tEGFR enrollment status, with HRs ranging from 0.39 to 0.48 and consistent to the HR obtained from the FLAURA FAS population (HR=0.46).  A separate analysis was performed on those patients from the standard of care (SoC) arm treated with Iressa. Of all Iressa treated patients with an investigator-assessed objective response in FLAURA, 105 patients were positive by the cobas plasma test. The ORR for all cobas plasma positive patients was 71.4% (75/105, 95% CI: 62.2%, 79.2%), Of the 105 patients with positive results from the cobas plasma test, 47 patients were randomized by the cobas tissue test (primary efficacy population for cobas plasma test) and 58 patients were randomized by a local test. A total of 36 patients were considered as responders by investigator assessment in the primary efficacy population for cobas plasma test (n=47), resulting in an ORR of 76.6% (95% CI: 62.8%, 86.4%), The ORR was 62.2% (28/45, 95% CI: 47.6%, 74.9%) in locally randomized patients who were positive by both cobas tissue and cobas plasma tests. The ORR was 69.6% (64/92, 95% CI: 59.5%, 78.0%) in all Iresssa treated patients who were both cobas tissue and cobas plasma positive. The results indicate that the treatment effect of Iresssa based on the cobas plasma test was maintained in each subpopulation and consistent with the results reported for the the original registration study (IFUM) for patients selected for Iressa.

 

FoundationOne Liquid CDx

FoundationOne Liquid CDx utilizes circulating cell-free DNA (cfDNA) isolated from plasma derived from anti-coagulated peripheral whole blood of cancer patients collected in FoundationOne Liquid CDx cfDNA blood collection tubes included in the FoundationOne Liquid CDx Blood Sample Collection Kit. The test is intended to be used as a companion diagnostic to identify patients who may benefit from treatment with the targeted therapies listed in the below table in accordance with the FDA approved therapeutic product labeling. Additionally, FoundationOne Liquid CDx is intended to provide tumor mutation profiling for substitutions and indels to be used by qualified health care professionals in accordance with professional guidelines in oncology for patients with solid malignant neoplasms.

 

Tumor TypeBiomarker(s) DetectedTherapy
Non-small cell lung cancer (NSCLC) EGFR Exon 19 deletions and EGFR Exon 21 L858R substitution IRESSA® (gefitinib)
TAGRISSO® (osimertinib)
TARCEVA® (erlotinib)

 

Clinical validity of FoundationOne Liquid CDx assay was established as a companion diagnostic to identify patients with advanced NSCLC who may be eligible for treatment with Tarceva (erlotinib), Iressa (gefitinib), or Tagrisso (osimertinib). Two hundred and eighty retrospective samples from NSCLC patients were included in this study, which were tested for EGFR exon 19 deletion and exon 21 L858R alterations (EGFR alterations) by the FoundationOne Liquid CDx assay and the previously approved cobas® EGFR Mutation Test v2 (Roche Molecular Systems, referred to cobas assay). Both EGFR alteration-positive and EGFR alteration-negative samples (based on CTA results) were selected from the screen failed population of an unrelated clinical trial in NSCLC. To avoid selection bias, the samples were selected starting with a specific testing date until the predefined number of 150 EGFR alteration-positive and 100 EGFR alteration-negative samples were fulfilled. Samples were tested across two replicates by the cobas assay (denoted as CCD1 and CCD2) and one replicate by FoundationOne Liquid CDx. The tested samples, from NSCLC patients, were compared against the intended use (IU) population with respect to gender to ensure the screening population is representative of the IU population. The variant cells were evaluated based on the agreement between both the FoundationOne Liquid CDx and the cobas assay results and between the two cobas assay replicates. For any samples in which there was insufficient plasma to process both CCD1 and CCD2, processing was not performed. In total there were 177 samples with complete test results available for analysis.

 

Agreement Analysis Results for EGFR exon 19 deletion and L858R separately

Exon 19 Deletion
PPAC1F 95.5% NPAC1F 95.6%
PPAC1C2 97.7% NPAC1C2 98.9%
PPAC2F 95.5% NPAC2F 96.0%
PPAC2C1 96.2% NPAC2C1 99.4%

 

L858R
PPAC1F 100.0% NPAC1F 95.6%
PPAC1C2 92.9% NPAC1C2 98.9%
PPAC2F 100.0% NPAC2F 94.7%
PPAC2C1 96.0% NPAC2C1 98.0

 

Concordance Among CCD1, CCD2 and FoundationOne Liquid CDx Results with Eligible Samples (n=177)

 CCD1+CCD1-
CCD2+CCD2-TotalCCD2+CCD2-Total
FoundationOne Liquid CDx+ 80 4 84 1 3 4
FoundationOne Liquid CDx- 2 0 2 0 87 87
Total 82 4 86 1 90 91

 

Agreement Analysis Results Between FoundationOne Liquid CDx and cobas Assay

 PPANPA
CCD2/CCD1* 95.3% 98.9%
CCD1/CCD2** 96.1% 98.7%
FoundationOne Liquid CDx/CDD1* 97.7% 95.6%
FoundationOne Liquid DCx/CCD2** 97.7% 95.4%

 

*CCD1: The 1st replicate of cobas assay as the reference
**CCD2: The 2nd replicate of cobas assay as the reference

 

The estimates of PPA1, PPA2, NPA1 and PA2 and the corresponding one-sided 95% upper bounds confidence limit computed using the bootstrap method
 Point EstimateMean one-sided 95% upper confidence limit
PPA1 -2.3% 2.3%
NPA1 3.3% 6.6%
PPA2 -1.6% 4.7%
NPA2 3.3% 6.6%

 

Based on these results, FoundationOne Liquid CDx has been demonstrated to be non-inferior to the cobas assay for the detection of EGFR exon 19 deletions and EGFR exon 21 L858R mutations in metastsic non-small cell lung cancer (NSCLC) patients. This study establishes the clinical validity of the FoundationOne Liquid CDx assay for identifying patients eligible for treatment with erlotinib, gefitinib, and osimertinib.

 

OncoBeam Lung

In 2016, Karlovich et. al. reported on results from a large prospective series of matched tissue and plasma samples drawn from an ongoing phase I clinical trial of rociletinib and an observational study. The primary objective was to assess detection of the T790M resistance mutation in patients with acquired resistance to first- and second-generation EGFR tyrosine kinase inhibitor therapy. Evaluated the cobas EGFR mutation test, a test platform based on allele-specific PCR. We also tested a partially overlapping set of plasma samples for EGFR mutations using BEAMing (Beads, Emulsions, Amplification and Magnetics), a technology based on digital PCR, and compared the results to the cobas plasma test results. To investigate the diagnostic utility of plasma EGFR testing, also evaluated ORR based on plasma EGFR status in the subgroup of phase I study patients who were treated at therapeutic doses of rociletinib. The observational, multicenter study sponsored by Clovis Oncology enrolled patients between April 2011 and June 2013 and was designed to prospectively collect matched blood and tumor tissue from newly diagnosed or relapsed patients with advanced (stage IIIB, IV) NSCLC. The observational study protocol allowed enrollment of patients without a requirement for documented evidence of an EGFR mutation. Data from local testing is incomplete; only central testing results are presented here. Eligible patients were undergoing, or had recently undergone, a clinically indicated biopsy or rebiopsy and signed an Ethics Committee/Institutional Review Board (EC/IRB)-approved consent prior to donating a blood sample and matched FFPE tumor tissue. Patients in the observational study did not receive rociletinib.  The positive percent agreement (PPA) between cobas plasma and tumor results was 73% (55/75) for activating mutations and 64% (21/33) for T790M. The PPA between BEAMing plasma and tumor results was 82% (49/60) for activating mutations and 73% (33/45) for T790M. Presence of extrathoracic (M1b) versus intrathoracic (M1a/M0) disease was found to be strongly associated with ability to identify EGFR mutations in plasma (P < 0.001). Rociletinib objective response rates (ORR) were 52% [95% confidence interval (CI), 31 – 74%] for cobas tumor T790M-positive and 44% (95% CI, 25 – 63%) for BEAMing plasma T790M-positive patients. A drop in plasma-mutant EGFR levels to ≤10 molecules/mL was seen by day 21 of treatment in 7 of 8 patients with documented partial response. The authors concluded these findings suggest the cobas and BEAMing plasma tests can be useful tools for noninvasive assessment and monitoring of the T790M resistance mutation in NSCLC, and could complement tumor testing by identifying T790M mutations missed because of tumor heterogeneity or biopsy inadequacy.

 

In 2018, Ramalingam et.al. performed a prospective review of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC), the AURA study (ClinicalTrials.gov identifier: NCT01802632) included two cohorts of treatment-naïve patients to examine clinical activity and safety of osimertinib (an epidermal growth factor receptor [EGFR] -tyrosine kinase inhibitor selective for EGFR-tyrosine kinase inhibitor sensitizing [ EGFRm] and EGFR T790M resistance mutations) as first-line treatment of EGFR-mutated advanced non-small-cell lung cancer (NSCLC). Sixty treatment-naïve patients with locally advanced or metastatic EGFRm NSCLC received osimertinib 80 or 160 mg once daily (30 patients per cohort). End points included investigator-assessed objective response rate (ORR), progression-free survival (PFS), and safety evaluation. Plasma samples were collected at or after patients experienced disease progression, as defined by Response Evaluation Criteria in Solid Tumors (RECIST), to investigate osimertinib resistance mechanisms. At data cutoff (November 1, 2016), median follow-up was 19.1 months. Overall ORR was 67% (95% CI, 47% to 83%) in the 80-mg group, 87% (95% CI, 69% to 96%) in the 160-mg group, and 77% (95% CI, 64% to 87%) across doses. Median PFS time was 22.1 months (95% CI, 13.7 to 30.2 months) in the 80-mg group, 19.3 months (95% CI, 13.7 to 26.0 months) in the 160-mg group, and 20.5 months (95% CI, 15.0 to 26.1 months) across doses. Of 38 patients with post-progression plasma samples, 50% had no detectable circulating tumor DNA. Nine of 19 patients had putative resistance mechanisms, including amplification of MET (n = 1); amplification of EGFR and KRAS (n = 1); MEK1, KRAS, or PIK3CA mutation (n = 1 each); EGFR C797S mutation (n = 2); JAK2 mutation (n = 1); and HER2 exon 20 insertion (n = 1). Acquired EGFR T790M was not detected. The authors concluded osimertinib demonstrated a robust ORR and prolonged PFS in treatment-naïve patients with EGFR advanced NSCLC. There was no evidence of acquired EGFR T790M mutation in post-progression plasma samples.

 

Guardant360 CDx and InvisionFirst-Lung Circulating Tumor DNA

Guardant360 CDx

Note: The Guardant360 version updated to Guardant360 CDx

 

Thompson et.al. (2016) in a single center, observational study conducted at the Hospital of the University of Pennsylvania between February 2015 and March 2016, enrolling a consecutive blood sample of 102 prospectively enrolled subjects. This included both new patients referred to our institution and existing patients. The clinical indications and inclusion criteria for this study were that the patient must have a diagnosis of NSCLC or suspected NSCLC (by pathology) seen in our Thoracic Oncology Group, and had blood samples sent for ctDNA NGS as part of their routine clinical care. This study did not require a specific course of treatment. Because our primary objective was to evaluate the feasibility of the ctDNA test for detecting actionable mutations, consecutive patients who fulfilled the inclusion criteria were enrolled, with a target sample size of 100 patients. Blood draws for commercial ctDNA NGS were ordered as clinically indicated by the primary oncologist. Clinical variables and results from solid tumor sequencing were determined by chart review. The study was approved by the University of Pennsylvania Internal Review Board (IRB). 112 plasma samples obtained from a consecutive study of 102 prospectively enrolled patients with advanced NSCLC were subjected to ultra-deep sequencing of up to 70 genes and matched with tissue samples, when possible. Blood was collected in two 10 mL Streck tubes (Streck) and shipped overnight at ambient temperature to Guardant Health, Inc, a CLIA-certified, CAP-accredited laboratory facility. The current 70-gene Guardant360 panel includes complete exons for 30 genes, and critical exons (those reported as having a somatic mutation in COSMIC) of 40 additional genes resulting in a 146,000 bp (146KB) target region. The platform detects fusions in 6 genes, and multiple indels in 3 genes. The average coverage depth was 10,000X. During this study, the Guardant platform expanded from a 68- to a 70-gene panel. This expansion added ERBB2 and MET indels, full exon coverage of RB1, and critical exon coverage of TSC1. Samples from 36 patients were sequenced on the 68-gene panel and samples from the remaining 66 patients on the 70-gene panel. All tissue samples were processed at the CAP/CLIA-certified University of Pennsylvania Center for Personalized Diagnostics clinical laboratory. 38 patient samples were processed using the Illumina TruSeq Amplicon – Cancer Panel (TSACP, FC-130-1008; Illumina) to sequence hotspots or exonic regions for 47 gene. For the remaining 12 patients, the DNA extracted from submitted tissue was of insufficient quantity for the full 47-gene panel; these samples were assessed using the Penn Precision Panel for mutations in a smaller panel of 20 commonly mutated genes. Detection of 275 alterations in 45 genes, and at least one alteration in the ctDNA for 86 of 102 patients (84%), with EGFR variants being most common. ctDNA NGS detected 50 driver and 12 resistance mutations, and mutations in 22 additional genes for which experimental therapies, including clinical trials, are available. While ctDNA NGS was completed for 102 consecutive patients, tissue sequencing was only successful for 50 patients (49%). Actionable EGFR mutations were detected in 24 tissue and 19 ctDNA samples, yielding concordance of 79%, with a shorter time interval between tissue and blood collection associated with increased concordance (p=0.038). ctDNA sequencing identified 8 patients harboring a resistance mutation who developed progressive disease while on targeted therapy, and for whom tissue sequencing wasn’t possible. The authors concluded therapeutically targetable driver and resistance mutations can be detected by ctDNA NGS, even when tissue is unavailable, thus allowing more accurate diagnosis, improved patient management, and serial sampling to monitor disease progression and clonal evolution.

 

In 2016, Villaflor et. al. performed a retrospective study that was approved by the Institutional Review Board at the University of Chicago. Subjects were males and females with a diagnosis of non-small cell lung cancer (NSCLC) who had undergone at least one ctDNA test at a single commercial ctDNA laboratory Guardant360™ (Guardant Health, Inc. Redwood City, CA) between September 2014 through August 2015. All subjects were seen at the University of Chicago and all provided written informed consent. Clinical characteristics of the subjects were extracted from the subject’s electronic health record. There was direct comparisons between a single ctDNA assay, Guardant360™ (Guardant Health, Inc. Redwood City, CA) and 11 different tissue-based assays, which ranged from a single mutation companion diagnostic test to an NGS-based panel of over 300 genes. Of the 90 patients submitted for ctDNA analysis as part of clinical care, 68 had provided informed consent for inclusion in this study. Eighty-three percent of subjects had at least one genomic alteration identified in plasma. Most commonly mutated genes were TP53, KRAS and EGFR. Subjects with no detectable ctDNA were more likely to have small volume disease, lepidic growth pattern, mucinous tumors or isolated leptomeningeal disease.  The authors concluded this is the first clinic-based series of NSCLC patients assessing outcomes of targeted therapies using a commercially available ctDNA assay. Over 80% of patients had detectable ctDNA, concordance between paired tissue and blood for truncal oncogenic drivers was high and patients with biomarkers identified in plasma had PFS in the expected range. These data suggest that biopsy-free ctDNA analysis is a viable first choice when the diagnostic tissue biopsy is insufficient for genotyping or at the time of progression when a repeated invasive tissue biopsy is not possible/preferred.

 

Schwaederle et. al. (2017) retrospectively reviewed the clinicopathologic and outcome data of 88 consecutively tested patients with lung adenocarcinoma followed at UC San Diego Moores Cancer Center, for whom molecular testing (ctDNA test) had been performed on their plasma (August 2014 until October 2015). Data was abstracted from the electronic medical record and performed in accordance with the Declaration of Helsinki. For all patients, this study (PREDICT-UCSD (Profile Related Evidence Determining Individualized Cancer Therapy; NCT02478931) was performed and consents obtained whenever necessary after approval by UCSD Institutional Review Board guidelines. Digital Sequencing of ctDNA (DNA) in all patients was performed by Guardant Health, Inc. (Guardant360, Redwood City, California. Comprehensive plasma ctDNA testing was performed in 88 consecutive patients; 34 also had tissue next generation sequencing; 29, other forms of genotyping; and 25 (28.4%) had no tissue molecular tests because of inadequate tissue or biopsy contraindications. Seventy-two patients (82%) had ≥ 1 ctDNA alteration(s); amongst these, 75% carried alteration(s) potentially actionable by FDA-approved (61.1%) or experimental drug(s) in clinical trials (additional 13.9%). The most frequent alterations were in TP53 (44.3% of patients), EGFR (27.3%), MET (14.8%), KRAS (13.6%), and ALK (6.8%) genes. The concordance rate for EGFR alterations was 80.8% (100% versus 61.5% (≤ 1 versus > 1 month between tests; P = 0.04)) for patients with any detectable ctDNA alterations. Twenty-five patients (28.4%) received therapy matching ≥ 1 ctDNA alteration(s); 72.3% (N=16/22) of the evaluable matched patients achieved stable disease ≥ 6 months (SD) or partial response (PR). Five patients with ctDNA-detected EGFR T790M were subsequently treated with a third generation EGFR inhibitor; all five achieved SD ≥ 6 months/PR. Patients with ≥ 1 alteration with ≥ 5% variant allele fraction (versus < 5%) had a significantly shorter median survival (P = 0.012). The authors concluded ctDNA analysis detected alterations in the majority of patients with potentially targetable aberrations found at expected frequencies. Therapy matched to ctDNA alterations demonstrated appreciable therapeutic efficacy, suggesting clinical utility that warrants future prospective studies.

 

In 2019, Leighl et.al. Prospectively enrolled patients with previously untreated malignant non-small cell lung cancer (mNSCLC) undergoing physician discretion standard of care (SOC) tissue genotyping submitted a pretreatment blood sample for comprehensive cfDNA analysis (Guardant360). The NILE study (Non-invasive versus Invasive Lung Evaluation; ClinicalTrials.gov; NCT03615443) enrolled 307 patients with biopsy proven, previously untreated, nonsquamous mNSCLC (stage IIIB/IV) undergoing physician discretion SOC tissue genotyping at one of 28 North American centers. Eligible patients were prospectively consented to this institutional review board–approved study and enrolled between July 2016 and April 2018. Patients with previously treated localized NSCLC (stage I–IIIA) were eligible if primary surgical resection and/or radiation treatment was completed at least 6 months prior to the development of metastatic disease and adjuvant systemic therapy was completed at least 6 weeks prior to study enrollment. Standard of care tissue genotyping included genomic testing and PD-L1 expression analysis. In accordance with NCCN guidelines, Standard of care tissue genotyping may include NGS, PCR "hotspot" testing, FISH and/or IHC, or Sanger sequencing. The tissue genotyping methodology and spectrum of biomarkers assessed was allowable per physician discretion based on the genotyping they would pursue in a normal and customary SOC setting. Patients submitted a pretreatment blood sample for cfDNA analysis utilizing a CLIA certified, CAP-accredited, New York State Department of Health–approved comprehensive NGS test (Guardant360; Guardant Health). The cfDNA test assesses for single-nucleotide variants (SNV) in 73 genes, insertion–deletion (indel) and fusion alterations, and copy-number amplifications in select genes including all eight guideline-recommended biomarkers and KRAS). The primary analysis for this study was based on results reported to the ordering provider according to study procedures. Among 282 patients, physician discretion SOC tissue genotyping identified a guideline-recommended biomarker in 60 patients versus 77 cfDNA identified patients (21.3% vs. 27.3%; P < 0.0001 for noninferiority). In tissue-positive patients, the biomarker was identified alone (12/60) or concordant with cfDNA (48/60), an 80% cfDNA clinical sensitivity for any guideline-recommended biomarker. For FDA-approved targets (EGFR, ALK, ROS1, BRAF) concordance was >98.2% with 100% positive predictive value for cfDNA versus tissue (34/34 EGFR-, ALK-, or BRAF-positive patients). Utilizing cfDNA, in addition to tissue, increased detection by 48%, from 60 to 89 patients, including those with negative, not assessed, or insufficient tissue results. cfDNA median turnaround time was significantly faster than tissue (9 versus 15 days; P < 0.0001). Guideline-complete genotyping was significantly more likely (268 versus 51; P < 0.0001). The authors concluded, In the largest cfDNA study in previously untreated mNSCLC, a validated comprehensive cfDNA test identifies guideline-recommended biomarkers at a rate at least as high as SOC tissue genotyping, with high tissue concordance, more rapidly and completely than tissue-based genotyping.

 

InVisionFirst-Lung

In 2019 Pritchett et. al. reported on the multicentered prospective clinical validation of the InVision ctDNA assay in patients with advanced untreated NSCLC. A total of 264 patients with untreated advanced NSCLC were prospectively recruited, and their plasma was analyzed using a ctDNA NGS assay for detection of genomic alterations in 36 commonly mutated genes. Tumor tissue was available in 178 patients for molecular profiling for comparison with plasma profiling. The remaining 86 patients were included to compare ctDNA profiles in patients with and without tissue for profiling. Concordance of InVisionFirst with matched tissue profiling was 97.8%, with 82.9% positive predictive value, 98.5% negative predictive value, 70.6% sensitivity, and 99.2% specificity. Considering specific alterations in eight genes that most influence patient management, the positive predictive value was 97.8%, with 97.1% negative predictive value, 73.9% sensitivity, and 99.8% specificity. Across the entire study, 48 patients with actionable alterations were identified by ctDNA testing compared with only 38 by tissue testing. ctDNA NGS reported either an actionable alteration or an alteration generally considered mutually exclusive for such actionable changes in 53% of patients. The liquid biopsy NGS assay demonstrated excellent concordance with tissue profiling in this multicenter, prospective, clinical validation study, with sensitivity and specificity equivalent to Food and Drug Administration–approved single-gene ctDNA assays. The use of plasma-based molecular profiling using NGS led to the detection of 26% more actionable alterations compared with standard-of-care tissue testing in this study.

 

Remon et. al. 2019, assessed the feasibility and utility of circulating tumor DNA (ctDNA) by amplicon-based next-generation sequencing (NGS) analysis in the daily clinical setting in a cohort of patients with advanced non–small-cell lung cancer (NSCLC), as an alternative approach to tissue molecular profiling. In this single-center prospective study, treatment-naïve and previously treated patients with advanced NSCLC were enrolled. Clinical validation of ctDNA using amplicon-based NGS analysis (with a 36-gene panel) was performed against standard-of-care tissue molecular analysis in treatment-naïve patients. The feasibility, utility, and prognostic value of ctDNA as a dynamic marker of treatment efficacy was evaluated. Results of tissue molecular profile were blinded during ctDNA analysis. Of 214 patients with advanced NSCLC who were recruited, 156 were treatment-naïve patients and 58 were pretreated patients with unknown tissue molecular profile. ctDNA screening was successfully performed for 91% (n = 194) of all patients, and mutations were detected in 77% of these patients. Tissue molecular analysis was available for 111 patients (52%), and tissue somatic mutations were found for 78% (n = 87) of patients. For clinically relevant variants, concordance agreement between ctDNA and tumor tissue analysis was 95% among 94 treatment-naïve patients who had concurrent liquid and tumor biopsy molecular profiles. Sensitivity and specificity were 81% and 97%, respectively. Of the 103 patients with no tissue available, ctDNA detected potential actionable mutations in 17% of patients; of these, 10% received personalized treatment. ctDNA kinetics correlated with response rate and progression-free survival in 31 patients treated with first-line platinum-based chemotherapy. The authors concluded, our data provides additional validation that ctDNA with InVisionSeq Lung, an amplicon-based technology, can be used for molecular profiling and to monitor disease in patients with advanced NSCLC with high sensitivity and specificity to detect clinically relevant and actionable mutations when tissue biopsy is unavailable or uninformative. This study also suggests that ctDNA offers a potential prognostic biomarker for treatment efficacy.

 

Summary

A chain of evidence based on the sensitivity and specificity of liquid biopsy for the detection of EGFR TKI-sensitizing variants and other predictive/prognostics biomarkers for NSCLC (ALK fusion oncogene; ROS1 gene fusions, BRAF V600E point mutations; NTRK gene fusions; METex14 skipping mutations; RET rearrangements; PD-L1 expression; high level-MET amplifications, TMB [tumor mutational burden];  ERBB2 (HER2) mutations and KRAS) for tests with established clinical validity such as the cobas EGFR Mutation Test v2, FoundationOne Liquid CDx, OncoBEAM, Guardant360 CDx or InvjsionFirst-Lung can support its utility. The body of evidence has demonstrated sensitivity generally between 60% and 80%, with high specificities (>95%). If a liquid biopsy is used to detect EGFR TKI-sensitizing variants and other predictive and prognostic biomarkers for NSCLC with reflex testing of tissue samples in those with negative liquid biopsies, then the sensitivity of the testing strategy will be equivalent to tissue biopsy, and the specificity will be high. Therefore, outcomes should be similar.

 

EGFR p.Thr790Met (T790M) (EGFR TKI-resistant variant) is a mutation associated acquired resistance to EGFR TKI therapy and been reported in about 60% of patients with disease progression after initial response to erlotinib, gefitinib or afatinib. Acquired resistance can also be mediated by other molecular events such as acquisition of ALK rearrangement, MET or ERBB2 amplification. For EGFR TKI resistant variants such as T790M, T790M can be assessed using an FDA approved test or other validated laboratory test done in a CLIA-approved laboratory. Data suggest (AURA Study) that plasma genotyping (also known as plasma testing or liquid biopsy) may be considered at progression instead of tissue biopsy to detect whether patients have T790M; however, if plasma is negative, then tissue biopsy is recommended.

 

Limited evidence based on clinical validity suggests that liquid biopsy with cobas EGFR Mutation Test v2, FoundationOne Liquid CDx (found to be non-inferior to cobas EGFR Mutation Test v2), OncoBEAM, Guardant360 CDx or InvjsionFirst-Lung Circulating Tumor DNA (ctDNA) tests, in patients with metastatic NSCLC, may be a reasonable in patients unable to undergo standard of care tissue biopsy (medically unfit) or in cases where tumor tissue is lacking or insufficient for proper mutation analysis.

 

Other Commercially Available Liquid Biopsy Tests for EGFR TKI-Sensitizing Variants

For the other commercially marketed available tests including but not limited to the below, to include detection of EGFR TKI-sensitizing variants and for liquid biopsy testing of other driver mutations (predictive/prognostics biomarkers in NSCLC) sufficient evidence of clinical validity is lacking (no available evidence assessing the diagnostic characteristics of liquid biopsy compared with lung tissue biopsy as a reference standard), and therefore a chain of evidence cannot be linked to support a conclusion that results these ctDNA test methods will be similar to those for tissue biopsy. The current NCCN Guideline Non-Small Cell Lung Cancer Version 8.2020 recommends that broad molecular profiling be done as part of a biomarker testing using a validated test(s).

 

TestAvailable StudiesStudy Quality
Circulogene Liquid Biopsy Test 0 Not applicable
ClearID Lung Cancer 0 Not applicable
ctDX Lung 1 Several limitations identified (Paweletz. et. al.)
Biodesix ddPCR (formerly known as GeneStra) 1 Patient characteristics and selection unclear; timing of blood and tissue samples unclear; precision estimates not provided (Mellert et. al.)
LiquidGx 0 Not applicable
PlasmaSelect 64 0 Not applicable
Signatera Lung 0 Not Applicable
Target Selector 1 Limitations identified to include no available evidence assessing the diagnostic characteristics of liquid biopsy compared with lung tissue biopsy reference standard (Poole et. al.)

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

 

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

 

No RCTs comparing management with and without liquid biopsy were identified.

 

Evidence on the ability of liquid biopsy to predict treatment response similar to, or better than, a tissue biopsy is of interest. If the 2 tests are highly correlated, they are likely to stratify treatment response similarly overall.

 

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

 

Clinical utility might alternatively be established based on a chain of evidence. Assuming that tissue biomarkers are the standard by which treatment decisions are made, agreement between liquid and tissue biopsies would infer that treatment selection based on liquid or tissue biopsies is likely to yield similar outcomes. Also, a liquid biopsy would reduce the number of patients undergoing tissue sampling and any accompanying morbidity.

 

Evidence was considered on the ability of liquid biopsy to predict treatment response. Liquid biopsy could improve patient outcomes if it predicts treatment response similar to, or better than tissue biopsy. Treatment response as measured by overall survival (OS) outcomes would be most informative. Progression free survival (PFS) can be difficult to interpret because of confounding influences in retrospective observational subgroup analyses. Response rate may be more informative than PFS.

 

Summary

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs. No RCTs comparing management with and without liquid biopsy were identified.

 

Limited evidence based on clinical validity suggests that liquid biopsy with cobas EGFR Mutation Test v2, FoundationOne Liquid CDx (found to be non-inferior to cobas EGFR Mutation Test v2), OncoBEAM, Guardant360 CDx or InvjsionFirst-Lung Circulating Tumor DNA (ctDNA) tests, in patients with metastatic NSCLC, may be a reasonable in patients unable to undergo standard of care tissue biopsy (medically unfit) or in cases where tumor tissue is lacking or insufficient for proper mutation analysis.

 

For the other commercially marketed available tests including but not limited to the above, to include detection of EGFR TKI-sensitizing variants and for liquid biopsy testing of other driver mutations, sufficient evidence of clinical validity is lacking (no available evidence assessing the diagnostic characteristics of liquid biopsy compared with lung tissue biopsy reference standard), and therefore a chain of evidence cannot be linked to support a conclusion that results these ctDNA test methods will be similar to those for tissue biopsy. The current NCCN Guideline Non-Small Cell Lung Cancer Version 8.2020 recommends that broad molecular profiling be done as part of a biomarker testing using a validated test(s).

 

Summary of Evidence

The current NCCN guideline Non-Small Lung Cancer Version 8.2020 includes the following:

 

“The use of cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most notably:

  • If the patient is medically unfit for invasive tissue sampling
  • In the initial diagnostic setting, if following pathologic confirmation of NSCLC diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA should be used only if follow-up tissue-based analysis is planned for all patients in which an oncogenic driver is not identified. 

 

To minimize tissue use and potential wastage, the NCCN NSCLC Panel recommends that broad molecular profiling be done as part of a biomarker testing using a validated test(s) that assess a minimum of the following potential genetic variants: EGFR mutations, BRAF mutations, METex14 skipping mutations, RET rearrangements, ALK fusions and ROS1 fusions. Broad molecular profiling is also recommended to identify rare driver mutations for which effective therapy may be available, such as NTRK gene fusions, high-level MET amplification, ERBB2 mutations and TMB. Although clinicopathologic features such as smoking status, ethnicity and histology are associated with specific genetic variants (e.g. EGFR mutations), these features should not be used to select patients for testing. Although the NCCN Guidelines for NSCLC provide recommendations for individual biomarkers that should be tested and recommended testing techniques, the guidelines do not endorse any specific commercially available biomarker assay.”

 

Cobas EGFR Mutation Test v2 Liquid Biopsy

For individuals with advanced non-small-cell lung cancer (NSCLC) who receive testing for biomarkers/genetic variants of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) sensitivity using circulating tumor DNA (ctDNA) with the cobas EGFR Mutation Test v2 (liquid biopsy), the evidence includes numerous studies assessing the diagnostic characteristics of liquid biopsy compared with tissue biopsy. The relevant outcomes are overall survival (OS), disease-specific survival (DSS), and test validity. Current evidence does not permit determining whether cobas liquid biopsy or tissue biopsy is more strongly associated with patient outcomes or treatment response. No randomized controlled trials (RCTs) providing evidence of the clinical utility of cobas EGFR Mutation Test v2 (liquid biopsy) were identified. The cobas EGFR Mutation Test v2 (liquid biopsy) has adequate evidence of clinical validity for the EGFR TKI-sensitizing variants. The Food and Drug Administration has suggested that a strategy of liquid biopsy followed by referral (reflex) tissue biopsy of negative liquid biopsies for the cobas test would result in an overall diagnostic performance equivalent to tissue biopsy. Several additional studies of the clinical validity of cobas liquid biopsy have shown it to be moderately sensitive and highly specific compared with a reference standard of tissue biopsy. A chain of evidence demonstrates that the reflex testing strategy with the cobas liquid biopsy test should produce outcomes similar to tissue testing. Patients who cannot undergo tissue biopsy would likely otherwise receive chemotherapy. The cobas EGFR Mutation Test v2 (liquid biopsy) test can identify patients for whom there is a net benefit of targeted therapy versus chemotherapy with high specificity. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.

 

FoundationOne Liquid CDx

FoundationOne Liquid CDx has been demonstrated to be non-inferior to the cobas EGFR Mutation Test v2 (liquid biopsy) test for the detection of EGFR exon 19 deletions and EGFR exon 21 L858R mutations in metastatic non-small cell lung cancer (NSCLC). The studies completed establish the clinical validity of the FoundationOne Liquid CDx assay for identifying patients eligible for treatment with erlotinib, gefitinib, and osimertinib. The FoundationOne Liquid CDx test can identify patients for whom there is a net benefit of targeted therapy versus chemotherapy with high specificity. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.

 

OncoBEAM Lung

For individuals with metastatic non-small cell lung cancer (NSCLC) who receive testing for biomarkers/genetic variants of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) sensitivity using circulating tumor DNA (ctDNA) with OncoBEAM Lung, the evidence includes studies assessing the diagnostic characteristics of liquid biopsy compared with tissue biopsy. OncoBEAM Lung has adequate evidence of clinical validity for the EGFR TKI-sensitizing variants. A strategy of liquid biopsy followed by referral (reflex) tissue biopsy of negative liquid biopsies for the tests would result in an overall diagnostic performance similar to tissue biopsy. A chain of evidence demonstrates that the reflex testing strategy with the OncoBEAM Lung should produce outcomes similar to tissue testing. Patients who cannot undergo tissue biopsy would likely otherwise receive chemotherapy. This test can identify patients for whom there is a net benefit of targeted therapy versus chemotherapy with high specificity. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.

 

Guardant360 CDx and InvisionFirst-Lung Tests

Note: The Guardant360 version updated to Guardant360 CDx

 

For individuals with metastatic non-small cell lung cancer (NSCLC) who receive testing for EGFR TKI-sensitizing variants and other biomarkers/genetic variants/gene fusions in NSCLC using circulating tumor DNA (ctDNA) liquid biopsy testing with the Guardant360 CDx or InVisionFirst-Lung tests, the evidence includes several studies assessing the diagnostic characteristics of liquid biopsy compared with tissue biopsy. The relevant outcomes are overall survival (OS), disease specific survival (DSS), and test validity. Current evidence does not permit determining whether liquid or tissue biopsy is more strongly associated with patient outcomes or treatment response. Currently no randomized controlled trials (RCTs) providing evidence of the clinical utility of these tests were identified. The Guardant360 CDx and InVisionFirst-Lung tests have adequate evidence of clinical validity. A strategy of liquid biopsy followed by referral (reflex) tissue biopsy of negative liquid biopsies for the tests would result in an overall diagnostic performance similar to tissue biopsy. A chain of evidence demonstrates that the reflex testing strategy with the Guardant360 CDx, or InVisionFirst-Lung tests should produce outcomes similar to tissue testing. Patients who cannot undergo tissue biopsy would likely otherwise receive chemotherapy. These tests can identify patients for whom there is a net benefit of targeted therapy versus chemotherapy with high specificity. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes.

 

All Other Commercially Available Tests for Circulating Tumor DNA (ctDNA) (Liquid Biopsy)

For individuals with metastatic non-small cell lung cancer (NSCLC) who receive testing for EGFR TKI-sensitizing variants and other genomic biomarkers for NSCLC using circulating tumor DNA (ctDNA) liquid biopsy to select a targeted therapy, the evidence includes studies assessing the diagnostic characteristics of liquid biopsy compared with the tissue biopsy reference standard, however, given the breadth of molecular diagnostic methodologies available to assess circulating tumor DNA (ctDNA), the clinical validity of each commercially available test must be established independently. At this time except for cobas EGFR Mutation Test v2, FoundationOne Liquid CDx, OncoBEAM Lung, Guardant360 CDx, and InvisionFirst-Lung none of the other commercially available tests have studies of adequate quality in demonstrating that this testing would produce outcomes similar to tissue testing to select targeted therapy. No RCTs were found providing evidence of the clinical utility that compared health outcomes for patients managed with and without these tests. The current NCCN guideline Non-Small Cell Lung Cancer Version 8.2020 states: ”The NCCN NSCLC Panel recommends that molecular profiling as part of biomarker testing use validated test(s).” The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Practice Guideline and Position Statements

National Comprehensive Cancer Network (NCCN)

Non-Small Cell Lung Cancer Version 8.2020
Principles of Molecular Biomarker Analysis

Molecular Diagnosis Studies in Non-Small Cell Lung Cancer

  • Numerous gene alterations have been identified that impact therapy selections. Testing of lung cancer specimens for these alterations is important for indentification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit.
  • Some selection approaches for targeted therapy include predictive immunohistochemical analysis, which are distinct from immunohistochemical studies utilized to identify tumor type and lineage.
  • Major elements of molecular testing that are critical for utilization and interpretation of molecular results include:
    • Use of laboratory that is properly accredited, with a minimum of CLIA accreditation
    • Understanding the methodologies that are utilize and the major limitations of those methodologies
    • Understanding the spectrum of alterations tested (and those not tested) by a specific assay
    • Knowledge of whether a tumor sample is subjected to pathologic review and tumor enrichment (i.e. microdissection, microdissection) prior to testing
  • Specimen Acquisition and Management:
    • Although tumor testing has been primarily focused on use of formalin-fixed paraffin-embedded (FFPE) tissues, increasingly, laboratories accept other specimen types, notably cytopathology preparations not processed by FFPE methods. Although testing on cell blocks is not included in the FDA approval for multiple companion diagnostic assays, testing on these specimen types is highly recommended when it is the only or best material.
    • A major limitation in obtaining molecular testing results for NSCLC occurs when minimally invasive techniques are used to obtain samples; the yield may be insufficient for molecular biomarker and histologic testing. Therefore, bronchoscopists and interventional radiologists should procure sufficient tissue to enable all appropriate testing.
    • When tissue is minimal, laboratories should deploy techniques to maximize tissue for molecular and ancillary testing, including dedicated histology protocols for small biopsies, including “up-front” slide sectioning for diagnostic and predictive testing. 
  • Testing Methodologies
    • Appropriate possible testing methodologies are indicated below for each analyst separately; however, several methodologies are generally considerations for use:
      • Next-generation sequencing (NGS) is used in clinical laboratories. Not all types of alterations are detected by individual NGS assays or combination(s) of assays.
      • It is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS). For patients who, in broad panel testing don’t have identifiable driver oncogenes (especially in never smokers), consider RNA-based NGS if not already performed, to maximize detection of fusion events.
      • Real-time polymerase chain reaction (PCR) can be used in a highly targeted fashion (specific mutations targeted). When this technology is deployed, only those specific alterations that are targeted by the assay are assessed.
      • Sanger sequencing requires the greatest degree of tumor enrichment. Unmodified Sanger sequencing is not appropriate for detection of mutations in tumor samples with less than 25% to 30% tumor after enrichment is not appropriate for assays in which identification of subclonal events (e.g. resistance mutations) is important. If Sanger sequencing is utilized, tumor enrichment methodologies are nearly always recommended.
      • Other methodologies may be utilized, including multiplex approaches not listed above (i.e SNaPshot, MassARRAY).
      • Fluorescence in situ hybridization (FISH) analysis is utilized for many assays examining copy number, amplifications, and structural alterations suchas gene rearrangements.
      • Immunohistochemistry (IHC) is specifically utilized for some specific analytes and can be useful surrogate or screening assays for others.
  • Molecular Targets for Analysis
    • In general, the mutations/alterations described below are seen in a non-overlapping fashion, although between 1%-3% of NSCLC may harbor concurrent alterations.
    • EGFR (Epidermal Growth Factor Receptor) Gene Mutations: EGFR is a receptor is a receptor tyrosine kinase normally found on the surface of epithelial cells and is often overexpressed in a variety of human malignancies.
      • The most commonly described mutations in EGFR (exon 19 deletions, p.L858R point mutation in exon 21) are associated with responsiveness to EGFR tyrosine kinase inhibitor (TKI) therapy; most recent data indicated that tumors that do not harbor a sensitizing EGFR mutation should not be treated with EGFR TKI in any line of therapy.
      • Many of the less commonly observed alterations of EGFR, which cumulatively account for -10% of EGFR mutated NSCLC (i.e. exon 19 insertions, p>L861Q, p.G719X, p.S768I) are also associated with responsiveness to EGFR TKI therapy, although the number of studied patients is lower.
      • Some mutations in EGFR are associated with lack of responsiveness to EGFR TIK therapy, including most EGFR exon 20 insertions, and p.T790M.
        • Most EGFR exon 20 insertion mutations predict resistance to clinically achievable levels of TKIs. The exception is a rare EGFR exon 20 insertion variant, p.A763_Y764insFQEA, which is associated with responsiveness to EGFR TKI therapy. Therefore, knowledge of an EGFR 20 insertion must be included in the specific sequence alteration.
        • The finding of p.T790M is most commonly associated with relapse following initial therapy with EGFR TKI, which is known mechanism of resistance. If identified prior to TKI exposure, genetic counseling should be considered, because germline p.T790M is associated with familial lung cancer predisposition and additional testing is warranted.
      • As use of NGS testing increases, additional EGFR variants are increasingly identified; however, the clinical implications of individual alterations are unlikely to be well established.
      • Some clinicopathologic features such as smoking status, ethnicity, and histology are associated with the presence of an EGFR mutation; however, these features should not be utilized in selecting patients for testing. 
      • Testing methodologies: Real-Time PCR, Sanger sequencing (Ideally paired with tumor enrichment), and NGS are the most commonly deployed methodologies for examining EGFR mutations status.
  • ALK (Anaplastic Lymphoma Kinase) Gene Rearrangements: ALK is a receptor tyrosine kinase that can be rearranged in NSCLC, resulting in dysregulation and inappropriate signaling through the ALK kinase domain.
    • The most common fusion partner seen with ALK is echinoderm microtubule-associated protein-like 4 (EML4), although a variety of other fusion partners have been identified.
    • The presence of an ALK rearrangement is associated with responsiveness to ALK TKIs, with recent studies demonstrating improved efficacy of alectinib or crizotinib in the first-line setting.
    • Some clinicopathologic features such as smoking status and histology have been associated with the presence of an ALK rearrangement; however, these features should not be utilized in selecting patients for testing.
    • Testing methodologies: FISH break-apart probe methodology was the first methodology deployed widely. IHC can be deployed as an effective screening strategy. FDA-approved ICH (ALK[D5F3] CDx Assay) can be utilized as a stand-alone test, not requiring confirmation by FISH. Numerous NGS methodologies can detect ALK fusions. Targeted real-time PCR assays are used in some settings, although it is unlikely to detect fusions with novel partners.
  • ROS1 (ROS proto-oncogene 1) Gene Rearrangements: ROS1 is a receptor tyrosine kinase that can be rearranged in NSCLC, resulting in dysregulation and inappropriate signaling through the ROS1 kinase domain.
    • Numerous fusion partners are seen with ROS1, and common fusion partners include: CD74, SLC34A2, CCDC6, and FIG.
    • The presence of a ROS1 rearrangement is associated with the responsiveness to oral ROS1 TKIs.
    • Some clinicopathologic features such as smoking status and histology have been associated with the presence of ROS1 rearrangements; however, these features should not be utilized in selecting patients for testing.  
    • Testing methodologies: FISH break-apart probe methodology can be deployed; however, it may under-detect the FIG-ROS1 variant. IHC approaches can be deployed; however, IHC for ROS1 fusions has low specificity, and follow-up confirmatory testing is a necessary component of utilizing ROS1 IHC as a screening modality. Numerous NGS methodologies can detect ROS1 fusions, although DNA-based NGS may under-detect ROS1 fusions. Targeted real-time PCR assays are utilized in some settings, although they are unlikely to detect fusions with novel partners.
  • BRAF (B-Raf proto-oncogene) point mutations: BRAF if a serine/threonine kinase that is part of the canonical MAP/ERK signaling pathway. Activating mutations in BRAF result in unregulated signaling through the MPA/ERK pathway.
    • Mutations in BRAF can be seen in NSCLC. The presence of a specific mutation resulting in a change in amino acid position 600 (p.V600E) has been associated with responsiveness to combine therapy with oral inhibitors of BRAF and MEK.
    • Note that other mutations in BRAF are observed in NSCLC, and the impact of those mutations on therapy selection is o tweel understood at this time. 
    • Testing methodologies; Real time PCR, Sanger sequencing (ideally paired with tumor enrichment), and NGS are commonly deployed methodologies for examining BRAF mutation status. While an anti-BRAF pV600E-specific monoclonal antibody is commercially available, and some studies have examined utilizing this approach, it should only be deployed after extensive validation.
  • KRAS (KRAS proto-oncogene) point mutations: KRAS is a G-protein with intrinsic GTPase activity, and activating mutations result in unregulated signaling through the MAP/ERK pathway.
    • Mutations in KRAS are most commonly seen at codon 12, although other mutations can be seen in NSCLC.
    • The presence of a KRAS mutation is prognostic of poor survival when compared to patients with tumors without KRAS mutation.
    • Mutations in KRAS have been associated with reduced responsiveness to EGFR TKI therapy.
    • Owing to the low probability of overlapping targetable alterations, the presence of a known activating mutations in KRAS identifies patients who are unlikely to benefit from further molecular testing.
  • NTKR (neurotropic tyrosine receptor kinase) gene fusions
    • NTKR 1/2/3 are tyrosine receptor kinases that are rarely rearranged in NSCLC as well as in other tumor types, resulting in dysregulation and inappropriate signaling.
    • Numerous fusion partners have been identified.
    • To date, no specific clinicopathologic features, other than the absence of other driver alterations, have been identified in association with these fusions.
    • Testing Methodologies: Various methodologies can be used to detect NTRK gene fusions, including: FISH, ICH, PCR and NGS; false negatives may occur. IHC methods are complicated by baseline expression in some tissues. FISH testing may require at least 3 probe sets for full analysis. NGS testing can detect a broad range of alterations. DNA-based NGS may under-detect NTKR-1 and NTKR-3 fusions.
  • Testing in the Setting of Progression on Targeted Therapy:
    • For many of the above listed analytes, there is growing recognition of the molecular mechanisms of resistance to therapy. Re-testing of a sample from a tumor that is actively progressing while exposed to targeted therapy can shed light on appropriate next therapeutic steps:
      • For patients with an underlying EGFR sensitizing mutation who have been treated with EGFR TKI, minimum appropriate testing includes high-sensitivity evaluation for p.T790M; when there is no evidence of p.T790M, testing for alternate mechanisms of resistance (MET amplification, ERBB2 amplification) may be used to direct patients for additional therapies. The presence of p.T790M can direct patients to third-generation EGFR TKI therapy.
        • Assays for the detection of EGFR p.T790M should be designed to have an analytic sensitivity of a minimum of 5% allelic fraction. The original sensitizing mutation can be utilized as an internal control in many assays to determine whether a p.T790M is within range of detection if present as sub-clonal event.
      • For patients with underlying ALK rearrangement who have been treated with ALK TKI, it is unclear whether identification of specific tyrosine kinase domain mutation can identify appropriate next steps in therapy, although some preliminary data suggest that specific kinase domain mutations can impact next line of therapy.
  • PD-L1 (Programmed Death Ligand 1): PD-L1 is a co-regulatory molecule that can be expressed on tumor cells and inhibit T-cell-mediated cell death. T-cells express PD-1, a negative regulator, which binds to ligands including PD-L1 (CD274) or PD-L2 (CD273). In the presence of PD-L1, T-cell activity is suppressed.
    • Checkpoint inhibitor antibodies block the PD-1 and PD-L1 interaction, thereby improving the antitumor effects of endogenous T-cells.
    • IHC for PD-L1 can be utilized to identify disease most likely to respond to first-line anti PD-1/PD-L1.
      • Various antibody clones have been developed for IHC analysis of PD-L1 expression, and while several show relative equivalence, some do not.
      • Interpretation of PD-L1 IHC in NSCLC is typically focused on the proportion of tumor cells expressing membranous staining at any level and therefore is a linear variable, scoring systems may be different in other tumor types.
      • The FDA-approved companion diagnostics for PD-L1 guides utilization of pembrolizumab in patients with NSCLC and is based on the tumor proportion score (TPS). TPS is the percentage of viable tumor cells showing partial or complete membrane staining at any intensity.
      • The definition of positive and negative testing is dependent on the individual antibody and platform deployed, which may be unique to each checkpoint inhibitor therapy. The potential for multiple different assays for PD-L1 has raised concern among both pathologist and oncologists.  
      • Although PD-L1 expression can be elevated in patients with oncogenic driver, targeted therapy for the oncogenic driver should take precedence over treatment with an immune checkpoint inhibitor.
  • Plasma Cell-Free/Circulating Tumor DNA Testing:
    • Cell-free/circulating tumor DNA testing should not be used in lieu of a histologic tissue diagnosis.
    • Some laboratories offer testing for molecular alternations examining nucleic acids in peripheral circulation, most commonly in processed plasma (sometimes referred to as Ava
    • Studies have demonstrated cell-free tumor DNA testing to generally have very high specificity, but significantly compromised sensitivity, with up to 30% false-negative rate.
    • Standards for analytic performance characteristics of cell-free tumor DNA have not been established, and in contrast to tissue-based testing, no guidelines exist regarding the recommended performance characteristics of this type of testing.
    • Cell-free tumor DNA testing can identify alterations that are unrelated to a lesion of interest, for example, clonal hematopoiesis of indeterminate potential (CHIP).
    • The use of cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most notably:
      • If the patient is medically unfit for invasive tissue sampling
      • In the initial diagnostic setting, if following pathologic confirmation of NSCLC diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA should be used only if follow-up tissue-based analysis is planned for all patients in which an oncogenic driver is not identified.

 

Emerging Biomarkers to Identify Novel Therapies for Patients with Metastatic NSCLC
Genetic Alterations (i.e. Driver Event)Available Targeted Agents with Activity Against Drive Event in Lung Cancer
High-level Met amplification Crizotinib
ERBB2 (HER2) mutations Ado-trastuzumab emtansine
Tumor mutations burden (TMB)* Nivolumab + ipiliumab
Nivolumab

 

*TMB is an evolving biomarker that may be helpful in selecting patients for immunotherapy. There is no consensus on how to measure TMB.

 

Discussion

Predictive and Prognostic Biomarkers

Several biomarkers have emerged as predictive and prognostic markers for NSCLC. A predictive biomarker is indicative of therapeutic efficacy because there is an interaction between the biomarker and therapy on patient outcome. A prognostic biomarker is indicative of patient survival independent of the treatment received because the biomarkers is an indicated the innate tumor behavior (see KRAS Mutations at the end of this section. The NSCLC Panel recommends testing for certain molecular and immune biomarkers in all appropriate patients with metastatic NSCLC to assess whether patients are eligible for targeted therapies or immunotherapies based on data showing improvement in overall survival for patients receiving targeted therapies or immunotherapies compared with traditional chemotherapy regimens.

 

Predictive biomarkers include the ALK fusion oncogene (fusion between ALK and other genes (e.g. echinoderm microtubule-associated protein-like 4), ROS1 gene fusions, sensitizing EGFR gene mutations, BRAF V600E point mutations, NTRK gene fusions, METex14 skipping mutations, RET rearrangements, and PD-L1 expression (see Principles of Molecular Biomarker Analysis in the NCCN guidelines for NSCLC). Emerging predictive biomarkers include ERBB2 mutations. High-level MET amplifications, and tumor mutational burden (TMB) (See Emerging Biomarkers to Identify Novel Therapies for Patients with Metastatic NSCLC).  The presence of EGFR exon 19 deletions or exon 21 L858R mutations is predictive of treatment benefit from EGFR tyrosine kinase inhibitor (EGFR TKI) therapy (e.g. Osimertinib); therefore, these mutations are referred to as sensitizing EGFR mutations. The presence of EGFR exon 19 deletions (LREA0 or exon 21 L858R mutations does not appear to be prognostic of survival for patients with NSCLC, independent of therapy.

 

ALK fusion oncogenes (i.e. ALK gene fusions) and ROS1 fusions are predictive biomarkers that have been identified in a small subset of patients with NSCLC; both predict for benefit from targeted therapy such as crizotinib or ceritinib. Other gene fusions have recently been identified, such as ERBB2 (HER2) mutations that are susceptible to targeted therapies, particularly therapies currently under investigation in clinical trials.

 

Testing for ALK gene fusions and EGFR gene mutations is recommended (category 1 for both) in the NSCLC algorithm for patients with metastatic nonsquamous NSCLC or NSCLC NOS so that patients with these genetic variants an receive effective treatment with targeted agents. Testing for ROS1 fusions and BRAF mutations (both are category 2A) is also recommended int eh NCCN Guidelines for nonsquamous NSCLC or NSCLC NOS. Although rare, patients with ALK fusions or EGFR mutations can have mixed squamous cell histology. Therefore, testing for ALK fusions and EGFR mutations can be considered in select patients with metastatic squamous cell carcinoma if they are never smokers, small biopsy specimens were used for testing, or mixed histology was reported. Data suggest that EGFR mutations occur in patients with adenosquamous carcinoma at a rate similar to adenocarcinoma which is harder to discriminate from squamous cell carcinoma in small specimens. Thus, testing for EGFR mutations and ALK fusions in recommended in mixed squamous cell lung specimens that contain an adenocarcinoma component, such as adenosquamous NSCLC or in samples in which an adenocarcinoma component cannot be excluded. The incidence of EGFR mutations is very low in patients with pure squamous cell history (,4%). Testing for ROS1 fusions or BRAF mutations is also recommended (category 2A) in patients with squamous cell carcinoma who have small biopsy specimens of mixed histology.

 


For patients with metastatic nonsquamous NSCLC, the NCCN NSCLC Panel currently recommends the minimum of the following biomarkers should be tested, including EGFR mutations, BRAF mutations, ALK fusions, ROS1 fusions, METex14 skipping mutations, RET rearrangements, and PD-L1 expression levels. This list of recommended biomarkers may be revised as new oncogenic driver variants are identified and new agents are approved. The NCCN Guidelines for NSCLC provide recommendations for individual biomarkers that should be tested and recommend testing techniques but do not endorse any specific commercially available biomarker assay. Biomarker testing should be done at properly accredited laboratories (minimum of Clinical Laboratory Improvement Amendments [CLIA] accreditation). EGFR, KRAS, ROS1. BRAF, METex14 skipping mutations, RET rearrangements, and ALK genetic variants do not usually overlap; thus testing for KRAS mutation may identify patients who will not benefit from further molecular testing. The KRAS oncogene is a prognostic biomarker. The presence of KRAS mutations is prognostic of poor survival for patients with NSCLC when compared to the absence of KRAS mutations, independent of therapy. KRAS mutations are also predictive of lack of benefit from EGFR TKI therapy.

 

Other oncogenic driver variants are being identified such as high-level MET amplification, ERBB2 mutations and TMB. TMB is emerging biomarker that may be helpful for identifying patients with metastatic NSCLC who are eligible for first line therapy with nivolumab with or without ipilimumab. However, there is no consensus on how to measure TMB. Targeted agents are available for patients with NSCLC who have these other genetic variants, although they are FDA approved for other indications. Thus, the NCCN NSCLC Panel recommends molecular testing but strongly advises broad molecular profiling to identify these other rare driver variants for which targeted therapies may be available to ensure that patients receive the most appropriate treatment; patients may be eligible for clinical trials for some of these targeted agents. Several online resources are available that describe NSCLC driver events such as My Cancer Genome.

 

Information about biomarker testing and plasma cell-free/circulating tumor DNA testing (so-called “liquid biopsy”) for genetic variants is included in the algorithm (See Principles of Molecular and Biomarker Analysis in the NCCN guidelines for NSCLC). Briefly, the pane feels that plasma cell-free/circulating tumor DNA testing should be sued to diagnose NSCLC; tissue should be used to diagnosis NSCLC. Standards and guideline for cell-free DNA (cfDNA)/circulating tumor DNS testing for genetic variants have not been established, there is up to 30% false-negative rate, and variants can be deterred that are not related to the tumor (e.g. clonal hematopoiesis of indeterminate potential [CHIP]). For example, an IDH1 mutation identified by cfDNA testing is likely unrelated to NSCLC, given exceptionally low incidence and is more likely to represent CHIP. Rare examples of CHIP with KRAS mutations have been described, suggesting caution in the interpretation of cfDNA findings. In addition, CHIP can be identified following prior chemotherapy or radiotherapy, further confounding interpretation of variants such as in TP53. Given the previous caveats, careful consideration is required to determine whether cfDNA findings reflect a true oncogenic driver or unrelated finding.

 

However, cfDNA testing can be used in specific circumstances if 1) the patient is not medically fit for invasive tissue sampling, or 2) there is insufficient tissue for molecular analysis and follow-up tissue-based analysis will be done if an oncogenic driver is not identified. Recent data suggest that plasma cell-free/circulating tumor DNA testing can be used to identify EGFR, ALK and other oncogenic biomarkers that would not otherwise be identified in patients with metastatic NSCLC.

 

Testing for Molecular Biomarkers

Molecular testing is used to test for genomic variants associated with oncogenic driver events for which targeted therapies are available; these genomic variants (also known as molecular biomarkers) include gene mutations and fusions. The various molecular testing methods that may be used assess for the different biomarkers are described in the algorithm (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). Broad molecular profiling systems may be used to simultaneously test for multiple biomarkers.

 

Next-generation sequencing (NGS0 (also known as massively parallel sequencing) is a type of broad molecular profiling system that can detect panels of mutations and gene fusions if the NGS platforms have been designed and validated to detect these genetic variants. It is important to recognize that NGS requires quality control as much as any other diagnostic technique; because it is primer dependent, the pan of genes and abnormalities detected with NGS will vary depending on the design of the NGS platform. For example, some NGS platforms can detect both mutations and gene fusions, as well as copy number variation, but they are not uniformly present in all NGS assays being conducted either commercially or in institutional laboratories.

 

Other mutation screening assays are available for detecting multiple biomarkers simultaneously such as Sequenom’s MassARRAY system and SNaPshot Multiplex System which can detect more than 50 point mutations; NGS platforms can detect even more biomarkers. However, these multiplex polymerase chain reaction (PCR) system do not typically detect gene fusions. ROS1 and ALK gene fusions can be detected using fluorescence in situ hybridization (FISH), NGS and other methods (see ALK Gene Rearrangements and ROS1 Rearrangements in this Discussion and Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC).

 

To minimize tissue use and potential wastage, the NCCN NSCLC Panel recommends that broad molecular profiling be done as part of biomarker testing using a validated test(s) that assess a minimum of following potential genetic variants: EGFR mutations, BRAF mutations, METex14 skipping mutations, RET rearrangements, ALK fusions, and ROS1 fusions. Both FDA and laboratory developed test platforms are available that address the need to evaluate these and other analytes. Broad molecular profiling is also recommended to identify rare driver mutations for which effective therapy may be available, such NTRK gene fusion, high level MET amplification, ERBB2 mutations and TMB. Although clinicopathologic features such as smoking status, ethnicity and histology are associated with specific genetic variants (e.g. EGFR mutations), these features should not be used to select patients for testing. Although the NCCN guidelines for NSCLC provide recommendations for individual markers that should be tested and recommend testing techniques, the guidelines do not endorse any specific commercially available biomarkers assays.

 

EGFR Mutations

In patients with NSCLC, the most commonly found EGFR mutations are deletions in exon 19 (Exon19del [with conserved deletion of the LREA sequence] in 45% of patients with EGFR mutations) and a point mutations in exon 21 (L858R in 40%). Both mutations result in activation of the tyrosine kinase domain, and both are associated with sensitivity to the small-molecule EGFR TKIs, such as erlotinib, gefitinib, afatinib, osimertinib, and dacomitinib (See Targeted Therapies in this Discussion). Thus, these drug-sensitive EGFR mutations are referred to as sensitizing EGFR mutations. Other less common mutations (10%) that are also sensitive to EGFR TKIs include exon 19 insertions, p.L861Q, p.G719X, and p.S768I (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). Data suggest that patients harboring tumors without sensitizing EGFR mutations should not be treated with EGFR TKIs in any line of therapy. These sensitizing EGFR mutations are found in approximately 10% of Caucasian patients with NSCLC and up to 50% of Asian patients.

 

Most patients with sensitizing EGFR mutations are nonsmokers or former light smokers with adenocarcinoma histology. Data suggest that EGFR mutations can occur in patients with adenosquamous carcinoma, which is harder to discriminate from squamous cell carcinoma in small specimens. Patients with pure squamous cell carcinoma are unlikely to have sensitizing EGFR mutations; those with adenosquamous carcinoma may have mutations. However, smoking status, ethnicity, and histology should not be used in selecting patients for testing. EGFR mutation testing is not usually recommended in patients who appear to have squamous cell carcinoma unless they are a former light or never smoker, if only a small biopsy specimen (i.e. not a surgical resection) was used to assess histology, or if the histology is mixed. The ESMO Guidelines specify that only patients with nonsquamous cell (e.g. adenocarcinoma) should be assessed for EGFR mutations. ASCO recommends that patients be tested for EGFR mutations.

 

The predictive effects of the drug-sensitive EGFR mutations are well defined. Patients with these mutations have a significantly better response to erlotinib, gefitinib, afatinib, Osimertinib or dacomitinib. Data show that EGFR TKI therapy should be used as first-line monotherapy in patients advanced NSCLC and sensitizing EGFR mutations documented before first-line systemic therapy (e.g. carboplatin/paclitaxel) (see Targeted Therapies in this Discussion). Progression-free survival (PFS) is longer with use of EGFR TKI monotherapy in patients with sensitizing EGFR mutations when compared with cytotoxic systemic therapy, although overall survival is not statistically different.

 

Non-responsiveness to EGFR TKI therapy is associated with KRAS and BRAF mutations and ALK or ROS1 gene fusions. Patients with EGFR exon 20 insertion mutations are usually resistant to erlotinib, gefitinib, afatinib, or dacomitinib, although there are rare exceptions (See Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). Patients typically progress after first-line EGFR TKI monotherapy; subsequent therapy recommendations are described in the algorithm [see Second-Line and Beyond (Subsequent) Systemic Therapy in this Discussion and the NCCN Guidelines for NSCLC].  EGFR p.Thr790Met (T790M) is a mutations associated with acquired resistance to EGFR TKI therapy and has been reported in about 60% of patients with disease progression after initial response to erlotinib, gefitinib or afatinib. Most patients with sensitizing EGFR mutations become resistant to erlotinib, gefitinib or afatinib; PFS is about 9.7 to 13 months. Studies suggest T790M may rarely occur in patients who have previously received erlotinib, gefitinib or afatinib. Genetic counseling is recommended for patients with pre-treatment p.T790M, because this suggest the possibility of germline mutations and is associated with predisposition to familial lung cancer. Acquired resistance to EGFR TKIs may also be associated with histologic transformation from NSCLC to SCLC and with epithelial to mesenchymal transition. For the 2020 updated (Version 1), the NCCN NSCLC Panel suggest that a biopsy can be considered at progression to rule out SCLC transformation, Acquired resistance an also be mediated by other molecular events, such as acquisition of ALK rearrangement, MET or ERBB2 amplification.

 

The NCCN NSCLC Panel recommends testing for sensitizing EBFR mutations in patients with metastatic nonsquamous NSCLC or NSCLC NOS based on data showing the efficacy of Osimertinib, erlotinib, gefitinib, afatinib or dacomitinib and on DFA approval. DNA mutational analysis is the preferred method to assess for EGFR status; IHC is not recommended for detecting EGFR mutations. Real-time PCR, Sanger sequencing (paired with tumor enrichment), and NGS are the most commonly used methods to assess EGFR mutation status (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). Direct sequencing of DNA corresponding to exons 18 to 21 (or just testing for exons 19 and 21) is a reasonable approach; however, more sensitive methods are available. Mutation screening assays using multiplex PCR (e.g. Sequenom’s MassARRAY system, SNaPshot Multiplex system) can simultaneously detect more than 50- point mutations. NGS can also be used to detect EGFR mutations.

 

Osimertinib is a preferred first-line EGFR TKI option for patients with EGFR positive metastatic NSCLC. For the 2020 update (Version 1), the NCCN Panel preference stratified first-line therapy for patients with EGFR mutation positive metastatic NSCLC. Erlotinib, gefitinib, afatinib or dacomitinib are “other recommended” EGFR TKI options for first-line therapy. Osimertinib is recommended (category 1) as second-line and beyond (subsequent) therapy for patients with EGFR T790M-positive metastatic NSCLC who have progressed on erlotinib, gefitinib, afatinib, or dacomitinib. Sensitizing EGFR mutations and ALK or ROS1 fusions are generally mutually exclusive. Thus, crizotinib, ceritinib, alectinib, brigatinib or lorlatinib are not recommended as subsequent therapy for patients with sensitizing EGFR mutations who relapse on EGFR TKI therapy. The phrase subsequent therapy was recently substituted for the terms second-line or beyond systemic therapy, because the line of therapy may vary depending on previous treatment with targeted agents.  

 

BRAF V600E Mutations

BRAF (v-RAF murine sarcoma viral oncogene homolog B) is a serine-threonine kinase that is part of the MAP/ERK signaling pathway. BRAF V 600E is the most common of the BRAF point mutations when considered across all tumor types; it occurs in 1% to 2% of patients with lung adenocarcinoma. Although other BRAF mutations occur in patients with NSCLC at a rate approximately equal to pV600E (unlike many other tumor types), specific targeted therapy is not available for these other mutations. Patients with BRAF V600E mutations are typically current or former smokers in contrast to those with EGFR mutations or ALK fusion who are typically nonsmokers. Mutations in BRAF typically do not overlap with EGFR mutations, METex14 skipping mutations, RET rearrangements, ALK fusions, or ROS1 fusions. Testing for BRAF mutations is recommended (category 2A) in patients with metastatic nonsquamous NSCLC and may be considered in patients with squamous cell NSCLC (category 2A) if small biopsy specimens were used to assess histology or mixed histology was reported. Real time PCR, Sanger sequencing and NGS are the most commonly used methods to assess for BRAF mutations (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC).

 

The NCCN NSCLC Panel recommends testing for BRAF mutations in patients with metastatic nonsquamous NSCLC based on data showing the efficacy of dabrafenib plus trametinib for patients with BRAF V600E mutations and on the FDA approval. For the 2020 update (Version 1), the NCCN Panel preference stratified first-line therapy for patients with BRAF V600E mutation-positive metastatic NSCLC. Dabrafenib plus trametinib is recommended (category 2A; preferred) for patients with BRAF V600E mutations. If combination therapy with dabrafenib/trametinib is not tolerated, single-agent therapy with dabrafenib or vemurafenib are “other recommended” agents. Chemotherapy regimens are also used for initial systemic therapy (e.g. carboplatin/pemetrexed for nonsquamous NSCLC) and are “useful in certain circumstances.” Patients with BRAF mutations response (24%) to immune checkpoint inhibitors (ICIs).

 

ALK Gene Rearrangements

About 5% of patients with NSCLC have ALK gene rearrangements (also known as ALK fusions). Patients with ALK fusions are resistant to EGFR TKIs but have similar clinical characteristics to those with EGFR mutations, such as adenocarcinoma histology and being light or never smokers. ALK fusions are not routinely found in patients with squamous cell carcinoma. Patients with ALK gene fusions can have missed squamous cell histology. It can be challenging to accurately determine histology in small biopsy specimens; thus, patients may have mixed squamous cell histology (or squamous components) instead of pure squamous cell.

 

The NCCN NSCLC Panel recommends testing for ALK fusion in patients with metastatic nonsquamous NSCLC based on data showing the efficacy of alectinib, brigatinib, certinib, and crizotinib for ALK fusions and on the FDA approvals. If patients appear to have squamous cell NSCLC, then testing can be considered if small biopsy specimens were used to assess histology, mixed histology was reported, or patients are light or never smokers. The different testing methods for ALK fusions are described in the algorithm (see Principles of Molecular and Biomarker analysis in the NCCN guidelines for NSCLC). A molecular diagnosis FISH test has been approved by the FDS for detecting ALK fusions. Rapid prescreening with IHC to assess for ALK fusions can be done. AN IHC assay for ALK fusions has also been approved by the FDA. NGS can also be used to assess whether ALK fusions are present, if the platform has been appropriately designed and validated to detect ALK fusions.

 

Alectinib is recommended as a preferred first-line therapy for patients with ALK rearrangement-positive metastatic NSCLC. For the 2020 update (Version 1), the NCCN Panel preference stratified first-line therapy with brigatinib, ceritinib, or crizotinib for patients with ALK rearrangement-positive metastatic NSCLC. Brigatinib and ceritinib are “other recommended” options, whereas crizotinib is “useful” in certain circumstances.”. Patients with ALK rearrangements do not respond to ICIs.

 

Patients typically progress after first-line therapy with alectinib, brigatinib, crizotinib, or ceritinib. ALK or ROS1 fusions, RET rearrangements, BRAF mutations, METex14 skipping mutations, and sensitizing EGFR mutations are generally exclusive. Specific targeted therapy for RET rearrangements, BRAF mutations, METex14 skipping mutations, and sensitizing EGFR mutations is not recommended as subsequent therapy in patients with ALK or ROS1 fusions who replace on alectinib, brigatinib, crizotinib, ceritinib, or lorlatinib.

 

ROS1 Rearrangements

Although ROS proto-oncogene 1 (ROS1) is a distinct receptor tyrosine kinase, it is very similar to ALK and members of the insulin receptor family. It is estimated that ROS1 gene rearrangements (also known as ROS1 fusions) occur in about 1% to 2% of patient with NSCLC; they occur more frequently in those who are negative for EGFR mutations, KRAS mutations and ALK gene fusions. The NCCN NSCLC Panel recommends ROS1 testing (category 2A) in patients with metastatic nonsquamous NSCLC or NSCLC NOS based on data showing the efficacy of crizotinib, ceritinib, and entrectinib for patients with ROS1 fusions (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). ROS1 testing can be considered in patients with metastatic squamous cell NSCLC if small biopsy specimens were used to assess histology or mixed histology was reported. Similar to testing for ALK fusions, testing for ROS1 fusions is done with FISH. NGS can also be used to assess whether ROS1 fusions are present if the platform has been appropriately designed and validated to detect ROS1 fusions. Clinicians should use an appropriately validated test to detect ROS1 fusions.

 

Crizotinib is very effective for patients with ROS1 fusions with response rates of about 70% to 80% including complete responses. The NCCN NSCLC Panel recommends crizotinib, entrectinib or ceritinib (all are category 2A) as first-line therapy options for patients with ROS-1-positive metastatic NSCLC based on the clinical trial data. The NCCN NSCLC Panel voted that criztonib and entrectinib are preferred first-line therapy options for patients with ROS1-positive metastatic NSCLC because they are better tolerated, have been assessed in more patients, and are approved by the FDA. Although entrectinib has better CNS penetratin than crizotinib, it is more toxic. If ROS1 fusions are discovered during first-line systemic therapy (e.g. carboplatin/paclitaxel), then the planned therapy may be either completed or interrupted followed by crizotinib (preferred), entrectinib (preferred) or certinib.

 

The NCCN NSCLC Panel recommends lorlatinb (category 2A) as a subsequent therapy option for select patients with ROS1-positive metastatic NSCLC who have progressed after treatment with crizotinib, entrectinib, or certinib. Initial systemic therapy options that are used for adenocarcinoma or squamous cell carcinoma are also an option in this setting (e.g. carboplatin/paclitaxel). Patients with ROS1 rearrangements have a slight response (17%) to ICIs. Alectinib, brigatinib, and ceritinib are not recommended in patients with ROS1 fusions whose disease becomes resistant to crizotinib. Studies are ongoing regarding new agents for patients with ROS1 fusions whose disease become resistant to crizotinib, ceritinib, or entrectinib. The phrase subsequent therapy was recently substituted for the terms second-line or beyond systemic therapy, because the line of therapy may vary depending on previous treatment with targeted agents.

 

NTRK Gene Fusions

NTKR gene fusions encode tropomyosin receptor kinase (TRK) fusion proteins (e.g. TRKA, TRKB, TRKC) that act as oncogenic drivers for solid tumors including lung, salivary gland, thyroid, and sarcoma. A diverse range of solid tumors in children and adults may be caused by NTRK gene fusions (e.g. NTRK1, NTRK2, NTRK3). It is estimated that NTRK gene fusions occur in 0.2% of patients with NCSLC and do not typically overlap with other oncogenic drivers such as EGFR, ALK or ROS1. Various methods can be used to detect NTRK gene fusions, including FISH, IHC, NGS, and PCR assays (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). DNA-based NGS may not detect some NTRK1 and NTRK3 fusions; RNA-based NGS may be considered to assess for fusions. In a clinical trial, NTRK gene fusions were detected with NGS (50 patients) and FISH (5 patients). Lacrotrectinb and entrectinib are oral TKIs that inhibit TRK across a diverse range of solid tumors in younger and older patients with NTRK gene-fusion positive disease. 

 

The NCCN NSCLC Panel recommends NTRK gene fusion testing in patients with metastatic NSCLC based on clinical trial data showing the efficacy of lacrotrectinib and entrectinib for patients with NTRK gene fusion-positive disease; however, clinical data are limited in NSCLC to support this recommendation. The NCCN NSCLC Panel recommends lacrotrectinib and entrectinib (both are category 2A) as either first-line or subsequent therapy options for patients with NTRK gene fusion-positive metastatic NSCLC based on data and the FDA approvals. For the 2020 update (Version 1), the NCCN Panel voted that lacrotrectinib and entrectinb are both preferred (category 2A) as first-line therapy for patients with NTRK gene fusion-positive metastatic disease. A new section was also added to the algorithm (see Principles of Molecular and Biomarker Analysis in the NCCN Guidelines for NSCLC). For example, if NRTK 1/2/3 testing was not included as part of a broad upfront panel, then NTRK 1/2/3 testing can be considered if the patients tumor is negative for the main oncogenic drivers (i.e. pan-negative for EGFR, ALK, ROS1 and BRAF drivers).

 

METex14 Skipping Mutations

C-MET, the hepatocyte growth factor (HGF) receptor, is a tyrosine kinase receptor that is involved in cell survival and proliferation; oncogenic drive genomic alterations in MET include METex14 skipping mutations, MET gene copy number (GCN) gain or amplification, and MET overexpression. MET genomic alterations do not typically overlap with EGFR, ROS1, BRAF and ALK genetic variants. However, METex14 skipping mutations and MET amplification may occur together. METex14 skipping mutations occur in 3% to 4% of patients with adenocarcinomas NSCLC and 1% to 2% of patients with other NSCLC histologies. METex14 skipping mutations are more frequent in older women who are nonsmokers.

 

Several different types of METex14 skipping mutations may occur, such as mutations, based substitutions, and deletions, which makes it difficult to test for other mutations. NGS and RT-PCR assays can be used to detect METex14 skipping mutations with MET amplification. Patients with METex14 skipping mutations have a modest response (16%) to immunotherapy, even those with high PD-L1 levels.

 

For the 2020 update (Version 4), the NCCN NSCLC Panel recommends testing for METex14 skipping mutations (category 2A) in eligible patients with metastatic NSCLC based on data showing the efficacy of several agents for patients with METex14 skipping mutations and on the FDA approval for capmatinib.

 

RET Rearrangements
RET is a tyrosine kinase receptor that affects cell proliferation and differentiation. Rearrangements (fusions) may occur in NSCLC between the RET gene and other domains, especially kinesin family 5B (KIF5B) and coiled coil domain containing-6 (CCDC6), which lead to overexpression of the RET protein. RET rearrangements occur in about 1% to 2% of patients with NSCLC and are more frequent in patients with adenocarcinoma histology. In European patients, RET rearrangements occur in both smokers and nonsmokers. RET rearrangements do not typically overlap with EGFR, ROS1, BRAF, METex14 skipping and ALK genetic variants. However, a few studies suggest that RET rearrangements may infrequently overlap with EGFR and KRAS mutations. FISH, RT-PCR, and NGS assays can be used to detect RET rearrangements. Patients with RET rearrangements have minimal response (6%) to immunotherapy.

 

For the 2020 update (Version 4), the NCCN NSCLC Panel recommends testing for RET rearrangements (category 2A) in eligible patients with metastatic NSCLC based on data showing the efficacy of several agents for patients with RET rearrangements and on the FDA approval for selpercatinib (LOXO-292).

 

KRAS Mutations

KRAS is a G-protein with GTPase activity that is part of the MAP/ERK; point mutations in KRAS most commonly occur at codon 12. Data suggest that approximately 25% of patients with adenocarcinomas in a North American population have KRAS mutations; KRAS is the most common mutation in this population. KRAS mutation prevalence is associated with cigarette smoking. Patients. With KRAS mutations appear to have a shorter survival than patient with wild-type KRAS; therefore, KRAS mutations are prognostic biomarkers. KRAS mutational status is also predictive of lack of therapeutic efficacy with EGFR TKIs; it does not appear to affect chemotherapeutic efficacy. KRAS mutations do not generally overlap with EGFR, ROS1, BRAF and ALK genetic variants. Therefore, KRAS testing may identify patients who may not benefit from further molecular testing. KRAS mutations my infrequently overlap with EGFR mutations and RET rearrangements. Targeted therapy is not currently available for patients with KRAS mutations, although immune checkpoint inhibitors (ICIs) appear to be effective.

 

Testing for Immune Biomarkers: PLD-L1 Expression Levels

Human ICI antibodies inhibit the PD-1 receptor or PD-L1, which improves antitumor immunity; PD-1 receptors are expressed on activated cytotoxic T-cells. Nivolumab and pembrolizumab inhibit PD-1 receptors. Atezolizumab and durvalumab inhibit PD-L1. The NCCN NSCLC Panel recommends (category 1) IHC testing for PD-L1 expression ideally before first-line treatment (if clinically feasible) in all patients with metastatic NSCLC to assess whether the ICI regimens are an option based on clinical data showing the efficacy of these regimens.

 

The FDA approve companion diagnostic test for PD-L1 expression is based on tumor proportion score (TPS) and used to determine usage of pembrolizumab in patients with metastatic NSCLC. TPS is the percentage of viable tumor cells showing partial or complete membrane staining at any intensity. Testing for PD-L1 is not required for prescribing first-line therapy with atezolizumab plus chemotherapy regimens or for subsequent therapy with single agent nivolumab or atezolizumab.

 

Although it is not an optimal biomarkers, PD-L1 expression is currently the best available biomarker to assess whether patients are candidates for PD-1 or PD-L1 inhibitors (ICIs; also known as immune-oncology [IO] agents, immunotherapy). PD-L1 expression is continuously variable and dynamic; thus, a cutoff value for a positive result is artificial. Patients with PD-L1 expression levels just below and just above 50% will probably have similar responses. Unique anti-PD-L1 IHC assays have been developed for each one of the different ICIs. The definition of a positive PD-L1 test result varies depending on which biomarker assay is used. Extensive effort has been undertaken to examine the cross-comparability or different clones with regard to each other to facilitate adoption of testing.

 

The NCCN NSCLC Panel emphasizes that clinicians should obtain molecular testing results for actionable biomarkers before administering first-line ICI therapy, if clinically feasible. Therefore, the 2020 update (Version 1), the panel deleted “or unknown” regarding test results for certain actionable molecular biomarkers before administering PD-1 or PD-L1 inhibitors. Patients with metastatic NSCLC and PD-L1 expression levels of 1% or more but who also have a targetable driver oncogene molecular variant (e.g. EGFR, ALK, ROS1) should receive first-line targeted therapy for that oncogene and not first-line ICIs because targeted therapies yield higher response rates (e.g. Osimertinib, 80%) than ICIs (poor response rates) in the first-line setting, targeted therapy is better tolerated, and these patients are unlikely to respond to ICIs. For the 2020 update (version 1), the NCCN NSCLC Panel also deleted “or known” regarding test results  for PD-L1 expression levels; the panel also added “ROS1 fusions” and “BRAF mutations” to the list of actionable biomarkers that need to be negative before administering PD-1 or PD-L1 inhibitors. At a minimum, EGFR and ALK status should be known before starting systemic therapy with ICI regimens; however, it is ideal if ROS1 and BRAF status are also known. If it is not feasible to do molecular testing, then patients are treated as though they do not have driver oncogenes.

 

Targeted Therapies

Specific targeted therapies are available for the treatment of eligible patients with metastatic NSCLC. Afatinib, alectinib, brigatinib, ceritinib, crizotinib, erlotinib, gefitinib, lacrotrectinib, and lorlatinib are oral TKIs. Bevacizumab and ramucirumab are recombinant monoclonal antibodies that target the vascular endothelial growth factor (VEGF) or VEGF receptor, respectively. Cetuximab is a monoclonal antibody that targets EGFR. Erlotinib, gefitinib, afatinib and dacomitinib inhibit EGFR sensitizing mutations; Osimertinib inhibits both EGFR sensitizing mutations and T790M. Crizotinib inhibits ALK fusions, ROS1 fusions and MET tyrosine kinase (i.e. high- level MET amplification, METex14 skipping mutation). Ceritinib inhibits ALK fusions and IGF-1 receptor. Alectinib inhibits ALK and RET fusions. Brigatinib inhibits various ALK fusions and other targets. Lorlatinib inhibits ALK and ROS fusions. Debrafenib inhibits BRAF V600E mutations; trametinib inhibits MEK; both agents inhibit different kinases in the RAS/RAF/MEK/ERK pathway. Entrectinib and lacrotrectinib inhibit TRK fusion proteins. Capmatinib inhibits several MET tyrosine kinases including METex14 skipping mutations. Selpercatinib, cabozantibin and candetanib inhibit RET rearrangements. Other targeted therapies are being developed (see Emerging Biomarkers to Identify in Novel Therapies for Patients with Metastatic NSCLC Guidelines for NSCLC). Flare phenomenon may occur in some patients who discontinue targeted therapies for EGFR, ALK, or ROS1 genetic variants. If disease flare occurs, then the targeted therapies should be restarted.

 

It is important to note that targeted therapies are recommended for patients with metastatic NSCLC and specific oncogenic drivers independent of PD-L1 levels. Patients with metastatic NSCLC and PD-L1 expression levels of 1% or more but who also have targetable driver oncogene molecular variant (e.g. EGFR, ALK, ROS1) should receive first-line targeted therapy for that oncogene and not first-line ICIs, because targeted therapies yield higher response rates (e.g. Osimertinib 80%) than ICIs (poor response rates)  in the first-line setting, targeted therapy is better tolerated, and these patients are unlikely to response to ICIs. For the 2020 update (version 1), the NCCN NSCLC Panel emphasizes that clinicians should obtain molecular testing results for actionable biomarkers before administering first-line therapy, if clinically feasible. Therefore, the panel deleted “or unknown” regarding test results for actionable molecular biomarkers before administering PD-1 or PD-L1 inhibitors. At a minimum, EGFR and ALK status should be known before starting first-line systemic therapy, if clinically feasible; however, it is ideal if ROS1 and BRAF status are also known. It is not feasible to do molecular testing, then patients are treated as though they do not have driver oncogenes. 

 

Systemic Therapy for Advanced or Metastatic Disease

  • Adenocarcinoma; Large Cell; NSCLC NOS
    • Molecular testing
  • Squamous cell carcinoma
    • Molecular testing

 

Sensitizing EGFR Mutation Positive

  • EGFR mutation discovered prior to first-line systemic therapy

    • Preferred Osimertinib
    • Other Recommended
      • Erlotinib; or
      • Afatinib; or
      • Gefitinib; or
      • Dacomitinib; or
      • Erlotinib + ramucirumab
    • Useful in certain circumstances
      • Erlotinib + bevacizumab (category 2B)
  • EGFR mutation discovered during first-line systemic therapy
    • Complete planned systemic therapy, including maintenance therapy, or interrupt, followed by Osimertinib (preferred); or
    • Erlotinib or afatanib or gefitinib or dacomitinib or erlotinib + ramucirumab or erlotinib + bevacizumab (category 2B)

 

Targeted Therapy or Immunotherapy for Advanced Metastatic Disease

Sensitizing EGFR Mutation Positive

  • First line therapy
    • Afatinib
    • Erlotinib
    • Dacomitinib
    • Gefitinib
    • Osimertinib
    • Erlotinib + ramucirumab
    • Erlotinib + bevacizumab (nonsquamous)
  • Subsequent therapy
    • Osimertinib

ALK Rearrangement Positive

  • First-line therapy

    • Alectinib

    • Brigatinib

    • Ceritinib

    • Crizotinib

  • Subsequent therapy

    • Alectinib

    • Brigatinib

    • Ceritinib

    • Lorlatinib

ROS1 Rearrangement Positive

  • First-line therapy
    • Certinib
    • Crizotinib
    • Entrectinib

BRAF V600E Mutation Positive

  • First-line therapy
    • Dabrafinib/trametinib
  • Subsequent therapy
    • Dabrafinib/trametinib

NTRK Gene Fusion Positive

  • First-line/Subsequent therapy
    • Lacrotrectinib
    • Entrectinib

METExon14 Skipping Mutation

  • First-line therapy/Subsequent therapy
    • Capmatinib
    • Crizotinib

 

RET Rearrangement Positive

  • First-line therapy/Subsequent therapy
    • Selpercatinib
    • Cabozantinib
    • Vandetanib

 

PD-L1 ≥ 1%

  • First-line therapy*

    • Pembrolizumab

    • Carboplatin or cisplatin/pemetrexed/pembrolizumab (nonsquamous)

    • Carboplatin/paclitaxel/bevacizumab/atezolizumab** (nonsquamous)

    • Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous)

    • Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous)

    • Nivolumab/ipilimumab

    • Nivolumab + ipilimumab + pemetrexed + (carboplatin or cisplatin) (nonsquamous)

    • Nivolumab + ipilimumab + paclitaxel + carboplatin (squamous)

 

*Continuation maintenance refers to the use of at least one of the agents given in first line, beyond 4-6 cycles, in the absence of disease progression.

 

**An FDA approved biosimilar is an appropriate substitute for bevacizumab

 

American Society of Clinical Oncology (ASCO)

In 2017, the American Society of Clinical Oncology (ASCO) issued a guideline on systemic therapy for stage IV non-small cell lung cancer which included the following recommendations:

 

New or revised recommendations include the following. Regarding first-line treatment for patients with non–squamous cell carcinoma or squamous cell carcinoma (without positive markers, eg, EGFR/ALK/ROS1), if the patient has high programmed death ligand 1 (PD-L1) expression, pembrolizumab should be used alone; if the patient has low PD-L1 expression, clinicians should offer standard chemotherapy. All other clinical scenarios follow 2015 recommendations. Regarding second-line treatment in patients who received first-line chemotherapy, without prior immune checkpoint therapy, if NSCLC tumor is positive for PD-L1 expression, clinicians should use singleagent nivolumab, pembrolizumab, or atezolizumab; if tumor has negative or unknown PD-L1 expression, clinicians should use nivolumab or atezolizumab. All immune checkpoint therapy is recommended alone plus in the absence of contraindications. For patients who received a prior firstline immune checkpoint inhibitor, clinicians should offer standard chemotherapy. For patients who cannot receive immune checkpoint inhibitor after chemotherapy, docetaxel is recommended; in patients with nonsquamous NSCLC, pemetrexed is recommended. In patients with a sensitizing EGFR mutation, disease progression after first-line epidermal growth factor receptor tyrosine kinase inhibitor therapy, and T790M mutation, osimertinib is recommended; if NSCLC lacks the T790M mutation, then chemotherapy is recommended. Patients with ROS1 gene rearrangement without prior crizotinib may be offered crizotinib, or if they previously received crizotinib, they may be offered chemotherapy.

 

Recommendations 

First-Line Treatment for Patients

  • Patients with non–squamous cell carcinoma without a tumor EGFR-sensitizing mutation or ALK or ROS1 gene rearrangement and with a performance status (PS) of 0 or 1 (and appropriate PS of 2):
  • With high PD-L1 expression (tumor proportion score [TPS] $ 50%) and no contraindications, single-agent pembrolizumab is recommended (Evidence quality: high; Strength of recommendation: strong).
  • With low PD-L1 expression (TPS , 50%), a variety of combination cytotoxic chemotherapies (with or without bevacizumab if patients are receiving carboplatin and paclitaxel) are recommended (Platinum based [Evidence quality: high; Strength of recommendation: strong]; Non–platinum based [Evidence quality: intermediate; Strength of recommendation: weak]).
  • There is insufficient evidence to recommend bevacizumab in combination with pemetrexed plus carboplatin.
  • Other checkpoint inhibitors, combination checkpoint inhibitors, or immune checkpoint therapy with chemotherapy are not recommended.
  • With PS of 2, combination or single-agent therapy or palliative care alone may be used (chemotherapy [Evidence quality: intermediate; Strength of recommendation: weak]; palliative care [Evidence quality: intermediate; Strength of recommendation: strong]).

 

Patients with squamous cell carcinoma without a tumor EGFR-sensitizing mutation or ALK or ROS1 gene rearrangement and with a PS of 0 or 1 (and appropriate PS of 2):

  • With high PD-L1 expression (TPS $ 50%) and no contraindications, single-agent pembrolizumab is recommended (Evidence quality: high; Strength of recommendation: strong).
  • With low PD-L1 expression (TPS , 50%), a variety of combination cytotoxic chemotherapies are recommended (Platinum based [Evidence quality: high; Strength of recommendation: strong]; Non–platinum based [Evidence quality: low; Strength of recommendation: weak]).
  • Other checkpoint inhibitors, combination checkpoint inhibitors, or immune checkpoint therapy with chemotherapy are not recommended.

 

With PS of 2, combination or single-agent therapy or palliative care alone may be used (chemotherapy [Evidence quality: intermediate; Strength of recommendation: weak]; palliative care [Evidence quality: intermediate; Strength of recommendation: strong]).

  • With squamous NSCLC treated with cisplatin and gemcitabine, the Panel neither recommends for nor recommends against the addition of necitumumab to chemotherapy.
  • With sensitizing EGFR mutations, afatinib, erlotinib, or gefitinib is recommended (Evidence quality: high; Strength of recommendation: strong for each).
  • With ALK gene rearrangements, crizotinib is recommended (Evidence quality: strong; Strength of recommendation: high).
  • With ROS1 rearrangement, crizotinib is recommended (Type: informal consensus; Evidence quality: low; Strength of recommendation: weak).

 

Second-Line Treatment for Patients

Without a tumor EGFR-sensitizing mutation or ALK or ROS1 gene rearrangement and with PS of 0 or 1 (and appropriate PS of 2):

  • In patients with high PD-L1 expression (TPS $ 1%) and no contraindications who received first-line chemotherapy and have not received prior immune therapy, single-agent nivolumab, pembrolizumab, or atezolizumab is recommended (Evidence quality: high; Strength of recommendation: strong).
  • In patients with negative or unknown tumor PD-L1 expression (TPS , 1%) and no contraindications who received first-line chemotherapy, nivolumab, or atezolizumab, a variety of combination cytotoxic chemotherapies are recommended (Evidence quality: high; Strength of recommendation: strong).
  • Other checkpoint inhibitors, combination checkpoint inhibitors, and immune checkpoint therapy with chemotherapy are not recommended.
  • In patients who received an immune checkpoint inhibitor as first-line therapy, a variety of combination cytotoxic chemotherapies are recommended (Platinum based [Evidence quality: high; Strength of recommendation: strong];

 

Non–platinum based [Informal consensus; Evidence quality: low; Strength of recommendation: strong]).

  • In patients with contraindications to immune checkpoint inhibitor therapy after first-line chemotherapy, docetaxel is recommended (Evidence quality: intermediate; Strength of recommendation: moderate).
  • In patients with non–squamous cell carcinoma who have not previously received pemetrexed, pemetrexed is recommended (Evidence quality: intermediate; Strength of recommendation: moderate).

 

With sensitizing EGFR mutations:

  • In patients with disease progression after first-line therapy with an EGFR tyrosine kinase inhibitor (TKI) and the presence of the T790M resistance mutation, osimertinib is recommended (Evidence quality: high; Strength of recommendation: strong).
  • If T790Mmutation is not present, a platinum doublet is recommended (Type: informal consensus; Evidence quality: low; Strength of recommendation: strong).
  • In patients who received an EGFR-TKI in the first-line setting, had an initial response, and subsequently experienced slow or minimal disease progression at isolated sites, EGFR-TKI with local therapy to the isolated sites is an option (Type: informal consensus; Evidence quality: insufficient; Strength of recommendation: weak).

 

With ROS1 rearrangement:

  • In patients who have not received prior crizotinib, crizotinib is recommended (Type: informal consensus; Evidence quality: low; Strength of recommendation: moderate).
  • In patients who have received prior crizotinib, platinum-based therapy in the second line with or without bevacizumab is recommended (Type: informal consensus; Evidence quality: insufficient; Strength of recommendation: moderate).

 

With BRAF mutations:

  • In patients without prior immune checkpoint therapy and high PD-L1 expression (TPS. 1%), atezolizumab, nivolumab, or pembrolizumab is recommended (Type: informal consensus; Evidence quality: insufficient; Strength of recommendation: weak).

  •  In patients who have received prior immune checkpoint therapy, dabrafenib alone or in combination with trametinib in third line is an option (Type: informal consensus; Evidence quality: insufficient; Strength of recommendation: moderate).

 

Third-Line Treatment for Patients

  • In patients without a tumor EGFR-sensitizing mutation or ALK or ROS1 gene rearrangement and with non–squamous cell carcinoma and PS of 0 or 1 (and appropriate PS of 2), who received chemotherapy with or without bevacizumab and immune checkpoint therapy, single-agent pemetrexed or docetaxel are options (Type: informal consensus; Evidence quality: low; Strength of recommendation: strong).
  • In patients with tumor EGFR-sensitizing mutation(s) who have received at least one first-line EGFR-TKI and prior platinum-based chemotherapy, there are insufficient data to recommend immunotherapy in preference to chemotherapy (pemetrexed or docetaxel [Type: informal consensus; Evidence quality: insufficient; Strength of recommendation: weak]).

 

Fourth-Line Treatment for Patients

  • Patients and clinicians should consider and discuss experimental treatment, clinical trials, and continued best supportive (palliative) care.

 

In 2018, the American Society of Clinical Oncology (ASCO) Expert Panel determined that the recommendations from the College of American Pathologists (CAP)/ the International Association for the Study of Lung Cancer (IASLC)/the Association for Molecular Pathology (AMP) molecular testing guideline are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the guideline with minor modifications.

 

Target Population

Patients with advanced lung cancer (i.e., stage IV or other incurable lung cancer).

 

Target Audience

Medical or surgical oncologists, pathologists, thoracic surgeons, and specialists in pulmonary medicine or interventional radiology.

 

Key Recommendations

2013 Recommendations that were reaffirmed or updated for 2018:

1. Expert Consensus Opinion: Pathologists may use either cell blocks or smear preparations as suitable specimens for lung cancer biomarker molecular testing.
2. Expert Consensus Opinion: Laboratories should use, or have available at an external reference laboratory, clinical lung cancer biomarker molecular testing assays that are able to detect molecular alterations in specimens with as little as 20% cancer cells.
3. Strong Recommendation: Laboratories should not use epidermal growth factor receptor (EGFR) expression by immunohistochemistry (IHC) testing to select patients for EGFR-targeted TKI therapy.
4. Recommendation: Physicians should use molecular testing for the appropriate genetic targets on either primary or metastatic lung lesions to guide initial therapy selection.
5. Recommendation: Pathologists and laboratories should not use EGFR copy number analysis (i.e., fluorescent in situ hybridization or chemiluminescent in situ hybridization) to select patients for EGFR-targeted TKI therapy.

 

New 2018 Recommendations:

Key Question 1: Which genes should be tested for patients with lung cancer?

1. Recommendation: ROS1 testing should be performed on all patients with advanced lung adenocarcinoma, irrespective of clinical characteristics.
2. Expert Consensus Opinion: ROS1 IHC may be used as a screening test in patients with advanced lung adenocarcinoma; however, positive ROS1 IHC results should be confirmed by a molecular or cytogenetic method.
3. Expert Consensus Opinion: BRAF testing should be performed on all patients with advanced lung adenocarcinoma, irrespective of clinical characteristics.
4. Expert Consensus Opinion: RET molecular testing is not recommended as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include RET as part of larger testing panels performed either initially or when routine EGFR, ALK, BRAF, and ROS1 testing is negative.
5. Expert Consensus Opinion: ERBB2 (HER2) molecular testing is not indicated as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include ERBB2 (HER2) mutation analysis as part of a larger testing panel performed either initially or when routine EGFR, ALK, BRAF, and ROS1 testing is negative.
6. Expert Consensus Opinion: KRAS molecular testing is not indicated as a routine stand-alone assay as a sole determinant of targeted therapy. It is appropriate to include KRAS as part of larger testing panels performed either initially or when routine EGFR, ALK, BRAF, and ROS1 testing is negative.
7. Expert Consensus Opinion: MET molecular testing is not indicated as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include MET as part of larger testing panels performed either initially or when routine EGFR, ALK, BRAF, and ROS1 testing is negative.

 

Key Question 2: What methods should be used to perform molecular testing?

8. Recommendation: IHC is an equivalent alternative to FISH for ALK testing.

CAP/IASLC/AMP Qualifying Statement: ALK IHC is an acceptable standard alternative to FISH, and treatment decisions can be made when IHC results are clearly positive, as manifested by strong granular cytoplasmic staining, with or without membrane accentuation, or negative; however, weak staining can be challenging to interpret, and the specificity of weak staining relative to FISH should be determined in each laboratory during validation.

 

9. Expert Consensus Opinion: Multiplexed genetic sequencing panels are preferred where available over multiple single genetests to identify other treatment options beyond EGFR, ALK, BRAF, and ROS1.
10. Expert Consensus Opinion: Laboratories should ensure that test results that are unexpected, discordant, equivocal, or otherwise of low confidence are confirmed or resolved by using an alternative method or sample.

 

Key Question 3: Is molecular testing appropriate for lung cancers that do not have an adenocarcinoma component?

 

11. Expert Consensus Opinion: Physicians may use molecular biomarker testing in tumors with:
a. an adenocarcinoma component;
b. nonsquamous, non–small-cell histology;
c. any non–small-cell histology when clinical features indicate a higher probability of an oncogenic driver (e.g., young age [, 50 years]; light or absent tobacco exposure).

 

Key Question 4: What testing is indicated for patients with targetable mutations who have relapsed on targeted therapy?

 

12. Strong Recommendation: In patients with lung adenocarcinoma who harbor sensitizing EGFR mutations and have progressed after treatment with an EGFR-targeted TKI, physicians must use EGFR T790M mutational testing when selecting patients for third-generation EGFR-targeted therapy.
13. Recommendation: Laboratories testing for EGFR T790M mutation in patients with secondary clinical resistance to EGFR-targeted kinase inhibitors should deploy assays capable of detecting EGFR T790M mutations in as little as 5% of viable cells.
14. No Recommendation: There is currently insufficient evidence to support a recommendation for or against routine testing for ALK mutational status for patients with lung adenocarcinoma with sensitizing ALK mutations who have progressed after treatment with an ALK-targeted TKI.

 

Key Question 5: What is the role of testing for circulating cell-free DNA (cfDNA) for patients with lung cancer?

 

15. No Recommendation: There is currently insufficient evidence to support the use of cfDNA molecular methods for the diagnosis of primary lung adenocarcinoma.
16. Recommendation: In some clinical settings in which tissue is limited and/or insufficient for molecular testing, physicians may use a cfDNA assay to identify EGFR mutations.
17. Expert Consensus Opinion: Physicians may use cfDNA methods to identify EGFR T790M mutations in patients with lung adenocarcinoma who have progression or secondary clinical resistance to EGFR-targeted TKIs; testing of the tumor sample is recommended if the plasma result is negative.
18. No Recommendation: There is currently insufficient evidence to support the use of circulating tumor cell molecular analysis for the diagnosis of primary lung adenocarcinoma, the identification of EGFR or other mutations, or the identification of EGFR T790M mutations at the time of EGFR TKI resistance.

 

College of American Pathologists (CAP), International Association for the Study of Lung Cancer (IASLC) and Association for Molecular Pathology (AMP)

In 2018, the College of American Pathologists (CAP), the International Association for the Study of Lung Cancer (IASLC) and the Association for Molecular Pathology (AMP) updated their molecular testing guidelines for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors.

 

Key Question 1: Which new genes should be tested for lung cancer patients?
 Guideline StatementStrength of Recommendation
1. ROS1 testing must be performed on all lung adenocarcinoma patients, irrespective of clinical characteristics. Strong Recommendation
2. ROS1 IHC may be used as a screening test in lung adenocarcinoma patients; however, positive ROS1 IHC results should be confirmed by a molecular or cytogenetic method. Expert Consensus Opinion
3. BRAF molecular testing is currently not indicated as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include BRAF as part of larger testing panels performed either initially or when routine EGFR, ALK, and ROS1 testing are negative. Expert Consensus Opinion
4. RET molecular testing is not recommended as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include RET as part of larger testing panels performed either initially or when routine EGFR, ALK, and ROS1 testing are negative. Expert Consensus Opinion
5. ERBB2 (HER2) molecular testing is not indicated as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include ERBB2 (HER2) mutation analysis as part of a larger testing panel performed either initially or when routine EGFR, ALK, and ROS1 testing are negative. Expert Consensus Opinion
6. KRAS molecular testing is not indicated as a routine stand-alone assay as a sole determinant of targeted therapy. It is appropriate to include KRAS as part of larger testing panels performed either initially or when routine EGFR, ALK, and ROS1 testing are negative. Expert Consensus Opinion
7. MET molecular testing is not indicated as a routine stand-alone assay outside the context of a clinical trial. It is appropriate to include MET as part of larger testing panels performed either initially or when routine EGFR, ALK, and ROS1 testing are negative. Expert Consensus Opinion

 

Key Question 2: What methods should be used to perform molecular testing?
 Guideline StatementStrength of Recommendation
8. IHC is an equivalent alternative to FISH for ALK testing. Recommendation
9. Multiplexed genetic sequencing panels are preferred over multiple single-gene tests to identify other treatment options beyond EGFR, ALK, and ROS1. Expert Consensus Opinion
10. Laboratories should ensure test results that are unexpected, discordant, equivocal, or otherwise of low confidence are confirmed or resolved using an alternative method or sample. Expert Consensus Opinion

 

Key Question 3: Is molecular testing appropriate for lung cancers that do not have an adenocarcinoma component?
 Guideline StatementStrength of Recommendation
11. Physicians may use molecular biomarker testing in tumors with histologies other than adenocarcinoma when clinical features indicate a higher probability of an oncogenic driver. Expert Consensus Opinion

 

Key Question 4: What testing is indicated for patients with targetable mutations who have relapsed on targeted therapy?
 Guideline StatementStrength of Recommendation
12. In lung adenocarcinoma patients who harbor sensitizing EGFR mutations and have progressed after treatment with an EGFR-targeted TKI, physicians must use EGFR T790M mutational testing when selecting patients for third-generation EGFR-targeted therapy. Strong Recommendation
13. Laboratories testing for EGFR T790M mutation in patients with secondary clinical resistance to EGFR-targeted kinase inhibitors should deploy assays capable of detecting EGFR T790M mutations in as little as 5% of viable cells. Recommendation
14. There is currently insufficient evidence to support a recommendation for or against routine testing for ALK mutational status for lung adenocarcinoma patients with sensitizing ALK mutations who have progressed after treatment with an ALK-targeted TKI. No Recommendation

 

Key Question 5: What is the role of testing for circulating cell-free DNA for lung cancer patients?
 Guideline StatementStrength of Recommendation
15. There is currently insufficient evidence to support the use of circulating cfDNA molecular methods for the diagnosis of primary lung adenocarcinoma. No Recommendation
16. In some clinical settings in which tissue is limited and/or insufficient for molecular testing, physicians may use a cfDNA assay to identify EGFR mutations. Recommendation
17. Physicians may use cfDNA methods to identify EGFR T790M mutations in lung adenocarcinoma patients with progression or secondary clinical resistance to EGFR-targeted TKI; testing of the tumor sample is recommended if the plasma result is negative. Expert Consensus Opinion
18. There is currently insufficient evidence to support the use of circulating tumor cell molecular analysis for the diagnosis of primary lung adenocarcinoma, the identification of EGFR or other mutations, or the identification of EGFR T790M mutations at the time of EGFR TKI resistance. No Recommendation

 

Abbreviations: ROS1, ROS Proto-Oncogene 1, Receptor Tyrosine Kinase; IHC, Immunohistochemistry; BRAF, B-Raf Proto-Oncogene, Serine/Threonine Kinase; EGFR, Epidermal Growth Factor Receptor; ALK, RET, Ret Proto-Oncogene; ERBB2, Erb-B2 Receptor Tyrosine Kinase 2; HER2, human epidermal growth factorreceptor 2; KRAS, MET, MET Proto-Oncogene, Receptor Tyrosine Kinase; FISH, fluorescence in situ hybridization; TKI, tyrosine kinase inhibitors; cfDNA, cell-free plasma DNA

 

Regulatory Status

In June 2016, the U.S. Food and Drug Administration approved cobas EGFR Mutation Test v2 (Roche Molecular Systems, Inc.) using plasma specimens as a companion diagnostic test for the detection of exon 19 deletions or exon 21 (L858R) substitution mutations in the epidermal growth factor receptor (EGFR) gene to identify patients with metastatic non-small cell lung cancer (NSCLC) eligible for treatment with Tarceva (erlotinib). Patients who are negative by this test should undergo routine biopsy and testing for EGFR mutations with the FFPE tissue sample type.”

 

The U.S. Food and Drug Administration approved a label extension of Roche’s cobas EGFR Mutation Test v2 as a companion diagnostic test for osimertinib (Tagrisso). According to the company, the test can now “be used as a companion diagnostic test (CDx) with Tagrisso for the first line of patients diagnosed with metastatic NSCLC whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R mutations.” The test was previously FDA-approved as a companion diagnostic test for osimertinib for second-line treatment and beyond in NSCLC patients with EGFR T790M mutations.

 

In August 2020, FoundationOne Liquid CDx (Foundation Medicine), a qualitative next generation sequencing-based diagnostic for circulating cell-free DNA in plasma,was approved by the FDA through the premarket approval process (P190032). The plasma test is approved as a companion diagnostic for selecting NSCLC patients who have EGFR exon 19 deletions and EGFR exon 21 L858R substitution variants. Patients who test negative for the variants detected should be referred for (or "reflexed" to) routine biopsy with tissue testing for EGFR variants. Prior versions of FoundationOne Liquid CDx werepreviously marketed as FoundationACT and FoundationOne laboratory developed test (LDT).

 

Tumor TypeBiomarker(s) DetectedTherapy
Non-small cell lung cancer (NSCLC) EGFR Exon 19 deletions and EGFR Exon 21 L858R substitution IRESSA® (gefitinib
TAGRISSO® (osimertinib)
TARCEVA® (erlotinib)

 

In August 2020 Guardant360 CDx (Guardant Health) a qualitative next generation sequencing-based diagnostic of circulating cell-free DNA in plasma, was approved by the FDA through the premarket approval process (P200010). The plasma test is approved as a companion diagnostic for selecting NSCLC patients who have EGFR exon 19 deletions, L858R substitution variants, or T790M variants, for treatment with osimertinib. Patients who test negative for the variants detected should bereferred for (or "reflexed" to) routine biopsy with tissue testing for EGFR variants. Testing for T790M using plasma specimens is most appropriate for consideration in patients for whom a tumor biopsy cannot be obtained, as the efficacy of osimertinib has not been established in T790M plasma-positive, tissue-negative or unknownpatient populations. Prior version of Guardant360 CDx was previously marketed as Guardant360.

 

Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments. Several companies market tests that detect tumor markers from peripheral blood, including TKI-sensitizing variants for NSCLC. Laboratories that offer laboratory-developed tests must be licensed by the Clinical Laboratory Improvement Amendments for high-complexity testing. To date, FDA has chosen not to require any regulatory review of this test. Clinical laboratories accredited through the College of American Pathologists enroll in proficiency testing programs to measure the accuracy of the test results. There are currently no College of American Pathologists proficiency testing programs available for ctDNA testing to ensure the accuracy of ctDNA laboratory-developed tests.

 

Prior Approval:

Not applicable

 

Policy:

See Related Medical Policies

  • 02.04.16 Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsies)
  • 02.04.77 Proteomic Testing for Systematic Therapy in Non-Small Cell Lung Cancer
  • 02.04.78 Molecular Analysis for Targeted Therapy of Non-Small Cell Lung Cancer
  • 02.04.63 Expanded Genetic Panels to Identify Targeted Cancer Therapy
  • 02.04.55 Epidermal Growth Factor Receptor (EGFR) Testing
  • 02.04.20 KRAS/NRAS and BRAF Mutation Analysis

 

EGFR Testing

Testing for sensitizing EGFR mutations (exon 19 deletions [E19del] or exon 21 [L848R]) using the cobas EGFR Mutation, FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, OncoBEAM Lung with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to EGFR tyrosine kinase inhibitor (TKI) therapy (e.g. afatinib [gilotrif], erlotinib [tarceva], dacomitinib [vizimpro], gefitinib [iressa], osimertinib [tagrisso] when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy-amendable lesion; OR
  • The individual is unable to undergo a tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Using the cobas® EGFR Mutation Test v2, FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test or OncoBEAM Lung with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy for patients whose metastatic non-small cell lung cancer (NSCLC) progresses on or after tyrosine kinase inhibitor (TKI) therapy as repeat EGFR testing to identify the emergence of a T790M mutation may be considered to determine whether further treatment with osimertinib (tagrisso) would be indicated when the individual meets one of the following:

  • There is insufficient tumor tissue available for molecular analysis; OR 
  • The individual does not have a biopsy-amendable lesion; OR
  • The individual is unable to undergo an initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

The use of cobas EGFR Mutation Test v2, FoundationOne CDx, Guardant360 CDx, InvsitionFirst-Lung Test or OncoBEAM Lung with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

ALK Rearrangements Testing

Testing for ALK rearrangements (anaplastic lymphoma kinase (ALK) gene) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to ALK inhibitor therapy (e.g., crizotinib [xalkori], ceritinib [zykadia], alectinib [alecensa], or brigatinib [alunbrig]) in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy-amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for ALK rearrangements with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

ROS1 Rearrangements Testing

Testing for ROS1 rearrangements (ROS1 gene) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to ALK inhibitor therapy (crizotinib [xalkori]) in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial e tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for ROS1 rearrangements with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

BRAF V600E Testing

Testing for BRAF V600E mutations with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to BRAF or MEK inhibitor therapy (e.g., dabrafenib [tafinlar] and trametinib [mekinist]), in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met: 

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysi; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for BRAF V600E mutations with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

Tumor Mutations Burden (TMB)

Testing for tumor mutations burden (TMB) with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy in patients with metastatic non-small cell lung cancer (NSCLC) before therapy with nivolumab (opdivo) when the following criteria is met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for tumor mutations burden (TMB) with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

METex14 Skipping Mutations

Testing for METex 14 skipping mutations with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to capmatinib (tabrecta) in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for METex 14 skipping mutations to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

High-Level MET Amplification

Testing for high-level MET amplification with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to crizotinib (xalkori) in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for high-level MET amplification with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

RET Rearrangements

Testing for RET rearrangements with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to selpercatinib (retevmo) in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for RET rearrangements with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

ERBB2 (HER2) Mutations

Testing for ERBB2 (HER2) mutations with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to targeted therapy in patients with metastatic non-small cell lung cancer (NSCLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for ERBB (HER2) mutations with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

NTKR Gene Fusion Testing

Testing for NTRK gene fusion with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to predict treatment response to lacrotrectinib (vitrakvi) or entrectinib (rozlytrek) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for NTKR gene fusions with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

KRAS Testing

Testing for KRAS (KRAS proto-oncogene) point mutations with plasma specimen (liquid biopsy) using FoundationOne Liquid CDx, Guardant360 CDx, Invision-First Lung Test, or OncoBEAM Lung to detect circulating tumor DNA (ctDNA) may be considered medically necessary as an alternative to tissue biopsy to assess for reduced responsiveness to EGFR TKI therapy, identify patients who may not benefit from further molecular testing and for consideration of immune checkpoint inhibitors (immunotherapy), in patients with metastatic non-small cell lung cancer (NCSLC) when the following criteria are met:

  • The individual has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
  • There is insufficient tumor tissue available for molecular analysis; OR
  • The individual does not have a biopsy- amendable lesion; OR
  • The individual is unable to undergo initial tissue biopsy or an additional tissue biopsy due to documented medical reasons (i.e. invasive tissue sampling is contraindicated due to the individual’s clinical condition).

 

Testing for KRAS (KRAS proto-oncogene) point mutations with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to biopsy for indications not meeting the above criteria is considered not medically necessary based on current NCCN guidelines.

 

Other Commercially Available Tests for Circulating Tumor DNA (ctDNA) (Liquid Biopsy)

The use of the commercially available tests, including but not limited to the following, using plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) as an alternative to tissue biopsy to predict treatment response of targeted therapy in the treatment and management of metastatic non-small cell lung cancer (NSCLC) is considered investigational:

  • Circulogene’s Liquid Biopsy Test
  • ClearID Biomarker Expression Assays
  • ClearID Lung Cancer
  • ctDX Lung
  • GeneStrat
  • LiquidGX
  • PlasmaSelect 64
  • Signatera Lung
  • Target Selector

 

For individuals with metastatic non-small cell lung cancer (NSCLC) who receive testing for EGFR TKI-sensitizing variants and other genomic biomarkers for NSCLC using circulating tumor DNA (ctDNA) liquid biopsy to select a targeted therapy, the evidence includes studies assessing the diagnostic characteristics of liquid biopsy compared with the tissue biopsy reference standard, however, given the breadth of molecular diagnostic methodologies available to assess circulating tumor DNA (ctDNA), the clinical validity of each commercially available test must be established independently. At this time except for cobas EGFR Mutation Test v2, FoundationOne Liquid CDx, OncoBEAM Lung, Guardant360 CDx, and InvisionFirst-Lung none of the other commercially available tests have studies of adequate quality in demonstrating that this testing would produce outcomes similar to tissue testing to select targeted therapy. No randomized controlled trials (RCTs) were found providing evidence of the clinical utility that compared health outcomes for patients managed with and without these tests. The current NCCN guideline Non-Small Cell Lung Cancer Version 8.2020 states: ”The NCCN NSCLC Panel recommends that molecular profiling as part of biomarker testing use validated test(s).” The evidence is insufficient to determine the effects of the technology on net health outcomes.

 

Other Genetic Variants in Non-Small Cell Lung cancer

Testing for the following genomic biomarkers with plasma specimen (liquid biopsy) to detect circulating tumor DNA (ctDNA) to predict treatment response of targeted therapy in the treatment of metastatic non-small cell lung cancer (NSCLC) as an individual biomarker including but not limited to the following, is considered investigational, because the evidence is insufficient to determine the effects for the technology and net health outcomes and based on current NCCN guideline Non-Small Cell Lung Cancer Versin 8.2020 these genetic biomarkers are currently not identified as gene alterations that impact targeted therapy selections for metastatic non-small cell lung cancer:

  • AKT1
  • APC Sequencing
  • AR
  • ARAF
  • ARID1A
  • ATM
  • CCND1
  • CCND2
  • CCNE1
  • CDH1
  • CDK4
  • CDK6
  • CDKN2A
  • CTNNB1
  • DDR2
  • ESR1
  • E2H2
  • FBXW7
  • FGFR1
  • FGFR2
  • FGFR3
  • GATA3
  • GNA11
  • GNAQ
  • GNAS
  • HNF1A
  • HRAS
  • IDH1
  • IDH2
  • JAK2
  • JAK3
  • KIT
  • MAP2K1/MEK1
  • MAP2K2/MEK2
  • MAPK1/ERK2
  • MAPK3/ERK1
  • MLH1
  • MPL
  • MTOR
  • MYC
  • NF1
  • NFE2L2
  • NOTCH1
  • NPM1
  • NRAS
  • PDGFRA
  • PIK3CA
  • PTEN
  • PTPN11
  • RAF1
  • RB1
  • RHEB
  • RHOA
  • RIT1
  • SMAD4
  • SMO
  • STK11
  • TERT
  • TP53
  • SCI1
  • VHL

 

Note: When panel testing is performed the appropriate panel code(s) would be 81445 and 81455 versus multiple CPT codes for components of the panel.

 

Policy Guidelines

A negative result from plasma specimen does not assure that the individual’s tumor is negative for genomic findings. Non-small cell lung cancer patient negative for genomic biomarkers should be reflexed to tissue biopsy if feasible.

 

National Comprehensive Cancer Network (NCCN) Non-Small Cell Lung Cancer Version 8.2020

Targeted Therapy or Immunotherapy for Advanced Metastatic Disease
Sensitizing EGFR Mutation Positive
  • First line therapy
    • Afatinib
    • Erlotinib
    • Dacomitinib
    • Gefitinib
    • Osimertinib
    • Erlotinib + ramucirumab
    • Erlotinib + bevacizumab (nonsquamous)
  • Subsequent therapy
    • Osimertinib

 

ALK Rearrangement Positive
  • First-line therapy
    • Alectinib
    • Brigatinib
    • Ceritinib
    • Crizotinib
  • Subsequent therapy
    • Alectinib
    • Brigatinib
    • Ceritinib
    • Lorlatinib

 

ROS1 Rearrangement Positive
  • First-line therapy
    • Certinib
    • Crizotinib
    • Entrectinib

 

BRAF V600E Mutation Positive
  • First-line therapy
    • Dabrafinib/trametinib
  • Subsequent therapy
    • Dabrafinib/trametinib

 

NTRK Gene Fusion Positive
  • First-line/Subsequent therapy
    • Lacrotrectinib
    • Entrectinib

 

METExon14 Skipping Mutation
  • First-line therapy/Subsequent therapy
    • Capmatinib
    • Crizotinib

 

RET Rearrangement Positive
  • First-line therapy/Subsequent therapy
    • Selpercatinib
    • Cabozantinib
    • Vandetanib

 

PD-L1 ≥ 1%
  • First-line therapy*
    • Pembrolizumab
    • Carboplatin or cisplatin/pemetrexed/pembrolizumab (nonsquamous)
    • Carboplatin/paclitaxel/bevacizumab/atezolizumab** (nonsquamous)
    • Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous)
    • Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous)
    • Nivolumab/ipilimumab
    • Nivolumab + ipilimumab + pemetrexed + (carboplatin or cisplatin) (nonsquamous)
    • Nivolumab + ipilimumab + paclitaxel + carboplatin (squamous)

 

*Continuation maintenance refers to the use of at least one of the agents given in first line, beyond 4-6 cycles, in the absence of disease progression.

 

**An FDA approved biosimilar is an appropriate substitute for bevacizumab

 

Emerging Biomarkers to Identify Novel Therapies for Patients with Metastatic NSCLC
Genetic Alterations (i.e. Driver Event)Available Targeted Agents with Activity Against Drive Event in Lung Cancer
High-level Met amplification Crizotinib
ERBB2 (HER2) mutations Ado-trastuzumab emtansine
Tumor mutations burden (TMB)* Nivolumab + ipiliumab
Nivolumab

 

*TMB is an evolving biomarker that may be helpful in selecting patients for immunotherapy. There is no consensus on how to measure TMB

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 81120 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (e.g., glioma), common variants (e.g., R132H, R132C)
  • 81121 IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (e.g., R140W, R172M)
  • 81173 AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosomeinactivation) gene analysis; full gene sequence
  • 81191 NTRK1 (neurotrophic receptor tyrosine kinase 1) (e.g. solid tumors) translocation analysis 
  • 81192 NTRK2 (neurotrophic receptor tyrosine kinase 2) (e.g. solid tumors) translocation analysis
  • 81193 NTRK3 (neurotrophic receptor tyrosine kinase 3) (e.g. solid tumors) translocation analysis
  • 81194 NTRK (neurotrophic receptor tyrosine kinase 1. 2. 3) (e.g. solid tumors) translocation analysis
  • 81201 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence
  • 81210 BRAF (B-Raf proto-oncogene, serine/threonine kinase) (e.g., colon cancer, melanoma), gene analysis, V600 variant(s)
  • 81235 EGFR (epidermal growth factor receptor) (e.g., non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719
  • A, G719S, L861Q)
  • 81270 JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant
  • 81272 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18)
  • 81275 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (e.g., codons 12 and 13)
  • 81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (e.g., codon 61, codon 146)
  • 81277 Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
  • 81293 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants
  • 81310 NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants
  • 81311 NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (e.g., colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (e.g., codon 61)
  • 81314 PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (e.g., gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12,18)
  • 81321 PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis
  • 81400 Molecular pathology procedure, level 1
  • 81401 Molecular pathology procedure, level 2 (includes EML4/ALK)
  • 81402 Molecular pathology procedure, level 3
  • 81403 Molecular pathology procedure, level 4 (e.g., analysis of single exon by DNA sequence analysis of > 10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons)
  • 81404 Molecular pathology procedure, level 5
  • 81405 Molecular pathology procedure, level 6 (includes RET (ret proto-oncogene)
  • 81406 Molecular pathology procedure, Level 7
  • 81445 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed
  • 81455 Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed
  • 81479 Unlisted molecular pathology procedure
  • 86152 Cell enumeration using immunologic selection and identification in fluid specimen (e.g., circulating tumor cells in blood)
  • 86153 Cell enumeration using immunologic selection and identification in fluid specimen (e.g., circulating tumor cells in blood); physician interpretation and report, when required
  • 88360 Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual
  • 88361 Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology
  • 0179U Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) (Resolution ctDx Lung Assay)
  • 0239U Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations

 

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  • Circulogene Liquid Biopsy Test.
  • ClearID Biomarkers Expression Assays and ClearID Lung Cancer. 
  • ctDX Lung.
  • GeneStrat.
  • Guardant360. 
  • FoundationAct Liquid Biopsy.
  • LiquidGx.
  • OncoBEAM for Lung and OncoBEAM Lung2.
  • PlasmaSelect64.
  • Target Selector.
  • National Comprehensive Cancer Network (NCCN) Non-Small Cell Lung Cancer Version 8.2020.
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  • Mellert H, Alexander K, Jackson L, et. al. A blood test for the detection of ROS1 and RET fusion transcripts from circulating ribonucleic acid using digital polymerase chain reaction. Journal of Visualized Experiments April 2018 134 e57079
  • Linderman N, Cagle P, Aisner D, et. al. Updated molecular testing guideline for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors. Arch Pathol Lab Med Vol 142 March 2018
  • Resolution Bioscience Resolution ctDx Lung Assay
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  • Food and Drug Administration. Summary of Safety and Effectiveness Data (SSED) Guardant360 CDx. 2020
  • Food and Drug Administration. Summary of Safety and Effectiveness Data (SSED) FoundationOne Liquid CDx. 2020
  • Resolution Bioscience Resolution ctDx Lung Assay
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  • FDA Approved Companion Diagnostic Testing updated 9/10/2020

 

Policy History:

  • September 2020 - Annual Review, Policy Revised
  • September 2019 - New Medical Policy Created

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

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