Stage IV NSCLC Biomarker testing - which ones?

[Aida]

Hi All,

My dad was diagnosed with Stage IV NSCLC, lung adenocarcinoma metastasised to the bones. Diagnosis was made by way of pathological lab findings on his bone sample that was surgically extracted, the primary source in the lungs could not be detected in the scans.

He is now undergoing Biomarker testing to assess his suitability for targeted therapy. 

I gathered from the hospital paperwork that they are checking for EGFR, ALK and ROS1 as well as PDL for immunotherapy. 

However I've been researching online and found testings and therapies relating to other kinds of mutations as well - e.g. KRAS and BRAF.

My question - should the doctors not be checking for these mutations as well concurrently, whilst they have the bone sample handy? 

Thanks in advance!

[Curt]

Not all biomarker panels are created equal. Some test for more mutations than others.  Some are more comprehensive than others.  It’s worth asking who does the testing and how comprehensive it is.  Here is some info from Lungevity https://lungevity.org/for-patients-caregivers/lung-cancer-101/diagnosing-lung-cancer/biomarker-tests

[Rower Michelle]

Hi Aida,

I'm sorry that you are having to deal with this situation.  It's so stressful and complicated trying to learn about lung cancer mutations.  First it is good news that you Dad is being tested for the most "common" driver mutations, EGFR, ALK, ROS1 and PDL-1.   Not everyone receives this critical test that can determine the best treatment option.  It's typical to be tested for the most common ones first,  if there is no response, a more comprehensive molecular or bio-marker test is available.  Sometimes this is referred to as "the full panel". 

In my case,  negative for the most common mutations and PDL-1 on the first go around. When we received the full panel results, I was actually ALK Positive.  There are two ALK tests, one is more sensitive than the other.  

Let us know what you find out when the results come back.  There's a lot of experience in this group so we can jump in and lend a hand to guide you through the next couple of weeks.  

There have been more  lung cancer treatment advances in the last 3 years than in the last 30.  Hold onto your hope; brighter days are coming. 

Michelle 

[Aida]

Dear Curt and Michelle,

Many thanks for your replies. They were really helpful for us to understand a bit more about biomarker testing. 

To update, the results came back negative for all three EGFR, ALK and ROS1, and 30% for PDL. The oncologist is therefore sending the sample off for full panel testing which will take at least 3 weeks for results. Hence in the meantime he is suggesting starting first line treatment immediately to keep the cancer growth in check - combination of chemotherapy (Carboplatin + Pemetrexed) and immunotherapy (Pembrolizumab). I assume if we are lucky that the full panel testing throws up a mutation positive result then he would then be switched to targeted therapy. 

We might seek another opinion in the next day or two on the combination first line therapy. Obviously nervous about chemo side effects and want to be sure it’s the right choice.

 

[Rower Michelle]

Hi Aida-

This sounds very similar to my situation. I received the same triple combo that has been recommended for your Dad.  Other than some insomnia from the pre- treatment steroids and post treatment fatigue, I didn’t have any side effects.  This is pretty much the standard of care and generally well tolerated.  

Keep us posted and let us know what other questions you might have. 

Hang in there! 

Michelle

[islandgirls]

Has anyone been "restested" for the biomarkers? Or do they send them for a more detailed panel after getting the initial results back? We waited only two weeks for these results. My boyfriend's panel came back with no actionable mutations, and with HER2 and a PD-L1 of 0.

On other sites I have seen stories of people being retested and then ALK or some other marker appears.

I'm confused... and as a long-time girlfriend, but not spouse, I have not been going to appointments with him, as his daughter is going. Unfortunately I am not getting detailed information, so the oncologist may have answered this question. I am just trying to cope by being a bit on the "outside" of the current new-diagnosis storm that is brewing.

Thanks!

[LexieCat]

There are various genetic tests--I asked for a re-test because the original genetic tests looked only for the most common actionable mutations. I wanted something that showed even those not currently actionable--after all, something else might be developed down the line to treat one of the other mutations. So I had a liquid biopsy, which was not originally done. (My then-oncologist saw no point in it but the one I consulted--who is now my regular oncologist--thought the more info, the better.) So the additional testing isn't doing me any good currently, but at least I know they looked at everything. 

If they did any genetic testing on your boyfriend's samples (which clearly they did), there was, I'm sure, testing done for ALK--it's a pretty common mutation with known treatments.

Sometimes additional testing is done after there is a progression, because the cancer cells can mutate down the line and develop new mutations enabling them to avoid treatment. That's when re-testing is most likely to be of benefit.