By Daniel A. Saez, M.Sc., Treatment and Trials Navigator, GO2 for Lung Cancer

In today’s lung cancer care landscape, biomarker testing has become a crucial part of the treatment decision for many oncologists. Targeted therapies can be more effective than chemotherapy for patients with driver mutations123 including approved medications for patients with multiple driver mutations including ROS1, MET, NTRK, and RET. However, it can be difficult to know how to approach such an important part of your treatment journey with your doctor without having some information. In this article we will cover whether or not you should be getting biomarker testing, at what point in your treatment journey you should get testing, the types of biomarker tests available to you, and what the results of the test mean for you.

Should I get biomarker testing?

All non-small cell lung cancer (NSCLC) patients should receive biomarker testing as part of their diagnosis. Until very recently, it was believed that only stage 4 patients should receive this testing.

The results of recent clinical trials show that even early stage patients with surgically removed lung cancer get benefit from targeted therapy4. Additionally, there are clinical trials for NSCLC patients with surgically treatable tumors with driver mutations5. In short, to have access to all the options available, NSCLC patients should get biomarker testing regardless of stage.

NSCLC can be broadly grouped into two different cell types, squamous cell and adenocarcinoma. Patients with adenocarcinoma are more likely to have driver mutations. However, due to there being different types of driver mutations6 in squamous cell NSCLC, there is a different world of clinical trials available for squamous cell patients that cannot be accessed without biomarker testing.

With how important biomarker tests are, when should I get tested?

Because it can affect your treatment choices, NSCLC patients should receive their biomarker testing at diagnosis before any treatment is started. But it is also important to know which type of biomarker test would be the most beneficial to you as a patient. Most patients who receive biomarker testing at diagnosis will have the test results come from the biopsy that their doctor used to confirm the diagnosis. This means that there is a limited amount of tumor tissue to test. Previously, this meant that oncologists could only test for a handful of driver mutations meaning they had to prioritize which mutation they tested for. If the mutations they prioritized were not present, the patient could have a different mutation which was never detected, leading to less than ideal treatment. In today’s lung cancer treatment landscape, patients can receive next generation sequencing (NGS) or panel biomarker testing to test for hundreds of genes at the same time. This means that any possible driver mutation is found by your oncologist.

Another point in your treatment journey where it is important to receive biomarker testing is if you are experiencing progression from a targeted therapy. Broadly speaking, progression from a targeted therapy is likely caused by a new biomarker change in your cancer. As outlined in the article titled Trends in Treatment of EGFR+ NSCLC after Progression Following Tagrisso Treatment, there are different options for patients depending on what biomarker change caused the resistance. And like at diagnosis, the only way to identify these biomarker changes is through biomarker testing. Stage 4 patients experiencing progression can receive biomarker testing through a liquid biopsy, usually a blood draw, instead of surgery for a tissue biopsy. Several different companies offer both tissue and liquid biomarker tests which your doctor could use for your results. The most important thing is that the company is able to do an NGS or panel test and that their results are accurate and verified. Other cancer centers will perform the biomarker test themselves.

I’ve had the biomarker test. Now what happens with the results?

Your oncologist will likely go over the results of the test and identify any driver mutations that have an approved targeted therapy available, such as EGFR. However, even if there are no mutations with approved targeted therapies, the results of the test are extremely valuable. There are many driver mutations with no approved targeted therapy but very promising clinical trials that you may qualify for. There are also other genetic changes that could be present in your cancer which could help predict the results of other therapies such as immunotherapy or chemotherapy. The amount of information associated with biomarker test results can be extremely overwhelming. As a patient, you are not alone in trying to interpret these results. In addition to your treatment team, GO2 for Lung Cancer offers a substantial amount of free resources ranging from easy to understand educational materials to personalized test result interpretation through our LungMATCH program that can help you understand how the results affect you. To access these resources, please call us at 1-800-298-2436 or email us at support@go2.org and ask to speak with a LungMATCH specialist.

I tried to get biomarker testing, but my doctor says I don’t need it. What do I do?

It can feel discouraging to be told by your oncologist that you can’t have a diagnostic test done. In this situation, it is important to talk to your oncologist about why they feel biomarker testing is not a good option for you. Many times, your oncologist will point out a good reason why not. Oncologists have the best intentions for their patients in mind. If you are not comfortable with the reason they give you, it may be in your best interest to confirm their reason with another oncologist as part of a second opinion.

GO2 for Lung Cancer is committed to empowering patients to have access to the best care available to them. For many patients, this involves biomarker testing. If you have not gotten biomarker testing, talk to your doctor about how it might affect you.

1 Mok, T. S., Wu, Y., Ahn, M., Garassino, M. C., Kim, H. R., Ramalingam, S. S., Shepherd, F. A., He, Y., Akamatsu, H., Theelen, W. S., Lee, C. K., Sebastian, M., Templeton, A., Mann, H., Marotti, M., Ghiorghiu, S., Papadimitrakopoulou, V. A., & AURA3 Investigators (2017). Osimertinib or Platinum-Pemetrexed in EGFR T790M-Positive Lung Cancer. The New England journal of medicine, 376(7), 629–640. https://doi.org/10.1056/NEJMoa1612674

2 Shaw, A. T., Kim, D. W., Nakagawa, K., Seto, T., Crinó, L., Ahn, M. J., … & Wu, Y. L. (2013). Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. New England Journal of Medicine, 368(25), 2385-2394.

3 Weart, T. C., Miller, K. D., & Simone, C. B., 2nd (2018). Spotlight on dabrafenib/trametinib in the treatment of non-small-cell lung cancer: place in therapy. Cancer management and research, 10, 647–652. https://doi.org/10.2147/CMAR.S142269

4 Wu, Y. L., Tsuboi, M., He, J., John, T., Grohe, C., Majem, M., … & Vu, H. V. (2020). Osimertinib in resected EGFR-mutated non–small-cell lung cancer. New England Journal of Medicine, 383(18), 1711-1723.

5 https://clinicaltrials.gov/ct2/show/NCT04302025?term=resectable&recrs=a&cond=Non+Small+Cell+Lung+Cancer&draw=2&rank=31

6 Liao, R. G., Watanabe, H., Meyerson, M., & Hammerman, P. S. (2012). Targeted therapy for squamous cell lung cancer. Lung cancer management, 1(4), 293–300. https://doi.org/10.2217/lmt.12.40