Improving Early-Stage Lung Cancer Care

More than 80% of patients with lung cancer receive care in their communities, but this can leave them vulnerable to gaps in care quality and delivery.

To better outcomes among patients diagnosed with early stage non–small cell lung cancer (NSCLC) who receive care in community settings, experts stress the importance of closing equity and efficiency gaps in testing, as well as optimizing comprehensive care delivery for long-term patient outcomes, according to data presented at the 2024 World Conference on Lung Cancer.¹

Joseph Kim, MD, MPH, MBA, FACHE | Image Credit: © Q Synthesis LLC

“I think the biggest improvement efforts are recognizing that there's really this opportunity not only to perform the testing as early as possible,” said Joseph Kim, MD, MPH, MBA, FACHE, president, Q Synthesis LLC, and consultant, Xaf Solutions, who presented the data at WCLC on behalf of the Association of Cancer Care Centers (ACCC). “But using that information to then tailor treatment plans for patients who undergo surgery, they get resected, and then they may be eligible for adjuvant therapies.”

NSCLC was the focus of the analysis because overall survival rates for it remain low despite recent treatment advances; in 2024, amivantamab alone has received 3 FDA approvals.^2-4 Coupled with the fact that more than 80% of patients with this cancer are treated in their communities, ACCC was inspired to launch a 2-phase quality improvement initiative for patients with stage Ib to stage IIIa (early-stage) disease who receive treatment both within their communities and at academic cancer centers. Phase 1 comprised a provider survey that asked about barriers and facilitators to care, and in phase 2, the results from phase 1 were used to pinpoint target areas for improvement at 3 cancer centers. Information was collected on patient demographics, biomarker testing rates, multidisciplinary tumor board (MTB) use, and patterns of adjuvant and neoadjuvant therapy delivery.

Overall Findings

From the data they gathered for 2020 and 2021, there were 70 cases of lung cancer diagnosed, with 20 at site 1, 40 at site 2, and 10 at site 3. The corresponding ages of these patients were 69, 71, and 67 years, and female patients accounted for at least 50% of each patient group. The most common disease histologies were adenocarcinoma (site 1, 65%; site 2, 52%; site 3, 70%) and squamous cell (30%, 40%, and 30%, respectively).

Findings also show that a majority of the diagnosed cases were discussed during MTBs and that EGFR and PD-L1 testing were performed at high rates:

• MTB:
  • Site 1: 65%
  • Site 2: 62%
  • Site 3: 90%
• EGFR testing:
  • Site 1: 55%
  • Site 2: 45%
  • Site 3: 80%
• PD-L1 testing:
  • Site 1: 55%
  • Site 2: 95%
  • Site 3: 80%

Marked for Improvement: Biomarker Testing

At site 1, the above results demonstrate there are 45% of patients with early-stage disease not being tested for EGFR or PD-L1, when these tests are typically ordered 13 days after surgery. Potential causes were variations in what and when tests are ordered, as lack of testing protocol for these patients.

At site 2, results show that 55% of patients were not tested for EGFR and 5% were not tested for PD-L1. Also, that just over half of patients with adenocarcinoma were tested for EGFR (59%), meaning 41% were not. Blames were placed on lack of an automatic testing protocol for early-stage NSCLC, lack of liquid biopsy, and no testing due to insufficient tumor tissue.

At site 3, just 10% of patients underwent biomarker testing at initial diagnosis vs the 90% who were only tested at surgery or later. Reasons given for the subpar biomarker testing results were lack of a biomarker testing protocol at diagnosis and delayed testing due to hospitalization.

The identified solution for all 3 sites was to implement a pathology-driven reflect biomarker testing protocol at diagnosis—for EGFR, PD-L1, and ALK alterations—to increase use of MTBs, and for everyone to contribute.

“One of the biggest lessons is that when it comes to cancer care, a lot of clinicians have very strong opinions, and they may have their own ideas on what should be done. But if you gather everyone together and try to achieve consensus, that's often one of the biggest hurdles to overcome at the very beginning,” Kim stated. “This project led these systems to achieve that type of consensus on when should testing occur, what type of testing are they going to be doing, tracking that information, and making sure that it's as consistent as possible.”

References

1. Smeltzer M, Kim J, Alvarez B, et al. A quality improvement initiative to address biomarker testing and quality of care delivery for early-stage NSCLC at 3 cancer centers in the US. Presented at: World Conference on Lung Cancer; September 7-10, 2024; San Diego, CA.

2. Shaw M. Dr Joshua Sabari discusses amivantamab’s first-line approval for NSCLC. AJMC^®. March 4, 2024. Accessed October 30, 2024. https://www.ajmc.com/view/dr-joshua-sabari-discusses-amivantamab-s-first-line-approval-for-nsclc

3. Bonavitacola J. Lazertinib with amivantamab approved by FDA for use in NSCLC. AJMC. August 20, 2024. Accessed October 30, 2024. https://www.ajmc.com/view/lazertinib-with-amivantamab-approved-by-fda-for-use-in-nsclc

4. Shaw M. Amivantamab accolades add up for NSCLC. AJMC. September 27, 2024. Accessed October 30, 2024. https://www.ajmc.com/view/amivantamab-accolades-add-up-for-nsclc