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Professor Tom John
There was a high level of consensus when ESMO brought together 34 experts from 18 countries including Australia, to address nuances in the management of EGFR mutant non-small cell lung cancer (NSCLC).
The broad set of statements, published in Annals of Oncology, encompasses topics within the themes of tissue and biomarker analyses, early and locally advanced disease, and metastatic disease.
Panel member Professor Tom John, from the Peter MacCallum Cancer Centre, told the limbic that most participants agreed on most of the statements.
He said that consistency possibly reflected the reality that people who were part of the panel were clinically trialists from large academic centres. Applying some of the statements in the real world might be trickier.
“There are some things we all agree should be part of what we do – even when we may not be able to,” he said.
For example, the expert panel agreed (90.3% consensus) that cell free DNA (cfDNA) testing was of value and recommended if there was no tissue available.
“But it is not readily available for us in Australia. We all agree it is a great thing to have access to … but the reality is we barely use plasma testing because it’s not a funded test and it costs around $3,000 to do it.”
He said until it was reimbursed, cfDNA use was restricted to clinical trials and very specific circumstances in which the cost was often incurred by the patient.
“There is real utility in being able to do it and everyone agrees on that and that’s what the consensus statement says but unfortunately for us, it isn’t straightforward.”
“The other catch for us is that … even if you find something in plasma, PBS rules are really strict at defining the mutation… The PBS doesn’t even acknowledge that the plasma assay is okay as a means of getting access.”
Some of the other ESMO consensus statements related to testing included:
- reinforcing the role of tissue rebiopsy at disease progression on TKI in order to assess for actionable mechanisms of resistance and potential histologic transformation (100% consensus)
- simultaneous testing of PD-L1 and molecular testing of EGFR is to allow expeditious triaging and selection of appropriate therapy (100% consensus)
- EGFR exon20 insertion mutations are activating for EGFR kinase signalling and are of therapeutic relevance as specific targeted therapies are emerging (100% consensus).
To a lesser extent (93.5% consensus) the expert panel agreed that the co-mutational landscape with EGFR mutation in advanced NSCLC may be a poor prognostic indicator.