Lung Cancer Screening and Diagnosis: Panelists Share Experiences, Challenges

A roundtable discussion, moderated by Millie Das, MD, covered challenges, advances, and future directions for the diagnosis, treatment, and management of non-small cell lung cancer (NSCLC), as well as critical clinical trial data and updates from the 2024 American Society of Clinical Oncology Annual Meeting. Dr. Das was joined by Ticiana Leal, MD, Martin Dietrich, MD, PhD, and Kent Shih, MD.

In the first segment of the roundtable series, the panel discusses screening and diagnostic challenges in NSCLC, as well as the prevalence of metastatic disease at diagnosis.

View the next segment on how to talk to patients about starting lung cancer treatment.

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Dr. Das: Hi everyone. My name is Millie Das, I’m a thoracic medical oncologist at Stanford University and at the Veterans Affairs Hospital in Palo Alto. I’d like to welcome you all here today with Lung Cancers Today, where I’m joined here today by colleagues to discuss non-small cell lung cancer with a focus on metastatic disease and new [American Society of Clinical Oncology] 2024 data. I’ll allow my colleagues to introduce themselves.

Dr. Shih: I’m a medical oncologist based in Nashville, Tennessee with Tennessee Oncology, part of One Oncology.

Dr. Dietrich: I’m Martin Dietrich and I’m a medical oncologist at US Oncology in Orlando, Florida.

Dr. Leal: I’m Ticiana Leal. I’m an associate professor and director of the thoracic oncology program at the Winship Cancer Institute of Emory University in Atlanta, Georgia. Thanks for the invite.

Dr. Das: We’re going to start with just talking about an overview of non-small cell lung cancer. I’d love for us to just speak a little bit to our experiences on how we think about our patients with metastatic lung cancer, how these patients are typically diagnosed and getting to you in your clinics, and perhaps also, speaking a little bit to the unmet needs in these patients. I’ll start with you, Kent.

Dr. Shih: There’s a lot of lung cancer where I’m from in the south, and early detection and early diagnosis is very important. [Patients are] funneled into our multidisciplinary team, as I’m sure that they are with you guys, and we manage each patient individually. But increasingly, particularly in the community, I think it’s becoming more complex and more difficult as data rolls in.

Dr. Das: Martin, similar?

Dr. Dietrich: We have a very low rate, unfortunately, in Central Florida, of lung cancer screening. We’re still improving. Obviously, those would have been interventions for us to detect disease earlier, and to have a better chance for a better outcome. And so, we’re still working on implementing this on a broader scale of raising awareness in the at-risk community to actually implement lung cancer screening.

Dr. Leal: Similar experience. I think rates of lung cancer screening are still below what they should be. Although I have had patients in my clinic with lung cancer diagnosed with low-dose [computed tomography] scans, those are a low number of patients still. I would say that more than half of the patients in my clinic still have either locally advanced disease or advanced disease. Certainly, these patients, a lot of them come in with a lot of symptoms, and there could be a lot of issues with just the time that it takes to still get to that initial treatment discussion. A lot of times, we’re still talking about, at that initial discussion, we need to do to [next-generation sequencing (NGS)].

We don’t have reflex testing yet. Doing NGS, managing symptoms, completing the staging workup many times, and then certainly trying to get patients on the right treatment as quickly as possible, and addressing all of their needs, takes a village. We work with a multi-[disciplinary] team, and that is, I think, an essential part of lung cancer care.

Dr. Das: Absolutely. I think that we’re all excited about the data that supports lung cancer screening. I think we can all agree that we’re not doing a very good job on a national level, and unfortunately the majority of our patients are still presenting with metastatic disease, and it does become a challenge.

On the topic of NGS testing, I wanted to ask each of you, at your various institutions, how does NGS testing happen? Does it happen reflexively? Ticiana, you mentioned it’s not happening reflexively. If you are having to order it as a medical oncologist, what’s the turnaround time? Are you using those results to help inform treatment decisions?

Dr. Leal: Yeah, I mean [we’re doing] NGS testing now that we have targeted therapy in early-stage lung cancer. We just heard the LAURA trial today, where we’re going to be using targeted therapy in stage III non-small cell lung cancer. So, we are doing NGS. We do broad NGS panels, both in tissue as well as in plasma, but it really is something that is ordered by medical oncology. We have it integrated into EPIC, which has facilitated ordering for sure. Certainly, I think a lot of our multi-[disciplinary] team members will order NGS testing, but it’s not their primary role. It still is primarily medical oncology requesting all those tests.

We do have something that has been very helpful, which is, we have a diagnostic clinic. We have a diagnostic clinic where patients come in and they clearly have a diagnosis of cancer but are not yet diagnosed. We’re doing the work-up in this initial diagnostic clinic. I have found that very helpful, because then the diagnostic clinic will just start the NGS testing. So, by the time they hit our clinic, hopefully we have results or are very close to getting results for NGS testing. Turnaround time for plasma, it’s the usual 7-10 days, and then turnaround time for the tissue-based testing tends to be 2-3 weeks.

Dr. Das: Martin?

Dr. Dietrich: Yeah, similar experience, it’s mainly upon us to order tissue testing. Unfortunately, our turnaround times are closer to 3 weeks. Not as fast unfortunately. Depending on where the biopsy was taken, this may be a delay. That’s why we include routinely now liquid-based approaches as well to accelerate time to treatment. Many of the actionable alterations are detected very sensitively on biopsies from plasma.

I think those are combined approaches that help us facilitate some of those time-to-treatment concerns that we have with patients, especially symptomatic patients that oftentimes have a higher circulating tumor DNA fraction. Now that it’s a bonus, and unfortunately the speed is a main issue. Now that we have it approved in all stages, I think it’s a good time to start thinking about reflex protocols in pathology.

Dr. Shih: That’s kind of an interesting story. We do reflex testing now. I fought that battle 5 or 10 years ago where we didn’t, and sort of hit my head against the wall several times until I gave up because of cost, which is what I was told. Then, several years ago, they just did a 180 and decided to reflex test everybody. Squamous, non-squamous, [stages] IA to IV. That has its pros and cons, right? I get information earlier. At the same time, I also run out of tissue to submit for the 8 slides, 16 slides as necessary for protocols.

There’s always a yin and yang, pros and cons to getting reflex testing. Also, it may be an [endobronchial ultrasound-guided fine-needle aspiration] where we get a nip of tissue just enough for diagnosis, but not quite enough for everything. So then that falls to me to do the serum testing, which then delays things. But in all, our hospital that I’m at is small and nimble enough to where most, if not all, early-stage cases get presented in multi-[disciplinary] conference. We can kind of work out what needs to be done prior to them seeing me officially.

Dr. Das: I had a similar experience where reflex testing was not being done. As of a few years ago, it is now being routinely ordered by the interventionalists who are performing the biopsies, which is really great. By the time the patients do come to us, we do have those results. Every now and then, you’ll find an instance where a patient didn’t have it done for whatever reason, and I do find that you’re already behind the ball when you’re having to order it.