Overview: Why Genomic Testing Matters in NSCLC
Genomic testing has become a cornerstone of precision care for non-small cell lung cancer (NSCLC). During a recent session at the AONN+ Conference, experts highlighted how oncology nurses, advanced practitioners, and navigators can use biomarker information to guide testing and treatment decisions. For patients with different NSCLC subtypes, understanding which tests to order, how to interpret results, and how to communicate implications is essential to delivering timely, personalized care.
Key Biomarkers to Test by NSCLC Subtype
Guidelines increasingly favor comprehensive and targeted testing to identify driver mutations and predictive markers. The following biomarkers are commonly prioritized for NSCLC, with test choices tailored to histology and clinical scenario:
- EGFR mutations: Especially relevant in adenocarcinoma; influences first-line tyrosine kinase inhibitor (TKI) therapy.
- ALK and ROS1 rearrangements: Targetable fusions with approved TKIs; important for nonsquamous NSCLC but considered in all cases where tissue allows.
- KRAS G12C: A prevalent mutation in NSCLC with emerging targeted inhibitors; testing informs eligibility for KRAS-directed therapies or clinical trials.
- BRAF V600E and NTRK fusions: Less common but clinically actionable with available targeted agents and trials.
- MET exon 14 skipping: A driver alteration with MET inhibitors showing benefit in selected patients.
- HER2, RET, and other alterations: Less frequent but important to identify for trial matching and novel therapies.
- PD-L1 expression and tumor mutational burden (TMB): Predictive and prognostic markers that can guide immunotherapy decisions in combination with tumor histology and driver status.
Notes for navigators: the presence of a driver mutation often supersedes PD-L1 status when choosing first-line targeted therapy in eligible patients. Conversely, patients without actionable drivers may rely on immunotherapy or chemo-immunotherapy regimens guided by PD-L1 levels and clinical factors.
Testing Strategies: When and How to Test
Experts emphasized that the timing and modality of testing are as critical as the results themselves. Practical guidance for navigators includes:
- Tissue-based panel testing: Multigene next-generation sequencing (NGS) panels identify a broad range of alterations from a single test, conserving tissue and accelerating results.
- Liquid biopsy (ctDNA): A noninvasive option useful when tissue is insufficient or when monitoring for resistance mutations during treatment. It may complement tissue testing rather than replace it.
- Coordinating testing: Early orders at initial diagnosis or relapse can shorten time to treatment, especially when clinically actionable alterations are present.
- Re-testing on progression: Tumors evolve under therapy; repeat genomic testing can reveal new targets or resistance mechanisms that open avenues for subsequent therapies or trials.
For navigators, workflow optimization means clear referral pathways to molecular pathology, timely result reporting, and proactive patient education about what the results mean for treatment options and eligibility for trials.
Communication and Patient-Centered Care
Conversations with patients should balance clarity and hope. Navigators can:
- Explain that biomarker results guide targeted therapies and may influence immunotherapy choices.
- Provide accessible summaries of what each mutation implies for treatment and prognosis.
- Prepare patients for possible re-testing as disease evolves, and discuss the benefits and limitations of liquid biopsies.
- Coordinate logistics—biopsy scheduling, specimen handling, insurance approvals, and participation in clinical trials.
The session at AONN+ underscored that streamlined genomic testing, combined with patient-centered navigation, can shorten the time from diagnosis to effective treatment, improving outcomes for NSCLC patients across the spectrum of disease.
