For many patients with early-stage lung cancer, targeted immunotherapies have transformed treatment options and prognosis. These immunotherapies are now being used earlier in the process and have been shown to improve not just disease-free survival but also overall survival.

In a recent webinar, oncology and pathology experts from Thailand and Korea offered insight into the latest clinical trial results that shed light on immunotherapy benefits, as well as best practices for biomarker testing to match patients to the right targeted therapy. They also spoke about the value of multidisciplinary teams in lung cancer care.

The entire webinar is well worth a listen, but if you don’t have time, check out these highlights summarised by Lab Insights.

Immunotherapy clinical trials

According to Dr Min-Hee Hong, an associate professor at Yonsei Cancer Center in Korea, two recent trials have proven particularly significant for oncologists who treat lung cancer: the ADAURA trial and the IMpower010 trial.

The ADAURA trial was a double-blind, randomised phase 3 study comparing osimertinib to placebo in surgically-resected EGFR-mutation-positive non-small cell lung cancer (NSCLC). The trial’s primary endpoint was disease-free survival in patients with lung cancer classified as stage II to stage IIIA. Remarkably, there was 83% reduction in recurrence or death in osimertinib arm compared to placebo, noted Dr Hong.

Among the trial arm receiving osimertinib, 20% of patients experienced disease recurrence or death within three years, compared to 72% of patients in the placebo arm. Because of these compelling results, the National Comprehensive Cancer Network (NCCN) in the United States now recommends adjuvant osimertinib for patients with fully resected EGFR-positive NSCLC graded as stage II or stage III.

In the IMpower010 trial, researchers compared adjuvant atezolizumab to best supportive care in completely resected cases of stage II or III non-small cell lung cancer. In the latest tranche of data from the study, atezolizumab was shown to increase overall survival in patients with high PD-L1 markers. The NCCN now recommends atezolizumab in an adjuvant setting for these patients. This study is “definitely the practice-changing trial,” Dr Hong said.

Biomarker testing recommendations

Historically, testing for lung cancer biomarkers associated with targeted therapies was performed later in the cancer journey—after surgical options or standard care. But trial results like those above have caused many pathologists to change their practices.

For EGFR, PD-L1, ALK and other clinically relevant biomarkers, some hospitals in Asia now perform testing at the time of initial diagnosis, even before the cancer has been staged.

According to Dr Pimpin Incharoen, an assistant professor in the pathology department at Ramathibodi Hospital in Thailand, molecular testing for all patients with NSCLC is now recommended for biomarkers including EGFR, ALK and ROS1. In addition, her lab performs PD-L1 immunohistochemistry testing for all NSCLC cases. They often select multiple clones for this testing because results may differ across the tumours.

Dr Pimpin’s team also offers an expanded panel of additional markers for samples that turn out to be negative for the initial biomarker test. Ideally, though, she would like to see a more comprehensive approach that includes all relevant biomarkers plus PD-L1 immunohistochemistry screening for immunotherapy. If much of the testing could be performed in a single assay, that would help pathologists generate more answers from limited tissue samples, she noted.

Dr Tae-Jung Kim, a professor of pathology at the Catholic University of Korea, noted that the increased need for molecular and other tests means each sample must be treated with even more care to maintain its quality. “You can easily see the result of poor fixation versus good fixation,” he said, adding that “careful cooperation between [the] pathology laboratory and surgeon or operation room [can help] prevent ischemic degradation of the sample, which will impact biomarker research eventually.”

The value of multidisciplinary teams

All webinar participants spoke about the benefit of reviewing lung cancer cases with a multidisciplinary team (MDT). At Dr Pimpin’s institute, for example, the MDT team consists of biologists, oncologists, pulmonologists, thoracic surgeons and oncologists. This team meets twice monthly and primarily discusses treatment options.

At Chiang Mai University in Thailand, the MDT can also get involved in biomarker testing recommendations such as when to use a liquid biopsy prior to tissue analysis or when to perform certain kinds of biomarker testing, said Dr Somcharoen Saeteng, associate professor and thoracic surgeon. The MDT can also weigh in on questions such as whether or not cancer is resectable.

Dr Kim in Korea said his MDT meets twice a month and reviews four to seven cases each time. In addition to the usual specialist experts who participate, he noted that his hospital’s MDT also includes a large number of residents and students for educational purposes.

To learn more about biomarker testing and immunotherapy treatment practices in Korea and Thailand, please listen to the on-demand webinar.