Predictive biomarkers can indicate whether a treatment is likely to provide clinical benefit to the patient with NSCLC, thus helping to facilitate personalized therapy and possibly reducing toxicities and costs associated with ineffective therapies. Even though current guidelines for the management of NSCLC recommend biomarker testing for therapy selection, numerous studies have indicated that not all patients receive this testing, and testing is not being optimally used to select therapy. For example, in a study of patients with non-squamous advanced NSCLC, 24.7% of cases had no evidence of testing for any of the NCCN-recommended molecular tests, including EGFR, ALK, ROS1, KRAS, or BRAF.
Furthermore, in an international survey of oncologists and other specialists involved in the care of
patients with lung cancer, 51% of respondents in the US and Canada reported that most patients in their country do not receive molecular testing, and 22% reported trouble understanding molecular testing result reports. Within this US/Canada population, 26% were not aware of current guidelines for
molecular testing, highlighting the need for clinician education on this topic. As noted by Christine M.
Lovly, MD, PhD, Associate Professor of Medicine in the Division of Hematology-Oncology and Ingram
Associate Professor of Cancer Research at Vanderbilt University Medical Center and Vanderbilt-IngramCancer Center, “If clinicians are not aware that a patient’s tumor is positive for a certain biomarker, they cannot prescribe the appropriate therapy that targets that biomarker. Biomarker testing results are crucial data. Without that information, an oncologist cannot make a fully informed diagnosis or treatment decision.” Additional education regarding guideline recommendations for molecular testing, interpretation of results, and implications for treatment selection are needed to improve outcomes for patients with NSCLC.
PCPs have historically lacked comprehensive or consistent guidance on NAFLD/NASH. Fortunately,
clinical care pathways are available for PCPs managing patients with NAFLD or NASH. PCPs—along with endocrinologists, gastroenterologists, and obesity specialists—need to be aware of which patients should be screened for advanced fibrosis related to NAFLD/NASH. All individuals with T2DM, anyone who has 2 or more components of the metabolic syndrome, and those displaying steatosis or elevated aminotransferases should undergo screening. PCPs also should query all at-risk individuals about alcohol use and order liver function tests (or comprehensive metabolic panel) and a CBC. Noninvasive testing for clinically significant fibrosis (ie, FIB-4 score) is recommended for at-risk patients. The FIB-4 score can be calculated from a standard liver function test and CBC. If the FIB-4 score is <1.3, the patient is at low risk for progression to advanced fibrosis and does not need to be referred to a specialist (ie, hepatologist). In contrast, patients who have an FIB-4 score of >2.67 are at high risk for advancing to fibrosis; PCPs should directly refer these individuals to hepatology. Meanwhile, patients with FIB-4 scores between 1.3 and 2.67 are at indeterminate risk and in need of further testing with a liver stiffness measurement (eg, transient elastography), which can be ordered and interpreted by a PCP. If the liver stiffness measurement is ≥8 kPa, the patient should then be evaluated by a hepatologist (Figure).
Figure. Screening for Advanced Fibrosis Related to NAFLD/NASH