Metastatic NSCLC: Why and How to Standardize Biomarker Testing
—This study demonstrated that implementing a standardized approach to biomarker testing, including provider education, EHR templates, and order sets, increased comprehensive biomarker testing rates in a community oncology practice setting.
Optimizing treatment for metastatic non-small cell lung cancer (mNSCLC) hinges on comprehensive biomarker testing. Yet, achieving optimal testing rates remains a persistent challenge in many settings. Biomarker testing, which identifies specific genetic alterations in tumors, is crucial for guiding targeted therapy decisions in this patient population. National Comprehensive Cancer Network (NCCN) guidelines strongly recommend comprehensive biomarker testing, including both PD-L1 immunohistochemistry and comprehensive genomic profiling (CGP), for all patients with mNSCLC.1 However, research suggests testing rates often fall short of these guidelines.2
In a recent study published in the Journal of Oncology Practice, David Waterhouse, MD, MPH, and colleagues investigated this disparity by implementing a program to standardize comprehensive biomarker testing in a large community oncology practice. The year-long initiative resulted in a significant increase in testing rates, highlighting the potential of standardized protocols to improve patient care in real-world settings.3
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“The primary goal was to increase comprehensive biomarker testing rates in patients with newly diagnosed metastatic lung cancer by creating a New Patient mNSCLC EHR template and accompanying mNSCLC Order Set,” stated the authors.3
Multi-faceted intervention strategy
The authors employed a Plan-Do-Study-Act methodology targeting patients who were 18 years or older and newly diagnosed with mNSCLC over a 1-year period from September 1, 2021, though August 31, 2022, to which all physicians in the Oncology Hematology Care group agreed. After exclusions, a total of 316 patients were included in the study.3
Cycle 1: Education and Streamlining Processes
- Provider education: The team conducted targeted educational sessions for healthcare providers, emphasizing the importance of comprehensive biomarker testing in managing mNSCLC.
- Standardized workflows: An EHR template specifically designed for the initial mNSCLC consultation was created. This template included prompts and reminders for ordering comprehensive biomarker testing, ensuring a consistent approach.
- Workflow monitoring: The team actively monitored workflow processes to identify and address any roadblocks that might impede testing completion.
Cycle 2: Refining the Approach
- Improving cancer staging: Efforts focused on ensuring complete and accurate cancer staging (TNM classification) alongside biomarker testing, as researchers had observed poor or inaccurate disease staging during cycle 1.
- Data-driven monitoring: Data analytics reports were implemented to track testing rates and identify patients who might have missed testing. Regular audits were conducted to assess adherence to the new protocols.
- Targeted re-education: Based on audit findings, the team conducted re-education sessions for providers who deviated from the standardized testing approach.
Impact and sustainability of programmatic approach to biomarker testing
The pre-intervention testing rate for comprehensive biomarker testing in patients with mNSCLC was 68%. Following the implementation of the program, this rate rose to 92.7% within the 1-year intervention period. This substantial increase, the authors noted, reflected “a meaningful impact of the multifaceted provider educational process.”3
The study also reported a 71% utilization rate of the new NSCLC physician note template, indicating strong integration into the workflow. However, complete and accurate documentation of both TNM staging and relevant biomarkers within the template was 40%, highlighting an area for further optimization.3
The researchers noted a potential limitation, which was that during Cycle 1 providers often provided poor or inaccurate NSCLC staging. Thus, they wrote, their pre-grant testing rate may not have been as accurate as the improved testing rate during the study period.3
They also wrote that, “[o]ur EHR template, order sets, proposed workflow, provider education series, and audit processes provide a reproducible and scalable solution for other practices and/or malignancies. However, although the proposed auditing process is feasible for most practices, it is not optimal and can be labor intensive. Automating the
chart auditing process and building structured fields for biomarkers within the EHR will be essential for the widespread scaling of these efforts.”3
In acknowledging the importance of long-term sustainability, they note that establishing reliable tracking metrics and ongoing monitoring processes will be crucial to ensure continued adherence to the new protocols. Going forward, the authors plan to scale this best practice across the US Oncology Network, potentially impacting a much larger patient population. The goal will be to have accurate staging updates, to have no missed results, and to ultimately save time for physicians.3
In this study, Dr. Waterhouse and coauthors offered a practical model of how a community oncology practice can successfully implement a standardized approach to comprehensive biomarker testing in mNSCLC. By streamlining processes and emphasizing the importance of testing, this initiative significantly improved testing rates, paving the way for more personalized and potentially life-saving treatment options for patients.
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