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October 24, 2019
As the landscape of cancer biomarker testing grows in complexity, pathologists and oncologists must work closely together to coordinate test ordering processes and to make clinically meaningful interpretation of the results. More than ever before, pathologists need to have a stronger understanding about which tests to order, how they should be ordered and how to interpret the results.
Given the wealth of new clinical data that is constantly emerging, oncologists often return to work after attending a national conference, with many fresh and exciting ideas. They may bombard the pathology department with new biomarker test requests or new operational ideas that reflect "cutting edge" research, but are not necessarily reflected in current guidelines or best practices yet. Pathology must work with the hospital administration to review the data, discuss how to allocate resources, prioritize requests and consider financial implications.
“Pathologists need to know how to work with their utilization committees and sort these types of requests,” says Joseph Kim, MD, MPH, MBA, who runs a company called Q Synthesis, LLC, that specializes in quality improvement initiatives. “Increasingly, pathologists are realizing that they need to lead in this area; they need to be able to provide guidance on appropriate tests to order, in addition to interpreting test results.”
To address this obstacle, ASCP is implementing its immuno-oncology (IO) education through a series of online education and quality improvement projects in community hospitals nationwide. Several of the educational programs focus on the latest science surrounding molecular testing and the use of other IO biomarkers that can guide patient selection for different medical therapies.
At the ASCP 2019 Annual Meeting, a panel discussion addressed some of the implications around how community hospitals are evaluating their biomarker testing processes as they broaden the use of IO to treat different types of cancers. One of the panelists was Alejandro R. Zuretti, MD, FASCP, medical director at Maimonides Medical Center and also the medical director of the laboratory at SUNY Downstate Health Sciences University in Brooklyn, NY.
“The conversations I’ve been having about biomarker testing are with the entire cancer care team,” he explains. “Some of these relate to issues that are important to the nursing staff or medical oncologists, in addition to pathologists. As we identify those issues and assign responsibilities to different individuals, it allows them to examine their processes.”
For example, biomarker testing for advanced non-small cell lung cancer (NSCLC) is well established and, therefore, the test ordering requests made by medical oncologists tend to be highly standardized. In contrast, test ordering patterns for small cell lung cancer (SCLC) may be more variable because oncologists do not see this type of cancer frequently; they may have different testing preferences, or may lack education around the latest evidence. Hence, this may reflect an example of an opportunity for pathologists to work with their medical oncology colleagues and standardize biomarker testing processes for all types of lung cancers.
According to Dr. Zuretti, “Having a standardized approach allows you to develop an algorithm, and make everyone aware of the steps required in the algorithm. It is an ideal way to tackle these issues.” Establishing a standardized process requires pathologists to play an active leadership role when speaking with oncologists, educating them about the latest evidence, and navigating decisions around how their institution should apply clinical practice guidelines.
“The tumor board is one of the most important aspects for all patients with a neoplastic disease as it brings together the oncologist, pathologist and other members of the multidisciplinary team so that everyone is on the same page and aware of the different modalities that can be used to treat the patient,” he says.
ASCP’s IO initiatives at the various hospitals have increasingly led to more pathologists actively engaging in conversations with oncologists, leading efforts to standardize biomarker testing processes and ensuring that they and their colleagues are reviewing and evaluating the latest clinical evidence to update their institutional policies and procedures. According to Dr. Kim, this active role of pathologists has led to more patients receiving timely cancer care and also receiving guideline-concordant treatments that are based on the right biomarker tests.
Learn more about how cancer centers are putting these principles into practice by visiting www.ascp.org/immuno-oncology.
Fast Facts:
At the time of this writing, the following immune checkpoint inhibitors are approved by the FDA for the treatment of patients with advanced NSCLC and SCLC:
NSCLC:
SCLC:
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