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Routine EGFR Testing in Lung Cancer

Posted Apr 23 2009 12:00am

I attended the Cecil A. Krakower Memorial Lecture at University of Illinois at Chicago on Saturday, April 18 and was treated to an informative lecture on EGFR-targeted therapy in lung cancer by Dr. Odile David from U of I/Chicago.  I have followed this with interest on a parallel track with KRAS mutations in colorectal cancer (recent CAP NewsPath article) and this lecture prompted some consideration of this issue.
Although we have performed an immunohistochemical stain for EGFR on a few NSCLC tumors the past couple years, we have had few requests for EGFR assessment.  Based on discussions at Tumor Board, it would seem that our patients are treated with conventional platinum-based chemotherapy in the adjuvant setting, usually carboplatin with paclitaxel or docetaxel or vinorelbine.  According to a recent "Patterns of Care in Medical Oncology: Management of Lung Cancer in the Adjuvant and Metastatic Settings," this appears to be the most common strategy for practicing oncologists as well as clinical investigators.  The Editor's Note asks the question: "Is lung cancer the new breast cancer?  Are novel biologics the new chemo?"
The issues regarding EGFR as a prognostic marker and predictive marker for response to EGFR-TKIs (erlotinib and gefitinib) and assessment by EGFR mutations, gene copy number and expression by FISH or IHC is discussed in the v.2.2009 NCCN Practice Guidelines for NSCLC.  This is a rapidly evolving area of translational oncology with conflicting reports on the relationship between EGFR "status" and predictive response to therapy.  Some centers do not performed IHC or FISH for EGFR but instead do EGFR mutation analysis from the start.
There are numerous practical issues that need to be sorted out but you may be seeing some requests for "EGFR testing" in patients with NSCLC.  First, any testing for EGFR (at least today) should probably be performed only on Stage IIIA/B patients.  Second, it is probably only informative in adenocarcinoma (but I want to look at histology more carefully in the papers that have recently come out).  Third, it does not appear that surrogate tests, ISH or IHC, are useful for predicting response.  At this point, only mutation testing should be offered.  Which mutation test?
Many other issues...more to come.

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