Developing effective ctDNA testing services for lung cancer
Cancer care is changing. More personalised therapies are available, for a variety of cancers, which target tumours that harbour specific genetic mutations. To prescribe these therapies, a genetic test must be carried out on a tumour sample. In non-small cell lung cancer (NSCLC), 30% of the biopsies to collect tumour tissue fail - these patients do not receive testing and potentially miss out on targeted therapy. New tests that analyse circulating tumour DNA (ctDNA) are an alternative for these patients, increasing access to these therapies. But currently this technology is not in widespread use throughout the NHS and not all eligible patients receive testing.
Our report outlines the most pressing issues affecting the implementation and provision of ctDNA testing services for lung cancer and describes the early experiences of some of the laboratories that have pioneered the introduction of ctDNA testing into the NHS. The report was informed by a multidisciplinary workshop, where we brought together clinicians, NHS clinical scientists and the commercial sector, to discuss ctDNA testing services for lung cancer.
Evidence from the early adopters of ctDNA technology showed that ctDNA testing in NSCLC lung cancer patients increases access to targeted therapies and is meeting an unmet clinical need, but there are issues that need to be addressed to support the implementation of effective and equitable ctDNA testing.
- The NHS should consider offering ctDNA testing of EGFR in lung cancer to all eligible patients
- The NHS should use existing ctDNA testing to maximise access to TKIs
- There are lessons that can be learned from existing ctDNA services that will support the wider use of ctDNA tests in future
We present seven recommendations to support the development of effective ctDNA testing services.
- Healthcare commissioners should formally consider the provision of ctDNA services in lung cancer and improve and strengthen current service provision
- Ongoing service evaluation is required to ensure that the health system has the appropriate information for further implementation
- Laboratory websites should include up-to-date and clear electronic referral information and resources, including testing information, costs and logistics
- Engagement about ctDNA testing can take place within the multidisciplinary team (MDT) – ideally via an individual who can act as a point of contact for queries and information. This person could be a clinician, clinical scientists or a pathologist
- Clinical guidelines on the use of ctDNA testing in NSCLC should be developed by one or more of the professional societies and organisations, such as: British Thoracic Oncology Group, British Thoracic Society, Royal College of Pathologists, Cancer Research UK (including the ECMC network), NICE (clinical guidelines for lung cancer). Clinician and laboratory expertise in ctDNA should be actively collected to inform these guidelines
- Service establishment and validation should be supported, by and within the health system, by promotion of available funding, promotion of test funding structures, linking of test development into accelerated access of technologies and support of collaborative test development
- NHS England should consider how patients can have improved access to funded targeted therapies and take steps through policy development to ensure that the health system is better prepared to implement targeted therapies when commissioned
By Laura Blackburn, Leila Luheshi, Sandi Deans, Mark Kroese, Hilary Burton