I really enjoyed today's session on cracking the code of targeted therapy in non-small cell lung cancer. It emphasized next-gen sequencing and the importance of identifying actionable mutations for cancer patients with non-small cell lung cancer. The session today highlighted the difference between tissue-based sequencing and liquid-based sequencing, which I think as nurse practitioners is very important for us to understand. Tissue-based sampling gives us a more comprehensive molecular profile, which includes PD-L1 as well as IHC, although more invasive, and it also has a slower turnaround time, which I think are things we have to keep in mind. Whereas liquid biopsies, they can be done in-office, it's just a blood draw, it's least invasive, and has a quicker turnaround time. But again, it also lacks the PD-L1 as well as the IHC. So, these are things we have to keep in mind when we order these tests.
I'll also emphasize that a negative biopsy from a liquid standpoint does not actually rule out a mutation, which I think is important for us to know and to understand. Just because we see a liquid biopsy that comes back negative doesn't mean that the game is over just yet. It's important to follow up on the tissue sampling, which usually comes back a little bit later, but it can also be more sensitive because again, it's coming from the actual tumor itself. We have to remember that liquid biopsies work better when there's a lot of disease and the patient has bulky disease, whereas patients with minimal disease, there's not as much shedding into the bloodstream, therefore making it harder to pick up on the ctDNA.
The session today really focused on NGS interpretation, which includes the pathway, the reliability of the mutation, as well as whether or not it was a true driver mutation, meaning something that's actionable. While driver mutations can be rare, they can also provide great treatment options for our patients with non-small cell lung cancer.
The first thing I ever learned as a nurse practitioner was we have to optimize all of our treatments and my preceptor always said it's like we're going to war with three bullets and we can all relate to that in some way, but finding an oncologic driver can help us add another bullet to our war against lung cancer.
From there, the session went on to go through targetable agents that are used to treat non-small cell lung cancer, which include EGFR, KRAS, BRAF, V600E, ALK, RET fusions, MET, and the less common NTRK and EBBR2 mutations. It also went through the side effects that were associated with treatments for those drugs, which I felt was a nice reminder, especially when we don't see these drugs regularly.
It's important as nurse practitioners that we're able to interpret the next-gen sequencing reports as well as understand when it's time to initiate treatment. We have to assess our patients in real time and understand if they're able to wait to start treatment or if they need to start treatment right away. Oftentimes we're able to identify these patients who are more likely to have mutations such as never-smokers, patients who are young, patients of certain ethnicities. And so being able to target those patients and saying, "Yes, this patient will likely have a mutation," is something that we try to focus on doing. And again, how sick is the patient? Are they on oxygen? Are they in pain? Are they able to wait for treatment to get the NGS back before we start or do we simply need to get started with some sort of IV systemic therapy treatment?
The session also included a scenario where changing from first-line therapy after we saw a mutation return on NGS and how that resulted in toxicity because, again, a TKI for a mutation of some sort followed by IV therapy can sometimes again result in toxicity. So, these are all things we have to think about when it comes to are we ready to start treatment? Do we wait for NGS or do we go ahead and get going?
Something I found interesting on today's session was the emerging evidence when it comes to managing swelling on patients who have a RET fusion that are on capmatinib. We know these patients have the swelling that happens as a result, a side effect from the medication, and how do we help patients manage that? I have several patients who have debilitating swelling and it requires frequent holds, they get cellulitis, that sort of thing. So being able to have a medication which they're looking at these SGLT2 inhibitors, which can help with swelling, this is the first I've heard of that. So, it was pretty exciting to hear, especially for my patients.
