Abstract

INTRODUCTION

Palliative chemotherapy in lung cancer has undergone major changes in the last decade.[1] Initially, palliative chemotherapy in lung cancer was decided on the basis of histology. Whether it was nonsmall-cell lung cancer (NSCLC) or small-cell lung cancer was sufficient to decide treatment. However, currently, not merely histological subclassifications (squamous cell carcinoma or adenocarcinoma) but also the mutation analysis determines the treatment. The discovery of driver mutations and development of small molecules targeting them has changed the way we treat NSCLC today.[1,2,3] Lung cancer treatment guidelines now recommend that at least epidermal growth factor receptor (EGFR) tyrosine kinase domain mutation analysis and ALK rearrangement must be done before starting treatment. Treatment recommendations are based on the results of these analysis.[4,5]

At our center, we follow these international guidelines. However, frequently we encounter a situation where either the patient or the treating physician is unwilling to wait for the mutation analysis report. In an attempt to understand the reasons why either the patient or the physicians are unwilling to wait for the report we did an audit of all consecutive NSCLC patients who came to medical oncology lung cancer outpatient department. The objective of this audit was to determine the proportion of patients refusing to wait for the report and the reasons for the same.

MATERIALS AND METHODS

DISCUSSION

The era of personalized medicine comes with a challenge. A major challenge faced by physicians is to convince patients to perform investigations which make it possible to plan personalized treatment and in addition to patiently wait for such a report is available. Literature from the Western world clearly shows that patients are willing to do this. A study from North America by Cuffe et al. highlighted that 99% of patients in adjuvant setting and 97.4% in palliative setting respectively, are willing to undergo pharmacogenomic testing that would identify the cohort of patients who would benefit from therapy.[6] Though the majority of patients wanted to be a part of the decision-making process, 20% of patients lack the basic knowledge to do so.[6] A similar attitude toward pharmacogenetic testing was noted in the UK public by Finegold et al.[7] However, in our study, surprisingly one-third of patients even after being counseled regarding the benefit of EGFR mutation testing were not willing to wait for the report. EGFR and ALK testing is a part of routine protocol and hence, we recommend tissue biopsy in all NSCLC patients. Hence, the sample for mutation testing is acquired at the time of diagnostic confirmation itself. The report at our center is provided within 2 weeks which is at par with the international standards. Inspite of this, we face opposition from many patients to wait for the report and hence we wanted to identify the factors responsible. Even the large studies done in Western countries have identified a small proportion of patients who are resistant to such testing but they fail to identify the reason behind this resistance.[7]

Our analysis determines that poor symptom control (40.1%) was the major reason for patient resistance to wait. Poor symptom control is associated with high distress and deterioration in performance status. The reason behind this may be that a dedicated palliative care clinic for lung cancer is not available for these patients. The other common reason which was provided by patients was a poor general condition. This seems to corroborate with poor performance status. The important question here is the reason for poor PS. If the reason were uncontrolled comorbidity or disease related immediately correctable (pleural effusion) cause then may be a repeat interview after corrective treatment may help the patient to change their decision. However, in case of poor PS because of other causes, waiting for report is unjustifiable. This is reflected in the fact that poor PS patients and those with breathlessness were recommended the immediate start of therapy without awaiting the molecular report. The third common reason given by patients was logistics which was mainly because of lack of social support for staying in the city. This is a problem peculiar to our tertiary care referral center that draws patients from all parts of the country.

We have planned corrective steps toward improving patients compliance with the recommendation to wait for EGFR report. First is repeated counselling of patients who are unwilling to wait for the report. We are conducting group discussion meetings between patients, relatives, doctors and social workers so that in a more elaborate way, with the aid of audio-visual presentations the importance of mutation testing can be stressed. We thought that this step is necessary, as the Western population is nearly 100% literate but nearly 20% of Indian population is illiterate and hence the basic knowledge of decisions need to be explained in more simplified manner with visual aids.[8] Further efforts will be made for getting a dedicated palliative care expert for better management of symptoms preferably located near the medical oncology lung clinic. Facility would be provided for patients to access their reports online itself with a telephonic alert so that these patients staying far away can revisit our center or a center nearby for starting appropriate treatment. Finally, we are planning to expedite our lab efforts so that reports can be available within 1 week and develop liquid biopsy based molecular tests. We plan to repeat our analysis after 1 year of implementation of these measures to quantify the effect of our measures.

CONCLUSION

At present, in our setup, nearly one-third of our NSCLC patients opt for immediate chemotherapy treatment and are unwilling to wait for mutation analysis report. The major reasons for such attitude are poor symptom control and deteriorating general condition.