Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspective
  • Published:

Strategies for the successful implementation of plasma-based NSCLC genotyping in clinical practice

Nature Reviews Clinical Oncology volume 18, pages 56–62 (2021)Cite this article

Subjects

Abstract

Upfront tumour genotyping is now considered an essential step in guiding treatment decision-making in the management of patients with advanced-stage non-small-cell lung cancer (NSCLC) in light of the ever-expanding toolbox of targeted therapies and immune-checkpoint inhibitors. However, genotyping of tumour biopsy samples is not feasible for all patients and, therefore, genomic analysis of circulating tumour DNA (ctDNA) has emerged as a compelling non-invasive option. Current guidelines universally recommend genotyping and support the use of ctDNA testing in certain settings, although they often omit the detail necessary for integrating these tests into clinical care on an individual basis. In this Perspective, we describe the rationale, promise and challenges associated with ctDNA-based NSCLC genotyping and suggest a framework for the implementation of these assays into routine clinical practice. We also offer considerations for the interpretation of ctDNA genotyping results, which, particularly when using next-generation sequencing panels, can be nuanced. Through the addition of this new approach to clinical practice, we propose that oncologists might finally be able to utilize effective genotyping in nearly all patients with advanced-stage NSCLC.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Convenience of plasma ctDNA genotyping.
Fig. 2: Approaches for genotyping a patient with advanced-stage NSCLC.

Similar content being viewed by others

References

  1. Carlisle, J. W. & Ramalingam, S. S. A banner year for immunotherapy and targeted therapy. Nat. Rev. Clin. Oncol. 16, 79–80 (2019).

    PubMed  Google Scholar 

  2. Lisberg, A. et al. A phase II study of pembrolizumab in EGFR-mutant, PD-L1+, tyrosine kinase inhibitor naïve patients with advanced NSCLC. J. Thorac. Oncol. 13, 1138–1145 (2018).

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Mazieres, J. et al. Immune checkpoint inhibitors for patients with advanced lung cancer and oncogenic driver alterations: results from the IMMUNOTARGET registry. Ann. Oncol. 30, 1321–1328 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Brown, H. et al. Programmed cell death ligand 1 expression in untreated EGFR mutated advanced NSCLC and response to osimertinib versus comparator in FLAURA. J. Thorac. Oncol. 15, 138–143 (2020).

    CAS  PubMed  Google Scholar 

  5. Mok, T. S. K. et al. Pembrolizumab versus chemotherapy for previously untreated, PD-L1-expressing, locally advanced or metastatic non-small-cell lung cancer (KEYNOTE-042): a randomised, open-label, controlled, phase 3 trial. Lancet 393, 1819–1830 (2019).

    CAS  PubMed  Google Scholar 

  6. Reck, M. et al. Pembrolizumab versus chemotherapy for PD-L1–positive non–small-cell lung cancer. N. Engl. J. Med. 375, 1823–1833 (2016).

    CAS  PubMed  Google Scholar 

  7. Lindeman, N. I. et al. Updated molecular testing guideline for the selection of lung cancer patients for treatment with targeted tyrosine kinase inhibitors: guideline from the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology. J. Thorac. Oncol. 13, 323–358 (2018).

    CAS  PubMed  Google Scholar 

  8. Ettinger, D. S. et al. NCCN guidelines insights: non–small cell lung cancer, version 1.2020. J. Natl Compr. Canc. Netw. 17, 1464 (2019).

    PubMed  Google Scholar 

  9. Kalemkerian, G. P. et al. Molecular testing guideline for the selection of patients with lung cancer for treatment with targeted tyrosine kinase inhibitors: American Society of Clinical Oncology Endorsement of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology Clinical Practice guideline update. J. Clin. Oncol. 36, 911–919 (2018).

    CAS  PubMed  Google Scholar 

  10. Pennell, N. A. et al. Economic impact of next-generation sequencing versus single-gene testing to detect genomic alterations in metastatic non–small-cell lung cancer using a decision analytic model. JCO Precis. Oncol. 3, 1–9 (2019).

    PubMed  Google Scholar 

  11. Sholl, L. M. et al. Institutional implementation of clinical tumor profiling on an unselected cancer population. JCI Insight 1, e87062 (2016).

    PubMed  PubMed Central  Google Scholar 

  12. Zehir, A. et al. Mutational landscape of metastatic cancer revealed from prospective clinical sequencing of 10,000 patients. Nat. Med. 23, 703–713 (2017).

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Tan, A. C. et al. Utility of incorporating next-generation sequencing (NGS) in an Asian non-small cell lung cancer (NSCLC) population: Incremental yield of actionable alterations and cost-effectiveness analysis. Lung Cancer 139, 207–215 (2020).

    PubMed  Google Scholar 

  14. Aggarwal, C. et al. Clinical implications of plasma-based genotyping with the delivery of personalized therapy in metastatic non–small cell lung cancer. JAMA Oncol. 5, 173–180 (2019).

    PubMed  Google Scholar 

  15. Bettegowda, C. et al. Detection of circulating tumor DNA in early- and late-stage human malignancies. Sci. Transl Med. 6, 224ra224 (2014).

    Google Scholar 

  16. Fan, H. C., Blumenfeld, Y. J., Chitkara, U., Hudgins, L. & Quake, S. R. Noninvasive diagnosis of fetal aneuploidy by shotgun sequencing DNA from maternal blood. Proc. Natl Acad. Sci. USA 105, 16266–16271 (2008).

    CAS  PubMed  PubMed Central  Google Scholar 

  17. Kapeleris, J. et al. The prognostic role of circulating tumor cells (CTCs) in lung cancer. Front. Oncol. 8, 311 (2018).

    PubMed  PubMed Central  Google Scholar 

  18. Russo, A. et al. Liquid biopsy tracking of lung tumor evolutions over time. Expert. Rev. Mol. Diagn. 19, 1099–1108 (2019).

    CAS  PubMed  Google Scholar 

  19. Yung, T. K. F. et al. Single-molecule detection of epidermal growth factor receptor mutations in plasma by microfluidics digital PCR in non–small cell lung cancer patients. Clin. Cancer Res. 15, 2076–2084 (2009).

    CAS  PubMed  Google Scholar 

  20. Diehl, F. et al. Detection and quantification of mutations in the plasma of patients with colorectal tumors. Proc. Natl Acad. Sci. USA 102, 16368–16373 (2005).

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Oxnard, G. R., Paweletz, C. P. & Sholl, L. M. Genomic analysis of plasma cell-free DNA in patients with cancer. JAMA Oncol. 3, 740–741 (2017).

    PubMed  Google Scholar 

  22. Wu, Y.-L. et al. Clinical utility of a blood-based EGFR mutation test in patients receiving first-line erlotinib therapy in the ENSURE, FASTACT-2, and ASPIRATION studies. Lung Cancer 126, 1–8 (2018).

    CAS  PubMed  Google Scholar 

  23. Jenkins, S. et al. Plasma ctDNA analysis for detection of the EGFR T790M mutation in patients with advanced non–small cell lung cancer. J. Thorac. Oncol. 12, 1061–1070 (2017).

    PubMed  Google Scholar 

  24. Sacher, A. G. et al. Prospective validation of rapid plasma genotyping for the detection of EGFR and KRAS mutations in advanced lung cancer. JAMA Oncol. 2, 1014–1022 (2016).

    PubMed  PubMed Central  Google Scholar 

  25. Remon, J. et al. Real-world utility of an amplicon-based next-generation sequencing liquid biopsy for broad molecular profiling in patients with advanced non–small-cell lung cancer. JCO Precis. Oncol. https://doi.org/10.1200/po.18.00211 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Paweletz, C. P. et al. Bias-corrected targeted next-generation sequencing for rapid, multiplexed detection of actionable alterations in cell-free DNA from advanced lung cancer patients. Clin. Cancer Res. 22, 915–922 (2016).

    CAS  PubMed  Google Scholar 

  27. Schrock, A. B. et al. Hybrid capture–based genomic profiling of circulating tumor DNA from patients with advanced non–small cell lung cancer. J. Thorac. Oncol. 14, 255–264 (2019).

    CAS  PubMed  Google Scholar 

  28. Müller, J. N. et al. Concordance between comprehensive cancer genome profiling in plasma and tumor specimens. J. Thorac. Oncol. 12, 1503–1511 (2017).

    PubMed  Google Scholar 

  29. Cheng, J. et al. Clinical validation of a cell-free DNA gene panel. J. Mol. Diagn. 21, 632–645 (2019).

    CAS  PubMed  Google Scholar 

  30. Leighl, N. B. et al. Clinical utility of comprehensive cell-free DNA analysis to identify genomic biomarkers in patients with newly diagnosed metastatic non–small cell lung cancer. Clin. Cancer Res. 25, 4691–4700 (2019).

    CAS  PubMed  Google Scholar 

  31. Gadgeel, S. M. et al. Phase II/III blood first assay screening trial (BFAST) in patients (pts) with treatment-naïve NSCLC: initial results from the ALK+ cohort. Ann. Oncol. 30 (Suppl. 5), v851–v934 (2019).

    Google Scholar 

  32. Hu, Y. et al. False-positive plasma genotyping due to clonal hematopoiesis. Clin. Cancer Res. 24, 4437–4443 (2018).

    CAS  PubMed  Google Scholar 

  33. Razavi, P. et al. High-intensity sequencing reveals the sources of plasma circulating cell-free DNA variants. Nat. Med. 25, 1928–1937 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  34. Li, B. T. et al. Ultra-deep next-generation sequencing of plasma cell-free DNA in patients with advanced lung cancers: results from the Actionable Genome Consortium. Ann. Oncol. 30, 597–603 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Gray, J. E. et al. Tissue and plasma EGFR mutation analysis in the FLAURA trial: osimertinib versus comparator EGFR tyrosine kinase inhibitor as first-line treatment in patients with EGFR-mutated advanced non–small cell lung cancer. Clin. Cancer Res. 25, 6644–6652 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  36. Passiglia, F et al. Metastatic site location influences the diagnostic accuracy of ctDNA EGFR- mutation testing in NSCLC patients: a pooled analysis. Curr. Cancer Drug Targets 18, 697–705 (2018).

    CAS  PubMed  Google Scholar 

  37. Meador, C. et al. Refining the sensitivity of plasma cell-free DNA (cfDNA) genotyping by controlling for plasma tumor content. J. Clin. Oncol. 36, 9071–9071 (2018).

    Google Scholar 

  38. Supplee, J. G. et al. Sensitivity of next-generation sequencing assays detecting oncogenic fusions in plasma cell-free DNA. Lung Cancer 134, 96–99 (2019).

    PubMed  Google Scholar 

  39. Dagogo-Jack, I. et al. Molecular analysis of plasma from patients with ROS1-positive NSCLC. J. Thorac. Oncol. 14, 816–824 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  40. Oxnard, G. R. et al. Association between plasma genotyping and outcomes of treatment with osimertinib (AZD9291) in advanced non-small-cell lung cancer. J. Clin. Oncol. 34, 3375–3382 (2016).

    CAS  PubMed  PubMed Central  Google Scholar 

  41. Oxnard, G. R. et al. Assessment of resistance mechanisms and clinical implications in patients with EGFR T790M–positive lung cancer and acquired resistance to osimertinib. JAMA Oncol. 4, 1527–1534 (2018).

    PubMed  Google Scholar 

  42. Siravegna, G. et al. Clonal evolution and resistance to EGFR blockade in the blood of colorectal cancer patients. Nat. Med. 21, 795–801 (2015).

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Pectasides, E. et al. Genomic heterogeneity as a barrier to precision medicine in gastroesophageal adenocarcinoma. Cancer Discov. 8, 37–48 (2018).

    CAS  PubMed  Google Scholar 

  44. Parikh, A. R. et al. Liquid versus tissue biopsy for detecting acquired resistance and tumor heterogeneity in gastrointestinal cancers. Nat. Med. 25, 1415–1421 (2019).

    CAS  PubMed  PubMed Central  Google Scholar 

  45. Bai, H. et al. Detection and clinical significance of intratumoral EGFR mutational heterogeneity in chinese patients with advanced non-small cell lung cancer. PLoS ONE 8, e54170 (2013).

    CAS  PubMed  PubMed Central  Google Scholar 

  46. Yatabe, Y., Matsuo, K. & Mitsudomi, T. Heterogeneous distribution of EGFR mutations is extremely rare in lung adenocarcinoma. J. Clin. Oncol. 29, 2972–2977 (2011).

    CAS  PubMed  Google Scholar 

  47. Jamal-Hanjani, M. et al. Tracking the evolution of non-small-cell lung cancer. N. Engl. J. Med. 376, 2109–2121 (2017).

    CAS  PubMed  Google Scholar 

  48. Gandara, D. R. et al. Blood-based tumor mutational burden as a predictor of clinical benefit in non-small-cell lung cancer patients treated with atezolizumab. Nat. Med. 24, 1441–1448 (2018).

    CAS  PubMed  Google Scholar 

  49. Rolfo, C. et al. Liquid biopsy for advanced non-small cell lung cancer (NSCLC): a statement paper from the IASLC. J. Thorac. Oncol. 13, 1248–1268 (2018).

    PubMed  Google Scholar 

  50. Roche. cobas® EGFR Mutation Test v2 https://diagnostics.roche.com/us/en/products/params/cobas-egfr-mutation-test-v2.html (2020).

  51. Sabari, J. K. et al. A prospective study of circulating tumor DNA to guide matched targeted therapy in lung cancers. J. Natl Cancer Inst. 111, 575–583 (2018).

    PubMed Central  Google Scholar 

  52. Sorber, L. et al. Specialized blood collection tubes for liquid biopsy: improving the pre-analytical conditions. Mol. Diagn. Ther. 24, 113–124 (2020).

    PubMed  Google Scholar 

  53. Siravegna, G., Marsoni, S., Siena, S. & Bardelli, A. Integrating liquid biopsies into the management of cancer. Nat. Rev. Clin. Oncol. 14, 531–548 (2017).

    CAS  PubMed  Google Scholar 

  54. Travis, W. D. et al. Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification. Arch. Pathol. Lab. Med. 137, 668–684 (2013).

    PubMed  Google Scholar 

  55. Trisolini, R. et al. Randomized trial of endobronchial ultrasound-guided transbronchial needle aspiration with and without rapid on-site evaluation for lung cancer genotyping. Chest 148, 1430–1437 (2015).

    PubMed  Google Scholar 

  56. Zill, O. A. et al. The landscape of actionable genomic alterations in cell-free circulating tumor DNA from 21,807 advanced cancer patients. Clin. Cancer Res. 24, 3528–3538 (2018).

    CAS  PubMed  Google Scholar 

  57. Merker, J. D. et al. Circulating tumor DNA analysis in patients with cancer: American Society of Clinical Oncology and College of American Pathologists joint review. J. Clin. Oncol. 36, 1631–1641 (2018).

    CAS  PubMed  Google Scholar 

  58. Vu, P., Khagi, Y., Riviere, P., Goodman, A. & Kurzrock, R. Total number of alterations in liquid biopsies is an independent predictor of survival in patients with advanced cancers. JCO Precis. Oncol. 4, 192–201 (2020).

    Google Scholar 

  59. Hu, Y. et al. Discrimination of germline EGFR T790M mutations in plasma cell-free DNA allows study of prevalence across 31,414 cancer patients. Clin. Cancer Res. 23, 7351–7359 (2017).

    CAS  PubMed  PubMed Central  Google Scholar 

  60. Slavin, T. P. et al. Identification of incidental germline mutations in patients with advanced solid tumors who underwent cell-free circulating tumor DNA sequencing. J. Clin. Oncol. 36, 3459–3465 (2018).

    CAS  PubMed Central  Google Scholar 

Download references

Acknowledgements

G.R.O. is the Damon Runyon-Gordon Family Clinical Investigator supported by the Damon Runyon Cancer Research Foundation (CI-86-16) and is supported in part by the National Cancer Institute of the NIH (R01CA240592, P30CA093373). The authors wish to thank AstraZeneca and Guardant Health for providing timely information regarding regulatory developments, which helped to make this Perspective possible.

Author information

Author notes

  1. These authors contributed equally to this work: Charu Aggarwal, Christian D. Rolfo

Authors and Affiliations

  1. Division of Hematology and Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Charu Aggarwal

  2. Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Balitmore, MD, USA

    Christian D. Rolfo

  3. Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Geoffrey R. Oxnard

  4. Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA

    Jhanelle E. Gray

  5. Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA

    Lynette M. Sholl

  6. UC Davis Comprehensive Cancer Center, Sacramento, CA, USA

    David R. Gandara

Authors
  1. Charu Aggarwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christian D. Rolfo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Geoffrey R. Oxnard
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jhanelle E. Gray
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lynette M. Sholl
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. David R. Gandara
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

G.R.O. researched data for this manuscript, all authors made a substantial contribution to discussions of content, and all authors wrote the manuscript and edited and/or reviewed the manuscript prior to submission.

Corresponding author

Correspondence to Charu Aggarwal.

Ethics declarations

Competing interests

C.A. has received consultancy fees or honoraria from AstraZeneca, BMS, Celgene, Lilly, Merck, and Roche-Genentech and institutional research funding from Macrogenics, Merck, Novartis, and Xencor. C.D.R. has received honoraria from AstraZeneca and MSD, consultancy fees from Archer, EMD, Inivata, Mylan, and Serono and has acted as an adviser (non-compensated) of Oncompass. G.R.O. became a full-time employee of Foundation Medicine after submission of this manuscript and has received consultancy fees or honoraria from Abbvie, AstraZeneca, Blueprint, Dropworks, Foundation Medicine, GRAIL, Guardant Health, Illumina, Inivata, Janssen, Loxo Oncology, Sysmex, and Takeda and institutional research funding from GRAIL. J.E.G. has received consultancy fees from AstraZeneca, BMS, EMD Serono/Merck KGaA, Inivata, Merck, and Novartis and institutional research funding from Array, AstraZeneca, BMS, Boehringer–Ingelheim, Merck and Roche-Genentech. L.M.S. has received consultancy fees or honoraria from AstraZeneca, EMD Serono, Foghorn Therapeutics, and Loxo Oncology and institutional research funding from Roche Genentech. D.R.G. has received consultancy fees from AstraZeneca, Celgene, FujiFilm, Guardant Health, Inivata, IO Biotech, Lilly, Merck, Oncocyte, Roche-Genentech, and Samsung Bioepis and institutional research funding from Amgen, Astex, Merck, and Roche-Genentech.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Aggarwal, C., Rolfo, C.D., Oxnard, G.R. et al. Strategies for the successful implementation of plasma-based NSCLC genotyping in clinical practice. Nat Rev Clin Oncol 18, 56–62 (2021). https://doi.org/10.1038/s41571-020-0423-x

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41571-020-0423-x

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer