Improving Therapy Options and Patient Experiences in NSCLC: Part 2

Key Takeaways:

• Improving biomarker testing: Reflexive biomarker testing and improved biopsy practices could expand comprehensive biomarker testing among patients with non–small lung cancer (NSCLC) and streamline the process between diagnosis and treatment prescription.
• The challenge of acquired resistance: Even with targeted therapies, patients still develop resistance to treatment, highlighting the need for better methods of determining next-line treatment options.
• Patient-focused pathways: Clinical pathways for NSCLC should consider patient priorities and experience, measuring quality of life and symptom burden in addition to adherence.

In this interview, Upal Basu Roy, PhD, MPH, executive director of research at LUNGevity, explores current challenges in delivering precision medicine to patients with NSCLC. He promotes patient-focused clinical pathways, explaining the importance of considering the patient experience when making treatment decisions.

Upal Basu Roy, PhD, MPH: I am Dr Upal Basu Roy, the executive director of research at the LUNGevity Foundation. I manage the foundation’s research program and have worked in lung cancer advocacy since 2015.

In your opinion, what are the biggest challenges to delivering targeted treatment for NSCLC?

Dr Basu Roy: A recent study showed that 64% of patients with advanced NSCLC are not benefiting from the progress in precision medicine. The steps between diagnosis and treatment prescription are well-documented, and a breakdown at any step means a patient can miss a targeted therapy they were eligible for.

Comprehensive biomarker testing, the first step to accessing personalized medicine, is not yet universal, and uptake varies by care setting, geography, and patient population. Even when testing is ordered, the amount of tissue acquired is often insufficient, which is why LUNGevity’s Precision Medicine Initiative has focused on biopsy and specimen-handling practices. Tumor sequencing results can take weeks, and patients and physicians understandably feel the pressure to start treatment. When treatment begins before results are back, patients can end up on a regimen inadequate for their tumor biology and may also prevent them from getting the appropriate treatment in the future. Concurrent tissue and liquid biopsy testing are known to shorten the waiting window, but they aren’t consistently used or reimbursed.

Even if testing occurs, interpreting the biomarker report and acting on it doesn’t always happen. Biomarker reports are complex, and our research on patient experience shows that patients often don’t understand what was tested or what the results mean. A result also has to be matched to the right drug or clinical trial, which is harder when there are many rare alterations and when trials are concentrated at academic centers, far from where most patients are treated.

Beyond that, there are systemic barriers, such as coverage inconsistencies for testing and therapies, financial toxicity, and disparities that mean patients from underserved communities are less likely to be tested and treated. Finally, acquired resistance after starting targeted therapy continues to be a problem. Targeted therapies rarely cure advanced disease, so the challenge doesn't end at first-line treatment. We need better ways to detect progression early, retest at progression, and match patients to next-line options. This is why understanding resistance and recurrence are central to our research funding.

How can clinical pathways evolve to become more patient focused while remaining practical and actionable for busy oncology teams?

Dr Basu Roy: I would argue that the most patient-focused pathway and the most practical pathway are often the same thing. Both patients and clinicians really have the same goal. The steps that matter most to patients, such as getting tested, getting results quickly, and getting the right treatment, are also the steps health care teams most want to get right.

First, pathways should build the right defaults into the health care system so clinicians don't have to remember them. Standing orders for comprehensive biomarker testing, automatically triggered by pathology at diagnosis rather than requiring a separate order, along with concurrent tissue and liquid biopsy where appropriate, can reduce decision-making burden from busy teams and help ensure that patients do not fall through the cracks. The same logic applies to electronic health record (EHR)-embedded prompts, such as a hard stop or alert when immunotherapy is ordered before driver alteration results are available.

Second, pathways should include explicit points for shared decision-making. Many NSCLC decisions involve genuine trade-offs, such as between treatment intensity and toxicity, or between standard therapy and clinical trial. Research conducted through our Patient-Focused Research Center consistently shows that patients’ priorities don’t always match what clinicians assume. Pathways can flag these moments and pair them with brief, plain-language decision aids so the conversation happens without adding much time to the visit.

Third, patient experience during the journey matters. Therefore, pathways should account for the patient’s experience between visits. For example, navigation support during the wait for biomarker results, clear communication about what’s being tested and why, and structured collection of patient-reported outcomes so symptoms and side effects are caught early and managed proactively. Navigators and nurses can own many of these steps, keeping the burden off physicians.

Fourth, pathways should measure what matters to patients, not only adherence to a specific treatment. Time from diagnosis to treatment, the percentage of patients with complete biomarker results before first-line therapy, access to trials, and patient-reported quality of life are all actionable metrics that align quality improvement with patient benefit.

Finally, patient-focused pathways need to be dynamic living documents. The NSCLC landscape is rapidly changing, so pathways should be updated frequently, kept simple with clear decision nodes rather than exhaustive lists, and developed with input from patients and advocates as well as clinicians.