NSCLC in the Era of Targeted and Immunotherapy: What Every Pulmonologist Must Know

Abstract

The treatment of non-small cell lung cancer has dramatically changed over the last decade through the use of targeted therapies and immunotherapies. Implementation of these treatment regimens relies on detailed knowledge regarding each tumor's specific genomic profile, underscoring the necessity of obtaining superior diagnostic tissue specimens. While these treatment approaches are commonly utilized in the metastatic setting, approval among earlier-stage disease will continue to rise, highlighting the importance of early and comprehensive biomarker testing at the time of diagnosis for all patients. Pulmonologists play an integral role in the diagnosis and staging of non-small cell lung cancer via sophisticated tissue sampling techniques. This multifaceted review will highlight current indications for the use of targeted therapies and immunotherapies in non-small cell lung cancer and will outline the quality of various diagnostic approaches and subsequent success of tissue biomarker testing. Pulmonologist-specific methods, including endobronchial ultrasound and guided bronchoscopy, will be examined as well as other modalities such as CT-guided transthoracic biopsy and more.

Keywords: biomarker testing; endobronchial ultrasound; guided bronchoscopy; immunotherapy; non-small cell lung cancer; targeted therapy.

Figure 1

Timeline of FDA-approved targeted therapies for NSCLC. First-line therapies depicted above, and second-line therapies depicted below the central arrow.

Figure 2

Approach to tissue biopsy and biomarker testing and treatment in NSCLC by disease stage. IO = immunotherapy; SOC = standard of care. * The utility of routine mediastinal and hilar staging for lesions < 1–2 cm is not clear at present. † Many factors need to be considered such as lung function, local expertise, patient’s preference, and probability of disease. ‡ If obvious widely metastatic disease or certainty on single/minimal metastasis on imaging, the easiest/fastest/highest yield site should be biopsied. § The benefit of consolidative durvalumab has not been established in these patients.