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doi: 10.4103/0970-2113.110417
PMID: 23741090
This article has been cited by other articles in PMC.
Abstract
Background:
Pulmonary complications of diabetes mellitus (DM) have been poorly characterized. Some authors have reported normal pulmonary functions and even concluded that spirometry is not at all necessary in diabetic patients. Some studies have shown abnormal respiratory parameters in patients of DM. Moreover, the duration of DM and glycemic control have varied impact on the pulmonary functions.
Aims and Objectives:
The study was undertaken to analyze the pulmonary function parameters in diabetic patients and compare them with age and gender matched healthy subjects. We correlated forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) in diabetic patients with duration of the disease and glycosylated hemoglobin (HbA1c).
Materials and Methods:
Pulmonary function tests (PFTs) were recorded in 60 type 2 diabetic male patients and 60 normal healthy male controls aged 40-60 years by using Helios 702 spirometer. The PFTs recorded were - FVC, FEV1, FEV1/FVC, FEF25, FEF50, FEF75, FEF25–75, FEF0.2–1.2, and peak expiratory flow rate (PEFR). HbA1c of all the patients was estimated by ion exchange resin method, which is a very standard method of estimation. PFTs of diabetic patients and controls were compared by applying Student′s unpaired t test. Associations between FVC and FEV1 and HbA1c and duration of illness in diabetic patients were analyzed by applying Pearson′s coefficient.
Results:
The PFTs were significantly decreased in diabetic patients compared with the healthy controls except FEV1/FVC. There was no correlation found between FVC and FEV1 and duration of illness as well as HbA1c.
Conclusion:
DM being a systemic disease, which also affects lungs causing restrictive type of ventilatory changes probably because of glycosylation of connective tissues, reduced pulmonary elastic recoil and inflammatory changes in lungs. We found glycemic levels and duration of disease are probably not the major determinants of lung pathology, which requires further research.
Keywords: Diabetes, glycemic control, pulmonary function
INTRODUCTION
The World Health Organization estimates that more than 180 million people worldwide have diabetes, and by 2030 it is expected that this number will have doubled.[1] There is an alarming increase in the incidence and prevalence of diabetes mellitus (DM) in Asian Indians.[] Diabetes is a micro-macrovascular disorder with debilitating effects on many organs. Pulmonary complications of DM have been poorly characterized with conflicting results. The alveolar capillary network in the lung is a large micro-vascular unit and may be affected by microangiopathy.[] However, because of its large reserve, substantial loss of the microvascular bed can be tolerated without developing dyspnoea. As a result, pulmonary diabetic micro-angiopathy may be under-recognized clinically. In DM pulmonary functions have been studied frequently in countries other than India,[] while in our country there are few studies concerning these abnormalities and their relationship with glycosylated hemoglobin (HbA1c) and duration of the disease.
Reduced elastic recoil, reduced lung volume, diminished respiratory muscle performance, chronic low grade inflammation,[,] decrease in pulmonary diffusion capacity for carbon monoxide,[] autonomic neuropathy involving respiratory muscles[] are some of the important changes occurring in DM.
Despite the unclear nature, the relationship between DM and pulmonary function tests (PFTs) remains important because of potential epidemiological and clinical implications. The loss of pulmonary reserve may become clinically important.
Hence, we hypothesized that PFTs are affected in DM in Indian population and the changes may correlate with HbA1c and the duration of the disease.
Objectives
- The study aims to evaluate the PFTs in type 2 DM patients and compare them with the age and gender matched healthy controls.
- We also determine the co-relation of the HbA1c and duration of the disease with PFTs in type 2 DM patients.
MATERIALS AND METHODS
The study was carried out in collaboration with Diabetes Outpatient Department of Sassoon General Hospitals. The Institutional Ethics Committee approved the study protocol. Sixty male patients of type 2 DM diagnosed by the treating physician, of the age group 40–60 years taking oral hypoglycemics, were randomly selected from the Diabetes Outpatient Department.
Exclusion criteria
- Patients having complaints of cough, sputum, or dyspnoea.
- Smokers and patients with any cardio-respiratory illnesses or major diseases.
Sixty normal healthy males of the same age group and socioeconomic status from patient′s relatives were selected as control group. The controls were also thoroughly examined clinically. Those with cardio-respiratory, musculoskeletal, or endocrine diseases were excluded from the study. Fasting and postprandial blood glucose levels were measured by glucose oxidase method to rule out type 2 DM in them.
Informed written consent was taken from patients as well as from controls. All the patients were handed a questionnaire that contained a detailed personal and medical history. PFTs of the patients as well as of the controls were performed with turbine flow sensor-based 702 Helios - Spirometer (Chandigarh, India) between 11 am and 12 pm. All the tests were conducted according to American Thoracic Society/European Respiratory Society (ATS/ERS guidelines) in a quiet room in sitting position by the trained personnel.[] The controls and patients performed spirometry three times at the interval of 15 minutes and the best of the three was taken into account. Parameters recorded were - forced vital capacity (FVC) in liters, forced expiratory volume in 1 second (FEV1), FEV1/FVC in percentage (%), forced expiratory flow during 25% of FVC (FEF25), forced expiratory flow during 50% of FVC (FEF50), forced expiratory flow during 75% of FVC (FEF75), forced expiratory flow during 25–75% of FVC (FEF25–75), forced expiratory flow during 0.2–1.2 liters of FVC (FEF0.2–1.2), and peak expiratory flow rate (PEFR). For all these parameters percentage of predicted values for the respective age, height, and weight were taken into consideration.
Nearly 2 ml of venous blood was collected in ethylenediamine tetra acetic acid (EDTA) bulb in all the diabetic patients with aseptic precautions. HbA1c of all the patients was estimated by ion exchange resin method by the diagnostic glycohaemoglobin kits of Asritha Diatech as per the guidelines provided.[]
All data were collected in a data collection form and then transferred to an Excel sheet by two independent data entry operators. Discrepant values were corrected by checking the data collection form. Clean data was then analyzed statistically.
PFTs of diabetic patients and controls were compared by applying Student′s unpaired ′t′ test. Correlations between FVC and FEV1 and HbA1c and duration of illness in diabetic patients were analyzed by applying Pearson′s coefficient. Statistical analysis was done by using SSPS version 11 and Graphic Prism Pad version 5 (Statistician, B.J. Medical College).
RESULTS
Table 1 depicts the physical characteristics of the normal controls as well as the patients of DM. Age, height, and weight of both the groups were comparable as statistically there was no difference between them (P > 0.05). Our study showed that all the pulmonary parameters, that is, FVC, FEV1, FEF25, FEF50, FEF75, FEF25–75, FEF0.2–1.2, and PEFR were significantly reduced except FEV1/FVC in patients of type 2 DM as compared with the healthy controls (P < 0.05). The ratio FEV1/FVC is almost equal in normal controls and diabetic patients (P > 0.05) [Table 2, Figure 2]. On correlating the FVC and FEV1 with duration of illness and HbA1c, we found that there was no significant correlation between them (P > 0.05) [Table 3, Figures Figures11 and and22].
Table 1
Table 2
Comparison of PFTs in patients with type 2 DM and healthy controls
Correlation of HbA1c with PFTs. P > 0.05 - Statistically not significant
Table 3
Correlation of PFTs with duration of diabetes. P > 0.05 - Statistically not significant
DISCUSSION
Our study showed that all the pulmonary parameters, that is, FVC, FEV1, FEF25, FEF50, FEF75, FEF25–75, FEF0.2–1.2, and PEFR were significantly reduced except FEV1/FVC in patients of type 2 DM as compared with the healthy controls. This is in accordance with previous studies.[–]
Some of the prospective and cross sectional studies have shown low vital capacity or restrictive pattern in type 2 DM.[,17]
Meta-analysis by van den Borst, et al. showed that DM is associated with statistically significant, impaired pulmonary function in a restrictive pattern. Moreover, these results were irrespective of body mass index (BMI), smoking, diabetes duration, and HbA1c levels.[]
Uchida, et al. found that there was decreased pulmonary diffusing capacity in patients with diabetes with perfusion defect on ventilation perfusion scintigrams.[] It was not possible for us to analyze the pulmonary diffusing capacity because of practical difficulties.
Davis, et al. conducted a study in Western Australia in large number of patients of type 2 DM. They found that VC, FVC, FEV1, and PEFR decreased at an average of between 1.1% and 3.1% of predicted values/year in type 2 DM patients.[]
Ehrlich, et al. showed that patients with type 2 DM were at increased risk of several pulmonary condition like - asthma, Chronic Obstructive Pulmonary Disease (COPD), fibrosis, and pneumonia.[]
Few studies have mentioned that no significant differences were observed in patients of type 2 DM.[21–] Probably the small sample size is the reason behind these findings.
Pathophysiology of reduced lung function is still an interesting research issue. Normal lung mechanics and gas exchange are influenced by the integrity of the pulmonary connective tissue and microvaculature. Acceleration of aging process in connective tissue cross links and presence of nonenzymatic glycosylation and modification of alveolar surfactant action causes reduction in PFTs.[] There have been reports of histopathological changes in the diabetic patients. In the study by Weynand et al.,[] it was found that alveolar epithelium, endothelium capillary, and basal laminaes were thickened in lungs on electron microscopy, when compared with the controls. In addition, the thickening of basal laminae was of the same magnitude in lung and kidney. Diabetic microangiopathy might be existing in the pulmonary vascular bed. Moreover, reduced pulmonary capillary blood volume was found, favoring the evidence of microangiopathy. This could lead to redistribution of the pulmonary circulation, resulting in well ventilated areas to become underperfused.[]
The thorax and lungs are rich in collagen and elastin. Stiffening of thorax and lung parenchyma can occur because of nonenzymatic glycosytion of these structural compounds. This may lead to restrictive pattern.[] In our studies, since the FVC/FEV1 ratio is statistically not significantly different in DM patients as compared with normal controls, other PFT values are lower in DM patients; this strongly suggests restrictive pattern in DM patients.
Studies have even shown diabetic polyneuropathy, which affects respiratory neuromuscular function and thus reducing pulmonary volumes.[]
On correlating the FVC and FEV1 with duration of illness and HbA1c, we found that there was no significant correlation between them [Table 3, Figures Figures22 and 3].
There are certain studies showing no correlationship between HbA1c and PFTs.[,] They argued that HbA1c levels are indicators of glycemic control for a short period of 1–2 months, it was not adequate to conclude that the plasma glucose level was not related to decreased PFTs. While some studies have shown that the decline in PFTs was negatively correlated with HbA1c.[,]
There are studies that have reported no significant correlation between PFTs and duration of diseases,[] while some of the studies have reported a strong negative correlation of PFTs with duration.[,] Since DM is a disease, which involves multiple organs randomly, the study of the effect of duration of the disease on them requires further research.
Several studies have analyzed the association between impaired lung function and death and found that a 10% decrease in FEV1 was associated with a 12% increase in all cause mortality in type 2 DM.[]
Clinical implications
Pulmonary dysfunction should be regarded as a specific derangement induced by DM. Further studies may clarify whether this should be included as a long-term complication of diabetes. The role of strict glycemic control on pulmonary function in diabetic patients is another interesting aspect and needs further studies. The impairment in PFTs can lower the threshold for clinical manifestations of acute or chronic lung disease. Patients with DM admitted with pneumonia have increased risk of complications and mortality.[]
Limitations and scope
It seems to be necessary to repeat PFTs and to assess the changes of pulmonary functions among the same subjects. Over a long observation course, the relationship between the plasma glucose concentration and the PFTs can be elucidated.
SUMMARY AND CONCLUSION
DM being a systemic disease, also affects lungs causing restrictive type of ventilatory changes probably because of glycosylation of connective tissues, reduced pulmonary elastic recoil, and inflammatory changes in lungs. We found that glycemic levels and duration of disease are probably not the major determinants of lung pathology, which requires further research.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
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Articles from Lung India : Official Organ of Indian Chest Society are provided here courtesy of Wolters Kluwer -- Medknow Publications
Release Date: June 30, 2017
Expiration Date: June 30, 2018
Media: Internet - based
Expiration Date: June 30, 2018
Media: Internet - based
Activity Overview
Community Practice Connections™: Working Group to Optimize Outcomes in EGFR-mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care features a summary of clinical evidence guiding best practices in the treatment of patients with non–small-cell lung cancer (NSCLC) and mutations in the epidermal growth factor receptor (EGFR) gene, as well as case-based discussions of adverse event management, compliance with oral therapies, and counseling of patients awaiting molecular test results. Interactive clinical vignettes are followed by short video interviews with leading experts in the management of patients with EGFR mutation-positive NSCLC. The video interviews address decision points in the clinical vignettes, as well as questions commonly faced in the community oncology practice setting by nursing professionals engaged in the care of patients with lung cancers.
Acknowledgement of Commercial Support
This activity is supported by an educational grant from AstraZeneca.
Instructions for This Activity and Receiving Credit
|
Target Audience
This educational activity is directed toward nurses and other healthcare professionals with an interest in the treatment of lung cancers.
Learning Objectives
At the conclusion of this activity, you should be better prepared to:
- Explain current and emerging testing platforms in the context of emerging methods to overcome barriers associated with tumor biopsies in the field of lung cancer treatment
- Detail key counseling points to address with patients with lung cancer who are awaiting results from tumor tissue testing
- Describe current and emerging evidence concerning the use of EGFR-targeted strategies in frontline and relapsed advanced non–small-cell lung cancer (NSCLC) disease settings
- Apply best nursing practices to counsel patents with advanced NSCLC concerning the prevention, mitigation, and management of treatment-related toxicities
Faculty, Staff, and Planners' Disclosures
Faculty
Karen C. Lee, MSN, FNP-BC
Clinical Nurse Practitioner
Thoracic Oncology Service
Memorial Sloan Kettering Cancer Center
New York, NY
Clinical Nurse Practitioner
Thoracic Oncology Service
Memorial Sloan Kettering Cancer Center
New York, NY
Disclosure: Consultant: Boehringer Ingelheim; Speakers Bureau: Pfizer, Bristol-Meyers Squibb, Boehringer Ingelheim, AstraZeneca
Benjamin P. Levy, MD
Assistant Professor, Johns Hopkins School of Medicine
Clinical Director, Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital
Washington, DC
Medical Director, Thoracic Oncology Program
at SKCC at Sibley Memorial Hospital
Washington DC
Assistant Professor, Johns Hopkins School of Medicine
Clinical Director, Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital
Washington, DC
Medical Director, Thoracic Oncology Program
at SKCC at Sibley Memorial Hospital
Washington DC
Disclosure: Consultant: Celgene, AstraZeneca, Eli Lilly, Genentech, Pfizer, Merck Speakers Bureau: Eli Lilly, Genentech
Ann Culkin, RN, OCN
Department of Nursing
Office Practice Nurse, Ambulatory, Thoracic Service
Memorial Sloan Kettering Cancer Center
New York, NY
Department of Nursing
Office Practice Nurse, Ambulatory, Thoracic Service
Memorial Sloan Kettering Cancer Center
New York, NY
Disclosure: Consultant: Creative Educational Concepts, CE Program consultant
Alexander Drilon, MD
Clinical Director, Developmental Therapeutics
Assistant Attending Physician, Thoracic Oncology Service
Memorial Sloan Kettering Cancer Center, New York, NY
Clinical Director, Developmental Therapeutics
Assistant Attending Physician, Thoracic Oncology Service
Memorial Sloan Kettering Cancer Center, New York, NY
Disclosure: Grant Research Support: Foundation Medicine; Other: Honoraria: Ignyta, Exelixis, Genentech/Roche, AstraZeneca, Blueprint Medicines, Loxo.
Jonathan W. Riess, MD, MS
Assistant Professor of Medicine
Division of Hematology and Oncology
UC Davis Comprehensive Cancer Center
Sacramento, CA
Assistant Professor of Medicine
Division of Hematology and Oncology
UC Davis Comprehensive Cancer Center
Sacramento, CA
Disclosure: Grant Research Support: Merck, Novartis, Millennium; Consultant: Celgene, Ariad, Clovis Oncology, Medtronic, and Abbvie
Christine H. Teklehaimanote, MSN, GNP-BC, ACHPN
University of California
Davis Medical Center
Sacramento, CA
University of California
Davis Medical Center
Sacramento, CA
Disclosure: No relevant financial relationships to disclose
The staff of PER® have no relevant financial relationships with commercial interests to disclose.
Disclosure Policy and Resolution of Conflicts of Interest (COI)
As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.
Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.
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This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.
PER Pulse™ Recap
1 of 3
PER Pulse™ Recap
PER Pulse™ Recap
Clinical Data With EGFR TKIs in Lung Cancer
The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This first of 3 PER Pulse™ Recaps from this program focuses on recent and emerging clinical data with EGFR tyrosine kinase inhibitors (TKIs) in lung cancer.
- Three EGFR TKIs, erlotinib, afatinib, and gefitinib are approved in the first-line setting for patients with EGFR-mutated non¬–small-cell lung cancer. All 3 of these TKIs have demonstrated improved outcomes (response rates, progression-free survival [PFS], and quality of life) compared with chemotherapy in this patient population.
- In addition, osimertinib, a third-generation TKI that is currently approved for recurrent T790M-positive disease, is being tested in the frontline setting. Phase I data for frontline osimertinib in patients with EGFR-mutated disease demonstrated a median PFS of 19 months. The ongoing Phase III FLAURA trial is a head-to-head trial of osimertinib vs first-generation EGFR TKIs in this setting, and its results should indicate whether there should be a change in practice.
- Combination therapies are also under investigation for this patient population. In a Japanese randomized phase II trial, the addition of bevacizumab to erlotinib in the first-line setting produced a 6.3-month improvement in median PFS. This combination, as well as the combination of afatinib + the anti-EGFR monoclonal antibody cetuximab are currently being investigated in phase III trials.
- For patients whose disease progresses on first-line EGFR TKI therapy, molecular testing for the T790M resistance mutation prior to changing therapy is a standard approach. Liquid-based biopsies, with their procedural ease and rapid turnaround time, have demonstrated utility in this setting. For patients whose disease harbors the T790M mutation, osimertinib is approved. If molecular tests are negative for T790M, this diagnosis should be confirmed, particularly if obtained by a liquid-based biopsy. For these patients, platinum-based chemotherapy is an appropriate approach.
For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting.
2 of 3
PER Pulse™ Recap
PER Pulse™ Recap
Toxicities of EGFR TKIs in Lung Cancer
The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This second of 3 PER Pulse™ Recaps from this program focuses on the toxicities associated with EGFR tyrosine kinase inhibitors (TKIs) in non¬–small-cell lung cancer.
Ann Culkin, RN, OCN, office practice nurse at Memorial Sloan Kettering Cancer Center and Christine H. Teklehaimanote, MSN, NP, AOCNP from the University of California Davis Medical Center provided a number of management tips for the care of patients who experience mild acneiform rash in multiple locations during EGFR TKI therapy.
- Acknowledge the emotional distress that some patients feel when they develop rash
- Warn them prior to treatment initiation that rash is a common toxicity and give them a prescription for clindamycin topical solution upfront, so they can start treatment immediately upon developing the rash
- Remind them to call the office if they feel the rash is not under control
- Account for the distribution of rash when grading it
- Recommend sunscreen for even minimal sun exposure (eg, walking from a car into a building)
- Discover how patients are currently managing skin care
- Provide education on several aspects of skin care, including the need to moisturize, which soaps to use, and how to care for fingernails and toenails
- Consider combination therapy with clindamycin and pimecrolimus 1% cream
For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting.
3 of 3
PER Pulse™ Recap
PER Pulse™ Recap
Role of Plasma Biopsies in Lung Cancer in 2017
The Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, which was held May 6, 2017, in conjunction with the 2017 Oncology Nursing Society Annual Meeting, updated oncology nurses and other practitioners on key lung cancer data sets, educating them on how this evidence can be interpreted in the context of evolving epidermal growth factor receptor (EGFR)-targeted treatment paradigms. In addition, this program provided expert guidance on how to proactively mitigate and manage treatment-related toxicities, navigate molecular testing concerns, and improve patient compliance. This third of 3 PER Pulse™ Recaps from this program focuses on the role of plasma biopsies in lung cancer in 2017.
Benjamin P. Levy, MD, assistant professor and clinical director at Johns Hopkins Sidney Kimmel Cancer Center, and Karen C. Lee, MSN, FNP-BC, clinical nurse practitioner at Memorial Sloan Kettering Cancer Center, discussed the clinical implications of different sources of biopsy from patients with advanced lung cancer.
Treatment-naïve disease
Dr Levy stated that tissue biopsy remains the gold standard for treatment-naïve disease, at the very least for making a histology diagnosis (eg, adenocarcinoma, squamous cell carcinoma). While it is ideal to also use tissue for molecular testing, often the amount of tissue available makes that impossible. In those circumstances, it is reasonable to use a plasma biopsy, also called a liquid biopsy, for molecular testing rather than waiting for a tissue rebiopsy. Plasma biopsies have the advantage of being less invasive, having a quicker turnaround time, and may be more attractive to someone who is reluctant to undergo a rebiopsy.
Dr Levy stated that tissue biopsy remains the gold standard for treatment-naïve disease, at the very least for making a histology diagnosis (eg, adenocarcinoma, squamous cell carcinoma). While it is ideal to also use tissue for molecular testing, often the amount of tissue available makes that impossible. In those circumstances, it is reasonable to use a plasma biopsy, also called a liquid biopsy, for molecular testing rather than waiting for a tissue rebiopsy. Plasma biopsies have the advantage of being less invasive, having a quicker turnaround time, and may be more attractive to someone who is reluctant to undergo a rebiopsy.
Ms Lee jumped in to share a patient case illustrating one way plasma biopsies are used at her institution. For a recent asymptomatic newly diagnosed patient, who had a high likelihood of harboring an EGFR sensitizing mutation due to his Asian ethnicity, adenocarcinoma histology, and never smoker status, his tissue biopsy was insufficient to perform molecular testing. In this case, his team sent off his plasma biopsy both for standard molecular testing, which has a turnaround time of 1 week or less, and next-generation sequencing, which is expected to take much longer (4-5 weeks). Therefore, if his standard molecular testing results are positive for a sensitizing EGFR mutation, he can quickly start on an EGFR TKI such as erlotinib. If results are negative and given that he is asymptomatic, they will wait for the sequencing results in order to plan treatment. This use of a plasma biopsy allows Ms Levy’s team to quickly obtain molecular testing without having to schedule a rebiopsy.
Treatment-refractory disease
Dr Levy discussed how the use of biopsies differs in the treatment-refractory setting for patients receiving first-line EGFR TKIs. Research has shown that patients progressing on an EGFR TKI who test positive for the EGFR resistance mutation T790M using a plasma biopsy are just as likely to respond to T790M-targeted therapy (such as osimertinib) as patients testing positive using a tissue biopsy. Therefore, he has no hesitation in using a plasma biopsy to test these patients for T790M. However, because research has shown a weaker correlation between patient outcomes with plasma and tissue biopsies when T790M results are negative, patients with T790M-negative results using a plasma biopsy need to be retested using a new tissue biopsy.
Dr Levy discussed how the use of biopsies differs in the treatment-refractory setting for patients receiving first-line EGFR TKIs. Research has shown that patients progressing on an EGFR TKI who test positive for the EGFR resistance mutation T790M using a plasma biopsy are just as likely to respond to T790M-targeted therapy (such as osimertinib) as patients testing positive using a tissue biopsy. Therefore, he has no hesitation in using a plasma biopsy to test these patients for T790M. However, because research has shown a weaker correlation between patient outcomes with plasma and tissue biopsies when T790M results are negative, patients with T790M-negative results using a plasma biopsy need to be retested using a new tissue biopsy.
For additional commentary about these topics and others, visit www.gotoper.com for archived video of the Working Group to Optimize Outcomes in EGFR-Mutated Lung Cancers: Evolving Concepts for Nurses to Facilitate and Improve Patient Care, as well as downloadable slides summarizing results from the meeting.