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Routine molecular profiling of patients with advanced non-small-cell lung cancer: Results of a 1-year nationwide programme of the French Cooperative Thoracic Intergroup (IFCT)

Barlesi, F., Mazieres, J., Merlio, J.-P.,(...), Soria, J.-C., Zalcman, G.

THE LANCET Volume 387, Issue 10026, 2–8 April 2016, Pages 1415–1426

Commentary by Solange Peters

French Cooperative Thoracic Intergroup (IFCT) 1-year nationwide program of routine molecular profiling of patients with advanced non-small-cell lung cancer (NSCLC) is unprecedented in its size and logistic complexity. Its results highlight an impact of targeted therapy on outcome that extends well beyond what can be attributed to baseline prognostic characteristics. Moreover, it represents a striking example of health-policy implementation mobilizing pre-existing but previously scattered resources.

Recognizing that lung cancer remains by far the leading cause of death in countries with very high or high human development index (HDI), the translation of these development into nationwide everyday practice is expected to yield tremendous benefits. Yet from a public-health point of view, there are further conditions for true personalized medicine in the face of an ever-growing list of molecularly targeted drugs: broad availability of testing, high quality of testing, timeliness of test results compatible with patient care, as well as satisfactory cost-effectiveness. Importantly these parameters may harbour some very distinct definitions across countries. In this regard, the French initiative is remarkable: acting on the Cancer Plan 2009-2013 calling for equal access to innovative and existing therapy, the French National Cancer Institute and the Ministry of Health have set up a nation-wide network of regional hubs for molecular testing that perform tests free of charge for patients and institutions. Between April 2012 and April 2013, 17’664 NSCLC patients were routinely screened for EGFR mutations, ALK rearrangements, as well as HER2, KRAS, BRAF, and PIK3CA mutations. Considering an estimated annual incidence of close to 39’000 new NSCLC cases with an estimated 85% of which either initially present with advanced stage or with subsequent metastatic relapse, and considering that only 5% of the samples analyzed were of squamous histology, the number of samples tested demonstrates a very high nation-wide testing rate, with very little selection bias. The study thus provides a very comprehensive cohort that carries general applicability.

This high coverage dataset suffers however obvious limitations regarding missing clinical annotations, in particular demographic information, tumour staging details as well as outcome indicators. Capture of such parameters would have brought an invaluable knowledge to the field, nonetheless, the study clearly succeeds in demonstrating the feasibility of the implementation of large-scale nationwide decentralized testing, fulfilling one crucial public health requirement, namely broad unrestricted access to testing.