Emerging molecular testing paradigms in non-small cell lung cancer management—current perspectives and recommendations

Abstract

Advances in molecular testing and precision oncology have transformed the clinical management of lung cancer, especially non-small cell lung cancer, enhancing diagnosis, treatment, and outcomes. Practical guidelines offer insights into selecting appropriate biomarkers and assays, emphasizing the importance of comprehensive testing. However, real-world data reveal the underutilization of biomarker testing and consequently targeted therapies. Molecular testing often occurs late in diagnosis or not at all in clinical practice, leading to delayed or inadequate treatment. Enhancing precision requires adherence to best practices by all health care professionals involved, which can ultimately improve lung cancer patient outcomes. The future of precision oncology for lung cancer will likely involve a more personalized approach, starting increasingly from earlier disease settings, with novel and more complex targeted therapies, immunotherapies, and combination regimens, and relying on liquid biopsies, muti-detection advanced genomic technologies and data integration, with artificial intelligence as a central orchestrator. This review presents the currently known actionable mutations in lung cancer and new upcoming ones that are likely to enter clinical practice soon and provides an overview of established and emerging concepts in testing methodologies. Challenges are discussed and best practice recommendations are made that are relevant today, will continue to be relevant in the future, and are likely to be relevant for other cancer types too.

Introduction

Over the years, lung cancer has served as a prototype disease for medical oncology. Its study has helped to not only understand cancer biology but also importantly to test and develop novel therapies and reinforce paradigms in disease management that are relevant across cancer types. While in the early 20th century lung cancer was considered a rare disease, in the decades that followed its incidence rose sharply. By the middle of the century, single-agent chemotherapy was gradually replaced by combination chemotherapy for both major histologies of lung cancer, non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), without much success and the disease became the key example to demonstrate the link between environmental factors, namely tobacco, and cancer. The reality of lung cancer history is that 30 years ago there were editorials written debating whether or not lung cancer was a treatable disease. A landmark meta-analysis by the Non-Small Cell Lung Cancer Collaborative Group (1995) demonstrated that platinum-based chemotherapy can change the natural history of lung cancer by increasing overall survival and was adopted as the standard of care.¹ Chemotherapy was however a one-size-fits-all approach. The discovery of epidermal growth factor receptor gene (EGFR) mutations, first reported in early 2000s, changed that mentality with a number of other mutations/fusions reported subsequently transforming NSCLC into a genomic disease. In parallel, advances in immunotherapy led to such therapies being initially approved in the second-line setting and rapidly moving into the front-line setting.

Even though molecular testing practices are increasing, real-world data reveal underutilization of biomarker testing impacting the broader benefit from targeted therapies, especially in the community setting.^2,3 A study including patients with newly diagnosed and actively managed advanced NSCLC in the United States in 2019 found that approximately 50% of them did not receive any biomarker testing and among those who did, approximately 30% did not receive appropriate targeted treatments.⁴

Socioeconomic barriers to biomarker testing related to reimbursement, health inequalities and disparity in access are well documented.^5,6 Logistical issues and practical challenges may occur at any step between presentation, diagnosis, and reporting of results.^7,8 Waiting for test results and treatment decisions may cause anxiety and stress to patients and their families, while recent studies have shown that at least in NSCLC outcomes depend not only on the time-to-treatment but also on having an optimal pre-treatment assessment and accurately determining tumor characteristics.^9,10

This review presents a comprehensive but practical view of current molecular testing in lung cancer. It aims to increase awareness of such critical aspects among lung physicians and other healthcare professionals and provide practical advice about how to optimally implement the latest approaches in the day-to-day care of lung cancer patients. It predominantly focuses on NSCLC, as this is most applicable at present, but offers examples and learnings that are relevant to SCLC and potentially to other cancer types too.

Molecularly guided NSCLC therapies

Approximately 15% of lung cancer is SCLC while NSCLC accounts for the remaining approximately 85% of cases. The latter can be further subdivided into adenocarcinoma and squamous-cell carcinoma, representing 50%-60% and 20%-30% of total NSCLC cases, respectively. The benefits of tyrosine kinase inhibitors (TKIs) for various forms of mutated NSCLC have been remarkable, as for example with osimertinib in first-line therapy of EGFR-mutated NSCLC, alectinib and larotrectinib for anaplastic lymphoma kinase gene (ALK) and neurotrophic tyrosine receptor kinase (NTRK) fusion-positive NSCLC, respectively.^11-14 Molecularly guided immunotherapy has shown remarkable benefits across NSCLC settings.^15-17

It is estimated that at diagnosis a total of 50%-60% of patients with advanced NSCLC have an actionable driver alteration, with similar estimates reported for early disease (Table 1).^18-21 Following treatment, molecular transformation may occur and although the frequency of such molecular alterations during relapse can vary, the most common include EGFR mutations, ALK rearrangements, fusions involving ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) or rearranged during transfection (RET), amplification of human epidermal growth factor receptor 2 (ERBB2) or mesenchymal-epithelial transition (MET), and programmed cell death-ligand (PD-L1) expression.^22-27

These alterations are significant because they can influence treatment decisions and prognosis. For instance, patients with EGFR mutations often have targeted therapies available, which can improve outcomes. In addition, there are several other biomarkers whose role in NSCLC is emerging that are being investigated in late-stage clinical trials (Table 2).^28-30

The development of resistance to TKI and immunotherapies is a crucial factor in the management of NSCLC cancer. Although not routine practice, repeated biopsies and testing during disease progression can be used to elucidate the molecular mechanisms underlying the development of resistance mechanisms and guide subsequent therapy, as illustrated in the case study in Figure 1. The expansion of the use of liquid rather than tissue biopsies greatly facilitates this process, where real-time quantitative monitoring of EGFR and ALK treatment resistance mutations has already been shown to lead to better outcomes.^31-34

Aspects to be considered for biomarker testing in NSCLC

Clinical practice guidelines, the European Society for Medical Oncology (ESMO), American Society for Clinical Oncology (ASCO), and National Comprehensive Cancer Network (NCCN), offer recommendations how to manage patients with NSCLC emphasizing the importance of appropriate and comprehensive molecular testing (Table 3)^35-39 Currently, tumor testing at diagnosis and progression on targeted therapy is recommended, while the standard of care mandates testing for all patients with advanced NSCLC and testing to be considered in early-stage NSCLC where therapies targeting EGFR and ALK are available. New therapies and molecular assays are continuously improving, and hence clinical practice recommendations are evolving documents being regularly updated. It should be stressed that that molecular testing at diagnosis and at progression (if feasible) is recommended based on clinical trial data, and that, if feasible, broad molecular profiling should be performed to identify molecular alterations for which there is clinical evidence that targeted or other therapies offer clinical benefit and/or to support early drug access or clinical trials. All expert guidelines support using a broad multi-panel approach is the preferred and most highly recommended option and although recommendations are made mostly based on histopathology, the patient’s clinical situation should also be carefully considered. It follows that the choice of specific treatment should be guided by clinical trial evidence and current recommendations for clinical practice (by ASCO, ESMO, NCCN, or other national professional body). A molecular testing approach with a minimal set of biomarkers that could be followed in cases where comprehensive testing is not feasible according to the clinical situation is proposed in Figure 2.

Real-world clinical practice is complex, as local institutional set-up and procedures as well as issues about cost and reimbursement, cannot be ignored. In addition, as mentioned previously, molecular testing is variable and frequently suboptimal, either occurring too late in the diagnostic journey or even not at all, and several challenges may contribute to this (Table 4). In delivering precision medicine-based patient-centered care, effective collaboration and communication are paramount and require several types of expertise and specialized knowledge that is best delivered via a well-coordinated multidisciplinary team (MDT). Logistical issues such as a lack of standardized protocols and operating procedures, together with time pressure or capacity issues hinder efficient communication. The need for sharing and interpreting data in real-time compounds these challenges.^45,46 Other critical and more practical challenges are discussed below.

Specimen acquisition

Any method that provides high-quality tissue for diagnosis, staging, and biomarker testing, while posing minimal risk to the patient, may be considered suitable for tissue acquisition.⁴⁷ In diagnosing lung cancer, the most appropriate biopsy site is determined by a team of specialists, including respiratory physicians, pathologists, oncologists, and surgeons. Bronchoscopy, with or without endobronchial ultrasound (EBUS), surgical resections, percutaneous transthoracic core needle biopsy (CNB), or pleural or lymph node biopsy procedures may all be used to collect lung tissue. Cytology-type samples collected via bronchial brushings and washings, percutaneous transthoracic fine needle aspiration (TFNA) or pleural fluid lymph node needle aspirates of accessible metastases may also be considered.⁴⁷

The choice of biopsy needles and number of passes vary, depending on the risk-benefit and tissue requirements, with some experts recommending conducting as many passes as possible to enhance tissue yield. For example, EBUS-guided transbronchial needle aspiration employs needles ranging from 19 to 22 gauge, with three to five passes typically performed. TFNA can use up to 25-gauge needles and transthoracic CNB typically involves needles up to 20 gauge. TFNA without CNB involves multiple passes sufficient to obtain a tissue block for analysis.⁴⁸

Specimen processing

Once the tissue sample is collected, it is important to use an appropriate and optimal fixative, fixation procedure and duration, to minimize tissue, protein and nucleic acid damage. Neutral-buffered formalin (10%) is the most-used fixative and recommended fixation times are 6-12 hours for small biopsy specimens, and 8-19 hours for larger ones.⁴⁸ Extraction of DNA for molecular-based procedures may be performed using formalin-fixed, paraffin-embedded specimens (FFPE) or fresh frozen, or alcohol-fixed specimens. Usually, 10 unstained slides, each 4- to 5-µm thick, with a surface area between 5 and 25 mm², containing at least 20% tumor nuclei are required. Macro- or micro-dissection is recommended to maximize tumor DNA content and to achieve the ≥20% threshold number of nuclei required.^48,49 It should be noted that cytology samples typically have lower cellularity, limiting their utility for extensive molecular analysis.⁵⁰

Traditionally, tumor tissue has been the standard biospecimen for most molecular-based biomarker testing. However, it carries several inherent limitations related to the accessibility of the biopsy locations and inadequate tissue for molecular testing and tumor heterogeneity, particularly in patients progressing on treatment. Immunohistochemistry and fluorescence in situ hybridization are not suitable for ctDNA evaluation. Increasingly, liquid biopsy offers a more practical alternative, in the diagnostic setting if tumor tissue testing is not possible and more often at the time of progression or metastasis when tissue may not be accessible. NSCLC has been the main test area for establishing this sampling method for examining tumor-derived alterations.⁵¹ Liquid biopsy refers to the procedure of collecting blood, from which molecular components can be isolated and examined. In lung cancer, liquid biopsies are most frequently used to isolate circulating tumor DNA (ctDNA). This in turn can be assessed for gene mutations. The first liquid biopsy test ever approved was the cobas EGFR Mutation Test v2 in 2016, which uses plasma specimens as a companion diagnostic test for the detection of exon 19 deletions or exon 21 substitution mutations in the EGFR gene to guide therapy with anti-EGFR TKIs, and more sensitive tests have become available since.⁵² Liquid biopsy is not invasive, and bypasses issues related to tumor heterogeneity.^51,53 Thus having the potential to be used for real-time detection and monitoring of lung cancer disease progression.⁵⁴ It does have limitations however, namely the risk of false negatives (up to 30%) and detection of non-tumor variants, either because the tumor foci have very low shedding and/or because the technique used is not sensitive enough (dd-PCR and NGS preferred) or specific enough (identification of fusions and CNVs).³⁵ Due to these reasons and the lack of relevant standards for ctDNA testing, at present, clinical practice guidelines do not recommend using plasma ctDNA testing for NSCLC diagnosis and provide no strict recommendations related to testing during disease progression.^35-39 It is, however, remarked that upon disease progression, plasma or tissue-based testing should be considered using broad molecular profiling to identify genomic resistance mechanisms. In this case, if plasma-based testing is negative, the panel strongly recommends tissue-based testing with re-biopsy material.

Genomic testing methodologies

Although genomic testing is sometimes performed as a sequential series of single-gene tests, a more comprehensive multigene testing approach is highly recommended, especially next-generation sequencing (NGS). Tests that directly or indirectly assess single genes include immunohistochemistry (IHC), fluorescence in situ hybridization (FISH), and polymerase chain reaction (PCR), reverse-transcriptase PCR (RT-PCR), or digital droplet-PCR (dd-PCR), a more recent ultra-sensitive method of quantification of targeted mutation.^55,56

IHC can detect changes at the protein level arising from gene amplifications, as well as from specific DNA rearrangements or point mutations, such as is the case for B-Raf proto-oncogene, serine/threonine kinase gene (BRAF) V600E point mutation, ELM4-ALK, NTRK, and ROS1 translocations.⁵⁷ IHC is also used to assess PD-L1 expression to guide immunotherapy decisions (a minimum of 100 viable tumor viable cells).³⁶ FISH has long been considered the gold standard technique for routine detection of gene amplifications (eg, MET and ERBB2), especially when IHC results are inconclusive, as well as for identifying DNA rearrangements, such as with ALK, NTRK, rearranged during transfection gene (RET) and ROS1 but serial IHC and FISH testing are tissue-consuming and ultimately expensive.⁵⁵

NGS, if available, should be preferable to individual single-gene tests to ensure thorough evaluation for multiple biomarkers.^58,59 Polymerase chain reaction tests have different levels of sensitivity, with dd-PCR (digital droplet-PCR) being the most sensitive. PCR tests allow a certain level of multiplexing but are limited by the number of potentially targetable mutations in thoracic oncology and can only detect predetermined mutations. Comprehensive NGS panels can detect various genetic alterations, including fusions, CNVs, single nucleotide variants, and small insertions and deletions and may allow the evaluation of tumor mutational burden. If NGS is available, only PD-L1 remains to be assessed using IHC, while all other biomarkers can be assessed with NGS. ALK IHC could also be retained, with FISH control only when rapid results are necessary, in cases having a 2+ score.

It should be noted that not all NGS assays are identical.⁶⁰ There are differences in the type and breadth of biomarkers they can detect and levels of detection, the specific enrichment methods used (especially for targeted assays), tissue requirements for testing, and importantly the associated costs. In most cases, tissue specimens collected from patients with advanced lung cancer have a low tumor cell content and diagnosis often relies on small bronchial or transparietal biopsies. This may pose a challenge for molecular testing, depending on the test platform used.⁶⁰ Interestingly, a high success rate for reporting five or more biomarkers on CNBs and fine needle aspirations has been reported in one study of 1402 NSCLC small samples (10% FNA, 70% core needle biopsies) submitted for clinical NGS testing.⁶¹

Ideally, NGS testing should cover both DNA and RNA, as assessing DNA alone does not accurately capture all gene fusions (essential for ALK, NTRK, RET, ROS1).^62,63 Furthermore, comprehensive genomic profiling may provide additional data on molecular alterations beyond established actionable biomarkers.⁵⁹

Two types of NGS assays are commonly used for molecular testing: amplicon-based and hybrid capture-based NGS.⁶⁴ Amplicon-based NGS uses multiple primers for direct genomic region amplification. It shows high analytical sensitivity for specific targets and performs efficiently with limited material. However, it is not as reliable in detecting fusions or copy number alterations. In addition, its multiplex design often limits the number of genes and regions they can cover. Consequently, amplicon-based NGS is mostly used for small gene panels focusing on clinical hotspots or selected areas of interest.

Hybrid capture-based NGS uses hybridization techniques to capture extensive genomic regions, enabling a more comprehensive assessment of mutations, copy number variations (CNVs), and gene arrangements (pre-specified in the panel design). Although typically more complex, hybrid capture-based NGS often has longer turnaround times compared to amplicon-based panels, although it is preferrable for upfront comprehensive testing, if limited sample availability prohibits conducting multiple tests.⁴⁷ Recent ultrafast NGS solutions deliver results for the main actionable targets in an average of 18.3 hours.⁶⁵ Such fully automated solutions could optimize patient care by significantly shortening the time needed to deliver results.

Staying up to date and interpretation of results

The rapid advancements in the state-of-the art in biomarker research and technology can create gaps in knowledge among healthcare practitioners. Molecular testing and interpreting genomic reports are becoming increasingly complex and health professionals may find it difficult to understand how to correctly read or interpret the results.^66,67 A recent survey found that oncologists feel less confident when dealing with multigene panel results compared to single-gene tests.⁶⁸ Clinical practice guidelines for the management of lung cancer include guidance on how to perform molecular testing and several professional bodies (ESMO, ASCO, NCCN) have also issued additional specific guidance on how to select patients, perform procedures, or interpret molecular test results.^38,59,69

Practical advice for biomarker testing in NSCLC

Patients should be evaluated by an MDT

Collaborative discussions among oncologists, respiratory physicians, interventional/thoracic radiologists, thoracic surgeons, nurses, pathologists, and/or molecular biologists within MDT are vital throughout the processes involved, from tissue acquisition to testing and interpreting the results.^70,71 Molecular tumor boards (MTB) play a crucial role in coordinating care and enhancing awareness among the MDT.⁷² This enables informed decisions about patient treatment options and overall leads to improvements in the quality of care and optimization of molecular testing processes. Coordinated testing avoids unnecessary and redundant procedures, and therefore also decreases associated costs.

It is important that electronic health records are accessible and securely shared among all healthcare professionals involved in the patient’s treatment. Information about previous tests results and treatments equips the team with the necessary knowledge to make informed decisions. The inclusion of patient navigators should be considered to act as facilitators, following up on MDT molecular testing decisions and ensuring cross-team alignment.⁷³

ROSE should be applied during specimen acquisition, if possible

Rapid on-site evaluation (ROSE) should be considered as the approach for assessing the adequacy of the specimen effectively. It involves the respiratory physician obtaining a tissue specimen, which is then mounted on a slide by a cytotechnologist and examined by a cytopathologist, who promptly provides immediate feedback on the suitability of the sample for molecular testing.⁷⁴ Implementing ROSE has been shown to improve diagnostic yield, reduce the number of biopsy sites and complications.⁷⁵ It is however a more costly approach, and difficult to implement if there is a shortage of staff and/or the necessary medical expertise. In its absence, a visual inspection of the adequacy of the tissue sample is still valuable. Alternatively, the possibility of using a liquid biopsy, together with tumor cell enrichment techniques to maximize the specimen utility, should be considered.^49,76 The key limitation to this double evaluation is financial.

Institutes should implement reflex testing

In de novo advanced NSCLC, reflex testing should be initiated by pathologists immediately after histological diagnosis, eliminating waiting time for physicians to order molecular tests. This proactive approach significantly reduces the time-to-treatment initiation compared to on-demand testing, ensuring faster interventions.^77,78 Reflex testing not only optimizes tissue usage by analyzing all biomarkers at once but also enhances testing rates and increases the number of patients tested by enabling rapid and standardized ordering of biomarker tests. It was recommended that reflex testing is governed by a protocol defined by the MDT and that the MDT itself should engage with policy makers to establish and maintain the reflex testing protocol.⁷⁹

Establishing formal platforms for biomarker education

Continued education is essential for healthcare professionals to remain updated in the rapidly evolving field of biomarkers and molecular testing.⁸⁰ Encouraging attendance at conferences, active participation in continuing medical education, journal clubs, and collaborative platforms like MDTs and tumor boards is crucial. Inconsistencies in the use of terminologies related to biomarker testing have been observed, posing risks of miscommunication with potentially other detrimental consequences. The Oncology Nursing Society, for example, has established the Genomics and Precision Oncology Learning Library, providing information on standardized terminology for improved communication.⁸⁰ As mentioned above, professional bodies such as ESMO and ASCO are offering guidance through their clinical practice guidelines but also ad hoc publications and dedicated training workshops.

New directions and conclusions

While routine molecular testing has not been required for stages I-III NSCLC for many years, this is changing fast. Immunotherapies and more recently targeted therapies are becoming established in non-metastatic disease.⁸¹ Osimertinib significantly reduces the risk of disease recurrence in the adjuvant setting for patients with stage IB-IIIA EGFR mutation-positive NSCLC following complete tumor resection.^82,83 This underscores the role of molecular testing in early-stage NSCLC, as selection of patients for adjuvant treatment relies on the presence of an EGFR-TKI sensitizing mutation. Furthermore, in the early stages, the prescription of immunotherapy, based on PD-L1 expression levels, is approved for eligible patients pending the absence of EGFR-activating mutations and ALK gene fusions.

Encouraging data continue beyond EGFR-mutated NSLC. Practice-changing findings have been recently reported from the Phase III ALINA trial of adjuvant alectinib in patients with completely resected ALK-positive NSCLC. Alectinib is the first ALK inhibitor to significantly improve disease-free survival across disease stages.⁸⁴ The phase III LIBRETTO-431 trial in RET fusion-positive advanced or metastatic NSCLC in the first line, comparing selpercatinib to control treatment consisting of platinum-based chemotherapy with or without pembrolizumab at investigator’s discretion, reported significant prolongation of median progression-free survival in the selpercatinib group and prolongation in the time to central nervous system progression versus control.⁸⁵ The approval of the antibody-drug conjugate (ADC) fam-trastuzumab deruxtecan-nxki (Enhertu) for the treatment of patients with advanced HER2-mutated NSCLC has heralded a new era in lung cancer therapy.^86,87 Several ADCs and bispecific antibodies are in clinical trials in lung cancer.^87-89

Multiomic sequencing within oncogenic driver subgroups, such as whole exome, genome, transcriptome, and proteome sequencing, as well as high-throughput functional genomic sequencing and spatial profiling is likely to reveal molecular features associated with response and resistance to therapies. Greater characterization of the underlying cancer heterogeneity and biology (driver alterations) will allow for the development of therapies with higher selectivity and specificity. In parallel, advances in molecular techniques are continuously enabling higher sensitivity assays, sampling technologies, and validating unconventional cytologic and liquid tissue substrates (such as pleural and cerebrospinal fluids) and allows multiomic approaches.⁹⁰ Liquid biopsy technologies have the potential to identify genetic alterations in the diagnostic process and may enable real-time monitoring of the minimal residual disease. Nevertheless, tissue collection is still necessary to assess the initial diagnosis, to evaluate morphological tumor heterogeneity, a possible change in phenotype in the event of resistance to TKIs (switch to small cell carcinoma), and to perform immunohistochemical tests such as PD-L1.

Artificial intelligence (AI) tools are transformative in many ways. AI algorithms can process extensive biomarker data, identifying patterns, and correlations that might elude human attention.^91,92 Deep learning-based systems are emerging that have been shown to significantly improve the diagnostic accuracy of clinicians and predict the survival benefit in patients with stage IV NSCLC under treatment with EGFR-targeting therapies and immunotherapies and that can assist pathologists in the detection of lung cancer subtypes or gene mutations.⁹³ They have, for example, been trained to predict the probability of mutations in the 10 most frequently mutated genes in lung adenocarcinoma tissue (histopathology) images and have shown improved performance in the evaluation of PD-L1 expression consistent with that of pathologists.^94,95

The future of precision oncology for lung cancer is becoming even more personalized. Emphasis is moving towards having more complex targeted modalities therapies, immunotherapies, and combination treatments that are gradually being used in earlier treatment lines, faster than before. With advances in molecular techniques, the availability of high sensitivity, multi-detection genomic assays, and the growing recognition for validating unconventional cytologic substrates such as urine, sputum, effusions, and FNA, the role of alternate liquid samples will continue to advance. By integrating diverse patient data, ranging from computed tomography (CT) scans to omics information like DNA, RNA, proteins, and microRNA, Artificial intelligence is transforming patient care and advancing not only diagnostic accuracy but also early cancer detection, prognosis prediction, and treatment evaluation. Fundamentally though, enhancing precision requires adherence to current best practices. The concepts and practical considerations presented in this review are relevant today and are likely to continue to be relevant in the future for any healthcare professional caring for patients with lung cancer, and they may very well be applicable to other cancers too.

Acknowledgments

Patient case study illustrating the importance of repeat biopsy for disease progression (Figure 1), provided courtesy of Dr Tarek Mekhail, AdventHealth Cancer Institute, Florida, USA. Medical writing assistance was provided by Nadina Grosios, PhD and Constance Bos, MSc, and editorial review was provided by Tracey Gashi, PhD, of COR2ED Medical Affairs, Basel, Switzerland, supported by an educational grant from Bayer Pharmaceuticals.

Author contributions

Frédérique Penault-Llorca (Conceptualization, Methodology, Writing—review & editing), and Mark A. Socinski (Conceptualization, Methodology, Writing—review & editing).

Funding

COR2ED received financial support through an independent educational grant from Bayer.

Conflicts of interest

Frédérique Penault-Llorca reports speaker/consultancy honoraria from AstraZeneca, Daiichi Sankyo, Eisai, Pfizer, MSD, Novartis, Roche, Seagen, Medscape, Gilead, Janssen, Lilly, Astellas, and Amgen; and travel grants from AstraZeneca, Roche, Pfizer, Daiichi Sankyo, Gilead, MSD, and Novartis. Mark A. Socinski reports speaker/consultancy honoraria from AbbVie, AstraZeneca, Bristol-Myers Squibb, Foundation Medicine, Genentech, Gilead, Guardant, Janssen, Jazz Pharmaceuticals, Mirati Therapeutics, Novartis, OncoC4, Regeneron, and Summit. He also reports research funding (institutional) from Cullinan Oncology, Daiichi Sankyo, Genentech, OncoC4, Pfizer, and Spectrum Pharmaceuticals.

Data availability

Not applicable.

References