Table 1 Guide for semi-structured one-on-one interviews (phase 1)

Molecular testing knowledge and relationship to lung needle biopsy

 1. What have you heard about molecular testing specifically for lung cancer?

 2. How (if at all) has molecular testing changed or impacted lung needle biopsy procedures?

 3. To what extent are you aware of whether providers are requesting this type of testing?

 4. How much do you know about the role that tissue obtained from biopsy plays in the testing process for lung cancer biomarkers?

 5. What role does tissue quantity play in molecular testing for non-small cell lung cancer? For example, minimum sample requirements, standards around tissue acquisition for molecular testing?

 6. Are there implications for testing based on the quality of the sample? What are those?

 7. What does it mean to have a sample that is “representative” of the tumor?

 8. How much of a priority is it to have enough tissue sample to be able to test for biomarkers that do not have currently approved treatments? What about biomarkers in clinical trials?

 9. What do you know or what have you heard about liquid biopsy (blood-based molecular testing)? Does the promise of liquid biopsy influence how you think about your role? Could it influence the importance of your role for acquiring tissue for molecular testing?

Challenges to quality and quantity of tissue acquisition

 1. What do you see as the most significant challenges to getting samples of sufficient amount and quality in a lung needle biopsy?

  a. What other members of the healthcare team are involved? How do their interactions make this more or less challenging?

  b. Is this challenge unique to the setting you are in? What could help?

  c. What guidelines exist to standardize how your profession conducts lung needle biopsy so that patients receive standard of care comprehensive molecular testing? Are these guidelines well utilized/known by other radiologists?

 2. Breaking down the challenges step-by-step, does the request for a lung needle biopsy usually come from an oncologist, pulmonologist, or does it depend?

  a. Do you know that the tissue will be used for molecular testing before the lung needle biopsy procedure begins?

  b. Are there differences in what is done based on the request and the type of provider writing the request?

  c. What, if any, challenges to communication are there?

  d. If the requesting provider is far away or at a different hospital, does that create any challenges?

  e. Who handles communications to prepare the patient for what they will experience and need to do during the procedure?

  f. How (if at all) does communication with the patient and patient preparedness impact the success of the procedure?

 3. How about challenges with the procedure itself? Are there specific challenges to the quality and quantity of sample based on

  a. Type of biopsy—core vs FNA

  b. Type of imaging equipment used

  c. Tumor location

  d. Tumor type

 4. To what extent is the desire to be less invasive and less stressful for the patient at odds with getting sufficient tissue?

 5. What are the challenges with performing multiple passes?

  a. Are there tradeoffs between doing multiple passes and patient well-being?

 6. How do you now if the sample is sufficient and if you have samples that are representative of the tumor?

  a. When (if ever) is a pathologist on site to evaluate the sample before it is sent for testing?

  b. How might that be helpful? How does this work?

 7. Are there challenges with preparation of tissue for transport or transport itself?

  a. How does tissue get from the collection site to the molecular pathology lab? Do you play a role in determining how tissue is transported to the lab?

  b. Are you aware of any potential problems with tissue handling?

  c. Is dealing with these labs that do molecular testing different than other labs for histologic staining?

  d. Are there any unique challenges for hospital systems in the transport of samples to the lab that are different from a specialized cancer center or a university/research hospital?

 8. Do you get feedback from the lab or pathologist on the quality or quantity of the sample?

  a. If so, how does it get to you? What is helpful about that?

  b. If not, what might be helpful about it?

 9. Are there aspects of the lung needle biopsy process that are made more difficult because of the insurance or reimbursement policies? For example, challenges with patients on Medicare, Medicaid, or private insurance?

  a. Are there challenges with reimbursing more than one biopsy due to insufficient tissue for molecular testing?