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Table 3 Potential solutions to increase comprehensive molecular testing of lung needle biopsy specimens in patients with advanced non-small cell lung cancer

From: Optimizing molecular testing of lung cancer needle biopsy specimens: potential solutions from an interdisciplinary qualitative study

Biopsy request

 1. Educate referring clinicians that NSCLC workup requires comprehensive molecular testing through designated training modules or workshops

 2. Add a “checkbox” to the biopsy request in the electronic medical record to indicate the request for molecular testing. Have the requesting provider check this box in all suspected and confirmed cases of advanced NSCLC

 3. Pre-screen lung needle biopsy requests and call the referring provider for clarification if the need for molecular testing is unclear

Biopsy procedure

 4. Review available imaging prior to the procedure and stratify targets by imaging characteristics, if possible. For example, assess FDG and intravenous contrast to avoid areas of necrosis

 5. Use real-time CT guidance during the procedure

 6. Obtain multiple tissue cores using coaxial technique while angling the biopsy device in all four quadrants

 7. Sample the periphery of large tumors to avoid areas of central necrosis

 8. During ROSE, have the cytotechnologist verify that the specimen contains viable tumor cells

 9. Collect at least four tissue cores once ROSE confirms viable tumor cells

 10. Consider a higher tolerance for potential risk and obtain additional cores if molecular testing is likely to affect survival, especially in suspected advanced NSCLC

Specimen analysis

 11. Clarify how to allocate the specimens depending on institutional requirements

 12. Use NGS panels instead of sequential single-gene tests to conserve tissue and obtain more comprehensive results

 13. If feasible, bank tissue for future molecular testing

 14. Institute “reflex-molecular testing” following histologic diagnosis of NSCLC to reduce turnaround time

Communication

 15. Track frequency of insufficient tissue, reasons for insufficiency, molecular testing results (especially true negatives versus insufficient sample), complications from the biopsy procedure, and patient treatment outcomes

 16. Integrate radiologists who perform lung needle biopsies more closely into the oncology care team and foster a culture of continuous feedback and follow-up

 17. Institute a multidisciplinary tumor board with data-driven discussions to increase the quality of lung needle biopsies

 18. Report tissue adequacy and cellularity in uniquely identified fields (not free-form comments) in the molecular testing report

 19. Institute patient navigators to facilitate multidisciplinary follow-up on molecular testing outcomes

  1. Solutions are listed by barriers to the lung needle biopsy workflow. CT computed tomography, FDG 18-fluorodeoxyglucose, FNA fine needle aspiration, NGS next generation sequencing, NSCLC non-small cell lung cancer, ROSE rapid on-site evaluation