1. Molecular Pathology Tests: Choosing Among the Many Jennifer Laudadio, MD University of Arkansas for Medical Sciences

2. Disclosures None

3. Objectives Assess appropriateness of molecular testing requests and decide among the available methods Evaluate quality and cost-effectiveness of testing options when deciding which ones to bring in-house

4. THE 3PM PHONE CALL (OR EMAIL)

5. What Now? The test you know absolutely nothing about The test you know about but don’t know if the methodology matters and don’t know where to send it The test you know all about but don’t know where to send it The test request you know how to handle – EASY, DONE

6. The test you know nothing about Spend a couple of hours researching the test Knock on your colleagues door Ask your colleague requesting the test to send you information Check reference lab test menus Check www.amp.org test menuwww.amp.org

7. The test you know nothing about Is this medically necessary? What is the cost? Has the requesting doctor talked to the patient about this super expensive test? Do multiple labs offer the test? Do all labs use the same test method?

8. Example “That test that tells me where the primary tumor is”

9. What tests are available? Biotheranostics Pathwork Diagnostics Rosetta Genomics

10. Biotheranostics CancerType ID Laser micro-dissection (need special slides) Real Time RT-PCR 92 genes 87 tumor associated 5 reference Classifies 50 cancer types/subtypes 87% accurate for 28 main tumor types 82% accurate for 50 subtypes

11. Pathwork Diagnostics Tissue of Origin Test DNA based expression array ~2000 genes Classifies 15 primary types/ 58 morphologies 89% positive agreement FDA-cleared for formalin fixed paraffin embedded tissue

12. Rosetta Genomics miRview Mets 2 Expression levels of micro-RNAs 64 micro-RNAs Classifies 42 tumor types 85% sensitivity

13. What tissue is available for testing? What are the specimen requirements for each test? Specimen size? Tumor cellularity? Decalcified? Test methodology can impact what sample is acceptable.

14. Is each test equally “good”? Monzon FA and Koen TJ. Diagnosis of metastatic neoplasms: molecular approaches for identification of tissue of origin. Arch Pathol Lab Med. 2010; 134(2):216-224.

15. Shipping Requirements? Don’t forget about the $$! Does the company direct patient/insurance bill? What is the cost of the test? Has the oncologist discussed this test with the patient?

16. The test you know nothing about Yes, there will be preliminary information gathering necessary – Ask the requesting oncologist for information – Ask your colleagues if they have had any experience with any of the tests and what they thought Yes, the second time you get this request, it will go much smoother

17. The test you have heard about Method? – Probably the hardest part – Intro to molecular methods CME – Webinars Which reference lab? Specimen requirements? – Test the primary or metastasis?

18. Example KRAS mutation testing for metastatic colorectal carcinoma

19. Methodology Sensitivity Specific codons targeted by the method Examples of methods used for KRAS testing – Sequencing – Pyrosequencing – Allele specific PCR

20. KRAS Methodology Sequencing – Get information on entire exon – Need at least 20% mutant allele – Does lab inhibit wild type alleles to increase sensitivity? Pyrosequencing – Improves sensitivity – Targets specific mutations – Special instrumentation Allele specific PCR – Targets specific codon 12 and 13 point mutations – Sensitivity down to ~1% mutant allele – Is it too sensitive?

21. Specimen Requirements and Selecting a Reference Lab FFPE acceptable – Block – Unstained slides (don’t have to be charged) Test either the metastasis or primary The usual reference lab – all our reference testing has to go to lab X Search for a reference lab – Google reference lab test menus Mayo Test Menu – Get info on methodology, specimen requirements, clinical utility, access requisition form, etc

22. Scenarios have been reactive What about being proactive?

23. Proactive You make that phone call to recommend a test Reflex testing policy

24. You recommend a test You diagnose metastatic colorectal carcinoma in a liver biopsy – call surgeon or oncologist and ask if they want it sent for KRAS testing.

25. Reflex Testing HPV for oropharyngeal squamous cell carcinomas

26. Establishing a Reflex Testing Policy Communication – Requests from clinicians – Agreement among Pathologists Methodology How to get a reflex testing policy approved? – Medical Center Dependent – How to communicate the new policy once approved Monitor adherence

27. Specifics from experience with HPV Multi-disciplinary requests ENT surgeons Medical oncologist Radiation oncologist Indications Prognostic and Predictive Diagnostic

28. Specifics from experience with HPV Choosing a Methodology – In situ hybridization High specificity Low sensitivity – PCR High sensitivity Is it too sensitive? – P16 Surrogate High sensitivity Lower specificity In situ hybridization p16 IHC

29. Specifics from experience with HPV Drafting a Reflex Policy – Specific Diagnoses that would trigger the reflex test – CPT codes Getting the Policy Approved Communicating the Policy

30. You want to get into the Molecular Diagnostics Game What tests to bring in house?

31. Test Volumes If you build it, will they come? Cost savings?

32. Type of equipment and expertise needed? FDA approved tests Require less expertise Expense Verification of performance characteristics Lab Developed tests Time for development Expertise More rigorous validation

33. What’s Realistic Dedicated Research/Development person One test a month Pathologists also involved in patient care 3-4 tests per year Don’t forget the need for IT support!!

34. Will I get paid? New CPT codes Based on analyte being tested Not method specific Replace “stacking” codes On clinical lab fee schedule G code for professional interpretation Gap-fill method of determining reimbursement Critical time to work with payers

35. Take Home Points Yes, it can be taxing to your practice to evaluate molecular testing requests. You can handle these requests either proactively or reactively Reactive is not necessarily bad Take advantage of the resources around you – the requesting MD, other pathologists, On-line test menus, Google, webinars, CME

36. Take Home Points: Examples of Tests Tests for tumor of unknown origin – Medical necessity – Methodology and Targeted genes – Specimen Requirements KRAS – Methodology and Mutation targets – Finding a reference lab – Mets versus Primary HPV – Developing a reflex testing policy – Selecting a method

37. Take Home Points A basic understanding of molecular techniques may prove useful Deciding to bring tests in-house – FDA-approved versus lab developed – Performance Characteristics – Cost – Expertise necessary

38. Thank You