Clinical Implications of Plasma-Based Genotyping With the Delivery of Personalized Therapy in Metastatic Non–Small Cell Lung Cancer | Lung Cancer | JAMA Oncology | JAMA Network
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Original Investigation
October 11, 2018

Clinical Implications of Plasma-Based Genotyping With the Delivery of Personalized Therapy in Metastatic Non–Small Cell Lung Cancer

Author Affiliations
  • 1Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 3Division of Pulmonary, Allergy, and Critical Care Medicine, Thoracic Oncology Group, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 4Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 5Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
  • 6Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
JAMA Oncol. 2019;5(2):173-180. doi:10.1001/jamaoncol.2018.4305
Key Points

Question  Does adding plasma-based sequencing to tissue next-generation sequencing improve mutation detection for patients with non–small cell lung cancer?

Findings  In this single-center cohort study of 323 patients with non–small cell lung cancer, 229 had concurrent plasma and tissue next-generation sequencing or were unable to complete tissue testing. Tissue alone detected targetable mutations for 47 patients (20.5%), whereas plasma sequencing increased targetable mutation detection to 82 (35.8%); 36 of 42 patients (85.7%) who received plasma next-generation sequencing–indicated therapy achieved a complete or a partial response or stable disease.

Meaning  Adding plasma next-generation sequencing testing to the routine management of metastatic non–small cell lung cancer appears to increase targetable mutation detection and improve delivery of targeted therapy.


Importance  The clinical implications of adding plasma-based circulating tumor DNA next-generation sequencing (NGS) to tissue NGS for targetable mutation detection in non–small cell lung cancer (NSCLC) have not been formally assessed.

Objective  To determine whether plasma NGS testing was associated with improved mutation detection and enhanced delivery of personalized therapy in a real-world clinical setting.

Design, Setting, and Participants  This prospective cohort study enrolled 323 patients with metastatic NSCLC who had plasma testing ordered as part of routine clinical management. Plasma NGS was performed using a 73-gene commercial platform. Patients were enrolled at the Hospital of the University of Pennsylvania from April 1, 2016, through January 2, 2018. The database was locked for follow-up and analyses on January 2, 2018, with a median follow-up of 7 months (range, 1-21 months).

Main Outcomes and Measures  The number of patients with targetable alterations detected with plasma and tissue NGS; the association between the allele fractions (AFs) of mutations detected in tissue and plasma; and the association of response rate with the plasma AF of the targeted mutations.

Results  Among the 323 patients with NSCLC (60.1% female; median age, 65 years [range, 33-93 years]), therapeutically targetable mutations were detected in EGFR, ALK, MET, BRCA1, ROS1, RET, ERBB2, or BRAF for 113 (35.0%) overall. Ninety-four patients (29.1%) had plasma testing only at the discretion of the treating physician or patient preference. Among the 94 patients with plasma testing alone, 31 (33.0%) had a therapeutically targetable mutation detected, thus obviating the need for an invasive biopsy. Among the remaining 229 patients who had concurrent plasma and tissue NGS or were unable to have tissue NGS, a therapeutically targetable mutation was detected in tissue alone for 47 patients (20.5%), whereas the addition of plasma testing increased this number to 82 (35.8%). Thirty-six of 42 patients (85.7%) who received a targeted therapy based on the plasma result achieved a complete or a partial response or stable disease. The plasma-based targeted mutation AF had no correlation with depth of Response Evaluation Criteria in Solid Tumors response (r = −0.121; P = .45).

Conclusions and Relevance  Integration of plasma NGS testing into the routine management of stage IV NSCLC demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy.