Non-Small Cell Lung Cancer

Lung cancer is the leading cause of cancer death in the U. S., with an estimated 228150 new cases and142670 deaths due to the disease in 2019.^1, NSCLC accounts for approximately 85% of lung cancer cases and includes nonsquamous carcinoma (adenocarcinoma, large cell carcinoma, other cell types) and squamous cell carcinoma.

Diagnosis

The stage at which lung cancer is diagnosed has the greatest impact on prognosis.^2, Localized disease confined to the primary site has a 55.6% relative 5-year survival but accounts for only 16% of lung cancer cases at diagnosis. Mortality increases sharply with advancing stage. Metastatic lung cancer has a relative 5-year survival of 4.5%. Overall, advanced disease, defined as regional involvement and metastatic, accounts for approximately 80% of cases of lung cancer at diagnosis. These statistics are mirrored for the population of NSCLC, with 85% of cases presenting as advanced disease and up to 40% of patients with metastatic disease.

In addition to tumor stage, age, sex, and performance status are independent prognostic factors for survival particularly in early-stage disease. Wheatley-Price et al (2010) reported on a retrospective pooled analysis of 2349 advanced NSCLC patients from 5 randomized chemotherapy trials.^3, Women had a higher response rate to platinum-based chemotherapy than men. Additionally, women with adenocarcinoma histology had greater overall survival than men. A small survival advantage exists for squamous cell carcinoma over non-bronchiolar nonsquamous histology.^4,

The oncology clinical care and research community use standard measures of performance status: Eastern Cooperative Oncology Group scale and Karnofsky Performance Scale.

Treatment

Treatment approaches are multimodal and generally include surgery, radiotherapy, and chemotherapy (either alone or in combination with another treatment, depending on disease stage and tumor characteristics). Per the National Comprehensive Cancer Network (NCCN) guidelines, the clinical management pathway for stage I or II NSCLC is dependent on surgical findings and may involve resection, radiotherapy, chemotherapy, or chemoradiation. First-line chemotherapy regimens for neoadjuvant and adjuvant therapy utilize platinum-based agents (eg, cisplatin, carboplatin) in combination with other chemotherapeutics and/or radiotherapy. Treatment recommendations are based on the overall health or performance status of the patient, presence or absence of metastases, as well as the presence or absence of a treatment-sensitizing genetic variant. These aspects inform the selection of targeted and systemic therapies. ^1,

For patients who experience disease progression following initial systemic therapy, subsequent treatment regimens are recommended, mainly featuring novel programmed death-ligand 1 (PD-L1) inhibitors. For patients with sensitizing epidermal growthfactor receptor (EGFR)mutations, recommendations include first-line therapy with EGFR tyrosine kinase inhibitors (TKIs) afatinib, erlotinib, dacomitinib, gefitinib, or osimertinib and subsequent therapy with osimertinib. The NCCN does not make any recommendations for the use of EGFR TKIs in the absence of a confirmed sensitizing EGFR mutation. For patients with progression on TKIs other than osimertinib, testing for T790M is recommended, however, switching to osimertinib can be considered regardless of mutational status. Osimertinib carries a Category 1 recommendation for T790M+ patients with disease progression on an alternative EGFR TKI. For progression on osimertinib with limited and/or isolated lesions, a continuation of osimertinib and definitive local therapy via surgery, stereotactic ablative radiotherapy, or stereotactic radiosurgery is recommended. Initial systemic therapy recommendations can be considered for multiple, symptomatic, systemic lesions. ^1,

Genomic Alterations

Several common genetic alterations in NSCLC have been targets for drug therapy, the most well-established of which areTKIs targeting theEGFR and crizotinib targeting the anaplastic lymphoma kinase (ALK) gene rearrangement.

EGFR Variants

EGFR, a tyrosine kinase (TK) receptor, is frequently overexpressed and activated in NSCLC. Drugs that inhibit EGFR-signaling either prevent ligand-binding to the extracellular domain (monoclonal antibodies) or inhibit intracellular TK activity (small molecule TKIs). These targeted therapies dampen signal transduction through pathways downstream to the EGFR, such as the RAS/RAF/MAPK cascade. RAS proteins are G proteins that cycle between active and inactive forms in response to stimulation from cell surface receptors such as EGFR, acting as binary switches between cell surface EGFR and downstream signaling pathways. These pathways are important in cancer cell proliferation, invasion, metastasis, and the stimulation of neovascularization.

Variants in 2 regions of the EGFR gene, including small deletions in exon 19 and a point mutation in exon 21 (L858R), appear to predict tumor response to TKIs such as erlotinib. The prevalence of EGFR variants in NSCLC varies by population, with the highest prevalence in nonsmoking Asian women with adenocarcinoma; for that subpopulation, EGFR variants have been reported to as high as 30% to 50%. The reported prevalence of EGFR variants in lung adenocarcinoma patients in the U. S. is approximately 15%.^5,

ALK Variants

For 2% to 7% of NSCLC patients in the U. S., tumors express a fusion gene comprising portions of the echinoderm microtubule-associated protein-like 4 (EML4) gene and the ALK gene (EML4-ALK), which is created by an inversion on chromosome 2p.^6, The EML4 fusion leads to ligand-independent activation of ALK,which encodes a receptor TK whose precise cellular function is not completely understood.EML4-ALK variants are more common in never smokers or light smokers, tend to be associated with younger age of NSCLC onset, and typically do not occur in conjunction with EGFR variants.

Testing for the EML4-ALK fusion gene in patients with adenocarcinoma-type NSCLC is used to predict response to the small molecule TKI crizotinib.

Other Genetic Variants

Other genetic variants, identified in subsets of patients with NSCLC, are summarized in Table 1. The role of testing for these variants is to help select targeted therapies for NSCLC is less well-established than for EGFR variants.

Table 1. Non-EGFR Variants in NSCLC

Gene	Gene Function	Estimated Variants Prevalence in NSCLC	Patient and Tumor Characteristics
KRAS	Encodes RAS proteins; variants associated with constitutively activated protein	20%-30%	Adenocarcinomas Heavy smokers
ALK	Encodes a receptor TK in the insulin receptor family	4-5%	Never smokers Male Advanced disease
ROS1	Encodes a receptor TK in the insulin receptor family	0.9%-3.7%	Adenocarcinoma Never smokers
RET	Proto-oncogene that encodes a receptor TK growth factor	0.6%-2%
MET	Oncogene that encodes a receptor TK that is activated in response to binding of hepatocyte growth factor	2-4% of previously untreated NSCLC; 5%-20% of patients with acquired resistance to EGFR TKIs	Patients with acquired resistance to EGFR TKIs
BRAF	Serine-threonine kinase downstream from RAS in RAS-RAF-ERK-MAPK pathway	1%-3% of adenocarcinomas	Heavy smokers
HER	HER (EGFR) family of TK receptors; dimerizes with EGFR family members when activated	1%-2% of NSCLC	Adenocarcinomas Nonsmoking women
PIK3CA	Intracellular signaling pathway	»4% of NSCLC

ALK: anaplastic lymphoma kinase; EGFR: epidermal growth factor receptor; HER: human epidermal growth factor receptor; NSCLC: non-small-cell lung cancer; TK: tyrosine kinase; TKI: tyrosine kinase inhibitor.

Targeted Treatment Options

EGFR-Selective Small Molecule TKIs

Five orally administered EGFR-selective small-molecule TKIs have been approved by the U.S. Food and Drug Administration (FDA) for treating NSCLC: gefitinib, erlotinib, afatinib, dacomitinib, and osimertinib(see Table 2). Although theFDA approved gefitinib in 2004, a phase 3 trial has suggested gefitinib was not associated with a survival benefit. In 2003, the FDA revised gefitinib labeling, further limiting its use to patients who had previously benefited or were currently benefiting from the drug; no new patients were to be given gefitinib. However, in 2015, the FDA approved gefitinib as a first-line treatment for patients with metastatic, sensitizing EGFR-variant positive NSCLC.

In 2015, osimertinib (Tagrisso), an irreversible selective EGFR inhibitor that targets T790M variant-positive NSCLC, received the FDA approval for patients with T790M variant-positive NSCLC who have progressed on an EGFR TKI.

A meta-analysis by Lee et al (2013) assessing 23 trials on the use of erlotinib, gefitinib, and afatinib in patients with advanced NSCLC reported improved progression-free survival (PFS) in EGFR variant-positive patients treated with EGFR TKIs in the first- and second-line settings and as maintenance therapy.^7, Comparators were chemotherapy, chemotherapy and placebo, and placebo in the first-line, second-line, and maintenance therapy settings. Among EGFR variant-negative patients, PFS was improved with EGFR TKIs compared with placebo for maintenance therapy but not in the first- and second-line settings. OS did not differ between treatment groups in either variant-positive or variant-negative patients. Statistical heterogeneity was not reported for any outcomes. Reviewers concluded that EGFR-variant testing is indicated to guide treatment selection in NSCLC patients.

On the basis of the results of five, phase 3 randomized controlled trials, the American Society of Clinical Oncology has recommended that patients with NSCLC being considered for first-line therapy with an EGFR TKI (patients who have not previously received chemotherapy or an EGFR TKI) should have their tumor tested for EGFRvariants to determine whether an EGFR TKI or chemotherapy is the appropriate first-line therapy.^5,

The primary target population for TKIs in NSCLC is for EGFR variant-positive patients with advanced NSCLC. The use of TKIs in NSCLC for patients with non-sensitizing, wild-type EGFR-variant status is controversial. The TITAN trial as reported by Ciuleanu et al (2012) demonstrated no significant differences in OS between erlotinib and chemotherapy as a second-line treatment for patients unselected on the basis ofEGFR-variant status, with fewer serious adverse events in erlotinib-treated patients.^8, Karampeazis et al (2013) reported similar efficacy between erlotinib and standard chemotherapy (pemetrexed) for second-line therapy in patients unselected on the basis ofEGFR-variant status.^9,By contrast, in the TAILOR trial, as reported by Garassino et al (2013), standard chemotherapy was associated with longer OS than erlotinib for second-line therapy in patients with wild-type EGFR.^10, Auliac et al (2014) compared sequential erlotinib plus docetaxel with docetaxel alone as second-line therapy among patients with advanced NSCLC and EGFR wild-type or unknown status.^11, Based on Simon’s optimal 2-stage design, the erlotinib plus docetaxel strategy was rejected. Despite the rejection, it is worth noting that in the erlotinib plus docetaxel arm 18 of the 73 patients achieved PFS at 15 weeks; comparatively, in the docetaxel arm, 17 of 74 patients achieved PFS at 15 weeks.

Cicenas et al (2016) reported on results of the IUNO randomized controlled trial, which compared maintenance therapy using erlotinib followed by second-line chemotherapy if progression occurred with placebo followed by erlotinib if progression occurred in 643 patients who had advanced NSCLC and no known EGFR variant.^12, Because there were no significant differences between groups in PFS, objective response rate, or disease control rate, maintenance therapy with erlotinib in patients without EGFR variants was not considered efficacious.

Exon 19 deletions and p.L858R point mutations in exon 21 are the most commonly described sensitizing EGFR mutations, or mutations in EGFR that are associated with responsiveness to EGFR TKI therapy. According to the NCCN, most recent data indicate that NSCLC tumors that do not harbor a sensitizing EGFR mutation should not be treated with an EGFR TKI in any line of therapy.^1,

Anti-EGFR Monoclonal Antibodies

For the treatment of KRAS-mutated NSCLC, anti-EGFR monoclonal antibodies have been investigated as possible treatment options. Available anti-EGFR monoclonal antibodies include cetuximab and panitumumab. The NCCN states that a combination of afatinib and cetuximab may be considered in patients harboring sensitizing EGFR mutations with disease progression on EGFR TKI therapy.^1,

Programmed Death-Ligand 1 Inhibitors

Some tumors, including some NSCLCs, express aPD-L1 on the cell surfaces to interact with host T cells and evade the immune system. Several humanized monoclonal antibodies have been developed to act as immune checkpoint inhibitors by interfering with this interaction, to interact with the PD-L1, block cancer/T-cell interaction, and thus act as immune checkpoint inhibitors. Pembrolizumab, nivolumab, and atezolizumab, which inhibit the programmed death 1 receptor, and atezolizumab, which inhibits the PD-L1, are used in NSCLC that have a PD-L1 expression on its cells. Durvalumab also targets the PD-L1 protein but is used in unresectable, stage III NSCLC whose disease has not progressed following concurrent platinum-based chemotherapy and radiotherapy.

Other Targeted Therapies

Crizotinib is a novel MET, ROS1, and ALK TKI, and associated with improved PFS in patients with advanced NSCLC who test positive for ALK gene rearrangements.^13, Crizotinib is considered first-line therapy for advanced ALK-positive lung adenocarcinoma.^1,Other small-molecule TKIs, designed to selectively bind to and inhibit ALK activation,have the FDA approval: ceritinib, alectinib, and brigatinib.

Proposed targeted therapies for other genetic alterations in NSCLC are trastuzumab for HER2 variants, crizotinib for MET amplification and ROS1 rearrangement, vemurafenib and dabrafenib for BRAF variants, and cabozantinib for RET rearrangements.

Proteomics Testing for Selecting Targeted Treatment for NSCLC

The term proteome refers to the entire complement of proteins produced by an organism, or cellular system and proteomicsrefers to the large-scale comprehensive study of a specific proteome. The proteome may differ from cell to cell and may vary over time and in response to selected stressors.

A cancer cell’s proteome is related to its genome and genomic alterations. The proteome may be measuredby mass spectrometry (MS) or protein microarray. For cancer, proteomic signatures in the tumor or bodily fluids (ie, pleural fluid or blood) other than the tumor have been investigated as a biomarker for cancer activity.

A commercially available serum-based test (VeriStrat) has been developed and proposed to be used as a prognostic tool to predict expected survival for standard therapies used in the treatment of NSCLC. The test is also proposed to have predictive value for response to EGFRTKIs.^14, The test uses matrix-assisted laser desorption ionization MS analysis, and a classification algorithm was developed on a training set of pretreatment sera from 3 cohorts (Italian A, Japan A, Japan B) totaling 139 patients with advanced NSCLC who were treated with second-line gefitinib.^15, The classification result is either “good” or “poor". Two validation studies using pretreatment sera from 2 cohorts of patients (Italian B, Eastern Cooperative Oncology Group 3503) totaling 163 patients have been reported (see Tables 3 and 4).

This assay uses an 8-peak proteomic signature; four of the eight have been identified as fragments of serum amyloid A protein 1.^16, This protein has been found to be elevated in individuals with a variety of conditions associated with acute and chronic inflammation.^{17,18,19,20,21,} The specificity for malignant biologic processes and conditions has not been determined.^22, With industry support, Fidler et al (2018) used convenience biorepository samples to investigate 102 analytes for potential correlations between the specific peptide and protein biomarkers and VeriStrat classification.^23,The VeriStrat test is currently marketed as a tool to measure a patient's "immune response to lung cancer." Biodesix indicates that a VeriStrat "Good" result indicates "a disease state that is more likely to respond to standard of care treatment," whereas a VeriStrat "Poor" rating indicates a chronic inflammatory disease state associated with aggressive cancer and patients that "may benefit from an alternative treatment strategy." The Biodesix website does not indicate whether the VeriStrat test should be reserved for use in patients with advanced lung cancer.^14,

Although the VeriStrat matrix-assisted laser desorption ionization MS-based predictive algorithm has the largest body of literature associated with it, other investigators have used alternative MS methods, such as surface-enhanced laser desorption ionization/time-of-flight MS, and alternative predictive algorithms, to assess proteomic predictors of lung cancer risk.^24,

Best practices for peptide measurement and guidelines for publication of peptide and protein identification have been published for the research community.^25,

Table 2. Targeted Treatment Options Approved by FDA

Drug		Indication			Manufacturer	Approved		NDA/BLA
Gefitinib (Iressa®)		Monotherapy for locally advanced or metastatic NSCLC after failure of platinum-based and docetaxel chemotherapies Revised label to limit use to patients currently benefiting or previously benefited from gefitinib First-line treatment of patients with metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 (L858R) substitution variants as detected by an FDA-approved test			AstraZeneca	05/03 06/05 08/18		NDA 21-399 (Discontinued) NDA 206995 NDA 206995/S3
Erlotinib (Tarceva®)		Monotherapy for patients with locally advanced or metastatic NSCLC after failure of at least 1 prior chemotherapy regimen Maintenance therapy for patients with locally advanced or metastatic NSCLC whose disease has not progressed after 4 cycles of platinum-based first-line chemotherapy First-line treatment of patients with metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 (L858R) substitution variants as detected by an FDA-approved test Treatment of patients with metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 (L858R) substitution variants as detected by an FDA-approved test receiving first-line, maintenance, or second- or greater line treatment after progression following at least 1 prior chemotherapy regimen			OSI Pharmaceuticals and Genentech	11/04 04/10 05/13 10/16		NDA 021743 NDA 021743/S16 NDA 021743/S18 NDA 021743/S25
Afatinib (Gilotrif®)		First-line treatment of patients with metastatic NSCLC whose tumors have EGFR exon 19 deletions or exon 21 (L858R) substitution variants as detected by an FDA-approved test Treatment of patients with metastatic, squamous, NSCLC progressing after platinum-based chemotherapy Treatment of patients with NSCLC whose tumors have nonresistant EGFR variants as detected by an FDA-approved test, which includes variants other than EGFR exon 19 deletions or exon 21 (L858R) substitution variants			Boehringer Ingelheim	07/13 04/16 01/18		NDA 201292 NDA 201292/S7 NDA 201292/S14
Necitumumab (Portrazza®)		EGFR antagonist indicated, in combination with gemcitabine and cisplatin, for first-line treatment of patients with metastatic squamous NSCLC			Eli Lilly	11/15		BLA 125547
Osimertinib (Tagrisso®)		Treatment of patients with metastatic EGFR T790M variant-positive NSCLC, as detected by an FDA-approved test, who have progressed on or after EGFR TKI therapy First-line treatment of patients with metastatic NSCLC whose tumors have, as detected by an FDA-approved test, EGFR exon 19 deletions or exon 21 L858R variants			AstraZeneca	11/15 08/18		NDA 208065 NDA 208065/S11
Crizotinib (Xalkori®)		Treatment of patients with locally advanced or metastatic NSCLC that is ALK-positive as detected by an FDA-approved test Treatment of patients with metastatic NSCLC whose tumors are ROS1-positive Treatment of patients with metastatic NSCLC whose tumors are ROS1- or ALK-positive			Novartis	08/11 03/16 06/19		NDA 202570 NDA 202570/S16 NDA 202570/S28
Ceritinib (Zykadia®)		A kinase inhibitor indicated for treatment of patients with ALK-positive metastatic NSCLC who have progressed on or are intolerant to crizotinib A kinase inhibitor indicated for treatment of patients with ALK-positive metastatic NSCLC			Novartis	04/14 03/19		NDA 205755 (Discontinued) NDA 211225
Alectinib (Alecensa®)		A kinase inhibitor indicated for treatment of patients with ALK-positive metastatic NSCLC who have progressed on or are intolerant to crizotinib A kinase inhibitor indicated for treatment of patients with ALK-positive metastatic NSCLC as detected by an FDA-approved test			Hoffman-La Roche	12/15 06/18		NDA 208434 NDA 208434/S4
Brigatinib (Alunbrig®)		Treatment of patients with ALK-positive metastatic NSCLC who have progressed on or are intolerant to crizotinib			ARIAD	04/17		NDA 208772
Pembrolizumab (Keytruda®)		Treatment of patients with metastatic, PD-L1- positive NSCLC, as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy Treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥ 1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy Expansion of metastatic NSCLC indication to include first-line treatment of patients whose tumors have high PD-L1 expression (TPS ≥50%) as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations Use in combination with pemetrexed and carboplatin, for the first-line treatment of patients with metastatic nonsquamous, NSCLC			Merck	10/15 10/16 10/16 05/17		BLA 125514/S5 BLA 125514/S8 BLA 125514/S12 BLA 125514/S16
Nivolumab (Opdivo®)		Treatment of patients with metastatic NSCLC with progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving drug			Bristol-Myers Squibb	10/15		BLA 125554/S005
Atezolizumab (Tecentriq®)		Metastatic NSCLC patients who have disease progression during or following platinum-containing chemotherapy. Patients with EGFR or ALK gene tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Tecentriq.			Genentech	4/17		BLA 761034
Durvalumab (Imfinzi®)		Treatment of patients with unresectable, stage III NSCLC whose disease has not progressed following concurrent platinum-based chemotherapy and radiotherapy			AstraZeneca	02/18		BLA 761069/S-002
Dacomitinib (Vizimpro®)		First-line treatment of patients with metastatic NSCLC with EGFR exon 19 deletion or exon 21 L858R substitution variants, as detected by an FDA-approved test			Pfizer	09/18		NDA 211288
Larotrectinib (Vitrakvi®)		A kinase inhibitor indicated for the treatment of patients with solid tumors that have anNTRK gene fusion without a known acquired resistance mutation, are metastatic or where surgical resection is likely to result in severe morbidity, and have no satisfactory alternative treatments or that have progressed following treatment			Bayer	11/18		NDA 210861
Lorlatinib (Lorbrena®)		A kinase inhibitor indicated for the treatment of patients with ALK-positive metastatic NSCLC whose disease has progressed on crizotinib and at least one other ALK inhibitor for metastatic disease, or alectinib as the first ALK inhibitor for metastatic disease, or ceritinib as the first ALK inhibitor for metastatic disease			Pfizer	11/18		NDA 210868
Dabrafenib (Tafinlar®)		A kinase inhibitor indicated for the treatment of patients with metastatic NSCLC with BRAF V600E mutation as detected by an FDA-approved test			Novartis	07/19		NDA 202806/S13
Trametinib (Mekinist®)		A kinase inhibitor indicated for the treatment of patients with metastatic NSCLC with BRAF V600E mutation as detected by an FDA-approved test			Novartis	07/19		NDA 204114/S13
Entrectinib (Rozlytrek®)		A kinase inhibitor for the treatment of patients with metastatic ROS1-positive NSCLC			Genentech	08/19		NDA 212726

ALK: anaplastic lymphoma kinase; BLA: biologics license application; EGFR: epidermal growth factor receptor; FDA: Food and Drug Administration; NDA: new drug application; NSCLC: non-small-cell lung cancer; PD-L1: programmed death-ligand 1; TKI: tyrosine kinase inhibitor; TPS: Tumor Proportion Score.

Regulatory Status

Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments. The commercially available proteomic test (VeriStrat®; Biodesix) is available underthe Clinical Laboratory Improvement Amendments. Laboratories that offer laboratory-developed tests must be licensed by the Clinical Laboratory Improvement Amendments for high-complexity testing. To date, the U.S. Food and Drug Administration has chosen not to require any regulatory review of these tests.

Related Policies

• Cerebrospinal Fluid and Urinary Biomarkers of Alzheimer Disease (Policy #043 in the Pathology Section)
• Molecular Analysis for Targeted Therapy for Non-Small-Cell Lung Cancer (Policy #053 in the Pathology Section)
• Multimarker Serum Testing Related to Ovarian Cancer (Policy #046 in the Pathology Section)

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Non-Small Cell Lung Cancer

Clinical Context and Test Purpose

The purpose of proteomic testing in individuals withNSCLC who have wild-type or unknown epidermal growth factor receptor (EGFR)-variant statusis to predict expected survival when receiving standard therapies for the treatment of NSCLC. More specifically, the testing could impact the decision point for the selection of treatment based on a prediction of response to EGFRtyrosine kinase inhibitors (TKIs). That is, that the VeriStrat classification might be predictive of a differential response to EGFR TKIs.

The questions addressed in this policy are: Does proteomic testing in patients with NSCLC who have wild-type or unknown EGFR-variant statuspredict survival after receiving standard therapies , predict response to systemic therapy, and improve the net health outcome?

The following PICOswereused to select literature to inform this review.

Patients

The relevant populations of interest are patients with wild-type or unknownEGFR-variant statusNSCLC who are newly diagnosed or who have progressed after first-line treatment.

Intervention

The test being considered is management with a serum proteomic test to predict survival and select systemic therapy. The test is available commercially through a single laboratory.

Comparator

The following practice is currently being used to manage NSCLC: standard medical management. See the Background section for a discussion of standard treatment pathways, protocols, and agents.

Outcomes

The outcomes of interest are overall survival (OS) and progression-free survival (PFS). The timing of testing is prior to treatment following a new diagnosis of NSCLC or with disease progression after first-line systemic therapy.

Technically Reliable

Assessment of technical reliability focuses on specific tests and operators and requires a review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this evidence review, and alternative sources exist. This evidence review focuses on the clinical validity and clinical utility.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Proteomic Testing in NSCLC for Disease Prognosis

The largest body of evidence on the clinical validity of proteomic testing for NSCLC relates to its ability to predict disease outcomes.

No published studies were identified that assessed the use of VeriStrat proteomic testing in newly diagnosed stage I or II NSCLC.

For individuals with newly diagnosed advanced NSCLC without prior systemic therapy, multiple studies (Taguchi et al [2007],^15, Amann et al [2010],^26, Kuiper et al [2012],^27, Akerley et al [2013],^28, Gautschi et al [2013],^29, Stinchcombe et al [2013],^30, Grossi et al [2017]^31,, Grossi et al [2018]^32,, Lee et al [2019]^33,) have assessed the use of VeriStrat score (good or poor) as a prognostic test to discriminate between OS (primary outcome) and PFS (secondary outcome) outcomes. Most studies were retrospective and intended to validate the extent to which the VeriStrat proteomic classification correlated with OS or PFS. Grossi et al (2017) was an observational nonrandomized study with prospective sample collection for proteomic testing before NSCLC treatment and reported PFS as the primary outcome.^31, This is the only study that included a first-line treatment consistent with current guidelines-based recommendations; platinum-doublet-based chemotherapy with cisplatin or carboplatin in combination with pemetrexed.

A summary ofthecharacteristics and results of thesestudies is presented in Tables 3 and 4.

The VeriStrat classification was not used to direct the selection of treatment in any of the clinical trials from which the validation samples were derived. Testing for the presence of a sensitizing variant (EGFR) for targeted therapy with TKIs was variably performed in these studies. When testing was performed and results known as wild-type (negative) or positive, the analysis of OS and PFS was variably adjusted for variant status. The relationship between VeriStrat classification and OS and PFS in populations with unknown variant status, when reported, was not analyzed. Disposition of populations with variant status “not reported” was generally not clear and could not be construed as “unknown” when wild-type or positive variant status was reported.

For individuals with advanced NSCLC who had recurrent disease or who had failed prior systemic therapy, multiple studies assessed the use of VeriStrat as a prognostic test to discriminate between good and poor survival outcomes (Taguchi et al [2007],^15, Carbone et al [2010],^34, Keshtgarpour et al [2016],^16, Spigel et al [2018]^32,). All studies were retrospective and intended to validate the extent to which VeriStrat proteomic classification correlated with OS or PFS. The VeriStrat classification was not used to direct the selection of treatment in any of the clinical trials from which the validation samples were derived. None of the trials from which the samples for VeriStrat proteomic classification were derived used a therapy consistent with current guidelines-based recommendations. The populations in all studies were unselected for EGFR-variant status.

A summary ofthecharacteristics and results of these studies is presented in Tables 3 and 4.

Grossi et al (2018) conducted a retrospective study that combined samples from 3 separate cohorts of treatment-naive recurrent or advanced NSCLC patients who received platinum-based chemotherapy.^35, One cohort, identified as Italian, is duplicative of the population reported in Grossi et al (2017).^31, The NExUS and eLung cohorts reported data that is only referenced in abstracts in Grossi et al (2018) and, thus, is of limited value to the evidentiary appraisal of VeriStrat classification. The data imported into the publication for the PFS outcome showed that the median PFS of 5.7 months for VeriStrat “good” is included in the outer bound of the confidence interval (CI) for VeriStrat “poor” in the NExUS cohort. The median PFS of 5.1 months for VeriStrat “good” is included within the CI of VeriStrat “poor” in the eLung cohort. A summary of the study characteristics and results of this study is presented in Tables 3 and 4. Appendix Table 1 summarizes the treatment regimens used in Grossi et al (2018). As noted, only the Italian cohort included from Grossi et al (2017) represents current approaches to treatment.Cetuximab does not have an established role in the treatment of NSCLC either as a component of initial therapy or as second-line therapy.

While most of the literature has focused on the use of matrix-assisted laser desorption ionization (MALDI) mass spectrometry (MS) techniques and predictive algorithms similar to those used in the VeriStrat assay, other MS techniques,and predictive algorithms have been investigated. Jacot et al (2008) used surface-enhanced laser desorption ionization/time-of-flight MS technology in combination with a predictive algorithm to discriminate between malignant and benign disease and between good and poor outcomes.^24, Using data from a population of 87 patients with stage III or IV NSCLC receiving conventional first-line chemotherapy and with at least 1-year follow-up available, the authors developed a predictive survival classifier to differentiate between poor prognosis (n=33; OS <12 months) and good prognosis (n=54; OS >12 months). In the multivariate analysis, the proteomic-based predictor was significantly associated with OS (hazard ratio [HR], 3.45; 95% CI, 1.22 to 6.13; p<0.001).

The purpose of the limitations tables (see Tables 5 and 6) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

The characteristics and results of additional studies using non-VeriStrat proteomic assays are summarized in Table 7.

Table 3. Clinical Validity Study Characteristics of Proteomic Testing in NSCLC for Disease Prognosis

Study	Study Type	N	Population				Selection Criteria	Participant Disposition
VeriStrat-specific studies
Taguchi et al (2007)15,,b Italian B validation set	Retrospective	67	Sequential cohort of late-stage or recurrent NSCLC treated with single-agent gefitinib used as VS algorithm validation set. Stage IIIA: 2 (3%) Stage IIIB: 5 (7.4%) Stage IV: 58 (86.6%) Postoperative recurrence: 0				ECOG PS: 29.8% grade 0; 46.3% grade 1; 23.9% grade 2 Histology: 56.7% adeno; 22.4% squamous; 20.9% NOS	2 (3%) had stage IIA disease
			Previous Chemotherapya		n (%)
			0		13 (19.4)
			1		26 (38.9)
			2		15 (22.4)
			≥3		4 (6.0)
Taguchi et al (2007)15,ECOG 3503 validation set	Retrospective	96	ECOG 3503 single-arm phase 2 trial of first-line erlotinib in patients with stage IIIB or IV or recurrent NSCLC used as VS algorithm validation set. Stage IIIA: 0 Stage IIIB: 9 (9.4%) Stage IV: 67 (69.8%) Postoperative recurrence: 20 (20.8%)				ECOG PS: 30.2% grade 0; 43.8% grade 1; 26.0% grade 2 Histology: 64.6% adeno; 11.5% squamous; 1% LCC; 22.9% NOS	20 (20.8%) had postoperative occurrence
			Previous Chemotherapya	n (%)
			0	96 (100)
Amann et al (2010)26,,b	Retrospective	88	Sample of ECOG 3503 trial patients (enrolled 137) with stage IIIB or IV or recurrent NSCLC in phase 2 single-arm treatment with first-line erlotinib				ECOG PS: 28.4% grade 0; 46.1% grade 1; 25.5% grade 2 Histology: 64.7% adeno; 10.8% squamous; 1% LCC; 16.7% NOS; 6.9% other	102 analyzable pretreatment biologic samples Missing values: 14 (16%) VS score EGFR exon 19 status: 61 (60%) EGFR exon 21 status: 61 (60%) No EGFR exon 19-positive samples
Carbone et al (2010)34,,b; Herbst et al (2005)36,	Retrospective	35	Sample of phase 1/2 stage IIIB or IV (n=40): phase 1 (n=12), phase 2 (n=28) recurrent, nonsquamous NSCLC treated with open-label erlotinib and bevacizumab 22 (55%) had ≥2 prior chemotherapy regimens				KPS: 7.5% KPS 70%; 47.5% KPS 80%; 45% KPS 90% Histology: 75% adeno; 22.5% NOS; 2.5% other	35 available pretreatment samples with associated clinical data
Kuiper et al (2012)27,,b	Retrospective	50	Sample of chemotherapy-naive patients (n=50) with pathologically documented, inoperable, locally advanced, recurrent, or metastatic NSCLC; single-arm phase 2 treated with erlotinib and sorafenib				ECOG PS: 40% grade 0; 60% grade 1 Histology: 68% adeno; 32% other	VS score not available or indeterminate (n=2) EGFR status: (31) 62% WT; (7) 14% variant positive; 12 (24%) unknown
Akerley et al (2013)28,,b	Retrospective	42	Sample of stage IIIB or IV or recurrent nonsquamous NSCLC, with no prior chemotherapy for metastatic disease (n=40), treated with erlotinib and bevacizumab; PET and serum biomarker ancillary study (n=10)				ECOG PS: 26% grade 0; 74% grade 1 Histology: 48% adeno; 48% NOS; 4% other	Previously treated brain metastases allowed in expanded cohort Participant accrual (n=20) prior to interim safety analysis; additional 20 participants accrued after safety threshold of PFS at 6 mo exceeded 42 VS assays performed on pretreatment sera 28 patients received cytotoxic chemotherapy after study therapy
Gautschi et al (2013)29,,b	Retrospective	117	Pooled analysis of patients (158 enrolled) from SAKK19/05 (n=101) and NTR528 trials (n=47): untreated, advanced nonsquamous NSCLC, treated with first-line therapy using erlotinib and bevacizumab				ECOG PS: 52.9% grade 0; 42.5% grade 1; 4.6% grade 2 Histology: 89.7% adeno; 10.2% other	117 pretreatment frozen serum available for VS (SAKK19/05, n=88; NTR528, n=29) SAKK19/05: EGFR variant status: positive identification but data NR NTR528: EGFR variant status: NR
Stinchcombe et al (2013)30,,b	Retrospective	98	Sample from noncomparative randomized phase 2 trial of first-line treatment for stage IIIB or IV NSCLC: Arm A (gemcitabine) Arm B (erlotinib) or Arm C (gemcitabine and erlotinib)				Age: ≥70 y ECOG PS: 0-2 Histology: unselected	Treatment arm assignments stratified for sex, smoking history (never or light vs current or former use), and PS 146 eligible patients received protocol therapy 124 samples available for VS 14 samples unevaluable 110 samples assayed
Keshtgarpour et al (2016)16,	Retrospective	49	Advanced-stage squamous and nonsquamous NSCLC medical record review at a single clinic (62 patients identified). Determine use of VS in African Americans Determine relation between of VS and comorbidities using CCI				Baseline histology and PS not reported	49 cases qualified for inclusion VS pretreatment: 31 VS during or after first-line chemotherapy
Grossi et al (2017)31,,b	Prospective	76	Clinically based stage IIIB NSCLC with supraclavicular lymph node metastases, or stage IV or recurrent NSCLC, chemotherapy-naive To be treated with platinum doublet chemotherapy: pemetrexed plus carboplatin or cisplatin				ECOG PS: 26% grade 0; 71% grade 1; 3% grade 2 Histology: 100% nonsquamous	105 participants enrolled 89 with nonsquamous histology included 15 with squamous histology and 1 with small cell lung cancer excluded 6 additional patients ineligible (no treatment, consent, had surgery) 83 eligible for VS 7 did not receive VS Choice of chemotherapy regimen at physician discretion based on age, ECOG PS, creatinine clearance
Grossi et al (2018)35,,b	Retrospective	481	3 cohorts (NExUS, Italian, eLung) of treatment-naive recurrent or advanced NSCLC patients who received platinum-based chemotherapy NExUS cohort: prospective RCT of gemcitabine plus cisplatin and sorafenib vs gemcitabine plus cisplatin and placebo Italian: clinically-based cohort treated with platinum-doublet chemotherapy eLung: multicenter randomized phase 2b study of cetuximab plus platinum-based chemotherapy as first-line treatment. Arm A: carboplatin plus paclitaxel and cetuximab then maintenance cetuximab Arm B: carboplatin or cisplatin (investigator choice) plus gemcitabine and cetuximab then maintenance cetuximab Arm C: carboplatin or cisplatin (investigator choice) plus pemetrexed and cetuximab then maintenance cetuximab Arm C limited to squamous histology Delivery of 4, 5, or 6 cycles of chemotherapy atinvestigator discretion				NExUS: stage IIIB or IV NSCLC ECOG PS: 0/1 Histology: NR Italian: stage IIIB NSCLC with supraclavicular lymph node metastases, or stage IV or recurrent NSCLC Histology:100% nonsquamous (Grossi et al [2017]) eLung ECOG PS: 0/1 Histology: nonsquamous and squamous	NExUS: Baseline plasma samples 419 of 722 nonsquamous participants available for VS assay Italian: 105 participants enrolled 89 with nonsquamous histology included 15 with squamous histology and 1 with small cell lung cancer excluded 6 additional patients ineligible (no treatment, consent, had surgery) 83 eligible for VS 7 did not receive VS eLung: 206 of 601 participants had serum available for VS 203 VS performed
			Previous Chemotherapy a				n (%)
			1				119 (62%)
			2				73 (38%)
Spigel et al (2018)32,	Retrospective	192	Sample from RCT of treatment for stage IV NSCLC following 1-2 chemotherapy regimens Arm A (erlotinib plus pazopanib) or Arm B (erlotinib plus placebo)				Age: 35-88 y ECOG PS: 0-2 Histology: nonsquamous and squamous	Treatment arm assignments stratified for histology and prior exposure to bevacizumab 190 eligible patients received protocol therapy 93 samples available for VS 2 samples unevaluable 88 samples assayed

adeno: adenocarcinoma; CCI: Charleston Comorbidity Index; ECOG: European Cooperative Oncology Group; EGFR: epidermal growth factor receptor; KPS: Karnofsky Performance Status; LCC: large cell carcinoma; NOS: not otherwise specified; NR: not reported; NSCLC: non-small-cell lung cancer; PET: positron emission tomography; PFS: progression-free survival; PS: Performance Status; RCT: randomized controlled trial; VS: VeriStrat; WT: wild-type.

^a Number of prior chemotherapy regimens.

^b Industry sponsorship or collaboration.

Table 4. Clinical Validity Study Results of Proteomic Testing in NSCLC for Disease Prognosis

Study	Study Type	N	Patient Population	Summary of Outcomes: OS for "Good" vs "Poor" Assay (95% CI)	Summary of Outcomes: PFS for "Good" vs "Poor" Assay (95% CI)
VeriStrat-specific studies
Taguchi et al (2007)15, Italian B validation set	Retrospective	67	Sequential cohort of late-stage or recurrent NSCLC treated with single-agent gefitinib: VS "good": 39 (58.3%) VS "poor": 27 (40.3%) VS undefined: 1	Unadjusted HR of death, 0.50 (0.24 to 0.78; p=0.005) Adjusteda HR of death, 0.74 (0.55 to 0.99; p=0.048)	Unadjusted TTP: HR=0.56 (0.28 to 0.89; p=0.02)
Taguchi et al (2007)15, ECOG 3503 validation set	Retrospective	96	ECOG 3503 single-arm, phase 2 trial of first-line erlotinib in patients with stage IIIB or IV or recurrent NSCLC: VS "good": 69 (71.9%) VS "poor": 27 (28.1%) VS undefined: 0	Unadjusted HR of death, 0.4 (0.24 to 0.70; p<0.001) Adjustedb HR of death, 0.53 (0.30 to 0.94; p=0.03)	Unadjusted TTP: HR=0.53 (0.33 to 0.85; p=0.007)
Amann et al (2010)26,		88	VS "good" (n=64),VS “poor” (n=24) EGFR exon 19 WT: 41 EGFR exon 19-positive: none identified EGFR exon 21 WT: 38 EGFR exon 21-positive: 3 EGFR exon 21-positive and VS “good”: 2 EGFR exon 21-positive and VS “poor”: 1	Unadjusted HR of death, 0.36 (0.21 to 0.60; p=0.001) Adjusted (for EGFR status) HR of death, 0.26 (0.06 to 1.16; p=0.08)	Unadjusted TTP: HR=0.51 (0.28 to 0.90; p=0.02)
Carbone et al (2010)34,	Retrospective	35	Treatment-experienced recurrent stage IIIB or IV, nonsquamous NSCLC treated with erlotinib and bevacizumab enrolled in a phase 1 dose-finding and phase 2 efficacy and tolerability study: VS "good": 26 VS “poor”: 8	Unadjusted HR of death (61 wk vs 24 wk), 0.14 (0.03 to 0.58)	Unadjusted PFS (36 wk vs 8 wk): HR=0.045 (0.008 to 0.237)
Kuiper et al (2012)27,	Retrospective	50	Chemotherapy-naive patients with pathologically documented, inoperable, locally advanced, recurrent, or metastatic NSCLC, treated with erlotinib and sorafenib VS classification was performed at 3 time points (pretreatment, 1 and 3 wk after initiation therapy) Pretreatment VS "good" (n=33), VS "poor" (n=15): EGFR WT: 31 EGFR-positive: 7 EGFR unknown: 12	Unadjusted using pretreatment classification only HR for OS=0.30 (0.12 to 0.74; p=0.009) Median OS=13.7 mo (12 mo to undefined) for VS “good” and 5.6 mo (1.6 to 7.6 mo) for VS “poor”	Unadjusted using pretreatment classification only PFS: HR=0.40 (0.17 to 0.94; p=0.035) Median PFS=5.5 mo (3.0 to 6.9 mo) for VS “good” vsand 2.7 mo (1.4 to 5.6 mo) for VS “poor”
Akerley et al (2013)28,	Retrospective	42	Stage IIIB or IV or recurrent nonsquamous NSCLC, with no prior chemotherapy for metastatic disease, treated with erlotinib and bevacizumab: VS "good": 32 (76%) VS "poor": 9 (21%) VS indeterminate: 1 (2%)	Unadjusted on study therapy · HR for OS=0.27 (0.11 to 0.64) · Median OS=71.4 wk vs VS “good” and 19.9 wk for VS “poor” (p=0.002)	Unadjusted on study therapy · Median PFS=18.9 wk VS “good” vs 6.3 wk VS “poor” (p=0.004) Study therapy plus chemotherapy · Median PFS=43.9 wk for VS “good” and 6.3 wk for VS “poor” (p<0.001)
Gautschi et al (2013)29,	Retrospective	117	Pooled analysis from SAKK19/05 and NTR528 trials: untreated, advanced nonsquamous NSCLC, treated with first-line therapy with erlotinib and bevacizumab: VS "good": 87 (SAKK19/05, n=70; NTR528, n=17) VS "poor": 27 (SAKK19/05, n=16; NTR528, n=11) SAKK19/05: EGFR variant status: positive identification but data NR NTR528: EGFR variant status: NR	Unadjusted · HR=0.48 (0.29 to 0.78; p=0.003) · Median OS=13.4 mo for VS “good” and 6.2 mo for VS “poor”	Unadjusted · PFS: HR=0.768 (0.482 to 1.22; p=0.253) · Median PFS=4 mo for VS “good” vs 3.2 mo for VS “poor”
Stinchcombe et al (2013)30,	Retrospective	98	110 samples VS assayed: VS "good": 64 VS "poor": 39 VS Indeterminate: 7 (5 samples could not be matched with clinical data VS "good": 1 and VS "poor": 4) VS results matched with clinical data: VS "good": 63 VS "poor": 35 Arm A (gemcitabine): VS "good": 20 VS "poor": 8 12 of 28 also received erlotinib as second-line therapy on protocol in absence of disease progression or unacceptable toxicity Arm B (erlotinib): VS "good": 26 VS "poor": 12 14 of 38 received second-line therapy (type NR) off protocol Arm C (gemcitabine and erlotinib): VS "good": 17 VS "poor": 15 13 of 32 received second-line therapy (type NR) off protocol	Unadjusted Arm A · HR=0.82 (0.35 to 1.90; p=0.64) · Median OS=201 d for VS “good” vs 197 d for VS “poor” Unadjusted Arm B · HR=0.40 (0.19 to 0.86; p=0.014) · Median OS=255 d for VS “good” vs 51 d for VS “poor” Unadjusted Arm C · HR= 0.48 (0.23 to 1.02; p=0.051) · Median OS=302 d for VS “good” vs 106 d for VS “poor” Adjusted e · HR=0.53 (0.32 to 0.90; p=0.017)	Unadjusted Arm A · HR=1.21 (0.51 to 2.88; p=0.67) · Median PFS=133 d for VS “good” vs 137 d for VS “poor” Unadjusted Arm B · HR=0.33 (0.16 to 0.70; p=0.002) · Median PFS=89 d for VS “good” vs 22 d for VS “poor” Unadjusted Arm C · HR=0.42 (0.19 to 0.93; p=0.027) · Median PFS=122 d for VS “good” vs 89 d for VS “poor” Adjusted e · HR=0.51 (0.30 to 0.86; p=0.011)
Keshtgarpour et al (2016)16,	Retrospective	49	Advanced-stage squamous and nonsquamous NSCLC seen at a single clinic: VS "good": 32 VS "poor": 16 VS indeterminate: 1	Unadjusted for CCI · HR=0.97 (0.48 to 1.97; p=0.94) CCI adjusted model · HR=0.80 (0.39 to 1.64; p=0.54) VS “poor” on erlotinib vs chemotherapy, CCI adjusted · HR=9.48 (1.27 to 70.81; p=0.03)
Grossi et al (2017)31,	Prospective	76	Stage IIIB NSCLC with supraclavicular lymph node metastases, or stage IV or recurrent NSCLC, chemotherapy-naive treated with platinum doublet chemotherapy Carboplatin plus pemetrexed (n=43; median age, 57 y) Cisplatin plus pemetrexed (n=33; median age, 70 y) VS “good”: 50 VS "good": carboplatin/pemetrexed: 28 VS "good": cisplatin/pemetrexed: 22 VS "poor": 26 VS "poor": carboplatin/pemetrexed:15 VS "poor": cisplatin/pemetrexed: 11 TKI-sensitizing variant status results: EGFR WT: 67 (88%) EGFR-negative: 2 (3%) EGFR unknown: 7 (9%) ALK translocation negative: 54 (71%) ALK translocation positive: 1 (1%) ALK translocation unknown: 21 (28%) KRAS WT: 31 (41%) KRAS-positive: 29 (38%) KRAS unknown: 16 (21%)	Unadjusted secondary outcome in study · HR=0.26 (0.15 to 0.47; p<0.001) · Median OS=10.8 mo for VS “good” vs 3.4 mo for VS “poor” Unadjusted secondary outcome based on treatment-defined group · Carboplatin plus pemetrexed vs cisplatin plus pemetrexed: o HR=1.64 (0.96 to 2.82; p=0.070) o Median OS carboplatin plus pemetrexed, 6.0 mo (954.2 to 10.0 mo) vs cisplatin plus pemetrexed 10.3 mo (6.6 to 17.9 mo) · Carboplatin plus pemetrexed VS “good” vs VS “poor”: o HR=0.26 (0.12 to 0.55; p<0.001) o Median OS=9.4 mo (5.0 to 15.3 mo) for VS “good” vs 3.4 mo (1.0 to 4.3 mo) for VS “poor · Cisplatin plus pemetrexed VS “good” vs VS “poor”: o HR=0.25 (0.10 to 0.62; p=0.001) o Median OS=17.7 mo (9.9 to 24.19 mo) for VS “good” vs 4.2 mo (2.6 to 8.9 mo) for VS “poor” Adjustedc · HR=0.23 (0.12 to 0.44; p<0.001) Adjustedd · HR=0.23 (0.11 to 0.46; p<0.001)	Unadjusted primary outcome in study · HR=0.36 (0.22 to 0.61; p<0.001) · Median PFS=6.5 mo for VS “good” vs 1.6 mo for VS “poor” Unadjusted primary outcome based on treatment-defined group · Carboplatin plus pemetrexed vs cisplatin plus pemetrexed: o HR=1.59 (0.97 to 2.61; p=0.063) o Median PFS carboplatin plus pemetrexed, 2.8 mo (2.0 to 4.0 mo) vs cisplatin plus pemetrexed 5.7 mo (3.8 to 8.8 mo) · Carboplatin plus pemetrexed VS “good” vs VS “poor”: o HR=0.30 (0.14 to 0.62; p<0.001) o Median PFS=3.8 mo (2.7 to 8.7 mo) for VS “good” vs 1.6 mo (1.0 to 2.5 mo) for VS “poor · Cisplatin plus pemetrexed VS “good” vs VS “poor”: o HR=0.39 (0.18 to 0.85; p=0.014) o Median PFS=7.9 mo (5.2 to 13.1 mo) for VS “good” vs 1.7 mo (1.1 to 3.9 mo) for VS “poor Adjustedc · HR=0.32 (0.18 to 0.58; p<0.001) Adjustedd · HR=0.39 (0.22 to 0.71; p=0.002)
Grossi et al (2018)35,		481	NExUS: VS assay: 202 patients in gemcitabine/cisplatin/placebo arm: · VS “good”: 136 · VS “poor”: 66 Italian: VS assay: 76 patients pemetrexed plus carboplatin or cisplatin: · VS “good”: 50 · VS “good”: carboplatin plus pemetrexed: 28 · VS “good”: cisplatin plus pemetrexed: 22 · VS “poor”: 26 · VS “poor”: carboplatin plus pemetrexed: 15 · VS “poor”: cisplatin plus pemetrexed: 11 eLung: VS assay: 203 · VS “good”: 142 · VS “good”: carboplatin plus paclitaxel and cetuximab: 52 · VS “good”: carboplatin or cisplatin plus gemcitabine and cetuximab: 56 · VS “good”: carboplatin or cisplatin plus pemetrexed and cetuximab :34 · VA “poor”: 61 · VS “poor”: carboplatin plus paclitaxel and cetuximab:27 · VS “poor”: carboplatin or cisplatin plus gemcitabine and cetuximab: 26 · VS “poor”: carboplatin or cisplatin plus pemetrexed and cetuximab: 8	Unadjustedsecondary outcome in NExUS study · HR=0.41 (0.30 to 0.58; p<0.001) · Median OS=14.7 mo (12.5 to 16.9 mo) for VS “good” vs 6.3 mo (5.6 to 8.1 mo) for VS “poor” Unadjustedsecondary outcome in Italian study · HR=0.26 (0.15 to 0.47; p<0.001) · Median OS=10.8 mo (7.8 to 17.7 mo) for VS “good” vs 3.4 mo (2.4 to 4.3 mo) for VS “poor” Unadjustedsecondary outcome in eLung study · HR=0.51 (0.37 to 0.71; p<0.001) · Median OS=10.9 mo (9.5 to 12.9 mo) for VS “good” vs 6.4 mo (4.0 to 9.0 mo) for VS “poor”	Unadjustedprimary outcome in NExUS study · HR=0.51 (0.37 to 0.71; p<0.001) · Median PFS=5.7 mo (5.5 to 6.9 mo) for VS “good” vs 4.6 mo (4.1 to 5.7 mo) for VS “poor” Unadjustedprimary outcome in Italian study · HR=0.36 (0.22 to 0.61; p<0.001) · Median PFS=6.5 mo (3.9 to 8.8 mo) for VS “good” vs 1.6 mo (1.1 to 2.5 mo) for VS “poor” Unadjustedprimary outcome in eLung study · HR=0.72 (0.53 to 0.97) · Median PFS=5.1 mo (4.2 to 5.7 mo) for VS good” vs3.6 mo (2.7 to 5.3 mo) for VS “poor”
Spigel et al (2018)32,	Retrospective	88	Stage IV NSCLC, with prior chemotherapy · VS “good”: 63 · VS “good”: erlotinib plus placebo: 23 · VS “good”: erlotinib plus pazopanib: 40 · VS “poor”: 25 · VS “poor”: erlotinib plus placebo: 8 · VS “poor”: erlotinib plus pazopanib: 17	Unadjusted secondary outcome · HR=0.42 (0.26 to 0.69; p<0.001) · Median OS=8.6 mo (6.6 to 11.6 mo) for VS “good” vs 2.8 mo (1.4 to 4.9 mo) for VS “poor” Unadjusted secondary outcome based on VS-defined groups · VS “good” o HR=1.02 (0.58 to 1.81; p=0.934) o Median PFS: erlotinib plus pazopanib, 8.2 mo (5.4 to 12.4 mo) vs erlotinib plus placebo, 8.6 mo (5.1 to 13.9 mo) o VS “poor” o HR=2.10 (0.83 to 5.26; p=0.1089) o Median PFS: erlotinib plus pazopanib, 2.8 mo (1.2 to 4.7 mo) vs erlotinib plus placebo, 7.5 mo (0.9 to 16.8 mo)	Unadjusted primary outcome · HR=0.44 (0.26 to 0.73; p < 0.001) · Median PFS=2.1 mo (1.8 to 3.6 mo) for VS “good” vs 1.8 mo (1.4 to 2.2 mo) for VS “poor” Unadjusted primary outcome based on VS-defined groups · VS “good” o HR=0.47 (0.26 to 0.86; p=0.010) o Median PFS: erlotinib plus pazopanib, 3.6 mo (1.8 to 4.1 mo) vs erlotinib plus placebo, 1.8 mo (1.7 to 2.5 mo) o VS “poor” o HR=0.87 (0.37 to 2.05; p=0.745) o Median PFS: erlotinib plus pazopanib, 1.8 mo (1.0 to 2.5 mo) vs erlotinib plus placebo, 1.7 mo (0.8 to 2.8 mo)

ALK: anaplastic lymphoma kinase; CI: confidence interval; CCI: Charleston Comorbidity Index; ECOG: European Cooperative Oncology Group; EGFR: epidermal growth factor receptor; HR: hazard ratio; NR: not reported; NSCLC: non-small-cell lung cancer; OS: overall survival; PFS: progression-free survival; TKI: tyrosine kinase inhibitor; TTP: time to progression; VS: VeriStrat; WT: wild-type.

^a Adjusted based on age, performance status, sex, histology, smoking history, and MALDI-MS classification.

^b Adjusted based on age, number of involved sites, prior weight loss, histology, and MALDI-MS classification.

^c Adjusted based on clinical characteristics: VS classification, sex, smoking status (ever vs never), ECOG PS (≥1 vs 0), KRAS status (mutant vs WT or unknown), KRAS (known vs unknown), maintenance (yes vs no).

^d Adjusted based on clinical characteristics and treatment: VS classification, sex, cisplatin/pemetrexed vs carboplatin/pemetrexed smoking status (ever vs never), ECOG PS (≥1 vs 0), KRAS status (mutant vs WT or unknown), KRAS (known vs unknown), maintenance (yes vs no).

^e Adjusted for VS status, histology (other histologies vs adenocarcinoma), race (nonwhite vs white), sex (female vs male), treatment arm (erlotinib vs gemcitabine), treatment arm (gemcitabine/erlotinib vs gemcitabine), smoking history (never vs ever), PS (2 vs 0 or 1), stage IV vs IIIB.

Table 5. Clinical Validity Relevance Limitations for Proteomic Testing in NSCLC for Disease Prognosis

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of FUe
Taguchi et al (2007)15, Italian B validation set	1. Population unselected for EGFR variant status	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Taguchi et al (2007)15, ECOG 3503 validation set	1. Population unselected for EGFR variant status 2. 20 (20.8%) of participants had postoperative recurrence, which may be an indicator of earlier stage at diagnosis	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Amann et al (2010)26,	1. EGFR variant status unknown excluded 4. Use of erlotinib (or other TKIs) in EGFR variant-negativepopulation no longer accepted treatment approach 5. 90 (88.2%) with multisite metastatic disease; 55 (54%) had prior radiotherapy or surgery	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Carbone et al (2010)34,	1. No determination of EGFR variant status 4. Study population participating in phase 1/2 study 4. Use of erlotinib (or other TKIs) in EGFR variant-negativeor -unknown population no longer accepted treatment approach 4. Use of combination EGFR (erlotinib) and VEGF inhibition (bevacizumab) not currently accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Kuiper et al (2012)27,	4. Use of erlotinib (or other TKIs) in EGFR variant-negativeor -unknown population no longer accepted treatment approach 4. Use of combination EGFR (erlotinib) and VEGF inhibition (sorafenib) not currently accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. A typical clinical assessment tool used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway No outcome reported for EGFR variant status unknown
Akerley et al (2013)28,	Participants might have received prior adjuvant chemotherapy 4. Use of combination EGFR (erlotinib) and VEGF inhibition (bevacizumab) not currently accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy 3.Survival of participants without VeriStrat assay reported as not different but no data provided
Gautschi et al (2013)29,	4. Use of combination EGFR (erlotinib) and VEGF inhibition (bevacizumab) not currently accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Stinchcombe et al (2013)30,	1. Population unselected for EGFR variant status 2. Participants in 2 arms received treatment off protocol 4.Use of erlotinib (or other TKIs) in EGFR variant-negative or -unknownpopulation no longer accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1.VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway
Keshtgarpour et al (2016)16,	1.No determination of EGFR variant status 1. Participants may have received prior first-line chemotherapy 4. Use of erlotinib (or other TKIs) in EGFR variant-negative or -unknownpopulation no longer accepted treatment approach	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	Other related: Decision model based on outdated clinical pathway
Grossi et al (2017)31,	3. Median age (57 y) of patients in cisplatin plus pemetrexed arm significantly younger than median age (70 y) in carboplatin plus pemetrexed arm	Other related: Identity of proteins that make up the MALDI-MS features still being investigated at time of publication	3. Clinical assessment of prognosis not used	1. VeriStrat classification not used to direct therapy 2. Inclusion of KRAS variant/exclusion of EGFR and ALK testing results in adjusted analyses appears to be potential new decision model Other related: No outcome reported for EGFR variant status unknown No outcomes reported for EGFRwild-type No outcomes reported for ALK variant status Range of values for median OS and PFS not reported in this publication but reported in Grossi et al (2018)
Grossi et al (2018)35,	1.NExUS cohort reference is abstract only 1.eLung cohort reference is abstract only 2.NExUS cohort reference is abstract only 2.eLung cohort reference is abstract only 4.eLung cohort results based on treatment (cetuximab) not currently used for first- or second-line NSCLC	Other related: Identity of the proteins that make up the MALDI-MS features still being investigated at the time of publication		1. VeriStrat classification not used to direct therapy Other related: Decision model based on outdated clinical pathway in NExUS and eLung cohorts
Spigel et al (2018)32,	1.No determination of EGFR variant status 4. Use of erlotinib (or other TKIs) in EGFR variant -negative or -unknownpopulation no longer accepted treatment approach	Other related: Identity of the proteins that make up the MALDI-MS features still being investigated at the time of publication		1. VeriStrat classification not used to direct therapy

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.

ALK: anaplastic lymphoma kinase; EGFR: epidermal growth factor receptor; FU: follow-up; MALDI-MS: matrix-assisted laser desorption ionization mass spectrometry; NSCLC: non-small-cell lung cancer; OS: overall survival; PFS: progression-free survival; TKI: tyrosine kinase inhibitor;VEGF: vascular endothelial growth factor.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.

^b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.

^c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.

^d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).

^e Follow-Up key: 1. Follow-up duration not sufficient with respect tonatural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).

Table 6. Clinical Validity Study Design and Conduct Limitations for Proteomic Testing in NSCLC for Disease Prognosis

Study	Selectiona	Blindingb	Delivery of Testc	Selective Reportingd	Data Completenesse	Statisticalf
Taguchi et al (2007)15, Italian B validation set	2. Selection not random or consecutive (ie, convenience)				Other related: · Variable response assessment times and intervals	Other related: · Sample sizes small · Impacts test of difference in multivariate analysis
Taguchi et al (2007)15, ECOG 3503 validation set	2. Selection not random or consecutive (ie, convenience)					Other related: · Sample sizes small · Impacts test of difference in multivariate analysis
Amann et al (2010)26,	2. Selection not random nor consecutive (ie, convenience)		Other related: · Proteomic testing not applied to EGFR variant status unknown population		Other related: · Variable response assessment times and intervals	Other related: · Confidence that the proteomic classifier is independent of EGFR variant status is limited by very small number of positive variants · Small sample sizes · Unadjusted for demographic and histologic characteristics associated with prognosis · Small sample sizes
Carbone et al (2010)34, Herbst et al (2005)36,	2.Selection not random or consecutive (ie, convenience)				Other related: · Variable response assessment times and intervals	1. p-value not reported Other related: · Sample sizes small · Unadjusted for demographic and histologic characteristics associated with prognosis
Kuiper et al (2012)27,	2. Selection not random or consecutive (ie, convenience)		3. VeriStrat classification performed at 3 time points (pretreatment, 1 and 3 wk after initiation therapy)		Other related: · Variable response assessment times and intervals	Other related: · Sample sizes small · Unadjusted for demographic and histologic characteristics associated with prognosis
Akerley et al (2013)28,	2. Selection not random or consecutive (ie, convenience)				Other related: · Variable response assessment times and intervals	Other related: · Small sample sizes
Gautschi et al (2013)29,	2. Selection not random or consecutive (ie, convenience)				Other related: · Variable response assessment times and intervals	Other related: · Small sample sizes · OS (primary outcome) and PFS (secondary outcome) data not shown for reported multivariate analysis or stratification by trial · Adjusted analysis (sex, age, histology, disease stage, PS, smoking status) reported as no significant association between VeriStrat and tumor variant status; data not shown
Stinchcombe et al (2013)30,	2.Selection not random or consecutive (ie, convenience)				Other related: · Variable response assessment times and intervals	Other related: · Small sample sizes
Keshtgarpour et al (2016)16,	2.Selection not random or consecutive (ie, convenience)		Other related · Pre- and posttreatment VeriStrat scores used		Other related: · Variable response assessment times and intervals	Other related: · Small sample sizes · VeriStrat indeterminate case added to VeriStrat “good” data pool
Grossi et al (2017)31,	2. Participant recruitment not random from single lung cancer treatment unit				Other related: · Variable response assessment times and intervals	Other related: · Adjusted analyses for PFS and OS did not include age or other sensitizing variants (EGFR, ALK) although data reported · Overall sample sizes small · Slow accrual · Number of EGFR variant-positive and ALK translocation findings too small to assess correlation with VeriStrat classification
Grossi et al (2018)35,	2. Participant selection differs between and among cohorts			2. VeriStrat classification results for 2 of 3 cohorts imported from abstract sources	Other related: · Variable response assessment times and intervals	Other related: · Small sample sizes
Spigel et al (2018)32,	2.Selection not random or consecutive (ie, convenience)					Other related: Unadjusted for demographic and histologic characteristics associated with prognosis

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
ALK: anaplastic lymphoma kinase; EGFR: epidermal growth factor receptor; OS: overall survival; PFS: progression-free survival; PS: performance status.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).

^b Blinding key: 1. Not blinded to results of reference or other comparator tests.

^c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.

^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.

^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Table 7. Clinical Validity Results of Proteomic Testing in NSCLC for Disease Prognosis Non-VeriStrat Assays

Study	Study Type	N	Population	Summary of Outcomes: OS for “Good” vs “Poor” Assay (95% CI)	Summary of Outcomes: PFS for “Good” vs “Poor” Assay (95% CI)
Salmon et al (2009)37, Erlotinib/ bevacizumab generation setc	Retrospective	35	Stage IIIB or IV, recurrent, nonsquamous NSCLC treated with erlotinib and bevacizumab	Adjusted a · HR of death, 1.024 (1.009 to 1.040; p=0.003)
Salmon et al (2009) ECOG 3503 validation setc	Retrospective	82	ECOG 3503 trial patients with stage IIIB or IV or recurrent NSCLC treated with first-line erlotinib	Adjusted b · HR of death, 1.012 (1.003 to 1.021; p=0.012)
Wu et al (2013)38, Validation setd	Retrospective	44	Stage IIIB or IV NSCLC failed or intolerant to chemotherapy, treated with gefitinib or erlotinib · Histology: 79.2% adeno; 20.8% squamous	OS (predicted “good” vs predicted “poor”): HR=0.357 (0.186 to 0.688; p=0.002)	PFS (predicted “good” vs predicted “poor”): HR=0.06 (0.022 to 0.016; p<0.001)
Yang et al (2015)39, Validation sete	Retrospective	123	Stage IIIB or IV NSCLC with a known EGFR variant status · Variant status: 42.3% with EGFR TKI-sensitive variant; 57.7% with EGFR WT · Previous EGFR treatment: 67.5% (30.9% as first-line, 26.8% as second-line, 9.8% as third-line or greater)	Following EGFR TKI treatment (81 patients in validation set): OS=29.0 mo for assay “mutant” and 28.0 mo for assay “wild” (p=NS)	Following EGFR TKI treatment (81 patients in validation set): PFS=10.0 mo for assay “mutant” and 2.3 mo for assay “wild” (p<0.001)

adeno: adenocarcinoma; CI: confidence interval; ECOG: European Cooperative Oncology Group; EGFR: epidermal growth factor receptor; HR: hazard ratio; NSCLC: non-small-cell lung cancer; OS: overall survival; PFS: progression-free survival; TKI: tyrosine kinase inhibitor; WT: wild-type.

^a Adjusted based on age, sex, histology.

^b Adjusted based on metastatic site and performance status.

^c Test based on 11 m/z features.

^d Test based on 3 peptides/proteins.

^e Test based on 5 peptides/proteins.

Proteomic Testing in NSCLC to Predict Response to Therapy

No studies were identified that used VeriStrat proteomic testing to inform therapeutic options for patients with stage I or II NSCLC if surgery or surgery plus radiotherapy had been completed or who were upstaged as a result of surgical findings.

No studies were identified that used VeriStrat proteomic testing to inform therapeutic options for patients with stage I or II NSCLC who were considered medically inoperable.

Based on the association between VeriStrat status and outcomes in patients treated with EGFR TKIs, it was postulated that VeriStrat testing might predict response to EGFR TKIs.

No studies were identified that used VeriStrat proteomic testing to predict response to first-line targeted therapies or first-line chemotherapy in patients with newly diagnosed advanced NSCLC.

Randomized Controlled Trials

In the PROSE trial, Gregorc et al (2014) prospectively evaluated the VeriStrat test in a randomized controlled trial (RCT) comparing erlotinib with chemotherapy as a second-line treatment for patients with stage IIIB or IV NSCLC, stratified by performance status, smoking history, treatment center, and (masked) pretreatment VeriStrat classification.^40,

In a multivariate model to predict OS, which included clinical characteristics and EGFR-variant status, VeriStrat classification was significantly associated with OS (HR for VeriStrat “good” vs “poor,” 1.88; 95% CI, 1.25 to 2.84; p=0.003).

In the entire analysis cohort, the median OS was 9.0 months in the chemotherapy group and 7.7 months in the erlotinib group; OS did not differ significantly by treatment group in adjusted or unadjusted analyses. Moreover, PFS did not differ significantly by treatment group in the unadjusted analysis but was improved for the chemotherapy group in adjusted analysis (HR=1.35; 95% CI, 1.05 to 1.73; p=0.020). Stratification of patients by VeriStrat classification changed the estimate of the effect of chemotherapy. In the VeriStrat “good” group, there was no significant difference in OS between the two treatment groups, whereas,in the VeriStrat “poor” group, OS was shorter for patients treated with erlotinib (see Table 8-9).

The authors of the PROSE trial concluded that the VeriStrat proteomic test predicted differential benefit for erlotinib compared with chemotherapy as second-line treatment of NSCLC, suggesting that patients classified as VeriStrat “poor” would have better outcomes with chemotherapy than erlotinib.

Peters et al (2017) published a randomized phase 2, open-label (EMPHASIS) trial exploring the differential effect of second-line erlotinib vs docetaxel in VeriStrat “good” vs VeriStrat “poor” patients.^41, Patients had stage IIIB or IV squamous cell NSCLC and had failed first-line platinum-based doublet chemotherapy. Recruitment for the trial ended early due to low enrollment and the release of results from other trials (eg, PROSE). The EMPHASIS investigators analyzed trial findings and conducted an exploratory analysis combining EMPHASIS results with those from the squamous cell NSCLC cohort in the PROSE trial. Eighty patients were randomized, of whom 58 (72.5%) were categorized as VeriStrat “good.” The primary endpoint was PFS and was analyzed on an intention-to-treat basis. After a median follow-up of 20.5 months, 73 patients had experienced disease progression (median PFS, 2.7 months). Median PFS was 1.6 months in the erlotinib group and 3.0 months in the docetaxel group; the difference between groups was not statistically significant (p=0.37). PFS did not differ significantly by VeriStrat status, and there was no significant interaction between treatment and VeriStrat status (p=0.80). These trial characteristics and results, as well as results for the secondary outcome OS, are presented in Tables 8 and 9. This trial was restricted to squamous NSCLC histology, and the treatment decision model is not representative of current guideline recommendations.

Lee et al (2019) published results from a randomized, double-blind trial (TOPICAL) in patients (n=527) with previously untreated advanced-stage IIIB/IV NSCLC who were considered unfit for platinum doublet chemotherapy due to poor performance status (PS 2: 56%; PS 3: 27%) and/or the presence of multiple comorbidities.^33, Patients were unselected for EGFR status and randomized for treatment with erlotinib or placebo and active supportive care. This treatment approach is not consistent with current guidelines that cite recent data indicating that NSCLC tumors that do not harbor a sensitizing EGFR mutation should not be treated with an EGFR TKI in any line of therapy. For patients with comorbidities and PS 0-1, carboplatin-based regimens are often used. For patients with PS 2, several alternative systemic therapy regimens not involving platinum-based agents are also available, including paclitaxel, albumin-bound paclitaxel, docetaxel, gemcitabine, gemcitabine/docetaxel, gemcitabine/vinorelbine, and pemetrexed.^1,Fifty-five percent of patients were categorized as VeriStrat 'good,' which includes 164 patients in the erlotinib arm and 124 patients in the placebo arm. Forty-five percent of patients were classified as VeriStrat 'poor,' which includes 115 patients in the erlotinib arm and 124 patients in the placebo arm. For patients with VeriStrat 'good' vs 'poor' scores, median OS was 4.6 months vs 2.9 months in the placebo group (HR=0.54; 95% CI, 0.41 to 0.78; p<0.001) and 4.9 months vs 3.1 months in the erlotinib group (HR=0.60; 95% CI, 0.47 to 0.77; p<0.001). The difference between groups was not statistically significant in the unadjusted analysis (HR=0.93; 95% CI, 0.87 to 1.11; p=0.41). EGFR-variant status was known in 41.2% of patients, which includes EGFR-variant positive status in 21/288 (7.3%) with a VeriStrat 'good' score and 6/239 (2.5%) with a VeriStrat 'poor' score. were EGFR-variant positive. Both VeriStrat "good" vs "poor" classification and EGFR-variant positive vs wild-type status were found to have prognostic value for OS. Only VeriStrat classification was found to have prognostic value for PFS. VeriStrat classification did not have predictive value for response to erlotinib vs placebo. The authors indicate that the VeriStrat assay was able to stratify patients within ECOG PS grades 0-1 and 2-3, however, CIs for these groups were not reported. EGFR-variant status was not reported according to respective treatment groups. Trial characteristics and results are presented in Tables 8-9.

Retrospective Studies

Several retrospective analyses of data from RCTs evaluating the efficacy of TKIs have examined VeriStrat as a prognostic and/or predictive test. Carbone et al (2012) investigated the prognostic and predictive effects of VeriStrat classification on response to treatment and survival in a subset of patients enrolled in a phase 3 trial of erlotinib vs placebo.^42, BR.21, a randomized, placebo-controlled study of erlotinib, enrolled 731 previously treated patients with advanced NSCLC. In the primary study, PFS and OS were prolonged by erlotinib. EGFR variants were prognostic for OS, but not predictive of erlotinib benefit, while increased EGFR copy number variants were both prognostic and predictive of erlotinib benefit. For the present trial, plasma from 441 patients was tested with the VeriStrat test, of which 436 (98.9%) could be classified as “good” or “poor.”

Among the 144 placebo patients, VeriStrat test results were prognostic, with “good” patients (median OS=6.6 months; 95% CI, 4.4 to 8.2 months) surviving significantly longer than “poor” patients (median OS=3.1 months; 95% CI, 2.2 to 3.7 months; HR=0.44, 95% CI, 0.31 to 0.63; p<0.001). Similar results were seen for PFS, with VeriStrat “good” patients having longer PFS than “poor” patients (HR=0.59; 95% CI, 0.42 to 0.86; p=0.002). Median survival was 10.5 months for VeriStrat “good” patients treated with erlotinib and 6.6 months for those on placebo (HR=0.63; 95% CI, 0.47 to 0.85; p=0.002), while for VeriStrat “poor” patients, the median survival for erlotinib was 3.98 months and 3.09 months for placebo (HR=0.77; 95% CI, 0.55 to 1.06; p=0.11). For 252 erlotinib-treated patients with data available to evaluate for objective response, VeriStrat “good” patients (n=157 [62%]) had a significantly higher response rate (11.5%) than VeriStrat “poor” patients (1.1%; p=0.002). In a Cox multivariate regression model to predict OS, the interaction between VeriStrat status and treatment type was not statistically significant, indicating that both “good” and “poor” cohorts derived a similar survival benefit from erlotinib. The authors concluded that VeriStrat status predicted response to erlotinib but did not predict differential benefit from erlotinib for OS or PFS.

Gadgeel et al (2017) retrospectively analyzed data from the LUX-Lung 8 trial, which compared second-line treatment with 1 of 2 TKIs (erlotinib, afatinib) in patients with advanced-stage IIIB or IV squamous NSCLC.^43,EGFR-variant status was not considered in study eligibility. Blood samples for VeriStrat analysis were available for 691 (87%) of 795 randomized patients; of these, 12 were indeterminate results, and 4 could not be analyzed. The primary objective of the analysis was to evaluate whether VeriStrat status pretreatment is associated with OS and in the afatinib vs erlotinib groups. In the cohort with VeriStrat results (n=675), OS was significantly longer in the afatinib group (median, 7.8 months) than in the erlotinib group (median, 6.9 months; p=0.03). When stratified by VeriStrat status, OS was significantly longer with afatinib than with erlotinib in the VeriStrat “good” group (median, 11.5 months vs 8.9 months; HR=0.79; 95% CI, 0.63 to 0.98) but not the VeriStrat “poor” group (median, 4.7 months vs 4.8 months; HR=0.90; 95% CI, 0.70 to 1.16). In the VeriStrat stratified analysis, findings were similar for PFS. The study lacked a group receiving chemotherapy with which to compare the efficacy of TKIs.

Buttigliero et al (2018)^44, retrospectively examined VeriStrat as a prognostic and/or predictive test in a randomized controlled phase 3 RCT (MARQUEE trial^45,) of previously treated patients with advanced nonsquamous NSCLC who were given erlotinib plus tivantinib or placebo. EGFR-variant status was not considered in trial eligibility, and patients previously treated with EGFR inhibitors were excluded from the trial. Of the 1048 patients assigned to treatment protocols, 976 (93%) patients discontinued treatment by protocol (duration of therapy, 0.1-92 weeks), which was discontinued for futility at an interim analysis. In this cohort, no significant difference was seen between the treatment arms for OS. Intention-to-treat analysis of VeriStrat pretreatment status was performed on data for 996 patients.

When stratified by VeriStrat status, PFS and OS were significantly longer for patients in the VeriStrat “good” group than the VeriStrat “poor” group for both treatment arms (p<0.01); no direct comparison of treatment arms within the VeriStrat “good” or “poor” groups was performed. A prespecified Cox multivariate regression analysis of OS for the cohort demonstrated that there was a statistically significant difference between VeriStrat “good” and “poor” groups (p<0.001). There was a significant correlation between treatment and VeriStrat status (p=0.037) in multivariate analysis considering EGFR variant status; this interaction was no longer significant (p=0.068) whenKRAS variant status was entered into the analysis. For patients who were EGFR wild-type (n=895 [90%]), OS was higher for both treatment arms in the VeriStrat “good” group (tivantinib arm median, 10.3 months; 95% CI, 8.9 to 11.5 months; placebo arm median, 9.2 months; 95% CI, 7.8 to 10.2 months) than in the VeriStrat “poor” group (tivantinib arm median, 3.9 months,;95% CI, 3.1 to 4.3 months; placebo arm median, 3.8 months; 95% CI, 2.9 to 5.4 months). The trial was restricted to nonsquamous NSCLC and lacked a group receiving chemotherapy with which to compare the efficacy of TKIs.

Section Summary: Clinically Valid

No published studies were identified that assessed the prognostic use of VeriStrat proteomic testing in newly diagnosed stage I or II NSCLC.

For individuals with newly diagnosed advanced NSCLC without prior systemic therapy, five retrospective studies assessed the use of VeriStrat (“good” or “poor”) as a prognostic test to discriminate between OS (primary outcome) and PFS (secondary outcome) using available samples from previously conducted clinical trials as validation of the classification. Classification based on proteomic testing (ie, VeriStrat “good” vs “poor”) was associated with survival outcomes in analyses that were primarily unadjusted for clinical and patient factors known to be associated with disease survival. The evidence is limited by heterogeneity in the patient population characteristics such as histology and the treatment regimens used. The treatment regimens using EGFR TKIs represent an outdated clinical decision model. The populations studied were unselected for EGFR-sensitizing variants or unknown variant status was excluded. The use of erlotinib (or other TKIs) in EGFR variant-negativeor unknown population is no longer an accepted treatment approach. Combination EGFR plus VEGF inhibition therapy is not an accepted treatment approach. The disposition of indeterminate proteomic test results varied, and sample sizes in the classification groups were small. There is a single observational, nonrandomized study with prospective sample collection for proteomic testing before NSCLC treatment; it reported PFS as the primary outcome. This is the only study that included a first-line treatment consistent with current guidelines-based recommendations (platinum-doublet-based chemotherapy with cisplatin or carboplatin in combination with pemetrexed). Participant recruitment was nonrandom from a single lung cancer treatment unit. Adjusted analyses for PFS and OS did not include age or other sensitizing variants (EGFR, ALK), although data were reported. Overall, sample sizes in classification groups were small and limited generalizability.

For individuals with advanced NSCLC that was recurrent or had advanced on prior systemic therapy, retrospective studies have assessed the use of VeriStrat (“good” or “poor”) as a prognostic test to discriminate between OS (primary outcome) and PFS (secondary outcome) using available samples from previously conducted clinical trials as validation of the classification. None of the trials from which the samples for VeriStrat proteomic classification were derived used a therapy consistent with current guidelines-based recommendations. The populations in all studies were unselected for EGFR-variant status. One study used pre- and posttreatment proteomic test scores and added an indeterminate result to the “good” result data pool.

One additional retrospective study (Grossi et al [2018]) has limited evidentiary value. It combined the previouslyreported single prospective study cohort with results from two cohorts that are only referenced in abstract form.

No published studies were identified that assessed the use of VeriStrat proteomic testing to inform treatment options in newly diagnosed stage I or II NSCLC.

No published studies were identified that assessed the use of VeriStrat proteomic testing to inform treatment options for newly diagnosed advanced NSCLC patients who had not received prior systemic therapy.

The literature on the predictive value of proteomic testing consists oftwo RCTs in patients with advanced NSCLC who failed first-line chemotherapy. The two RCTs demonstrated that classification based on proteomic testing (ie, VeriStrat “good” vs “poor”) is associated with survival outcomes. The evidence is limited by heterogeneity in the treatment regimens used and patient population characteristics. In the PROSE RCT, for patients classified as VeriStrat “good,” there were no significant differences in OS between the erlotinib and chemotherapy groups; however, for patients classified as VeriStrat “poor,” there was a significantly longer median OS in patients in the erlotinib group. In the EMPHASIS trial, there were no significant differences in PFS or OS among patients with VeriStrat “good” status receiving erlotinib or chemotherapy or among patients with VeriStrat “poor” status receiving erlotinib or chemotherapy. Moreover, in both the PROSE and EMPHASIS RCTs, there were no significant benefits to PFS or OS with erlotinib treatment compared with chemotherapy overall, making the application of VeriStrat in this population uncertain.

Tables 8 and 9 summarize study relevance, design, and conduct limitations analyses for proteomic testing in NSCLC to predict response to therapy.

Table 8. Clinical Validity Study Characteristics of Proteomic Testing in NSCLC to Predict Response to Therapy

Study	Study Type	N	Population	Selection Criteria	Participant Disposition
Gregorc et al (2014)40, (PROSE)a	Prospective multicenter	263	Stage IIIB or IV NSCLC progressed on or were judged to be refractory to 1 prior platinum-based chemotherapy regimen randomized 1:1 to erlotinib or chemotherapy (single-agent pemetrexed or docetaxel investigator choice) ·Erlotinib arm: 134 o EGFR WT: 79 o EGFR positive: 8 o EGFR unknown: 47 ·Chemotherapy arm: 129 (74 docetaxel only, 55 pemetrexed only) o EGFR WT: 84 o EGFR positive: 6 o EGFR unknown: 39	·ECOG PS: 0-2 (93.9% grade 0-1) ·Histology: 63.5% adeno; 17.8% squamous; 18.6% other	·296 patients screened ·285 randomized (2/11 exclusions due to “not classified as good or poor”) ·142 assigned to chemotherapy ·129 primary analysis population in chemotherapy group (13 exclusions) ·143 assigned to erlotinib ·134 primary analysis population in erlotinib arm (9 exclusions) ·Total: 19 (7.2%) exclusions due to not starting treatment ·Patients with controlled brain metastases could be included
Peters et al (2017)41, (EMPHASIS-lung Trial)a	Prospective multicenter	80	Randomized phase 3 trial of second-line erlotinib vs docetaxel in VS “good” vs VS “poor” ·Stage IIIB or metastatic stage IV NSCLC patients with documented progression during or after a previous line of chemotherapy (including platinum-doublet therapy) ·Erlotinib arm: 38 ·Docetaxel arm: 42 Combined with Gregorc (2014) PROSE squamous cell population	·ECOG PS: 0-2 ·Histology: squamous cell	Stage IIIB patients not amenable to radical radiotherapy were eligible: ·94 assessed for eligibility ·81 randomized (1 randomized by mistake) Intention-to-treat cohort: ·Erlotinib arm: 38 ·Docetaxel arm: 42
Lee et al (2019)46, (TOPICAL)	Prospective multicenter	527	Randomized trial of active supportive care plus erlotinib vs placebo for previously untreated stage IIIB or IV NSCLC considered unfit for first-line platinum-based chemotherapy based on presence of comorbidities or poor ECOG PS ·Erlotinib + active supportive care arm: 279 ·Placebo + active supportive care arm: 248	·ECOG PS: 0-3 (17% grade 0-1; 56% ·Histology: squamous cell	670 patients were randomized from original cohort, of which: ·350 assigned to erlotinib ·329 received erlotinib ·320 assigned to placebo ·311 received placebo ·527/535 VeriStrat samples collected and available, due to 8 indeterminate classifications ·EGFR status: known (n=310/527), wild-type (283/310, 91.3%), positive (27/310, 8.7%) ·EGFR status for VeriStrat 'good': positive (n=21); wild-type (n=145) ·EGFR status for VeriStrat 'poor': positive (n=6); wild-type (n=138)

adeno: adenocarcinoma; ECOG: European Cooperative Oncology Group; EGFR: epidermal growth factor receptor; NSCLC: non-small-cell lung cancer; PS: performance status; VS: VeriStrat; WT: wild-type.
^a Industry sponsor or collaborator.

Table 9. Clinical Validity Results of Proteomic Testing in NSCLC to Predict Response to Therapy

Study	Median (95% CI), mo	Median (95% CI), mo	HR (95% CI)	HR (95% CI)
Gregorc et al (2014)40, (PROSE)	VeriStrat “Good” (n=184)	VeriStrat “Poor” (n=79)	VeriStrat “Good” vs “Poor”	Chemotherapy vs Erlotinib
OS	11.0 (9.3 to 12.6) Chemotherapy (n=88): 10.9 (8.4 to 15.1) Erlotinib (n=96 ):11.0 (9.2 to 12.9)	3.7 (2.9 to 5.2) Chemotherapy (n = 41): 6.4 (3.0 to 7.4) Erlotinib (n =38): 3.0 (2.0 to 3.8)	2.5 (1.88 to 3.31; p<0.001)	·Unadjusted HR=1.14 (0.88 to 1.49; p=0.313) ·Adjusted HR=1.22 (0.93 to 1.59; p=0.148) ·For VeriStrat 'Good': 1.05 (0.77 to 1.46, p=0.714) ·For VeriStrat 'Poor': 1.72 (1.08 to 2.74, p=0.022)
PFS	3.4 (2.4 to 4.6)	2.0 (1.6 to 2.4)	1.75 (1.34 to 2.29; p<0.001)	·Unadjusted HR=1.27 (0.99 to 1.62; p=0.60) ·Adjusted HR=1.35 91.05 to 1.73; p=0.20) ·Median OS=9.0 mo (6.8 to 10.9 mo) vs 7.7 mo (5.9 to 10.4 mo)
Peters et al (2017)41,(EMPHASIS-lung Trial)	VeriStrat “Good” (n=58)	VeriStrat “Poor” (n=22)	VeriStrat 'Good' vs 'Poor'	Erlotinib and Docetaxel
OS	8.2 (6.7 to 10.6)	5.2 (3.1 to 7.1)	0.49 (0.28 to 0.86; p=NR)	Median OS=7.1 mo for both erlotinib and docetaxel
PFS	NR (87% experienced a progression-defining event)	NR (100% experienced a progression defining event)	0.73 (0.44 to 1.22; p=NR)
Lee et al (2019)46, (TOPICAL)	VeriStrat 'Good' (n=288)	VeriStrat 'Poor' (n=239)	VeriStrat 'Good' vs 'Poor'	Erlotinib + ASC vs Placebo + ASC
OS	Median OS unadjusted for treatment NR Erlotinib (n=164): 4.9 (NR) Placebo (n=124): 4.6 (3.3 to 6.9)	Median OS unadjusted for treatment NR Erlotinib (n=115): 3.1 (NR) Placebo (n=124): 2.9 (2.3 to 3.5)	0.58 (0.48 to 0.70; p<0.001) For erlotinib: 0.60 (0.47 to 0.77; p<0.001) For placebo: 0.54 (0.41 to 0.71; p<0.001)	0.93 (0.87 to 1.11; p=0.41) For EGFR-variant positive vs wild-type: 0.53 (0.33 to 0.83; p=0.006)
PFS	Median PFS unadjusted for treatment NR Erlotinib (n=164): 2.9 (NR) Placebo (n=124): 2.8 (NR)	Median PFS unadjusted for treatment NR Erlotinib (n=115): 2.2 (NR) Placebo (n=124): 2.2 (NR)	0.67 (0.56 to 0.81; p<0.001) For erlotinib: 0.70 (0.55 to 0.89; p=0.004) For placebo: 0.66 (0.51 to 0.85; p=0.001)	0.85 (0.71 to 1.02; p=0.51) For EGFR-variant positive vs wild-type: 0.65 (0.42 to 1.01; p=0.06)

ASC: active supportive care; CI: confidence interval; HR: hazard ratio; NR: not reported; NSCLC: non-small-cell lung cancer; OS: overall survival; PFS: progression-free survival.

Table 10. Clinical Validity Relevance Limitations for Proteomic Testing in NSCLC to Predict Response to Therapy

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Duration of Follow-Upe
Gregorc et al (2014)40, (PROSE)	2.Table 5 reports other drug interventions used as third-line treatment without protocol information 4.Use of erlotinib (or other TKIs) in EGFR-variant wild-type orunknown population is not consistent with published treatment guidelines	Other related: · Identity of proteins that make up the MALDI-MS features still being investigated at the time of publication		1.VeriStrat assay not used to direct clinical management Other related: · Decision model based on outdated clinical pathway · Variable response assessment times and intervals
Peters et al (2017)41, (EMPHASIS-lung Trial)	1. Accrual terminated 3. PROSE (Gregorc et al [2014]) squamous cell cohort not described	Other related: · Identity of proteins that make up the MALDI-MS features still being investigated at the time of publication		1. VeriStrat assay not used to direct clinical management Other related: · Decision model based on outdated clinical pathway for treatment of squamous cell histology · Variable response assessment times and intervals · Incomplete data on PROSE squamous cell cohort
Lee et al (2019)46, (TOPICAL)	4. Use of erlotinib in EGFR-variant wild-type or unknown population is not consistent with published treatment guidelines, including patients with poor performance status or comorbidities			1. VeriStrat assay not used to direct clinical management Other related: ·Decision model based on outdated clinical pathway ·Response assessment times and intervals unclear

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
EGFR: epidermal growth factor receptor; MALDI-MS: matrix-assisted laser desorption ionization mass spectrometry; NSCLC: non-small-cell lung cancer; TKI: tyrosine kinase inhibitor.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.

^b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest.

^c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose.

^d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests).

^e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).

Table 11. Clinical Validity Study Design and Conduct Limitations for Proteomic Testing in NSCLC to Predict Response to Therapy

Study	Selectiona	Blindingb	Delivery of Testc	Selective Reportingd	Data Completenesse	Statisticalf
Gregorc et al (2014)40, (PROSE)						Other related: · Included variables not explicit for adjusted PFS comparing treatment groups
Peters et al (2017)41, (EMPHASIS-lung Trial)				Other related: · Incomplete data on PROSE squamous cell cohort		1. Confidence intervals and/or p values not reported
Lee et al (2019)46, (TOPICAL)				1-2. Referenced study registry number does not describe published study.	Other related: ·Unadjusted median OS for VeriStrat 'Good" vs "Poor" independent of treatment group not provided ·Known EGFR-variant status characteristics not described according to treatment group	1. Confidence intervals and/or p values not reported Other related: ·Confidence that the VeriStrat classification is independent of EGFR variant status is limited by trend toward higher number of EGFR variant positive patients with VeriStrat 'Good" score among those with known mutation status

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitions assessment.
EGFR: epidermal growth factor receptor; OS: overall survival; PFS: progression-free survival.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience).

^b Blinding key: 1. Not blinded to results of reference or other comparator tests.

^c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.

^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.

^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from RCTs.

The proposed clinical utility of VeriStrat is for use by physicians to predict expected survival for standard therapies in the treatment of patients with NSCLC. Clinical utility is also proposed for physicians to use VeriStrat to select patients for systemic therapy based on the presence or absence of EGFR-sensitizing variants. Direct evidence from studies that demonstrate improved outcomes for patients managed with a strategy that includes proteomic testing compared with a strategy that does not, is not available for use of proteomic testing to select targeted therapy or other systemic therapy for NSCLC. Confidence that the proteomic classifier is independent of EGFR-variant status, as well as other tumor and patient characteristics, has not been demonstrated and, thus, VeriStrat lacks clinical validity. The identity of the proteins that make up the MALDI-MS features was still being investigated at the time of publication of the studies for both prognostic and predictive uses, further challenging the specificity for malignant biologic processes and conditions.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

Absent direct evidence, a chain of evidence could be used to support the use of VeriStrat to select patients for EGFR TKI therapy. If EGFR TKI therapy were used as a standard of care in patients with unknown or negative EGFR status in the first-, second-, or third-line settings, proteomic testing could be used to select patients who are least likely to benefit. However, the IUNO trial did not find that erlotinib was efficacious in patients with NSCLC with no known EGFR variant, and the PROSE and EMPHASIS trials found that OS did not differ significantly for patients with advanced NSCLC treated with second-line erlotinib or chemotherapy. There were mixed findings on PFS in the PROSE and EMPHASIS trials. Due to study findings and the lack of support from guidelines for EGFRTKIs in this setting, EGFR TKI therapy is no longer standard therapy for any EGFR-negative or -unknown patients. Platinum-based chemotherapy and immunotherapy (based on programmed death-ligand 1 testing) are the guidelines-based options for previously untreated advanced EGFR-negative or -unknown patients with NSCLC or those with recurrent NSCLC or who have progressed on prior systemic therapy.

The available evidence does not demonstrate that the addition of a VeriStrat proteomic classification of “good” or “poor” to the standard clinical assessment of prognosis would influence treatment or define a treatment pathway. Similarly, there is no evidence to demonstrate the impact of the substitution of a VeriStrat proteomic classification in the standard of care treatment pathways. The negative predictive value of a VeriStrat “poor” score has not been demonstrated; there has been no validation in patients who received no or surgical therapy only.

Although studies of physician decision making using VeriStrat proteomic testing have been reported; they did not evaluate patient outcomes and did not evaluate the impact of EGFR testing on treatment recommendations (the number of patients who had previously received EGFR tests was not reported). Thus, these studies are insufficient to demonstrate clinical utility.

Two studies have evaluated the impact of VeriStrat testing on physician treatment recommendations. Akerley et al (2013) reported on 226 physicians who provided pre- and post-test treatment plan information for 403 VeriStrat tests.^47, In the 262 cases where pretreatment recommendations were for erlotinib only, for those patients who were classified as VeriStrat “poor,” physicians recommended erlotinib in 13.3%. In a larger study, Akerley et al (2017) reported on 2411 physicians who received 14327 VeriStrat test results.^48, The investigators only included tests that were ordered for NSCLC, were ordered as the sole test, were not indeterminate, and were not ordered in patients with known EGFR-variant status. VeriStrat findings were a classification of “good” for 1950 (78.2%) patients and “poor” for 544 (21.8%) patients. After receiving the test results, physicians changed their treatment recommendations in 28.2% of the cases; within this group, 13.2% were classified as VeriStrat “good” and 81.6% as VeriStrat “poor.” Physicians initially considered treatment with an EGFR TKI in 484 (89.0%) of 544 classified as VeriStrat “poor”; after receiving test results only, 49 (10%) were actually recommended EGFR TKI treatment.

Section Summary: Clinically Useful

No direct evidence for a serum proteomic test for the selection of an NSCLC treatment strategy was identified.In the absence of direct evidence, a chain of evidence could be developed to support the use of VeriStrat to select patients for EGFR TKI therapy. If EGFR TKI therapy were used as a standard of care in patients with EGFR-unknown or wild-type status in the first-, second-, or third-line settings, proteomic testing could be used to identify patients who are least likely to benefit. However, given the evidence from the available trials and the lack of support from guidelines for EGFR TKIs in this setting, EGFR TKI therapy is no longer standard therapy for any patient with wild-type or unknown EGFR-variant status. There are no studies that have directly evaluated the use of the proteomic classification to inform treatment selection based on current treatment pathways that consider other targeted therapy, chemotherapy, or immunotherapy options. Two studies by the same research group evaluated changes in treatment recommendations before and after receiving VeriStrat test results; patient outcomes were not reported.

Summary of Evidence

For individuals with newly diagnosed NSCLC and wild-type EGFR-variant status who receive management with a serum proteomic test to predict survival and select treatment, the evidence includes retrospective studies and a prospective nonrandomized study. The relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. No published studies were identified that assessed the prognostic use of VeriStrat proteomic testing in newly diagnosed stage I or II NSCLC. For individuals with newly diagnosed advanced NSCLC and EGFR-negative variant status without prior systemic therapy, five studies have assessed the use of VeriStrat (“good” or “poor”) as a prognostic test to discriminate between OS (primary) and PFS(secondary) outcomes. All studies were retrospective and intended to validate the extent to which the VeriStrat proteomic classification correlated with OS or PFS. Only one of the five studies reported the percentage of participants who were EGFR-negative, but it did not report outcomes based on variant status. One observational, nonrandomized study with prospective sample collection for proteomic testing before NSCLC treatment reported the percentage of participants who were EGFR-negative, but it did not report outcomes based on variant status. This was also the only study that included a first-line treatment consistent with current guideline-based recommendations¾platinum-doublet-based chemotherapy plus cisplatin or carboplatin plus pemetrexed. The VeriStrat classification was not used to direct the selection of treatment in any of the clinical trials from which the validation samples were derived. Disposition of populations with variant status “not reported” was generally not clear and could not be construed as “unknown” when wild-type or positive were reported. No studies were identified that used VeriStrat proteomic testing to inform therapeutic options for patients with stage I or II NSCLC if surgery or surgery plus radiotherapy have been completed or who were upstaged as a result of surgical findings. No studies were identified that used VeriStrat proteomic testing to inform therapeutic options for patients with stage I or II NSCLC who were considered medically inoperable. No studies were identified that used VeriStrat proteomic testing to predict response to first-line targeted therapies or first-line chemotherapy in patients with newly diagnosed advanced NSCLC. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with newly diagnosed NSCLC and unknown EGFR-variant status who receive management with a serum proteomic test to predict survival and select treatment, the evidence includes an RCT, four retrospective studies, and a prospective study. The relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. All study populations were either unselected for EGFR-variant status or status was expressly reported as unknown in conjunction with negative or positive status reports. None of the studies that reported unknown EGFR-variant status reported outcomes for the proteomic score based on unknown EGFR-variant status. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with NSCLC and wild-type EGFR-variant status and disease progression after first-line systemic therapy who receive management with a serum proteomic test to predict survival and select treatment, the evidence includes an RCT and a retrospective analysis. The relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. No studies were identified that reported or analyzed outcomes using the proteomic test as a prognostic tool in EGFR-negative variant status populations. The evidence includes an RCT (PROSE) using proteomic testing to predict response to erlotinib compared with chemotherapy as second-line treatment for patients with stage IIIB or IV NSCLC, stratified by performancestatus, smoking history, treatment center, and (masked) pretreatment VeriStrat classification. In a multivariate model to predict OS, which included clinical characteristics and EGFR-variant status, VeriStrat classification was significantly associated with OS(HR for VeriStrat “good” vs “poor,” 1.88; 95% CI, 1.25 to 2.84; p=0.003). However, 62% of the combined study population was EGFR-negative. A retrospective analysis was also performed on the MARQUEE trial, a phase 3 RCT in patients with stage IIIB or IV nonsquamous NSCLC, comparing the patient response to erlotinib in conjunction with either tivantinib or a placebo; patients were stratified by EGFR and KRAS variant status, sex, smoking history, and treatment history. Protocol treatments were subsequently discontinued by 93% of patients, and the trial discontinued after prespecified interim futility analysis. In a multivariate model to predict OS, which included clinical characteristics and EGFR-variant status, VeriStrat classification was significantly associated with OS (HR for VeriStrat “good” vs “poor,” 0.52; 95% CI, 0.40 to 0.67; p<0.001). Ninety percent of the combined study population was EGFR-negative. An interaction between treatment and VeriStrat status was significant for multivariate analysis including EGFR status (p=0.036) but not significant for multivariate analysis including both EGFR and KRAS variant status (p=0.068). Currently, the use of erlotinib in patients unselected for the presence or absence of an EGFR-sensitizing variant is not standard clinical practice. It is recommended that variant status be determined, if not previously ascertained, before selecting treatment after progression or recurrence. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with NSCLC and unknown EGFR-variant status with disease progression after first-line systemic therapy who receive management with a serum proteomic test to predict survival and select treatment, the evidence includes twoRCTs and three retrospective studies. The relevant outcomes are OS, disease-specific survival, and treatment-related mortality and morbidity. The use of VeriStrat as a prognostic test to discriminate between good and poor survival outcomes was assessed in three retrospective studies intended to validate the extent to which VeriStrat proteomic classification correlates with OS or PFS. The VeriStrat classification was not used to direct treatment selection in any of the trials from which the validation samples were derived. None of the clinical trials from which the samples for VeriStrat proteomic classification were derived used a therapy consistent with current guidelines-based recommendations. The populations in all three studies were unselected for EGFR-variant status. In the PROSE RCT, using a multivariate model to predict OS, which included clinical characteristics and EGFR-variant status, VeriStrat classification was significantly associated with OS (HR for VeriStrat “good” vs “poor,” 1.88; 95% CI, 1.25 to 2.84; p=0.003). However, 32.6% of the combined study population had unknown EGFR status. In the EMPHASIS RCT, there were no significant differences in PFS or OSamong patients with VeriStrat “good” status receiving erlotinib or chemotherapy or among patients with VeriStrat “poor” status receiving erlotinib or chemotherapy. The results of the EMPHASIS RCT were restricted to squamous NSCLC histology. Currently, the use of erlotinib in patients unselected for the presence or absence of an EGFR-sensitizing variant is not standard clinical practice. It is recommended that variant status be determined, if not previously ascertained, before selecting treatment after progression or recurrence. The evidence is insufficient to determine the effects of the technology on health outcomes.

SUPPLEMENTAL INFORMATION

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 1 academic medical center and 2 community health systems, one of which provided 4 responses, while this policy was under review in 2017. Input was uniform that erlotinib is not considered routine for individuals with non-small-cell lung cancer who are epidermal growth factor receptor (EGFR)-negative or EGFR-status unknown in the second-line setting. Reviewers had limited confidence that there was adequate evidence that the use of VeriStrat to guide treatment selection would improve outcomes for individuals with non-small-cell lung cancer who are EGFR-negative or EGFR-status unknown in the second-line setting.

Practice Guidelines and Position Statements

National Comprehensive Cancer Network

The National Comprehensive Cancer Network (v.7.2019) guidelines on the management of non-small cell lung cancer (NSCLC) recommend routine testing for EGFR variants in patients with advanced or metastatic nonsquamous NSCLC (category 1 recommendation) and consideration for EGFR-variant testing in patients with metastatic squamous NSCLC who were never smokers or with small biopsy specimens or mixed histology (category 2A recommendation).^1, Recommendations for first-line treatment for EGFR-positive patients with advanced or metastatic NSCLC, and EGFR-negative or -unknown patients as well as for patients in either category who have progressed on therapy are provided. See the Background section for additional information.

American Society of Clinical Oncology

The American Society of Clinical Oncology (2017) updated its clinical practice guidelines on systemic therapy for stage IV NSCLC.^33, New or revised recommendations included the following recommendations: first-line treatment for patients with nonsquamous cell carcinoma or squamous cell carcinoma (without positive markers, eg, EGFR, ALK, ROS1), based on programmed death-ligand 1 expression; second-line treatment in patients who received first-line chemotherapy, without prior immune checkpoint therapy based on programmed death-ligand 1 expression; as well as recommendations for those patients who cannot receive immune checkpoint inhibitor. Recommendations are included for patients with a sensitizing EGFR variant, for patients with disease progression after first-line EGFR tyrosine kinase inhibitor therapy based on the results of T790M variant testing, and for patients with ROS1 gene rearrangements without prior crizotinib may be offered crizotinib, or if they previously received crizotinib, they may be offered chemotherapy.

The Society (2018) endorsed practice guidelines from other medical associations (College of American Pathologists, International Association for the Study of Lung Cancer, Association for Molecular Pathology) addressing molecular testing for the selection of patients with lung cancer for treatment with targeted tyrosine kinase inhibitors.^49,

American College of Chest Physicians

The American College of Chest Physicians (2013) updated its evidence-based clinical practice guidelines on the treatment of stage IV NSCLC.^50, Based on a review of the literature, the College reported improved response rates, progression-free survival, and toxicity profiles with first-line erlotinib or gefitinib compared with first-line platinum-based therapy in patients with EGFR variants, especially exon 19 deletion and L858R variant. Moreover, the College recommended, “testing patients with NSCLC for EGFR mutations at the time of diagnosis whenever feasible, and treating with first-line EGFR-TKIs if mutation-positive.”

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 12.

Table 12. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT02271581	Effect of Symptom Management on Inflammation and Survival in Metastatic Lung Cancer (INSYNC)	100	Jul 2020 (recruiting)
NCT03289780a	Clinical Effectiveness Assessment of VeriStrat® Testing and Validation of Immunotherapy Tests in NSCLC Subjects (INSIGHT)	1000	Dec 2020 (recruiting)

NCT: national clinical trial.

^a Denotes industry sponsorship or cosponsorship.]
________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer
Veristrat
Veristrat Test
Veristrat Assay

References:
1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Version 7.2019. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed October 7, 2019.

2. Surveillance Epidemiology and End Results Program. Cancer Stat Facts: Lung and Bronchus Cancer. n.d.; https://seer.cancer.gov/statfacts/html/lungb.html. Accessed October 7, 2019.

3. Wheatley-Price P, Blackhall F, Lee SM, et al. The influence of sex and histology on outcomes in non-small-cell lung cancer: a pooled analysis of five randomized trials. Ann Oncol. Oct 2010;21(10):2023-2028. PMID 20332134.

4. Chansky K, Sculier JP, Crowley JJ, et al. The International Association for the Study of Lung Cancer Staging Project: prognostic factors and pathologic TNM stage in surgically managed non-small cell lung cancer. J Thorac Oncol. Jul 2009;4(7):792-801. PMID 19458556.

5. Keedy VL, Temin S, Somerfield MR, et al. American Society of Clinical Oncology provisional clinical opinion: epidermal growth factor receptor (EGFR) mutation testing for patients with advanced non-small-cell lung cancer considering first-line EGFR tyrosine kinase inhibitor therapy. J Clin Oncol. May 20 2011;29(15):2121-2127. PMID 21482992.

6. Lindeman NI, Cagle PT, Beasley MB, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. J Thorac Oncol. Jul 2013;8(7):823-859. PMID 23552377.

7. Lee CK, Brown C, Gralla RJ, et al. Impact of EGFR inhibitor in non-small cell lung cancer on progression-free and overall survival: a meta-analysis. J Natl Cancer Inst. May 1 2013;105(9):595-605. PMID 23594426.

8. Ciuleanu T, Stelmakh L, Cicenas S, et al. Efficacy and safety of erlotinib versus chemotherapy in second-line treatment of patients with advanced, non-small-cell lung cancer with poor prognosis (TITAN): a randomised multicentre, open-label, phase 3 study. Lancet Oncol. Mar 2012;13(3):300-308. PMID 22277837.

9. Karampeazis A, Voutsina A, Souglakos J, et al. Pemetrexed versus erlotinib in pretreated patients with advanced non-small cell lung cancer: a Hellenic Oncology Research Group (HORG) randomized phase 3 study. Cancer. Aug 1 2013;119(15):2754-2764. PMID 23661337.

10. Garassino MC, Martelli O, Broggini M, et al. Erlotinib versus docetaxel as second-line treatment of patients with advanced non-small-cell lung cancer and wild-type EGFR tumours (TAILOR): a randomised controlled trial. Lancet Oncol. Sep 2013;14(10):981-988. PMID 23883922.

11. Auliac JB, Chouaid C, Greillier L, et al. Randomized open-label non-comparative multicenter phase II trial of sequential erlotinib and docetaxel versus docetaxel alone in patients with non-small-cell lung cancer after failure of first-line chemotherapy: GFPC 10.02 study. Lung Cancer. Sep 2014;85(3):415-419. PMID 25082565.

12. Cicenas S, Geater SL, Petrov P, et al. Maintenance erlotinib versus erlotinib at disease progression in patients with advanced non-small-cell lung cancer who have not progressed following platinum-based chemotherapy (IUNO study). Lung Cancer. Dec 2016;102:30-37. PMID 27987585.

13. Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med. Jun 20 2013;368(25):2385-2394. PMID 23724913.

14. Biodesix. VeriStrat proteomic test. 2019; https://www.biodesix.com/products/lung-cancer/veristrat. Accessed October 7, 2019.

15. Taguchi F, Solomon B, Gregorc V, et al. Mass spectrometry to classify non-small-cell lung cancer patients for clinical outcome after treatment with epidermal growth factor receptor tyrosine kinase inhibitors: a multicohort cross-institutional study. J Natl Cancer Inst. Jun 6 2007;99(11):838-846. PMID 17551144.

16. Keshtgarpour M, Tan WS, Zwanziger J, et al. Prognostic value of serum proteomic test and comorbidity index in diversified population with lung cancer. Anticancer Res. Apr 2016;36(4):1759-1765. PMID 27069156.

17. Wang DX, Liu H, Yan LR, et al. The relationship between serum amyloid A and apolipoprotein A-I in high-density lipoprotein isolated from patients with coronary heart disease. Chin Med J (Engl). Oct 2013;126(19):3656-3661. PMID 24112159.

18. Santoso A, Kaniawati M, Bakri S, et al. Secretory phospholipase A2 Is associated with the odds of acute coronary syndromes through elevation of serum amyloid-A protein. Int J Angiol. Mar 2013;22(1):49-54. PMID 24436584.

19. Kotani K, Koibuchi H, Yamada T, et al. The effects of lifestyle modification on a new oxidized low-density lipoprotein marker, serum amyloid A-LDL, in subjects with primary lipid disorder. Clin Chim Acta. Nov 2009;409(1-2):67-69. PMID 19723514.

20. Bozinovski S, Uddin M, Vlahos R, et al. Serum amyloid A opposes lipoxin A(4) to mediate glucocorticoid refractory lung inflammation in chronic obstructive pulmonary disease. Proc Natl Acad Sci U S A. Jan 17 2012;109(3):935-940. PMID 22215599.

21. Filippin-Monteiro FB, de Oliveira EM, Sandri S, et al. Serum amyloid A is a growth factor for 3T3-L1 adipocytes, inhibits differentiation and promotes insulin resistance. Int J Obes (Lond). Aug 2012;36(8):1032-1039. PMID 21986708.

22. Diamandis EP. Analysis of serum proteomic patterns for early cancer diagnosis: drawing attention to potential problems. J Natl Cancer Inst. Mar 3 2004;96(5):353-356. PMID 14996856.

23. Fidler MJ, Fhied CL, Roder J, et al. The serum-based VeriStrat(R) test is associated with proinflammatory reactants and clinical outcome in non-small cell lung cancer patients. BMC Cancer. Mar 20 2018;18(1):310. PMID 29558888.

24. Jacot W, Lhermitte L, Dossat N, et al. Serum proteomic profiling of lung cancer in high-risk groups and determination of clinical outcomes. J Thorac Oncol. Aug 2008;3(8):840-850. PMID 18670301.

25. Abbatiello S, Ackermann BL, Borchers C, et al. New guidelines for publication of manuscripts describing development and application of targeted mass spectrometry measurements of peptides and proteins. Mol Cell Proteomics. Mar 2017;16(3):327-328. PMID 28183812.

26. Amann JM, Lee JW, Roder H, et al. Genetic and proteomic features associated with survival after treatment with erlotinib in first-line therapy of non-small cell lung cancer in Eastern Cooperative Oncology Group 3503. J Thorac Oncol. Feb 2010;5(2):169-178. PMID 20035238.

27. Kuiper JL, Lind JS, Groen HJ, et al. VeriStrat((R)) has prognostic value in advanced stage NSCLC patients treated with erlotinib and sorafenib. Br J Cancer. Nov 20 2012;107(11):1820-1825. PMID 23079575.

28. Akerley W, Boucher K, Rich N, et al. A phase II study of bevacizumab and erlotinib as initial treatment for metastatic non-squamous, non-small cell lung cancer with serum proteomic evaluation. Lung Cancer. Mar 2013;79(3):307-311. PMID 23273522.

29. Gautschi O, Dingemans AM, Crowe S, et al. VeriStrat(R) has a prognostic value for patients with advanced non- small cell lung cancer treated with erlotinib and bevacizumab in the first line: pooled analysis of SAKK19/05 and NTR528. Lung Cancer. Jan 2013;79(1):59-64. PMID 23122759.

30. Stinchcombe TE, Roder J, Peterman AH, et al. A retrospective analysis of VeriStrat status on outcome of a randomized phase II trial of first-line therapy with gemcitabine, erlotinib, or the combination in elderly patients (age 70 years or older) with stage IIIB/IV non-small-cell lung cancer. J Thorac Oncol. Apr 2013;8(4):443-451. PMID 23370367.

31. Grossi F, Rijavec E, Genova C, et al. Serum proteomic test in advanced non-squamous non-small cell lung cancer treated in first line with standard chemotherapy. Br J Cancer. Jan 3 2017;116(1):36-43. PMID 27898657.

32. Spigel DR, Burris HA, 3rd, Greco FA, et al. Erlotinib plus either pazopanib or placebo in patients with previously treated advanced non-small cell lung cancer: A randomized, placebo-controlled phase 2 trial with correlated serum proteomic signatures. Cancer. Jun 1 2018;124(11):2355-2364. PMID 29645086.

33. Hanna N, Johnson D, Temin S, et al. Systemic therapy for stage IV non-small-cell lung cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. Oct 20 2017;35(30):3484-3515. PMID 28806116.

34. Carbone DP, Salmon JS, Billheimer D, et al. VeriStrat classifier for survival and time to progression in non-small cell lung cancer (NSCLC) patients treated with erlotinib and bevacizumab. Lung Cancer. Sep 2010;69(3):337- 340. PMID 20036440.

35. Grossi F, Genova C, Rijavec E, et al. Prognostic role of the VeriStrat test in first line patients with non-small cell lung cancer treated with platinum-based chemotherapy. Lung Cancer. Mar 2018;117:64-69. PMID 29395121.

36. Herbst RS, Johnson DH, Mininberg E, et al. Phase I/II trial evaluating the anti-vascular endothelial growth factor monoclonal antibody bevacizumab in combination with the HER-1/epidermal growth factor receptor tyrosine kinase inhibitor erlotinib for patients with recurrent non-small-cell lung cancer. J Clin Oncol. Apr 10 2005;23(11):2544-2555. PMID 15753462.

37. Salmon S, Chen H, Chen S, et al. Classification by mass spectrometry can accurately and reliably predict outcome in patients with non-small cell lung cancer treated with erlotinib-containing regimen. J Thorac Oncol. Jun 2009;4(6):689-696. PMID 19404214.

38. Wu X, Liang W, Hou X, et al. Serum proteomic study on EGFR-TKIs target treatment for patients with NSCLC. Onco Targets Ther. Nov 2013;6:1481-1491. PMID 24204163.

39. Yang L, Tang C, Xu B, et al. Classification of epidermal growth factor receptor gene mutation status using serum proteomic profiling predicts tumor response in patients with stage IIIB or IV non-small-cell lung cancer. PLoS One. Jun 2015;10(6):e0128970. PMID 26047516.

40. Gregorc V, Novello S, Lazzari C, et al. Predictive value of a proteomic signature in patients with non-small-cell lung cancer treated with second-line erlotinib or chemotherapy (PROSE): a biomarker-stratified, randomised phase 3 trial. Lancet Oncol. Jun 2014;15(7):713-721. PMID 24831979.

41. Peters S, Stahel RA, Dafni U, et al. Randomized phase III trial of erlotinib versus docetaxel in patients with advanced squamous cell non-small cell lung cancer failing first-line platinum-based doublet chemotherapy stratified by VeriStrat good versus VeriStrat poor. The European Thoracic Oncology Platform (ETOP) EMPHASIS-lung Trial. J Thorac Oncol. Apr 2017;12(4):752-762. PMID 28017787.

42. Carbone DP, Ding K, Roder H, et al. Prognostic and predictive role of the VeriStrat plasma test in patients with advanced non-small-cell lung cancer treated with erlotinib or placebo in the NCIC Clinical Trials Group BR.21 trial. J Thorac Oncol. Nov 2012;7(11):1653-1660. PMID 23059783.

43. Gadgeel S, Goss G, Soria JC, et al. Evaluation of the VeriStrat(R) serum protein test in patients with advanced squamous cell carcinoma of the lung treated with second-line afatinib or erlotinib in the phase III LUX-Lung 8 study. Lung Cancer. Jul 2017;109:101-108. PMID 28577938.

44. Buttigliero C, Shepherd FA, Barlesi F, et al. Retrospective assessment of a serum proteomic test in a phase III study comparing erlotinib plus placebo with erlotinib plus tivantinib (MARQUEE) in previously treated patients with advanced non-small cell lung cancer. Oncologist. Aug 23 2018. PMID 30139835.

45. Scagliotti G, von Pawel J, Novello S, et al. Phase III multinational, randomized, double-blind, placebo-controlled study of tivantinib (ARQ 197) plus erlotinib versus erlotinib alone in previously treated patients with locally advanced or metastatic nonsquamous non-small-cell lung cancer. J Clin Oncol. Aug 20 2015;33(24):2667-2674. PMID 26169611.

46. Lee SM, Upadhyay S, Lewanski C et al. The clinical role of VeriStrat testing in patients with advanced non-small cell lung cancer considered unfit for first-line platinum-based chemotherapy. Eur. J. Cancer, 2019 Sep 10;120:86-96. PMID 31499384.

47. Akerley WL, Nelson RE, Cowie RH, et al. The impact of a serum based proteomic mass spectrometry test on treatment recommendations in advanced non-small-cell lung cancer. Curr Med Res Opin. May 2013;29(5):517- 525. PMID 23452275.

48. Akerley WL, Arnaud AM, Reddy B, et al. Impact of a multivariate serum-based proteomic test on physician treatment recommendations for advanced non-small-cell lung cancer. Curr Med Res Opin. Jun 2017;33(6):1091- 1097. PMID 28277859.

49. Kalemkerian GP, Narula N, Kennedy EB, et al. Molecular testing guideline for the selection of patients with lung cancer for treatment with targeted tyrosine kinase inhibitors: American Society of Clinical Oncology Endorsement of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology Clinical Practice Guideline Update. J Clin Oncol. Mar 20 2018;36(9):911-919. PMID 29401004.

50. Socinski MA, Evans T, Gettinger S, et al. Treatment of stage IV non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. May 2013;143(5 Suppl):e341S-368S. PMID 23649446.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

81538