How close are we to standardised extended RAS gene mutation testing? The UK NEQAS experience

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Kelley Anthony
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1 How close are we to standardised extended RAS gene mutation testing? The UK NEQAS experience Dr Susan D. Richman, Dr Jennifer Fairley, Dr Rachel Butler, Dr Zandra C. Deans

2 Overview Introduction to UK NEQAS Background to this study on extended RAS testing Methodology Results Discussion

produced Charity organisation Self funding, non-profit making schemes Over 45

3 UK National External Quality Assessment Services helping to ensure clinical laboratory test results are accurate, reliable and comparable wherever they are produced Charity organisation Self funding, non-profit making schemes Over 45 years experience providing EQA ISO accredited EQA schemes Participants worldwide

4 Scheme activity in countries

5 Background to RAS testing-1 Since 2008, KRAS exon 2 mutation status has been used to predict response to anti-egfr therapies. Patients with an activating mutation in KRAS exon 2 failed to benefit from anti-egfr therapy

6 Background to RAS testing-2 Prospective-retrospective analysis

7 PRIME and CRYSTAL Trials Prospective-retrospective analysis PRIME Trial (NEJM 2013;369: ) CRYSTAL Trial (JCO 2015; 33: ) Treatment arms Pan-FOLFOX4 v FOLFOX4 FOLFIRI + Cet v FOLFIRI OS PFS Additional RAS mutations 26.0 months v 20.2 months (HR =0.78) 10.1 months v 7.9 months (HR=0.72) 17% of 639 patients 4% in KRAS codon 61 6% in KRAS codons 117/146 3% in NRAS codons 12/13 4% in NRAS codon months v 20.2 months (HR =0.69) 11.4 months v 8.4 months (HR=0.56) 14.7% of 430 patients 3% in KRAS codon 61 5% in KRAS codons 117/146 3% in NRAS codons 12/13 3% in NRAS codon 61 1% in NRAS codons 117/146

UK and ASCO guidance KRAS exon 2 (codons 12 and 13)

and 146) NRAS exon 2 (codons 12 and 13) NRAS exon 3

(codons 59 and 61) NRAS exon 4 (codons 117 and 146)

8 UK and ASCO guidance KRAS exon 2 (codons 12 and 13) KRAS exon 3 (codons 59 and 61) KRAS exon 4 (codons 117 and 146) NRAS exon 2 (codons 12 and 13) NRAS exon 3 (codons 59 and 61) KRAS exon 2 (codons 12 and 13) KRAS exon 3 (codons 59 and 61) KRAS exon 4 (codons 117 and 146) NRAS exon 2 (codons 12 and 13) NRAS exon 3 (codons 59 and 61) NRAS exon 4 (codons 117 and 146) What percentage of laboratories are complying with these guidelines?

schemes per EQA year Testing of 9 CRC samples per year

9 Materials and Methods Data from four consecutive UK NEQAS for Molecular Genetics Colorectal cancer EQA schemes ( ) 2 schemes per EQA year Testing of 9 CRC samples per year Laboratories asked to provide; genotyping and interpretation screening panel details

10 Data collection and assessment Sample type requested for testing Codons assessed for RAS mutation screening Percentage of laboratories meeting minimum requirements

11 Results (1) Sample type requested. Run 1 Run 2 Run 1 Run (n=86) (n=91) (n=101) (n=120) Mounted FFPE sections only 34 (40%) 34 (37%) 37 (37%) 46 (38%) Rolled section plus FFPE section 36 (42%) 40 (44%) 46 (46%) 53 (44%) Rolled sections only 16 (19%) 17 (19%) 18 (18%) 21 (18%)

(2014-15) n=84 KRAS run 2 (2014-15) n=84 KRAS

12 Results (2) KRAS panel testing Percentage of L KRAS run1 ( ) n=84 KRAS run 2 ( ) n=84 KRAS run 1 ( ) n=99 KRAS run 2 ( ) n=108

13 Results (3) NRAS panel testing Percentage of Lab NRAS run 1 ( ) n=84 NRAS run 2 ( ) n=84 NRAS run 1 ( ) n=99 NRAS run 2 ( ) n=108

Results (4) Who meets the UK recommendations? KRAS exons 2, 3 & 4 NRAS exons 2 & 3 80 Percentage (%) 70 68.7 60 55.6 50 40 36.1 30 25.

14 Results (4) Who meets the UK recommendations? KRAS exons 2, 3 & 4 NRAS exons 2 & 3 80 Percentage (%) Labs testing at least according to UK Guidelines Labs undertesting Run 1 (n=99) Run 2 (n=108) Testing panel undetermined

15 Results (5) Who meets the USA guidelines? KRAS exons 2, 3 & 4 NRAS exons 2, 3 & 4 80 Percentage (%) Labs testing at least according to USA Guidelines Labs undertesting Testing panel undetermined Run 1 (n=99) Run 2 (n=108)

16 Summary Increases in % screening of KRAS exons 3 and 4 Increases in % screening of NRAS exons 2, 3 and 4, Shift to NGS technologies BUT, clearly a delay in the implementation of evidencebased guidelines

European Medicines Agency (EMA) Not prescriptive

17 Why the delay? Use of FDA-approved Kits in the USA QIAGEN therascreen KRAS RGQ PCR Kit Roche cobas KRAS kit NICE patients with wild-type RAS metastatic colorectal cancer European Medicines Agency (EMA) Not prescriptive regarding testing methodology Allows in-house methods/new kits Costs involved in validating are prohibitive

18 Take home messages Provided evidence of the nature of current RAS testing Alarming lack of extended RAS testing Practice needs to be altered to prevent over-treatment of patients with anti-egfr therapy

19 Acknowledgements Sample sourcing & validation laboratories UK NEQAS for Molecular Pathology Specialist Advisory Group Peer assessors UK NEQAS for Molecular Genetics team Scheme participants

KRAS G13D mutation testing and anti-egfr therapy

KRAS G13D mutation testing and anti-egfr therapy KRAS G13D mutation and anti-egfr therapy Current data do not support a need to specifically identify this mutation for assessing anti-egfr eligibility in