Moleculr Testing in Antomic Pthology nd Adherence to Guidelines A College of Americn Pthologists Q-Probes Study of 2230 Testing Events Reported by 26 Institutions Keith E. Volmr, MD; Michel O. Idowu, MD, MPH; Rhon J. Souers, MS; Rouf E. Nkhleh, MD Context. The pproprite nd timely performnce of moleculr testing in ntomic pthology is n indictor of qulity. The Ntionl Comprehensive Cncer Network (NCCN) publishes comprehensive tretment guideline tht includes recommendtions for ncillry testing. Objective. To estblish benchmrks for rtes of dherence to NCCN testing recommendtions through multiinstitutionl study. Design. Prticipnts in 2013 Q-Probes study of the College of Americn Pthologists reported dt from moleculr testing on ntomic pthology cses, excluding hemtolymphoid neoplsms, brest primry crcinoms, nd gynecologic cytology. Results. Twenty-six institutions reported dt from 2230 moleculr testing events. In retrospective study limited to colon, lung, nd melnom, there ws strict dherence to guidelines in medin 71% (10th to 90th percentile rnge, 33% 90%) nd there ws t lest loose dherence in medin 95% (10th to 90th percentile rnge, 57% 100%). There ws dequte tissue to complete testing in medin 98% (10th to 90th percentile rnge, 86% 100%); in ggregte the dequcy rte for cell blocks ws lower (84%, P,.001). Medin test turnround time ws 8 dys (10th to 90th percentile rnge, 4 13 dys). In prospective collection of ll orgn sites, there ws strict dherence to guidelines in medin 53% (10th to 90th percentile rnge, 20% 71%), nd there ws t lest loose dherence in medin 94% (10th to 90th percentile rnge, 75% 100%). Adherence to guidelines ws higher for lung specimens nd in institutions with more multidisciplinry conferences. Conclusions. This multi-institutionl study provides benchmrking dt on ppropriteness nd timeliness of moleculr testing in ntomic pthology. (Arch Pthol Lb Med. 2015;139:1115 1124; doi: 10.5858/rp.2014-0513-CP) With the rpid growth of specilized ncillry testing, lbortories re frequently sked to use ntomic pthology mteril to perform moleculr testing. Such testing my be conducted either in-house or s send-out to reference lbortory, nd the testing my be quite costly. In some cses, lbortories perform reflex moleculr tests s initited by pthologists. While there re some guidelines on clinicl relevnce nd performnce of these tests, there is currently limited informtion in the literture bout dherence to these guidelines. There re severl chemotherpeutic regimens tht rely upon ncillry testing to guide therpy. The Ntionl Accepted for publiction November 24, 2014. From the Deprtment of Pthology, Rex Pthology Assocites, Rleigh, North Crolin (Dr Volmr); the Deprtment of Pthology, Virgini Commonwelth University, Richmond (Dr Idowu); the Deprtment of Biosttistics, College of Americn Pthologists, Northfield, Illinois (Ms Souers); nd the Deprtment of Pthology, Myo Clinic Jcksonville, Jcksonville, Florid (Dr Nkhleh). The uthors hve no relevnt finncil interest in the products or compnies described in this rticle. Reprints: Keith E. Volmr, MD, Rex Pthology Assocites, 4420 Lke Boone Tril, Rleigh, NC 27607 (e-mil: keith.volmr@ rexhelth.com). Comprehensive Cncer Network (NCCN) guidelines 1 re widely used nd they provide recommendtions for the use of ncillry testing in vrious tumor types. Guidelines for lung crcinom, 2 colorectl crcinom, 3 nd melnom 4 (current t the time this study ws conducted [2013]) re briefly summrized herein. For metsttic or loclly dvnced nonsqumous, non smll cell lung crcinom, the NCCN guidelines include epiderml growth fctor receptor gene (EGFR) muttion nlysis nd nplstic lymphom kinse gene (ALK) rerrngement testing by fluorescence in situ hybridiztion (FISH), with testing for ROS1 gene rerrngement by FISH listed s n dditionl considertion. For metsttic colorectl denocrcinom, KRAS nd BRAF muttion testing ppers on the NCCN guidelines, but EGFR muttion testing is not recommended. In metsttic melnom, NCCN guidelines include BRAF muttion nlysis, s the V600E or V600K muttions of the BRAF gene guide vemurfenib therpy. In ddition, KITmutted melnoms my be treted with imtinib. A recently published guideline from the College of Americn Pthologists, Interntionl Assocition for the Study of Lung Cncer, nd Assocition for Moleculr Pthology (CAP/IASLC/AMP) specificlly ddresses EGFR nd ALK testing for lung crcinoms. 5 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l 1115
This Q-Probes study imed to ssess how frequently moleculr testing in ntomic pthology dhered to NCCN guidelines nd to determine if ny prctice or demogrphic chrcteristics were relted to this rte. In ddition, dt were collected to determine testing turnround times nd dequcy of vrious specimen types for moleculr testing. MATERIALS AND METHODS Dt Collection The study consisted of 2 dt collections. One ws retrospective collection limited to cses of lung primry crcinom, colorectl primry crcinom, nd melnom for which moleculr testing ws performed or ttempted during the prior yer, or until 40 cses were collected, whichever cme first. The second ws prospective collection of ll cses of solid tumors for which moleculr testing ws requested during period of 2 months or until 30 cses were collected, whichever cme first. For both dt collections prticipnts recorded the following for ech cse: primry tumor site; tumor histology; ordering provider; specimen type; extent of clinicl disese; which moleculr tests were requested, performed, or ttempted; nd the primry rtionle for the test request. The study uthors then compred these dt points to the NCCN guidelines s were current t the time of dt collection (beginning erly 2013) nd ssessed ech moleculr test s either (1) strictly meeting the guideline, (2) loosely meeting the guideline, or (3) not meeting the guideline. In ddition, turnround time informtion nd specimen dequcy were reported for the retrospective study. Both dt collections excluded brest primry crcinoms, hemtolymphoid tumors, nd gynecologic cytology. Lynch syndrome screening ws excluded from the retrospective study but included in the prospective study. Both dt collections included in-house nd send-out testing. Definitions To clssify the moleculr testing events nd to ssess dherence to guidelines, the following definitions were pplied. Moleculr Test. Anlysis for the presence or quntittion of nucleic cids (either DNA or RNA) nd proteins with the im to guide therpy, predict prognosis, dignose disese, or predict occurrence of disese. Exmples pplied to ntomic pthology specimens include gene sequencing, DNA hybridiztion techniques (eg, fluorescence in situ hybridiztion, chromogenic in situ hybridiztion, microrrys), nd mplifiction methods (eg, polymerse chin rection). Strict Adherence to Guidelines. The test is included in the NCCN guideline s n integrl prt of the decision-mking lgorithm (eg, EGFR testing in metsttic or loclly dvnced lung denocrcinom, KRAS testing in metsttic colorectl denocrcinom). Loose Adherence to Guidelines. The test is not prt of the NCCN decision-mking lgorithm but it flls into either of the following ctegories: (1) the test is directly relted to other stndrd tests in the guideline, mking its performnce resonble in certin situtions (eg, KRAS or ROS1 testing in metsttic or loclly dvnced lung denocrcinom) or (2) the test is mentioned in the guideline s considertion for certin ptients (eg, Lynch syndrome screening in colon denocrcinom, BRAF testing in metsttic colorectl denocrcinom). Dt Anlysis For both dt collections the primry performnce indictors were the percentge of tests tht strictly met the NCCN guidelines nd the percentge of tests tht t lest loosely met the guidelines. There were 2 dditionl performnce indictors for the retrospective study of lung crcinom, colon crcinom, nd melnom: the percentge of cses with dequte tissue for moleculr testing nd the medin turnround time from moleculr test request to test result. Sttisticl nlysis ws performed to determine which fctors were significntly ssocited with the performnce indictors. Prticipnt results were excluded from the nlysis for those indictors bsed on fewer thn 5 tests. Associtions between the performnce indictors with the demogrphic nd prctice vribles were nlyzed by using Kruskl-Wllis tests for discrete-vlued independent vribles nd regression nlysis for the continuous independent vribles. Vribles with significnt ssocitions (ny P vlue,.10) identified by this initil nlysis were then included in forwrd selection multivrite regression model for which significnce level of.05 ws used. The distributions of the ggregte test chrcteristics were compred by using the v 2 tests nd Fisher exct test; significnce level of.05 ws used for these tests. All sttisticl tests were performed with SAS 9.2 (SAS Institute, Cry, North Crolin). RESULTS Demogrphics Twenty-six institutions submitted dt for this Q-Probes study. Twenty-five (97%) were locted in the United Sttes nd 1 in Brzil. Sixteen (62%) were teching hospitls nd 12 (46%) hd pthology residency trining progrms. Prticipnt Chrcteristics Within the pst 2 yers, ll 26 prticipting lbortories hd been inspected by the CAP, nd 3 (11%) hd been inspected by The Joint Commission. Seventeen (65%) institutions were urbn, 5 (19%) were suburbn, nd 4 (15%) were rurl. Fifteen (58%) were voluntry nonprofit hospitls, 6 (23%) were nongovernmentl university hospitls, nd there ws 1 lbortory from ech of the following ctegories: governmentl nonfederl university, other nongovernmentl, proprietry hospitl, system/integrted delivery network, nd veterns hospitl. Distribution of bed size ws s follows: 0 150, 8 (31%); 151 300, 7 (27%); 301 450, 2 (8%); 451 600, 5 (19%); nd greter thn 600, 4 (15%). Prctice Chrcteristics In the prior yer (2012), prticipting lbortories hd ccessioned medin of 16 963 surgicl pthology cses (10th to 90th percentile rnge, 4832 40 425) nd medin of 2507 nongynecologic cytology cses (10th to 90th percentile rnge, 276 11 530). Retrospective Study of Lung, Colon, nd Melnom The retrospective portion of the study consisted of collection of testing tht hd been either performed or ttempted on cses of colon primry crcinom, lung primry crcinom, nd melnom. Twenty-six institutions reported dt on 1508 testing events. In ggregte, 996 of 1508 (66%) strictly dhered to NCCN guidelines nd 1319 of 1508 (87%) t lest loosely met guidelines. For ll institutions the medin for strict dherence ws 71% nd medin for loose dherence ws 95% (Tble 1). The medin turnround time ws 8 dys, with 10th to 90th percentile rnge of 4 to 13 dys. The ggregte turnround time ws wide, rnging from sme dy to 127 dys. There ws dequte tissue to obtin test result in medin 98%, with 10th to 90th percentile rnge of 86% to 100%. Detils of the individul cses re listed in Tble 2. Pthologistinitited reflex testing ccounted for 483 of 1508 of testing (32%), while medicl oncologist orders ccounted for 56%. The tested specimen ws n excision in minority of cses (498 of 1508, 33%), with the reminder of specimens 1116 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l
Tble 1. Moleculr Testing Adherence to Ntionl Comprehensive Cncer Network Guidelines All Institutions Percentiles n 10th 25th Medin 75th 90th Retrospective study (lung, colorectl, melnom) Percentge of tests tht strictly meet the guideline 26 32.6 64.7 70.9 82.7 89.7 Percentge of tests tht t lest loosely meet the guideline 26 57.4 90.7 95.1 98.9 100.0 Prospective study (ll cse types) Percentge of tests tht strictly meet the guideline 23 20.0 31.4 53.3 66.7 70.5 Percentge of tests tht t lest loosely meet the guideline 23 75.0 87.0 94.3 100.0 100.0 consisting of smller biopsy smples. The moleculr tests performed or ttempted re listed in Tble 3; EGFR, ALK, nd KRAS were the most common by lrge mrgin. Detils regrding dequcy of mteril by specimen type re in Tble 4; cell blocks showed significntly lower dequcy rte thn other specimen types (P,.001). Lynch syndrome screening ws to be excluded from the retrospective study, but some prticipnts did include such cses (93 of 1508 test events, 6.2% of totl). Prospective Study of All Cse Types The prospective portion of the study consisted of collection of requests for moleculr testing regrdless of orgn site. Twenty-three institutions reported dt on 722 testing events. In ggregte, 360 of 722 (50%) strictly dhered to NCCN guidelines nd 645 of 722 (89%) t lest loosely met guidelines. For ll institutions the medin for strict dherence ws 53% nd the medin for loose dherence ws 94% (Tble 1). Detils for the individul cses re listed in Tble 5. The most common orgn sites were the lower gstrointestinl trct nd lung. Pthologistinitited reflex testing ccounted for 303 of 722 tests (42%) nd medicl oncologists ccounted for 325 of 722 test requests (45%). Agin, excision specimens were in the minority (303 of 722, 42%). Detils regrding the moleculr tests requested re listed in Tble 6. The most common requests were for EGFR, KRAS, ALK, Lynch syndrome screening, nd BRAF. Generl Questionnire Prticipnts lso completed generl questionnire regrding vrious spects of institutionl prctices nd hndling of some specific testing situtions (Tbles 7 through 12). Most lbortories do not hve written policy for turnround time gols in moleculr testing. There ws vrition in how moleculr test orders re hndled, including 4 of 23 prticipnts (17%) reporting tht neither MD nor PhD personnel re involved in the process. Slightly more thn hlf of prticipnts require pthology deprtment pprovl for some moleculr testing, nd generlly such pprovl is required for send-out testing, proprietry tests, nd testing for inptients. One institution required pthology pprovl for ll moleculr tests. It ppers tht some effort is mde to hve block nd slide selection performed by pthologist fmilir with the cse, though smll minority of lbortories (2 of 23, 9%) hve designted specific pthologist for this function. In terms of creting n integrted report, 15 of 23 lbortories (65%) routinely incorporte moleculr test results into ntomic pthology reports, nd two-thirds of those prticipnts routinely include correltive informtion s to the significnce of the test results. Prticiption in tumor bords ws common, with generl tumor bords (18 of 23, 78%) nd brest conferences (18 of 23, 78%) the most common. Nerly ll of the prticipting institutions (19 of 21, 90%) hold cncer ccredittion of some form. Additionl prctice detils re listed in Tble 7. Pthologist-initited reflex testing is performed in slightly more thn hlf of prticipting lbortories (13 of 23, 57%), nd most (8 of 13, 62%) of these institutions do not require stnding written order for such reflex testing. The most commonly performed reflex tests were immunohistochemistry for mismtch repir proteins (12 of 13, 92%), followed by ALK nd EGFR testing on lung tumors with pproprite histology (8 of 13, 62% ech) nd KRAS testing on colon cncers (8 of 13, 62%). A minority of lbortories (5 of 13, 39%) use sequentil or lgorithmic pproch to reflex testing. Most lbortories (18 of 23, 78%) re ble to meet the 10-dy turnround time gol for EGFR nd ALK testing on lung cses. Additionl detils re listed in Tble 8. Prticipnts reported detils on specil hndling techniques for smll biopsy smples nd cytology specimens in nticiption of moleculr testing. Roughly hlf of lbortories hndle lung biopsy smples differently from other specimen types, including cutting dditionl unstined slides or mking fewer initil levels for hemtoxylin-eosin stining. Preliminry dequcy ssessment for fine-needle spirtion specimens is provided in 21 of 23 lbortories (91%). Additionl detils re listed in Tble 9. Lbortories reported which moleculr tests were performed in-house versus send-out in their prctices (Tble 10). Most tests re send-outs, nd 10 lbortories do not perform ny in-house moleculr tests. For in-house testing, prticipnts reported vrious detils regrding microdissection nd reporting. The Medicre 14-dy rule ws not consistently followed, s more thn hlf of prticipnts (6 of 11, 55%) disregrd the rule for in-house testing nd 9 of 22 (41%) disregrd the rule for send-out testing. Additionl detils re listed in Tble 11. There ws vrition in the pproch to screening for Lynch syndrome, with 6 of 23 (26%) using n lgorithm involving reflex immunohistochemistry nd polymerse chin rection testing nd n equl proportion routinely performing both tests concurrently. The reminder vried by clinicin request nd individul pthologist prctice. Similrly, there ws wide vrition in how ptients were selected for testing. Additionl detils re provided in Tble 12. Prctice Chrcteristics nd the Effect on the Performnce Indictors The performnce indictors were tested for ssocitions with institutionl demogrphic nd prctice vribles. A P vlue below.05 ws considered sttisticlly significnt. Although no ssocitions were identified between the performnce indictors nd the demogrphic or prctice chrcteristics, 2 observtions were found for the retrospec- Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l 1117
Tble 2. Detils of Retrospective Study (Lung, Colon, Melnom) Cse type Lung crcinom 499 60.7 Colon crcinom 251 30.5 Melnom 72 8.8 Histology Adenocrcinom (invsive) 598 73.4 Melnom 73 9.0 Non smll cell crcinom, not otherwise specified 49 6.0 Crcinom, not otherwise specified 26 3.2 Squmous cell crcinom 20 2.5 Adenocrcinom in situ 15 1.8 Adenosqumous crcinom 5 0.6 Lrge cell neuroendocrine crcinom 5 0.6 Lrge cell crcinom, not otherwise specified 3 0.4 Smll cell crcinom 3 0.4 Crcinoid/low-grde neuroendocrine tumor 1 0.1 Other 17 2.1 Ordering provider Medicl oncologist 451 56.4 Pthologist (reflex test) 257 32.1 Surgeon 61 7.6 Rdiology oncologist 6 0.8 Generlist 3 0.4 Other 22 2.8 Specimen type Excision 268 32.6 Core biopsy 186 22.6 Incisionl or open biopsy 163 19.8 Cytology cell block 96 11.7 Cytology smer 5 0.6 Other smll biopsies (eg, forceps biopsies) 104 12.7 Extent of clinicl disese Metstsis proven 354 43.1 Not known 247 30.0 Loclly confined 120 14.6 Metstsis suspected 51 6.2 Loclly dvnced 44 5.4 Recurrence or refrctory 6 0.7 Primry reson for test request Predictive/guide therpy 515 62.8 Not known 138 16.8 Dignostic 91 11.1 Prognostic 74 9.0 Ptient request 1 0.1 Reserch/clinicl tril 1 0.1 Adequte mteril for testing Yes 752 95.7 No 34 4.3 No. of moleculr tests performed or ttempted per cse 1 387 47.4 2 261 32.0 3 110 13.5 4 27 3.3 5 25 3.1 6 6 0.7 tive study of lung, colon, nd melnom cses. First, institutions holding higher number of multidisciplinry conferences tended to hve higher rte of moleculr testing t lest loosely meeting guidelines (P ¼.07). Second, compred to colon cncer nd melnom, lung cncer testing more often strictly met guidelines (74% lung, 44% colon, 61% melnom, P,.001) nd more often t lest Tble 3. Tests Performed or Attempted in Retrospective Study (Lung, Colon, Melnom) Moleculr Test Performed or Attempted EGFR 446 29.6 ALK (EML4-ALK) 358 23.7 KRAS 307 20.4 BRAF 114 7.6 Lynch syndrome screening (MMR/MSI) 93 6.2 NRAS 39 2.6 PIK3CA 39 2.6 ROS1 24 1.6 KIT 22 1.5 HER2/ERBB2 (only nonbrest cses) 5 0.3 ERCC1 3 0.2 HRAS 2 0.1 MET 2 0.1 Other 54 3.6 Other moleculr test, submitted text response Proprietry tests (45)...... Unrecognized tests (9)...... Abbrevitions: ALK, nplstic lymphom receptor tyrosine kinse (nplstic lymphom kinse); BRAF, B-Rf proto-oncogene, serine/ threonine kinse (v-rf murine srcom virl oncogene homolog B); EGFR, epiderml growth fctor receptor; EML4, echinoderm microtubule-ssocited protein-like 4; ERCC1, excision repir cross-complementtion group 1; HER2/ERBB2, v-erb-b2 vin erythroblstic leukemi virl oncogene homolog 2 (humn epiderml growth fctor receptor 2); HRAS, Hrvey rt srcom virl oncogene homolog; KIT,vkit Hrdy-Zuckermn 4 feline srcom virl oncogene homolog; KRAS, Kirsten rt srcom virl oncogene homolog; MET, MET protooncogene, receptor tyrosine kinse; MMR, mismtch repir protein; MSI, microstellite instbility; NRAS, neuroblstom rt srcom virl (v-rs) oncogene homolog; PIK3CA, phosphtidylinositol-4,5-bisphosphte 3-kinse, ctlytic subunit ; ROS1, ROS proto-oncogene 1, receptor tyrosine kinse. loosely met guidelines (90% lung, 81% colon, 82% melnom, P,.001). Two similr observtions were found for the prospective study of ll cse types. First, testing on lung cncer more often strictly met guidelines when compred to other specimen sites, such s melnom nd lower gstrointestinl trct (71% lung, 63% melnom, 29% colon, 39% ggregte other, P,.001). Second, testing on lung, colon, brin/spinl cord, nd skin/melnom more often t lest loosely met guidelines when compred to ll other sites (96% lung, 87% colon, 96% melnom, 96% brin/spinl cord, 82% ggregte other, P,.001), bsed on the ggregte test results. Rurl institutions hd longer moleculr testing turnround time thn institutions locted in city/suburbn res. This observtion ws not formlly tested becuse of the low smple size (4 rurl nd 22 city/ Tble 4. Specimen Type nd Adequcy for Moleculr Testing (Retrospective Study of Lung, Colon, Melnom) Specimen Type No. of Specimens No. With Adequte Mteril (%) Excision 251 250 (99.6) Core biopsy 176 163 (92.6) Incisionl or open biopsy 155 152 (98.1) Cytology cell block 95 80 (84.2) Cytology smer 5 4 (80.0) Other smll biopsies (eg, forceps biopsies) 103 102 (99.0) Sttisticlly significnt difference between cytology cell block nd ll other types (Fisher exct test; P,.001). 1118 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l
Tble 5. Detils of Prospective Study (All Cse Types) Tumor site Lower gstrointestinl trct (smll bowel, colon) 177 35.8 Lung 171 34.6 Skin 24 4.9 Brin nd spinl cord 19 3.8 Genitl, femle 19 3.8 Lymph node 14 2.8 Upper gstrointestinl trct (esophgus, stomch, duodenum) 14 2.8 Thyroid 11 2.2 Liver nd biliry trct 9 1.8 Nsophrynx-orophrynxhypophrynx 7 1.4 Unknown primry 7 1.4 Soft tissue 6 1.2 Kidney 5 1.0 Genitl, mle 2 0.4 Brest (exclude primry crcinom) 1 0.2 Slivry glnd 1 0.2 Other 7 1.4 Histology Adenocrcinom (invsive) 359 72.7 Melnom 30 6.1 Crcinom, not otherwise specified 27 5.5 Gliom 18 3.6 Non smll cell crcinom, not otherwise specified 16 3.2 Squmous cell crcinom 14 2.8 Adenocrcinom in situ 5 1.0 Lrge cell neuroendocrine crcinom 4 0.8 Srcom 3 0.6 Gstrointestinl stroml tumor 1 0.2 Lrge cell crcinom, not otherwise specified 1 0.2 Smll cell crcinom 1 0.2 Other 15 3.0 Ordering provider Medicl oncologist 216 45.0 Pthologist (reflex test) 201 41.9 Surgeon 50 10.4 Rdiology oncologist 7 1.5 Geneticist 2 0.4 Other 4 0.8 Specimen type Excision 208 42.3 Core biopsy 82 16.7 Incisionl or open biopsy 76 15.4 Cytology cell block 47 9.6 Other smll biopsies (eg, forceps biopsies) 79 16.1 Extent of clinicl disese Metstsis proven 202 40.9 Not known 138 27.9 Loclly confined 90 18.2 Loclly dvnced 36 7.3 Metstsis suspected 23 4.7 Recurrence or refrctory 5 1.0 Primry reson for test request Predictive/guide therpy 285 57.9 Prognostic 117 23.8 Dignostic 70 14.2 Not known 19 3.9 Reserch/clinicl tril 1 0.2 No. of requested moleculr tests per cse 1 254 55.8 2 142 31.2 3 52 11.4 4 7 1.5 Tble 6. Test Requests From Prospective Study (All Cse Types) Moleculr Test Requested EGFR 163 22.6 KRAS 159 22.0 ALK (EML4-ALK) 114 15.8 Lynch syndrome screening (MMR/MSI) 113 15.7 BRAF 74 10.2 HER2/ERBB2 (only nonbrest cses) 14 1.9 MGMT methyltion 14 1.9 KIT 13 1.8 HPV in situ hybridiztion (excluding GYN cytology) 9 1.2 ROS1 8 1.1 1p nd 19q deletion 6 0.8 IDH1 nd/or IDH2 muttion 4 0.6 NRAS 2 0.3 PAX8-PPARA 2 0.3 HPV genotype (excluding GYN cytology) 1 0.1 HRAS 1 0.1 MET 1 0.1 PDGFRA 1 0.1 Other 23 3.2 Other moleculr test, submitted text response Proprietry tests (19)...... MSH6 (1)...... TP53 (1)...... Thymidylte synthse (1)...... Unrecognized test (1)...... Abbrevitions: ALK, nplstic lymphom receptor tyrosine kinse (nplstic lymphom kinse); BRAF, B-Rf proto-oncogene, serine/ threonine kinse (v-rf murine srcom virl oncogene homolog B); EGFR, epiderml growth fctor receptor; EML4, echinoderm microtubule-ssocited protein-like 4; GYN, gynecologic; HER2/ERBB2, v-erbb2 vin erythroblstic leukemi virl oncogene homolog 2 (humn epiderml growth fctor receptor 2); HPV, humn ppillom virus; HRAS, Hrvey rt srcom virl oncogene homolog; IDH, isocitrte dehydrogense; KIT, v-kit Hrdy-Zuckermn 4 feline srcom virl oncogene homolog; KRAS, Kirsten rt srcom virl oncogene homolog; MET, MET proto-oncogene, receptor tyrosine kinse (protooncogene/c-met); MGMT, O-6-methylgunine-DNA-methyltrnsferse; MMR, mismtch repir protein; MSH6, muts homolog 6; MSI, microstellite instbility; NRAS, neuroblstom rt srcom virl oncogene homolog; PAX8-PPARA, pired box 8 peroxisome prolifertor-ctivted receptor ; PDGFRA, pltelet-derived growth fctor receptor, polypeptide; ROS1, ROS proto-oncogene 1, receptor tyrosine kinse (c-ros oncogene 1); TP53, tumor protein p53. suburbn institutions), but the rurl turnround time ws medin 13 dys (rnge, 8 16 dys), wheres city/suburbn turnround time ws medin 7 dys (rnge, 1 12 dys). COMMENT This Q-Probes study exmined the rte of dherence to NCCN guidelines for moleculr testing, the turnround time for moleculr tests, nd the dequcy of specimens for testing. The study included both in-house nd send-out testing on ntomic pthology specimens. Excluded from the study were cses of hemtolymphoid neoplsi, brest primry crcinoms, nd gynecologic cytology specimens. The study consisted of 2 dt collections: 1 retrospective nd 1 prospective. The retrospective collection consisted of testing tht hd been previously performed or ttempted nd ws restricted to lung crcinom, colorectl crcinom, nd melnom. In ddition to llowing more focused ssessment of solid tumors tht re commonly tested, the retrospective collection enbled ssessment of turnround time nd dequcy of mteril for test completion. The Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l 1119
Tble 7. Lbortory Prctices Relted to Mngement nd Reporting of Moleculr Tests Does your lbortory hve written policy for turnround time gols for moleculr testing on solid tumors in ntomic pthology? Yes 5 21.7 No 18 78.3 Who typiclly mnges orders for moleculr testing on solid tumors in ntomic pthology in your deprtment? Any vilble pthologist 10 43.5 Non-MD, non-phd personnel 4 17.4 Select pthologist(s) specificlly designted for this function 4 17.4 Other 4 17.4 Other ctegory, submitted text response Cse pthologist (2)...... Combintion of MD, non-md, non-phd personnel (1)...... PhD specificlly ssigned for cse (1)...... N/A, such orders re typiclly mnged through stnding protocols 1 4.3 Is pthology deprtment pprovl required for ny moleculr tests on solid tumors in ntomic pthology in your institution? Yes 12 52.2 No 11 47.8 If yes, which of the following require pthology deprtment pprovl? (n ¼ 12) Send-out moleculr tests 11 91.7 Moleculr tests on inptients 8 66.7 Proprietry moleculr tests 7 58.3 Moleculr tests bove cost threshold 1 8.3 Other 1 8.3 Other ctegory submitted text response All moleculr testing (1) Who typiclly chooses the blocks or slides used for moleculr testing on solid tumors in ntomic pthology? Pthologist fmilir with the cse 14 60.9 Any vilble pthologist 7 30.4 Select pthologist(s) specificlly designted for this function 2 8.7 Do you incorporte the results of moleculr testing for solid tumors into ntomic pthology reports? Yes, either n ddendum or mendment is issued to the ntomic pthology report 15 65.2 No 8 34.8 If yes, do you routinely provide correltive informtion regrding the significnce of the moleculr test results? Yes 10 66.7 No 5 33.3 Which multidisciplinry conferences re held t your institution? (n ¼ 23) Brest 18 78.3 Generl tumor bord 18 78.3 Gstrointestinl 11 47.8 Genitourinry 11 47.8 Gynecologic 11 47.8 Generl surgicl conference 9 39.1 Hemtopthology 9 39.1 Infectious disese 9 39.1 Liver 9 39.1 Neurosurgery 9 39.1 Renl 9 39.1 Thorcic 9 39.1 Endocrine 8 34.8 Hed nd neck 7 30.4 None 1 4.3 Does your institution hold ccredittion s recognized cncer progrm? (n ¼ 21) Yes, Americn College of Surgeons Commission on Cncer 15 71.4 Yes, other cncer progrm ccredittion 5 23.8 No, my institution is not cncer center 2 9.5 Abbrevition: N/A, not pplicble. Multiple responses llowed. retrospective dt collection reveled tht medin 71% of cses strictly met guidelines nd medin 95% t lest loosely met guidelines. In the retrospective collection the most common tests were for EGFR, ALK, nd KRAS, in ggregte comprising 74% (1111 of 1508) of tests. The prospective dt collection consisted of requests for moleculr testing nd included broder spectrum of orgn sites. This dt collection enbled ssessment of the bredth of moleculr test requests, the distribution of tumor types nd orgn sites undergoing testing, nd llowed cpture of ny test requests tht, for vrious resons, ultimtely my not hve been completed. For the prospective collection, medin of 53% of cses strictly met guidelines nd medin 94% t lest loosely met guidelines. The most common tests 1120 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l
Tble 8. Lbortory Prctices Relted to Reflex Testing nd Turnround Time Does your lbortory routinely initite reflex moleculr testing on solid tumors in ntomic pthology? Yes 13 56.5 No, we do not perform reflex moleculr testing 10 43.5 If yes, do you require stnding order for reflex testing? Yes 5 38.5 No 8 61.5 If yes, wht reflex moleculr testing do you routinely perform on solid tumors in ntomic pthology? (n ¼ 13) MMR immunohistochemistry for colon cncers 12 92.3 ALK (EML4-ALK) for lung cncers with pproprite histology 8 61.5 EGFR for lung cncers with pproprite histology 8 61.5 KRAS for colon cncers with pproprite histology 8 61.5 KRAS for lung cncers with pproprite histology 7 53.8 MSI polymerse chin rection for colon cncers 7 53.8 BRAF for melnoms 5 38.5 BRAF for colon cncers with pproprite histology 3 23.1 ROS1 for lung cncers with pproprite histology 1 7.7 If yes, does ny of your reflex testing on solid tumors follow sequentil or lgorithmic pproch? Yes 5 38.5 No 8 61.5 Wht is your most common pproch for EGFR nd EML4-ALK testing in non smll cell lung crcinoms? Both tests re performed t the sme time (only EGFR nd EML4-ALK re performed) 15 65.2 These 2 tests re performed s prt of broder test pnel 7 30.4 A sequentil/lgorithmic pproch is used (involving only EGFR nd EML4-ALK) 1 4.3 Are you ble to consistently meet the recommended turnround time gol of 10 working dys for EGFR nd EML4-ALK testing in non smll cell lung crcinoms? Yes 18 78.3 No 5 21.7 Abbrevitions: ALK, nplstic lymphom receptor tyrosine kinse (nplstic lymphom kinse); BRAF, B-Rf proto-oncogene, serine/threonine kinse (v-rf murine srcom virl oncogene homolog B); EGFR, epiderml growth fctor receptor; EML4, echinoderm microtubule-ssocited protein-like 4; KRAS, Kirsten rt srcom virl oncogene homolog; MMR, mismtch repir protein; MSI, microstellite instbility; ROS1, ROS protooncogene 1, receptor tyrosine kinse (c-ros oncogene 1). Multiple responses llowed. Tble 9. Lbortory Prctices Relted to Smll Biopsy nd Cytology Specimens Do you routinely use techniques to preserve tissue for moleculr testing for smll biopsy nd FNA specimens? Yes, lung tumor biopsy specimens re hndled differently 12 52.2 No, ll specimens re hndled in bsiclly the sme mnner 11 47.8 If pplicble, how re lung tumor biopsy specimens hndled differently? (n ¼ 12) Additionl unstined slides re initilly cut from biopsy specimens 9 75.0 Fewer initil levels re mde compred to other biopsy specimens 3 25.0 Immunohistochemicl study is typiclly limited to certin number of stins 2 16.7 Additionl unstined FNA smers re mde 1 8.3 Other 4 33.3 Other ctegory submitted text response Dul stins used (1)...... EGFR ordered before immunohistochemistry (1)...... For lung biopsy specimens, wht is the number of dditionl unstined slides initilly cut? 3 1 11.1 5 4 44.4 6 2 22.2 9 1 11.1 15 1 11.1 For lung biopsy specimens, wht is the typicl limit of the number of slides for immunohistochemicl study? 2 1 50.0 3 1 50.0 For fine-needle spirtion specimens, does your deprtment provide preliminry dequcy ssessment? Yes, routinely 21 91.3 No, we do not provide on-site ssessment 2 8.7 Abbrevitions: EGFR, epiderml growth fctor receptor; FNA, fine-needle spirtion. Multiple responses llowed. Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l 1121
Tble 10. Lbortory Prctices Relted to Moleculr Testing Loction In-House Send-Out Where re ech of the following moleculr tests performed in your prctice? MMR immunohistochemistry 12 54.5 10 45.5 HER2/ERBB2 fluorescence in situ hybridiztion 9 39.1 14 60.9 KRAS muttion nlysis 8 34.8 15 65.2 BRAF muttion nlysis 7 30.4 16 69.6 EGFR muttion nlysis 5 21.7 18 78.3 ALK (EML4-ALK) fluorescence in situ hybridiztion 5 21.7 18 78.3 MSI polymerse chin rection 5 23.8 16 76.2 KIT muttion nlysis 2 11.1 16 88.9 RET muttion nlysis 0 0.0 17 100.0 Abbrevitions: ALK, nplstic lymphom receptor tyrosine kinse (nplstic lymphom kinse); BRAF, v-rf murine srcom virl oncogene homolog B; EGFR, epiderml growth fctor receptor; EML4, echinoderm microtubule-ssocited protein-like 4; HER2/ERBB2, v-erb-b2 vin erythroblstic leukemi virl oncogene homolog 2 (humn epiderml growth fctor receptor 2); KIT, v-kit Hrdy-Zuckermn 4 feline srcom virl oncogene homolog; KRAS, Kirsten rt srcom virl oncogene homolog; MMR, mismtch repir protein; MSI, microstellite instbility; RET, RET proto-oncogene. requested were for EGFR, KRAS, ALK, Lynch syndrome screening, nd BRAF, in ggregte comprising 86% (621 of 722) of the test requests. Rnges of guideline dherence were quite brod mong the prticipting institutions. Institutions holding higher number of multidisciplinry conferences tended to hve higher percentge of testing tht met guidelines. Tests were most frequently requested nd/or performed on lung nd lower gstrointestinl trct specimens. Testing on lung crcinoms more often met NCCN guidelines thn for other orgn sites. Perhps this is relted to the higher profile nd incresed emphsis on moleculr testing of lung cncers through both the NCCN nd the recently published CAP/ IASLC/AMP guideline for EGFR nd ALK testing. 5 Medin turnround time for moleculr tests ws 8 dys, which meets the recommended 10-dy turnround time gol set by the Tble 11. Lbortory Prctices Relted to Technicl Aspects of Moleculr Testing For in-house moleculr testing on solid tumors, do you perform microdissection of specimens for moleculr testing? (n ¼ 22) Yes, mnul microdissection 6 27.3 Yes, lser cpture microdissection 1 4.5 No, do not perform microdissection of specimens 5 22.7 N/A, we do not perform in-house moleculr testing on solid tumors 10 45.5 If pplicble, which personnel type typiclly performs lser cpture microdissection of specimens? Personnel other thn histotechnologist/histotechnicin, pthologist, or pthologist ssistnt 1 100 If pplicble, which personnel type typiclly performs mnul microdissection of specimens? Histotechnologist/histotechnicin 2 28.6 Personnel other thn histotechnologist/histotechnicin, pthologist, or pthologist ssistnt 5 71.4 For in-house moleculr testing on solid tumors, does your moleculr report include n ssessment of the mount of tumor in the specimen? Yes 5 41.7 No 7 58.3 If yes, how is n ssessment of the mount of tumor in the specimen reported? (n ¼ 5) Percentge of tumor cellulrity is reported 4 80.0 Other 1 20.0 For in-house moleculr testing on solid tumors, which of the following best reflects how your lbortory typiclly hndles the 14-dy rule for Medicre ptients? Rule is disregrded; testing is initited t the time of request 6 54.5 Request is held; testing is initited fter pproprite time intervl hs pssed 2 18.2 Other 3 27.3 Other ctegory submitted text response Immunohistochemistry performed in-house, no requisition (1)...... Rule is followed; testing initited upon request (1)...... Test is performed s soon s possible (1)...... For send-out moleculr testing on solid tumors, which of the following best reflects how your lbortory typiclly hndles the 14-dy rule for Medicre ptients? Rule is disregrded; testing is initited t the time of request 9 40.9 Request is held; mteril is sent out fter the pproprite time intervl hs pssed 8 36.4 N/A, we do not send out moleculr tests on solid tumors 1 4.5 Reference lbortory holds the specimen then runs the test t the pproprite time 1 4.5 Other 3 13.6 Other ctegory submitted text response Ask oncologist if result is needed (1)...... Rule is followed; testing initited upon request (1)...... Abbrevition: N/A, not pplicble. Multiple responses llowed. 1122 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l
Tble 12. Lbortory Prctices Relted to Lynch Syndrome Screening For colorectl crcinoms, how does your prctice typiclly hndle requests for Lynch syndrome screening (MMR/MSI testing) by IHC nd PCR? No lgorithm, IHC nd PCR re typiclly performed concurrently 6 26.1 Depends on clinicin/geneticist request 6 26.1 Algorithm strting with IHC, with reflex PCR 5 21.7 Depends on pthologist 2 8.7 Algorithm strting with PCR, with reflex IHC 1 4.3 Other 3 13.0 Other ctegory submitted text response IHC no reflex PCR (2)...... IHC performed first, then reflex PCR if pplicble (1)...... How re ptients typiclly selected for Lynch syndrome screening in colorectl cncers in your institution? All (or nerly ll) ptients with colorectl cncer re tested 11 47.8 Depends on clinicin request 7 30.4 Bethesd guidelines 1 4.3 Amsterdm criteri 0 0.0 Other 2 8.7 Other ctegory submitted text response Amsterdm criteri, Bethesd guidelines, clinicin request nd findings (1)...... Histology with/without Bethesd guidelines (1)...... Do not know 2 8.7 For Lynch syndrome screening in colorectl crcinoms, does your deprtment require informed consent from the ptient for MMR/MSI testing by IHC nd/or PCR? Yes 2 8.7 No 18 78.3 Do not know 3 13.0 Does your deprtment perform Lynch syndrome screening tests on colorectl biopsy mteril? Yes 12 52.2 No 11 47.8 If yes, how is this typiclly hndled? (n ¼ 12) IHC is performed 12 100.0 PCR is performed 4 33.3 If yes nd PCR is performed, wht is typiclly used for the ptient s norml DNA? (n ¼ 4) Norml tissue is microdissected from the tumor biopsy block 3 75.0 Additionl norml tissue is purposely obtined t the time of biopsy 1 25.0 Abbrevitions: IHC, immunohistochemistry; MMR, mismtch repir protein; MSI, microstellite instbility; PCR, polymerse chin rection. Multiple responses llowed. CAP/IASLC/AMP guideline. From our study s generl questionnire, 78% of prticipnts report they re ble to routinely meet the 10-dy turnround time gol for EGFR nd ALK testing in lung cncer. Thus, the 10-dy gol seems resonble. A sequentil or lgorithmic pproch to lung testing hs potentil to reduce the number of tests performed, but only minority (5 of 13, 39%) of our study prticipnts reported such n pproch, nd this ws likely becuse of turnround time concerns. In recent survey of Ntionl Cncer Institute designted cncer centers, verge turnround time for lung cncer testing with sequentil pproch ws 22.8 dys, s compred to 7.6 dys when tests were performed concurrently. 6 Most lbortories (18 of 23, 78%) in our study do not hve forml written gol for turnround time in moleculr testing in ntomic pthology. This study provides some insights into pthologist involvement in moleculr testing nd the importnt function of the pthologist s gtekeeper. In our study most specimens used for moleculr testing were smll biopsy smples, highlighting the pthologist s continuing chllenge to ccomplish ever more with ever less mteril. In ggregte, 96% (751 of 785) of specimens hd dequte mteril for testing, but there were sttisticlly significnt differences for the specimen type, with cytology cell block dequcy rte of only 84% (80 of 95). It is notble tht 91% (21 of 23) of prticipnts routinely perform preliminry dequcy ssessments for fine-needle spirtion specimens, thus the cell block dequcy rte in our study my ctully be higher thn typicl. There were too few dt points to link specimen dequcy to moleculr lbortory dissection prctices. Although pthologist-initited reflex testing comprised minority of the testing in our study, 57% (13 of 23) of lbortories reported tht they routinely provide some form of either reflex or lgorithmic testing, nd most of those lbortories (8 of 13, 62%) do not require stnding written order for the testing. Perhps the other lbortories require written orders s mens to void ny ppernce of inpproprite self-referrl. The most common reflex testing ws for Lynch syndrome screening in colon crcinoms, followed by ALK nd EGFR for lung crcinoms, nd KRAS for colon crcinoms. Similr to other studies, 7 9 we found considerble vribility in both the selection of ptients for Lynch syndrome screening nd in the performnce of the vrious test components, highlighting the need for stndrdiztion in this re. More thn hlf of prticipnts report tht pthology deprtment pprovl is required for t lest subset of moleculr tests, with pprovl most often required for sendout testing, tests for inptients, nd proprietry tests. There ws inconsistent considertion of the 14-dy rule for Medicre ptients; for in-house testing, 55% (6 of 11) of lbortories ignore the rule nd perform testing t the time of request, but only 41% (9 of 22) ignore the rule for send-out testing. This likely reflects n ttempt to blnce finncil concerns with turnround time pressures, but lbortories must tred lightly since indvertent submission of inppro- Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l 1123
prite chrges to Medicre my risk flse clims ccustions. In most prctices orders for moleculr testing re hndled by pthologist or PhD scientist, but 17% (4 of 22) of lbortories reported tht such orders re typiclly hndled by non-md, non-phd personnel. Most lbortories (15 of 23, 65%) incorporte moleculr testing into comprehensive ntomic pthology report, with 67% (10 of 15) of those lbortories routinely dding correltive informtion regrding the significnce of the moleculr testing results. There re limittions to the dt we report. We chose NCCN guidelines becuse they re comprehensive nd widely used, but we recognize tht other tretment guidelines exist. The field of moleculr pthology is rpidly evolving, thus the ppropriteness of testing on specific tumors or orgn sites is fluid nd ongoing clinicl trils will continue to lter prctice ptterns. The NCCN guidelines hve been updted multiple times since the dt collection for this study begn. Assessing dherence to NCCN guidelines ws not lwys cler cut nd there were some gry res involved, hence the designtions of strict dherence nd loose dherence to guidelines. In some cses the mbiguity ws relted to the guidelines themselves, in others it ws due to limittions in our dt collection, nd in others it ws due to limittions in wht prticipnts reported. One exmple of guideline mbiguity is screening for Lynch syndrome. While NCCN encourges testing of ll ptients with colorectl crcinom who re younger thn 50 yers or ptients with stge II disese, it does not stte specific criteri for Lynch syndrome testing. Some centers hve implemented screening of ll colorectl nd endometril cncers, regrdless of ge t dignosis or fmily history, nd this pproch hs been endorsed for colorectl cncer by the Evlution of Genomic Applictions in Prctice nd Prevention Working Group from the Centers for Disese Control. 9 Similrly, ROS1 testing for lung cncer is considertion in ptients who re ALK negtive. For melnom, KIT muttion nlysis is listed s prt of other ctive regimens without strict guidnce s to which ptients should be tested. To keep the dt collection mngeble for prticipnts, the required dt points for ech submitted cse were kept to minimum nd, in some instnces, this ffected ssessment of guideline dherence. For exmple, we did not sk for tumor grde; O-6-methylgunine-DNA-methyltrnsferse gene (MGMT) testing is not pproprite for ll glioms but is restricted to high-grde tumors. We lso did not delinete specific loctions of hed nd neck squmous cell crcinoms; humn ppillom virus testing is not necessrily pproprite for every site in the hed nd neck. We did not collect dt regrding prior tretment regimens; KIT nd pltelet-derived growth fctor receptor gene (PDGFR) muttion testing is not necessrily wrrnted for every ptient with gstrointestinl stroml tumor. We lso did not collect dt regrding ppropriteness of specific testing methodologies (eg, EGFR muttion nlysis versus EGFR mplifiction by fluorescence in situ hybridiztion). Assessment of testing ppropriteness is not possible for tumors of unknown primry site. Limittions in prticipnts submitted dt included some cses with clerly inccurte dt entered (eg, bone primry denocrcinom ) nd some write-in responses for test nmes tht were unrecognizble. For lung primry crcinoms, the study input form listed ll possible crcinom histologic subtypes, but some cses were submitted with histology of other, mking it likely tht t lest some of the dt were reported by nonpthologists. Our dt collection did not scertin if moleculr testing ws performed on ll cses tht could hve potentilly undergone testing, thus we do not hve denomintor or ny mens of mesuring underutiliztion of moleculr testing. Our dt lso do not ddress wht inpproprite testing my hve been performed despite objection by the pthologist. Prticulrly in the community setting, where pthologist s livelihood depends on providing good customer service, it cn be difficult to deny insistent clinicins. We lso do not know if the results of the moleculr tests were cted upon, which could be the focus of future study. Finlly, considering our smll smple size of 26 institutions, nerly ll of which held cncer center ccredittion, our dt re likely not generlizble to ll of pthology prctice. In summry, this Q-Probes study imed to ssess the proportion of ntomic pthology moleculr testing tht dheres to NCCN guidelines. We re not wre of ny prior multi-institutionl study of this topic. The study is limited by low number of prticipnts, but it does provide useful benchmrking dt nd importnt informtion regrding how lbortories re hndling this rpidly growing fcet of pthology prctice. The uthors thnk the prticipting institutions for their time nd diligence in collecting the dt for this study. References 1. Ntionl Comprehensive Cncer Network. NCCN clinicl prctice guidelines in oncology. 2013. http://www.nccn.org/professionls/physicin_gls/f_ guidelines.sp#site. Accessed Mrch 30, 2013. 2. Ntionl Comprehensive Cncer Network. NCCN clinicl prctice guidelines in oncology non smll cell lung crcinom. Version 2. 2013. http://www. nccn.org/professionls/physicin_gls/pdf/nscl.pdf. Accessed Mrch 30, 2013. 3. Ntionl Comprehensive Cncer Network. NCCN clinicl prctice guidelines in oncology colon cncer. Version 3. 2013. http://www.nccn.org/ professionls/physicin_gls/pdf/colon.pdf. Accessed Mrch 30, 2013. 4. Ntionl Comprehensive Cncer Network. NCCN clinicl prctice guidelines in oncology melnom. Version 2. 2013. http://www.nccn.org/ professionls/physicin_gls/pdf/melnom.pdf. Accessed Mrch 30, 2013. 5. Lindemn NI, Cgle PT, Besley MB, et l. Moleculr testing guideline for selection of lung cncer ptients for EGFR nd ALK tyrosine kinse inhibitors: guideline from the College of Americn Pthologists, Interntionl Assocition for the Study of Lung Cncer, nd Assocition for Moleculr Pthology. Arch Pthol Lb Med. 2013;137(6):828 1174. 6. Schink JC, Trosmn JR, Weldon, CB, et l. Biomrker testing methods in brest, gstric, nd lung cncers: benchmrking survey of NCI cncer centers. J Clin Oncol. 2013;31(suppl):Abstrct e22093. 7. Bemer LC, Grnt ML, Espenschied CR, et l. Reflex immunohistochemistry nd microstellite instbility testing of colorectl tumors for Lynch syndrome mong US cncer progrms nd follow-up of bnorml results. J Clin Oncol. 2012;30:1058 1063. 8. Bellcross CA, Bedrosin SR, Dniels E, et l. Implementing screening for Lynch syndrome mong ptients with newly dignosed colorectl cncer: summry of public helth/clinicl collbortive meeting. Genet Med. 2012; 14(1):152 162. 9. Evlution of Genomic Applictions in Prctice nd Prevention (EGAPP) Working Group. Recommendtions from the EGAPP Working Group: genetic testing strtegies in newly dignosed individuls with colorectl cncer imed t reducing morbidity nd mortlity from Lynch syndrome in reltives. Genet Med. 2009;11(1):35 41. 1124 Arch Pthol Lb Med Vol 139, September 2015 Moleculr Testing in Antomic Pthology Volmr et l