Напоминания в электронных медкартах повысили уровень молекулярной диагностики при раке легких

‘Proof of concept’: EHR nudges can improve guideline-concordant cancer care Key takeaways: - Electronic health record nudges led to significant uptake of molecular testing for patients with early-stage nonsquamous non-small cell lung cancer. - The intervention could be used in many other settings. An electronic health record nudge-based intervention led to a significant increase in molecular testing among patients with early-stage non-small cell lung cancer. The trial provided “proof of concept” for the strategy, which could be applied in the neoadjuvant setting for nonsquamous NSCLC, and broadly within cancer care, both at large centers and in the community setting. “If you make something the easiest default option within an electronic medical record system, it can lead to guideline-concordant change,” Melina E. Marmarelis, MD, MSCE, associate professor of medicine at University of Pennsylvania Perelman School of Medicine, told Healio. ‘Universally acknowledged issue’ More than a dozen biomarkers are linked to lung cancer, including EGFR, HER2, KRAS, ALK and PD-L1, according to American Lung Association. National Comprehensive Cancer Network put an emphasis on biomarker testing when it updated its NSCLC treatment guidelines in 2025, Healio previously reported. Guideline changes included recommendations for osimertinib (Tagrisso, AstraZeneca) plus chemotherapy and lazertinib (Lazcluze, Janssen) plus amivantamab-vmjw (Rybrevant, Janssen) as first-line treatment for EGFR-mutant metastatic NSCLC. “You need biomarker testing for basically every treatment decision that you’re making now,” Marmarelis previously told Healio. Healio also reported on a study of patients with nonsquamous NSCLC treated at Dana-Farber Cancer Institute regional practice sites that showed substantial variation in biomarker testing, with high rates for PD-L1 (88%), EGFR (86%) and ALK (86%), but lower rates for RET (50%) and NTRK (44%). Overall, 45% of patients did not receive next-generation sequencing, although rates substantially increased from 2018 to 2021 (14% to 61%). “Not all patients that underwent surgery were getting the proper sequencing to be identified for those targeted therapies in the adjuvant setting,” Marmarelis said. “This was a universally acknowledged issue as these new targeted therapies were approved in early-stage lung cancer.” Marmarelis and colleagues conducted the EMBER-Lung trial to evaluate whether an EHR nudge-based intervention would improve uptake. The trial included 460 patients (median age, 68.8 years; range, 30.8-88.1; 64.3% women; 78.9% white) with early-stage nonsquamous NSCLC undergoing surgical resection. The trial featured two cohorts, a retrospective control and a prospective group to evaluate the intervention. The retrospective cohort included 217 consecutive patients treated at University of Pennsylvania between July 2021 and July 2022. The prospective cohort included 243 participants treated from November 2022 to November 2023. During their first postoperative visit, clinicians received a default prompt within the EHR to order genomic testing when any order was placed. Receipt of comprehensive molecular testing served as the primary endpoint. ‘Things have changed’ The prospective cohort had a significantly higher rate of patients who received molecular testing (85.6% vs. 46.5%; P < .001) and comprehensive molecular sequencing (81.1% vs. 36.9%; P < .001). The nudge coincided with a significant increase in the number of patients who had detected EGFR (6.5% to 16.9%; P < .001) and KRAS G12C (5.5% to 13.6%; P < .01) mutations. Marmarelis credited the increase to both the nudge and improved recognition of the importance of testing. “When we designed this trial, the need for molecular testing was really after surgery to determine adjuvant therapy,” she said. “Things have changed. We now need this molecular information prior to surgery so that we can decide about neoadjuvant therapy. In early-stage lung cancer, you need molecular information at the time of biopsy, and you need it quickly. “We have put into place, as have many other institutions, reflex pathways on the pathology side for that to happen for any nonsquamous non-small cell lung cancer specimen that comes through. We have moved away from this type of intervention, which is really now just too late for what we need. Unfortunately, not every institution is able to create a reflex pathway, and so a lot of institutions still need to have clinicians physically placing the order. I think that’s where some of these nudge interventions in the electronic medical record system can still be very useful.” Researchers acknowledged study limitations, including the trial being conducted at a tertiary care cancer center with ample resources. A platform ‘that can grow’ Marmarelis estimated the “ceiling” for genetic testing to be between 85% and 90%. “There are issues with not enough tissue, with patients lost at follow-up, with the assays,” she said. “I think that it’s important that we set those benchmarks.” As rates continue to climb, research into the best ways to test could be useful. “You only need a few biomarkers in the neoadjuvant setting, but you need it really quickly,” Marmarelis said. “At Penn Medicine, we’ve actually gone back to some of the smaller, faster panels on tissue to get that information. We use a smaller panel of 50 genes to get this information within about 5 days. We have to think about when we’re using these really big 500 gene panels vs. quicker, less than 50 gene panels, and it depends on the situation. “We’re looking at the real-world experience of using this smaller panel in early-stage lung cancer vs. some of the bigger ones. How much time did it take to get the information? Was that information used to make decisions about neoadjuvant therapy? Is this something that we should be trying to employ across the board?” Although the nudge intervention has become outdated for adjuvant treatment for nonsquamous NSCLC, Marmarelis emphasized this approach could be used in the neoadjuvant setting, for various other malignancies and across community settings. “It’s the type of platform that can grow with new indications,” she said. For more information: Melina E. Marmarelis, MD, MSCE, can be reached at [email protected].