ACS awards grant to Hollings pulmonologist to improve lung cancer biomarker testing at community hospitals

The American Cancer Society has awarded an MUSC Hollings Cancer Center pulmonologist a career development grant to begin research on a logistical question that could improve care for lung cancer patients at community hospitals across South Carolina.

Adam Fox, M.D., primarily sees patients who have or are likely to have lung cancer. A West Ashley native who returned to Charleston to practice after his residency in Richmond, Virginia, Fox was inspired by the example of his mentor, Gerard Silvestri, M.D., the George C. and Margaret M. Hillenbrand Endowed Chair in the MUSC College of Medicine, to pursue a career that combines research and clinical care.

Silvestri, in turn, praised Fox’s work.

“Adam Fox is one of the most gifted early career faculty members I have ever mentored in my three decades at MUSC. He is committed to improving cancer care locally, at the state level and nationally,” Silvestri said.

The Clinician Scientist Development Grant from the American Cancer Society will allow Fox to devote time to a seemingly straightforward question: How can community hospitals implement a process to order biomarker testing immediately upon lung cancer diagnosis?

Biomarker testing is an important part of modern lung cancer care, especially for advanced or metastatic lung cancer, which includes more than half of new diagnoses. Not all lung cancers are the same. Knowing whether a tumor has certain genetic mutations can allow doctors to prescribe a targeted therapy instead of chemotherapy.

The difference that a targeted therapy can make is huge for both survival and quality of life. But biomarker testing is uneven across the country.

“The evidence is that most patients don’t have all the testing they should have before they start a treatment,” Fox said.

"The evidence is that most patients don’t have all the testing they should have before they start a treatment."

Adam Fox, M.D.

Fox explained that patients typically get a biopsy first. The tissue is tested, and if it’s cancer, the patient is referred to an oncologist. More often than not, the oncologist orders biomarker testing at this visit, which can take about two weeks to complete.

“Well, then you're kind of starting over, waiting around. Theoretically and practically, these could be ordered the day of or the day after diagnosis,” Fox said. “We know you need them. Let's just go in and order them."

Last fall, MUSC Health implemented “reflex testing,” a process by which ordering the biomarker testing becomes an automatic reflex for the pathologist. Fox said there are several reports in the academic literature about hospitals implementing reflex testing, but they’re all from academic health systems or highly specialized medical centers.

“No one's looked at the barriers or facilitators or anything for a community site, which is where most lung cancer gets treated,” he said.

Community hospitals, he noted, have “drastically different resources” than academic health systems.

“We've got a molecular pathologist; we run our tests in-house,” he said.

Community sites, on the other hand, usually have to send out their testing. Their oncologists usually treat the whole spectrum of cancers instead of specializing in cancers in one body system. Further, oncologists at both community and academic sites feel the urgency from patients who have just learned they have metastatic cancer and want to begin treatment immediately.

Fox will begin by conducting a needs assessment. He’ll talk to providers at hospitals within the MUSC Regional Health Network and the Hollings Cancer Network, and potentially with other hospitals in the state, to understand their processes and challenges.

He noted that reflex testing most often involves the pathologist ordering the biomarker testing, but it could be set up in other ways, depending on what works best for a particular hospital.

“There are a variety of ways, logistically, to get everyone tested. That's why we chose an implementation science design for the study. We will meet with people, see what is happening, what people think will work and what resources they have. And then looking at the results of the needs assessment, and with the relevant stakeholders, design an intervention at a single site, test it and learn from it,” he said.

The end goal is to get personalized treatment to more patients.

“If they do a personalized treatment regimen with drugs that target their tumor, the patient will have a much better chance at surviving,” Silvestri said. “This American Cancer Society career development award will allow Adam the time and provide him with the education to pursue these lofty goals.”

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