In this episode of The Pathology Report, Dr Pranav Dorwal interviews Prof Wendy Cooper, an anatomical pathologist and senior staff specialist in tissue pathology and diagnostic oncology at the Royal Prince Alfred Hospital in Sydney, about the recently released evidence-based best practice recommendations for molecular testing in lung cancer. These guidelines were developed by the Royal College of Pathologists of Australasia (RCPA) in collaboration with the Thoracic Oncology Group Australasia (TOGA).

Key discussion points:

• Rationale for the new recommendations. Professor Cooper explains the need for Australian-specific recommendations given previous reliance on overseas standards and inconsistencies in local practices. The goal was to ensure uniformity and optimal patient care in molecular testing for lung cancer.
• Collaborative process. How the RCPA and TOGA worked together to combine pathology and oncology expertise, emphasising the importance of including oncologists due to the predictive and treatment-focused role of molecular testing.
• Consensus building and challenges. The process for reaching consensus within a multidisciplinary advisory group. While most recommendations were unanimous, they also debated how to proceed with molecular testing when the cancer stage is unknown, ultimately recommending reflex testing in such cases to avoid delays in treatment.
• Guidance on early vs advanced stage disease. The evolving role of molecular testing in early-stage lung cancer, driven by emerging adjuvant and neoadjuvant therapies. The guidance recommends biomarker testing for EGFR, ALK, ROS1, and PD-L1 for early stage disease treated with curative intent from stage 1B and above, and more comprehensive testing for advanced stage disease.
• Squamous cell carcinoma testing. The recommendations differentiate testing protocols for squamous cell carcinoma. For pure squamous carcinoma, only MET exon 14 skipping and PD-L1 testing are recommended. Additional testing may be considered in small biopsies from young or non-smoking patients as they may have further actionable alterations.
• Updates for recommendations. Professor Cooper highlights that the recommendations will be formally reviewed every two years, or sooner if significant new evidence emerges.
• Access to recommendations. Listeners are reminded that the full recommendations and additional patient information are available on the RCPA website and in a recent publication in the RCPA’s peer-reviewed Pathology journal:

• RCPA – Molecular Testing of Lung Cancer in Australia
• Molecular Testing of Lung Cancer in Australia. Evidence-Based Best Practice Recommendations 2025
• Pathology journal peer-reviewed article. Molecular testing of lung cancer in Australia: consensus best practice recommendations from the Royal College of Pathologists of Australasia in collaboration with the Thoracic Oncology Group of Australasia
• Information for patients

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