Recommendations for the use of next-generation sequencing (NGS) for patients with metastatic cancers: a report from the ESMO Precision Medicine Working Group

      Highlights

      • ESMO recommends the use of tumour multigene NGS in NSCLC, cholangiocarcinoma, prostate and ovarian cancers.
      • It is recommended to test TMB in well- and moderately-differentiated neuroendocrine tumours (NETs), cervical, salivary, thyroid and vulvar cancers.
      • Academic research centres should perform multigene NGS as part of their missions to enable access to innovative treatments.
      • A large panel of genes could be ordered, considering the benefit for the patient and the cost for the public health care system.
      Next-generation sequencing (NGS) allows sequencing of a high number of nucleotides in a short time frame at an affordable cost. While this technology has been widely implemented, there are no recommendations from scientific societies about its use in oncology practice. The European Society for Medical Oncology (ESMO) is proposing three levels of recommendations for the use of NGS. Based on the current evidence, ESMO recommends routine use of NGS on tumour samples in advanced non-squamous non-small-cell lung cancer (NSCLC), prostate cancers, ovarian cancers and cholangiocarcinoma. In these tumours, large multigene panels could be used if they add acceptable extra cost compared with small panels. In colon cancers, NGS could be an alternative to PCR. In addition, based on the KN158 trial and considering that patients with endometrial and small-cell lung cancers should have broad access to anti-programmed cell death 1 (anti-PD1) antibodies, it is recommended to test tumour mutational burden (TMB) in cervical cancers, well- and moderately-differentiated neuroendocrine tumours, salivary cancers, thyroid cancers and vulvar cancers, as TMB-high predicted response to pembrolizumab in these cancers.
      Outside the indications of multigene panels, and considering that the use of large panels of genes could lead to few clinically meaningful responders, ESMO acknowledges that a patient and a doctor could decide together to order a large panel of genes, pending no extra cost for the public health care system and if the patient is informed about the low likelihood of benefit. ESMO recommends that the use of off-label drugs matched to genomics is done only if an access programme and a procedure of decision has been developed at the national or regional level. Finally, ESMO recommends that clinical research centres develop multigene sequencing as a tool to screen patients eligible for clinical trials and to accelerate drug development, and prospectively capture the data that could further inform how to optimise the use of this technology.

      Key words

      Introduction

      Next-generation sequencing (NGS) allows sequencing of a high number of nucleotides in a short time frame and at an affordable cost per patient.
      • van Nimwegen K.J.M.
      • van Soest R.A.
      • Veltman J.A.
      • et al.
      Is the $1000 genome as near as we think? A cost analysis of next-generation sequencing.
      • Marino P.
      • Touzani R.
      • Perrier L.
      • et al.
      Cost of cancer diagnosis using next-generation sequencing targeted gene panels in routine practice: a nationwide French study.
      • Pagès A.
      • Foulon S.
      • Zou Z.
      • et al.
      The cost of molecular-guided therapy in oncology: a prospective cost study alongside the MOSCATO trial.
      In this document, we will discuss the clinical utility of using NGS as a technology, and how this technology should be used (small versus large panels) in frequent diseases. The recommendations will be done at three levels: from a public health perspective, from the perspective of academic clinical research centres and the level of each individual patient. NGS has recently moved into the clinics with the aim of sequencing long and complex genes and/or multiple genes per tumour sample, in order to identify driver and/or targetable alterations. Pioneering studies have shown that NGS presents a good analytical validity to detect clonally dominant alterations.
      • Frampton G.M.
      • Fichtenholtz A.
      • Otto G.A.
      • et al.
      Development and validation of a clinical cancer genomic profiling test based on massively parallel DNA sequencing.
      Based on this observation, several companies and academic centres have implemented NGS assays to guide treatment decisions. While this technology has been widely implemented, there are no recommendations from scientific societies about their use in daily clinical practice. Several prospective trials have reported outcomes associated with the use of multigene sequencing. In the SHIVA trial, the use of multigene sequencing did not improve outcome in patients with metastatic hard-to-treat cancers in comparison with unmatched therapies.
      • Tourneau C.L.
      • Delord J.-P.
      • Gonçalves A.
      • et al.
      Molecularly targeted therapy based on tumour molecular profiling versus conventional therapy for advanced cancer (SHIVA): a multicentre, open-label, proof-of-concept, randomised, controlled phase 2 trial.
      In the single-arm MOSCATO trial, the use of multigene sequencing and comparative genomic hybridisation (CGH) arrays was associated with an improved progression-free survival (PFS) in 30% of patients and an objective response rate (ORR) of 11%.
      • Massard C.
      • Michiels S.
      • Ferté C.
      • et al.
      High-throughput genomics and clinical outcome in hard-to-treat advanced cancers: Results of the MOSCATO 01 trial.
      Several other studies have consistently reported that ORRs ranged between 10% and 30% in patients whose tumours harboured actionable alterations.
      • André F.
      • Bachelot T.
      • Commo F.
      • et al.
      Comparative genomic hybridisation array and DNA sequencing to direct treatment of metastatic breast cancer: a multicentre, prospective trial (SAFIR01/UNICANCER).
      • Tsimberidou A.-M.
      • Wen S.
      • Hong D.S.
      • et al.
      Personalized medicine for patients with advanced cancer in the phase I program at MD Anderson: validation and landmark analyses.
      • Priestley P.
      • Baber J.
      • Lolkema M.P.
      • et al.
      Pan-cancer whole-genome analyses of metastatic solid tumours.
      • Trédan O.
      • Wang Q.
      • Pissaloux D.
      • et al.
      Molecular screening program to select molecular-based recommended therapies for metastatic cancer patients: analysis from the ProfiLER trial.
      One of the major issues with most of the prospective trials testing multigene sequencing is the exclusion of patients whose tumours present a genomic alteration that matches an approved drug. Aside from large prospective trials, several cases have been reported to present an outlier sensitivity to a drug given based on an unforeseen, non-recurrent, somatic genomic alteration.
      • Korphaisarn K.
      • Loree J.M.
      • Nguyen V.
      • et al.
      Genomic analysis of exceptional responder to regorafenib in treatment-refractory metastatic rectal cancer: a case report and review of the literature.
      ,
      • Espinosa M.
      • Roldán-Romero J.M.
      • Duran I.
      • et al.
      Advanced sporadic renal epithelioid angiomyolipoma: case report of an extraordinary response to sirolimus linked to TSC2 mutation.
      In the present article, we present the European Society for Medical Oncology (ESMO) recommendations about whether and how tumour multigene NGS could be used to profile metastatic cancers.

      Method

      The ESMO Precision Medicine Working Group has set up a group of experts in the field of clinical cancer genomics in order to address the following questions:
      Should NGS be used in daily practice?
      If so, should large panels of genes be used?
      These questions should be addressed from the perspective of public health, academic clinical research centres and from the perspective of the individual patients.
      In order to address these questions, the group developed the method summarised in Figure 1. The general strategy was to determine whether NGS can substitute complex or multiple testings. First, all recurrent genomic alterations were identified in the eight cancers that are associated with highest number of deaths in the world.
      • Bray F.
      • Ferlay J.
      • Soerjomataram I.
      Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      The ESMO Scale for Clinical Actionability of molecular Targets (ESCAT) ranking was then determined for each alteration. ESCAT is a framework that ranks a match between drug and genomic alterations, according to their actionability.
      • Mateo J.
      • Chakravarty D.
      • Dienstmann R.
      • et al.
      A framework to rank genomic alterations as targets for cancer precision medicine: the ESMO Scale for Clinical Actionability of molecular Targets (ESCAT).
      ESCAT level I means that the match of an alteration and a drug has been validated in clinical trials, and should drive treatment decision in daily practice. ESCAT level II means that a drug that matches the alteration has been associated with responses in phase I/II or in retrospective analyses of randomised trials. ESCAT level III includes alterations that are validated in another cancer, but not in the disease-to-treat. ESCAT level IV includes hypothetically targetable alterations based on preclinical data. ESCAT ranking was generated for each alteration by medical oncologists with an expertise in genomics, then validated by two external experts and by the Working Group. From the ESCAT ranking and prevalence of alterations for each tumour type, we calculated the number of patients to test with NGS, to identify one patient that can be matched to an effective drug in daily practice (ESCAT level I). The main document reports these numbers with the hypothesis that NGS has a perfect analytical validity, while Supplementary Tables, available at https://doi.org/10.1016/j.annonc.2020.07.014, report these numbers taking a hypothesis of 99% and 95% sensitivity/specificity.
      • Ramsey S.D.
      • Shankaran V.
      • Sullivan S.D.
      Basket cases: How real-world testing for drugs approved based on basket trials might lead to false diagnoses, patient risks, and squandered resources.
      We assume that there is no proven impact in terms of public health of detecting level II–IV actionable alterations. Finally, in addition to ESCAT ranking, the group integrated the results of the KN158 study
      FDA approves pembrolizumab for adults and children with TMB-H solid tumors - the ASCO Post.
      in the recommendations. The KN158 study evaluated the efficacy of pembrolizumab single agent according to tumour mutational burden (TMB) in 10 different diseases.
      Figure thumbnail gr1
      Figure 1Method to develop recommendation about NGS in daily practice.
      ESCAT, ESMO Scale for Clinical Actionability of molecular Targets.

      Multigene sequencing: prerequisites from the technical side

      In vitro diagnostic tests, such as NGS assays, can be broadly separated into two main categories. On one hand, there are manufactured products (reagents, instruments, kits) which have been cleared or approved by the respective authorities [e.g. US Food and Drug Administration (FDA)] and are sold to clinical laboratories for subsequent use. There are numerous instances where there are unmet analytical or clinical needs, not uncommonly due to the lack of approved and commercially available assays; in these cases, laboratory-developed tests (LDTs) are being designed by and deployed for clinical decision-making within a single clinical, often academic, laboratory. In the dynamic and fast-moving field of cancer precision medicine and molecular pathology, LDTs play a central role as they are often driving diagnostic innovation at times when no approved options exist. Regardless of the in vitro diagnostic category that is being used in a clinical laboratory, an environment that continuously assures and monitors assay quality and performance is critical, as inadequate validation and use of assays could place patients at risk. Whilst the assessment of test characteristics and quality assurance schemes are governed by country-specific legislation and different regulatory models, technical parameters, including modality of sequencing, sequencing depth, fraction of on-target reads, alignment quality, read quality, error rates, types of sources of DNA [ctDNA, frozen, formalin-fixed paraffin-embedded (FFPE)], minimal tumour cell content are essential and combined under the umbrella of ‘analytical validity’. Once the analytical validity and the robustness of the assay are ascertained, its clinical validity and clinical utility need to be considered. Professional groups have endeavoured to provide guidelines for the standardisation of the parameters of sequencing, data analysis and interpretation of the findings, and are listed in Table 1.
      Table 1Recommendations and guidelines for the standardisation of multigene sequencing
      Society guidelinesAuthor/journal
      Joint Recommendation of the Association for Molecular Pathology and the College of American PathologistsRoy S, et al. J Mol Diagn. 2018.
      • Roy S.
      • Coldren C.
      • Karunamurthy A.
      • et al.
      Standards and guidelines for validating next-generation sequencing bioinformatics pipelines: a joint recommendation of the Association for Molecular Pathology and the College of American Pathologists.
      Canadian College of Medical GeneticistsHume S, et al. J Med Genet. 2019.
      • Hume S.
      • Nelson T.N.
      • Speevak M.
      • et al.
      CCMG practice guideline: laboratory guidelines for next-generation sequencing.
      College of American Pathologistswww.cap.org 2020.
      Next Generation Sequencing (NGS) Worksheets. College of American Pathologists.
      Szymanski J, et al. J Pathol Inform. 2018.
      • Szymanski J.
      • Duncavage E.
      • Pfeifer J.
      Next-generation sequencing bioinformatics: Guidance between the sequencing and sign out.
      Burke W, et al. Curr Protoc Hum Genet. 2014.
      • Burke W.
      Genetic tests: clinical validity and clinical utility.
      US FDAKaul K, et al. J Mol Diag. 2001.
      • Kaul K.L.
      • Leonard D.G.B.
      • Gonzalez A.
      • et al.
      Oversight of genetic testing: an update.
      IQN PathDeans Z, et al. Virchows Arch. 2017.
      • Deans Z.C.
      • Costa J.L.
      • Cree I.
      • et al.
      Integration of next-generation sequencing in clinical diagnostic molecular pathology laboratories for analysis of solid tumours; an expert opinion on behalf of IQN Path ASBL.
      Matthijs G, et al. Eur J Hum Genet. 2015.
      • Matthijs G.
      • Souche E.
      • Alders M.
      • et al.
      Guidelines for diagnostic next-generation sequencing.
      A Joint Consensus Recommendation of the Association for Molecular Pathology and College of American PathologistsJennings L, et al. J Mol Diagn. 2017.
      • Jennings L.J.
      • Arcila M.E.
      • Corless C.
      • et al.
      Guidelines for validation of next-generation sequencing-based oncology panels: a joint consensus recommendation of the Association for Molecular Pathology and College of American Pathologists.
      College of American PathologistsAziz N, et al. Arch Pathol Lab Med. 2015.
      • Aziz N.
      • Zhao Q.
      • Bry L.
      • et al.
      College of American Pathologists' laboratory standards for next-generation sequencing clinical tests.
      FDA, Food and Drug Administration; IQN Path, International Quality Network for Pathology.
      In fact, a framework that includes standardised validation protocols and reflects the concepts of (i) analytical validity (i.e. the ability of a test to accurately measure the analyte of interest as e.g. defined by the parameters: accuracy, precision, sensitivity, specificity, positive and negative predictive values), (ii) clinical validity (i.e. the accuracy with which a genetic test identifies a particular clinical condition with respect to a diagnostic, prognostic or predictive category) and (iii) clinical utility (i.e. whether the test and any subsequent interventions result in an improved health outcome among people with a positive test result and the risks that occur as a result of the test being carried out) should be universally considered and applied. ESMO recommends that genomic reports include the ranking of the genomic alterations either by ESCAT or OncoKb.
      OncoKB

      Recommendations

       General frame

      Recommendations for NGS (summarised in Table 2) are done at three levels.
      • 1.
        Recommendations for daily practice (ESCAT level I) aim to reflect the impact of the use of tumour multigene NGS on public health.
      • 2.
        Recommendations for clinical research centres aim to determine whether performing multigene sequencing could increase access to innovation, accelerate drug development and could therefore be a mission of clinical research centres.
      • 3.
        Patient-centric recommendations.
      Table 2Summary recommendations
      Tumour typesGeneral recommendations for daily practiceRecommendation for clinical research centresSpecial considerations for patients
      Lung adenocarcinomaTumour multigene NGS to assess level I alterations. Larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (drug included
      a ESMO recommends using off-label drugs matched to genomics only if an access programme and a procedure of decision have been developed at the national or regional level, as illustrated by the DRUP programme.
      ) and if they report accurate ranking of alterations. NGS can either be done on RNA or DNA, if it includes level I fusions in the panel.
      It is highly recommended that clinical research centres perform multigene sequencing in the context of molecular screening programmes in order to increase access to innovative drugs and to speed up clinical research. This is particularly relevant in breast, pancreatic and hepatocellular cancers where level II–IV alterations are numerous.Using large panels of genes could lead to few clinically meaningful responders, not detected by small panels or standard testings. In this context and outside the diseases where large panels of genes are recommended, ESMO acknowledges that a patient and a doctor could decide together to order a large panel of genes, pending no extra cost for the public health care system, and if the patient is informed about the low likelihood of benefit.
      Squamous cell lung cancersNo current indication for tumour multigene NGS
      Breast cancersNo current indication for tumour multigene NGS
      Colon cancersMultigene tumour NGS can be an alternative option to PCR if it does not result in additional cost.
      Prostate cancersMultigene tumour NGS to assess level I alterations. Larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy and if they report accurate ranking of alterations.
      Gastric cancersNo current indication for tumour multigene NGS
      Pancreatic cancersNo current indication for tumour multigene NGS
      Hepatocellular carcinomaNo current indication for tumour multigene NGS
      CholangiocarcinomaMultigene tumour NGS could be recommended to assess level I alterations. Larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (drug included
      a ESMO recommends using off-label drugs matched to genomics only if an access programme and a procedure of decision have been developed at the national or regional level, as illustrated by the DRUP programme.
      ) and if they report accurate ranking of alterations. RNA-based NGS can be used.
      OthersTumour multigene NGS can be used in ovarian cancers to determine somatic BRCA1/2 mutations. In this latter case, larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (drug included
      a ESMO recommends using off-label drugs matched to genomics only if an access programme and a procedure of decision have been developed at the national or regional level, as illustrated by the DRUP programme.
      ) and if they report accurate ranking of alterations.

      Large panel NGS can be used in carcinoma of unknown primary.

      It is recommended to determine TMB in cervical cancer, salivary cancer, thyroid cancers, well-to-moderately differentiated neuroendocrine tumours, vulvar cancer, pending drug access (and in TMB-high endometrial and SCL cancers if anti-PD1 antibody is not available otherwise).
      anti-PD1, anti-programmed cell death 1; DRUP, drug rediscovery protocol; ESMO, European Society for Medical Oncology; NGS, next-generation sequencing; SCL, small-cell lung cancer; TMB, tumour mutational burden.
      a ESMO recommends using off-label drugs matched to genomics only if an access programme and a procedure of decision have been developed at the national or regional level, as illustrated by the DRUP programme.

       Health economics evidence

      From a payer perspective, evidence of the cost-effectiveness of the use of multigene sequencing in daily practice is weak.
      • Veenstra D.L.
      • Mandelblatt J.
      • Neumann P.
      • et al
      Health economics tools and precision medicine: Opportunities and challenges.
      • Weymann D.
      • Pataky R.
      • Regier D.A.
      Economic evaluations of next-generation precision oncology: a critical review.
      • Tan O.
      • Shrestha R.
      • Cunich M.
      • et al.
      Application of next-generation sequencing to improve cancer management: a review of the clinical effectiveness and cost-effectiveness.
      • Phillips K.A.
      • Deverka P.A.
      • Deborah A.
      • Marshall
      • et al.
      Methodological issues in assessing the economic value of next-generation sequencing tests: many challenges and not enough solutions.
      We identified two economic studies in non-small-cell lung cancer (NSCLC). The first one has compared the performance of targeted NGS panels with traditional assays in an EGFR-mutant predominant population.
      • Tan A.C.
      • Lai G.G.Y.
      • Tan G.S.
      • et al.
      Utility of incorporating next-generation sequencing (NGS) in an Asian non-small cell lung cancer (NSCLC) population: incremental yield of actionable alterations and cost-effectiveness analysis.
      The second one has studied the cost-effectiveness of multigene panel sequencing compared with single-marker testing.
      • Steuten L.
      • Goulart B.
      • Meropol N.J.
      • et al.
      Cost effectiveness of multigene panel sequencing for patients with advanced non–small-cell lung cancer.
      These studies suggest that multigene sequencing in NSCLC is moderately cost-effective. Moreover, implementation of multigene sequencing in daily practice requires investments that have to be considered, especially regarding sequencing and bioinformatics workflows in order to deliver results to clinicians in a timely manner.
      • Sboner A.
      • Mu X.J.
      • Greenbaum D.
      • et al.
      The real cost of sequencing: higher than you think!.
      Finally, from a public health perspective, it must also be considered that the results of NGS panels could lead to recommend expensive drugs outside of their approved indications.
      • Legras A.
      • Barritault M.
      • Tallet A.
      • et al.
      Validity of targeted next-generation sequencing in routine care for identifying clinically relevant molecular profiles in non-small-cell lung cancer: results of a 2-year experience on 1343 samples.
      There is a need to regulate the volumes of NGS procedures at the national level.

      Genomic alterations in advanced NON-SQUAMOUS NSCLC classified according to ESCAT

      EGFR mutations represent the first driver alterations identified in advanced non-squamous NSCLC.
      • Midha A.
      • Dearden S.
      • McCormack R.
      EGFR mutation incidence in non-small-cell lung cancer of adenocarcinoma histology: a systematic review and global map by ethnicity (mutMapII).
      Most of them are in-frame activating deletions in exon 19 and point hotspot activating mutations in exon 21 (L858R), followed by acquired resistant mutations in exon 20 (T790M). Several randomised, phase III trials have shown that EGFR tyrosine kinase inhibitors (TKIs) improve outcome in patients with EGFR-mutated NSCLC.
      • Mok T.S.
      • Cheng Y.
      • Zhou X.
      • et al.
      Improvement in overall survival in a randomized study that compared dacomitinib with gefitinib in patients with advanced non-small-cell lung cancer and EGFR-activating mutations.
      • Soria J.-C.
      • Ohe Y.
      • Vansteenkiste J.
      • et al.
      Osimertinib in untreated EGFR-mutated advanced non–small-cell lung cancer.
      • Ramalingam S.S.
      • Vansteenkiste J.
      • Planchard D.
      • et al.
      Overall survival with osimertinib in untreated, EGFR-mutated advanced NSCLC.
      • Mok T.S.
      • Wu Y.-L.
      • Ahn M.-J.
      • et al.
      Osimertinib or platinum–pemetrexed in EGFR T790M–positive lung cancer.
      Based on these data, these specific EGFR mutations reach the highest level in ESCAT. Point mutations or duplications in exons 18–21 (G719X in exon 18, L861Q in exon 21, S768I in exon 20) are unusual EGFR mutations. The efficacies of afatinib and osimertinib were assessed in prospective, non-randomised trials, reporting a high ORR and improving PFS.
      • Yang J.C.-H.
      • Sequist L.V.
      • Geater S.L.
      • et al.
      Clinical activity of afatinib in patients with advanced non-small-cell lung cancer harbouring uncommon EGFR mutations: a combined post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung 6.
      ,
      • Cho J.H.
      • Sun J.
      • Lee S.
      • et al.
      OA10.05 An open-label, multicenter, phase II single arm trial of osimertinib in NSCLC patients with uncommon EGFR mutation (KCSG-LU15-09).
      In addition, in patients with exon 20 insertions of EGFR, poziotinib (a selective TKI) presented a limited therapeutic efficacy, also evaluated in prospective studies.
      • Cardona A.F.
      • Rojas L.
      • Zatarain-Barrón Z.L.
      • et al.
      EGFR exon 20 insertion in lung adenocarcinomas among Hispanics (geno1.2-CLICaP).
      ,
      • Heymach J.
      • Negrao M.
      • Robichaux J.
      • et al.
      OA02.06 A phase II trial of poziotinib in EGFR and HER2 exon 20 mutant non-small cell lung cancer (NSCLC).
      Another predictive biomarker that reaches a high position in the ESCAT is ALK fusion. In randomised trials, anaplastic lymphoma kinase (ALK) inhibitors confirmed an improvement of clinical outcomes across patients with ALK-rearranged NSCLC.
      • Solomon B.J.
      • Kim D.-W.
      • Wu Y.-L.
      • et al.
      Final overall survival analysis from a study comparing first-line crizotinib versus chemotherapy in ALK-mutation-positive non-small-cell lung cancer.
      • Soria J.-C.
      • Tan D.S.W.
      • Chiari R.
      • et al.
      First-line ceritinib versus platinum-based chemotherapy in advanced ALK-rearranged non-small-cell lung cancer (ASCEND-4): a randomised, open-label, phase 3 study.
      • Peters S.
      • Camidge D.R.
      • ALEX Trial Investigators
      • et al.
      Alectinib versus crizotinib in untreated ALK-positive non-small-cell lung cancer.
      • Zhou C.
      • Lee S.H.
      • Wang C.
      • et al.
      Primary results of ALESIA: a randomised, phase III, open-label study of alectinib vs crizotinib in Asian patients with treatment-naïve ALK+ advance NSCLC.
      • Camidge D.R.
      • Kim H.R.
      • Ahn M.-J.
      • et al.
      Brigatinib versus crizotinib in ALK-positive non–small-cell lung cancer.
      Some other alterations like MET exon 14 skipping, BRAFV600E mutations and ROS1 fusions have been identified.
      • Tong J.H.
      • Yeung S.F.
      • Chan A.W.H.
      • et al.
      MET Amplification and exon 14 splice site mutation define unique molecular subgroups of non-small cell lung carcinoma with poor prognosis.
      A significant ORR and clinical meaningful benefit have been shown in phase I/II studies in patients with NSCLC with METex14 mutations treated with MET TKIs such as crizotinib, capmatinib or tepotinib, with BRAFV600E mutations that received dabrafenib-vemurafenib and with ROS1 fusions treated with crizotinib, ceritinib or entrectinib.
      • Drilon A.
      • Clark J.W.
      • Weiss J.
      • et al.
      Antitumor activity of crizotinib in lung cancers harboring a MET exon 14 alteration.
      • Planchard D.
      • Besse B.
      • Groen H.J.M.
      • et al.
      Dabrafenib plus trametinib in patients with previously treated BRAF(V600E)-mutant metastatic non-small cell lung cancer: an open-label, multicentre phase 2 trial.
      • Planchard D.
      • Smit E.F.
      • Groen H.J.M.
      • et al.
      Dabrafenib plus trametinib in patients with previously untreated BRAF(V600E)-mutant metastatic non-small-cell lung cancer: an open-label, phase 2 trial.
      • Planchard D.
      • Besse B.
      • Kim T.M.
      • et al.
      Updated survival of patients (pts) with previously treated BRAF V600E–mutant advanced non-small cell lung cancer (NSCLC) who received dabrafenib (D) or D + trametinib (T) in the phase II BRF113928 study.
      • Shaw A.T.
      • Ou S.-H.I.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged non-small-cell lung cancer.
      • Shaw A.T.
      • Riely G.J.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged advanced non-small-cell lung cancer (NSCLC): updated results, including overall survival, from PROFILE 1001.
      • Drilon A.
      • Siena S.
      • Dziadziuszko R.
      • et al.
      Entrectinib in ROS1 fusion-positive non-small-cell lung cancer: integrated analysis of three phase 1-2 trials.
      No randomised trials were developed for these aberrations. Based on these results, crizotinib obtained the Breakthrough Designation from the FDA for METex14-mutated NSCLC, entrectinib for ROS1-positive NSCLC by the FDA and dabrafenib-vemurafenib was approved for NSCLC with BRAFV600E mutation by both the FDA and the European Medicines Agency (EMA). Fusions involving neurotrophic tyrosine receptor kinase genes (NTRK1-3) occur with a low prevalence across different cancer types. Tropomyosin receptor kinase (TRK) inhibitors (larotrectinib, entrectinib) have demonstrated durable responses in NTRK fusion-positive tumours including NSCLC,
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
      • Hong D.S.
      • DuBois S.G.
      • Kummar S.
      • et al.
      Larotrectinib in patients with TRK fusion-positive solid tumours: a pooled analysis of three phase 1/2 clinical trials.
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      leading to agnostic drug approvals by the EMA and FDA. In addition, LOXO-292 showed efficacy in phase I/II studies in patients with RET fusion-positive NSCLC, receiving the FDA Breakthrough Designation.
      • Drilon A.
      • Oxnard G.
      • Wirth L.
      • et al.
      PL02.08 registrational results of LIBRETTO-001: a phase 1/2 trial of LOXO-292 in patients with RET fusion-positive lung cancers.
      Several other drivers with therapeutic potential have been identified including MET amplifications, KRASG12C mutations (AMG510) and ERBB2 mutations and amplifications.
      • Camidge D.R.
      • Otterson G.A.
      • Clark J.W.
      • et al.
      Crizotinib in patients (pts) with MET-amplified non-small cell lung cancer (NSCLC): updated safety and efficacy findings from a phase 1 trial.
      • Barlesi F.
      • Mazieres J.
      • Merlio J.-P.
      • et al.
      Routine molecular profiling of patients with advanced non-small-cell lung cancer: results of a 1-year nationwide programme of the French Cooperative Thoracic Intergroup (IFCT).
      • Fakih M.
      • O'Neil B.
      • Price T.J.
      • et al.
      Phase 1 study evaluating the safety, tolerability, pharmacokinetics (PK), and efficacy of AMG 510, a novel small molecule KRASG12C inhibitor, in advanced solid tumors.
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      • Wang Y.
      • Jiang T.
      • Qin Z.
      • et al.
      HER2 exon 20 insertions in non-small-cell lung cancer are sensitive to the irreversible pan-HER receptor tyrosine kinase inhibitor pyrotinib.
      • Tsurutani J.
      • Park H.
      • Doi T.
      • et al.
      OA02.07 Updated results of phase 1 study of DS-8201a in HER2-expressing or –mutated advanced non-small-cell lung cancer.
      Although it has been suggested that TMB-high (≥10 mut/Mb) could be a potential predictive biomarker for immune checkpoint inhibitors (ICIs), this data is not mature enough to drive decisions in NSCLC.
      • Hellmann M.D.
      • Paz-Ares L.
      • Bernabe Caro R.
      • et al.
      Nivolumab plus ipilimumab in advanced non-small-cell lung cancer.
      Finally, some alterations validated in other tumour types can be found in patients with NSCLC, but no evidence for drug efficacy has been reported yet (Table 3A).
      • Duruisseaux M.
      • Liu S.V.
      • Han J.-Y.
      • et al.
      NRG1 fusion-positive lung cancers: Clinicopathologic profile and treatment outcomes from a global multicenter registry.
      The Cancer Genome Atlas Research Network
      Comprehensive molecular profiling of lung adenocarcinoma.
      Cancer Genome Atlas Research Network
      Comprehensive genomic characterization of squamous cell lung cancers.
      • Vansteenkiste J.F.
      • Canon J.-L.
      • De Braud F.
      • et al.
      Safety and efficacy of buparlisib (BKM120) in patients with PI3K pathway-activated non-small cell lung cancer: results from the phase II BASALT-1 study.
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      In Table 3B, we have described the main molecular variations classified by ESCAT in advanced squamous NSCLC.
      Table 3AList of genomic alterations level I/II/III according to ESCAT in advanced non-squamous non-small-cell lung cancer (NSCLC)
      GeneAlterationPrevalenceESCATReferences
      EGFRCommon mutations (Del19, L858R)

      Acquired T790M exon 20

      Uncommon EGFR mutations (G719X in exon 18, L861Q in exon 21, S768I in exon 20)

      Exon 20 insertions
      15% (50%–60% Asian)

      60% of EGFR mutant NSCLC

      10%

      2%
      IA

      IA

      IB

      IIB
      Midha A, et al. Am J Cancer Res. 2015
      • Midha A.
      • Dearden S.
      • McCormack R.
      EGFR mutation incidence in non-small-cell lung cancer of adenocarcinoma histology: a systematic review and global map by ethnicity (mutMapII).


      Mok T, et al. J Clin Oncol. 2018
      • Mok T.S.
      • Cheng Y.
      • Zhou X.
      • et al.
      Improvement in overall survival in a randomized study that compared dacomitinib with gefitinib in patients with advanced non-small-cell lung cancer and EGFR-activating mutations.


      Soria J-C, et al. N Engl J Med. 2018
      • Soria J.-C.
      • Ohe Y.
      • Vansteenkiste J.
      • et al.
      Osimertinib in untreated EGFR-mutated advanced non–small-cell lung cancer.


      Ramalingam S, et al. N Engl J Med. 2020
      • Ramalingam S.S.
      • Vansteenkiste J.
      • Planchard D.
      • et al.
      Overall survival with osimertinib in untreated, EGFR-mutated advanced NSCLC.


      Mok T, et al. N Engl J Med. 2017
      • Mok T.S.
      • Wu Y.-L.
      • Ahn M.-J.
      • et al.
      Osimertinib or platinum–pemetrexed in EGFR T790M–positive lung cancer.


      Yang JC-H, et al. Lancet Oncol. 2015
      • Yang J.C.-H.
      • Sequist L.V.
      • Geater S.L.
      • et al.
      Clinical activity of afatinib in patients with advanced non-small-cell lung cancer harbouring uncommon EGFR mutations: a combined post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung 6.


      Cho J, et al. J Thorac Oncol. 2018
      • Cho J.H.
      • Sun J.
      • Lee S.
      • et al.
      OA10.05 An open-label, multicenter, phase II single arm trial of osimertinib in NSCLC patients with uncommon EGFR mutation (KCSG-LU15-09).


      Cardona A, et al. Lung Cancer. 2018
      • Cardona A.F.
      • Rojas L.
      • Zatarain-Barrón Z.L.
      • et al.
      EGFR exon 20 insertion in lung adenocarcinomas among Hispanics (geno1.2-CLICaP).


      Heymach J, et al. J Thorac Oncol. 2018
      • Heymach J.
      • Negrao M.
      • Robichaux J.
      • et al.
      OA02.06 A phase II trial of poziotinib in EGFR and HER2 exon 20 mutant non-small cell lung cancer (NSCLC).
      ALKFusions (mutations as mechanism of resistance)5%IASolomon B, et al. J Clin Oncol. 2018
      • Solomon B.J.
      • Kim D.-W.
      • Wu Y.-L.
      • et al.
      Final overall survival analysis from a study comparing first-line crizotinib versus chemotherapy in ALK-mutation-positive non-small-cell lung cancer.


      Soria J-C, et al. Lancet. 2017
      • Soria J.-C.
      • Tan D.S.W.
      • Chiari R.
      • et al.
      First-line ceritinib versus platinum-based chemotherapy in advanced ALK-rearranged non-small-cell lung cancer (ASCEND-4): a randomised, open-label, phase 3 study.


      Peters S, et al. N Engl J Med. 2017
      • Peters S.
      • Camidge D.R.
      • ALEX Trial Investigators
      • et al.
      Alectinib versus crizotinib in untreated ALK-positive non-small-cell lung cancer.


      Zhou C, et al. Ann Oncol. 2018
      • Zhou C.
      • Lee S.H.
      • Wang C.
      • et al.
      Primary results of ALESIA: a randomised, phase III, open-label study of alectinib vs crizotinib in Asian patients with treatment-naïve ALK+ advance NSCLC.


      Camidge D, et al. N Engl J Med. 2018
      • Camidge D.R.
      • Kim H.R.
      • Ahn M.-J.
      • et al.
      Brigatinib versus crizotinib in ALK-positive non–small-cell lung cancer.
      METMutations ex 14 skipping3%IBTong J, et al. Clin Cancer Res. 2016
      • Tong J.H.
      • Yeung S.F.
      • Chan A.W.H.
      • et al.
      MET Amplification and exon 14 splice site mutation define unique molecular subgroups of non-small cell lung carcinoma with poor prognosis.


      Drilon A, et al. Nat Med. 2020
      • Drilon A.
      • Clark J.W.
      • Weiss J.
      • et al.
      Antitumor activity of crizotinib in lung cancers harboring a MET exon 14 alteration.
      Focal amplifications (acquired resistance on EGFR TKI in EGFR-mutant tumours)3%IIBCamidge D, et al. J Clin Oncol. 2018
      • Camidge D.R.
      • Otterson G.A.
      • Clark J.W.
      • et al.
      Crizotinib in patients (pts) with MET-amplified non-small cell lung cancer (NSCLC): updated safety and efficacy findings from a phase 1 trial.
      BRAFV600EMutations2%IBPlanchard D, et al. Lancet Oncol. 2016
      • Planchard D.
      • Besse B.
      • Groen H.J.M.
      • et al.
      Dabrafenib plus trametinib in patients with previously treated BRAF(V600E)-mutant metastatic non-small cell lung cancer: an open-label, multicentre phase 2 trial.


      Planchard D, et al. Lancet Oncol. 2017
      • Planchard D.
      • Smit E.F.
      • Groen H.J.M.
      • et al.
      Dabrafenib plus trametinib in patients with previously untreated BRAF(V600E)-mutant metastatic non-small-cell lung cancer: an open-label, phase 2 trial.


      Planchard D, et al. J Clin Oncol. 2017
      • Planchard D.
      • Besse B.
      • Kim T.M.
      • et al.
      Updated survival of patients (pts) with previously treated BRAF V600E–mutant advanced non-small cell lung cancer (NSCLC) who received dabrafenib (D) or D + trametinib (T) in the phase II BRF113928 study.
      ROS1Fusions (mutations as mechanism of resistance)1%–2%IBShaw A, et al. N Engl J Med. 2014
      • Shaw A.T.
      • Ou S.-H.I.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged non-small-cell lung cancer.


      Shaw A, et al. Ann Oncol. 2019
      • Shaw A.T.
      • Riely G.J.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged advanced non-small-cell lung cancer (NSCLC): updated results, including overall survival, from PROFILE 1001.


      Drilon A, et al. Lancet Oncol. 2020
      • Drilon A.
      • Siena S.
      • Dziadziuszko R.
      • et al.
      Entrectinib in ROS1 fusion-positive non-small-cell lung cancer: integrated analysis of three phase 1-2 trials.
      NTRKFusions0.23%–3%ICDrilon A, et al. N Engl J Med. 2018
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.


      Hong D, et al. Lancet Oncol. 2020
      • Hong D.S.
      • DuBois S.G.
      • Kummar S.
      • et al.
      Larotrectinib in patients with TRK fusion-positive solid tumours: a pooled analysis of three phase 1/2 clinical trials.


      Doebele RC, et al. Lancet Oncol. 2020
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      RETFusions1%–2%ICDrilon A, et. J Thorac Oncol. 2019
      • Drilon A.
      • Oxnard G.
      • Wirth L.
      • et al.
      PL02.08 registrational results of LIBRETTO-001: a phase 1/2 trial of LOXO-292 in patients with RET fusion-positive lung cancers.
      KRASG12CMutations12%IIBBarlesi F, et al. Lancet. 2016
      • Barlesi F.
      • Mazieres J.
      • Merlio J.-P.
      • et al.
      Routine molecular profiling of patients with advanced non-small-cell lung cancer: results of a 1-year nationwide programme of the French Cooperative Thoracic Intergroup (IFCT).


      Fakih M, et al. J Clin Oncol. 2019
      • Fakih M.
      • O'Neil B.
      • Price T.J.
      • et al.
      Phase 1 study evaluating the safety, tolerability, pharmacokinetics (PK), and efficacy of AMG 510, a novel small molecule KRASG12C inhibitor, in advanced solid tumors.
      ERBB2Hotspot mutations

      Amplifications
      2%–5%IIBHyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.


      Wang Y, et al. Ann Oncol. 2018
      • Wang Y.
      • Jiang T.
      • Qin Z.
      • et al.
      HER2 exon 20 insertions in non-small-cell lung cancer are sensitive to the irreversible pan-HER receptor tyrosine kinase inhibitor pyrotinib.


      Tsurutani J, et al. J Thorac Oncol. 2018
      • Tsurutani J.
      • Park H.
      • Doi T.
      • et al.
      OA02.07 Updated results of phase 1 study of DS-8201a in HER2-expressing or –mutated advanced non-small-cell lung cancer.
      BRCA 1/2Mutations1.2%IIIABalasubramaniam S, et al. Clin Cancer Res. 2017
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      PIK3CAHotspot mutations1.2%–7%IIIACancer Genome Atlas Research Network. Nature. 2014
      The Cancer Genome Atlas Research Network
      Comprehensive molecular profiling of lung adenocarcinoma.


      Vansteenkiste J, et al. J Thorac Oncol. 2015
      • Vansteenkiste J.F.
      • Canon J.-L.
      • De Braud F.
      • et al.
      Safety and efficacy of buparlisib (BKM120) in patients with PI3K pathway-activated non-small cell lung cancer: results from the phase II BASALT-1 study.
      NRG1Fusions1.7%IIIBDuruisseaux M, et al. J Clin Oncol. 2019
      • Duruisseaux M.
      • Liu S.V.
      • Han J.-Y.
      • et al.
      NRG1 fusion-positive lung cancers: Clinicopathologic profile and treatment outcomes from a global multicenter registry.
      Summary of recommendations. It is recommended that a tumour (or plasma) sample from a patient with advanced non-squamous NSCLC is profiled using NGS technology, in order to detect level I alterations. Considering the high frequency of fusions, RNA-based NGS, or DNA-based NGS designed to capture such fusions, are the preferred options. There is no evidence that panels detecting genes with a lower level of evidence brings additional value from a public health perspective. They could be used only if the report ranks genomic alterations according to valid ranking systems (e.g. ESCAT, OncoKB) and on the basis of specific agreements with payers taking into account the overall cost of the strategy (including off-label use of drugs) as compared with small panels. Regarding this latter point, ESMO does not recommend the use of off-label drugs matched to genomic alterations, except if an access programme and a procedure of decision has been developed at the national or regional level, as illustrated by the drug rediscovery protocol programme.
      • Voest E.
      • van der Velden D.
      • Hoes L.
      • et al.
      Expanding the use of approved drugs: The CPCT's Drug Rediscovery Protocol (DRUP).
      It is recommended that hospitals that run drug development programmes and clinical trials run multigene sequencing in the context of molecular screening programmes, since lung cancer presents some level II–IV alterations.

      Genomic alterations in metastatic breast cancer classified according to ESCAT

      ERBB2 amplifications are predictive of clinical benefit of anti-HER2 therapies, which yield an improvement of overall survival (OS) and PFS,
      • Slamon D.J.
      • Leyland-Jones B.
      • Shak S.
      • et al.
      Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2.
      • Swain S.M.
      • Baselga J.
      • Kim S.-B.
      • et al.
      Pertuzumab, trastuzumab, and docetaxel in HER2-positive metastatic breast cancer.
      • Verma S.
      • Miles D.
      • Gianni L.
      • et al.
      Trastuzumab emtansine for HER2-positive advanced breast cancer.
      • Krop I.E.
      • Kim S.-B.
      • González-Martín A.
      • et al.
      Trastuzumab emtansine versus treatment of physician's choice for pretreated HER2-positive advanced breast cancer (TH3RESA): a randomised, open-label, phase 3 trial.
      • Murthy R.K.
      • Loi S.
      • Okines A.
      • et al.
      Tucatinib, trastuzumab, and capecitabine for HER2-positive metastatic breast cancer.
      while neratinib (an irreversible pan-HER TKI) has been associated with responses in patients with ERBB2 mutations.
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      Phase III studies reported a significant improvement of PFS with poly ADP ribose polymerase inhibitors (PARPi) in patients with germline BRCA1/2-mutated metastatic breast cancer (mBC).
      • Robson M.
      • Im S.-A.
      • Senkus E.
      • et al.
      Olaparib for metastatic breast cancer in patients with a germline BRCA mutation.
      ,
      • Litton J.K.
      • Rugo H.S.
      • Ettl J.
      • et al.
      Talazoparib in patients with advanced breast cancer and a germline BRCA mutation.
      It is currently estimated that somatic multigene sequencing cannot substitute germline testing for BRCA1/2 status. Alpelisib, an α-selective phosphatidylinositol 3-kinase (PI3K) inhibitor, improves PFS in patients with HR+/HER2− mBC that harbours PIK3CA hotspot mutations, and is approved in this group of patients.
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      Drugs targeting rare alterations found in different solid tumours, like microsatellite instability-high (MSI-H) and NTRK fusions, obtained approvals across tumour types.
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ,
      • Marcus L.
      • Lemery S.J.
      • Keegan P.
      • et al.
      FDA approval summary: pembrolizumab for the treatment of microsatellite instability-high solid tumors.
      Nevertheless, NTRK fusions highly correlate with secretory phenotype and MSI-high tumours are enriched in triple-negative breast cancers (TNBCs), where anti-PDL1 antibodies are approved. ESR1 mutations occur in around 20% of patients previously treated with aromatase inhibitors and are associated with response to selective estrogen receptor degraders.
      • Fribbens C.
      • O'Leary B.
      • Kilburn L.
      • et al.
      Plasma ESR1 mutations and the treatment of estrogen receptor–positive advanced breast cancer.
      Nevertheless, these data are preliminary and cannot be used in daily practice. Other promising targets in mBC are phosphatase and tensin homologue (PTEN) loss of function mutations and/or homozygous deletions (TNBCs) and AKT1E17K mutations, which in retrospective and prospective analyses, respectively, showed a clinical benefit and increased responsiveness to AKT inhibitors. Nevertheless, no results are available from practice changing trials yet.
      • Schmid P.
      • Abraham J.
      • Chan S.
      • et al.
      AZD5363 plus paclitaxel versus placebo plus paclitaxel as first-line therapy for metastatic triple-negative breast cancer (PAKT): a randomised, double-blind, placebo-controlled, phase II trial.
      ,
      • Hyman D.M.
      • Smyth L.M.
      • Donoghue M.T.A.
      • et al.
      AKT inhibition in solid tumors with AKT1 mutations.
      In addition, NF1 mutations were identified as a mechanism of endocrine resistance, but there is no targeted therapy available yet in this genomic segment.
      • Pearson A.
      • Proszek P.
      • Ring A.
      • et al.
      Inactivating NF1 mutations are enriched in advanced breast cancer and contribute to endocrine therapy resistance.
      Lastly, there are some alterations with no major impact in mBC that are validated in other malignances (Table 4).
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      ,
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      ,
      • Dembla V.
      • Somaiah N.
      • Barata P.
      • et al.
      Prevalence of MDM2 amplification and coalterations in 523 advanced cancer patients in the MD Anderson phase 1 clinic.
      Table 4List of genomic alterations level I/II/III according to ESCAT in metastatic breast cancer (mBC)
      GeneAlterationPrevalenceESCATReferences
      ERBB2Amplifications15%–20%IASlamon D, et al. N Engl J Med. 2001
      • Slamon D.J.
      • Leyland-Jones B.
      • Shak S.
      • et al.
      Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2.


      Swain S, et al. N Engl J Med. 2015
      • Swain S.M.
      • Baselga J.
      • Kim S.-B.
      • et al.
      Pertuzumab, trastuzumab, and docetaxel in HER2-positive metastatic breast cancer.


      Verma S, et al. N Engl J Med. 2012
      • Verma S.
      • Miles D.
      • Gianni L.
      • et al.
      Trastuzumab emtansine for HER2-positive advanced breast cancer.


      Krop I, et al. Lancet Oncol. 2014
      • Krop I.E.
      • Kim S.-B.
      • González-Martín A.
      • et al.
      Trastuzumab emtansine versus treatment of physician's choice for pretreated HER2-positive advanced breast cancer (TH3RESA): a randomised, open-label, phase 3 trial.


      Murthy R, et al. N Engl J Med. 2020
      • Murthy R.K.
      • Loi S.
      • Okines A.
      • et al.
      Tucatinib, trastuzumab, and capecitabine for HER2-positive metastatic breast cancer.
      Hotspot mutations4%IIBHyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      PIK3CAHotspot mutations30%–40%IAAndré F, et al. N Engl J Med. 2019
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      BRCA1/2Germline mutations4%IARobson M, et al. N Engl J Med. 2017
      • Robson M.
      • Im S.-A.
      • Senkus E.
      • et al.
      Olaparib for metastatic breast cancer in patients with a germline BRCA mutation.


      Litton J, et al. N Engl J Med. 2018
      • Litton J.K.
      • Rugo H.S.
      • Ettl J.
      • et al.
      Talazoparib in patients with advanced breast cancer and a germline BRCA mutation.
      Somatic mutations3%IIIABalasubramaniam S, et al. Clin Cancer Res. 2017
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      MSI-H1%ICMarcus L, et al. Clin Cancer Res. 2019
      • Marcus L.
      • Lemery S.J.
      • Keegan P.
      • et al.
      FDA approval summary: pembrolizumab for the treatment of microsatellite instability-high solid tumors.
      NTRKFusions1%ICDoebele RC, et al. Lancet Oncol. 2020
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ESR1Mutations (mechanism of resistance)10%IIAFribbens C, et al. J Clin Oncol. 2016
      • Fribbens C.
      • O'Leary B.
      • Kilburn L.
      • et al.
      Plasma ESR1 mutations and the treatment of estrogen receptor–positive advanced breast cancer.
      PTENMutations7%IIASchmid P, et al. J Clin Oncol. 2018
      • Schmid P.
      • Abraham J.
      • Chan S.
      • et al.
      AZD5363 plus paclitaxel versus placebo plus paclitaxel as first-line therapy for metastatic triple-negative breast cancer (PAKT): a randomised, double-blind, placebo-controlled, phase II trial.
      AKT1E17KMutations5%IIBHyman D, et al. J Clin Oncol. 2017
      • Hyman D.M.
      • Smyth L.M.
      • Donoghue M.T.A.
      • et al.
      AKT inhibition in solid tumors with AKT1 mutations.
      NF1Mutations (resistance biomarker)6%Not applicablePearson A, et al. Clin Cancer Res. 2020
      • Pearson A.
      • Proszek P.
      • Ring A.
      • et al.
      Inactivating NF1 mutations are enriched in advanced breast cancer and contribute to endocrine therapy resistance.
      MDM2Amplifications∼1%IIIADembla V, et al. Oncotarget. 2018
      • Dembla V.
      • Somaiah N.
      • Barata P.
      • et al.
      Prevalence of MDM2 amplification and coalterations in 523 advanced cancer patients in the MD Anderson phase 1 clinic.
      ERBB3Mutations2%IIIBHyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high.
      Summary of recommendations. Considering that somatic sequencing cannot fully substitute germline BRCA testing, that PIK3CA status can be determined by PCR on the three hotspots and pending that HER2 testing is accurately done by immunohistochemistry (IHC) in the local centre, there is currently no need to perform tumour multigene NGS for patients with mBC in the context of daily practice. From the perspective of clinical research centres, and considering the high number of level II alterations, it is important to include mBC patients in molecular screening programmes and include them in trials testing targeted therapies matched to genomic alterations (AKT1E17K, PTEN, ERBB2 mutations, ESR1 and NF1 mutations).

      Genomic alterations in metastatic colorectal cancer classified according to ESCAT

      Pivotal randomised trials and meta-analysis highlighted that hotspot RAS mutations (K-RAS and N-RAS) predict resistance to EGFR monoclonal antibodies (mAbs) in the metastatic setting.
      • Van Cutsem E.
      • Lenz H.-J.
      • Köhne C.-H.
      • et al.
      Fluorouracil, leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer.
      • Douillard J.-Y.
      • Oliner K.S.
      • Siena S.
      • et al.
      Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer.
      • Sorich M.J.
      • Wiese M.D.
      • Rowland A.
      • et al.
      Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal cancer: a meta-analysis of randomized, controlled trials.
      https://doi.org/10.1093/annonc/mdw235. The addition of encorafenib (a BRAF inhibitor) to cetuximab was associated with a significant survival benefit in a recent phase III trial in patients presenting a BRAFV600E mutation.
      • Kopetz S.
      • Grothey A.
      • Yaeger R.
      • et al.
      Encorafenib, binimetinib, and cetuximab in BRAF V600E-mutated colorectal cancer.
      Alterations in mismatch repair proteins (MLH1, MSH2, MSH6 and PMS2) can be identified by IHC and MSI-H by PCR to detect smaller length DNA fragments. Testing for MSI-H is of great clinical interest in metastatic colorectal cancer (mCRC) because it predicts the efficacy of pembrolizumab and nivolumab in this setting.
      • Overman M.J.
      • McDermott R.
      • Leach J.L.
      • et al.
      Nivolumab in patients with metastatic DNA mismatch repair-deficient or microsatellite instability-high colorectal cancer (CheckMate 142): an open-label, multicentre, phase 2 study.
      ,
      • Le D.T.
      • Kim T.W.
      • Van Cutsem E.
      • et al.
      Phase II open-label study of pembrolizumab in treatment-refractory, microsatellite instability-high/mismatch repair-deficient metastatic colorectal cancer: KEYNOTE-164.
      As mentioned before, TRK inhibitors showed high efficacy in multi-histology trials in NTRK fusion-positive tumours
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ,
      • Demetri G.D.
      • Paz-Ares L.
      • Multani P.S.
      • et al.
      Efficacy and safety of entrectinib in patients with NTRK fusion-positive tumours: Pooled analysis of STARTRK-2, STARTRK-1, and ALKA-372-001.
      ; and mCRC with ERBB2 amplifications/overexpression (detected with FISH or IHC) presented significant responses with dual HER2 therapy in prospective studies.
      • Meric-Bernstam F.
      • Hurwitz H.
      • Raghav K.P.S.
      • et al.
      Pertuzumab plus trastuzumab for HER2-amplified metastatic colorectal cancer (MyPathway): an updated report from a multicentre, open-label, phase 2a, multiple basket study.
      ,
      • Sartore-Bianchi A.
      • Trusolino L.
      • Martino C.
      • et al.
      Dual-targeted therapy with trastuzumab and lapatinib in treatment-refractory, KRAS codon 12/13 wild-type, HER2-positive metastatic colorectal cancer (HERACLES): a proof-of-concept, multicentre, open-label, phase 2 trial.
      In Table 5 we mention the main driver alterations categorised according to ESCAT, including those with a lack of clinical data in mCRC, but with impact in other tumours.
      • Hyman D.M.
      • Smyth L.M.
      • Donoghue M.T.A.
      • et al.
      AKT inhibition in solid tumors with AKT1 mutations.
      ,
      • Yakirevich E.
      • Resnick M.B.
      • Mangray S.
      • et al.
      Oncogenic ALK fusion in rare and aggressive subtype of colorectal adenocarcinoma as a potential therapeutic target.
      • Fabrizio D.A.
      • George T.J.
      • Dunne R.F.
      • et al.
      Beyond microsatellite testing: assessment of tumor mutational burden identifies subsets of colorectal cancer who may respond to immune checkpoint inhibition.
      • Juric D.
      • Rodon J.
      • Tabernero J.
      • et al.
      Phosphatidylinositol 3-kinase α–selective inhibition with alpelisib (BYL719) in PIK3CA-altered solid tumors: results from the first-in-human study.
      • Drilon A.E.
      • Subbiah V.
      • Oxnard G.R.
      • et al.
      A phase 1 study of LOXO-292, a potent and highly selective RET inhibitor, in patients with RET-altered cancers.
      • Wang C.
      • Jette N.
      • Moussienko D.
      • et al.
      ATM-deficient colorectal cancer cells are sensitive to the PARP inhibitor olaparib.
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      Savolitinib in treating participants with MET amplified metastatic or unresectable colorectal cancer - full text view - ClinicalTrials.gov.
      Table 5List of genomic alterations level I/II/III according to ESCAT in metastatic colorectal cancer (mCRC)
      GeneAlterationPrevalenceESCATReferences
      KRAS

      NRAS
      Mutations (resistance biomarker)44%

      4%
      Not applicableVan Cutsem E, et al. J Clin Oncol. 2015
      • Van Cutsem E.
      • Lenz H.-J.
      • Köhne C.-H.
      • et al.
      Fluorouracil, leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer.


      Douillard J-Y, et al. N Engl J Med. 2013
      • Douillard J.-Y.
      • Oliner K.S.
      • Siena S.
      • et al.
      Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer.


      Sorich M, et al. Ann Oncol. 2015
      • Sorich M.J.
      • Wiese M.D.
      • Rowland A.
      • et al.
      Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal cancer: a meta-analysis of randomized, controlled trials.
      BRAFV600EMutations8.5%IAhttps://doi.org/10.1093/annonc/mdw235

      Kopetz S, et al. N Engl J Med. 2019
      • Kopetz S.
      • Grothey A.
      • Yaeger R.
      • et al.
      Encorafenib, binimetinib, and cetuximab in BRAF V600E-mutated colorectal cancer.
      MSI-H4%–5%IAOverman M, et al. Lancet Oncol. 2017
      • Overman M.J.
      • McDermott R.
      • Leach J.L.
      • et al.
      Nivolumab in patients with metastatic DNA mismatch repair-deficient or microsatellite instability-high colorectal cancer (CheckMate 142): an open-label, multicentre, phase 2 study.


      Le DT, et al. J Clin Oncol. 2020
      • Le D.T.
      • Kim T.W.
      • Van Cutsem E.
      • et al.
      Phase II open-label study of pembrolizumab in treatment-refractory, microsatellite instability-high/mismatch repair-deficient metastatic colorectal cancer: KEYNOTE-164.
      NTRK1Fusions0.5%ICDemetri G, et al. Ann Oncol. 2018
      • Demetri G.D.
      • Paz-Ares L.
      • Multani P.S.
      • et al.
      Efficacy and safety of entrectinib in patients with NTRK fusion-positive tumours: Pooled analysis of STARTRK-2, STARTRK-1, and ALKA-372-001.


      Doebele RC, et al. Lancet Oncol. 2020
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ERBB2Amplifications2%IIBMeric-Bernstam F, et al. Lancet Oncol. 2019
      • Meric-Bernstam F.
      • Hurwitz H.
      • Raghav K.P.S.
      • et al.
      Pertuzumab plus trastuzumab for HER2-amplified metastatic colorectal cancer (MyPathway): an updated report from a multicentre, open-label, phase 2a, multiple basket study.


      Sartore-Bianchi A, et al. Lancet Oncol. 2016
      • Sartore-Bianchi A.
      • Trusolino L.
      • Martino C.
      • et al.
      Dual-targeted therapy with trastuzumab and lapatinib in treatment-refractory, KRAS codon 12/13 wild-type, HER2-positive metastatic colorectal cancer (HERACLES): a proof-of-concept, multicentre, open-label, phase 2 trial.
      PIK3CAHotspot mutations17%IIIAJuric D, et al. J Clin Oncol. 2018
      • Juric D.
      • Rodon J.
      • Tabernero J.
      • et al.
      Phosphatidylinositol 3-kinase α–selective inhibition with alpelisib (BYL719) in PIK3CA-altered solid tumors: results from the first-in-human study.
      ATMMutations5%IIIAWang C, et al. Transl Oncol. 2017
      • Wang C.
      • Jette N.
      • Moussienko D.
      • et al.
      ATM-deficient colorectal cancer cells are sensitive to the PARP inhibitor olaparib.


      De Bono J, et al. N Engl J Med. 2020
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      METAmplifications1.7%IIIAhttps://clinicaltrials.gov/ct2/show/NCT03592641
      Savolitinib in treating participants with MET amplified metastatic or unresectable colorectal cancer - full text view - ClinicalTrials.gov.
      AKT1E17KMutations1%IIIAHyman D, et al. J Clin Oncol. 2017
      • Hyman D.M.
      • Smyth L.M.
      • Donoghue M.T.A.
      • et al.
      AKT inhibition in solid tumors with AKT1 mutations.
      TMB-high in MSS1%IIIAFabrizio D, et al. J Gastrointest Oncol. 2018
      • Fabrizio D.A.
      • George T.J.
      • Dunne R.F.
      • et al.
      Beyond microsatellite testing: assessment of tumor mutational burden identifies subsets of colorectal cancer who may respond to immune checkpoint inhibition.
      RETFusions0.3%IIIADrilon A, et al. J Clin Oncol. 2018
      • Drilon A.E.
      • Subbiah V.
      • Oxnard G.R.
      • et al.
      A phase 1 study of LOXO-292, a potent and highly selective RET inhibitor, in patients with RET-altered cancers.
      ALKFusions0.2%IIIAYakirevich E, et al. Clin Cancer Res 2016
      • Yakirevich E.
      • Resnick M.B.
      • Mangray S.
      • et al.
      Oncogenic ALK fusion in rare and aggressive subtype of colorectal adenocarcinoma as a potential therapeutic target.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high; MSS, microsatellite stable.
      Summary of recommendations. Since most level I alterations are hotspot mutations in KRAS, NRAS and BRAF, and considering that MSI status is determined by IHC or PCR, there is no need to test samples using multigene NGS in the context of daily practice. Nevertheless, multigene NGS can be an alternative to PCR tests only if it does not generate extra cost compared with standard techniques already implemented in routine. This would allow detection of ERBB2 amplifications, and, in some panels, detect MSI status with high accuracy. If large panel NGS is carried out, it should include detection of NTRK fusions. As for mBC patients, patients with mCRC can present oncogenic alterations for which drugs are being developed and it is therefore recommended for clinical research centres to include patients in molecular screening programmes to propose access to innovative agents in clinical trials.

      Genomic alterations in advanced prostate cancer classified according to ESCAT

      Metastatic castration-resistant prostate cancer (mCRPC) presents aberrations in DNA repair genes with a high frequency (20%–30%). PARPi improved outcomes in patients with different DNA repair gene alterations in a randomised phase III trial; however, exploratory per-gene analysis suggested that most of the benefit was obtained in patients with BRCA1/2 somatic mutations.
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      This is supported by multiple phase II trials, where patients with BRCA1/2 alterations achieved the higher response rates. Data about PALB2, RAD50, RAD51 or BRIP1 mutations are promising but sparse due to the low frequency of these aberrations.
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      ,
      • Mateo J.
      • Carreira S.
      • Sandhu S.
      • et al.
      DNA-repair defects and olaparib in metastatic prostate cancer.
      Other genes involved in DNA repair, like MLH1/MSH2/MSH6 lead to MSI-H when mutated. Therapy with ICIs demonstrated effectiveness in multi-histology basket studies, although in advanced prostate cancer have shown minimal activity.
      • Marcus L.
      • Lemery S.J.
      • Keegan P.
      • et al.
      FDA approval summary: pembrolizumab for the treatment of microsatellite instability-high solid tumors.
      ,
      • Cortes-Ciriano I.
      • Lee S.
      • Park W.-Y.
      • Kim T.-M.
      • Park P.J.
      A molecular portrait of microsatellite instability across multiple cancers.
      ,
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      PTEN alterations are found very frequently in mCRPC,
      • Abida W.
      • Cyrta J.
      • Heller G.
      • et al.
      Genomic correlates of clinical outcome in advanced prostate cancer.
      and AKT inhibitors in combination with abiraterone showed antitumour activity in a retrospective analysis of a randomised phase II trial.
      • de Bono J.S.
      • De Giorgi U.
      • Rodrigues D.N.
      • et al.
      Randomized phase II study evaluating akt blockade with ipatasertib, in combination with abiraterone, in patients with metastatic prostate cancer with and without PTEN loss.
      Preliminary results of IPATential 150, a phase III randomised trial which evaluated ipatasertib (AKT inhibitor) with abiraterone and prednisone compared with standard therapy, showed an improvement of radiographic PFS (co-primary end point) in patients with PTEN loss and mCRPC, but not in the overall population.
      Ipatasertib plus abiraterone plus prednisone/prednisolone, relative to placebo plus abiraterone plus prednisone/prednisolone in adult male patients with metastatic castrate-resistant prostate cancer (IPATential150).
      Some alterations ranked level I/II in other diseases are observed in prostate cancer, but are not yet validated
      • Crumbaker M.
      • Khoja L.
      • Joshua A.M.
      AR signaling and the PI3K pathway in prostate cancer.
      (see Table 6).
      Table 6List of genomic alterations level I/II/III according to ESCAT in advanced prostate cancer
      GeneAlterationPrevalenceESCATReferences
      BRCA1/2Somatic mutations/deletions9%IADe Bono J, et al. N Engl J Med. 2020
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      MSI-H1%ICCortes-Ciriano I, et al. Nat Commun. 2017
      • Cortes-Ciriano I.
      • Lee S.
      • Park W.-Y.
      • Kim T.-M.
      • Park P.J.
      A molecular portrait of microsatellite instability across multiple cancers.


      Abida W, et al. J Clin Oncol. 2018
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.


      Marcus L, et al. Clin Cancer Res. 2019
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      PTENDeletions/mutations40%IIA
      a A press release suggests that AKT inhibitors could work specifically in PTEN-mutant prostate cancers. PTEN could be upgraded to IA depending on the magnitude of benefit and peer review assessment of the report.
      Abida W, et al. Proc Natl Acad Sci. 2019
      • Abida W.
      • Cyrta J.
      • Heller G.
      • et al.
      Genomic correlates of clinical outcome in advanced prostate cancer.


      De Bono J, et al. Clin Cancer Res. 2019
      • de Bono J.S.
      • De Giorgi U.
      • Rodrigues D.N.
      • et al.
      Randomized phase II study evaluating akt blockade with ipatasertib, in combination with abiraterone, in patients with metastatic prostate cancer with and without PTEN loss.


      NCT03072238
      Ipatasertib plus abiraterone plus prednisone/prednisolone, relative to placebo plus abiraterone plus prednisone/prednisolone in adult male patients with metastatic castrate-resistant prostate cancer (IPATential150).
      ATMMutations/deletions5%IIADe Bono J, et al. N Engl J Med. 2020
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      PALB2Mutations1%IIBMateo J, et al. N Engl J Med. 2015
      • Mateo J.
      • Carreira S.
      • Sandhu S.
      • et al.
      DNA-repair defects and olaparib in metastatic prostate cancer.


      De Bono J, et al. N Engl J Med. 2020
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      PIK3CAHotspot mutations3%IIIACrumbaker M, et al. Cancers. 2017
      • Crumbaker M.
      • Khoja L.
      • Joshua A.M.
      AR signaling and the PI3K pathway in prostate cancer.
      AKT1E17KMutations1%IIIACrumbaker M, et al. Cancers. 2017
      • Crumbaker M.
      • Khoja L.
      • Joshua A.M.
      AR signaling and the PI3K pathway in prostate cancer.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high; PTEN, phosphatase and tensin homologue.
      a A press release suggests that AKT inhibitors could work specifically in PTEN-mutant prostate cancers. PTEN could be upgraded to IA depending on the magnitude of benefit and peer review assessment of the report.
      Summary of recommendations. In countries where PARPi are accessible for patients with prostate cancer, it is recommended to perform NGS on tumour samples to assess the mutational status of, at least, BRCA1/2. According to the preliminary results of the phase III trial with AKT inhibitors in patients with PTEN alterations, this gene could be added to the panel. Given that they are unlikely to be cost-effective in these cases, larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (including off-label use of drugs) and pending a ranking of additional alterations using a valid ranking system. These panels should include DNA repair genes and MSI signature.

      Genomic alterations in metastatic gastric cancer classified according to ESCAT

      ERBB2 amplifications are observed in around 15% of gastric cancers.
      The Cancer Genome Atlas Research Network
      Comprehensive molecular characterization of gastric adenocarcinoma.
      In these patients, trastuzumab demonstrated a significant improvement of OS in randomised trials.
      • Bang Y.-J.
      • Van Cutsem E.
      • Feyereislova A.
      • et al.
      Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial.
      According to basket trials, patients with MSI-H and NTRK fusion-positive tumours treated with ICIs and TRK inhibitors are expected to provide benefit.
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
      ,
      • Marcus L.
      • Lemery S.J.
      • Keegan P.
      • et al.
      FDA approval summary: pembrolizumab for the treatment of microsatellite instability-high solid tumors.
      Some limited responses were observed in patients with EGFR- and MET-amplified metastatic gastric cancer (mGC) treated with cetuximab and crizotinib in prospective analysis.
      • Maron S.B.
      • Alpert L.
      • Kwak H.A.
      • et al.
      Targeted therapies for targeted populations: anti-EGFR treatment for EGFR amplified gastroesophageal adenocarcinoma.
      ,
      • Lennerz J.K.
      • Kwak E.L.
      • Ackerman A.
      • et al.
      MET amplification identifies a small and aggressive subgroup of esophagogastric adenocarcinoma with evidence of responsiveness to crizotinib.
      These findings require further investigation. In addition, many other level I/II aberrations of other cancer types are observed in gastric cancer, but not validated in this latter disease.
      • Shaw A.T.
      • Riely G.J.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged advanced non-small-cell lung cancer (NSCLC): updated results, including overall survival, from PROFILE 1001.
      ,
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      ,
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      ,
      • Juric D.
      • Rodon J.
      • Tabernero J.
      • et al.
      Phosphatidylinositol 3-kinase α–selective inhibition with alpelisib (BYL719) in PIK3CA-altered solid tumors: results from the first-in-human study.
      ,
      • Oxnard G.
      • Subbiah V.
      • Park K.
      • et al.
      Clinical activity of LOXO-292, a highly selective RET inhibitor, in patients with RET fusion+ non-small cell lung cancer.
      • Lee J.
      • Ou S.-H.I.
      • Lee J.M.
      • et al.
      Gastrointestinal malignancies harbor actionable MET exon 14 deletions.
      • Bang Y.-J.
      • Xu R.-H.
      • Chin K.
      • et al.
      Olaparib in combination with paclitaxel in patients with advanced gastric cancer who have progressed following first-line therapy (GOLD): a double-blind, randomised, placebo-controlled, phase 3 trial.
      • Van Cutsem E.
      • Bang Y.-J.
      • Mansoor W.
      • et al.
      A randomized, open-label study of the efficacy and safety of AZD4547 monotherapy versus paclitaxel for the treatment of advanced gastric adenocarcinoma with FGFR2 polysomy or gene amplification.
      • Loriot Y.
      • Necchi A.
      • Park S.H.
      • et al.
      Erdafitinib in locally advanced or metastatic urothelial carcinoma.
      All these alterations are described in Table 7.
      Table 7List of genomic alterations level I/II/III according to ESCAT in metastatic gastric cancer (mGC)
      GeneAlterationPrevalenceESCATReferences
      ERBB2Amplifications16%IAThe Cancer Genome Atlas Research Network. Nature. 2014
      The Cancer Genome Atlas Research Network
      Comprehensive molecular characterization of gastric adenocarcinoma.


      Bang Y-J, et al. Lancet. 2010
      • Bang Y.-J.
      • Van Cutsem E.
      • Feyereislova A.
      • et al.
      Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial.
      Hotspot mutations3%IIIAHyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      MSI-H8%ICThe Cancer Genome Atlas Research Network. Nature. 2014
      The Cancer Genome Atlas Research Network
      Comprehensive molecular characterization of gastric adenocarcinoma.


      Marcus L, et al. Clin Cancer Res. 2019
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      NTRKFusions2%ICDrilon A, et al. N Engl J Med. 2018
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
      EGFRAmplifications6%IIBMaron S, et al. Cancer Discov. 2018
      • Maron S.B.
      • Alpert L.
      • Kwak H.A.
      • et al.
      Targeted therapies for targeted populations: anti-EGFR treatment for EGFR amplified gastroesophageal adenocarcinoma.
      METAmplifications3%IIBLennerz J, et al. J Clin Oncol. 2011
      • Lennerz J.K.
      • Kwak E.L.
      • Ackerman A.
      • et al.
      MET amplification identifies a small and aggressive subgroup of esophagogastric adenocarcinoma with evidence of responsiveness to crizotinib.
      Mutations1.3%IIIALee J, et al. Oncotarget. 2015
      • Lee J.
      • Ou S.-H.I.
      • Lee J.M.
      • et al.
      Gastrointestinal malignancies harbor actionable MET exon 14 deletions.
      PIK3CAHotspot mutations7%IIIAJuric D, et al. J Clin Oncol. 2018
      • Juric D.
      • Rodon J.
      • Tabernero J.
      • et al.
      Phosphatidylinositol 3-kinase α–selective inhibition with alpelisib (BYL719) in PIK3CA-altered solid tumors: results from the first-in-human study.
      FGFR2Amplifications4%IIIAVan Cutsem E, et al. Ann Oncol. 2017
      • Van Cutsem E.
      • Bang Y.-J.
      • Mansoor W.
      • et al.
      A randomized, open-label study of the efficacy and safety of AZD4547 monotherapy versus paclitaxel for the treatment of advanced gastric adenocarcinoma with FGFR2 polysomy or gene amplification.


      Loriot Y, et al. N Engl J Med. 2019
      • Loriot Y.
      • Necchi A.
      • Park S.H.
      • et al.
      Erdafitinib in locally advanced or metastatic urothelial carcinoma.
      ATMMutations3%IIIABang Y-J, et al. Lancet Oncol. 2017
      • Bang Y.-J.
      • Xu R.-H.
      • Chin K.
      • et al.
      Olaparib in combination with paclitaxel in patients with advanced gastric cancer who have progressed following first-line therapy (GOLD): a double-blind, randomised, placebo-controlled, phase 3 trial.
      BRCA1/2Mutations1%–5%IIIABalasubramaniam S, et al. Clin Cancer Res. 2017
      • Balasubramaniam S.
      • Beaver J.A.
      • Horton S.
      • et al.
      FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
      ROS1Fusions<1%IIIAShaw A, et al. Ann Oncol. 2019
      • Shaw A.T.
      • Riely G.J.
      • Bang Y.-J.
      • et al.
      Crizotinib in ROS1-rearranged advanced non-small-cell lung cancer (NSCLC): updated results, including overall survival, from PROFILE 1001.
      RETFusions<1%IIIAOxnard G, et al. J Thorac Oncol. 2018
      • Oxnard G.
      • Subbiah V.
      • Park K.
      • et al.
      Clinical activity of LOXO-292, a highly selective RET inhibitor, in patients with RET fusion+ non-small cell lung cancer.
      ERBB3Hotspot mutations3%IIIBHyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high.
      Summary of recommendations. There is no current need to perform tumour multigene NGS in patients with mGC in daily practice. Detection of MSI and NTRK fusions should be done using cheap standard methods.

      Genomic alterations in advanced pancreatic ductal adenocarcinoma classified according to ESCAT

      Patients with germline BRCA1/2-mutated advanced pancreatic ductal adenocarcinoma (PDAC) presented a longer PFS with maintenance olaparib.
      The Cancer Genome Atlas Research Network
      Integrated genomic characterization of pancreatic ductal adenocarcinoma.
      ,
      • Golan T.
      • Hammel P.
      • Reni M.
      • et al.
      Maintenance olaparib for germline BRCA-mutated metastatic pancreatic cancer.
      In advanced PDAC with somatic BRCA1/2 mutations, an increased response with PARPi has been reported in few patients included in a prospective trial.
      • Shroff R.T.
      • Hendifar A.
      • McWilliams R.R.
      • et al.
      Rucaparib monotherapy in patients with pancreatic cancer and a known deleterious BRCA mutation.
      The panel therefore considered that somatic BRCA1/2 alterations are not yet validated in advanced PDAC. As we mentioned for other tumours, patients with MSI-H and NTRK fusion-positive tumours presented meaningful clinical benefit with matched therapies in multi-histology studies.
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ,
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      ,
      • Cocco E.
      • Scaltriti M.
      • Drilon A.
      NTRK fusion-positive cancers and TRK inhibitor therapy.
      ,
      • Pihlak R.
      • Weaver J.M.J.
      • Valle J.W.
      • et al.
      Advances in molecular profiling and categorisation of pancreatic adenocarcinoma and the implications for therapy.
      Several additional alterations are classified at high level according to ESCAT in other tumours, but have not yet shown a significant impact in pancreatic cancer like KRAS, PIK3CA, BRAFV600E mutations, MDM2, ERBB2 amplifications and NRG1, ALK, RET, ROS1 fusions.
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      ,
      • Drilon A.E.
      • Subbiah V.
      • Oxnard G.R.
      • et al.
      A phase 1 study of LOXO-292, a potent and highly selective RET inhibitor, in patients with RET-altered cancers.
      ,
      • Zeitouni D.
      • Pylayeva-Gupta Y.
      • Der C.J.
      • et al.
      KRAS mutant pancreatic cancer: no lone path to an effective treatment.
      • Heestand G.M.
      • Kurzrock R.
      Molecular landscape of pancreatic cancer: implications for current clinical trials.
      • Payne S.
      • Maher M.
      • Tran N.
      • et al.
      Mutant PIK3CA-mediated pancreatic tumorigenesis and the response to PI3K pathway inhibition.
      • Hyman D.M.
      • Puzanov I.
      • Subbiah V.
      • et al.
      Vemurafenib in multiple nonmelanoma cancers with BRAF V600 mutations.
      • Azmi A.S.
      • Aboukameel A.
      • Banerjee S.
      • et al.
      MDM2 inhibitor MI-319 in combination with cisplatin is an effective treatment for pancreatic cancer independent of p53 function.
      • Waddell N.
      • Pajic M.
      • Bailey P.
      • et al.
      Whole genomes redefine the mutational landscape of pancreatic cancer.
      • Harder J.
      • Ihorst G.
      • Heinemann V.
      • et al.
      Multicentre phase II trial of trastuzumab and capecitabine in patients with HER2 overexpressing metastatic pancreatic cancer.
      • Jones M.R.
      • Williamson L.M.
      • Topham J.T.
      • et al.
      NRG1 gene fusions are recurrent, clinically actionable gene rearrangements in KRAS wild-type pancreatic ductal adenocarcinoma.
      • Singhi A.D.
      • Ali S.M.
      • Lacy J.
      • et al.
      Identification of targetable ALK rearrangements in pancreatic ductal adenocarcinoma.
      • Pishvaian M.J.
      • Rolfo C.D.
      • Liu S.V.
      • Multani P.S.
      • Chow Maneval E.
      • Garrido-Laguna I.
      Clinical benefit of entrectinib for patients with metastatic pancreatic cancer who harbor NTRK and ROS1 fusions.
      The main drivers of PDAC and their classification are described in Table 8.
      Table 8List of genomic alterations level I/II/III according to ESCAT in advanced pancreatic ductal adenocarcinoma (PDAC)
      GeneAlterationPrevalenceESCATReferences
      BRCA1/2Germline mutations1%–4%IAThe Cancer Genome Atlas Research Network. Cancer Cell. 2017
      The Cancer Genome Atlas Research Network
      Integrated genomic characterization of pancreatic ductal adenocarcinoma.


      Golan T, et al. N Engl J Med. 2019
      • Golan T.
      • Hammel P.
      • Reni M.
      • et al.
      Maintenance olaparib for germline BRCA-mutated metastatic pancreatic cancer.
      Somatic mutations3%IIIBShroff R, et al. JCO Precis Oncol. 2018
      • Shroff R.T.
      • Hendifar A.
      • McWilliams R.R.
      • et al.
      Rucaparib monotherapy in patients with pancreatic cancer and a known deleterious BRCA mutation.
      MSI-H1%–3%ICPihlak R, et al. Cancers. 2018
      • Pihlak R.
      • Weaver J.M.J.
      • Valle J.W.
      • et al.
      Advances in molecular profiling and categorisation of pancreatic adenocarcinoma and the implications for therapy.


      Marcus L, et al. Clin Cancer Res. 2019
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      NTRKFusions<1%ICCocco E, et al. Nat Rev Clin Oncol. 2018
      • Cocco E.
      • Scaltriti M.
      • Drilon A.
      NTRK fusion-positive cancers and TRK inhibitor therapy.


      Doebele RC, et al. Lancet Oncol. 2020
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      KRASMutations90%IIIAZeitouni D, et al. Cancers. 2016
      • Zeitouni D.
      • Pylayeva-Gupta Y.
      • Der C.J.
      • et al.
      KRAS mutant pancreatic cancer: no lone path to an effective treatment.
      PIK3CAHotspot mutations3%IIIAHeestand G, et al. Oncotarget. 2015
      • Heestand G.M.
      • Kurzrock R.
      Molecular landscape of pancreatic cancer: implications for current clinical trials.


      Payne S, et al. J Clin Oncol. 2015
      • Payne S.
      • Maher M.
      • Tran N.
      • et al.
      Mutant PIK3CA-mediated pancreatic tumorigenesis and the response to PI3K pathway inhibition.
      BRAFV600EMutations3%IIIAHyman D, et al. N Engl J Med. 2015
      • Hyman D.M.
      • Puzanov I.
      • Subbiah V.
      • et al.
      Vemurafenib in multiple nonmelanoma cancers with BRAF V600 mutations.
      MDM2Amplifications2%IIIAAzmi A, et al. Eur J Cancer. 2010
      • Azmi A.S.
      • Aboukameel A.
      • Banerjee S.
      • et al.
      MDM2 inhibitor MI-319 in combination with cisplatin is an effective treatment for pancreatic cancer independent of p53 function.
      ERBB2Amplifications/mutations1%–2%IIIAWaddell N, et al. Nature. 2015
      • Waddell N.
      • Pajic M.
      • Bailey P.
      • et al.
      Whole genomes redefine the mutational landscape of pancreatic cancer.


      Harder J, et al. Br J Cancer. 2012
      • Harder J.
      • Ihorst G.
      • Heinemann V.
      • et al.
      Multicentre phase II trial of trastuzumab and capecitabine in patients with HER2 overexpressing metastatic pancreatic cancer.


      Hyman D, et al. Nature. 2018
      • Hyman D.M.
      • Piha-Paul S.A.
      • Won
      • et al.
      HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
      NRG1Fusions1%IIIAJones M, et al. Clin Cancer Res. 2019
      • Jones M.R.
      • Williamson L.M.
      • Topham J.T.
      • et al.
      NRG1 gene fusions are recurrent, clinically actionable gene rearrangements in KRAS wild-type pancreatic ductal adenocarcinoma.
      ALKFusions<1%IIIASinghi A, et al. J Natl Compr Canc Netw. 2017
      • Singhi A.D.
      • Ali S.M.
      • Lacy J.
      • et al.
      Identification of targetable ALK rearrangements in pancreatic ductal adenocarcinoma.
      RETFusions<1%IIIADrilon A, et al. J Clin Oncol. 2018
      • Drilon A.E.
      • Subbiah V.
      • Oxnard G.R.
      • et al.
      A phase 1 study of LOXO-292, a potent and highly selective RET inhibitor, in patients with RET-altered cancers.
      ROS1Fusions<1%IIIAPishvaian M, et al. J Clin Oncol. 2018
      • Pishvaian M.J.
      • Rolfo C.D.
      • Liu S.V.
      • Multani P.S.
      • Chow Maneval E.
      • Garrido-Laguna I.
      Clinical benefit of entrectinib for patients with metastatic pancreatic cancer who harbor NTRK and ROS1 fusions.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high.
      Summary of recommendations. It is not currently recommended to perform tumour multigene NGS in patients with advanced PDAC in daily practice. Considering the unmet medical needs and the high number of alterations ranked as level II–IV, ESMO considers it is the mission of clinical research centres and their networks to propose multigene sequencing to patients with advanced PDAC in the context of molecular screening programmes, in order for patients to get access to innovative drugs. If multigene sequencing is not carried out, detection of MSI and NTRK fusions should be done using cheaper standard methods, pending drugs are approved and reimbursed.

      Genomic alterations in advanced hepatocellular carcinoma classified according to ESCAT

      While numerous aberrations are being evaluated, very few targets currently have impact on clinical decisions.
      Cancer Genome Atlas Research Network
      Comprehensive and integrative genomic characterization of hepatocellular carcinoma.
      As we described for the majority of cancers, due to their clinical benefit larotrectinib and ICIs were approved for patients with NTRK fusion-positive and MSI-H solid tumours, respectively, who have no alternative treatments.
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
      ,
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      There are also other alterations with strong benefit across different tumour types like PIK3CA, RAS mutations and MET amplifications,
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      ,
      • Rimassa L.
      • Assenat E.
      • Peck-Radosavljevic M.
      • et al.
      Tivantinib for second-line treatment of MET-high, advanced hepatocellular carcinoma (METIV-HCC): a final analysis of a phase 3, randomised, placebo-controlled study.
      ,
      • Lim H.Y.
      • Merle P.
      • Weiss K.H.
      • et al.
      Phase II studies with refametinib or refametinib plus sorafenib in patients with RAS-mutated hepatocellular carcinoma.
      and no clinical evidence in this disease (Table 9).
      Table 9List of genomic alterations level I/II/III according to ESCAT in advanced hepatocellular carcinoma (HCC)
      GeneAlterationPrevalenceESCATReferences
      NTRKFusions1%ICThe Cancer Genome Atlas Research Network. Cancer Cell. 2017
      The Cancer Genome Atlas Research Network
      Integrated genomic characterization of pancreatic ductal adenocarcinoma.


      Drilon A, et al. N Engl J Med. 2018
      • Drilon A.
      • Laetsch T.W.
      • Kummar S.
      • et al.
      Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
      MSI-H1%ICMarcus L, et al. Clin Cancer Res. 2019
      • Abida W.
      • Cheng M.L.
      • Armenia J.
      • et al.
      Microsatellite instability in prostate cancer and response to immune checkpoint blockade.
      PIK3CAHotspot mutations4%IIIAAndré F, et al. N Engl J Med. 2019
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      METAmplifications2%–6%IIIARimassa L, et al. Lancet Oncol. 2018
      • Rimassa L.
      • Assenat E.
      • Peck-Radosavljevic M.
      • et al.
      Tivantinib for second-line treatment of MET-high, advanced hepatocellular carcinoma (METIV-HCC): a final analysis of a phase 3, randomised, placebo-controlled study.
      RASMutations2%IIIALim H, et al. Clin Cancer Res. 2018
      • Lim H.Y.
      • Merle P.
      • Weiss K.H.
      • et al.
      Phase II studies with refametinib or refametinib plus sorafenib in patients with RAS-mutated hepatocellular carcinoma.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets; MSI-H, microsatellite instability-high.
      Summary of recommendations. It is not currently recommended to perform tumour multigene NGS in patients with advanced hepatocellular carcinoma (HCC) in daily practice. Considering the unmet medical needs and the number of alterations ranked as level II–IV, ESMO considers it is the mission of clinical research centres to propose multigene sequencing to patients with advanced HCC in the context of molecular screening programmes. If multigene sequencing is not carried out, detection of MSI and NTRK fusions should be done using cheaper standard methods, pending drugs are approved and reimbursed.

      Genomic alterations in advanced cholangiocarcinoma classified according to ESCAT

      IDH1 mutations are ranked level I in ESCAT (IA).
      • Abou-Alfa G.K.
      • Macarulla Mercade T.
      • Javle M.
      • et al.
      ClarIDHy: a global, phase 3, randomized, double-blind study of ivosidenib (IVO) vs. placebo in patients with advanced cholangiocarcinoma (CC) with an isocitrate dehydrogenase 1 (IDH1) mutation.
      In addition, pemigatinib, a selective fibroblast growth factor receptor (FGFR)1,2,3 inhibitor, led to a 35% ORR in patients with advanced FGFR2 fusion-positive cholangiocarcinoma (CC) in a prospective phase II trial,
      • Vogel A.
      • Sahai V.
      • Hollebecque A.
      • et al.
      LBA40 - FIGHT-202: A phase II study of pemigatinib in patients (pts) with previously treated locally advanced or metastatic cholangiocarcinoma (CCA).
      getting accelerated approval by the FDA. As we mentioned previously, patients with MSI-H and NTRK fusion-positive tumours presented clinically meaningful benefit with ICIs and TRK inhibitors in basket studies.
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      ,
      • Marabelle A.
      • Le D.T.
      • Ascierto P.A.
      • et al.
      Efficacy of pembrolizumab in patients with noncolorectal high microsatellite instability/mismatch repair-deficient cancer: Results from the phase II KEYNOTE-158 study.
      Finally, rapidly accelerated fibrosarcoma/mitogen-activated protein kinase kinase inhibitors were associated with 42% OR in patients with advanced CC and BRAFV600E mutations
      • Wainberg Z.A.
      • Lassen U.N.
      • Elez E.
      • et al.
      Efficacy and safety of dabrafenib (D) and trametinib (T) in patients (pts) with BRAF V600E–mutated biliary tract cancer (BTC): a cohort of the ROAR basket trial.
      (Table 10). In Table 10 are also described some alterations with efficacy in other tumours, but not yet validated in this disease.
      • Camidge D.R.
      • Otterson G.A.
      • Clark J.W.
      • et al.
      Crizotinib in patients (pts) with MET-amplified non-small cell lung cancer (NSCLC): updated safety and efficacy findings from a phase 1 trial.
      ,
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      ,
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      ,
      • Javle M.M.
      • Hainsworth J.D.
      • Swanton C.
      • et al.
      Pertuzumab + trastuzumab for HER2-positive metastatic biliary cancer: preliminary data from MyPathway.
      Table 10List of genomic alterations level I/II/III according to ESCAT in advanced cholangiocarcinoma (CC)
      GeneAlterationPrevalenceESCATReferences
      IDH1Mutations20%IAAbou-Alfa G. K, et al. Ann Oncol. 2019
      • Abou-Alfa G.K.
      • Macarulla Mercade T.
      • Javle M.
      • et al.
      ClarIDHy: a global, phase 3, randomized, double-blind study of ivosidenib (IVO) vs. placebo in patients with advanced cholangiocarcinoma (CC) with an isocitrate dehydrogenase 1 (IDH1) mutation.
      FGFR2Fusions15%IBVogel A, et al. Ann Oncol. 2019
      • Vogel A.
      • Sahai V.
      • Hollebecque A.
      • et al.
      LBA40 - FIGHT-202: A phase II study of pemigatinib in patients (pts) with previously treated locally advanced or metastatic cholangiocarcinoma (CCA).
      MSI-H2%ICMarabelle A, et al. J Clin Oncol. 2020
      • Marabelle A.
      • Le D.T.
      • Ascierto P.A.
      • et al.
      Efficacy of pembrolizumab in patients with noncolorectal high microsatellite instability/mismatch repair-deficient cancer: Results from the phase II KEYNOTE-158 study.
      NTRKFusions2%ICDoebele RC, et al. Lancet Oncol. 2020
      • Doebele R.C.
      • Drilon A.
      • Paz-Ares L.
      • et al.
      Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
      BRAFV600EMutations5%IIBWainberg Z, et al. J Clin Oncol. 2019
      • Wainberg Z.A.
      • Lassen U.N.
      • Elez E.
      • et al.
      Efficacy and safety of dabrafenib (D) and trametinib (T) in patients (pts) with BRAF V600E–mutated biliary tract cancer (BTC): a cohort of the ROAR basket trial.
      ERBB2Amplifications

      Mutations
      10%

      2%
      IIIAJavle MM, et al. J Clin Oncol. 2017
      • Javle M.M.
      • Hainsworth J.D.
      • Swanton C.
      • et al.
      Pertuzumab + trastuzumab for HER2-positive metastatic biliary cancer: preliminary data from MyPathway.
      PIK3CAHotspot mutations7%IIIAAndré F, et al. N Engl J Med. 2019
      • André F.
      • Ciruelos E.
      • Rubovszky G.
      • et al.
      Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
      BRCA 1/2Mutations3%IIIADe Bono J, et al. N Engl J Med. 2020
      • De Bono J.
      • Mateo J.
      • Fizazi K.
      • et al.
      Olaparib for metastatic castration-resistant prostate cancer.
      METAmplifications2%IIIACamidge D, et al. J Clin Oncol. 2018
      • Camidge D.R.
      • Otterson G.A.
      • Clark J.W.
      • et al.
      Crizotinib in patients (pts) with MET-amplified non-small cell lung cancer (NSCLC): updated safety and efficacy findings from a phase 1 trial.
      ESCAT, European Society for Medical Oncology (ESMO) Scale for Clinical Actionability of molecular Targets.
      Summary of recommendations. Tumour multigene NGS could be used to detect level I actionable alterations in cholangiocarcinoma. Given that they are unlikely to be cost-effective in these cases, larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (including off-label use of drugs) and pending a ranking of additional alterations using a valid ranking system.

       Other tumour types

      While the systematic ranking of genomic alterations was done exclusively for the eight more frequent killers, we also assessed the frequency of level I alterations in other tumour types. In ovarian cancers, where BRCA1/2 somatic mutations have been associated with increased benefit to PARPi,
      • Moore K.
      • Colombo N.
      • Scambia G.
      • et al.
      Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer.
      the use of multigene NGS is justified. Larger panels can be used only on the basis of specific agreements with payers taking into account the overall cost of the strategy (including off-label use of drugs) and pending an appropriate method of reporting. While there is no level I evidence, multigene sequencing could also be used in carcinoma of unknown primary.
      • Clynick B.
      • Dessauvagie B.
      • Sterrett G.
      • et al.
      Genetic characterisation of molecular targets in carcinoma of unknown primary.

       Specific situations

       Tumour mutational burden and KN158 study

      KN158 has evaluated the efficacy of pembrolizumab according to TMB in 10 cancers (anal cancer, cervical cancer, endometrial cancer, small-cell lung cancer (SCLC), salivary cancer, thyroid cancers, well-to-moderately differentiated neuroendocrine tumours (NETs), biliary cancers, vulvar cancer, mesothelioma). Response rates were 27% and 7% in patients with TMB-high (MSI-low) or TMB-low cancers, respectively. There was no TMB-high detected in biliary cancers, and the percentage of response was lower in TMB-high in anal cancer and mesothelioma. We can classify TMB as level IIA according to ESCAT. If we consider that indications of anti-PD(L)1 antibodies are broad in endometrial cancers and SCLC, the TMB should be determined only in cervical cancer, NET, salivary cancers, vulvar cancers, thyroid cancers. Considering that the study was not agnostic, but limited to few cancers, the group thinks that additional studies are needed before implementing TMB in all cancers where anti-PD(L)1 antibodies are not approved.

       NTRK fusions

      TRK inhibitors have been shown to be effective in a broad range of cancers. NTRK fusions occur in <1% of cancers. The incidence of NTRK fusions is very high in mammary analogue secretory carcinoma of salivary glands and in secretory breast cancers. A high incidence is also observed in sarcoma and thyroid cancers. Considering the very low incidence, the group recommends using NGS to detect NTRK fusions only in cancers where this technology is recommended otherwise. In cancers where there is no need for multigene sequencing, it was considered that the detection of NTRK fusion is not an argument per se to recommend NGS since alternative, cheaper, diagnostic methods exist. Such alternative, cheaper methods should be prioritised to screen patients for NTRK fusions, in countries where TRK inhibitors are available.

      Conclusion

      ESMO recommends using tumour multigene NGS in patients presenting with advanced non-squamous NSCLC, prostate, ovarian cancers and cholangiocarcinoma. Large panels of genes can be used if they generate only an acceptable increase in the overall cost, drugs included. In addition, based on KN158, it is recommended to determine TMB in cervical cancer, salivary cancer, thyroid cancers, well-to-moderately differentiated NETs, vulvar cancer, pending drug access. In colorectal cancers, NGS can be an alternative to PCR-based tests, if it is not associated with extra cost. ESMO strongly recommends that clinical research centres perform multigene sequencing as part of their missions to accelerate cancer research and drug development through clinical trials, provide access to innovation to patients and to collect data. In addition, economic evaluations alongside clinical trials should also be implemented to foster evidence in this field. Outside the indications mentioned before, and considering that the use of large panels of genes could lead to identification of few exceptional responders, ESMO acknowledges that a patient and a doctor could decide together to order a large panel of genes, pending no extra cost for the public health care system, and if the patient is informed about the low likelihood of benefit.
      These recommendations will need to be updated on a regular basis as new data emerges for novel therapies across tumour types.

      Acknowledgement

      This is a project initiated by the ESMO Translational Research and Precision Medicine Working Group. We would also like to thank ESMO leadership for their support in this manuscript.

      Funding

      This work was supported by the European Society for Medical Oncology (no grant number is applicable).

      Disclosure

      JR: advisory: Merck Sharp & Dohme (MSD), Boehringer, Bristol-Myers Squibb (BMS), AstraZeneca, Roche; speaker's bureau: Pfizer; travel support: OSE Immunotherapeutics SA, BMS, AstraZeneca, Roche. JM: advisory board: Amgen, AstraZeneca, Clovis Oncology, Janssen, MSD and Roche-Foundation Medicine; research funding: AstraZeneca and Pfizer Oncology; principal investigator of several industry sponsored clinical trials. CBW: personal and speakers' fees, reimbursement for travel and accommodation and honoraria for participance in advisory boards from Bayer, Celgene, Ipsen, MedScape, Rafael Pharmaceuticals, RedHill, Roche, Servier, Shire/Baxalta and Taiho; scientific grant support by Roche. FB: personal fees from AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer–Ingelheim, Eli Lilly Oncology, F. Hoffmann–La Roche Ltd, Novartis, Merck, MSD, Pierre Fabre, Pfizer and Takeda. MPL: research grants (to hospital): MSD, Astellas, JnJ, Sanofi; advice: Roche, Bayer, Amgen, JnJ, Sanofi, Servier, Pfizer, Incyte. NN: speaker's fee and/or advisory boards: Amgen, AstraZeneca, Bayer, Biocartis, BMS, Boehringer Ingelheim, Eli Lilly, Ilumina, Incyte, MERCK, MSD, Qiagen, Roche, Thermofisher, Sanofi; institutional financial interests (financial support to research projects): AstraZeneca, Biocartis, BMS, Illumina, Merck, Qiagen, Roche, Sysmex, Thermofisher; non-financial interests: President of the International Quality Network for Pathology (IQN Path); President of the Italian Cancer Society (SIC). ASc: speakers bureau: Ypsen, Astra Zeneca, Amgen, MSD, GSK; consulting: INCYTE Biosciences. MR: consulting or advisory: AstraZeneca (uncompensated), Change Healthcare, Daiichi-Sankyo (uncompensated), Epic Sciences (uncompensated), Merck (uncompensated), Pfizer (uncompensated); research funding: AbbVie (institution), AstraZeneca (Institution), Invitae (Institution, in-kind), Merck (Institution), Pfizer (institution); travel, accommodation, expenses: AstraZeneca, Merck; editorial services: AstraZeneca, Pfizer. FM-B: consulting: Aduro BioTech Inc., Alkermes, DebioPharm, eFFECTOR Therapeutics, F. Hoffman-La Roche Ltd, Genentech Inc., IBM Watson, Jackson Laboratory, Kolon Life Science, OrigiMed, PACT Pharma, Parexel International, Pfizer Inc., Samsung Bioepis, Seattle Genetics Inc., Tyra Biosciences, Xencor, Zymeworks; advisory committee: Immunomedics, Inflection Biosciences, Mersana Therapeutics, Puma Biotechnology Inc., Seattle Genetics, Silverback Therapeutics, Spectrum Pharmaceuticals, Zentalis; sponsored research: Aileron Therapeutics, Inc., AstraZeneca, Bayer Healthcare Pharmaceutical, Calithera Biosciences Inc., Curis Inc., CytomX Therapeutics Inc., Daiichi Sankyo Co. Ltd, Debiopharm International, eFFECTOR Therapeutics, Genentech Inc., Guardant Health Inc., Millennium Pharmaceuticals Inc., Novartis, Puma Biotechnology Inc., Taiho Pharmaceutical Co.; honoraria: Chugai Biopharmaceuticals, Mayo Clinic, Rutgers Cancer Institute of New Jersey; other (Travel Related): Beth Israel Deaconess Medical Center. NW: research grant from Puma Biotechnology; scientific advisory board and stockholder for Relay Therapeutics; advisor to Eli Lilly. ASt: advisory board/speakers bureau: Astra Zeneca, Eli Lilly, Bayer, BMS, Illumina, Janssen, MSD, Pfizer, Roche, Seattle Genetics, Thermo Fisher; Grants: Bayer, BMS, Chugai. JB: travel support: BMS; consulting fees: BMS, MSD, Astellas. SM: statistical advice: IDDI and Janssen Cilag; Independent Data Monitoring Committee member: Hexal, Steba, IQVIA, Roche, Sensorion, Biophytis, Servier, Yuhan. IB: speaker’s fee: AstraZeneca. ER: board participation: AstraZeneca, BMS, Roche; travel funding: AstraZeneca, BMS. JSR-F: paid consultant: Goldman Sachs, REPARE Therapeutics, and Paige.AI; member of the scientific advisory board: REPARE Therapeutics, Paige.AI, and Volition Rx; member of the Board of Directors: Group Oncoclinicas; ad hoc member of the scientific advisory board: Roche Tissue Diagnostics, Roche, Genentech, Novartis, and Invicro; owns shares: REPARE Therapeutics. RD: advisory: Roche, Boehringer Ingelheim; speaker’s fee: Roche, Ipsen, Amgen, Servier, Sanofi, Merck Sharp & Dohme; research grants: Merck and Pierre Fabre. FA: research grants and talks/advisory boards compensate to the hospital: Roche, Pfizer, Novartis, AstraZeneca, Daiichi Sankyo, Lilly. All remaining authors have declared no conflicts of interest.

      Supplementary Data

      References

        • van Nimwegen K.J.M.
        • van Soest R.A.
        • Veltman J.A.
        • et al.
        Is the $1000 genome as near as we think? A cost analysis of next-generation sequencing.
        Clin Chem. 2016; 62: 1458-1464
        • Marino P.
        • Touzani R.
        • Perrier L.
        • et al.
        Cost of cancer diagnosis using next-generation sequencing targeted gene panels in routine practice: a nationwide French study.
        Eur J Hum Genet. 2018; 26: 314-323
        • Pagès A.
        • Foulon S.
        • Zou Z.
        • et al.
        The cost of molecular-guided therapy in oncology: a prospective cost study alongside the MOSCATO trial.
        Genet Med. 2017; 19: 683-690
        • Frampton G.M.
        • Fichtenholtz A.
        • Otto G.A.
        • et al.
        Development and validation of a clinical cancer genomic profiling test based on massively parallel DNA sequencing.
        Nat Biotechnol. 2013; 31: 1023-1031
        • Tourneau C.L.
        • Delord J.-P.
        • Gonçalves A.
        • et al.
        Molecularly targeted therapy based on tumour molecular profiling versus conventional therapy for advanced cancer (SHIVA): a multicentre, open-label, proof-of-concept, randomised, controlled phase 2 trial.
        Lancet Oncol. 2015; 16: 1324-1334
        • Massard C.
        • Michiels S.
        • Ferté C.
        • et al.
        High-throughput genomics and clinical outcome in hard-to-treat advanced cancers: Results of the MOSCATO 01 trial.
        Cancer Discov. 2017; 7: 586-596
        • André F.
        • Bachelot T.
        • Commo F.
        • et al.
        Comparative genomic hybridisation array and DNA sequencing to direct treatment of metastatic breast cancer: a multicentre, prospective trial (SAFIR01/UNICANCER).
        Lancet Oncol. 2014; 15: 267-274
        • Tsimberidou A.-M.
        • Wen S.
        • Hong D.S.
        • et al.
        Personalized medicine for patients with advanced cancer in the phase I program at MD Anderson: validation and landmark analyses.
        Clin Cancer Res. 2014; 20: 4827-4836
        • Priestley P.
        • Baber J.
        • Lolkema M.P.
        • et al.
        Pan-cancer whole-genome analyses of metastatic solid tumours.
        Nature. 2019; 575: 210-216
        • Trédan O.
        • Wang Q.
        • Pissaloux D.
        • et al.
        Molecular screening program to select molecular-based recommended therapies for metastatic cancer patients: analysis from the ProfiLER trial.
        Ann Oncol. 2019; 30: 757-765
        • Korphaisarn K.
        • Loree J.M.
        • Nguyen V.
        • et al.
        Genomic analysis of exceptional responder to regorafenib in treatment-refractory metastatic rectal cancer: a case report and review of the literature.
        Oncotarget. 2017; 8: 57882-57888
        • Espinosa M.
        • Roldán-Romero J.M.
        • Duran I.
        • et al.
        Advanced sporadic renal epithelioid angiomyolipoma: case report of an extraordinary response to sirolimus linked to TSC2 mutation.
        BMC Cancer. 2018; 18: 561
        • Bray F.
        • Ferlay J.
        • Soerjomataram I.
        Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2018; 68: 394-424
        • Mateo J.
        • Chakravarty D.
        • Dienstmann R.
        • et al.
        A framework to rank genomic alterations as targets for cancer precision medicine: the ESMO Scale for Clinical Actionability of molecular Targets (ESCAT).
        Ann Oncol. 2018; 29: 1895-1902
        • Ramsey S.D.
        • Shankaran V.
        • Sullivan S.D.
        Basket cases: How real-world testing for drugs approved based on basket trials might lead to false diagnoses, patient risks, and squandered resources.
        J Clin Oncol. 2019; 37: 3472-3474
      1. FDA approves pembrolizumab for adults and children with TMB-H solid tumors - the ASCO Post.
        (Available at:)
        • OncoKB
        (Available at:)
        https://www.oncokb.org/
        Date accessed: March 10, 2020
        • Veenstra D.L.
        • Mandelblatt J.
        • Neumann P.
        • et al
        Health economics tools and precision medicine: Opportunities and challenges.
        Forum Health Econ Policy. 2020; 23https://doi.org/10.1515/fhep-2019-0013
        • Weymann D.
        • Pataky R.
        • Regier D.A.
        Economic evaluations of next-generation precision oncology: a critical review.
        JCO Precis Oncol. 2018; 2https://doi.org/10.1200/PO.17.00311
        • Tan O.
        • Shrestha R.
        • Cunich M.
        • et al.
        Application of next-generation sequencing to improve cancer management: a review of the clinical effectiveness and cost-effectiveness.
        Clin Genet. 2018; 93: 533-544
        • Phillips K.A.
        • Deverka P.A.
        • Deborah A.
        • Marshall
        • et al.
        Methodological issues in assessing the economic value of next-generation sequencing tests: many challenges and not enough solutions.
        Value Health. 2018; 21: 1033-1042
        • Tan A.C.
        • Lai G.G.Y.
        • Tan G.S.
        • et al.
        Utility of incorporating next-generation sequencing (NGS) in an Asian non-small cell lung cancer (NSCLC) population: incremental yield of actionable alterations and cost-effectiveness analysis.
        Lung Cancer. 2020; 139: 207-215
        • Steuten L.
        • Goulart B.
        • Meropol N.J.
        • et al.
        Cost effectiveness of multigene panel sequencing for patients with advanced non–small-cell lung cancer.
        JCO Clin Cancer Inform. 2019; 3: 1-10
        • Sboner A.
        • Mu X.J.
        • Greenbaum D.
        • et al.
        The real cost of sequencing: higher than you think!.
        Genome Biol. 2011; 12: 125
        • Legras A.
        • Barritault M.
        • Tallet A.
        • et al.
        Validity of targeted next-generation sequencing in routine care for identifying clinically relevant molecular profiles in non-small-cell lung cancer: results of a 2-year experience on 1343 samples.
        J Mol Diagn. 2018; 20: 550-564
        • Midha A.
        • Dearden S.
        • McCormack R.
        EGFR mutation incidence in non-small-cell lung cancer of adenocarcinoma histology: a systematic review and global map by ethnicity (mutMapII).
        Am J Cancer Res. 2015; 5: 2892-2911
        • Mok T.S.
        • Cheng Y.
        • Zhou X.
        • et al.
        Improvement in overall survival in a randomized study that compared dacomitinib with gefitinib in patients with advanced non-small-cell lung cancer and EGFR-activating mutations.
        J Clin Oncol. 2018; 36: 2244-2250
        • Soria J.-C.
        • Ohe Y.
        • Vansteenkiste J.
        • et al.
        Osimertinib in untreated EGFR-mutated advanced non–small-cell lung cancer.
        N Engl J Med. 2017; 378: 113-125
        • Ramalingam S.S.
        • Vansteenkiste J.
        • Planchard D.
        • et al.
        Overall survival with osimertinib in untreated, EGFR-mutated advanced NSCLC.
        N Engl J Med. 2020; 382: 41-50
        • Mok T.S.
        • Wu Y.-L.
        • Ahn M.-J.
        • et al.
        Osimertinib or platinum–pemetrexed in EGFR T790M–positive lung cancer.
        N Engl J Med. 2017; 376: 629-640
        • Yang J.C.-H.
        • Sequist L.V.
        • Geater S.L.
        • et al.
        Clinical activity of afatinib in patients with advanced non-small-cell lung cancer harbouring uncommon EGFR mutations: a combined post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung 6.
        Lancet Oncol. 2015; 16: 830-838
        • Cho J.H.
        • Sun J.
        • Lee S.
        • et al.
        OA10.05 An open-label, multicenter, phase II single arm trial of osimertinib in NSCLC patients with uncommon EGFR mutation (KCSG-LU15-09).
        J Thorac Oncol. 2018; 13: S344
        • Cardona A.F.
        • Rojas L.
        • Zatarain-Barrón Z.L.
        • et al.
        EGFR exon 20 insertion in lung adenocarcinomas among Hispanics (geno1.2-CLICaP).
        Lung Cancer. 2018; 125: 265-272
        • Heymach J.
        • Negrao M.
        • Robichaux J.
        • et al.
        OA02.06 A phase II trial of poziotinib in EGFR and HER2 exon 20 mutant non-small cell lung cancer (NSCLC).
        J Thorac Oncol. 2018; 13: S323-S324
        • Solomon B.J.
        • Kim D.-W.
        • Wu Y.-L.
        • et al.
        Final overall survival analysis from a study comparing first-line crizotinib versus chemotherapy in ALK-mutation-positive non-small-cell lung cancer.
        J Clin Oncol. 2018; 36: 2251-2258
        • Soria J.-C.
        • Tan D.S.W.
        • Chiari R.
        • et al.
        First-line ceritinib versus platinum-based chemotherapy in advanced ALK-rearranged non-small-cell lung cancer (ASCEND-4): a randomised, open-label, phase 3 study.
        Lancet. 2017; 389: 917-929
        • Peters S.
        • Camidge D.R.
        • ALEX Trial Investigators
        • et al.
        Alectinib versus crizotinib in untreated ALK-positive non-small-cell lung cancer.
        N Engl J Med. 2017; 377: 829-838
        • Zhou C.
        • Lee S.H.
        • Wang C.
        • et al.
        Primary results of ALESIA: a randomised, phase III, open-label study of alectinib vs crizotinib in Asian patients with treatment-naïve ALK+ advance NSCLC.
        Ann Oncol. 2018; 29: ix173-ix178
        • Camidge D.R.
        • Kim H.R.
        • Ahn M.-J.
        • et al.
        Brigatinib versus crizotinib in ALK-positive non–small-cell lung cancer.
        N Engl J Med. 2018; 379: 2027-2039
        • Tong J.H.
        • Yeung S.F.
        • Chan A.W.H.
        • et al.
        MET Amplification and exon 14 splice site mutation define unique molecular subgroups of non-small cell lung carcinoma with poor prognosis.
        Clin Cancer Res. 2016; 22: 3048-3056
        • Drilon A.
        • Clark J.W.
        • Weiss J.
        • et al.
        Antitumor activity of crizotinib in lung cancers harboring a MET exon 14 alteration.
        Nat Med. 2020; 26: 47-51
        • Planchard D.
        • Besse B.
        • Groen H.J.M.
        • et al.
        Dabrafenib plus trametinib in patients with previously treated BRAF(V600E)-mutant metastatic non-small cell lung cancer: an open-label, multicentre phase 2 trial.
        Lancet Oncol. 2016; 17: 984-993
        • Planchard D.
        • Smit E.F.
        • Groen H.J.M.
        • et al.
        Dabrafenib plus trametinib in patients with previously untreated BRAF(V600E)-mutant metastatic non-small-cell lung cancer: an open-label, phase 2 trial.
        Lancet Oncol. 2017; 18: 1307-1316
        • Planchard D.
        • Besse B.
        • Kim T.M.
        • et al.
        Updated survival of patients (pts) with previously treated BRAF V600E–mutant advanced non-small cell lung cancer (NSCLC) who received dabrafenib (D) or D + trametinib (T) in the phase II BRF113928 study.
        J Clin Oncol. 2017; 35: 9075
        • Shaw A.T.
        • Ou S.-H.I.
        • Bang Y.-J.
        • et al.
        Crizotinib in ROS1-rearranged non-small-cell lung cancer.
        N Engl J Med. 2014; 371: 1963-1971
        • Shaw A.T.
        • Riely G.J.
        • Bang Y.-J.
        • et al.
        Crizotinib in ROS1-rearranged advanced non-small-cell lung cancer (NSCLC): updated results, including overall survival, from PROFILE 1001.
        Ann Oncol. 2019; 30: 1121-1126
        • Drilon A.
        • Siena S.
        • Dziadziuszko R.
        • et al.
        Entrectinib in ROS1 fusion-positive non-small-cell lung cancer: integrated analysis of three phase 1-2 trials.
        Lancet Oncol. 2020; 21: 261-270
        • Drilon A.
        • Laetsch T.W.
        • Kummar S.
        • et al.
        Efficacy of larotrectinib in TRK fusion-positive cancers in adults and children.
        N Engl J Med. 2018; 378: 731-739
        • Hong D.S.
        • DuBois S.G.
        • Kummar S.
        • et al.
        Larotrectinib in patients with TRK fusion-positive solid tumours: a pooled analysis of three phase 1/2 clinical trials.
        Lancet Oncol. 2020; 21: 531-540
        • Doebele R.C.
        • Drilon A.
        • Paz-Ares L.
        • et al.
        Entrectinib in patients with advanced or metastatic NTRK fusion-positive solid tumours: integrated analysis of three phase 1-2 trials.
        Lancet Oncol. 2020; 21: 271-282
        • Drilon A.
        • Oxnard G.
        • Wirth L.
        • et al.
        PL02.08 registrational results of LIBRETTO-001: a phase 1/2 trial of LOXO-292 in patients with RET fusion-positive lung cancers.
        J Thorac Oncol. 2019; 14: S6-S7
        • Camidge D.R.
        • Otterson G.A.
        • Clark J.W.
        • et al.
        Crizotinib in patients (pts) with MET-amplified non-small cell lung cancer (NSCLC): updated safety and efficacy findings from a phase 1 trial.
        J Clin Oncol. 2018; 36: 9062
        • Barlesi F.
        • Mazieres J.
        • Merlio J.-P.
        • et al.
        Routine molecular profiling of patients with advanced non-small-cell lung cancer: results of a 1-year nationwide programme of the French Cooperative Thoracic Intergroup (IFCT).
        Lancet. 2016; 387: 1415-1426
        • Fakih M.
        • O'Neil B.
        • Price T.J.
        • et al.
        Phase 1 study evaluating the safety, tolerability, pharmacokinetics (PK), and efficacy of AMG 510, a novel small molecule KRASG12C inhibitor, in advanced solid tumors.
        J Clin Oncol. 2019; 37: 3003
        • Hyman D.M.
        • Piha-Paul S.A.
        • Won
        • et al.
        HER kinase inhibition in patients with HER2- and HER3-mutant cancers.
        Nature. 2018; 554: 189-194
        • Wang Y.
        • Jiang T.
        • Qin Z.
        • et al.
        HER2 exon 20 insertions in non-small-cell lung cancer are sensitive to the irreversible pan-HER receptor tyrosine kinase inhibitor pyrotinib.
        Ann Oncol. 2019; 30: 447-455
        • Tsurutani J.
        • Park H.
        • Doi T.
        • et al.
        OA02.07 Updated results of phase 1 study of DS-8201a in HER2-expressing or –mutated advanced non-small-cell lung cancer.
        J Thorac Oncol. 2018; 13: S324
        • Hellmann M.D.
        • Paz-Ares L.
        • Bernabe Caro R.
        • et al.
        Nivolumab plus ipilimumab in advanced non-small-cell lung cancer.
        N Engl J Med. 2019; 381: 2020-2031
        • Duruisseaux M.
        • Liu S.V.
        • Han J.-Y.
        • et al.
        NRG1 fusion-positive lung cancers: Clinicopathologic profile and treatment outcomes from a global multicenter registry.
        J Clin Oncol. 2019; 37: 9081
        • The Cancer Genome Atlas Research Network
        Comprehensive molecular profiling of lung adenocarcinoma.
        Nature. 2014; 511: 543-550
        • Cancer Genome Atlas Research Network
        Comprehensive genomic characterization of squamous cell lung cancers.
        Nature. 2012; 489: 519-525
        • Vansteenkiste J.F.
        • Canon J.-L.
        • De Braud F.
        • et al.
        Safety and efficacy of buparlisib (BKM120) in patients with PI3K pathway-activated non-small cell lung cancer: results from the phase II BASALT-1 study.
        J Thorac Oncol. 2015; 10: 1319-1327
        • Balasubramaniam S.
        • Beaver J.A.
        • Horton S.
        • et al.
        FDA approval summary: rucaparib for the treatment of patients with deleterious BRCA mutation-associated advanced ovarian cancer.
        Clin Cancer Res. 2017; 23: 7165-7170
        • Voest E.
        • van der Velden D.
        • Hoes L.
        • et al.
        Expanding the use of approved drugs: The CPCT's Drug Rediscovery Protocol (DRUP).
        Ann Oncol. 2017; 28: v605-v649
        • Slamon D.J.
        • Leyland-Jones B.
        • Shak S.
        • et al.
        Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2.
        N Engl J Med. 2001; 344: 783-792
        • Swain S.M.
        • Baselga J.
        • Kim S.-B.
        • et al.
        Pertuzumab, trastuzumab, and docetaxel in HER2-positive metastatic breast cancer.
        N Engl J Med. 2015; 372: 724-734
        • Verma S.
        • Miles D.
        • Gianni L.
        • et al.
        Trastuzumab emtansine for HER2-positive advanced breast cancer.
        N Engl J Med. 2012; 367: 1783-1791
        • Krop I.E.
        • Kim S.-B.
        • González-Martín A.
        • et al.
        Trastuzumab emtansine versus treatment of physician's choice for pretreated HER2-positive advanced breast cancer (TH3RESA): a randomised, open-label, phase 3 trial.
        Lancet Oncol. 2014; 15: 689-699
        • Murthy R.K.
        • Loi S.
        • Okines A.
        • et al.
        Tucatinib, trastuzumab, and capecitabine for HER2-positive metastatic breast cancer.
        N Engl J Med. 2020; 382: 597-609
        • Robson M.
        • Im S.-A.
        • Senkus E.
        • et al.
        Olaparib for metastatic breast cancer in patients with a germline BRCA mutation.
        N Engl J Med. 2017; 377: 523-533
        • Litton J.K.
        • Rugo H.S.
        • Ettl J.
        • et al.
        Talazoparib in patients with advanced breast cancer and a germline BRCA mutation.
        N Engl J Med. 2018; 379: 753-763
        • André F.
        • Ciruelos E.
        • Rubovszky G.
        • et al.
        Alpelisib for PIK3CA-mutated, hormone receptor-positive advanced breast cancer.
        N Engl J Med. 2019; 380: 1929-1940
        • Marcus L.
        • Lemery S.J.
        • Keegan P.
        • et al.
        FDA approval summary: pembrolizumab for the treatment of microsatellite instability-high solid tumors.
        Clin Cancer Res. 2019; 25: 3753-3758
        • Fribbens C.
        • O'Leary B.
        • Kilburn L.
        • et al.
        Plasma ESR1 mutations and the treatment of estrogen receptor–positive advanced breast cancer.
        J Clin Oncol. 2016; 34: 2961-2968
        • Schmid P.
        • Abraham J.
        • Chan S.
        • et al.
        AZD5363 plus paclitaxel versus placebo plus paclitaxel as first-line therapy for metastatic triple-negative breast cancer (PAKT): a randomised, double-blind, placebo-controlled, phase II trial.
        J Clin Oncol. 2018; 36: 1007
        • Hyman D.M.
        • Smyth L.M.
        • Donoghue M.T.A.
        • et al.
        AKT inhibition in solid tumors with AKT1 mutations.
        J Clin Oncol. 2017; 35: 2251-2259
        • Pearson A.
        • Proszek P.
        • Ring A.
        • et al.
        Inactivating NF1 mutations are enriched in advanced breast cancer and contribute to endocrine therapy resistance.
        Clin Cancer Res. 2020; 26: 608-622
        • Dembla V.
        • Somaiah N.
        • Barata P.
        • et al.
        Prevalence of MDM2 amplification and coalterations in 523 advanced cancer patients in the MD Anderson phase 1 clinic.
        Oncotarget. 2018; 9: 33232-33243
        • Van Cutsem E.
        • Lenz H.-J.
        • Köhne C.-H.
        • et al.
        Fluorouracil, leucovorin, and irinotecan plus cetuximab treatment and RAS mutations in colorectal cancer.
        J Clin Oncol. 2015; 33: 692-700
        • Douillard J.-Y.
        • Oliner K.S.
        • Siena S.
        • et al.
        Panitumumab-FOLFOX4 treatment and RAS mutations in colorectal cancer.
        N Engl J Med. 2013; 369: 1023-1034
        • Sorich M.J.
        • Wiese M.D.
        • Rowland A.
        • et al.
        Extended RAS mutations and anti-EGFR monoclonal antibody survival benefit in metastatic colorectal cancer: a meta-analysis of randomized, controlled trials.
        Ann Oncol. 2015; 26: 13-21
        • Kopetz S.
        • Grothey A.
        • Yaeger R.
        • et al.
        Encorafenib, binimetinib, and cetuximab in BRAF V600E-mutated colorectal cancer.
        N Engl J Med. 2019; 381: 1632-1643
        • Overman M.J.
        • McDermott R.
        • Leach J.L.
        • et al.
        Nivolumab in patients with metastatic DNA mismatch repair-deficient or microsatellite instability-high colorectal cancer (CheckMate 142): an open-label, multicentre, phase 2 study.
        Lancet Oncol. 2017; 18: 1182-1191
        • Le D.T.
        • Kim T.W.
        • Van Cutsem E.
        • et al.
        Phase II open-label study of pembrolizumab in treatment-refractory, microsatellite instability-high/mismatch repair-deficient metastatic colorectal cancer: KEYNOTE-164.
        J Clin Oncol. 2020; 38: 11-19
        • Demetri G.D.
        • Paz-Ares L.
        • Multani P.S.
        • et al.
        Efficacy and safety of entrectinib in patients with NTRK fusion-positive tumours: Pooled analysis of STARTRK-2, STARTRK-1, and ALKA-372-001.
        Ann Oncol. 2018; 29: viii713
        • Meric-Bernstam F.
        • Hurwitz H.
        • Raghav K.P.S.
        • et al.
        Pertuzumab plus trastuzumab for HER2-amplified metastatic colorectal cancer (MyPathway): an updated report from a multicentre, open-label, phase 2a, multiple basket study.
        Lancet Oncol. 2019; 20: 518-530
        • Sartore-Bianchi A.
        • Trusolino L.
        • Martino C.
        • et al.
        Dual-targeted therapy with trastuzumab and lapatinib in treatment-refractory, KRAS codon 12/13 wild-type, HER2-positive metastatic colorectal cancer (HERACLES): a proof-of-concept, multicentre, open-label, phase 2 trial.
        Lancet Oncol. 2016; 17