Molly Mendenhall on Standardizing Comprehensive Biomarker Testing in NSCLC

In non–small cell lung cancer (NSCLC), comprehensive biomarker testing is an important step to administering the best possible care to patients. With a growing number of targeted therapies available, identifying actionable genetic alterations can help tailor treatment strategies for optimal outcomes. Still, there is room for improvement when it comes to rates of genetic testing in clinical practice. 

Molly Mendenhall, BSN, RN, director of quality and compliance at Oncology Hematology Care, Inc (OHC), spoke with The American Journal of Managed Care^® (AJMC^®) about a 1-year quality improvement project implemented by OHC to standardize comprehensive biomarker testing in patients with NSCLC. Following the project’s success in increasing biomarker testing rates from 68% to 92.7%, it is being scaled up as best-practice protocol across the US Oncology Network, McKesson.

This interview has been lightly edited for clarity.

AJMC: Can you tell us about the specific biomarkers or genetic tests that were included in the comprehensive biomarker testing protocol for patients with metastatic NSCLC? What is the significance of testing for these biomarkers in treatment decisions?

Mendenhall: This project really focused on comprehensive biomarker testing, so that's going to be all of your main actionable biomarkers plus your IHC [immunohistochemistry], which would be PD-L1. Really the significance is that about 70% of actionable biomarkers then lead to targeted therapies. So to enable the patient to get those targeted therapies, we really need to make sure that we are doing comprehensive biomarker testing.

Molly Mendenhall, BSN, RN

AJMC: Were there any major barriers or challenges faced during the implementation of the quality improvement project to increase biomarker testing rates, and if so, how were these challenges overcome?

Mendenhall: With any quality improvement project, there's going to be barriers, but physician champion buy-in was key here, so having those physician champions be available for peer-to-peer reeducation. Additionally, scorecards really helped with barriers, as well. We were able to look at scorecards and see if physicians needed reeducation in real time to help streamline their process, make it more efficient, and really be able to tweak that workflow. That was crucial to help any outliers who were struggling.

AJMC: Can you share how custom data reports and monitoring dashboards were used to boost practicewide adoption and sustainability of biomarker testing across multiple clinic sites?

Mendenhall: My favorite saying is, “You can't fix what you can't measure.” So, a big part of this initiative was just that—being able to create automated data reports, which we then could put into weekly scorecards and dashboards. So, physicians would really have the opportunity to see whether they are they utilizing the new initiative. Are they ordering the testing on their patients? Are we getting that testing back? Those scorecards really helped to drive efficiencies and drive better patient outcomes. Without that data, we really would have been a lot more in the dark with where are we, and are we testing appropriately? So again, your metrics are going to be key.

AJMC: How did these tools contribute to the project's success, and what metrics were monitored to assess progress?

Mendenhall: The key metrics for this one were really looking at a multitude of different steps. So, how are we staging our patients? Was staging complete? You really can't do a study on a patient population if you can't find that patient population, so really ensuring that: (A) Was our staging done? (B) Were the physicians utilizing the new non–small cell template? And if so, how was that adoption and uptake across the practice? And then part 3 of that, we then subsequently utilize the order set and order that comprehensive biomarker testing. So really, the key at the end was once we got those biomarker results back, were we putting them back into staging and back into practice? Because that has a big effect on a patient's first line of treatment and subsequent treatments, or getting them enrolled for clinical trials and research—but that is going to be really key. These scorecards really helped drive that, track how these initiatives are being adopted, and then subsequently, if we needed to incorporate our physician champion back into that peer-to-peer education, all of that really tied together nicely with the scorecards.

AJMC: As the project is scaled across the country through The US Oncology Network and McKesson, what recommendations do you have for other health care networks looking to adopt similar best-practice initiatives in oncology?

Mendenhall: My recommendation would be to start small. A lot of people look at quality improvement projects as sometimes daunting—that they're very hard to implement, they cannot be cost-effective. Are you going to need to hire more people or bring on more equipment? But with this project, what's really great about it is we tried to work around those EHR [electronic health record] limitations with something we can control. So really, just start small, work with peer-to-peer physician education, have that physician champion to help with buy-in. Note templates is something we all have control over in our practices, so inserting NCCN [National Comprehensive Cancer Network] guidelines and creating that simple order set. Not only did we find that this project was cost-efficient—you can run it on a very low budget—but also scalable to other diagnosis states. Breast or prostate would be another great example. And then it's also reproducible, so now we're working on getting that out as a best practice across the entire network.

AJMC: Can you share some strategies or insights for successful implementation and sustainability on a larger scale?

Mendenhall: For sustainability, we talked about the control phase, that's where your executive leadership buy-in is going to be crucial to make sure that you have the resources allocated to roll out this type of program. And again, lean on those physician champions. It's really important to have a front-end clinical person that can speak to biomarkers, why it's important, and that “why” behind it for the patient, but also administrative leadership and buy-in as well for any of the resource allocation that you might need for anything that can't be automated. A lot of us are working to put systems in place until our EHR limitations are more under control, so really utilizing all of your peers around you and having practicewide buy-in is really going to be key.