Even though all guideline recommends EGFR and ALK testing at diagnosis in all non-squamous Lung cancers, in the real world of community hospitals, this is seldom done, primarily because Medicare will reimburse hospitals for such testing only if done > 14 days after hospital discharge. This dictum will also apply to PD-L1 testing.
The pembrolizumab study in the NEJM yesterday excluded patients not tested for EGFR and ALK and those who did not get a core biopsy (fine needle aspirates were not permitted). The Medicare rule plus those exclusion criteria will likely greatly reduce the numbers of patients who may benefit from pembrolizumab.
So here is a question for you, Dr. West
An actionable mutation is highly unlikely in smokers and those with squamous histology. Would Pembrolizumab not be appropriate (and will insurances pay for it) for a patient who has a PD-L1 tumor proportional score >50% on FNA but has squamous histology and is a heavy smoker?
J Joshi, MD