title: Epidermal Growth Factor Receptor Mutational Testing and Erlotinib Treatment Among Veterans Diagnosed With Lung Cancer in the United States Department of Veterans Affairs.
abstract: We examined mutational testing of the epidermal growth factor gene (EGFR) and erlotinib treatment among veterans diagnosed with non-small-cell lung cancer in the United States Department of Veterans Affairs (VA). Our objectives were to identify the prevalence of clinically actionable EGFR mutations, to determine whether testing and treatment were guideline concordant, to evaluate the impact of testing and treatment on survival, and to estimate the rate of testing.
  
  
  
  Test results were linked to electronic health records from VA Corporate Data Warehouse and the VA Central Cancer Registry. We analyzed patient demographic and clinical characteristics, prevalence of EGFR mutations, and timing of EGFR mutational testing and erlotinib treatment based on pharmacy records. Overall survival was assessed by Kaplan-Meier analysis.
  
  
  
  Among 973 patients tested at 70 VA medical centers between 2011 and 2013, 64 (7%) had sensitizing EGFR mutations, 694 (71%) were EGFR wild type, and 168 (17%) had clinically insignificant polymorphisms or variants of unknown significance. Results were not documented in 47 tests (5%). Erlotinib administration was in agreement with test results in 843 cases (87%).
  
  
  
  Veterans have a much lower rate of sensitizing EGFR mutations than the reported average of 10% to 15%, which correlates with a high rate of smoking among veterans. This may partially explain clinicians' reluctance to prescribe EGFR testing, which results in underutilization. Although test results appear to have influenced erlotinib treatment decisions, we documented a substantial number of cases where treatment was not applied in accordance with clinical guidelines, potentially resulting in worse outcomes and unnecessary cost.
authors.affiliation: Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT; RTI International, Waltham, MA. Electronic address: Julie.Lynch@va.gov.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Lynch
authors.affiliation: RTI International, Waltham, MA; Veterans Health Administration, Bedford, MA; Boston University Medical School, Boston, MA.
authors.forename: Brygida
authors.initials: B
authors.lastname: Berse
authors.affiliation: Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Danielle
authors.initials: D
authors.lastname: Chun
authors.affiliation: National Cancer Institute, Rockville, MD.
authors.forename: Donna
authors.initials: D
authors.lastname: Rivera
authors.affiliation: National Cancer Institute, Rockville, MD.
authors.forename: Kelly K
authors.initials: KK
authors.lastname: Filipski
authors.affiliation: Division of Pathology, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
authors.forename: Scott
authors.initials: S
authors.lastname: Kulich
authors.affiliation: Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Viernes
authors.affiliation: Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT.
authors.forename: Scott L
authors.initials: SL
authors.lastname: DuVall
authors.affiliation: Veterans Administration Medical Center, Durham, NC; Duke University School of Medicine, Durham, NC.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Kelley
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D004252:DNA Mutational Analysis / Q000379:methods*; D066246:ErbB Receptors / Q000235:genetics*; D000069347:Erlotinib Hydrochloride / Q000627:therapeutic use; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009154:Mutation / Q000235:genetics*; D016019:Survival Analysis; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans; D055815:Young Adult
chemical_list: D000970:Antineoplastic Agents; D000069347:Erlotinib Hydrochloride; C512478:EGFR protein, human; D066246:ErbB Receptors
keywords: Cancer genomics; Clinical guidelines; EGFR; Mutation rate; NSCLC