Adherence to NCCN ALK testing guidelines for patients with advanced non‐small cell lung cancer in US Community Medical Centers – The Oncologist


NCCN guidelines recommend biomarker testing as the first step in the management of patients with advanced non‐small cell lung cancer (aNSCLC). We assessed ALK testing rates and factors related to underutilization in community medical systems between 2012 and 2019 to understand guideline adoption.


A retrospective observational study utilizing a nationwide electronic health record (EHR)‐derived de‐identified database was conducted. Patients with aNSCLC diagnosed in community medical centers from January 2012 to May 2019 were included to describe the ALK testing trend. This cohort was further restricted to patients diagnosed after 2015 to understand factors associated with testing underutilization, using mixed‐effects multivariable logistic regression models.


Trends for increased ALK testing rates by year were observed in both NCCN guideline eligible patients (59.5% in 2012 to 84.1% in 2019) and ineligible patients (15.6% to 50.8%) in a cohort of 41,728 patients. Histology type and smoking status had the greatest impact on test utilization. Compared to patients with non‐squamous histology and no smoking history, patients with squamous histology and no smoking history (adjusted odds ratio (aOR), 95% confidence interval (95%CI): 7.6, 5.6‐10.4), NSCLC histology not otherwise specified (NOS) with smoking history (3.4, 2.8‐4.2); NSCLC NOS/nonsmoker (1.8, 1.1‐3.2), and non‐squamous/smoker (1.5, 1.3‐1.7) were less likely to be tested. Factors related to underutilization also included ECOG performance status, stage at initial diagnosis and demographics.


This analysis of real‐world data shows increasing test utilization by year; however, one fifth of patients eligible for ALK testing still remain untested and potentially missing therapeutic options.

Implications for Practice

Advancement in treatment of lung cancer is accompanied by an increasing number of tests that should be run to determine potential therapy options for each patient. We assessed adoption of testing recommendations for ALK rearrangements in a national database. While test utilization increased over the time period studied (2012‐2019), there is still room for improvement. Efforts are needed to increase test utilization in under‐tested groups, thus enabling eligible patients to benefit from novel lung cancer therapies.