The Fast TRK Testing Program

What is Fast TRK?

Fast TRK is a clinical testing program for the diagnosis of NTRK gene fusions. Sponsored by Bayer, this is a complimentary service for clinicians to determine whether their patients’ cancer has an NTRK gene fusion.

The Fast TRK program has been updated to provide upfront NGS testing for specific solid tumours. Please review the patient eligibility criteria to determine if your sample is eligible.

    How do I access testing for my patients?

    Click here to download the appropriate requisition form based on where your hospital is located. Alternatively, email fasttrk@bayer.com to request the requisition form.

    Once you have downloaded the form:

    • 1 Please ensure that the patient eligibility and consent sections are completed.
    • 2 Send samples along with the requisition according to the instructions on the form.
    • 3 Note that turn-around time for the testing report will be anywhere from 2–15 business days depending on the test (IHC or NGS) and the outcome of the test(s).

    Which centres will do the NTRK testing in Canada for Fast TRK?

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    Currently, Bayer Canada has partnered with LifeLabs and the Kingston Health Sciences Centre (KHSC) to provide centralized NTRK gene fusion testing services for Canadians.

    The Fast TRK program will be supported at least until the end of 2022.

    Which tests are used to identify an NTRK gene fusion?

    Solid tumour patient samples (in the form of a solid tumour block, or prepared slides) that meet certain patient eligibility criteria may be tested with upfront next generation sequencing (NGS) or initially screened by immunohistochemistry (IHC) for TRK protein followed NGS, when appropriate, to confirm the NTRK gene fusion.

    Cancer types tested with NGS upfront:

    • Soft-tissue sarcoma (including KIT/PDGFRA-negative GIST)1,2
    • Salivary gland cancer2,3
    • Colorectal cancer (MSI-H/dMMR and BRAF wild-type)4,5
    • Thyroid cancer (RAI-R and TKI eligible)2,6
    • Primary CNS tumours2,7
    • Tumour types known to frequently harbour NTRK gene fusions: infantile fibrosarcoma, congenital mesoblastic nephroma, mammary analogue secretory carcinoma, and secretory breast cancer3,8,9
       

    Cancer types tested with pan-TRK IHC followed by NGS (if IHC positive)

    • All other solid tumours

    NTRK = neurotrophic tyrosine receptor kinase; TRK = tropomyosin receptor kinase; MSI-H = microsatellite instability-high; dMMR = mismatch repair deficient. IHC = immunohistochemistry; NGS = next-generation sequencing; PDGFRA = platelet-derived growth factor receptor alpha; KIT = receptor tyrosine kinase; BRAF = proto-oncogene B-raf; RAI-F = radioactive iodine refractory; TKI = tyrosine kinase inhibitor; NSCLC = non-small cell lung cancer; GIST = gastrointestinal stromal tumour; CNS = central nervous system

    References: 1. Demetri GD, et al. Diagnosis and management of tropomyosin receptor kinase (TRK) fusion sarcomas: expert recommendations from the World Sarcoma Network. Ann Oncol .2020, 31(11):1506-1517. 2. Rosen EY, et al. TRK Fusions Are Enriched in Cancers with Uncommon Histologies and the Absence of Canonical Driver Mutations. Clin Cancer Res . 2020,26(7):1624-1632. 3. Cocco E, et al. NTRK fusion-positive cancers and TRK inhibitor therapy. Nature Reviews Clinical Oncology 2018;15: 731–747. 2. 4. Chou A, et al. NTRK gene rearrangements are highly enriched in MLH1/PMS2 deficient, BRAF wild-type colorectal carcinomas—a study of 4569 cases. Mod Pathol. 2020, 33(5):924-932. 5. E. Cocco et al. Colorectal Carcinomas Containing Hypermethylated MLH1 Promoter and Wild-Type BRAF/KRAS Are Enriched for Targetable Kinase Fusions. Cancer Res. 2019; 9(6):1047-1053. 6. Chu Y.-H., et al. Clinicopathologic and molecular characterization of NTRK rearranged thyroid carcinoma (NRTC). Mod Pathol. 2020, 33(11):2186-2197. 7. Torre M. et al. nd clinicopathologic features of gliomas harboring NTRK fusions. Acta Neuropathol Commun. 2020, 8(1):107. 8. Zhao X. et al. NTRK Fusions Identified in Pediatric Tumors: The Frequency, Fusion Partners, and Clinical Outcome. JCO Precis Oncol. 2021, 1:PO.20.00250. 9. Bourgeois J. M. et al. Molecular detection of the ETV6-NTRK3 gene fusion differentiates congenital fibrosarcoma from other childhood spindle cell tumors. Am J Surg Pathol. 2000, 24(7):937-46. 10. Forschner A. et al.  gene fusions in melanoma: detection, prevalence and potential therapeutic implications. J Dtsch Dermatol Ges. 2020, 18(12):1387-1392. 11. Gupta M. et al. Targeting the NTRK Fusion Gene in Pancreatic Acinar Cell Carcinoma: A Case Report and Review of the Literature. J Natl Compr Canc Netw. 2021, 9(1):10-15.

    Testing for NTRK gene fusions should be performed for patients with the following tumour types:

    •  Soft-tissue sarcoma (including KIT/PDGFRA-negative GIST)1,2
    •  Salivary gland cancer2,3
    •  Colorectal cancer (MSI-H/dMMR and BRAF wild-type)4,5
    •  Thyroid cancer (RAI-R and TKI eligible)2,6
    •  Primary CNS tumours2,7
    • Tumour types known to frequently harbour NTRK gene fusions: infantile fibrosarcoma, congenital mesoblastic nephroma, mammary analogue secretory carcinoma, and secretory breast cancer3,8,9
    • NSCLC (negative for other driver mutations)2
    • Melanoma (BRAF wild-type)2,10
    • Pancreatic cancer2,11
    • Biliary tract cancer2

    Research has identified NTRK gene fusions in more than 2 dozen types of common and rare solid tumors5–8

    NTRK gene fusions may be found across various adult and pediatric tumour types5–8

    NTRK gene fusion frequency in adult cancers graphic

    Figure includes an example of tumour types which may harbour an NTRK gene fusion and is neither an all-inclusive list nor is it representative of all tumour types in which an NTRK gene fusion may present.

    NTRK = neurotrophic tyrosine receptor kinase; TRK = tropomyosin receptor kinase; MSI-H = microsatellite instability-high; dMMR = mismatch repair deficient. IHC = immunohistochemistry; NGS = next-generation sequencing; PDGFRA = platelet-derived growth factor receptor alpha; KIT = receptor tyrosine kinase; BRAF = proto-oncogene B-raf; RAI-F = radioactive iodine refractory;  TKI = tyrosine kinase inhibitor; NSCLC = non-small cell lung cancer; GIST = gastrointestinal stromal tumour; CNS = central nervous system

    References: 1. Demetri GD, et al. Diagnosis and management of tropomyosin receptor kinase (TRK) fusion sarcomas: expert recommendations from the World Sarcoma Network. Ann Oncol .2020, 31(11):1506-1517. 2. Rosen EY, et al. TRK Fusions Are Enriched in Cancers with Uncommon Histologies and the Absence of Canonical Driver Mutations. Clin Cancer Res . 2020,26(7):1624-1632. 3. Cocco E, et al. NTRK fusion-positive cancers and TRK inhibitor therapy. Nature Reviews Clinical Oncology 2018;15: 731–747. 4. Chou A, et al. NTRK gene rearrangements are highly enriched in MLH1/PMS2 deficient, BRAF wild-type colorectal carcinomas—a study of 4569 cases. Mod Pathol. 2020, 33(5):924-932. 5. E. Cocco et al. Colorectal Carcinomas Containing Hypermethylated MLH1 Promoter and Wild-Type BRAF/KRAS Are Enriched for Targetable Kinase Fusions. Cancer Res. 2019; 9(6):1047-1053. 6. Chu Y.-H., et al. Clinicopathologic and molecular characterization of NTRK rearranged thyroid carcinoma (NRTC). Mod Pathol. 2020, 33(11):2186-2197. 7. Torre M. et al. nd clinicopathologic features of gliomas harboring NTRK fusions. Acta Neuropathol Commun. 2020, 8(1):107. 8. Zhao X. et al. NTRK Fusions Identified in Pediatric Tumors: The Frequency, Fusion Partners, and Clinical Outcome. JCO Precis Oncol. 2021, 1:PO.20.00250. 9. Bourgeois J. M. et al. Molecular detection of the ETV6-NTRK3 gene fusion differentiates congenital fibrosarcoma from other childhood spindle cell tumors. Am J Surg Pathol. 2000, 24(7):937-46. 10. Forschner A. et al.  gene fusions in melanoma: detection, prevalence and potential therapeutic implications. J Dtsch Dermatol Ges. 2020, 18(12):1387-1392. 11. Gupta M. et al. Targeting the NTRK Fusion Gene in Pancreatic Acinar Cell Carcinoma: A Case Report and Review of the Literature. J Natl Compr Canc Netw.  2021, 9(1):10-15. 

    Studies show that a significant number of patients harbour potentially targetable alterations, and that a large proportion of those patients who undergo genomic testing may benefit from being paired with an approved or investigational targeted therapy1,2

    TRK fusion proteins are often a primary oncogenic driver across multiple tumour types3,4

    A subset of gene fusions involves NTRK1NTRK2, and NTRK3 3

    •  NTRK gene fusions lead to TRK fusion proteins that are oncogenic drivers5
    •  The presence of TRK fusion proteins has been associated with more aggressive cancer in some tumour types, highlighting an unmet medical need among TRK fusion cancer patients6,7
    •  While NTRK gene fusions were one of the first oncogenes identified, they are not routinely tested for and/or included on all test platforms3,8
    •  TRK fusion cancers can be detected through a number of testing methodologies; however, only sensitive and specific tests can reliably detect NTRK gene fusions3,8
    •  Testing for NTRK gene fusions is essential to identify patients who harbour these genomic alterations9

    NTRK=neurotrophic tyrosine receptor kinase; TRK=tropomyosin receptor kinase.

    References: 1. Massard 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(6):586–95. 2. Boland GM, et al. Clinical next generation sequencing to identify actionable aberrations in a phase I program. Oncotarget 2015;6(24):20099-20110. 3. Vaishnavi A, et al. TRKing Down an Old Oncogene in a New Era of Targeted Therapy. Cancer Discov 2015;5(1):25–34. 4. Okimoto RA, et al. Tracking down response and resistance to TRK inhibitors. Cancer Discov 2016;6(1):14–16. 5. Amatu A, et al. NTRK gene fusions as novel targets of cancer therapy across multiple tumour types. ESMO Open. 2016;1:e000023. doi:10.1136/esmoopen-2015-000023 6. Lange AM, et al. Inhibiting TRK proteins in clinical cancer therapy. Cancers 2018;10(4):E105. doi:10.3390/cancers10040105. 7. Musholt TJ, et al. Prognostic significance of RET and NTRK1 rearrangements in sporadic papillary thyroid carcinoma. Surgery 2000;128(6):984-993. 8. Kumar-Sinha C, et al. Landscape of gene fusions in epithelial cancers: seq and ye shall find. Genome Med 2015;7:129. 9. Kummar S, et al. TRK Inhibition: A New Tumor-Agnostic Treatment Strategy. Target Oncol 2018;13(5):545-556.

    PATIENT AND SAMPLE ELIGIBILITY

    1. What is the patient eligibility for this program?

    All patients with solid tumours that are metastatic or when surgical resection is likely to result in severe morbidity, and for whom no satisfactory treatment options are available meet the criteria to be tested.

    2. I have many patients to test. Which patients should be tested?

    Considering the above eligibility criteria, testing for NTRK gene fusions should be performed for patients with the following tumour types:

    • Soft-tissue sarcoma (including KIT/PDGFRA-negative GIST)1,2
    • Salivary gland cancer2,3
    • Colorectal cancer (MSI-H/dMMR and BRAF wild-type)4,5
    • Thyroid cancer (RAI-R and TKI eligible)2,6
    • Primary CNS tumours2,7
    • Tumour types known to frequently harbour NTRK gene fusions: infantile fibrosarcoma, congenital mesoblastic nephroma, mammary analogue secretory carcinoma, and secretory breast cancer3,8,9
    • NSCLC (negative for other driver mutations)2
    • Melanoma (BRAF wild-type)2,10
    • Pancreatic cancer2,11
    • Biliary tract cancer2

    References: 1. Demetri GD, et al. Diagnosis and management of tropomyosin receptor kinase (TRK) fusion sarcomas: expert recommendations from the World Sarcoma Network. Ann Oncol .2020, 31(11):1506-1517. 2. Rosen EY, et al. TRK Fusions Are Enriched in Cancers with Uncommon Histologies and the Absence of Canonical Driver Mutations. Clin Cancer Res . 2020,26(7):1624-1632. 3. Cocco E, et al. NTRK fusion-positive cancers and TRK inhibitor therapy. Nature Reviews Clinical Oncology 2018;15: 731–747. 4. Chou A, et al. NTRK gene rearrangements are highly enriched in MLH1/PMS2 deficient, BRAF wild-type colorectal carcinomas—a study of 4569 cases. Mod Pathol. 2020, 33(5):924-932. 5. E. Cocco et al. Colorectal Carcinomas Containing Hypermethylated MLH1 Promoter and Wild-Type BRAF/KRAS Are Enriched for Targetable Kinase Fusions. Cancer Res. 2019; 9(6):1047-1053. 6. Chu Y.-H., et al. Clinicopathologic and molecular characterization of NTRK rearranged thyroid carcinoma (NRTC). Mod Pathol. 2020, 33(11):2186-2197. 7. Torre M. et al. nd clinicopathologic features of gliomas harboring NTRK fusions. Acta Neuropathol Commun. 2020, 8(1):107. 8. Zhao X. et al. NTRK Fusions Identified in Pediatric Tumors: The Frequency, Fusion Partners, and Clinical Outcome. JCO Precis Oncol. 2021, 1:PO.20.00250. 9. Bourgeois J. M. et al. Molecular detection of the ETV6-NTRK3 gene fusion differentiates congenital fibrosarcoma from other childhood spindle cell tumors. Am J Surg Pathol. 2000, 24(7):937-46. 10. Forschner A. et al.  gene fusions in melanoma: detection, prevalence and potential therapeutic implications. J Dtsch Dermatol Ges. 2020, 18(12):1387-1392. 11. Gupta M. et al. Targeting the NTRK Fusion Gene in Pancreatic Acinar Cell Carcinoma: A Case Report and Review of the Literature. J Natl Compr Canc Netw.  2021, 9(1):10-15. 12. Solomon J.P. et al. NTRK fusion detection across multiple assays and 33,997 cases: diagnostic implications and pitfalls. Mod Pathol. 2020, 33(1):38-46. 13. Gatalica Z. et al. Molecular characterization of cancers with NTRK gene fusions. Mod Pathol. 2019, 32(1):147-153. 14. Okamura R. et al. Analysis of NTRK Alterations in Pan-Cancer Adult and Pediatric Malignancies: Implications for NTRK-Targeted Therapeutics. CO Precis Oncol . 2018;2018:PO.18.00183

    3. How do I access FastTRK and which requisition form do I use?

    • 1 Click here to download the appropriate requisition form, you will need to indicate your hospital name. (The testing lab option will change based on your geographical location). Please use the appropriate requisition form.
    • 2 Please ensure that the patient eligibility and consent sections are completed.
    • 3 Coordinate with your local pathology department to ship a copy of the completed requisition form and required patient sample to the testing lab. Please refer to sample details section for more information.
    • 4 Shipping costs associated with mailing samples to and from originating hospital to centralized testing labs is covered under the Fast TRK program. Please review to shipping details section as outlined on the requisition form.
    • 5 Turn-around time for the testing report will be anywhere from 2–15 business days depending on the test (IHC or NGS) and the outcome of the test(s).

    4. Are patients known to have other genomic alterations (i.e. KRAS, BRAF, etc.) eligible for testing?

    As per the exclusionary testing guidelines in the Fast TRK information sheet, the absence of other genomic alterations (such as KRAS) are not mandatory to qualify for the Bayer funded NTRK  fusion testing program. However, the disease will still need to meet the primary criteria of being metastatic or when surgical resection is likely to result in severe morbidity, and for whom no satisfactory treatment options are available.

    Dr. Jiao and groups presented at ESMO 2019 in Barcelona on the co-occurrence of NTRK  fusions with other genomic biomarkers in cancer patients.1 This retrospective study included patients with cancer from a de-identified Flatiron Health–Foundation Medicine Clinico-Genomic Database (CGDB; Version November 2018) whose tumours had been profiled by comprehensive genomic profiling (CGP) between January 2011 and July 2018. During this period, FoundationOne used an evolving set of baits for the detection of NTRK 1, 2 and 3. All bait sets had complete coverage of all NTRK 1, 2 and 3 coding exons; NTRK 1, NTRK 2 and ETV6 intron coverage varied by assay. In the study, data from 15,971 evaluable tumor samples across 18 distinct histologies were evaluated. Co-occurrence of the biomarkers ALKBRAF, ERBB2, EGFR, ROS 1 and KRAS was uncommon in patients with NTRK gene fusions, suggesting that NTRK  gene fusions are primary oncogenic drivers in tumours that harbour them. Additionally based on this data, the co-occurrence of NTRK  fusions with KRAS alternations although uncommon it was seen in 3/29 NTRK gene fusion positive samples (2 colorectal and 1 lung cancers) in this particular study. This highlights the importance of NTRK gene fusions as actionable drug targets and the need for NTRK gene fusion testing across different solid tumours. 
    In addition, Rosen and colleagues recently analyzed the co-mutational patterns of a TRK fusion cancer cohort in which broader profiling was available (n = 65) and a TRK fusion-negative cohort of 25,989 patients prospectively sequenced during the same time period. While 31.4% of TRK fusion-negative cases harbored activating alterations in select canonical MAPK pathway oncogenes, the authors of this study found similar alterations in only 1.5% (1 patient) of patients with TRK fusion cancer.2

    References: 1. Jiao X, et al. Co-occurrence of NTRK fusions with other genomic biomarkers in cancer patients. ESMO 2019. Abstract no. 485P. 2. Rosen EY, et al. TRK Fusions Are Enriched in Cancers with Uncommon Histologies and the Absence of Canonical Driver Mutations. Clin Cancer Res . 2020,26(7):1624-1632.

    5. What is the most efficient way to screen for NTRK fusions among CRC patients?

    Available data from multiple independent studies indicate that NTRK  fusions in CRC are highly enriched in MSI-H/dMMR/BRAF  wild-type patients. In their study, Pietrantonio et al, demonstrated that 77% of identified CRC patients with an NTRK  fusion were also MSI-H (10/13) and all were BRAF  wild-type (13/13, patients with various NTRK 1/3 fusion partners).1 In a distinct study, Chou et al, found that 89% of NTRK  fusion positive CRC cases identified (8/9 NTRK  fusion positive CRC patients identified from 4569 consecutive cases) were dMMR (MLH1/PMS2 loss) and 100% lacked BRAF V600E mutation (9/9).2 In a separate retrospective analysis of 29 NTRK  fusion cancer patients published at ESMO 2019, 75% of NTRK  fusion positive CRC cases for which MSI status was available (3/4 from a total of 7 CRC with NTRK  fusions) were shown to be MSI-H.3 Similarly, Cocco et al. also showed that MSI-H/BRAF wild-type colorectal carcinoma are characterized by a high frequency of NTRK gene fusions (associated with sporadic MLH1ph rather than with Lynch syndrome).4Therefore, while the identification of all CRC patients with NTRK  fusions would require systematic NGS detection, taken together, available data however indicate that NTRK  detection performed in MSI-H/BRAFV600E double negative or MLH1/PMS2/BRAF V600E triple negative (less than 4% of all CRCs) could enable the identification of the majority of NTRK  fusion positive CRC patients. This summary is up to date as of June 2021.

    References: 1. Pietrantonio F, et al. ALKROS1, and NTRK Rearrangements in Metastatic Colorectal Cancer. J Natl Cancer Inst 2017;109(12). 2. Chou A, et al. NTRK gene rearrangements are highly enriched in MLH1/PMS2 deficient, BRAF wild-type colorectal carcinomas—a study of 4569 cases. Mod Pathol 2019, doi.org/10.1038/s41379-019-0417-3. 3. Jiao X, et al. Co-occurrence of NTRK fusions with other genomic biomarkers in cancer patients. ESMO 2019. Abstract no. 485P. 4. Cocco et al. Colorectal Carcinomas Containing Hypermethylated MLH1 Promotor and Wild-Type BRAF/KRAS Are Enriched For Targetable Kinase Fusions. Cancer Res. 2019; 9(6):1047-1053.

    6. What if my patient is diagnosed with an NTRK gene fusion?

    If consent has been provided in the requisition form, Bayer Medical Affairs can be in contact with the clinician regarding additional medical information. For efficient communication, please ensure your e-mail address and phone number are accurately documented on the requisition form.

    SAMPLE PROCESSING AND TESTING FLOW

    7. For lung and colorectal cancer patients, do we need to provide documentation that shows exclusion of other known oncogenic drivers?

    Testing for NTRK  gene fusions should be performed for patients with commonly diagnosed tumour types (e.g. lung cancer and colorectal cancer) known to be negative for other oncogenic alterations through exclusionary testing. However, documentation of test results is not a “prerequisite” for Fast TRK. Please note, that Fast TRK is a complimentary clinical testing program for the diagnosis of NTRK  gene fusions where the primary reason for testing is suspicion of an NTRK  gene fusion.

    8. Who covers shipping costs of tumour sample?

    The shipping costs for sending the patient sample to and from a Fast TRK lab will be covered by Bayer. Both the shipping information and courier account number are available on your requisition form.

    9. Our lab routinely screens for NTRK gene fusion by IHC. Can we just send the samples that are pan-TRK IHC positive to Fast TRK for NGS confirmation or does Bayer require both IHC and NGS to be performed in the Fast TRK program?

    Yes, samples that are stained positive for TRK protein by a pan-TRK IHC assay can be sent to Fast TRK for immediate testing by NGS. The Fast TRK program does not have a requirement for exclusive IHC testing by its third-party service provider(s). Please indicate this in the section on the requisition form “Prior Testing” that this sample was found to be positive for TRK protein. A pathology report indicating the positive IHC test results for TRK protein over-expression obtained by a certified academic pathology lab should accompany the requisition form and shipped with the patient sample.

    10. How do I work with the pathology department to get the patient sample? Does the Fast TRK program help to coordinate this?

    The Fast TRK testing labs will not perform any coordination to procure the samples from the requesting institutions. You must coordinate the collection of the specimen with your pathology department. If the patient’s specimen is at another hospital, the requesting physician should co-ordinate with the pathology department at that hospital to complete the form, send it to that hospital (fax/email – as per privacy requirements for those institutions). The Pathology Department at the indicated hospital should include a copy of the completed requisition form with the patient sample prior to shipping to the service lab for testing.

    11. Who can initiate the request for NTRK  gene fusion testing? Does it need to be an oncologist?

    Yes, in most cases this testing request would be initiated by oncologists. However, if your institution has reflex testing for specific cancer types or stages, it is possible for pathologists to request NTRK  fusion testing. This could be relevant for tumour types known to frequently harbour NTRK  gene fusions (i.e. infantile fibrosarcoma, congenital mesoblastic nephroma, mammary analogue secretory carcinoma, and secretory breast cancer) or for commonly diagnosed tumour types (e.g. lung cancer and colorectal cancer) known to be negative for other driver mutations.

    12. How long does it take to get the patient sample returned from the Fast TRK lab?

    Patient samples will be returned by the Fast TRK laboratory immediately after the testing is complete. Samples will be returned by overnight courier.

    13. What if I have other questions?

    Please review the requisition form for further information including details on shipping, sample preparation, patient eligibility criteria, technical specifications of the tests, etc. For any other inquiries, Health Care Practitioners are welcome to email fasttrk@bayer.com to be in touch with a representative from Bayer Medical Affairs.