Introduction to INDONESIA Ring QUALITY ASSESSMENT (RQA) Dr. Diah Rini Handjari, SpPA(K)

OUTLINE Why QA is important? What is Ring Study? Indonesia Ring Quality Assessment Lessons Learned

Promoting HER2 testing through Centers of Excellence (COE) Phase 1 Phase 2 Try to achieve CoE status Achieve CoE status: Provide leadership, best practice guidance and training to local centres Ongoing assessment and improvement Participate in EQA Institutional mapping tool Lead local activities for peer education Ring studies Preceptorships Become Center of Reference: Implement national-level initiatives to reduce testing variations between centres Lead national-level quality initiatives HER2 testing guidelines Conduct External QA programme Phase 3 CoE, Centre of Excellence; HER2, human epidermal growth receptor 2. For healthcare professionals only

Three key elements of a QA system Internal QA plan External QA schemes Participation in ring studies Ideally, there should be three key elements of an optimal quality system: Internal quality assurance plan External quality assurance plan Participation in ring studies. Internal and external quality assurance plans should be mandatory in every laboratory. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

Internal QA – optimal protocol Ongoing QC and equipment maintenance Ongoing laboratory training and competency checks Protocols - adhere to defined standards Routine controls (positive, negative, and internal) Repeat test if not as expected with each batch Monitoring the rates of positivity and negativity for comparison with published rates Ongoing education and competency assessment of pathologists e.g. peer comparisons Ongoing regular reassessment and review, analysis of deficiencies, remedial action An ideal internal QA plan includes: ongoing QC measures and equipment maintenance with the necessary supporting documentation ongoing laboratory training and competency checks adherence to protocols, which should detail every step of the testing process use of routine controls (positive, negative, and internal) and adhering to principles of repeating assays when controls are not as expected monitoring the rates of HER2 positivity and negativity for comparison with published rates – these comparisons are able to detect and highlight discrepancies in reporting trends ongoing and regular education and competency assessment of pathologists (e.g. peer comparisons), possibly on an annual basis. this will prevent complacency and promote constant reassessment of scoring and interpretation procedures ongoing regular reassessment and review of protocols, manuals and work processes in laboratories. it will provide an analysis of deficiencies and the necessary remedial action. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

What do external QA plans look for? CAP accreditation elements requiring documentation at inspection Validation of test method Use of protocols Training of personnel involved in testing Proper labelling of samples and reagents Proper storage of samples and reagents Equipment calibration and QC Internal QA plan and evidence that it is followed Quality of tests for interpretation Ongoing competency assessment of technicians and pathologists Report adequacy and quality Accurate submission of results One key example of an external validation is the accreditation process by CAP, which assesses a number of criteria in laboratories performing HER2 testing. Validation of test method Use of protocols Training of personnel involved in testing Proper labelling of samples and reagents Proper storage of samples and reagents Equipment calibration and QC Internal QA plan and evidence that it is followed Quality of tests for interpretation Ongoing competency assessment of technicians and pathologists Report adequacy and quality Accurate submission of results. Wolff AC, et al. J Clin Oncol 2007;25:118–145. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

Benefits of participating in external QA Acquires or demonstrates accuracy of HER2 testing in your laboratory Validates the testing methodology of your laboratory Many programmes offer advice and assistance if performance is poor Insight into technical and interpretative difficulties unique to your laboratory, allowing remedial/corrective action to be taken Active participation in external QA provides many benefits, including: demonstration of or acquirement of accurate HER2 testing in a laboratory validation of the testing methodologies used in a laboratory, as assessed by an external party provision of advice and assistance to a poorly performing laboratory by the evaluating party, particularly with technical evaluation programmes provision of insight into technical and interpretative difficulties unique the laboratory, thereby leaving remedial/corrective action to be taken. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

CAP (breast and gastric cancer) CAP provides accreditation for HER2 testing in breast and gastric cancer Proficiency testing in breast cancer (based on the ASCO/CAP HER2 Testing Guidelines and accreditation checklists) Quality management/QC Results reporting CAP-accredited laboratories performing HER2 testing by IHC or ISH are required to enrol and participate in CAP-accepted proficiency testing Performance is monitored; laboratories must receive a passing score of 90% or better on each mailing to be considered successful Laboratories that send HER2 slides to another facility for processing/staining and have them returned for interpretation will be required to participate in proficiency testing In breast cancer, CAP provides accreditation for laboratories carrying out HER2 testing in breast and gastric cancer. It specifically offers: proficiency testing in breast cancer(based on the ASCO/CAP HER2 Testing Guidelines and accreditation checklists) quality management/quality control results reporting. CAP-accredited laboratories performing HER2 testing by IHC or ISH are required to enrol and participate in CAP-accepted proficiency testing. Performance is monitored and laboratories must receive a passing score of 90% or better on each mailing to be considered successful. Laboratories that send HER2 slides to another facility for processing/staining and have them returned for interpretation will also be required to participate in proficiency testing. CAP website. Available at: http://www.cap.org (Accessed March 2012) For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

Australian HER2 testing laboratory certification (breast cancer) All laboratories must take part in the RCPA QAP for HER2 testing and have satisfactory results All HER2 results are evaluated, with feedback provided to the participating laboratories Minimum case reports per year 50 cases per pathologist 150 cases per laboratory The pathologist must: Have an established interest in breast pathology Report on breast cancer cases on a routine basis HER2 results must be provided ≤7 working days from the date of request In another example of external quality assurance for breast cancer, the Royal College of Pathologists of Australasia requires all Australian laboratories performing HER2 testing in breast cancer to participate in its quality assurance programme, with the following acceptance criteria: All HER2 results will be evaluated and must be shown to achieve satisfactory results Each pathologist must handle a minimum of 50 case reports per year, have an established interest in breast pathology and report on breast cancer cases on a routine basis Each laboratory must handle a minimum of 150 cases per year. This would promote the creating of central laboratories that would specialise in testing as opposed to the distribution of cases to small, potentially under resourced laboratories Test results must also be provided within 7 working days from the date of request. RCPA QAP, Royal College of Pathologists of Australasia Quality-Assurance Programme For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

RCPA QAP Provides laboratories with tissue microarray slides with multiple cases Twice yearly for breast and gastric carcinomas Technical modules Virtual microscopy available The RCPA quality assurance programme provides laboratories with TMA slides that contain multiple cases (up to 50 cases). These cases are provided twice a year covering breast and gastric carcinomas. It provides technical modules and also allows users to participate online through a virtual microscopy programme that can be downloaded from the website. Available at: https://haematology.rcpaqap.com.au/ (accessed March 2012) For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

United Kingdom NEQAS Open to laboratories worldwide Schemes for IHC and ISH For IHC, participating laboratories test UK NEQAS-ICC cell-line sections on a quarterly basis and return them to the organising centre Sections are evaluated by a panel of four expert assessors with the median taken as the final score Systems are in place to identify and rectify suboptimal performance, providing advice for improvement and technical advice and training External accreditors like the United Kingdom National External Quality Assessment Scheme (UK NEQAS) and NordiQ are available to other laboratories worldwide. These schemes, which cover IHC and ISH, provide participating laboratories cell-line sections for testing and scoring on a quarterly basis. The sections are then returned and assessed by a panel of experts. These evaluation systems identifies and rectifies suboptimal performance, and provides valuable advice on improvements, and technical advice and training. UK NEQAS website. Available at: http://www.ukneqas.org.uk (accessed March 2012). NEQAS, National External Quality Assessment Scheme For healthcare professionals only . SPHERE Scientific Partnership for HER2 Testing Excellence

NordiQC (breast cancer) An independent scientific organisation, promoting the quality of IHC by: Arranging schemes for pathology laboratories Assessing tissue stains Giving recommendations for improvement Providing good protocols NordiQC is a Danish-based organisation that works along a similar premise and provides recommendation for improvements. The organisation also provides participating laboratories with good protocols. NordiQC website. Available at: http://www.nordiqc.org (accessed March 2012). NordiQC, Nordic immunohistochemistry Quality Control For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

WHAT IS Ring study or RING QUALITY ASSESSMENT? Form of external quality assessment (EQA) Coordinated slide exchange programs led by a reference or central testing laboratory Specimens are circulated to participating laboratories for assessment by IHC, ISH, or both Specimens are pre-scored by the originating centre Interpretation by other laboratories remains blinded Participating laboratories stain and interpret samples based on the laboratories’ validated HER2 testing protocols Results are collated by the coordinating laboratory and communicated to participants IHC, immunohistochemistry; ISH, in situ hybridisation; HER2, human epidermal growth factor receptor 2.

Ring studies can help ensure reliable and reproducible HER2 testing: experience in GC Ring studies have been published from Germany, France and other countries Preliminary data suggest that: HER2 testing is reproducible between different pathologists as long as guidelines are adhered to Pathologists responsible for HER2 status determination in BC require specific training and guidelines Ring studies are highly valuable for ensuring accurate and consistent HER2 testing. Preliminary data from ring studies conducted in gastric cancer testing suggest that: HER2 testing is reproducible between different pathologists as long as guidelines are adhered to pathologists responsible for HER2 status determination in gastric cancer appeared to improve in scoring accuracy with specific training and the provision of guidelines. Reference: Rüschoff J, et al. Virchows Archiv 2010;457:299–307. Rüschoff J, et al. Virchows Archiv 2010;457:299–307. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

Ring studies should determine if pathologists can reproduce HER2 testing and scoring Inter-laboratory variation Pre-selected samples representative of all tumour types Commercial assays performed according to manufacturer’s recommendations Inter-observer variation Pre-stained tumour samples of known HER2 expression levels Samples evaluated independently by different pathologists Variation of HER2 scoring is determined independent of inter-laboratory staining variation Ring studies are able to detect inter-laboratory variation when pre-selected samples representative of all tumour types are sent for testing. The results allow for comparisons between other participating laboratories i.e. trends in the rates of positivity and negativity can be a measure of laboratory's performance. Ring studies also allow for inter-observer variation, whereby pathologists evaluate pre-stained tumour samples of known HER2 expression levels. With appropriate training and guideline adherence, pathologists produce comparable scores. The supply of pre-stained samples ensures that any variation is independent of inter-laboratory staining variation. For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

Objectives of ring studies Ring studies can evaluate variations in: fixation and specimen handling inter-institutional specimen staining, IHC and/or ISH analyses inter-observer HER2 scoring and interpretation These proficiency testing studies: confirm technical and diagnostic competency and proficiency provide information on inter-laboratory HER2 testing consensus focus on interpretation of results, as well as methodological issues identify inter-laboratory discordance in interpretation of HER2 testing results. IHC, immunohistochemistry; ISH, in situ hybridisation; HER2, human epidermal growth factor receptor 2.

Example ring study flow chart Select core BC TMA samples Perform HER2 assessment (IHC or ISH) at different sites using commercial assays according to manufacturer’s instructions Issues relating to IHC HER2 scoring in BC identified Inter-laboratory variation Select IHC pre-stained TMA sample series Different pathologists evaluate samples independently (intensity and area scores) Inter-observer variation This is an example of a ring study flow chart. HER2 testing website. Available at: www.her2testing.org (accessed March 2012). For healthcare professionals only SPHERE Scientific Partnership for HER2 Testing Excellence

The value of ring studies Ring studies provide valuable insight into: testing performance of participating laboratories, highlighting areas for improvement the level of agreement between pathologists testing improvement following participation in quality initiatives e.g. UK NEQAS Creates opportunities for publication

Example OF RING STUDY FROM India and Hongkong

Indonesia Ring Quality Assessment First meeting (December 2015) Objective: Collective decision on ring study design and centers Establish timeline

Scoring system (1) Scored by 2 pathologists Each pathologist can give maximum score of 10 The score can be reduced if: - false positive/negative staining - non specific/ inappropriate staining - excessive cytoplasmic staining - weak/diffuse staining - too strong/weak haematoxylin counterstain - morphological/nuclear damage - poor tissue preservation

Scoring system (2) Individual scoring method: 0/10 = slide not returned for assessment 1-4/10 = unacceptable 5-7/10 = borderline acceptable 8-10/10 = acceptable Combined assessors scoring: ˂= 9/20 = unacceptable 10-12/20 = borderline acceptable 13-15/20 = acceptable 16-20/20 = excellent

Indonesia Ring Quality Assessment Run 1 – February 2016

Indonesia Ring Quality Assessment Run 2 – August 2016

What have we learned? There are many variation in IHC technique between centers  it’s a challenge to standardized the result Tissue fixation and processing method have an important role in determining IHC result Whether it is automation or using manual technique, could result in a good staining quality Good in house control tissue is crucial in determining IHC validation  but sometimes rather difficult to obtain

summary Coordination and collaboration between centers is needed to speed up the her2 testing improvement Continuous quality assurance program is mandatory to ensured assay validity