By Lung Cancer Europe
Published 13 November 2026. Last updated 13 November 2026.
Biomarker testing looks at the DNA inside a lung tumour to find out which mutation, if any, is driving it. The result decides whether someone can be offered a targeted treatment built for that specific mutation, rather than chemotherapy alone. New evidence published this month adds to a long-standing question for lung cancer care across Europe: does testing broadly for many mutations at once, rather than one or two at a time, actually change outcomes, and who in Europe can access that broader test.
This article sets out which mutations drive non-small cell lung cancer, what the newest survival evidence shows, and how far testing access still varies between European countries.
Key points
Biomarker testing identifies the mutation driving a tumour, such as EGFR, ALK, ROS1, KRAS G12C, MET, RET or BRAF, so treatment can be matched to it.
A new study in JNCCN, published 12 November 2026, found that broad-based genomic sequencing before first-line therapy was linked to significantly longer median overall survival (16 vs 14 months; adjusted hazard ratio 0.91) and progression-free survival (6.4 vs 6.0 months) in advanced non-small cell lung cancer, in a real-world US study of over 35,000 patients.
Testing rates for EGFR, ALK and ROS1 are strong in several European countries, but testing for newer biomarkers such as RET, BRAF and KRAS G12C lags well behind.
Targeted treatment availability varies by country, even where a mutation is reliably detected.
Lung Cancer Europe's Access to Treatment Atlas tracks these gaps country by country.
Which mutations drive lung cancer
Non-small cell lung cancer accounts for around 85% of all lung cancers, and most people are diagnosed once the disease has already spread (de Jager et al., 2024). A growing number of these cancers are driven by a single identifiable mutation, and each one now has, or is approaching, its own targeted treatment.
| Biomarker | Approximate prevalence in NSCLC (Europe) | Source |
|---|---|---|
| EGFR | 12 to 15% | de Jager et al., 2024 |
| KRAS (all subtypes) | 26 to 41%, including KRAS G12C at 12 to 17% | de Jager et al., 2024 |
| ALK | 2 to 5% | de Jager et al., 2024 |
| BRAF | 2 to 4% | de Jager et al., 2024 |
| MET exon 14 skipping | 1 to 3% | de Jager et al., 2024 |
| RET | 1 to 3% | de Jager et al., 2024 |
| ROS1 | approximately 1 to 2% worldwide | Fois et al., 2021 |
KRAS G12C deserves a specific mention. For years, KRAS mutations as a group were seen as undruggable, so testing for them had little practical use. KRAS G12C inhibitors changed that, and the subtype now has its own targeted treatment pathway in several countries, which is why it is tracked separately from KRAS overall.
Lung Cancer Europe has covered individual biomarkers as treatment landscapes shift, including RET fusion-positive lung cancer and the European access questions raised by the 2026 US approval of a new ROS1 inhibitor.
Broad genomic sequencing versus testing one gene at a time
There are two broad approaches to biomarker testing. Single-gene or sequential testing checks one mutation at a time, often starting with the most common ones and stopping once a result comes back positive. Broad-based genomic sequencing, sometimes called comprehensive genomic profiling or next-generation sequencing, reads dozens or hundreds of genes from one sample in a single run.
Sequential testing can take longer overall if several genes need to be ruled out one by one, and it risks missing a rarer mutation if testing stops early. Broad sequencing takes a tumour sample and tests for everything clinically relevant at once, which counts most for mutations that are rare individually but, taken together, now account for a meaningful share of lung cancers.
Does broader testing improve survival? The new JNCCN evidence
A study published in the November 2026 issue of the Journal of the National Comprehensive Cancer Network adds real-world evidence to this question. Led by Patricia Mae G. Santos and co-senior author Ravi B. Parikh at Emory University School of Medicine and the Winship Cancer Institute, the study used the Flatiron Health Research Database to follow more than 35,000 people treated for advanced non-small cell lung cancer in US community and academic practices between 2016 and 2022.
People who had broad-based genomic sequencing, a panel covering dozens or hundreds of genes, before starting first-line therapy had a longer median overall survival than those who had limited testing of only one or two genes: 16 months versus 14 months (adjusted hazard ratio 0.91, 95% CI 0.86 to 0.95). Progression-free survival was also longer, 6.4 versus 6.0 months (adjusted hazard ratio 0.96, 95% CI 0.92 to 1.00). Broad testing was linked to a much higher rate of testing positive for an actionable mutation, 60% compared with 22%, and to higher use of targeted therapy, 19% compared with 16%. The benefit held up when testing happened before first-line treatment, but not in a matched second-line analysis, so timing appears to matter as much as whether broader testing happens at all.
"The right test, done early, can open doors to treatments that might otherwise be missed," said Parikh. Santos added that "coverage should match the evidence," and suggested a direct question people could raise with their care team: has my tumour had comprehensive biomarker testing? Heather Hampel of City of Hope, an independent commentator not involved in the research, noted that the study's strength lies in using real-world electronic health data to show broad-based sequencing was associated with improved survival in this setting.
This is retrospective, real-world US data, not a randomised trial, so it shows an association rather than proof that broader testing alone caused the survival difference. The authors ran sensitivity analyses, including an instrumental-variable approach based on each practice's own testing rate, and found consistent results, which adds confidence that the difference is not simply explained by healthier patients being more likely to receive broader testing in the first place. Even with that caveat, a meaningful survival difference across more than 35,000 people, alongside a clear gap in targeted therapy uptake and in actionable mutations found, is a signal for health systems still deciding how broadly to fund genomic testing, including across Europe.
Is biomarker testing standard across Europe?
All 11 European countries examined by de Jager and colleagues (2024) have national guidelines covering predictive biomarker testing, and EGFR, ALK and ROS1 testing are recommended everywhere. In practice, reported testing rates still vary widely, and the data behind them comes from different years and methods in each country, so the figures below should be read as a snapshot of the spread rather than a strict ranking.
| Country | EGFR | ALK | ROS1 | PD-L1 |
|---|---|---|---|---|
| England | 92% | 80% | no data | 87% |
| Spain | 91.4% | 80.1% | 56.2% | 58.1% |
| Slovenia | 91% | 87% | 86% | 74 to 91% |
| Czech Republic | 79.3% | 82.7% | 82.7% | 89.5% |
| Germany | 72.5% | 74.5% | 66.1% | 66.2% |
| Austria | 77.1% | 62.5% | no data | no data |
| France | 53% | 46% | 34% | 17% |
| Belgium | 51% | no data | no data | no data |
Source: de Jager et al., Lancet Regional Health Europe, 2024, drawing on published national data of varying years.
Testing for newer biomarkers lags well behind. RET testing was reported at 26.9% in Germany and around 18 to 19% in the Netherlands, far below EGFR and ALK rates in the same countries. Testing for BRAF, KRAS, MET and other less common mutations is described by the authors as generally sparse across the countries studied.
Access to the treatments themselves adds a further layer. Among the 11 countries, EGFR, ALK and ROS1 inhibitors are standard of care everywhere, but standard-of-care access to other targeted treatments is patchier: RET-targeted therapy is standard of care in 8 of the 11 countries, BRAF V600 therapy in 9, MET exon 14 therapy in 6, KRAS G12C therapy in 5, and amivantamab in 4. An earlier European survey of testing practice (Thunnissen et al., 2020) found that ROS1 testing was not available at all in some countries at the time, including the UK, Romania and Serbia, and that pharmaceutical companies were directly funding EGFR testing in several countries because national reimbursement had not caught up. Molecular tumour boards, which bring specialists together to interpret complex results, are now widespread, but de Jager and colleagues found that only a handful of countries, including Germany and the Netherlands, have national guidelines governing how they operate.
The pattern across both papers is consistent: testing and treatment access improves quickly for the biomarkers found first, EGFR, ALK, ROS1 and PD-L1, and lags for everything identified since. Lung Cancer Europe's Access to Treatment Atlas tracks screening, biomarker testing and treatment access country by country, and is built to make exactly this kind of gap visible to advocates and policymakers.
What needs to change
The evidence points in one direction: broader testing, done earlier, is linked to better outcomes and more people reaching a targeted treatment, yet access to that testing still depends heavily on where someone happens to live in Europe. Closing that gap means national reimbursement systems catching up with newer biomarkers at the same pace they did for EGFR and ALK, rather than leaving pharmaceutical companies to fund testing on an ad hoc basis, and it means guidelines for molecular tumour boards becoming the norm rather than the exception.
Access to treatment, in all its forms, sits at the centre of Lung Cancer Europe's advocacy, from our annual Reports to the Access to Treatment Atlas. Explore the country-by-country data in the Access to Treatment Atlas to see how testing and treatment access compares where you work.
Member organisations raising this with national health authorities or health technology assessment bodies are welcome to get in touch with Lung Cancer Europe to discuss how the Atlas and this evidence can support that conversation.
FAQs
Is biomarker testing the same as genetic testing for inherited cancer risk?
No. Biomarker testing in lung cancer looks at mutations inside the tumour itself, known as somatic mutations, not mutations inherited from parents, known as germline mutations. A biomarker test result does not tell someone, or their relatives, anything about inherited cancer risk.
How is lung cancer biomarker testing actually carried out?
Most testing uses a tissue sample taken during biopsy or surgery, checked either one gene at a time or through broad genomic sequencing that reads many genes in a single run. When a tissue sample is too small or unavailable, a liquid biopsy, a blood test that looks for tumour DNA circulating in the blood, can be used instead or alongside it.
Which lung cancer biomarkers have targeted treatments available in Europe?
Targeted treatments for EGFR, ALK and ROS1 are standard of care across the European countries studied by de Jager and colleagues (2024). Treatments for BRAF V600, MET exon 14 skipping, RET and KRAS G12C are available in some countries but not others, so access depends heavily on where someone is treated.
Does everyone with lung cancer need biomarker testing?
Biomarker testing is recommended for everyone diagnosed with advanced non-small cell lung cancer, since the result can substantially change which treatment is offered. It is less relevant for early-stage disease treated with surgery alone, and for small cell lung cancer, which has different biology.
What is KRAS G12C, and why is it discussed separately from other KRAS mutations?
KRAS G12C is a specific subtype of KRAS mutation, found in roughly 12 to 17% of non-small cell lung cancers in Europe. KRAS mutations as a group were long seen as untreatable with targeted therapy, until KRAS G12C inhibitors reached the clinic, which is why this particular subtype is now tracked and tested for on its own.
Final summary
Broad-based genomic sequencing is linked to longer survival and higher use of targeted therapy in advanced non-small cell lung cancer, according to the newest real-world evidence. Across Europe, testing for the biomarkers found first, EGFR, ALK and ROS1, is strong in several countries, while testing and treatment access for RET, BRAF, MET and KRAS G12C still lags behind. Closing that gap is a question of reimbursement and guidelines catching up with the science, not a question of whether the science works. Explore how testing and treatment access compares across Europe in Lung Cancer Europe's Access to Treatment Atlas.
About Lung Cancer Europe
Lung Cancer Europe is a pan-European advocacy organisation working for equal access to high-quality lung cancer care across Europe. Our members are national lung cancer advocacy organisations, and we bring their evidence and experience to European policymakers. Through our annual Lung Cancer Europe Reports, our Charter and the Get Checked! campaign, we work to improve diagnosis, treatment and support for everyone affected by lung cancer.
References
Santos PMG, Parikh RB, et al. Broad-based genomic sequencing and survival outcomes in advanced non-small cell lung cancer, 2016 to 2022. Journal of the National Comprehensive Cancer Network. November 2026. doi:10.6004/jnccn.2026.7043.
de Jager VD, Timens W, Bayle A, et al. Developments in predictive biomarker testing and targeted therapy in advanced stage non-small cell lung cancer and their application across European countries. Lancet Regional Health Europe. 2024;38:100838.
Fois SS, Paliogiannis P, Zinellu A, Fois AG, Cossu A, Palmieri G. Molecular epidemiology of the main druggable genetic alterations in non-small cell lung cancer. International Journal of Molecular Sciences. 2021;22(2):612.
Thunnissen E, et al. Lung cancer biomarker testing: perspective from Europe. Translational Lung Cancer Research. 2020;9(3).
Lung Cancer Europe. RET fusion-positive lung cancer: a field transformed by science. 2026.
Lung Cancer Europe. A new drug for ROS1 lung cancer has been approved in the US. What next for Europe? 2026.
Lung Cancer Europe. Access to Treatment Atlas.