Most Patients With Advanced Cancer Still Aren't Getting Genomic Testing

Key Takeaways

• NGS use increased from 2018 to 2022 across all five tumor types, but testing remained incomplete.
• Longer time to testing was associated with lower socioeconomic status, Black race in several cancers, Hispanic ethnicity in several cancers, and Medicare or Medicaid coverage.
• The authors cited access, referral, counseling, awareness, mistrust, and cost or coverage issues as possible explanations, without establishing causation.

Testing also remained incomplete in advanced non-small cell lung cancer and metastatic colorectal, prostate, and pancreatic cancers. One-year testing rates rose from 2018 to 2022, yet substantial gaps persisted across every cohort. Longer waits for testing were associated with socioeconomic status, race and ethnicity, and insurance coverage.

NGS use was evaluated in metastatic breast, metastatic prostate, advanced non-small cell lung, metastatic colorectal, and metastatic pancreatic cancers. Researchers analyzed electronic health records from about 280 cancer clinics and 800 sites of care in the Flatiron Health Research Database. The cohort included patients diagnosed between January 2018 and December 2022 across US oncology practices. Time from diagnosis to NGS was modeled with multivariable cause-specific Weibull accelerated failure time methods, with death treated as a competing risk. The analysis examined both whether testing occurred within a year and how long patients waited.

Breast cancer had the lowest 1-year NGS incidence at 26.2%, followed by metastatic prostate cancer at 24.6%. One-year NGS incidence was 58.3% in advanced non-small cell lung cancer, 56.3% in metastatic colorectal cancer, and 50.3% in metastatic pancreatic cancer. Across all five tumor types, patients diagnosed in 2022 had higher one-year cumulative testing incidence than those diagnosed in 2018. Even in the better-tested cohorts, many patients still did not receive sequencing within a year.

Lower socioeconomic status was associated with significantly longer time to NGS across multiple cancers, including a time ratio of 1.6 in advanced non-small cell lung cancer for the lowest quintile. Black patients had longer times in advanced non-small cell lung, metastatic colorectal, and metastatic pancreatic cancers, with time ratios of 1.4, 1.4, and 1.5. Hispanic patients also had longer times in metastatic breast, metastatic colorectal, and metastatic prostate cancers, with time ratios of 1.4, 1.4, and 1.6. Medicare coverage was associated with longer time to testing in several cancers, including metastatic breast, advanced non-small cell lung, metastatic colorectal, and metastatic pancreatic cancers. Medicaid coverage was associated with a twofold delay in metastatic prostate cancer, and insurance category was associated with delayed testing in several cohorts.

The authors suggested that lower referral rates, fewer completed genetic counseling visits, and limited awareness of NGS among clinicians and patients may have contributed to the observed gaps. They also cited historical mistrust of the health care system among minoritized populations and the high cost of testing with inconsistent coverage. Patients treated in academic settings had longer times to NGS than those in community settings, reaching a time ratio of 3.1 in metastatic pancreatic cancer. The authors noted that the multigene-panel focus may not capture single-gene or hotspot assays used more often at academic centers. Overall, the findings were presented as benchmark data on persistent gaps in NGS use across common advanced cancers.