Data reflect disparities in use of next-generation sequencing for lung cancer
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Only one in four Black patients with advanced or metastatic non-small cell lung cancer underwent next-generation sequencing before first-line therapy compared with one in three white patients, according to results of a retrospective study.
The findings, presented during the virtual ASCO Annual Meeting, reflect the need to improve access to comprehensive genomic testing during the front-line assessment of every patient with advanced or metastatic NSCLC, a practice recommended by National Comprehensive Cancer Network guidelines, according to Debora S. Bruno, MD, MS, assistant professor of medicine at Case Western Reserve University and member of the Population and Cancer Prevention Program at Case Comprehensive Cancer Center.
“We have made strides when it comes to survival among patients with NSCLC during the past decade due in great part to the development of new targeted therapies and immunotherapies that require biomarker testing for their utilization. However, even though this improvement in outcomes permeates all racial groups in the U.S., there is still a substantial survival gap for racial minorities in this country, including Black patients with NSCLC compared with their white counterparts,” Bruno told Healio. “We asked ourselves whether Black patients with NSCLC undergoing testing for biomarkers are undergoing next-generation sequencing at the same rate as their white counterparts in the real-world setting. We also wanted to know whether Black patients are being exposed to targeted therapies at the same rates.
“In addition, we know there is inequity when it comes to the representation of Black patients in genomically driven trials, and we asked if racial disparities — when it comes to biomarker and comprehensive genomic testing — could be playing a role in such gaps,” she said.
Researchers pooled data from the Flatiron Health database between Jan. 1, 2017, and Oct. 30, 2020, on 14,768 patients (mean age, 68.6 years; 51.9% men; 66.3% white; 8.7% Black) with advanced or metastatic NSCLC who received systemic therapy. Of them, 10,333 (mean age, 68.3 years; 52.6% women; 64.9% white; 8.9% Black) had nonsquamous NSCLC.
Bruno noted that Black patients were more likely to be diagnosed at a younger age (mean, 66.5 years vs. 68.9 years; P < .0001), receive treatment in the South (65.9% vs. 42%; P < .0001) and have public health insurance (23.8% vs. 20%; P = .01).
Researchers used multivariable regression to examine differences in biomarker testing and trial enrollment by race and lung cancer type.
Results showed that, overall, 73.6% of Black patients and 76.4% of white patients underwent at least one single molecular test or comprehensive genomic analysis (P = .03). Specifically, only 39.8% of Black patients compared with 50.1% of white patients underwent next-generation sequencing and only 25.8% of Black patients vs. 31.5% of white patients underwent next-generation sequencing before first-line treatment (P < .0001 for both).
Among patients with nonsquamous NSCLC, only 43.8% of Black patients vs. 54.7% of white patients underwent next-generation sequencing and only 29.7% of Black patients vs. 36.6% of white patients underwent next-generation sequencing before first-line treatment (P < .0001 for both).
Results of adjusted regression analyses confirmed the statistically significant differences in next-generation sequencing testing, baseline biomarker testing and race (P < .01).
“We as oncology providers are not testing our patients enough. It was surprising to see that only 77% of all patients with advanced, metastatic NSCLC are undergoing any type of biomarker testing ever in their journey with cancer and that less than 50% of all patients undergo comprehensive genomic testing,” Bruno said. “With nine actionable mutations in the current arena, we cannot afford testing for only one or two alterations. The landscape of targeted therapies becoming available to our patients is rapidly changing and we must remain alert and ready to offer such therapies to the patients who qualify for them.”
Although rates of receipt of first-line targeted therapy were comparable among Black and white patients in the overall cohort (9.2% vs. 10.2%), researchers reported a trend toward inferior use of first-line targeted therapies among Black patients with nonsquamous NSCLC compared with their white counterparts (12.3% vs. 14.3%).
Overall, 22.6% of Black patients and 19.8% of white patients received first-line treatment with pembrolizumab (Keytruda, Merck), carboplatin and pemetrexed; 18.6% vs. 16.5% received carboplatin plus paclitaxel; and 11.5% vs. 14.8% received pembrolizumab alone.
Moreover, only 1.9% of Black patients compared with 3.9% of white patients participated in a clinical trial (P = .0002). Patients appeared twice as likely to participate in clinical trials if they received biomarker testing before the start of first-line therapy (OR = 2.29; 95% CI, 1.64-3.2) and if they ever received next-generation sequencing (OR = 2.41; 95% CI, 1.56-3.7).
A limitation of the study included the fact that self-identified race was unknown in approximately 11% of the overall study population, which could have affected analyses of biomarker testing rates in many patients, Bruno noted.
“We do not know the causes for the finding that only one in four patients with advanced, metastatic NSCLC underwent next-generation sequence testing prior to first-line therapy, but we must reflect on changes that we must ensure happen in order to bring comprehensive genomic testing to the front-line assessment of every patient with advanced, metastatic NSCLC,” Bruno said. “We are now looking into other databases that may provide better explanation on the reasons for such disparities. We also are looking into potential disparities that may exist for other histologies in which biomarker testing is an important player in systemic therapy allocation.”
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Bruno D, et al. Abstract 9005. Presented at: ASCO Annual Meeting (virtual meeting); June 4-8, 2021.
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