Biomarker testing decisions for lung cancer vary by practice setting
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Considerably fewer community oncology clinicians than academic clinicians use biomarker testing to guide discussions with patients with lung cancer, according to survey results.
The findings — presented at International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer — showed less than half of respondents in the community setting used biomarker testing to guide patient discussions about prognosis compared with nearly three-quarters of academic clinicians.
“Our study identifies key areas of ongoing clinician need related to biomarker testing, including increased guideline familiarity, practical applications of guideline-concordant testing and how to optimally help coordinate multidisciplinary care,” researcher Leigh Boehmer, PharmD, chief medical officer for Association of Community Cancer Centers (ACCC), told Healio.
Advocacy groups and professional organizations should help develop impactful education materials and tools for improving clinician-patient conversations about biomarker testing, Boehmer added.
A report released last year by American Association for Cancer Research addressed disparities in management of patients with cancer. One section of the report focused on the “imprecision of precision medicine” due partly to limited understanding of the etiology and genetics of cancer within underserved racial and ethnic populations.
Several factors may contribute to disparities in biomarker testing. These include environmental factors, access to quality health care, insurance status, patient mistrust of the health care system, and the extent to which clinicians and patients understand the important role biomarker testing can play in treatment decision-making, according to study background.
“The use of precision medicine was initially seen as an opportunity to address known care disparities by determining treatment largely on the genetic makeup of a tumor or mutation,” Boehmer said. “In reality, disparities have only grown related to ability to pay/insurance status for testing, mistrust in the healthcare system, and discordance between patients’ and clinicians’ understanding of the importance of biomarker testing to treatment planning. Our study attempts to identify inherent barriers in the equitable offering of biomarker testing [for] patients with non-small cell lung cancer to recommend specific interventions that can be implemented to optimize care.”
Boehmer and colleagues conducted a mixed-methods survey of U.S.-based oncology clinicians attitudes and educational needs regarding biomarker testing.
Researchers developed the survey instrument based on data analysis, open-ended response coding and sub-analyses between demographic cohorts to identify differences in attitudes and decision-making. Researchers also conducted two virtual groups to provide context for their data.
Objectives included assessment of current practice patterns, barriers and needed resources related to biomarker testing.
Eligible clinicians included those who treated patients with NSCLC who either were uninsured or covered by Medicaid, including dual-eligible beneficiaries.
Ninety-nine clinicians responded to the survey. Respondents included medical oncologists or hematologists/oncologists (40%), radiation oncologists or radiologists (20%), pulmonologists (15%), pathologists (8%), medical directors (8%), surgical oncologists (5%), and nurses, nurse coordinators or nurse navigators (2%).
Two-thirds of respondents (68%) practiced in community settings and one-third (32%) practiced in academic settings.
“Two findings really ‘jump out’ to me,” Boehmer told Healio.
First, only 40% of respondents indicated they were “very familiar” or “extremely familiar” with molecular testing guidelines for lung cancer issued in 2018 by College of American Pathologists, the IASLC and Association for Molecular Pathology.
Second, a significantly lower percentage of community clinicians than academic clinicians indicated they use biomarker testing to guide discussions with patients about prognosis (48% vs. 73%; P = .021).
“Both findings speak to enormous opportunities for education and greater engagement of oncology clinicians when addressing the critical role of biomarker testing,” Boehmer said.
A higher percentage of community clinicians indicated they ordered or recommended biomarker testing because the results impacted treatment decisions (88% vs. 82%. A higher percentage of academic oncology clinicians indicated they ordered or recommended testing because it is recommended in clinical practice guidelines (61% vs. 53%), the results may impact clinical trial enrollment eligibility (64% vs. 48%) and because patients expect molecular testing (12% vs. 9%).
Researchers also asked survey respondents about their preferences with regard to making final testing decisions. About half (52%) indicated they preferred to make the final decision themselves, whereas 41% indicated they prefer to share that responsibility with their patients. Six percent expressed preference for the patient making the final decision.
Focus group discussions revealed perceptions among clinicians that patients rarely understand what is entailed with testing and the role it plays in guiding treatment.
When asked what resources are needed to help make decisions about biomarker testing, the most common responses included information about financial assistance (26%), published guidelines (21%), better educational materials (14%), clinical data (10%), help from other oncologists (7%) and additional personnel (3%).
About two-thirds of respondents (65%) provide printed educational materials to their patients, 56% provide online educational materials and 44% provide financial counseling. When researchers asked clinicians what resources their patients need most, the most common responses included handouts or educational resources (27%) psychosocial support (23%) and financial assistance (22%).
An interventional project is underway to pilot a lung cancer biomarker testing care sequence plan designed to promote patient engagement and offer a coordinated treatment approach.
“In partnership with LUNGevity [Foundation] and the Center for Business Models in Healthcare, ACCC is actively developing a care sequence plan with patient and provider input to promote patient engagement and to offer a coordinated biomarker testing approach,” Boehmer told Healio. “Central to this model will be creation of education materials, informed by patients and caregivers, to be utilized by members of the multidisciplinary cancer care team when discussing the role and implications of biomarker testing for patients with lung cancer.”
Perspective
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Edward S. Kim, MD, MBA, FACP, FASCO
Precision medicine has transformed the treatment paradigms in several cancers, most notably lung cancer. The era of picking a doublet chemotherapy with equally poor outcomes has evolved into biomarker testing for a patient’s tumor to identify the best targeted treatment. Numerous biomarkers and drugs have been approved in NSCLC, leading to better outcomes. However, one cannot fully implement the science for patients if there are deficiencies in utilization.
Recent reports have indicated severe gaps in biomarker testing, both in rates and depending on what setting you practice in. Boehmer and colleagues report lower biomarker testing rates in community-based practices vs. academic centers. This issue is multifactorial, and we should approach this problem from each side. Education is important for clinicians and patients. Understanding the importance and impact on treatment decisions reinforces shared decision-making practices, as well as education for both parties. We need to have this information easy to access or delivered to both; thus, creation of tools will be needed. However, there also are logistical issues that impede the use of biomarker testing that could be more prevalent in community centers vs. academic sites. Operational processes tend to be more centralized and staffed in academic sites, where there is personnel responsible for tissue acquisition, a dedicated pathology group, payor coverage assessments, and quicker turnaround times to receive results. The recommended 14 days for results does not include the time to get the appropriate biopsy, acquiring the tissue and reviewing the adequacy, checking with insurance and sending the tissue. In some community settings, this can cause much anxiety and consternation for patients and providers who need to wait for all of these things to occur or may have to drive the process themselves due to fewer resources. If we want to raise the bar, we need to make sure we educate, but also find pragmatic operational solutions to facilitate a more streamlined approach to biomarker testing.
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Boehmer L, et al. Abstract OA10.01. Presented at: International Association for the Study of Lung Cancer World Conference on Lung Cancer (virtual meeting); Sept. 8-14, 2021.
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