Study reveals gaps in next-generation sequencing for patients with metastatic cancers
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Key takeaways:
- Next-generation sequencing testing rates have increased for patients with metastatic prostate or urothelial cancer since 2015.
- Race, health insurance status and other factors correlated with likelihood of testing.
Rates of next-generation sequencing have increased for individuals with metastatic prostate cancer or advanced urothelial carcinoma over the past several years, but more than half of these individuals still do not undergo testing.
Several factors — including race, insurance status and socioeconomic status — significantly correlated with likelihood of testing, retrospective study results showed.
“Despite the presence of actionable mutations in prostate and urothelial cancers, the majority of patients in both cohorts do not undergo testing,” Chadi Hage Chehade, MD, post-doctoral research fellow at Huntsman Cancer Institute at University of Utah, told Healio. “Furthermore, specific patient demographics or social determinants of health may be associated with reduced rates of testing. These hypothesis-generating data underscore the imperative for initiatives aimed at bridging these gaps.”
Background and methods
Genomic profiling has allowed clinicians to treat patients with metastatic prostate cancer and advanced urothelial carcinoma with targeted therapies. This has translated to improved survival for both groups, according to study background.
For example, 30% of men with advanced prostate cancer have BRCA or other homologous recombination repair alterations that can be treated with poly-ADP ribose polymerase inhibitors.
“Multiple targeted agents are approved for patients with metastatic prostate cancer and advanced urothelial carcinoma,” Hage Chehade said. “However, prior reports have suggested that a limited number of patients receive next-generation sequencing (NGS) testing in real-world settings.”
One large nationwide database showed low testing rates among patients with African (10.4%), Hispanic (9.1%) or East Asian (3.7%) ancestry, researchers wrote.
Hage Chehade and colleagues investigated NGS trends among patients with metastatic prostate cancer or advanced urothelial carcinoma. They also assessed disparities in testing rates.
They used the national Flatiron Health electronic health record database to construct a cohort that included 18,417 individuals (median age, 73 years) diagnosed with metastatic prostate cancer or advanced urothelial carcinoma between March 1, 2015, and Dec. 31, 2022.
The cohort included 11,927 men with prostate cancer (66% white, 11.6% Black, 6.4% Hispanic or Latino) and 6,490 patients with urothelial carcinoma (73.4% men; 74.9% white; 4.8% Black; 4.4% Hispanic or Latino).
Results and next steps
In the prostate cancer subgroup, 29.3% of men underwent NGS (median time from diagnosis to sequencing, 13.2 months). Less than half (43%) of men who received NGS underwent testing prior to first treatment.
In the urothelial cancer subgroup, 32% of individuals underwent NGS (median time from diagnosis to sequencing, 2.7 months). About half (51.3%) of individuals who received NGS underwent testing prior to second-line treatment.
Testing rates for men with prostate cancer increased from 19% in 2015 to 27.1% in 2022, with a single-year high of 36.1% in 2020. The cumulative incidence of testing by 1 year after diagnosis rose from 1.3% in 2015 to 32.7% in 2022 (P < .001).
However, likelihood of testing was significantly lower among Black men (HR = 0.75; 95% CI, 0.67-0.84) and Hispanic or Latino men (HR = 0.7; 95% CI, 0.6-0.82) compared with white men.
Researchers also reported lower testing rates among men in the two lowest quintiles of socioeconomic status compared with those in the upper quintiles, men with Medicare or other government insurance (HR = 0.89; 95% CI, 0.82-0.98) or Medicaid (HR = 0.53; 95% CI, 0.38-0.74) compared with private health plans, and men who lived in the West (HR = 0.81; 95% CI, 0.7-0.94) compared with those in the Midwest.
In the urothelial cancer cohort, testing rates increased from 14.1% in 2015 to 46.6% in 2022, with a 1-year high of 48.8% in 2021. The cumulative incidence of testing by 1 year after diagnosis rose from 6.9% in 2015 to 52.5% in 2022 (P < .001).
Subgroups in the urothelial cancer cohort with lower likelihood of NGS testing included Black patients (HR = 0.76; 95% CI, 0.61-0.96) compared with white patients, those with low socioeconomic status vs. high, and those with Medicare or other government insurance (HR = 0.88; 95% CI, 0.78-0.99) or Medicaid (HR = 0.72; 95% CI, 0.53-0.97) compared with those who had private insurance. Individuals who lived in the South appeared more likely to undergo testing (HR = 1.29; 95% CI, 1.12-1.49) than those who lived in the Midwest.
“Health care policies are essential to improving testing rates in populations underrepresented in genomic testing,” Hage Chehade said. “Some initiatives are already underway, such as the National Coverage Determination memorandum released by Medicare in 2018, which categorized NGS as an essential diagnostic tool for patients with advanced or metastatic cancer [within CMS]. However, for other populations, further patient-centered and provider-centered initiatives are needed. These can be achieved through patient education, improving access to genetic testing, enhancing access to genetic counselors and partnering with patient advocacy groups.”
Researchers noted study limitations, including its retrospective nature and lack of differentiation between somatic and germline testing.
“It is crucial for clinicians to discuss genetic testing with their patients because NGS testing may uncover tumor alterations that can be targeted by life-prolonging therapies,” Hage Chehade said. “Additionally, NGS can assist clinicians in prognostication and patient counseling in the clinic and, in some cases, patients may be eligible for enrollment in clinical trials based on their genetic profile.”
For more information:
Chadi Hage Chehade, MD, can be reached at chadi.chehade@hci.utah.edu.
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