NEW YORK (GenomeWeb) – A survey of 132 oncologists has found that although around 70 percent of oncologists consider genomic testing to be an important advance in cancer, more than half also believe it is over-promoted because the technology's value is "below expectations."
Medscape conducted the survey in partnership with Jack West, medical director of the thoracic oncology program at the Swedish Cancer Institute, between December 2016 and February 2017, to gain insights into how hematologists/oncologists and medical oncologists are using next-generation sequencing tests that gauge multiple genes or assess the entire tumor genome.
"It's important to get a sense of how a broader range of clinical oncologists actually perceive genomic testing, both its strengths and weaknesses," said West. Though there is a lot of optimism about the application of NGS in cancer, he noted that most of it is coming from leading proponents of precision oncology strategies or from companies marketing genomic tests.
Community oncologists, meanwhile, have been challenged to decipher the lengthy reports that come back with complex genetic findings. Around a third of doctors expressed concern that genomic testing rarely provides clinically actionable, evidence-based information; 18 percent said there is often not enough tissue to conduct genomic testing; 17 percent said it wasn't cost effective; and the same proportion said it takes too long to get results back.
"Community oncologists have a good understanding of how to apply the most common tests that are the standard of care and that can be done as a la carte testing," West said. "But the real issue now is how useful is the incremental benefit of the dozens-to-hundreds to more than a thousand additional mutations you can get results on with these really broad panels, and whether they add more insight or confusion."
In the Medscape survey, 60 percent said genomic testing benefits less than 25 percent of patients, while a third indicated that between 25 percent and 50 percent of their patients are helped by such testing. Meanwhile, three out of four oncologists said that genomic test results helped enroll patients into clinical trials for fewer than 25 percent of patients.
Other studies have also found that a limited number of cancer patients eventually enroll in a clinical trial after genomic testing or get on a personalized drug. A 2015 study of 2,000 patients who received multi-gene testing at MD Anderson found that around 40 percent of tested patients had a potentially actionable mutation. However, only 83 patients, or 11 percent of those with an actionable result, actually enrolled into a genotype-matched clinical trial, reported Meric-Bernstam et al. in the Journal of Clinical Oncology. Of 230 patients with mutations that can be targeted by a drug, 50 percent received a genotype-informed therapy.
In the Medscape survey, most respondents also indicated that poorly defined insurance coverage for genomic testing is hindering how readily they order it; and that getting approval for an unapproved indication was a hinderance to using test results to personalize care. Many of those surveyed also thought multiplex somatic genetic testing had unclear clinical utility; expressed concerns about overuse or misuse of such testing within the oncology community; and had worries about the clinical validity of tests provided by commercial firms.
The majority of oncologists (86 percent) felt that more education is needed before advocating for broad genomic testing. Only 30 percent said that they get guidance from their institution or practice on when to order tests.
Despite oncologists' reticence for NGS testing, around 90 percent had ordered a test in the past five months, while nearly a quarter had ordered a test in the past week. The top two reasons for ordering testing was for guiding treatment decisions (66 percent) and to direct patients to clinical trials (16 percent). According to the survey, oncologists are turning to genomic testing when standard treatments options have stopped working, for metastatic patients, and in research.
Most oncologists indicated they were "moderately confident" using test results to guide therapy decisions and when counseling patients about the detected mutations. Given the variety of multi-gene panels available, and no clear guidance on what test should be ordered under specific patient circumstances, 44 percent of oncologists said they turned to National Comprehensive Cancer Network guidelines, while 32 percent turned to scientific studies.
"What we saw reflected in the survey is that many oncologists remain confused and somewhat wary about how commonly they can use the results they get, and how well they can interpret the results particularly for the less common mutations," West said.
Reimbursement of genomic testing is another area of uncertainty. Approximately three-fourths of surveyed oncologists said their patients wouldn't pay out of pocket for testing, and 78 percent said that insurers should cover testing based on available evidence.
Currently, tests are being paid for a variety of ways. The majority of tests (85 percent) were paid for by patients' private health insurance, doctors said, while 35 percent and 29 percent were paid for via research funds and by patients, respectively.
Despite their reservations, 64 percent of surveyed oncologists still felt that genomic testing is useful today. Of the 36 percent who said it wasn't useful today, the majority (89 percent) indicated that genomic testing will be useful in the next decade.
What the survey has captured, West said, is that while oncologists may be ambivalent now about genomic testing given its utility in a small number of cancer patients, "it's nearly a uniform belief even among those who are wary ... that we're going to be living in a much more molecularly driven oncology world in the next several years."