NEW YORK – Biomarker testing practices and perceptions differ significantly among oncologists specializing in lung cancer depending on the treatment setting, according to the results of a survey presented during the International Association for the Study of Lung Cancer annual meeting earlier this week.
Notably, 73 percent of oncologists practicing at academic cancer centers reported using biomarker testing to guide conversations with their patients about disease prognosis, while only 48 percent of community oncologists surveyed said the same.
"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," said Leigh Boehmer, chief medical officer of the Association of Community Cancer Centers, the organization that conducted the study. "In reality, disparities have only grown." In particular, the survey data point to a "discordance between patients' and clinicians' understanding of the importance of biomarker testing in treatment planning," he explained.
Nearly 100 oncologists responded to the survey, which was designed by a panel of ACCC experts and conducted via email and social media from June to August 2020; 68 percent of the respondents were community oncologists and 32 percent worked in academic settings. After collecting the data, ACCC held two virtual focus groups — one with three academic oncologists and another with three community oncologists — to dive deeper into the findings. Importantly, to participate in the survey, clinicians had to treat lung cancer patients who were either uninsured or covered under Medicaid.
Other than identifying a wide gulf in terms of the proportion of academic and community oncologists who use biomarker testing to inform discussions with patients about their lung cancer prognosis, the survey data revealed other variances in patient care based on where it is delivered. For example, when asked why they order biomarker testing for lung cancer patients, 64 percent of academic oncologists said they did so to see if their patients are eligible for clinical trials, while only 48 percent of community oncologists cited the same reason.
Boehmer and colleagues also wanted to determine how familiar oncologists were with biomarker testing guidelines issued jointly in 2018 by the College of American Pathologists, IASLC, and the Association for Molecular Pathology and endorsed by the American Society of Clinical Oncology. When the survey asked respondents to rate their familiarity with the guidelines, most said they were "slightly" familiar, while 14 percent and 26 percent said they were "very" or "extremely" familiar, respectively.
Boehmer said he was surprised by this finding from the survey and the discrepancy between community and academic oncologists' use of biomarker testing to guide prognosis discussions with patients. "Both findings speak to enormous opportunities for education and greater engagement of oncology clinicians when addressing the critical role of biomarker testing," he said.
Additionally, only a quarter of surveyed oncologists said they were "extremely confident" with determining when to order testing, while 19 percent said they were "extremely confident" coordinating care, including biomarker testing, across the multidisciplinary team.
The delivery of precision cancer care can often necessitate the involvement of a variety of experts including oncologists, pathologists, nurse coordinators, genetic counselors, and even data scientists. In the focus groups, a medical oncologist at an urban hospital anonymously shared some of the challenges at his institution with coordinating multidisciplinary care. For example, the oncologist acknowledged that communication can break down between providers in different specialties, which in turn can lead to delays in conducting biomarker tests ordered for patients.
Beyond the challenges and disparities that the survey revealed, the results shed light on oncologists' attitudes about sharing biomarker testing decisions with their patients. Less than half of the respondents, 41 percent, said they preferred to make decisions about biomarker testing with their patients, whereas 52 percent said they preferred a more prescriptive approach, whereby they made the final decisions themselves. Just 6 percent of respondents indicated they let patients make the final decision about biomarker testing.
Discussions during the focus groups shed some light on why more than half of the surveyed oncologists took a more prescriptive approach to biomarker testing. During interviews, several clinicians said they believe their patients don't understand what biomarker testing entails or what it could mean for their treatment.
"If [patients are] not aware [of biomarker testing], I definitely don't want to confuse them and add to their problems," another oncologist shared anonymously. "Because the more I tell them, the more they ask me questions, and it will be so difficult for me to work with them. … So, I don't volunteer unless they outright ask me and put me on the spot."
A survey of cancer patients conducted recently by the clinical trial matching startup TrialJectory suggests that oncologists may be underestimating their patients' awareness and understanding of biomarker testing. In that survey of around 10,000 patients with a variety of cancers, more than 90 percent said they understood the importance of biomarker testing in guiding their treatment decisions.
ACCC also wanted to home in on what oncologists felt would help them improve biomarker testing access and equity among lung cancer patients, and asked what resources they need in this regard. Among the most pressing needs flagged by oncologists was access to clearer standardized guidelines on biomarker testing, with "definitive recommendation for every stage of disease."
Just over a quarter of oncologists said they needed clearer information on financial assistance for patients. Only 44 percent of oncologists said they currently offer lung cancer patients financial counseling, and 29 percent said they help patients enroll in Medicaid.
To address these needs and narrow biomarker testing disparities, Boehmer suggested increasing case-based learning opportunities for physicians, as well as providing interactive lessons on how to make their practice more concordant with biomarker testing guidelines. "Sharing resources and best practices around optimal care coordination, including biomarker testing for all eligible patients, could also help," he added.
To this end, Boehmer shared that the ACCC is partnering with the patient advocacy group LUNGevity and the Center for Business Models in Healthcare to develop a "care sequence plan" with patient and provider input. The project is still in its early stages, but the aim of the "care sequence plan," according to Boehmer, will be to create educational materials for oncologists to help them discuss the role and implications of biomarker testing with their lung cancer patients.