Genomic Testing May Be Currently Overhyped, Oncologists Say

Most oncologists believe genomic testing is a major advance, but that it is "significantly overpromoted," according to a survey conducted by Medscape and the Swedish Cancer Institute in Seattle.

The survey of 132 oncologists was conducted between Dec. 13, 2016 and Feb. 27, 2017. The respondents represented a wide range of practice settings including private practices (25 percent); hospital or hospital- owned group practice (47 percent); and military, research, academic or government institutions (16 percent).

Overall, 71 percent of oncologists believe genomic testing is "very" or "extremely" important to the practice of oncology. However, 55 percent believe it is "overpromoted" or "very overpromoted," with its value below expectations. One-third believes it is appropriately promoted and meets expectations. Yet, oncologists are hopeful about the future of testing. Among the roughly one-third of respondents that report genomic testing is not useful now, 89 percent believe it will be useful within 10 years.

Concerns with Genomic Testing
The survey assessed concerns among the oncologists. The biggest clinical concern is that too often genomic testing fails to provide clinically actionable information that would change patient management (31 percent). Sixty-one percent of oncologists say that less than one-quarter of their patients would benefit from genomic testing.

Yet, despite these concerns over clinical utility, 66 percent of those who have ordered genomic testing did so in order to guide treatment decisions.

Financial considerations loomed large in responses with 84 percent saying insurance coverage is too poorly defined and 73 percent saying that getting approval for an unapproved indication is "too great a hurdle." Seventy-three percent also have concerns over the cost effectiveness of multiplex genomic testing. Yet, despite these concerns, 78 percent of oncologists say insurers should pay for genomic testing and 73 percent don't believe patients are willing to pay outof- pocket for the testing. In practice the oncologists report that 85 percent of testing is paid for by patients' private health insurance, 35 percent by research funds, and 29 percent by self-pay.

Additional practical concerns ranked lower among the expressed concerns, with 18 percent saying there is not enough tissue to perform testing and 17 percent saying turnaround time is too long.

Despite more than two-thirds of respondents reporting using genomic testing within the last month, 86 percent felt that more physician education is needed before genomic testing could be widely used. This may be reflected in oncologists self-reported lack of confidence in counseling patients on the significance of identified genetic mutations. More than half (53 percent) reported a four or lower on a 7-point scale ("no" to "moderate" confidence). In terms of ordering guidance, National Comprehensive Cancer Network guidelines were most used (44 percent) followed by 32 percent who use published studies. Only eight percent said that their institution's guidance or practice pathways were their primary source for ordering information.

Nearly half (49 percent) said that genomic testing should be restricted to research settings currently. Twenty-seven percent of those who ordered testing did so to guide patients to clinical trials or in support of clinical research. However, of those that ordered a test to guide patients to a trial, fewer than a quarter of oncologists actually had a patient enroll a trial.

Testing is Ordered Inappropriately
The Medscape survey's revelations of oncologists' lack of comfort regarding genomic testing parallels a new study that shows genetic tests are often misordered.

One of every three genetic tests examined by a team of researchers shouldn't have been prescribed, according to an oral presentation at the 2017 annual clinical and scientific meeting for the American College of Obstetricians and Gynecologists (San Diego; May 6-9). The findings, the authors say, adds to a growing body of evidence suggesting that genetic tests are routinely overused and often misinterpreted.

Researchers from the Naval Medical Center San Diego in California, reviewed 114 charts associated with the genetic test billing codes for common genetic tests sent through LabCorp (cystic fibrosis, BRCA, factor V Leiden, prothrombin, alpha-thalassemia, hemochromatosis, and cell free DNA). The charts were examined for compliance with published clinical practice guidelines identified on Gene Reviews.

"As these tests are a small fraction of all genetic tests at our institution, future studies should broaden the scope of testing evaluated to understand the magnitude of this problem and potential cost savings," writes author Kathleen Ruzzo, M.D., in the abstract. "Genetic counselor review and/or involvement in genetic test ordering can decrease inappropriate healthcare expenditures and improve patient care."

Over the 3-month period 39 percent of tests (n=44) were misordered based on published clinical practice guidelines. Misorders were classified as not indicated (21 percent), false reassurance (7 percent), and 11 percent inadequate. Costs of ordered testing were compared to recommended testing. Had guidelines been adhered to, nearly $21,000 of cost savings could have been achieved.

Takeaway: The majority of oncologists report that genomic testing is not currently living up to expectations and that they feel ill-equipped to order and report the results. This discomfort may be reflected in a separate study's findings that one-third of genetic tests are misordered.