Genomic Testing: Oncologists Want More Education & Less Hype

When it comes to measuring Dx product effectiveness, few things speak louder than the attitudes of ordering physicians. With that in mind, genomic test manufacturers might want to take pause from a new oncologist survey finding that while such testing does represent a major advance, it is also being “significantly overpromoted.”

The Survey

Medscape and the Swedish Cancer Institute in Seattle surveyed 132 oncologists representing a range of practice settings including:

• Private practices (25 percent);
• Hospital and hospital-owned group practices (47 percent); and
• Military, research, academic or government institutions (16 percent).

The good news, at least for test makers, is that 71 percent characterized genomic testing as “very” or “extremely” important to oncology practice; the bad news is that 55 percent also said that such testing is “overpromoted” or “very overpromoted,” and that its value falls below expectations. The silver lining is that among the roughly one-third of respondents who said that they think genomic testing is not useful now, 89 percent believe it will be useful within 10 years.

Oncologists’ Concerns with Genomic Testing

Clinical: The biggest clinical concern cited by oncologists about genomic testing: It too often fails to provide clinically actionable information that would result in patient management changes (31 percent). Sixty-one percent say that less than one-quarter of their patients would benefit from genomic testing. But among those who have ordered genomic testing, 66 percent said they did so to guide their treatment decisions.

Financial: The oncologists also cited financial concerns with genomic testing, including:

• Insurance coverage is too poorly defined (84 percent);
• Getting approval for unapproved indication is “too great a hurdle” (73 percent);
• Concerns about cost-effectiveness of multiplex genomic testing (73 percent).

Yet, despite these concerns, 78 percent of oncologists say insurers should pay for genomic testing and 73 percent do not believe that patients are willing to pay for the tests out of their own pockets. 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.

Other: A relatively lower percentage cited other practical concerns associated with genomic testing, including not enough tissue to perform testing (18 percent) and too long a turnaround time (17 percent).

Need for More Education & Guidance

Despite the fact that more than two-thirds of respondents reported 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 “4” 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 published studies (32 percent). 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 currently should be restricted to research settings. Twenty-seven percent of those who said they ordered testing indicated that they 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 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.

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), one of every three genetic tests examined by a team of researchers should not have been prescribed. The findings, the authors say, add to a growing body of evidence suggesting that genetic tests are routinely overused and often misinterpreted.

Researchers from the Naval Medical Center San Diego reviewed 114 charts associated with the genetic test billing codes for common genetic tests sent through LabCorp, including 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.

Findings: Over the three-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 inadequate (11 percent). Costs of ordered testing were compared to recommended testing. Had guidelines been adhered to, nearly $21,000 of cost savings could have been achieved, according to the researchers.

“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.”