1
|
Grafham GK, Craddock KJ, Huang W, Louie AV, Zhang L, Hwang DM, Parmar A. Referred molecular testing as a barrier to optimal treatment decision making in metastatic non-small cell lung cancer: Experience at a tertiary academic institution in Canada. Cancer Med 2024; 13:e6886. [PMID: 38317584 PMCID: PMC10905241 DOI: 10.1002/cam4.6886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/08/2023] [Accepted: 12/16/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Molecular testing is critical to guiding treatment approaches in patients with metastatic non-small cell lung cancer (mNSCLC), with testing delays adversely impacting the timeliness of treatment decisions. Here, we aimed to evaluate the time from initial mNSCLC diagnosis to treatment decision (TTD) following implementation of in-house EGFR, ALK, and PD-L1 testing at our institution. METHODS We conducted a retrospective chart review of 165 patients (send-out testing, n = 92; in-house testing, n = 73) with newly diagnosed mNSCLC treated at our institution. Data were compared during the send-out (March 2017-May 2019) and in-house (July 2019-March 2021) testing periods. We performed a detailed workflow analysis to provide insight on the pre-analytic, analytic, and post-analytic intervals that constituted the total TTD. RESULTS TTD was significantly shorter with in-house testing (10 days vs. 18 days, p < 0.0001), driven largely by decreased internal handling and specimen transit times (2 days vs. 3 days, p < 0.0001) and laboratory turnaround times (TAT, 3 days vs. 8 days, p < 0.0001), with 96% of in-house cases meeting the international guideline of a ≤ 10-day intra-laboratory TAT (vs. 74% send-out, p < 0.001). Eighty-eight percent of patients with in-house testing had results available at their first oncology consultation (vs. 52% send-out, p < 0.0001), and all patients with in-house testing had results available at the time of treatment decision (vs. 86% send-out, p = 0.57). CONCLUSION Our results demonstrate the advantages of in-house biomarker testing for mNSCLC at a tertiary oncology center. Incorporation of in-house testing may reduce barriers to offering personalized medicine by improving the time to optimal systemic therapy decision.
Collapse
Affiliation(s)
- Grace K. Grafham
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Kenneth J. Craddock
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences CentreTorontoOntarioCanada
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Weei‐Yuarn Huang
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences CentreTorontoOntarioCanada
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Alexander V. Louie
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Radiation OncologySunnybrook Health Sciences CentreTorontoOntarioCanada
| | | | - David M. Hwang
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences CentreTorontoOntarioCanada
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Ambica Parmar
- Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
- Division of Hematology and Medical Oncology, Department of MedicineSunnybrook Health Sciences CentreTorontoOntarioCanada
| |
Collapse
|
2
|
Sheffield BS, Eaton K, Emond B, Lafeuille MH, Hilts A, Lefebvre P, Morrison L, Stevens AL, Ewara EM, Cheema P. Cost Savings of Expedited Care with Upfront Next-Generation Sequencing Testing versus Single-Gene Testing among Patients with Metastatic Non-Small Cell Lung Cancer Based on Current Canadian Practices. Curr Oncol 2023; 30:2348-2365. [PMID: 36826141 PMCID: PMC9955559 DOI: 10.3390/curroncol30020180] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/18/2023] Open
Abstract
This study assessed the total costs of testing, including the estimated costs of delaying care, associated with next-generation sequencing (NGS) versus single-gene testing strategies among patients with newly diagnosed metastatic non-small cell lung cancer (mNSCLC) from a Canadian public payer perspective. A decision tree model considered testing for genomic alterations using tissue biopsy NGS or single-gene strategies following Canadian guideline recommendations. Inputs included prevalence of mNSCLC, the proportion that tested positive for each genomic alteration, rebiopsy rates, time to test results, testing/medical costs, and costs of delaying care based on literature, public data, and expert opinion. Among 1,000,000 hypothetical publicly insured adult Canadians (382 with mNSCLC), the proportion of patients that tested positive for a genomic alteration with an approved targeted therapy was 38.0% for NGS and 26.1% for single-gene strategies. The estimated mean time to appropriate targeted therapy initiation was 5.1 weeks for NGS and 9.2 weeks for single-gene strategies. Based on literature, each week of delayed care cost CAD 406, translating to total mean per-patient costs of CAD 3480 for NGS and CAD 5632 for single-gene strategies. NGS testing with mNSCLC in current Canadian practice resulted in more patients with an identified mutation, shorter time to appropriate targeted therapy initiation, and lower total testing costs compared to single-gene strategies.
Collapse
Affiliation(s)
| | | | - Bruno Emond
- Analysis Group, Inc., Montréal, QC H3B 0G7, Canada
| | | | | | | | - Laura Morrison
- Analysis Group, Inc., Montréal, QC H3B 0G7, Canada
- Correspondence: ; Tel.: +514-871-3303
| | | | | | - Parneet Cheema
- William Osler Health System, Brampton, ON L6R 3J7, Canada
| |
Collapse
|
3
|
Johnston KM, Sheffield BS, Yip S, Lakzadeh P, Qian C, Nam J. Comprehensive genomic profiling for non-small-cell lung cancer: health and budget impact. Curr Oncol 2020; 27:e569-e577. [PMID: 33380872 PMCID: PMC7755443 DOI: 10.3747/co.27.5995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Single-gene tests and hotspot panels targeting specific subsets of biomarkers constitute the Canadian genomic testing landscape for non-small-cell lung cancer (nsclc). However, newer testing options such as comprehensive genomic profiling (cgp) offer improved detection rates and identification of multiple classes of genomic alterations in a single assay, minimizing tissue requirements and turnaround time. The objective of the present analysis was to assess the health and budget impacts of adopting cgp testing for nsclc in Canada. Methods This study assessed the impact of funding the cgp tests FoundationOne CDx and FoundationOne Liquid (Foundation Medicine, Cambridge, MA, U.S.A.) over a 3-year time horizon using a Canadian societal perspective for Ontario. Conventional testing strategies were summarized into two reference scenarios: a series of single-gene tests only, and reflex single-gene testing followed by a hotspot panel for negative results. Four adoption scenarios for cgp testing were considered: replacing all single-gene and hotspot panel testing, replacing hotspot panel testing only, use after negative single-gene and hotspot testing, and use of FoundationOne Liquid in individuals with insufficient tissue for conventional testing. Results When cgp testing was assumed to replace all conventional testing with 50% uptake, the budget impact per person per year ranged from $0.71 to $0.87, depending on the reference scenario, with a 3-year gain of 680.9 life-years and 3831 working days over the full cohort. Conclusions Given the present testing landscape for patients with nsclc in Canada, listing cgp testing could optimize the selection of appropriately targeted treatments, and thus add life-years and productivity for this population, with a minimal budget impact.
Collapse
Affiliation(s)
- K M Johnston
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC
| | | | - S Yip
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC
| | - P Lakzadeh
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC
| | - C Qian
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC
| | - J Nam
- Market Access and Pricing, Hoffmann-La Roche Ltd., Mississauga, ON
| |
Collapse
|
4
|
Johnston KM, Sheffield BS, Yip S, Lakzadeh P, Qian C, Nam J. Costs of in-house genomic profiling and implications for economic evaluation: a case example of non-small cell lung cancer (NSCLC). J Med Econ 2020; 23:1123-1129. [PMID: 32597288 DOI: 10.1080/13696998.2020.1789152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Genomic profiling in oncology is vital for determining eligible patients for mutation-specific targeted therapies. Use of commercial genomic testing has the potential to improve patient outcomes. Economic evaluations of in-house genomic profiling typically only include material costs while external commercial services include many other factors. Using non-small cell lung cancer (NSCLC) as an example, this study sought to characterize the unique challenges of costing testing services and their impact on results of economic evaluations. METHODS Structured interviews with Canadian oncologists, pathologists, and laboratory directors were conducted to identify material and non-material costs associated with genomic-testing laboratories to allow estimation of a more complete cost of in-house testing, with NSCLC cost-per-test calculated using annual operational costs and NSCLC-specific testing volume. A health and budget impact model of in-house versus external commercial profiling services was used to compare the impact of non-material costs on results. RESULTS In-house testing costs, limited to materials, was $133/single-gene test and $1,400/panel. For a laboratory running 1,300 in-house tests/year, total annual non-material costs included equipment maintenance ($6,842), labor ($502,313; technicians, administrative, and medical staff), shipping/reporting and software updates ($146,050), for an additional $519/test. The combined cost of $652/single-gene and $1,919/panel was compared to a cost of $6,194 for a commercial external test. Based on current Canadian testing patterns and anticipated utilization of external testing, inclusion of in-house non-material costs reduced the estimated 3-year budget impact by 12%. CONCLUSION When conducting economic evaluation to assess the value of introducing external tests, it is critical that non-material costs of standard testing strategies be measured and incorporated.
Collapse
Affiliation(s)
- Karissa M Johnston
- Broadstreet Health Economics and Outcomes Research, HEOR, Vancouver, Canada
| | | | - Stephen Yip
- Department of Pathology, BC Cancer, Vancouver, Canada
| | - Pardis Lakzadeh
- Broadstreet Health Economics and Outcomes Research, HEOR, Vancouver, Canada
| | - Christina Qian
- Broadstreet Health Economics and Outcomes Research, HEOR, Vancouver, Canada
| | - Julian Nam
- Hoffmann-La Roche Limited, Mississauga, Canada
| |
Collapse
|
5
|
Sabri A, Batool M, Xu Z, Bethune D, Abdolell M, Manos D. Predicting EGFR mutation status in lung cancer:Proposal for a scoring model using imaging and demographic characteristics. Eur Radiol 2016; 26:4141-4147. [PMID: 27027313 DOI: 10.1007/s00330-016-4252-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 01/16/2016] [Accepted: 01/26/2016] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine if a combination of CT and demographic features can predict EGFR mutation status in bronchogenic carcinoma. METHODS We reviewed demographic and CT features for patients with molecular profiling for resected non-small cell lung carcinoma. Using multivariate logistic regression, we identified features predictive of EGFR mutation. Prognostic factors identified from the logistic regression model were then used to build a more practical scoring system. RESULTS A scoring system awarding 5 points for no or minimal smoking history, 3 points for tumours with ground glass component, 3 points for airbronchograms, 2 points for absence of preoperative evidence of nodal enlargement or metastases and 1 point for doubling time of more than a year, resulted in an AUROC of 0.861. A total score of at least 8 yielded a specificity of 95 %. On multivariate analysis sex was not found to be predictor of EGFR status. CONCLUSIONS A weighted scoring system combining imaging and demographic data holds promise as a predictor of EGFR status. Further studies are necessary to determine reproducibility in other patient groups. A predictive score may help determine which patients would benefit from molecular profiling and may help inform treatment decisions when molecular profiling is not possible. KEY POINTS • EGFR mutation-targeted chemotherapy for bronchogenic carcinoma has a high success rate. • Mutation testing is not possible in all patients. • EGFR associations include subsolid density, slow tumour growth and minimal/no smoking history. • Demographic or imaging features alone are weak predictors of EGFR status. • A scoring system, using imaging and demographic features, is more predictive.
Collapse
Affiliation(s)
- Ali Sabri
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada. .,Halifax Infirmary, Room 3510, 1796 Summer Street, Halifax, NS, Canada.
| | - Madiha Batool
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - Zhaolin Xu
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Drew Bethune
- Department of Surgery, Dalhousie University, QEII Health Sciences center, Halifax, Nova Scotia, Canada
| | - Mohamed Abdolell
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Victoria Building, room 307, 1276 South Park Street, PO BOX 9000, Halifax, Nova Scotia, B3H 2Y9, Canada
| |
Collapse
|
6
|
Raedler LA. Zykadia (Ceritinib) Approved for Patients with Crizotinib-Resistant ALK -Positive Non-Small-Cell Lung Cancer. AMERICAN HEALTH & DRUG BENEFITS 2015; 8:163-166. [PMID: 26629283 PMCID: PMC4665050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|
7
|
Akerley WL, Nelson RE, Cowie RH, Spinella DG, Hornberger J. The impact of a serum based proteomic mass spectrometry test on treatment recommendations in advanced non-small-cell lung cancer. Curr Med Res Opin 2013; 29:517-25. [PMID: 23452275 DOI: 10.1185/03007995.2013.782282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of a serum-based proteomic test for non-small-cell lung cancer (NSCLC) on physician treatment recommendations. RESEARCH DESIGN AND METHODS A multivariate, serum-based proteomic test (VeriStrat) is commercially available to assist physicians when determining treatment using epidermal growth factor receptor inhibitor (EGFRi) therapy, such as erlotinib (Tarceva), by stratifying patients into two categories: those with significantly better ('good') and those with significantly worse ('poor') outcomes following treatment with EGFRi therapy. All tests ordered from August 9, 2011 to November 26, 2012, were considered for this study. Pre- and post-test treatment recommendations were prospectively collected from ordering physicians on a voluntary basis. Only those tests that had both pre- and post-test treatment information were included in the analysis group. MAIN OUTCOME MEASURES Proportional change and correlation of treatment recommendations before and after receipt of the test results. RESULTS Over the duration of the study, 724 physicians ordered 2854 tests. The analysis group comprised the 226 physicians who provided pre- and post-test treatment information (n = 403 tests). Following receipt of the test results, 90.3% (95% CI: 86.4-93.3%) of patients who tested as 'good' received erlotinib recommendations versus 9.6% (95% CI: 4.5-17.4%, p < 0.0001) of patients who tested as 'poor'. Ninety percent of post-test treatment recommendations positively correlated with test results, with 40% showing a change from pre-test considerations. STUDY LIMITATIONS Data based on physicians willing to submit recommendations and endpoint limited to therapy recommendations. CONCLUSIONS Among test orderers, serum-based proteomic mass spectrometry testing significantly influenced therapy recommendations in NSCLC. Usage patterns should be monitored as use expands.
Collapse
|
8
|
Dawe DE, Ellis PM. Challenges in Implementing Personalized Medicine for Lung Cancer within a National Healthcare System. J Pers Med 2012; 2:77-92. [PMID: 25562202 PMCID: PMC4251366 DOI: 10.3390/jpm2030077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 08/21/2012] [Accepted: 08/27/2012] [Indexed: 12/21/2022] Open
Abstract
The traditional approach to the treatment of advanced non-small cell lung cancer (NSCLC) relied on the uniform use of cytotoxic chemotherapy. Over the last eight years, this paradigm of care has been shifting towards the use of molecularly targeted agents. Epidermal growth factor receptor (EGFR) mutations have emerged as an important biomarker for these targeted agents and multiple studies have shown that tyrosine kinase inhibitors (TKI) that inhibit EGFR are superior to traditional chemotherapy in patients possessing an EGFR mutation. Nationally funded health care systems face a number of challenges in implementing these targeted therapies, most related to the need to test for biomarkers that predict likelihood of benefiting from the drug. These obstacles include the challenge of getting a large enough tissue sample, workload of involved specialists, reliability of subtyping in NSCLC, differences in biomarker tests, and the disconnect between the funding of drugs and the related biomarker test. In order to improve patient outcomes, in a national healthcare system, there is a need for governments to accept the changing paradigm, invest in technology and build capacity for molecular testing to facilitate the implementation of improved patient care.
Collapse
Affiliation(s)
- David E Dawe
- University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A 1R8, Canada.
| | - Peter M Ellis
- Department of Medical Oncology, McMaster University, Hamilton, ON, L8S 4L8, Canada.
| |
Collapse
|