Cost of Genomic Tests Often Not Discussed
With Patients

Pam Harrison

November 04, 2019

A substantial proportion of oncologists in the United States are loath to broach the issue of cost if patients require genomic testing as part of their cancer care, a recent survey has found.

And whereas half of those surveyed did frequently bring up the issue of cost with their patients, approximately one quarter only sometimes raise the issue of cost if genomic testing was required, and the other quarter rarely or never discuss it, the same survey shows.  

The survey involved 1220 oncologists who participated in the 2017 National Survey of Precision Medicine in Cancer Treatment.

This is a nationally representative survey of medical oncologists sponsored by the National Cancer Institute, National Human Genomic Research Institute, and the American Cancer Society, say the authors.

The results were published online November 1 in The Journal of the National Cancer Institute (JNCI)

"Use of genomic testing is increasing in the United States," note the authors. led by Robin Yabroff, PhD, an epidemiologist with the American Cancer Society.

More than 30 genomic tests associated with cancer drugs are now available in the US. Most often, these tests identify a genetic mutation and thus allow the use of a targeted agent instead of chemotherapy.

“Testing can be expensive and not all tests and related treatments are covered by health insurance,” the authors write, and even when those who have private health insurance can experience medical financial hardship.

"Oncologists may not be the providers best suited for all discussions about the expected costs of care," the authors acknowledge.

However, they can ensure that cost conversations do take place with someone from the medical team who is qualified to do so, they suggest.

The authors also point out that training materials and practice guides are available to help physicians overcome their discomfort about having discussions concerning the cost of care with patients as well as about how much genomic interventions may cost that patient.

"Even privately insured cancer survivors report problems paying medical bills, stress related to medical bills, or delaying or forgoing care because of cost," the authors warn.

"Thus, discussions about the expected costs of cancer care are important for all patients," they conclude.

These discussions can be difficult because of the nuances involved, suggests Richard Schilsky, MD, chief medical officer of the American Society of Clinical Oncology (ASCO), writing in an accompanying editorial

"The biggest challenge may be explaining to a patient the nuances of context of use and clinical utility that define the true value of a tumor biomarker test. Patients need to know not just what the test will cost but how it will inform their care, impact their options, affect their outcomes and whether, in the long run, it might even guide them to better treatments and/or lower their overall costs of care," he explains.

Further research on how best to convey these complex issues in the course of a clinical encounter is desperately needed before we can effectively 'talk the talk' about tumor genomic testing," Schilsky concludes.

Survey Findings

The findings are based on answers that were obtained to this question in the survey: 'In the past 12 months, when you or your staff discussed any form of genomic testing with your cancer patients or their families, how often did you discuss the likely costs of the testing and related treatment?'

Results showed that the frequency of cost discussions differed by the type of cancer that physicians treated.

For example, some 60.1% of oncologists who treated only solid tumors frequently discussed the cost of genomic testing with patients compared with 50.4% of those who treated both hematologic cancers and solid tumors, and 27.9% of oncologists who treated only hematologic cancers (P < .001)

In fact, oncologists who treated both solid and hematologic cancers were almost three times more likely to often have cost discussions with patients compared with oncologists who only treated hematologic malignancies (odds ratio [OR], 2.82).

Oncologists who only treated solid tumors were four times more likely to have frequent cost discussions (OR, 4.01) compared with those who only managed blood cancers, researchers add.

Oncologists who had graduated from medical school at least 15 years before taking the survey were also more likely to have frequent discussions about  the cost of genomic testing and related treatment costs, compared with those who had graduated less than 15 years ago.

Just over half (54%) of physicians who had used next-generation sequencing gene panel tests in the past 12 months reported often discussing the cost of genomic testing compared with almost 38% of those who did not (P < .001), the authors add.

"Oncologists with formal training in genomic testing were more likely than those without this training to report discussing costs often," the investigators continue — at 54.6% vs 44.1%, respectively (P =.001).

Similarly, oncologists who had electronic health record (EHR) alerts for genomic testing were at least twice as likely to have frequent cost discussions compared with oncologists who did not have EHR alerts (OR, 2.22).

Higher patient volumes also prompted more frequent discussions about genomic testing costs, as did a having a higher percentage of patients either insured by Medicaid, or who were self-pay or uninsured, as was practicing in lower income areas.  

In 2009, the American Society of Clinical Oncology highlighted the important role that oncologists have in discussions about potential out-of-pocket costs that patients may incur in the course of their cancer care.

The Institute of Medicine later categorized these discussions as being a critical element in high-quality care.

The study authors have disclosed no relevant financial relationships.

JNCI. Published online November 1, 2019. Abstract, Editorial

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