Purpose: To inform VA stakeholders of the availability of precision oncology (PO) services for Veterans with advanced cancer.
Background: PO offers the promise of effective, low-toxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A systemwide PO program (POP), including patients in rural areas, launched in July 2016.
Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from POP records and cancer characteristics were extracted from POP and medical records. Drug use data were obtained from the VA Corporate Data Warehouse. NGS testing results, and annotations were extracted from POP records.
Results: 1,442 tumor samples were sent for NGS testing as of 5/21/17 from 61 facilities. Rural patient testing (35%) was similar to VHA rurality (33%) and more than twice the US rate (14%). Most common diagnoses: lung (688: adeno 482, squamous 134), unknown (114), colorectal (103), skin (96), prostate (76), and H&N (66). Sample test requests increased rapidly after national implementation in July 2016 (23 samples/month prior to implementation to mean 126 samples/month 3 months later) as did the number of participating facilities (10/quarter to 39/month). Sequencing success rate increased from 68% to 71% over the same interval, while mean turn around time remained similar at 19.7 and 19.1 days, respectively. To date, 26 patients received a recommended drug outside a clinical trial, some more than 9 months after NGS. 5 additional patients had received an NGS-recommended drug prior to testing. NGS results are available for a cohort of 344 patients including: lung 200 (adeno 138, squamous 51), skin 28, LN 20, liver 19, GI 16. 979 variants were found most commonly in TP53, KRAS, STK11, APC, PIK3CA, and CDKN2A. 228 patients (66%) had actionable results (on-label drug 24, off-label drug 165, clinical trial 213). A PO consultation service (available by IFC) and a liquid biopsy are now available nationally.
Conclusions: Implementation of tumor NGS testing in VHA has been successful. Further program expansion, addition of hematological malignancies, deployment of informatics tools and efforts to expand access to appropriate drugs are ongoing.