From the Journals

Training, alerts up the odds of discussions about genomic testing costs

View on the News

Conveying complex issues to patients may be biggest challenge

Many oncology patients experience financial toxicity, whereby the high cost of care not covered by insurance takes a personal toll that can include bankruptcy, reduced treatment adherence, and ongoing stress, Richard L. Schilsky, MD, notes in an editorial.

Professional associations have developed frameworks to capture an intervention’s magnitude of clinical benefit and impact on the disease and patient – and sometimes the related cost. “However, the extent to which any of these frameworks is useful to guide decision making is hard to determine, perhaps because the perceived value of an intervention often depends on the lens through which it is viewed,” he comments.

Discussions about costs are only the first step in informed decision making, as the investigators point out. “In any context, the value of the test depends on its impact on clinical decision making and patient outcome, that is, its clinical utility,” Dr. Schilsky maintains.

Key challenges oncologists face in discussing these issues with patients, as also outlined by the investigators, include limited time, lack of training materials and discussion guides, and poor price transparency, he notes.

“But 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,” Dr. Schilsky concludes. “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. 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.”

Richard L. Schilsky, MD, is senior vice president and chief medical officer of the American Society of Clinical Oncology, Alexandria, Va. These comments are taken from the editorial accompanying the study by Yabroff et al (J Natl Cancer Inst. 2019 Nov 1. doi: 10.1093/jnci/djz175).



Training and alerts increase the likelihood that oncologists will discuss the costs of genomic testing and related treatments with their patients, suggests a nationally representative survey of oncologists.

“Testing can be expensive, and not all tests and related treatments are covered by health insurance,” note the investigators, who were led by K. Robin Yabroff, PhD, an epidemiologist and senior scientific director of the Surveillance and Health Services Research Program at the American Cancer Society in Atlanta.

Using data from the 2017 National Survey of Precision Medicine in Cancer Treatment, the investigators analyzed factors associated with cost discussions among 1,220 oncologists who had discussed genomic testing with their patients in the past year.

Results reported in the Journal of the National Cancer Institute showed that 50.0% of the oncologists often discussed the likely costs of genomic testing and related treatments with patients and 26.3% sometimes did, while 23.7% never or rarely did.

In adjusted analyses, oncologists were more likely to often discuss costs, versus rarely or never, if they had formal training in genomic testing (odds ratio, 1.74). And they were more likely to sometimes or often have these discussions if their practice had electronic medical record alerts for genomic testing (odds ratios, 2.09 and 2.22).

Additional physician factors positively associated with cost discussions were treating only solid cancers or both solid and hematologic cancers versus only hematologic cancers, and using next-generation sequencing gene panel tests. Additional practice factors showing positive associations included seeing a volume of 100 or more patients per month; having 10% or more of patients who were insured by Medicaid or were self-paying or uninsured; and being located in the West as compared with the Northeast.

When the survey was conducted, the cost of available genomic tests to inform treatment was $300 to more than $10,000, and molecularly targeted therapies commonly had a price tag exceeding $100,000 per year, Dr. Yabroff and coinvestigators note. Moreover, insurance coverage of this testing was in limbo.

“With rapid growth in the availability of genomic tests and targeted treatments for cancer and a large pipeline of treatments in development, improving provider discussions about expected out-of-pocket costs will be critical for ensuring informed patient treatment decision making and the opportunity to plan for treatment expenses and help address out-of-pocket costs by linking patients with available resources, and ensuring high-quality cancer care,” they maintain.

“Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of EMR alerts, may help improve cost discussions about genomic testing and related treatments,” the investigators conclude.

Dr. Yabroff did not disclose any relevant conflicts of interest. The study did not receive any specific funding; the survey was funded by the National Institutes of Health.

Next Article: