Comprehensive testing of newly diagnosed metastatic non–small cell lung cancer (NSCLC) with next-generation sequencing (NGS) for known lung cancer–related genomic alterations is cost-saving relative to single-gene testing strategies and often faster, a new study finds.

“We know now that genomic testing for all patients with advanced NSCLC is the standard of care to help detect oncogenic drivers, to inform treatment decisions,” lead study author Nathan A. Pennell, MD, PhD, codirector of the Cleveland Clinic lung cancer program, said in a press briefing leading up to the ASCO annual meeting. But the optimal strategy for this testing is unclear.

He and his colleagues conducted a decision analytic modeling study among hypothetical insurance plans having 1 million enrollees. Outcomes were compared between NGS testing and three single-gene testing strategies.

Data indicated that compared with exclusionary, sequential, or hot-spot panel testing approaches, NGS testing simultaneously for eight genomic alterations having Food and Drug Administration–approved or investigational targeted therapies could save up to $2.1 million among Medicare beneficiaries and up to $250,842 among patients covered by commercial insurance. The costs to payers decreased as the percentage of patients receiving NGS testing increased. Moreover, the wait time for results was similar or roughly half as long with NGS.

“Our results showed that there were substantial cost savings associated with upfront NGS testing compared to all other strategies,” Dr. Pennell said. “In addition, NGS had a faster turnaround time than either sequential or exclusionary testing, which is critically important for sick lung cancer patients, to make sure they get their treatment as quickly as possible. Waiting a month or longer is simply no longer viable for patients because they get sick very quickly and these treatments work very well.”

Of note, the model indicated that some patients undergoing initial single-gene testing strategies never had their genomic alterations detected because tissue for testing ran out and they were too sick to undergo another biopsy.

“The bottom line is, ultimately, using the best single test upfront results in the fastest turnaround time, the highest percentage of patients with targetable alterations identified, and overall the lowest cost to payers,” he summarized.

A major challenge in this population is going back and retesting for known or new genomic alterations, agreed ASCO President Bruce E. Johnson, MD, FASCO. “At our upcoming meeting, we are going to hear about RET, which may end up as a target and may therefore need to be tested for.”

Recently, oncologists have a new attractive option of billing for NGS panels rather than for single gene tests, he noted.

“This study really shows that by doing all the testing at the same time, you can both get results back more quickly as well as get information,” said Dr. Johnson, professor of medicine at the Dana-Farber Cancer Institute and a leader of the Dana-Farber/Harvard Cancer Center Lung Cancer Program, Boston. “This study looked at an NGS panel of eight genes, but most of the NGS panels contain somewhere between 50 and 400 genes, so you get a lot more information with this at a cost that’s competitive or less. So this will be welcome news to people who are ordering these gene panels.”

Study details

For NSCLC, there are currently approved treatments that target alterations in EGFR, ALK, ROS1, and BRAF, and investigational treatments in clinical trials that target alterations in MET, HER2, RET, and NTRK1.

In the model Dr. Pennell and his colleagues developed, patients with newly diagnosed metastatic NSCLC received testing for programmed death ligand 1 (PD-L1) plus testing for the above known lung cancer–related genes using one of four strategies:

NGS testing (testing of all eight genes plus KRAS simultaneously).
Sequential testing (testing one gene at a time starting with EGFR).
Exclusionary testing (testing for KRAS mutation, the most common genomic alteration, followed by sequential testing for changes in other genes only if KRAS was not mutated).
Hot-spot panel testing (combined testing for EGFR, ALK, ROS1, and BRAF), followed by either single-gene or NGS testing for alterations in other genes.

Model results indicated that among 1 million hypothetical plan enrollees, 2,066 patients covered by the Centers for Medicare & Medicaid Services and 156 covered by U.S. commercial insurers would have newly diagnosed metastatic NSCLC and therefore be eligible for testing.

Estimated time to receive test results was 2 weeks for NGS testing and for panel testing, compared with 4.7 weeks for exclusionary testing and 4.8 weeks for sequential testing.

In the CMS population, NGS testing would save about $1.4 million compared with exclusionary testing, more than $1.5 million compared with sequential testing, and about $2.1 million compared with panel testing. In the commercial health plan cohort, NGS would save $3,809 compared with exclusionary testing, $127,402 compared with sequential testing, and $250,842 compared with panel testing.

Dr. Pennell disclosed that he has a consulting or advisory role with AstraZeneca, Lilly, and Regeneron, and that his institution receives research funding from Genentech, NewLink Genetics, Clovis Oncology, Astex Pharmaceuticals, Celgene, AstraZeneca, Pfizer, and Merck. The study received funding from Novartis.

SOURCE: Pennell et al., ASCO Annual Meeting Abstract 9031.

Upfront NGS testing of metastatic NSCLC saves money, time