NEW YORK – Even when expert subspecialists weigh in on the care pancreatic cancer patients should receive, many end up not receiving the germline genetic testing and tumor sequencing recommended in guidelines for personalizing treatment.
City of Hope subsidiary AccessHope partners with employers and health plans to connect patients and local oncologists with experts at National Cancer Institute-designated comprehensive cancer centers. Cancer patients who have access to AccessHope through their employer-sponsored health plans can have their cases reviewed by subspecialists at City of Hope and other partner institutions, including Dana-Farber Cancer Institute, Emory Healthcare and Winship Cancer Institute of Emory University, Fred Hutchinson Cancer Center, Johns Hopkins Medicine, Northwestern Medicine, and the Robert H. Lurie Comprehensive Cancer Center at Northwestern University.
In launching this program three years ago, City of Hope said it hoped to improve patients' access to oncology expertise in community practices and improve outcomes, particularly for those with complex, hard-to-treat tumors like pancreatic cancer. In an effort to track the impact of this program, researchers led by AccessHope Chief Medical Officer Todd Sachs analyzed 94 pancreatic cancer cases that were reviewed by specialists and recently published the findings in the Journal of Personalized Medicine. The real-world care analysis revealed areas that still need improvement and missed opportunities to deliver precision medicine to pancreatic cancer patients.
The majority of cases included in the analysis were identified using AccessHope's automated claims-based program, Accountable Precision Oncology, and 9 percent were reviewed after a provider or patient requested it. About two-thirds of patients included in the analysis were treated at community cancer centers and one-third were receiving care at academic centers.
"The treatment [of pancreatic cancer] has not changed a lot in the past 10 years, but there are other services that have found their way to pancreatic cancer care that are of significance, such as universal germline testing for all patients with pancreatic adenocarcinoma, regardless of the stage at diagnosis and age," said Afsaneh Barzi, first author of the Journal of Personalized Medicine paper and medical director of gastrointestinal oncology at AccessHope.
Since pancreatic cancer is hard to treat but patients can still benefit from genomic testing, it presents a good setting for tracking how expert case reviews could impact care. When reviewing cases, AccessHope experts typically base their recommendations on guidelines set by the National Comprehensive Cancer Network, which, Barzi pointed out, supports germline testing for all patients and tumor molecular profiling for those with locally advanced or metastatic disease and who are candidates for anticancer therapy.
In the AccessHope study, subspecialists made guideline-concordant recommendations that are expected to improve outcomes in 94 percent of cases. Still, researchers found that 59 percent of patients completed the recommended germline testing and 69 percent of patients with unresectable and metastatic pancreatic cancer completed recommended somatic tumor molecular testing.
There may be multiple reasons why germline and somatic testing had not been completed in 41 percent and 31 percent of cases, respectively. Barzi suggested, for example, that clinicians may be forgetting to order testing in the rush to begin treatment, or they may be unsure how to interpret the test results.
"As a treating physician, sometimes it's overwhelming," she said. "It's not an easy conversation to say that this is an incurable disease with an expected short survival. You have to get the treatment started, get insurance authorization, and you may forget other things that are ancillary to the start of treatment, like this testing."
Patients that don't receive germline testing may forgo the chance to find out if they have an inherited predisposition for pancreatic and other cancers — information that may inform their screening for future cancers and that may help in assessing their family members' cancer risks. Patients that don't have somatic testing may miss an opportunity to receive treatment that targets the molecular abnormality driving their tumors that they're likely to benefit from.
Advanced pancreatic cancer patients may be eligible for three targeted therapies based on tumor biomarkers. Two are tissue-agnostic treatments that can be given to patients with any kind of advanced, refractory solid tumors harboring NTRK fusions: Bayer's Vitrakvi (larotrectinib) and Genentech's Rozlytrek (entrectinib). The third is AstraZeneca's PARP inhibitor Lynparza (olaparib) for metastatic pancreatic cancer patients harboring germline BRCA1/2-mutations.
Even though a small subset of pancreatic cancer patients are currently eligible for biomarker-informed precision treatment based on genomic testing, Barzi said "there is no reason to overlook them and not look at the opportunity for delivering these lifesaving and life-changing treatments."
Many pharma companies are testing other biomarker-informed targeted therapies in pancreatic cancer in clinical trials, and genetic testing can help determine whether patients are eligible for these studies. In the latest analysis, AccessHope experts recommended clinical trials for 40 percent of patients, though Barzi noted that her team did not track how many patients ultimately enrolled in the recommended studies.
Part of the problem in precision oncology today is the pace of advances. Oncologists are finding it difficult to keep up with rapidly changing guidelines about new biomarkers and associated treatments. Barzi noted that oncologists need help interpreting germline or somatic testing results or understanding what to do next if a patient has a positive result. The data from the real-world analysis suggests that community practitioners may not be the only ones struggling with implementing precision cancer care, since the rate of germline and somatic testing completion were similar across community and academic settings.
AccessHope experts cannot order testing for the clinician or influence their treatment plan; they only provide recommendations. Barzi pointed out that about one-quarter of local oncologists connected with an AccessHope expert to discuss and better understand the recommendations. Of those, 88 percent were receptive to AccessHope's recommendations and open to implementing them.
"We are hoping that the AccessHope [consultation] serves as a reminder to increase the chance of this being done," Barzi said. "We are further hoping that publication of these results will prompt the health systems to think about the strategies and mechanisms for delivering these services appropriately and in a timely manner."
Before this latest research in pancreatic cancer patients, AccessHope researchers explored care delivery in lung cancer and identified some gaps in recommended molecular testing for small cell and non-small cell lung cancer patients. Barzi and colleagues hope to continue exploring real-world data to track AccessHope's impact and gaps in cancer care in other settings, such as young-onset cancers and hematologic malignancies.
"The way we work is by coaching and helping the treating provider," Barzi said. "AccessHope has this capability of looking at care all across the US, which provides a great mechanism to look at the care delivery without the constraints of the geography."