NEW YORK – A survey of community oncology practices identified barriers that are preventing or slowing genomic test ordering and the delivery of targeted therapies, and spurred researchers to explore a pathologist-led genomic testing workflow.
Researchers published results of the wide-ranging survey in Implementation Science Communications this month, which also revealed opportunities for improving precision oncology implementation in the community setting.
Twenty-four cancer care providers at 11 US community oncology programs in rural and urban settings participated in the survey. Care providers interviewed included medical oncologists, pathologists, surgeons, pharmacists, healthcare executives, advanced practice nurses, and oncology nursing staff.
The researchers aimed to learn the process cancer centers used to order genomic testing for identifying treatment opportunities for patients and determine common barriers patients faced in accessing tests or follow-on targeted treatments. They hoped to use what they learned through the surveys about access barriers to find potential solutions to overcome them, said Shellie Ellis, lead author of the study and associate professor of population health at University of Kansas Medical Center.
One key factor identified in the survey that seemed to matter for cancer patients who got molecular testing was which provider in a community practice ordered genomic testing. In many practices, the oncologists were expected to order testing, but the researchers found through the survey that the practices where pathologists ordered genomic assessments reported high and timely testing rates.
"It is an accident of the rapidity with which precision oncology has evolved. We didn't really think about who the end user would be for these tests and how we should roll it out," Ellis said, noting that diagnostics firms started off marketing predictive genetic tests to physicians because they are usually the ones deciding which treatments to give patients. However, Ellis pointed out that surveyed pathologists felt managing genomic testing fell naturally into their role alongside staging a tumor and managing patients' tissue samples, while the oncologists felt their role was more focused on treatment decision-making and delivery.
"There's only a finite amount of tissue, and [pathologists] are the stewards of the tissue," Ellis said. "If they can manage that entire [testing] process, it's more efficient."
Some sites had created new roles focused on genomic test ordering and results management, such as a liaison between the pathology and oncology teams to improve cross-department communication. However, only community sites with a high volume of oncology patients can bear the cost of a dedicated role like this, the researchers concluded.
Making the testing process more efficient could also alleviate other barriers to accessing genomic testing and targeted treatments in the community setting, such as the bottleneck created while waiting for results, which can lead to treatment delays and increase patient and provider anxiety. Providers also cited the cost of testing and targeted therapies as a barrier. Although some providers questioned whether these costs were worth the benefit to patients, many recognized the societal benefits of wider genomic testing and noted that the costs were decreasing as more tests and treatments were being reimbursed.
Surveyed providers also cited the knowledge demands of practicing precision oncology as a barrier, especially among community oncologists who see patients with all types of cancers. Despite these barriers, the intent to deliver precision medicine to patients was high across all surveyed participants.
"People are frustrated about the current situation [of precision oncology implementation], such as their ability to solve the challenges of the huge knowledge explosion," Ellis said. "A lot of people are looking for solutions to figure out how this works in practice because they know it's here to stay."
Based on the survey results, Ellis and her team are now working on potential solutions to improve community-based precision oncology care. Last year, they began an interventional study based on the findings from this survey, called the Multi-TEAM Systems Framework Precision Oncology Reflex Testing (TEAMSPORT) study.
With the help of a National Cancer Institute grant, Ellis' team is conducting the single-site study to explore whether reflex testing by pathologists can improve testing rates and turnaround times in the community oncology setting. Within TEAMSPORT, pathologists initiate reflex testing for genomic tests in cancer care and support inter-team communication.
The survey also revealed that there are largely no guidelines for how genomic testing should be implemented into a practice. Ellis' group hopes this insight will spur the development of toolkits for integrating genomic testing within community oncology program workflows.
Separate from this survey, many cancer centers are trying to improve precision oncology delivery in the community setting using a wide range of approaches. A program at the University of Washington and Seattle Cancer Care Alliance is focused on educating community oncologists about molecular profiling and funneling testing through a large, urban cancer center. The MYLUNG (Molecularly Informed Lung Cancer Treatment in a Community Cancer Network) trial used a remote oncology pharmacist to improve comprehensive genomic profiling among non-small cell lung cancer patients and study enrollment in community settings. The Princess Margaret Cancer Center implemented a nurse navigator-led virtual care pathway to improve community patients' access to comprehensive genomic profiling and clinical trials.
The TEAMSPORT researchers hope to develop a toolkit that helps address implementation issues specifically for rural oncology programs, within which doctors and patients tend to face even more difficulties accessing genomic testing and targeted therapies.
The survey revealed, for example, that rural oncology practices lacked infusion centers, had fewer staff to keep up with testing demands, and sometimes could not get targeted therapies because the practices are located outside of delivery zones, Ellis said.
Despite these challenges to receiving cancer care, most rural health systems typically have a pathology program that the TEAMSPORT toolkit could be applied to, she noted.
"Even if a person in a rural community might not be able to get treated in their local setting, the [local] pathologists will have protocols about what to order while they're in their home setting," Ellis said. "When [a patient] transfers to get care elsewhere, they will be a step ahead because they've already gotten these genomic tests. If [reflex testing] can become routine when a person is worked up for their cancer diagnosis, that will facilitate some of the disparities that exist in rural cancer care."