2018 ASCO: Upfront, Comprehensive Genetic Testing in Advanced Lung Cancer Is Cost-Effective


Key Points

  • Applying economic factors to CMS payments, next-generation sequencing would save about $1.4 million compared to exclusionary testing, over $1.5 million compared to sequential testing, and about $2.1 million compared to panel testing.
  • For commercial health plans, next-generation sequencing would save $3,809 compared to exclusionary testing and $250,842 compared to panel testing.

An economic model comparing different types of genetic testing in metastatic non–small cell lung cancer (NSCLC) found that using next-generation sequencing to test for all known lung cancer–related gene changes at the time of diagnosis was more cost-effective and faster than testing one or a limited number of genes at a time.

The model included Medicare and commercial health plans with 1 million hypothetical members. In the model, next-generation sequencing saved as much as $2.1 million for Medicare and more than $250,000 for commercial insurance providers. The study was presented during a press briefing in advance of the upcoming 2018 ASCO Annual Meeting and will be reported by Pennell et al at the meeting (Abstract 9031).

“The field of lung cancer treatment is moving at a rapid pace, and we need to fully characterize genomic changes to determine the best treatment for patients shortly after they are diagnosed,” said lead study author Nathan A. Pennell, MD, PhD, Co-Director of the Cleveland Clinic Lung Cancer Program. “Today, many treatment decisions are guided by the presence or absence of certain genetic changes in a patient’s tumor, and I expect that several more genes will be identified in the near future. Therefore, it becomes even more imperative to find a cost-effective gene test that can quickly identify a large number of gene mutations that can be targeted with treatments.”

Genetic testing of the tumor is crucial to guide optimal treatment for NSCLC. Many different tests are available today, but there is no accepted standard for when and how the testing should be performed. The authors designed their model to determine which gene testing approach is most cost-effective and time-efficient. The model uses data from the Center for Medicare and Medicaid Services (CMS) and U.S. commercial health plans to estimate costs for each modality.

About the Study

The known genes that are altered in NSCLC include EGFR, ALK, ROS1, BRAF, MET, HER2, RET, and NTRK1 (of those, EGFR, ALK, ROS1, and BRAF can be targeted with approved treatments). The other genetic changes can be targeted with investigational agents that are being tested in clinical trials. Newer tests also look at programmed cell death ligand 1 (PD-L1) expression to predict whether a tumor is likely to respond to immunotherapy.

In the model, patients with newly diagnosed metastatic NSCLC received PD-L1 testing and testing for the known lung cancer–related genes using one of four different approaches:

  • Upfront next-generation sequencing (all eight NSCLC-related genes and KRAS were tested at once)
  • Sequential tests (one gene at a time was tested)
  • Exclusionary KRAS test followed by sequential tests for changes in other genes if KRAS was not mutated (if KRAS mutations were found, the tumor was not tested for other mutations because it is rare to have more than one of these genes mutated in an individual lung cancer)
  • Panel test (combined testing for EGFR, ALK, ROS1, and BRAF), followed by either single-gene or next-generation sequencing testing for changes in other genes

The model assumed that some participants who did not receive upfront next-generation sequencing might need to have another biopsy to test for additional genes (due to tissue from the first biopsy being insufficient) and that the need for rebiopsy would be lessened with upfront, comprehensive next-generation sequencing. (According to comments from the authors during the press briefing, approximately 8% of patients treated with a single-gene test require a repeat biopsy.) The model also accounted for the time it took to get test results back after biopsy samples were sent to the lab, costs for each type of gene testing, and the estimated number of people with metastatic NSCLC in the United States who could be tested.

Key Findings

Based on the number and age of people with metastatic NSCLC in the United States annually, the researchers estimated that for 1 million–member health plans, 2,066 tests would be paid for by CMS and 156 would be paid for by commercial insurers. The model also estimated that it would take 2 weeks for the next-generation sequencing and panel results to be processed, whereas it would take 4.7 or 4.8 weeks to process the exclusionary and sequential tests, respectively.

Applying economic factors to CMS payments, next-generation sequencing would save about $1.4 million compared to exclusionary testing, over $1.5 million compared to sequential testing, and about $2.1 million compared to panel testing. For commercial health plans, next-generation sequencing would save $3,809 compared to exclusionary testing and $250,842 compared to panel testing.

With next-generation sequencing, patients initiated appropriate therapy 2.8 and 2.7 weeks faster than sequential or exclusionary testing, respectively.

A limitation of this study is that it the model is based on several assumptions. The authors’ next step is to look at actual health systems and evaluate these differences, testing cost-efficiency in a real-world setting.


“Precision medicine is driving the most exciting and powerful advances in cancer care today, particularly in lung cancer. It’s encouraging to see that next-generation genetic testing tools can help physicians and their patients get the crucial genomic information they need to make treatment decisions, at a faster pace and lower cost than with other approaches,” said ASCO President Bruce E. Johnson, MD, FASCO. “Next-generation sequencing panels [test] between 50 and 400 genes—[much] more information with a cost that’s competitive or lower [than standard testing],” he commented during the press briefing.

This study received funding from Novartis. Author conflict of interest disclosures are available at the end of the study abstract.


The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.