Coverage for Biomarker Testing

There’s important work ongoing across the country to bring the promise of precision medicine to more patients regardless of their background or socioeconomic status. As you may know, biomarker testing is increasingly important in the treatment of cancer and other conditions, but many patients who could benefit from biomarker testing to inform their treatment are currently missing out.

In certain areas of medicine, such as cancer care, advances in precision medicine have been progressing rapidly in recent years and have led to targeted cancer therapies that work by interfering with specific cellular processes involved in the growth, spread, and progression of cancer. In other words, effective treatments can be selected based on the tumor itself rather than just its location in the body. In addition, appropriate biomarker testing can help doctors determine which cancer patients are more likely to have recurring or more aggressive disease. Testing may also help patients at low risk of recurrence avoid unnecessary treatment.

Research Shows That Targeted Therapy Can Improve Health Outcomes, Increase Quality of Life, and Prolong Patient Survival^1,2

Using the traditional trial and error method to identify an effective treatment for a particular patient can take months, even years. In chronic, degenerative diseases, such as rheumatoid arthritis, any length of time spent with ineffective treatments allows the disease to continue causing irreversible damage to the joints, increasing healthcare consumption and costs, while the patient continues to suffer. In cancer care and in the treatment of some autoimmune conditions, the length of time it takes to identify an effective treatment can be a matter of life or death.

Unfortunately, not all patients who could benefit from biomarker testing are getting it, and access varies across different groups. Studies have shown that patients who have lower incomes, are insured by Medicaid, are Black, or are receiving care at nonacademic medical centers are all less likely to receive guideline-indicated biomarker testing.

Reprinted with permission from the American Cancer Society Cancer Action Network.

Challenges Associated With Biomarker Testing

Without action to expand access to biomarker testing, advances in precision medicine could exacerbate existing disparities in access to care and, consequently, health outcomes associated with race, ethnicity, income, and geography. However, there are many challenges to the optimal use of biomarker testing: availability of relevant and reliable tests, adequate tumor tissue or other sample material for testing, provider awareness and comfort ordering appropriate testing, insurance coverage of needed testing, and timely testing analysis and interpretation, among others.

Problems at any step in this process can derail a patient’s access. While there is important work ongoing to address each of these barriers, the American Cancer Society Cancer Action Network (ACS CAN) is focused on addressing insurance coverage of comprehensive biomarker testing.

The benefits of biomarker testing are clear; however, many insurance plans do not cover evidence-based biomarker testing for all patients who need it. Improving coverage for and access to biomarker testing across insurance types is key to reducing health disparities.

Policy Change Is Needed to Bring Equitable Access to Patients

As the policy affiliate of the American Cancer Society, ACS CAN supports proven policies to save lives and reduce suffering from cancer, including access to biomarker testing. We’re working with lawmakers, partner organizations, providers, and patient advocates to pass state legislation to require more insurance plans, including Medicaid, to cover biomarker testing that is supported by the latest evidence.

So far, legislation to expand coverage of biomarker testing has passed in 16 states, and bills are moving through the legislative process in 9 states (Table).

While we’ve made a lot of progress, this work isn’t easy, and often several years of coordinated efforts are required to pass legislation that will make a real difference for patients.

Nurse navigators have a valuable role to play in advancing policies that will help patients get the best care. Visit fightcancer.org to learn more and get involved. You can connect with ACS CAN in your state to share your expertise and experience as a navigator. Lawmakers need to hear from people like you about the challenges you and your patients face.

Watch Heather Murphy, a nurse practitioner at Women and Infants Hospital in Providence, RI, describe the importance of biomarker testing in her care of patients with breast cancer  »

References

1. Gutierrez ME, Choi K, Lanman RB, et al. Genomic profiling of advanced non-small cell lung cancer in community settings: gaps and opportunities. Clin Lung Cancer. 2017;18:651-659.
2. Schwaederle M, Zhao M, Lee JJ, et al. Impact of precision medicine in diverse cancers: a meta-analysis of phase II clinical trials. J Clin Oncol. 2015;33:3817-3825.