The most common cancer diagnosed in Canada is lung cancer, making it the leading cause of cancer-related mortality. Non–small cell lung cancer (NSCLC) represents almost 90% of all confirmed lung cancer cases in Canada. Targeted therapies are available for patients with advanced NSCLC, and personalization of treatment based on routine molecular testing gives patients significant improvements in clinical outcomes. Biomarker testing with single-gene testing or next-generation sequencing (NGS) multigene testing has become the standard of care for patients with advanced NSCLC. When compared with single-gene testing, NGS has demonstrated advantages of correct identification of more actionable oncogenes, which gives a greater benefit from targeted therapies, improved treatment response, reduction in delayed test results, detection of nonstandard mutations, and a reduction in the need for retesting and repeat biopsies.
In the United States, studies have demonstrated that per-patient testing costs for patients with metastatic NSCLC are lower for NGS compared with single-gene testing. A health and budget impact model demonstrated that NGS among Canadian patients with NSCLC can optimize targeted treatment selection without a significant economic burden on the healthcare system.
A recently released study assessed the total cost of testing associated with NGS versus single-gene testing among newly diagnosed patients with metastatic NSCLC from the Canadian public payer perspective. Included in the total cost of testing are medical costs associated with testing and the estimated costs of delayed systemic therapy. A decision-tree model was developed that included the time from the first test after diagnosis until biomarker test results were achieved and the appropriate targeted therapy was started. Newly diagnosed patients received an initial biopsy and were subsequently tested using NGS or an alternative single-gene testing strategy. NGS testing followed clinical guidelines that included simultaneously testing for recommended alterations. Alternative single-gene testing strategy included exclusionary, sequential, noncomprehensive sequential, or rapid-panel testing. Testing for KRAS was considered first, with a positive test ending the testing sequence. A negative test led to sequential testing first for EGFR, then ALK, then ROS1, with any positive result ending testing. Negative testing led to biomarker testing in this order: BRAF, KRAS, MET, HER2, RET, NRG1, and NTRK 1/2/3. Noncomprehensive sequential testing comprised single-gene tests for EGFR, ALK, then ROS1. Rapid-panel tests were simultaneous single-gene tests for EGFR, ALK, and ROS1, with a positive result ending the tests. Negative tests for all 3 led to simultaneous single-gene tests for BRAF, KRAS, MET, HER2, RET, NRG1, and NTRK 1/2/3. Further testing may also have been performed if genetic alteration was not identified.
The proportion of patients who tested positive for a biomarker with an approved targeted therapy was 26.1% for single-gene testing strategies and 38.0% for NGS. The estimated mean time to appropriate targeted therapy was 9.2 weeks for single-gene strategies and 5.1 weeks for NGS testing. Mean per-patient cost for single-gene testing strategies was Can$5632, and for NGS it was Can$3480. NGS testing led to lower testing costs, shorter time to targeted therapy initiation, and increased identification of mutations in patients compared with single-testing strategies.
Source: Sheffield BS, Eaton K, Emond B, et al. Cost savings of expedited care with upfront next-generation sequencing testing versus single-gene testing among patients with metastatic non-small cell lung cancer based on current Canadian practices. Curr Oncol. 2023;30:2348-2365.