Achieving Health Equity in Oncology with Precision Medicine Stewards

Precision medicine can be a game changer in the diagnosis and treatment of cancer. Yet the playing field is nowhere near even when it comes to patient access to comprehensive biomarker testing, which is used to optimize treatment plans by tailoring them to an individual’s genomics, lifestyle, and environment. Social determinants of health create formidable barriers to precision medicine access, particularly for underserved patient populations, where one’s ZIP code, race, income, or insurance type often impacts their ability to receive biomarker testing. Precision medicine stewards—dedicated navigators who assist patients and providers through complex biomarker testing processes—can help level the playing field for these underserved populations through education and facilitation of biomarker testing and coverage. 

To better understand these disparities, ACCCBuzz spoke with Luis E. Raez, MD, FACP, FCCP—chief scientific officer and medical director at Memorial Cancer Institute/Memorial Healthcare System in Pembroke Pines, Fla., and Association of Community Cancer Centers (ACCC) Precision Medicine Stewardship Advisory Committee member—about the importance of closing the gap in access to biomarker testing and strategies to improve equity and inclusion in precision medicine. These strategies draw from Dr. Raez’s decades-long experience in treating lung and head and neck cancers, working in clinical hematology, and designing Phase I to Phase III clinical trials.

“Disparities in cancer care is a very important issue to me, as I am Hispanic and have seen how minorities struggle,” he said. “But it is so much more than that.” As Dr. Raez explained, barriers that impact biomarker testing go much further than poor socio-economic status, immigration status, or lack of insurance. Genetics—one’s race and/or ethnicity—can play a significant role as well.  

Trends in Biomarker Testing

In Black populations, studies show higher rates of cancer incidence across disease types, including higher rates of prostate cancer, multiple myeloma, and breast cancer. Black populations also carry a higher cancer burden, which includes the highest cancer mortality rate and shortest survival rate, compared to other racial and ethnic groups in the United States across multiple disease types. However, a recent study of patients with non-squamous non-small cell lung cancer revealed a significant difference in next-generation sequencing (NGS) rates between White and Black populations before first-line therapy (36.6 percent vs. 29.9 percent, respectively) and at any period during treatment (54.7 percent vs. 43.8 percent, respectively). 

Ensuring that cancer care teams are aware of these trends and utilizing precision medicine stewards to advocate for underserved patient populations, which often means addressing language and/or literacy barriers to educate patients on biomarker testing, advocating on the patient’s behalf for insurance coverage approvals, or seeking out financial assistance to offset costs, is integral to improving testing rates among these populations. ACCC’s recently released guide to biomarker testing in cancer can help precision medicine stewards and others better maneuver this complex landscape.

“We [the U.S.] are the best equipped country in the world to fight cancer,” Dr. Raez pointed out. “We have the best scientists and the best technology. Really, it is sad that our standards [i.e., rates of comprehensive biomarker testing in the country] are not good.” In fact, less than 50 percent of patients get adequate biomarker testing when they are diagnosed with cancer. And according to Dr. Raez, 70 percent of patients get some testing, but that testing may not be accurate nor does it allow providers to really practice precision medicine because they are missing information. “And among minorities, it [the percentage of patients who receive adequate precision medicine testing] is even worse,” he said. 

A Paradigm for Biomarker Testing 

At many larger, academic and research centers like Memorial Cancer Institute, biomarker testing is done for every patient, including both tissue testing and liquid biopsy (blood testing). While tissue testing is extremely useful, it is not 100 percent accurate when done on its own (irrespective of the vendor), mainly due a lack of adequate tissue to test; therefore, conducting liquid biopsy simultaneously offers providers the opportunity to identify even more gene mutations. “We don’t want to miss an opportunity to provide patients the opportunity to survive longer or, maybe, be cured,” Dr. Raez explained. 

Memorial Cancer Institute also understands the importance of patient navigators and precision medicine stewards, utilizing these roles to explain to patients the goals and purpose of having multiple biomarker tests and their impact on treatment plans and eligibility for clinical trials, as biomarkers are now a qualifying requirement for most clinical trials.

Enhancing Community-Based Cancer Care

But the challenges to conducting guideline-concordant biomarker testing, according to this paradigm, are numerous. Community-based cancer programs and practices, which often lack the sufficient staffing, funding, or resources required to conduct comprehensive biomarker testing and/or liquid biopsy, may face hurdles. While greater advocacy and legislative efforts to change policy and reimbursement for biomarker testing is vital to improving equity, Dr. Raez shared that increased education for providers and care teams on how to optimize biomarker testing and how precision medicine stewards can help facilitate this and empower patients is essential at the local level.

Supporting providers, particularly those in community-based cancer programs and practices, with resources and opportunities to learn when and why to order NGS, tissue testing, and/or liquid biopsy, as well as DNA vs. RNA and its potential for identifying more genetic aberrations, is vital. Following the latest guidance and accessing resources provided by centers of excellence in precision medicine, educational initiatives (i.e., the ACCC Precision Medicine Steward program), and organizations, such as the International Society of Liquid Biopsy, can help change the way providers approach precision medicine and help them become more aggressive in advocating for these tests.

Providers can also make the business case for hiring precision medicine stewards, who have been successful additions to several cancer care teams, to streamline biomarker testing and reduce treatment delays. These stewards and patient navigators are also on the frontlines of patient education and can be key to breaking down health literacy barriers and helping patients feel empowered to participate in shared decision-making, while also helping shrink the gap in health disparities in precision medicine. 

Dr. Raez also encouraged patients to become more empowered and advocate for their healthcare. “You need to ask your doctor, ‘Where is my NGS? Are you going to order my NGS in the blood or are you going to order it in the tissue?” he suggested asking. “If in the tissue, are you going to include RNA? I want to have RNA. I don’t want to miss anything or get chemotherapy when I can get one of these infusions.” Ultimately, patients and families who learn to advocate for their care, request clinical trials, and demand the latest and greatest in anti-cancer treatments have the greatest chance for better health outcomes.  

For more information on precision medicine, visit the ACCC website.  

The ACCC Precision Medicine Stewardshipeducation program is supported by AstraZeneca and Blueprint Medicines.