Barriers to Prescribing Targeted Therapies for Patients With NSCLC With Highly Actionable Gene Variants in the Veterans Affairs National Precision Oncology Program.

Purpose: Next-generation sequencing (NGS) gene panels are frequently completed for patients with advanced non-small-cell lung cancer (NSCLC). Patients with highly actionable gene variants have improved outcomes and reduced toxicities with the use of corresponding targeted agents. We sought to identify barriers to targeted agent use within the Veterans Health Affairs' National Precision Oncology Program (NPOP).
Methods: A retrospective evaluation of patients with NSCLC who underwent NGS multigene panels through NPOP between July 2015 and February 2019 was conducted. Patients who were assigned level 1 or 2A evidence for oncogenic gene variants by an artificial intelligence offering (IBM Watson for Genomics [WfG]) and NPOP staff were selected. Antineoplastic drug prescriptions and provider notes were reviewed. Reasons for withholding targeted treatments were categorized.
Results: Of 1,749 patients with NSCLC who successfully underwent NGS gene panel testing, 112 (6.4%) patients were assigned level 1 and/or 2A evidence for available targeted treatments by WfG and NPOP staff. All highly actionable gene variants were within ALK , BRAF , EGFR , ERBB2 , MET , RET , and ROS1 . Of these, 36 (32.1%) patients were not prescribed targeted agents. The three most common reasons were (1) patient did not carry a diagnosis of metastatic disease (33.3%), (2) treating provider did not comment on the NGS results (25.0%), and (3) provider felt that patient could not tolerate therapy (19.4%). No patients were denied access to level 1 or 2A targeted drugs because of rejection of a nonformulary drug request.
Conclusion: A substantial minority of patients with NSCLC bearing highly actionable gene variants are not prescribed targeted agents. Further provider- and pathologist-directed educational efforts and implementation of health informatics systems to provide real-time decision support for test ordering and interpretation are needed.
Competing Interests: Vishal VashisthaEmployment: UnitedHealthcare (I)Research Funding: IBM Watson HealthOther Relationship: IBMUncompensated Relationships: IBM Watson Health Pradeep J. PoonnenHonoraria: M3, Sermo Jane L. SnowdonEmployment: IBMStock and Other Ownership Interests: IBM Dilhan WeeraratneEmployment: IBM David BrotmanEmployment: IBM Gretchen P. JacksonEmployment: IBM, Vanderbilt University Medical CenterLeadership: IBM, American Medical Informatics AssociationStock and Other Ownership Interests: IBMSpeakers' Bureau: IBMResearch Funding: IBMTravel, Accommodations, Expenses: IBM Michael J. KelleyConsulting or Advisory Role: IBMResearch Funding: Novartis, AstraZeneca, Bristol-Myers Squibb, Regeneron, GenentechOther Relationship: IBMOpen Payments Link: https://openpaymentsdata.cms.gov/physician/827136No other potential conflicts of interest were reported.