This month we will continue discussing the common barriers to biomarker testing for cancer patients in the community.
As you may recall, these are the top 10 barriers that I’ve seen to biomarker testing in the community:
- High cost of testing.
- Long turnaround time for results.
- Limited tissue quantity.
- Preanalytical issues with tissue.
- Low biomarker testing rates.
- Lack of standardization in biomarker testing.
- Siloed disciplines.
- Low reimbursement.
- Lengthy complex reports.
- Lack of education on guidelines.
Despite being unique hurdles, a few of these barriers can be addressed together. If you are able to standardize biomarker testing despite the barriers that come with being in siloed disciplines, biomarker testing rates will go up. Sounds easy right! I am a firm believer in the multidisciplinary approach to precision medicine, because I have seen it work in my institution. I have also spoken with organizations where there is no collaboration among the multidisciplinary team (MDT) and observed what happens when the team is not working together. In these cases biomarker testing is often not being performed according to guideline and relationships between the pathology and oncology are strained.
In my organization we have a lot of complexity: 12 hospitals, inhouse and external reference labs, our own private payer, and pathology and oncology groups that are not related to the organization or each other. Everyone wants to do what’s right for the patient, unfortunately if everyone is not working together to help the patient, we tend to get in each other’s way. We found that our oncologists were not getting results back on biomarker tests in reasonable amount of time to make educated treatment decisions. The oncologist chose when to order testing, which biomarker to test, and the performing lab. This resulted in a great deal of variance in the care provided by each physician. It also added complexity in the pathology laboratory. We had to have shipping containers, portals, collection and specimen requirements that were different for every reference laboratory that the oncologists used. This delayed turnaround time even more as we navigated through the nonstandard process for biomarker testing. As you can imagine tensions were high between pathology and oncology.
Our organization began following the high performance team model some years ago. With this model we have a “team of teams” that can effect change rapidly despite a complex organizational structure (1). Every stakeholder is represented in the meeting, without every stakeholder having to attend the meeting. So if you have a team of oncologists that already trust their colleague they are typically comfortable allowing one oncologist to represent their best interest in the committee. We now have a vast structure of committees built on the principle of extending trust from one group into another group with stakeholder representation to build relationships between teams.
One of these committees is a Molecular Steering Committee. I co-chair this committee along with an oncologist. It is attended by radiologists, pathologists, oncologists, administrators and even the medical director from our payer. Every stakeholder and geographic region is represented. In this committee we discuss how to standardize biomarker testing by tumor type. Although our committee is distinct from a molecular tumor board where you can discuss molecular results for cases, any forum where standardizing the biomarker process can be addressed with a multidisciplinary team is the right forum. We have built relationships between the stakeholders involved in biomarker testing and help keep each other educated on changes to guidelines across tumor types.
This committee has allowed us to develop pathology-driven reflexes for testing in specific scenarios. Not all biomarker testing can or should be done at the time of diagnosis. However, some tumor types such as NSCLC adenocarcinoma where the tissue is limited and turnaround time is urgent, it makes a lot of sense to perform the testing as soon as we know the patient has this disease. In these cases the pathologist orders NGS and PD-L1 testing when they determine the diagnosis. This drastically cuts down on the turnaround time (2 weeks vs 6 weeks) and has the added benefit of ensuring all patients with this diagnosis get the standardized biomarker testing that they deserve.
Having a multidisciplinary forum to discuss biomarker testing by tumor type, including which tumor types, what stage, who’s ordering (pathology vs oncology), which test, and where it is performed is necessary to bridge the gap between siloes. In some institutions this can be done without a formal committee, a phone call between oncology and pathology may suffice. The most important thing you can do to improve your biomarker testing rates and increase standardization is to communicate across silos or disciplines to ensure everyone is in alignment on how to determine patients’ biomarkers status.
- McChrystal, T. C. D. S. C. F. S. A. (2015). Team of Teams: New Rules of Engagement for a Complex World.
-Tabetha Sundin, PhD, HCLD (ABB), MB (ASCP)CM, has over 10 years of laboratory experience in clinical molecular diagnostics including oncology, genetics, and infectious diseases. She is the Scientific Director of Molecular Diagnostics and Serology at Sentara Healthcare. Dr. Sundin holds appointments as Adjunct Associate Professor at Old Dominion University and Assistant Professor at Eastern Virginia Medical School and is involved with numerous efforts to support the molecular diagnostics field.