The past several years have seen an increased use of genetic markers and molecular testing in oncology clinical decision making. The evolution of personalized medicine is having an impact on oncology patient care—both diagnostically and therapeutically. The growth in both volume and complexity of molecular tests is presenting challenges for oncology and pathology programs. While these tests have been accepted into general practice guidelines once clinical utility is proven, adoption and use of molecular tests in the community setting have been slower and somewhat fragmented. Understanding the challenges around molecular testing for community-based providers is important to both practicing clinicians and the patients they serve.
In this study of the landscape of molecular testing in the community setting, ACCC took a three-pronged approach: development of an annotated bibliography, two informal online surveys (multidisciplinary team member survey and pathologist survey), and focus group and follow-up interviews to inform challenges and effective practices in the use of oncology molecular testing.
This project provides an environmental scan of molecular testing in the community oncology setting. A literature search revealed that little is currently published on the non-clinical aspects of use of molecular testing in the community oncology setting. Results of the two surveys conducted as part of this education project seem to indicate that molecular testing is a technical and clinical aspect of cancer care that is often not well understood by all members of the cancer care team.
Among the challenges identified are:
- Lack of physician interest (both pathologists and/or specialty physicians) to transition to individualized care
- Lack of collaborative relationships between specialty physicians
- Unwillingness on the part of administration to take risks and invest time, money, and staff upfront
- Need for significant up front capital investment and competing capital priorities
- Need for more education for both providers and patients.
Despite these barriers to integration of molecular testing into the community setting, some survey respondents and focus group participants indicate that they’ve developed strategies to move forward. These include:
- Using peer pressure to elevate non-utilizers (physician to physician)
- Discontinuing contracts of physician partners unwilling to elevate the standard of practice
- Having lead pathologists and oncologists present evidence of necessity to keep current with clinical offerings of competing health systems to prevent loss of downstream revenue
- Implementing multidisciplinary strategic planning processes that focus on developing team collaboration and communication strategies.
Finally, the project has identified five essential elements common among study participants who are successfully integrating molecular testing into practice:
- 1. Physician champions
- Pathologist and medical oncologist champions for molecular testing
- Strong collaborative relationships between disciplines
- Willingness to evaluate and discuss a test's clinical utility and predictive demand
- 2. Administrative support
- Resources to perform comparative analysis
- Support for significant resources up front with returns to follow later
- Assumption of risk that some tests may be a loss leader for several months
- 3. Multidisciplinary communication
- Early involvement of entire multidisciplinary team
- Consistent discussion of molecular testing at tumor boards, cancer committees, quality committees
- 4. Genetic counseling and care coordination
- Genetic counselor services are available
- Staff dedicated to coordinating care across settings, i.e., patient navigators
- 5. Ongoing staff education on molecular testing through
- Cancer conferences
- Tumor boards
- Journal clubs
- In-service trainings
This project is designed to fulfill ACCC’s learning objectives for the project:
- To understand from a multidisciplinary perspective the current molecular-testing landscape, including barriers to use of molecular testing in the community setting.
- To identify a wide variety of community-based cancer program centers that have excelled at implementing molecular testing, thereby improving patient care.
- To identify key success factors and effective practices demonstrated through case studies, to successfully implement molecular testing in the community setting.
It is hoped that this study will serve as a resource to ACCC members on challenges and successes in integrating molecular tests in the community oncology care setting.
If you have any comments about this project, we would like to hear from you.