Current Settings for Next-Generation Sequencing

Shubham Pant, MD:How do you think this trend is going to change over time? So you know next- generation sequencing [NGS] wasn’t very prevalent. Do you think it’s still restricted to mostly academic centers, community centers? What do you see as the overall trend in next-generation sequencing?

David S. Hong, MD:I think the trend is towards doing next-generation sequencing in the community more and more. I share that because 10 years ago when I started my career, it was rare that we would even see any outside mutational testing when we saw a patient from the outside to our clinic. It is an exception if we do not see now patients who come into our clinic looking for a trial who do not already have a next-generation sequencing profile already completed by their community oncologist or oftentimes requested by themselves.

And so I think this is a trend that is continuing, and the recent CMS [Centers for Medicare and Medicaid Services] announcement that they will pay for at least some NGS sequencing would suggest that that trend will continue. And, ultimately, I think it comes down to this issue of cost, right? We’ve said in 2002 it was $2 billion. NGS sequencing, I don’t know…the exact cost right now, but I think if you get FoundationOne or something, it’s a couple of thousand dollars. But once this cost goes down to a couple hundred dollars, I think you’re going to see people ordering this and without any major denials from insurers. And I think it’s going to become a routine part of all cancer care patients, whether metastatic or early.

Shubham Pant, MD:So right now though, what you’re saying is that more companies will come into the fray and then drive the cost down.

David S. Hong, MD:I agree.

Shubham Pant, MD:And then it will be much more affordable, so hopefully more payers will pick it up and pay for next-generation sequencing. Now, most of next-generation sequencing, just to be clear, is done in stage IV patients with metastatic and solid tumors, not in let’s say resected colorectal cancer or something. We don’t end up doing next-generation sequencing on the resected tumor.

David S. Hong, MD:Correct.

Shubham Pant, MD:Because essentially you are not going to change your treatment based on that currently.

David S. Hong, MD:Correct, correct. And I think that’s where the vast majority is being currently used right now. And I would say to some extent, in the community, most patients get next-generation sequencing once they failed standard chemotherapy. In the academic setting, obviously there are initiatives to bring NGS earlier, whether it’s in the neoadjuvant setting or even frontline setting for certain tumor types and many of our colleagues, as you know, are looking at that. But I think in the community, at least the vast majority is oftentimes after they failed standard chemotherapy.

Shubham Pant, MD:So after whatever stage IV cancer, they’ve had 1, 2 chemotherapies or some kind of tyrosine kinase inhibitor therapy or something.

David S. Hong, MD:But I think it also depends, as you know, on the tumor type. Increasingly, non—small cell lung cancer is being divided up into different categories.

Shubham Pant, MD:The subsets are getting smaller and smaller, you’re right.

David S. Hong, MD:Smaller and smaller of different subsets of tumors, and nowNTRK,RET,ROS,ALK/ROS,BRAF, etcetera. And so in some sense it’s more economical for community oncologists to go ahead in that frontline setting and order NGS. In colorectal, some would argue that and some other tumor types, etcetera. But I think the vast majority of other cancers, people are not really ordering it until after they failed standard chemotherapy.

Transcript edited for clarity.