Gray Stacy W, Kim Benjamin, Sholl Lynette, Cronin Angel, Parikh Aparna R, Klabunde Carrie N, Kahn Katherine L, Haggstrom David A, Keating Nancy L
City of Hope Comprehensive Cancer Center, Duarte; University of California, San Francisco, San Francisco; RAND Corporation, Santa Monica; University of California, Los Angeles, Los Angeles, CA; Brigham & Women's Hospital; Harvard Medical School; Dana-Farber Cancer Institute; Massachusetts General Hospital, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush VA Medical Center; and Indiana University School of Medicine, Indianapolis, IN.
J Oncol Pract. 2017 Mar;13(3):e185-e196. doi: 10.1200/JOP.2016.016659. Epub 2017 Jan 17.
Genomic testing improves outcomes for many at-risk individuals and patients with cancer; however, little is known about how genomic testing for non-small-cell lung cancer (NSCLC) and colorectal cancer (CRC) is used in clinical practice.
In 2012 to 2013, we surveyed medical oncologists who care for patients in diverse practice and health care settings across the United States about their use of guideline- and non-guideline-endorsed genetic tests. Multivariable regression models identified factors that are associated with greater test use.
Of oncologists, 337 completed the survey (participation rate, 53%). Oncologists reported higher use of guideline-endorsed tests (eg, KRAS for CRC; EGFR for NSCLC) than non-guideline-endorsed tests (eg, Onco typeDX Colon; ERCC1 for NSCLC). Many oncologists reported having no patients with CRC who had mismatch repair and/or microsatellite instability (24%) or germline Lynch syndrome (32%) testing, and no patients with NSCLC who had ALK testing (11%). Of oncologists, 32% reported that five or fewer patients had KRAS and EGFR testing for CRC and NSCLC, respectively. Oncologists, rather than pathologists or surgeons, ordered the vast majority of tests. In multivariable analyses, fewer patients in nonprofit integrated health care delivery systems underwent testing than did patients in hospital or office-based single-specialty group settings (all P < .05). High patient volume and patient requests (CRC only) were also associated with higher test use (all P < .05).
Genomic test use for CRC and NSCLC varies by test and practice characteristics. Research in specific clinical contexts is needed to determine whether the observed variation reflects appropriate or inappropriate care. One potential way to reduce unwanted variation would be to offer widespread reflexive testing by pathology for guideline-endorsed predictive somatic tests.
基因组检测可改善许多高危个体和癌症患者的治疗结果；然而，对于非小细胞肺癌（NSCLC）和结直肠癌（CRC）的基因组检测在临床实践中的应用情况，人们了解甚少。
在2012年至2013年期间，我们对美国各地不同执业环境和医疗保健机构中照顾患者的医学肿瘤学家进行了调查，了解他们对指南认可和非指南认可的基因检测的使用情况。多变量回归模型确定了与检测使用增加相关的因素。
337名肿瘤学家完成了调查（参与率为53%）。肿瘤学家报告称，与非指南认可的检测（如用于结直肠癌的Onco typeDX结肠检测；用于非小细胞肺癌的ERCC1检测）相比，他们对指南认可的检测（如用于结直肠癌的KRAS检测；用于非小细胞肺癌的EGFR检测）的使用频率更高。许多肿瘤学家报告称，没有结直肠癌患者进行错配修复和/或微卫星不稳定性检测（24%）或种系林奇综合征检测（32%），也没有非小细胞肺癌患者进行ALK检测（11%）。32%的肿瘤学家报告称，分别有5名或更少的患者进行了结直肠癌和非小细胞肺癌的KRAS和EGFR检测。绝大多数检测是由肿瘤学家而非病理学家或外科医生开出的。在多变量分析中，非营利性综合医疗保健服务系统中的患者接受检测的比例低于医院或基于办公室的单一专科组环境中的患者（所有P < .05）。高患者数量和患者要求（仅针对结直肠癌）也与更高的检测使用相关（所有P < .05）。
结直肠癌和非小细胞肺癌的基因组检测使用情况因检测和执业特征而异。需要在特定临床背景下进行研究，以确定观察到的差异反映的是适当还是不适当的治疗。减少不必要差异的一种潜在方法是通过病理学对指南认可的预测性体细胞检测进行广泛的反射性检测。
