Supporting Access to Biomarker/Molecular Testing Among Patients with, or at Risk for, High-Burden Cancers
This measure would calculate the percentage of patients with a cancer diagnosis and/or increased risk of high-burden cancers (NSCLC, breast, colorectal, cervical, prostate) eligible for guideline-recommended biomarker/molecular testing options who (1) were screened for the 5 domains of social drivers of health (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety) in the Screening for Social Drivers of Health quality measure (ID #487), and (2) received an intervention (e.g., referral to financial assistance resources, assignment to patient navigator to assist with genetic testing/counseling referral completion) if they screened positive. The concept is proposing to measure:
- The number of patients with a cancer diagnosis and/or increased risk of high-burden cancers eligible for guideline-recommended biomarker/molecular testing who: (1) were screened for the 5 domains of social drivers of health in the Screening for Social Drivers of Health quality measure (ID #487), and (2) received an intervention if they screened positive.
The population includes patients with a cancer diagnosis and/or increased risk of high-burden cancers (NSCLC, breast, colorectal, cervical, prostate) eligible for guideline-recommended biomarker/molecular testing options, and who may be at risk for barriers to access impacted by one or more of the 5 domains of social drivers of health (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety) described in the Screening for Social Drivers of Health quality measure (ID #487).
Improving access to biomarker/molecular testing in cancer promotes health equity by ensuring that all individuals, regardless of their socioeconomic background or geographic location, have equal opportunities to receive accurate and timely diagnoses. The American Cancer Society recognizes racism, poverty, inadequate health insurance coverage, low income, and lack of transportation, housing and affordable nutrition as barriers to a person's ability to prevent, find, treat, and survive cancer.[1] The National Comprehensive Cancer Network (NCCN) workgroup on Measuring and Addressing Health Related Social Needs in Cancer recommends transportation access, housing security, access to food, and financial security as measures that should be assessed for all patients presenting for cancer care. They also emphasize that after screening, healthcare institutions have a responsibility to address patients’ identified unmet needs.[2] This is particularly important amongst underserved populations for whom progress in cancer care has yielded disproportionately low reductions in mortality.[3]
For patients with a cancer diagnosis and/or increased risk of high-burden cancers with guideline-recommended biomarker/molecular testing options (NSCLC, breast, colorectal, cervical, prostate), social drivers of health can be barriers to the completion of testing. These social drivers (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety) are defined in the Screening for Social Drivers of Health quality measure (ID #487), citing 80% of health outcomes as linked to these drivers of health, including socioeconomic, environmental, and behavioral factors. Connecting patients to interventions may minimize the impact of these obstacles and lead to care delivery improvements.
In the United States (US), high-burden cancers–breast, lung and bronchus, prostate, and colorectal–account for almost 50% of all new cancer cases, with lung and bronchus cancer as the most common cause of cancer-related death.[4]The National Cancer Institute (NCI) estimates the number of new cancer cases in 2023 to be 238,340 for lung and bronchus, 153,020 for colon and rectum, 300,590 for breast, 13,960 for cervix uteri, and 288,300 for prostate among both sexes.xviii These high numbers of cancer cases have significant implications for US healthcare costs, which include direct medical costs (the total of all healthcare expenditures) and indirect costs, such as lost wages due to missed work from illness or premature death.[5] In 2020, NCI estimated that cancer-related medical costs in the US were $208.9 billion, and the out-of-pocket costs to patients were $16.2 billion.xx The estimate of national expenditures for cancer care in 2020 was $23.8 billion for lung, $29.8 billion for female breast, $24.3 billion for colorectal, $2.3 billion for cervix uteri, and $22.3 billion for prostate.[6]
Evidence on disparities between cancer prevalence and biomarker/molecular testing rates among different populations demonstrates the need to assess access to biomarker/molecular testing among individuals with NSCLC, breast, colorectal, cervical, and prostate cancers. Among patients diagnosed with advanced NSCLC, individuals who are Black, older adults, or Medicaid-insured, have lower odds of receiving next-generation sequencing (NGS) biomarker testing compared to those who are White, younger adults, or commercially insured.[7] Low socioeconomic status (SES) can also be associated with modestly lower predictive biomarker test utilization and access.[8]Among women with breast cancer, Black women are less likely to undergo BRCA1/2 testing and other multi-panel genetic testing than White women, despite a higher incidence of early-onset and triple-negative breast cancer (both indications for genetic evaluation and testing).[9] While colorectal cancer rates affect non-White populations at disproportionally higher rates, social drivers exacerbate existing genetic susceptibility. Black and Hispanic patients are 26% and 34% less likely, respectively, than White populations to receive colorectal cancer screening recommendations from providers.[10],[11],[12] Among prostate cancer patients, social factors including race and ethnicity contribute to disparities in receiving germline genetic testing.[13]
Additional factors, such as access to reliable transportation may impact a patient’s ability to receive timely and appropriate cancer screenings. A qualitative study on cervical cancer identified transportation and stressors due to poverty as barriers to women accessing cervical cancer screening.li In another study, costs associated with transportation to screening centers, such as gas and parking, have been identified as barriers in screening for lung cancer.[14] Patients with breast cancer also report transportation difficulties as a barrier to screening, where women who identify this as a barrier are 26.4% less likely to receive the recommended screening.[15] Particularly among African American women experiencing poverty, it can be difficult to prioritize breast cancer prevention and screening activities when faced with more pressing needs such as obtaining food, shelter, and safety.[16]For prostate cancer, evidence suggests that several factors including geographic location may create difficulties for patients to access prostate screenings.[17]
The proposed concept aligns with the CMS Framework for Health Equity priority to, “ensure that health equity is a shared goal and that providers and health care organizations have tools they can use to reduce disparities.”[18] It is important to identify cancer patients eligible for biomarker/molecular tests who face barriers to test completion in order to assess and monitor the equitable access to testing, identify and track disparities in care, and connect patients to appropriate interventions, including precision medicine options.
[1] American Cancer Society. Advancing Health Equity – Addressing Cancer Disparities. https://www.cancer.org/about-us/what-we-do/health-equity.html.
[2] National Comprehensive Cancer Network working group on Measuring and Addressing Health Related Social Needs in Cancer. Measuring And Addressing Health-Related Social Needs: Working Group Recommendations. 2023. https://www.nccn.org/docs/default-source/oncology-policy-program/HRSN-WG-Recommendations.pdf.
[3] Alcaraz KI, Wiedt TL, Daniels EC, Yabroff KR, Guerra CE, Wender RC. Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA Cancer J Clin. 2020;70(1):31-46. doi:10.3322/caac.21586
[4] SEER Cancer Statistics Factsheets: Common Cancer Sites. National Cancer Institute. Bethesda, MD. https://seer.cancer.gov/statfacts/html/common.html.
[5] American Cancer Society. Cancer Facts & Figures 2023. Atlanta: American Cancer Society; 2023.
[6] National Cancer Institute. Financial Burden of Cancer Care. https://progressreport.cancer.gov/after/economic_burden.
[7] Presley, C., Soulos, P., Chiang, A., Longtine, J., Adelson, K., Herbst, R., Nussbaum, N., Sorg, R., Abernethy, A., Agarwala, V., & Gross, C. 2017. Disparities in next generation sequencing in a population-based community cohort of patients with advanced non-small cell lung cancer. Journal of Clinical Oncology. 35. 6563-6563. 10.1200/JCO.2017.35.15_suppl.6563.
[8] Norris RP, Dew R, Sharp L, et al. Are there socio-economic inequalities in utilization of predictive biomarker tests and biological and precision therapies for cancer? A systematic review and meta-analysis. BMC Med. 2020;18(1):282. doi:10.1186/s12916-020-01753-0.
[9] Jones, T., McCarthy, A. M., Kim, Y., & Armstrong, K. (2017). Predictors of BRCA1/2 genetic testing among Black women with breast cancer: a population-based study. Cancer medicine, 6(7), 1787–1798. https://doi.org/10.1002/cam4.1120.
[10] Ahmed, N. U., Pelletier, V., Winter, K., & Albatineh, A. N. (2013). Factors explaining racial/ethnic disparities in rates of physician recommendation for colorectal cancer screening. American journal of public health, 103(7), e91–e99. https://doi.org/10.2105/AJPH.2012.301034.
[11] White, P. M., & Itzkowitz, S. H. (2020). Barriers Driving Racial Disparities in Colorectal Cancer Screening in African Americans. Current gastroenterology reports, 22(8), 41. https://doi.org/10.1007/s11894-020-00776-0.
[12] Daley, E., Alio, A., Anstey, E.H., Chandler, R., Dyer, K., Helmy, H. Examining barriers to cervical cancer screening and treatment in Florida through a socio-ecological lens. J Community Health. 2011;36(1):121-131. doi:10.1007/s10900-010-9289-7.
[13] Borno HT, Odisho AY, Gunn CM, Pankowska M, Rider JR. Disparities in precision medicine-Examining germline genetic counseling and testing patterns among men with prostate cancer. Urol Oncol. 2021;39(4):233.e9-233.e14. doi:10.1016/j.urolonc.2020.10.014.
[14] Kota KJ, Ji S, Bover-Manderski MT, Delnevo CD, Steinberg MB. Lung Cancer Screening Knowledge and Perceived Barriers Among Physicians in the United States. JTO Clin Res Rep. 2022;3(7):100331. Published 2022 Apr 22. doi:10.1016/j.jtocrr.2022.100331.
[15] Ponce-Chazarri L, Ponce-Blandón JA, Immordino P, Giordano A, Morales F. Barriers to Breast Cancer-Screening Adherence in Vulnerable Populations. Cancers (Basel). 2023;15(3):604. Published 2023 Jan 18. doi:10.3390/cancers15030604.
[16] Gerend M, and Pai M. Social Determinants of Black-White Disparities in Breast Cancer Mortality: A Review. Cancer Epidemiol Biomarkers Prev 1 November 2008; 17 (11): 2913–2923. https://doi.org/10.1158/1055-9965.EPI-07-0633.
[17] Mumuni S, O'Donnell C, Doody O. The Risk Factors and Screening Uptake for Prostate Cancer: A Scoping Review. Healthcare (Basel). 2023;11(20):2780. Published 2023 Oct 20. doi:10.3390/healthcare11202780.
[18] CMS.gov. 2023. CMS Framework for Health Equity | CMS.
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