Navigating Clinical Pathways and Improved Sequencing Awareness in mCRC

In his final thoughts, Dr Haumschild outlines opportunities for next-generation sequencing in treatment for metastatic colorectal cancer.

Ryan Haumschild, PharmD, MS, MBA: I talked about pathways, but an emerging area is including genomic testing into pathways. A lot of…providers have created pathways or value-based pathways around treatments. But…they don’t always consider the genomic testing that might be required prior to treatment. An emerging area that a lot of [providers] are getting on board for is sending off that panel in the pretreatment phase—whether it’s next-generation sequencing [NGS] or a genomic test—when we send that scheduling appointment to get those data before we make a treatment decision for a patient. This has been emerging from the lung cancer space, making sure we aren’t treating a patient with an anti–PD-L1 if they needed EGFR, and making sure that we have the right therapy earlier on.

In the metastatic colorectal space, if we can build these genomic testing panels into our pathways to make sure that we’re screening patients before we make a treatment decision, we’re going to make a more accurate decision, it’s going to be more timely, and it’s going to be more consistent across all types of providers. That way we don’t have a community provider or someone who deals with a lot of different solid tumors trying to remember, “Did I screen for this patient? Do I screen? What type of therapy do I need?” If we build that into the pathways, we’ll reflex to next-generation sequencing and then we can leverage those data to make the most informed decision possible for that patient.

Sequencing is going to continue to be something that we have to focus on, because if we don’t leverage the right genomic tests and start the right therapy for the patient, they might not receive the best progression-free survival by treatment. The important piece is to build this into our treatment pathways and order sets and try to hardwire as much as possible. As a payer, I want to make sure I’m approving therapies that are sequenced appropriately if they’re high cost or for unique patient populations. There’s nothing worse than treating a patient early on with a therapy that eliminates the opportunity of subsequent therapies that would push out their progression-free survival or give them the best overall response rate possible.

We like to do this through clinical treatment pathways or, if you’re within an integrated delivery network, building this into the order set. That way we create awareness, where providers will basically go to treat the specific indication or the ICD-10 [International Classification of Diseases, Tenth Revision] code and they’re going to see a certain amount of options for them. Those options are going to be presented in terms of the best practice in the first, second, and third lines. It allows them to naturally sequence after those treatment decisions, and there isn’t a mistake where [they say], “I forgot to screen for this patient I treated with this therapy, and the most appropriate therapy is now no longer an option for this patient. We have more limited treatments left.” Leveraging the education, guidelines, and treatment pathways is one of the best ways to ensure sequencing awareness and compliance with that sequencing across the individual providers.

Many more providers are starting to order next-generation sequencing. It’s something that we want as a payer as well because we want accurate use of medication. We’re looking for data up front to make sure the panels are appropriate. Sometimes people are testing for things in clinical trials for metastatic colorectal cancer, which is great, but it doesn’t have a commercial application at this time.

We’re trying to be thoughtful. We also look to our CMS [Centers for Medicare & Medicaid Services] providers to see what’s on the local coverage determination in terms of reimbursement. But at the end of the day, we want to make sure there’s a threshold. That means that we want to have next-generation sequencing applicable to maybe 80% of the [patients with] metastatic colorectal cancer. We want it to be a highly actionable biomarker as well. That means we need to have definitive data that show that there’s statistical clinical relevance to the biomarker and that a therapeutic decision that can be definitively made based on that information. We also want to make sure it significantly improves the care that patients are provided. Typically, if it checks those boxes, [we will] most likely approve it and encourage those prior to treatment decisions so that we know the most appropriate therapeutic selections are occurring.

Transcript edited for clarity.

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