Testing Is Key to Equitable Access When Selecting Targeted and Immuno-Oncology Therapies in NSCLC

Having a strategy to secure genomic testing for uninsured or underinsured patients with non–small cell lung cancer (NSCLC) is key to ensuring equitable access to the most cutting-edge therapies, according to panelists who took part in “Value-Driven Precision: Advancing Equitable Access to Targeted and Immuno-Oncology Therapies in NSCLC.” The discussion concluded the Institute for Value-Based Medicine event held on August 14, 2025, in Chicago, Illinois.

Moderator Frank Weinberg, MD, PhD, an assistant professor in the Department of Medicine, Division of Hematology and Oncology, who leads the lung cancer program at the University of Illinois Chicago (UIC), was joined by UIC colleague Ryan Nguyen, DO, also an assistant professor in the Department of Medicine, Division of Hematology and Oncology; and Nan Sethakorn, MD, PhD, an assistant professor of hematology/oncology and cancer biology at Loyola University Chicago Stritch School of Medicine, in a discussion of the various tactics for gaining equitable care. Weinberg discussed securing care through contracts with commercial partners, whereas Nguyen said he works through financial assistance programs.

“I tell patients, ‘I don’t think I’ve had a patient pay anything out of pocket for molecular testing so far.’ But I’m very acutely aware that that’s not a financially stable, sustainable model over the long term,” Nguyen said.

Nguyen noted that the hospital in the UI Health system where he works uses a different vendor than the one where Weinberg practices, and these differences mean that Nguyen faces limits on how much testing he can order for uninsured patients. This is a challenge, he said, as the most cutting-edge NSCLC regimens may recommend more frequent testing.

“I also worry a lot about the financial toxicity,” he said, especially if the patient needs both additional liquid and solid tumor testing. “I’ve had a number of patients…who will come to me and tell me that they’ve gotten a letter from their insurance company that specifically is denying molecular testing. There’s anxiety that comes with that. I haven’t, thankfully, heard of a patient who’s got a bill for it, but the anxiety of a potential bill for a multithousand-dollar test is always kind of hanging over my patient’s head.”

Weinberg then asked for comments on the emergence of minimal residual disease (MRD) and circulating tumor DNA (ctDNA) tests, which detect the presence of cancer cells and help guide treatment decision-making. Nguyen said ctDNA is especially useful in treatment decisions when tumor tissue is no longer available.

“I love the concept of MRD testing,” Sethakorn said, although she said questions remain on how to proceed if tests indicate cancer is at an early stage. Like others, she is waiting for even more data to add to recent studies on adjuvant and neoadjuvant therapy, including the phase 3 CheckMate 816 trial (NCT02998528), involving neoadjuvant chemoimmunotherapy,¹ and the phase 3 AEGEAN trial (NCT03800134), involving perioperative durvalumab (Imfinzi; AstraZeneca) in patients with nonresectable NSCLC.² Sethakorn also discussed the phase 3 NeoADAURA trial (NCT04351555),³ which is investigating adjuvant osimertinib (Tagrisso; AstraZeneca) following resection in EGFR-mutated
lung cancer.

“An interesting piece of data showed us that there were quite a few patients who were…actually MRD negative after the surgery,” Sethakorn said. But she noted that a number of patients who were MRD negative following surgery and received the placebo then quickly changed status, which gave her pause.
“Is this the right test?” asked Sethakorn, who added she would like to see more clinical trials that stratify patients based on newer, more sensitive MRD tests in the future.

Postoperative ctDNA-positive test results can predict cancer recurrence, “and often precedes radiographic relapse,” Weinberg said, citing results of early-stage studies. “Some centers use postoperative, ctDNA [testing] to inform the intensity of adjuvant therapy or surveillance frequency. That’s not yet standard of care.”
Weinberg concluded, “There’s this trial-guided escalation [or] de-escalation, where, basically, you’re using ctDNA, especially in the perioperative space, to make your decision: Does someone need to go on to adjuvant treatment after surgery? These are the areas where we’re integrating, especially into the early stage.”

References
1. Mayenga M, Pedroso AR, Ferreira M, Gille T, Pereira Catarata MJ, Duchemann B. The CheckMate 816 trial: a milestone in neoadjuvant chemoimmunotherapy of nonsmall cell lung cancer. Breathe (Sheff). 2024;20(3):240044. doi:10.1183/20734735.0044-2024
2. Heymach JV, Harpole D, Mitsudomi T, et al; AEGEAN investigators. Perioperative durvalumab for resectable non-small-cell lung cancer. N Engl J Med. 2023;389(18):1672-1684. doi:10.1056/NEJMoa2304875
3. He J, Tsuboi M, Weder W, et al; NeoADAURA investigators. Neoadjuvant osimertinib for resectable EGFR-mutated non–small cell lung cancer. J Clin Oncol. 2025;43(26):2875-2887. doi:10.1200/JCO-25-00883