Clinical Scorecard: Expanding Molecular Testing Access to Reduce Rural-Urban Disparities in Advanced NSCLC

At a Glance

Key Highlights

• Among 8,259 older Medicare beneficiaries with advanced NSCLC in rural US counties, molecular testing was performed in 35.9% overall from 2014 through 2019.
• Testing uptake increased from 18% by 30 days after diagnosis to 30% by 60 days and 36% by 180 days.
• The article reports that ASCO guidelines advise validated broad multigene testing using tissue and/or blood, with biomarker findings available when treatment decisions are made.
• In a prospective cohort of patients with metastatic NSCLC treated in US community practices from 2020 to 2022, complete guideline-concordant biomarker results were available before therapy in 44.1%.
• The article describes reflex testing, integrated tracking and reporting, regional networks, and plasma genotyping as approaches associated with improving access or timeliness.

Guideline-Based Recommendations

Diagnosis

• Use validated broad multigene testing with tissue and/or blood, as advised by the current ASCO guidelines cited in the article.
• Assess whether comprehensive biomarker results are available before treatment decisions.

Management

• Link tissue acquisition, pathologic diagnosis, genomic characterization, interpretation, and treatment selection across the care pathway.
• Consider reflex molecular testing and integrated ordering, tracking, and reporting systems to reduce reliance on individual clinician ordering and delays across specialties.
• Use regional networks, specimen referral, shared molecular expertise, and appropriately integrated plasma genotyping to connect local care with specialized diagnostic capabilities.

Monitoring & Follow-up

• Assess testing uptake and whether comprehensive molecular results are available before treatment.
• Evaluate whether molecular results are converted into appropriate molecularly informed care.

Risks

• Delayed or incomplete molecular profiling may limit opportunities to identify an appropriate initial therapy.
• Testing uptake in the 2014–2019 rural Medicare cohort was lower among older patients, people with dual Medicare and Medicaid coverage, and patients with squamous histology.
• The article notes that claims data cannot fully capture clinical fitness, treatment eligibility, access to care, or patient preferences.

Patient & Prescribing Data

In the rural Medicare cohort, tested patients were more likely to receive systemic therapy, particularly targeted treatment. The article states that this association likely reflects access to care, clinical fitness, treatment eligibility, and patient preferences, factors that claims data cannot fully capture. In the community-practice cohort, next-generation sequencing was performed in 72.8%, results preceded first-line treatment in 55.6%, and complete guideline-concordant biomarker results were available before therapy in 44.1%.

Clinical Best Practices

• Coordinate specimen acquisition, pathology, molecular testing, result interpretation, and treatment selection.
• Aim to have comprehensive biomarker results available when treatment decisions are made.
• Use systems that track orders and results across specialty transitions.
• Connect local care to centralized testing and expert interpretation through regional networks when appropriate.
• Measure equitable access by both testing uptake and timely availability and use of molecular results.

Related Resources & Content

• Rhinehart and colleagues: rural Medicare beneficiaries with advanced NSCLC, 2014–2019 (reference 1; full citation not provided)
• American Society of Clinical Oncology guidelines on broad multigene testing (reference 2; full citation not provided)
• Prospective cohort of metastatic NSCLC patients in US community practices, 2020–2022 (reference 3; full citation not provided)
• Study of early plasma genotyping in NSCLC (reference 4; full citation not provided)
• Assessment of molecular diagnostic implementation in 20 European countries (reference 5; full citation not provided)
• Network-based centralized genomic profiling and molecular tumor board model across 20 centers in 5 European countries (reference 6; full citation not provided)