Biomarker Inequities in Lung Cancer: What Patients Need to Know

Lisa Hatfield: 

What are the most significant biomarker disparities that you’ve observed in underserved populations compared to other demographic groups? And if you can speak specifically to things like socioeconomic factors that may contribute to these disparities. 

Dr. Joshua K. Sabari: 

I work in a very interesting system where we have a private hospital, a public hospital, as well as a VA. So it is really interesting to look at the sort of differences in testing rates across the different hospital systems. In the private system, the testing rate is higher. And again, you know, I think there’s a lot of bias here, right? Socioeconomic status, access. You know, patient education and literacy and patients advocating, patients, family members advocating. In the VA system, actually, our testing was at the lowest rate, again, because we’re seeing more of an older patient population, a Caucasian population, a heavy smoking population. This is a population where clinicians make a biased judgment to assume that, you know, folks in front of them in the office will not have an actionable driver alteration.

I think the only way to really overcome this is to really teach our trainees, our patients, our family members, that all you need is lungs to develop lung cancer and all patients should have all molecular testing done or broad molecular testing done. So it doesn’t matter the race, the ethnicity, the age, the sex, we should do reflex testing. It should not be dependent on our own individual bias, biases. So, I think this is an important problem. As much as we talk about it, we still see a 20 to 30 percent gap between Caucasian or white Americans when compared to Black Americans in the United States with broad panel next generation sequencing. So I think definitely more is needed. So a quick action tip or an activation tip here is no matter what your status is clinically, talk to your physician and demand, you know, next generation sequencing. If you have lung cancer, whether you’ve smoked or never smoked, it should be done to identify your genomic alteration.

Lisa Hatfield: 

And, Dr. Manley, I’m wondering if you have anything to add to that in particular, any comments on how to overcome some of these disparities?

Dr. Eugene Manley: 

Yes. I will say that he mentioned some very good points. One thing we know is that Black patients often are diagnosed earlier at earlier ages with more advanced diseases. They often aren’t offered biomarker testing, clinical trials or therapeutics. And then there’s bias in care delivery. So sometimes, you know, there’s…doctors may think, well, okay, they’re Black or they may be on Medicaid, so they won’t be able to pay or follow up. And so this all translates into suboptimal care delivery and actually not receiving the standard of care. And then there are just disparities in biomarkers based on location in the world. So there’s different frequencies in the U.S., Africa, Latin America. And then if you look in underserved communities, we may have other risk factors, you know, combined, you know, with the redlining and the freeways and all the toxic exposures based on where you live. So there’s multiple factors at play. And then the structural systemic racism that induces all this stress that can also drive lung cancer rates in those that don’t smoke and those that do smoke. And so I would say, I guess the activation tip is just really advocate for biomarker testing and try to advocate getting the full panel of at least 10 or 11 biomarkers. Because most often when you’re Black or underserved, you may get only one or three max, but there are about 11 biomarkers now.

Dr. Joshua K. Sabari: 

Yeah, I agree with Dr. Manley here. You know, one thing that we can do as institutions, as guidelines, is to remove the human bias, right? I mean, we know that there is human bias here, you know, whether it be socioeconomic or insurance bias or racial bias. I think if we reflexively test all people with lung cancer, right, the pathologist doesn’t know any clinical information about the patient. I think that could allow us to, you know, give more equitable care to all patients.

Lisa Hatfield: 

Dr. Sabari, how can healthcare systems encourage the routine reassessment or retesting of biomarkers at disease recurrence or progression, especially in the context of evolving treatment options?

Dr. Joshua K. Sabari: 

So I think first and foremost, we have to have better treatments for our patients. And if you have a therapy available for a biomarker-selected patient population, let’s use EGFR, for example, because it’s one of the most common mutations. If we don’t have subsequent therapies available after the front line, re-biopsying or retesting may not be an effective strategy. So we need better treatment options. The way to do that is to develop new therapies through clinical trials. So offering our patients clinical trials at every angle, at every time point, I think is critical, not just for that individual patient in front of you, but for those patients who come after or even before the patient there in the clinic with you. So thinking about the development strategy of novel targeted therapies, that will allow us to move forward with retesting, re-biopsying.

Another thing is cost, right? Oftentimes insurance companies, payers will not pay for a re-biopsy or re-sequencing of a patient’s tumor at the time of progression. And I think this is a systemic problem in our healthcare system in the United States. So I think we as physicians, as teams, need to advocate for our patients to explain to payers why it is critical to gather that information to help match patients to subsequent targeted therapy. So I think the activation tip here is we need to inform patients, we need to inform ourselves, but most importantly, we need to inform payers. And at the same time, we need to be developing novel therapeutic strategies in this setting. All of these will allow us to re-biopsy, re-sequence patients to allow them to have better opportunities for targeted therapies in the later line.