Genomic Confidence and Competence


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Patrick M. Boland, MD

Michael J. Hall, MD, MS

As more data are generated on the potential utility of multiplex testing in improving patient access to targeted novel therapeutics and in cancer-related outcomes, ground-breaking research such as that conducted by Gray et al to examine physician practice patterns becomes increasingly important.

—Patrick M. Boland, MD, and Michael J. Hall, MD, MS

As reported in the Journal of Clinical Oncology and reviewed in this issue of The ASCO Post, Stacy W. Gray, MD, AM, a medical oncologist at Dana-Farber Cancer Institute, Boston, and colleagues presented one of the first studies evaluating how academic oncologists perceive the incorporation of a novel multiplex somatic genomic testing platform, OncoMap, into clinical practice as part of the Profile study.1

A total of 160 academic oncologists at Dana-Farber and Brigham and Women’s Hospital completed the survey (an impressive 61% response rate), with the largest group being medical (43%) vs surgical or radiation oncologists. This was a group of physicians with substantial clinical and research experience: Over 70% had practiced oncology for at least 10 years, and 83% had served as a principal investigator for a clinical trial or laboratory research.

The study’s objectives were to describe current use of somatic testing by the participating physicians, to assess their intentions toward incorporation of OncoMap into clinical practice, and to examine how their intentions toward use of the OncoMap test would be impacted by their perceived ability to incorporate genomic medicine into their clinical practice. A novel measure, genomic confidence, was developed by the investigative team as a composite measure of perceived clinical acumen in genomics, including knowledge of, ability to communicate about, and ability to practice genomic medicine.

Variation in ‘Genomic Confidence’

The investigators found that somatic tests were commonly being ordered (for approximately one of every four patients), and that physicians held largely positive attitudes toward the potential impact of ­OncoMap on their practice and patients. Genomic confidence, however, was variable among participants, with a substantial minority reporting feeling “not very” or “not at all” confident in their knowledge (22%), communication skills (14%), and ability to use genomic data to guide treatment (26%).

High genomic confidence was associated with being a researcher or a medical oncologist, and greater use of genomic tests at baseline. In a multivariate model, genomic confidence was a significant predictor of intention to use clinically relevant (tier 1) and potentially actionable (tier 2) mutations to guide treatment and of disagreement with the institutional policy prohibiting disclosure of uncertain variants (tier 3).

Current Practice

Next-generation sequencing technologies allow multiplex genomic testing to be performed on a paraffin-embedded tumor specimen in a clinically relevant time period of 1 to 2 weeks. Coupled with the ongoing robust development of novel targeted cancer therapeutics, the number of putatively clinically actionable alterations detected by these tests will continue to rise.

These advances have the potential to fuel more widespread use of costly multiplex somatic genomic tests by the oncology community, despite uncertain benefits in improving patient outcomes. However, it is currently unclear how oncologists plan to use the information generated by multiplex somatic genomic tests in practice, especially results that may suggest a potential role for experimental therapy or off-label use of an approved agent. While these novel tests may be viewed as the future of personalized medicine, inappropriate testing and subsequent decision-making could in the short term result in increased costs without benefit, use of unproven or potentially harmful therapies, and ultimately greater clinical uncertainty.

Interpretation

Initiated in 2011, the survey developed by Gray et al was conducted at a time when few oncologists would have been expected to have been exposed to multiplex somatic tests in the clinic, which may have limited their perspective when responding to hypothetical questions about making treatment decisions based on test results. In addition, because the survey was conducted prior to the roll-out of OncoMap, physicians’ intentions were themselves hypothetical in nature.

Nonetheless, it is interesting to note that physicians’ intentions to discuss results with patients and to use results in therapeutic decisions had no relation to their phase I trial referral rate, an association one might have expected to see. We are also not informed of what providers actually did with the results of OncoMap and whether their behaviors changed over time during the study—specifically, which results were disclosed to patients and whether testing affected treatment decisions or outcomes.

Additionally, the measurement of genomic confidence was not accompanied by an objective assessment of knowledge. Thus, it remains difficult to understand whether genomic confidence is reflective of true genomic competence, and whether genomic incompetence could lead to inappropriate application of results and overuse of tests by inexperienced and/or ill-informed providers.

Finally, over half of participants surveyed were not medical oncologists, and many of these participants had never ordered a genomic test. Thus, the immediate relevance of intentions toward somatic genomic testing to guide targeted cancer therapeutics in this population is questionable.

Conclusions

As more data are generated on the potential utility of multiplex testing in improving patient access to targeted novel therapeutics and in cancer-related outcomes, ground-breaking research such as that conducted by Gray et al to examine physician practice patterns becomes increasingly important. Follow-up studies examining how providers incorporate the results of multiplex testing into decision-making and clinical practice will be highly informative.

Further, efforts on the part of professional societies like ASCO to develop guidelines on the use of multiplex genomic panels accompanied by educational efforts to address knowledge deficiencies related to this technology will also be critical to build provider confidence in adopting new technologies in clinical practice and to mitigate risks of inappropriate use. ■

Disclosure: Drs. Boland and Hall reported no potential conflicts of interest.

Reference

1. Gray SW, Hicks-Courant K, Cronin A, et al: Physicians’ attitudes about multiplex tumor genomic testing. J Clin Oncol 32:1317-1323, 2014.

 


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