Genomic Testing Uptake Among Medicare Beneficiaries With Cancer

Genomic testing plays a central role in precision oncology by guiding targeted therapies. Medicare established national coverage determinations (NCDs) for next-generation sequencing (NGS) in 2018 and 2020, yet population-level adoption patterns remain underexamined.

To examine trends and variation in uptake of NGS and non-NGS genomic testing among Medicare beneficiaries with common cancers.

This retrospective cohort study used Medicare fee-for-service beneficiaries aged 66 years or older with claims from January 1, 2016, to December 31, 2023. Beneficiaries with incident lung, breast, colorectal, prostate, or endometrial cancer were identified using the Chronic Conditions Data Warehouse. The data analysis was performed from July 1 to December 31, 2025.

Cancer types, time periods defined by implementation of Medicare NCDs for somatic NGS (March 16, 2018) and germline NGS (January 27, 2020), and patient characteristics (age, race and ethnicity, and geographic location).

Outcomes were receipt of NGS testing (primary) and receipt of any genomic testing and shift to NGS testing among tested beneficiaries (secondary), within 180 days after the first cancer diagnosis claim. Testing rates were described by cancer type and over time. Multivariable logistic regression was used to estimate adjusted probabilities of receiving NGS testing.

Of 391 151 Medicare beneficiaries with cancer (50.6% were female; 31.8% were older than 75 years), 7.0% received non-NGS testing only, 1.2% NGS only, 0.5% both, and 91.4% no genomic testing. NGS adoption increased modestly, whereas overall genomic testing nearly tripled from 6.0% in 2016 to 16.7% in 2023. Uptake varied across cancers; beneficiaries with lung cancer had the highest NGS uptake (1.6% in 2016 vs 9.2% in 2023; P < .001), whereas beneficiaries with breast cancer showed the sharpest increase in non-NGS testing without a parallel increase in NGS. Beneficiaries with colorectal or endometrial cancer showed a moderate increase, whereas beneficiaries with prostate cancer had the lowest uptake for any genomic testing. In adjusted analyses, the largest increase was observed among beneficiaries with lung cancer (5.16 percentage points [95% CI, 4.75-5.56 percentage points]; P < .001) during the post-germline NCD phase.

In this cohort study of Medicare beneficiaries with cancer, genomic testing increased after NCD implementation, with increases driven by NGS among beneficiaries with lung cancer and non-NGS among beneficiaries with breast cancer. Overall, NGS uptake remained modest, highlighting persistent gaps in access to precision oncology testing.