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Published on: September 8, 2023
Disparities in Epidermal Growth Factor Receptor Mutation Testing for Non-Small Cell Lung Cancer: Insights From the
Akul Arora1, Amisha Paul2, Max Barris3
1Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio; Case Western Reserve University School Of Medicine, Cleveland, Ohio.
Despite guidelines, most non-small cell lung cancer (NSCLC) patients lacked epidermal growth factor receptor (EGFR) testing, revealing significant disparities by race, income, and facility type. Facility-level factors largely explain testing variations, highlighting the need for standardized testing to ensure equitable precision oncology.
Area of Science:
- Oncology
- Genomics
- Health Services Research
Background:
- Epidermal growth factor receptor (EGFR) mutation testing is crucial for managing non-small cell lung cancer (NSCLC).
- National Comprehensive Cancer Network guidelines have recommended EGFR testing since 2011, with adjuvant osimertinib approved in December 2020.
- Real-world implementation and disparities in EGFR testing across different stages and practice settings remain understudied.
Purpose of the Study:
- To quantify EGFR testing rates in non-small cell lung cancer (NSCLC) patients.
- To assess patient- and facility-level disparities in EGFR testing.
- To analyze testing patterns in the initial years following expanded guideline recommendations for resectable disease.
Main Methods:
- Analysis of the 2022 National Cancer Database (NCDB) for NSCLC patients diagnosed in 2021-2022.
- Categorization of EGFR testing status: tested, not tested, or missing.
- Multivariable logistic regression with facility-level random effects to identify predictors of testing, including fixed effects models for sensitivity analysis and stage-stratified analyses.
Main Results:
- Only 36.9% of 144,017 eligible NSCLC patients had reported EGFR testing.
- Testing rates varied significantly by race/ethnicity, income, insurance, sex, comorbidity, geography, and facility type.
- Facility-level factors accounted for the majority of unexplained variation in testing (intraclass correlation coefficient = 0.94).
- Disparities drivers differed by disease stage: geographic barriers in early-stage, socioeconomic factors in locally advanced, and institutional factors in metastatic disease.
Conclusions:
- The majority of NSCLC patients lacked reported EGFR testing, with significant disparities persisting.
- Facility-level variations and stage-specific determinants underscore the complexity of addressing testing inequities.
- Standardized reflex testing, provider education, payer incentives, and infrastructure investment are essential for equitable precision oncology.