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As cancer costs rise, why employee benefits plans should include biomarker testing

Patricia J. Goldsmith, CancerCare
Patricia J. Goldsmith
Patricia J. Goldsmith is CEO of CancerCare. A frequent speaker at national meetings and symposia, Goldsmith was named in 2021 to Forbes Magazine’s 50 Over 50 Vision List, honoring women making an impact on society and culture. In 2022, CancerCare published a free Toolkit that helps inform the benefits package design and decision-making process and offers key considerations when plans include utilization management.

Every employer is aware of the rising costs of healthcare. Striking the right balance between organizational costs and adequate healthcare coverage for employees gets more difficult each year. This challenge has been amplified in part by delays in routine screenings and care over the course of the COVID pandemic.

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And even though cancer deaths have decreased by 27% since 2001, the country is now seeing a significant increase in late-stage cancers likely due to those pandemic-related delays. Cancer is an expensive disease to treat—and even more so when it’s diagnosed at a later stage. In fact, a 2022 survey of large employers by the nonprofit Business Group on Health found that cancer had become the top driver of those companies’ healthcare costs.

While this news seems gloomy, there are important lessons to be learned from the BGH data as well as the multiple studies regarding improvements in cancer outcomes over the past two decades. The bottom line? Cancer treatment is most effective when the cancer is detected early, and the patient receives the most effective treatment for their cancer as soon as possible.

This means employers need to be encouraging and covering regular screenings for cancer such as mammograms, colonoscopies and lung cancer scans, and ensuring that health plans fully cover modern diagnostic tools such as comprehensive biomarker testing.

These approaches can help detect cancer early, save lives, avoid unnecessary and ineffective treatments and conserve healthcare dollars.

What are cancer biomarkers and biomarker testing? 

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The sequencing of the human genome has led to enormous advances in the ways that diseases are diagnosed and treated. Cancer biomarkers are specific gene mutations in a cancer that may indicate important characteristics of the cancer, including how it may grow and spread, its sub-type, and if or how well the patient may respond to a particular treatment.

Over the past two decades, researchers have used genomic sequencing to identify cancer biomarkers and develop treatments that precisely target those biomarkers. These advances have literally changed the way that cancer is treated, leading to significantly more effective cancer treatment with fewer side effects for patients. Precision cancer treatments include targeted therapies, which are aimed at specific traits of cancer cells, and biomarker-guided immunotherapy that helps a patient’s immune system fight their cancer.

To date, researchers have developed 55 biomarker-directed treatments for 24 types of cancer, including common cancers like lung, breast, colorectal and melanoma, as well as rare cancers such as bile duct. This list is rapidly growing as biomarker testing is required or recommended for the use of most of the cancer drugs introduced since 2017, a trend that will likely continue.

See also: Late-stage cancer is rising; here’s why that’s HR’s latest challenge

There are many different types of biomarker tests designed to identify the specific characteristics of a patient’s cancer, with the goal of identifying the best treatment. Cancer patients need different types of tests at different times, depending on the type of cancer they have, its stage, and other factors.

Importantly, by identifying the most effective treatment options for cancer patients, biomarker testing can help reduce the overall cost of cancer treatment by eliminating unnecessary ineffective treatments.

Barriers to biomarker testing

Unfortunately, despite the overwhelming evidence that biomarker testing and biomarker-directed therapy improve outcomes for patients, most private insurance plans do not adequately cover biomarker testing. Two-thirds  of oncologists surveyed in 2021 reported that their patients face significant or moderate insurance barriers in accessing biomarker testing.

Some insurers only cover single-panel tests, or limit testing to certain types and stages of cancer. Others consider newer tests as experimental, even though they have been through rigorous testing protocols and are recommended as the standard of care by professional associations such as the National Comprehensive Cancer Network, the American Association of Clinical Oncology and the College of American Pathologists. Some plans will only cover a single instance of biomarker testing, despite evidence that repeated testing at different stages of treatment is clinically needed. And even when biomarker testing is covered, many insurance plans impose significant out-of-pocket cost sharing by patients, or require prior authorization, which can significantly delay the start of effective treatment.

Lack of access to biomarker testing and coverage barriers challenge many patients but have an even greater impact on racial and ethnic minorities and socioeconomically disadvantaged patients. In the specific case of the most common lung cancer, for example, despite the availability of extremely effective biomarker-directed therapies, up to one-fourth of these patients don’t receive the testing to determine whether a specific available treatment might work for them.

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This may be why there is a huge effort at the state level to pass laws requiring health plans to cover biomarker testing and limiting the use of prior authorization on biomarker testing. As of March, 11 states have passed biomarker coverage laws and another 17 have bills under consideration in the current legislative session.

A better way

As companies talk to their benefits consultants or insurers, it’s wise to choose plans that will get patients the most effective treatment as soon as possible after diagnosis, regardless of the illness.

In the case of cancer, insurance plans should provide access to approved and recommended biomarker testing at diagnosis, a transition in treatment plan, recurrence and any time other testing shows significant changs in the cancer or its impact on the patient. Coverage should follow guideline recommendations and FDA-approved uses, be comprehensive and avoid barriers such as prior authorization, referral restrictions, burdensome cost-sharing and denials that are likely to be overturned on appeal.

CancerCare has created a free toolkit for employers to help them design coverage that includes biomarker testing, so that their valued employees get the best, most effective, and most cost-efficient care possible if they are diagnosed with cancer.