Findings From a Multicancer Early Detection Survey

J Clin Pathways. 2023;9(2):E1-E2.

Multicancer early detection (MCED) tests are designed to identify the presence of cancer for multiple cancer types with a single blood-based test so that the disease can be diagnosed in early, more treatable stages. In combination with existing standard-of-care recommendations, MCED tests hold the potential to revolutionize cancer screening, in part by detecting cancers for which no routine screening exists—including liver, ovarian, and pancreatic cancers—as well as detecting cancers earlier in the disease trajectory.

In 2022, the Association of Community Cancer Centers (ACCC) conducted a comprehensive survey and a series of four focus groups with ACCC members to explore attitudes, beliefs, and concerns related to MCED and the capacity to integrate this testing into cancer programs and practices. The survey was conducted between June 2022 and August 2022 and included 108 providers representing diverse multidisci­plinary roles from institutions in 34 states. The focus groups, conducted in October and November 2022, included 27 providers and aimed to collect more in-depth, qualitative data about the perceptions, attitudes, and beliefs around MCED testing and to assess its potential impact. Below, you can read what ACCC found.

Members were asked about the landscape of cancer preven­tion, screening, and surveillance services, which set the stage to explore how MCED testing could integrate into services already being provided. Most survey respondents (96%) con­firmed that their program offered cancer screening services as described below:

• Screening and surveillance of cancer survivors who have completed treatment: 92%;
• Diagnostic services to confirm cancer, such as laboratory tests (eg, complete blood count or urine) and/or imaging tests (eg, positron emission tomography, magnetic resonance imaging [MRI], computed tomography [CT], ultrasound, x-ray, or tissue biopsy): 91%;
• Screening for new primary cancers (eg, mammography, colonoscopy, Papanicolaou test, low-dose CT) 87%; and
• Genetic counseling and testing for hereditary cancers: 87%.

 ACCC members also suggested strategies to support ad­herence to screening and/or increase screening, including:

• Building trust among health care organizations and communities through faith- and community-based partnerships, community health workers, and direct outreach at community gatherings;
• Increasing accessibility through mobile screening;
• Linking underutilized screening programs with more successful screening programs;
• Creating opportunities for family screenings;
• Leveraging patient navigators to increase completion of screening; and
• Reviewing electronic health record data, contacting patients who are overdue for a screening, and scheduling the screening at that time.

Respondents felt that these strategies could be leveraged and/or adapted as MCED testing becomes more widely available in community-based settings.

Findings from the survey and focus group data discovered varying degrees of awareness of MCED testing, ranging from very aware to not aware at all. The use of this test­ing in practice was limited, and only a handful of ACCC members indicated that their cancer program or practice was participating in an MCED clinical trial. Since MCED testing is an emerging screening tool, nearly one-third of respondents indicated that they were unsure or did not have enough information to answer questions about their aware­ness, confidence, attitudes, and beliefs related to this testing. This finding underscores the clear need for education as well as the need to build awareness around MCED.

Of the respondents who were comfortable enough to answer questions about their awareness, confidence, attitudes, and beliefs related to this testing, the majority (63%) indicated that they believed MCED testing will improve outcomes for patients diagnosed with cancer. About half (51%) believed that MCED testing will improve existing disparities in cancer screening. Focus group participants also noted the potential benefits of using MCED as a screening tool, which included the acceptability of a blood test, the ability to screen for can­cers where there is currently no screening tool available, and the hope of downstaging more cancers.

Although MCED testing offers the possibility of catch­ing cancer early on, ACCC members expressed concerns surrounding accessibility of testing. They discussed the need to proactively address the risk of widening disparities to en­sure that all individuals can access and benefit from these advances, rather than only individuals with higher incomes or more resources.

More than half of survey respondents (57%) indicated MCED testing would fit within existing processes used to care for pa­tients. This finding suggests that many respondents feel they have infrastructure and resources that could support MCED testing. However, most focus group participants also noted the need for Food and Drug Administration (FDA) approval and clear clinical guidelines to support the implementation of this testing into practice.

In addition to guidelines and/or workflows, focus group participants had a more in-depth discussion about who should conduct MCED testing as part of primary screening. While there was a lack of clear consensus from survey partici­pants on whether this testing should be conducted at a cancer program and/or by an oncology care team, most indicated that primary care providers should conduct MCED tests.

Focus group participants agreed there is a role for the field of oncology around MCED tests, particularly in sup­porting the development of patient and provider education and advising on the development of workflows. Participants also discussed the importance of transdisciplinary and multi­disciplinary health care approaches as screening continues to evolve, and the need to involve community health workers and health communication experts to incorporate evidence-based health literacy and equity strategies to support educat­ing the public about MCED.

ACCC members were asked to provide open-ended feedback regarding key considerations to successful implementation of MCED testing. Common themes that emerged were clinical implications, cost and coverage, and patient support services.

Clinical implications related to patient care, clinical work­flow, and integration of the test into clinical practice were the most frequently cited considerations among survey partici­pants. Respondents also indicated the need for a coordinated plan throughout the entire testing process. Other consider­ations included management of false positives, unnecessary procedures, overdiagnosis, and lead time bias. ACCC mem­bers called for more evidence on clinical utility and effect on patient outcomes, and subsequent public health policy inter­ventions to fully support MCED rollout, including FDA ap­proval and Medicare coverage. There were also concerns that if testing is rolled out without clear clinical guidelines, it will be implemented with varying degrees of fidelity and may cause confusion in the interpretation of results and follow-up diagnostic process.

Cost was a frequently cited implementation consideration for both the health care system and patients, including the cost of the actual test and potential financial toxicity from follow-up diagnostics, such as high out-of-pocket costs for MRI screenings for individuals who are at high risk for breast cancer. Participants noted that some state-level policies are being enacted to reduce out-of-pocket costs. Yet, as MCED testing moves forward, policies at both a federal and state level will be key to reduce financial toxicity for patients and ensure testing is accessible to all, while also balancing the cost to the health care system.

ACCC members noted the need for potential policies to protect patients’ rights, similar to the Genetic Informa­tion Nondiscrimination Act of 2008. Members were con­cerned that if an indolent cancer was found through testing and there was no treatment available, it could impact patients’ health and life insurance coverage.

There was a resounding call from ACCC members for patient support services to be in place for the successful roll­out of MCED testing. Support services included the need for education, particularly around potential out-of-pocket diagnostic costs that may not be covered because of a posi­tive MCED test compared to coverage for standard-of-care screenings; appropriate tools and resources to support shared decision-making; resources to manage patient anxiety during the waiting period or following a positive result; and peer-to-peer support.