Barriers to Molecular Testing in Metastatic Urothelial Cancer

A discussion on molecular testing in the community and recommendations that can address barriers.

Arlene O. Siefker-Radtke, MD: I’d like to ask you Scott, knowing you and I both work in the academic setting, and you’ve mentioned working with urologists who are also testing for these mutations. Have you seen in the community a lot of urologists or other medical oncologists ordering this testing in patients before they refer them to your clinic?

Scott T. Tagawa, MD, MS, FACP: I see it and I do see it more often than before, but it’s still overall the minority. I would say, not to disparage urologists particularly, but I’d say especially with urologists compared to oncologists. Most oncologists who will treat advanced urothelial carcinoma treat other types of cancers too. And for this aspect, let’s say non–small cell lung cancer, it’s part of the standard to do testing. We may be looking for different genes, but it is much more embedded in the medical oncology fields—maybe not for 100% of tumors but for many tumor types, the majority—doing testing, so I do see it more commonly there. I see metastatic biopsies much less commonly, so it’s finding whatever primary tissue was there. And I agree with you, if there was a nonmuscle-invasive TURBT [transurethral resection of a bladder tumor] and a muscle-invasive cystectomy specimen, go for the muscle-invasive. It’s much more common that it’ll be whatever is available rather than a metastatic biopsy, and that matters in certain situations. For instance, as you mentioned, PD-L1, that may change with time. Although that is a less useful test nowadays than it was before.

But as I said before, I would always say that some testing is better than no testing. At least we can start with that information, and then if it were me or a family member, it’s no different than I would advocate for a patient that I’m not related to, sitting in front of me. Particularly as disease advances and we are looking for more options, it’s even more important to do additional testing, whether it’s tissue or blood or both, if there’s no testing done, then for sure, but if it was just their primary specimen from years ago.

Transcript edited for clarity.

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