Medicare to cover genetic tests for breast and ovarian cancer

It might not seem so, but this is pretty big news. As you likely know, Medicare tends to set the standards for coverage throughout the medical insurance industry. Virtually all other carriers cover what Medicare covers, and, as the biggest insurer in the United States, Medicare can set a lot of rules. For example, Medicare cannot legally, unfortunately, negotiate drug prices with manufacturers. Their inability to do so is a major reason for our skyrocketing drug prices.

Here is the news: The Centers for Medicare & Medicaid Services (CMS) just released an updated version of its payment rules for diagnostic tests that use next-generation sequencing (NGS). NGS is defined as technology that can determine, in a single experiment, the sequence of a DNA molecule that has more than one million base pairs. I know that this definition leaves me rather baffled, but here is the practical meaning for us non-scientists: one test can provide information about an individual's cancer cells that can have direct implications for treatment.

There is increasing scientific and clinical evidence that using NGS to identify genetic mutations leads to better treatment for patients. Especially valuable in the treatment of inherited cancers (e.g., BRCA1 and BRCA2), doctors can use these results to identify targeted therapies that will likely be helpful for a particular individual. As cancer treatment generally moves further towards individualized treatment choices with more genetic understanding, this becomes really useful.

Any treatment is more useful when it is also affordable, and this decision by Medicare means that more people can benefit from this research. For example, I am currently working with a woman, who carries the BRCA1 mutation, and has had both early breast cancer and ovarian cancer. Her ovarian cancer recently recurred for the second time, so she will soon begin her third round of treatment. The first time, she received the standard care, and the second was also what most women get after a first recurrence. This time, her oncologist ordered next-generation sequencing, and the resulting information suggested several possible targeted therapies.

There are still issues of cost. The therapy that her oncologist thinks is best has, with her good insurance, a $3000 per month co-pay. Not many of us could manage that expense, particularly in an ongoing way. Fortunately, the pharmaceutical company has a program to help with that cost, and the hospital helped her access this resource. Not all pharmaceutical companies are so generous, and the issues of drug cost continue to be a national crisis.

Let us, however, take our small victories where we can find them. This decision by Medicare is an important step in the right direction.