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This article is part of a series of case studies on the use of NGS and digital tools to drive precision oncology in the Asia Pacific region. Scroll to the bottom of the article for the full list.
In 2017, the Korean government began to provide selective health insurance coverage so that next-generation sequencing (NGS) could be used to diagnose ten common cancers. Since then, the scope of reimbursement has widened to all solid cancers. Korean hospitals are now thought to be amassing data for over 15,000 NGS cases annually.
NGS tests have therefore become more affordable, but making them a routine part of clinical practice remains a challenge due to the complex infrastructure and specialised expertise needed, and its relatively long turnaround times compared to conventional tests. Prof Jee Hyun Kim, a breast cancer specialist at Seoul National University Bundang Hospital, explains her clinical experiences of NGS, and how she sees it evolving within South Korea’s innovative healthcare ecosystem.
Integrating NGS with molecular tumour boards (MTBs)
While many clinicians with no direct experience of NGS accept that it has many benefits, it is really only when a doctor has first-hand exposure that these benefits have a true impact. For example, NGS can explain a particular prognosis or identify a matched therapy for a specific indication, and physicians who have experienced these benefits will inevitably continue to use it. Prof Kim has seen profoundly positive outcomes in her patients, which has driven her use of NGS in all of her cases, and which she shares with fellow colleagues during MTBs.
Personal clinical experiences aside, Prof Kim hopes that strong levels of evidence will be incorporated into guideline recommendations (such as those from the US National Comprehensive Cancer Network), systematic reviews or meta-analyses to show exactly how NGS-based therapies improve survival, since oncologists rely heavily on such data.
Overcoming sample limitations
Many cancer centres wishing to use NGS must navigate the difficulties of getting sufficient samples for analysis. Prof Kim explains that doctors are often constrained by having to isolate tissue from tough-to-access areas or tissues with low tumor cellularity, or needing to enroll patients in clinical trials that also require such tissues for biopsies, leading to a shortage of tissues for NGS. When this happens, NGS is relegated to the second line; sometimes, a patient must be put into clinical trials so urgently that NGS is impossible.
NGS testing is also reimbursed just once after metastases. It can be done at the time of primary surgery but at higher cost (90% of total cost must be paid by the patient), so not many surgeons are adopting NGS testing at the time of surgery. This can be an obstacle as the oncologist must be careful to choose the right time for NGS testing after metastases develop. With breast cancers, the ER, PR and HER2 status are of prime importance, so to minimise tissue usage, Prof Kim’s pathology department tries to perform immunohistochemistry (IHC) and NGS concurrently. When tissues are still limited, IHC is prioritised over NGS since reimbursements mandate it.
Using digital tools to improve care
With the massive amounts of comprehensive genomic profiling data now available, doctors need a way to match patients to the many clinical trials now in progress across South Korea. Currently, matching is a manual process done by a clinical trial nurse who may not have access to trial databases at other hospitals.
“What we need are digital tools, algorithms and artificial intelligence that can match patients to a clinical trial in a manner that is unified and country-wide, so that fewer resources and less manpower is needed,” says Prof Kim.
In this respect, digital solutions may hold the key to improving a doctor’s day-to-day practice more efficiently and accurately. To get clinically actionable information to doctors quickly, Prof Kim also hopes to see NGS reports combined with hospital-generated pathology reports and interpretations, such as treatments or mechanisms of resistance. At present, this is done manually, and NGS reports that incorporate targeted agents or clinical trial matches would be invaluable when difficult cases are discussed during MTBs, particularly during germline MTBs for hereditary cancers.
Imagining the hospital of the future
In the future, Prof Kim envisions a patient undergoing whole genome analysis at diagnosis, and this information being collected in AI-driven digital platforms that quickly match drugs and clinical trials for the best treatment outcomes. Such clinical decision support tools benefit both patients and physicians.
“Together with our patients,” Prof Kim says, “we’ll be looking into these systems to select options suggested by AI.” As we navigate the range of digital tools and innovative systems that leverage AI, the future of patient care is becoming increasingly integrated with technology, and NGS will be a key platform supporting this healthcare evolution.
To learn more about the evolving role of next-generation sequencing, molecular tumour boards and clinical decision support tools in cancer care, check out some of these other case studies:
