NGS Uptake Rises but Equity Lags Behind Across US Cancer Clinics

While the utilization of next-generation sequencing (NGS) has increased exponentially over the last decade, significant racial and socioeconomic disparities remain in how these diagnostic tools are employed in clinical practice in the United States, a comprehensive cohort study recently published in JAMA Network Open finds.¹

The study, which included over 60,000 patients diagnosed with various types of advanced cancer between January 2018 and December 2022, revealed that while the overall use of NGS has risen within the studied time period, the "genomic divide" has not closed. Specifically, the investigators found that Black race and Hispanic ethnicity, Medicare or Medicaid insurance, and low socioeconomic status were associated with longer waits to undergo NGS across the cancer types examined.

Results: Social Determinants Drive Disparities

Black patients were significantly less likely to receive NGS in advanced non–small cell lung cancer (NSCLC), metastatic colorectal cancer, and metastatic pancreatic cancer (time ratio [TR], 1.4-1.5), while Hispanic patients were significantly less likely to be tested in metastatic breast cancer and metastatic prostate cancer (TR, 1.4-1.6).

NGS receipt also differed significantly depending on insurance coverage. Patients on Medicaid were less likely to receive NGS in prostate cancer (TR, 2.0; 95% CI, 1.2-3.5), while those on Medicare also experienced longer time to testing in breast cancer, NSCLC, colorectal cancer, and pancreatic cancer (TR, 1.3-1.5), compared with patients with commercial health plans. Finally, patients with low socioeconomic status were less likely to receive NGS in breast cancer, colorectal cancer, and NSCLC (TR, 1.3-1.6).

Study Design and Patient Characteristics

The retrospective cohort study analyzed deidentified electronic health record (EHR) data of 63,294 patients with advanced or metastatic cancer from the Flatiron Health database. The cohort included patients with advanced NSCLC (42.7%), metastatic colorectal cancer (21.6%), metastatic breast cancer (19.1%), metastatic pancreatic cancer (9.7%), and metastatic prostate cancer (6.9%) treated across approximately 280 cancer clinics in the United States.

Clinical Implications and Limitations

Limitations of the study include its retrospective design and reliance on EHR-derived data, which may not capture all testing performed outside participating practices. Additionally, residual confounding related to social determinants of health may persist despite adjustment. Nevertheless, the findings highlight persistent structural barriers to precision oncology, even as the volume of emerging genomic technologies expands.

From a clinical standpoint, delayed or absent NGS testing can directly affect treatment selection. Many first- and subsequent-line therapies across tumor types—including targeted therapies and certain immunotherapy strategies—depend on timely identification of actionable genomic alterations. Even modest delays, as reflected by the observed time ratios, may translate into missed opportunities to initiate optimal therapy, particularly in aggressive malignancies such as pancreatic or lung cancer.

The data thus point to several actionable gaps that the authors suggest could be addressed through targeted health policy interventions. Insurance design appears to be a key driver: patients covered by Medicaid experienced both lower rates of testing and the longest delays, suggesting barriers related to prior authorization requirements, reimbursement limitations, and variability in coverage policies across states. As such, improving equity in NGS utilization will require coordinated efforts across stakeholders, including payers, health systems, and policymakers.

“Addressing these obstacles through health care policies that enhance access to genomic testing, increase awareness, and promote education on level-1 evidence is crucial for optimizing the benefits of precision oncology,” the authors stated.

REFERENCES

1. Hage Chehade C, Ozay ZI, Jo Y, et al. Trends and disparities in the use of next-generation sequencing in patients with cancer in the United States. JAMA Network Open. 2026;9(4):e265585. doi:10.1001/jamanetworkopen.2026.5585