Genomic testing nearly triples among Medicare patients, but NGS use remains low

The share of Medicare beneficiaries with cancer who received genomic testing nearly tripled between 2016 and 2023, a cohort study published in JAMA Network Open found. However, adoption of next-generation sequencing (NGS), which is a more comprehensive and increasingly guideline-preferred form of tumor profiling, remained low and uneven across cancer types.

Researchers from Georgetown University analyzed Medicare fee-for-service claims for 391,151 beneficiaries aged 66 and older who were diagnosed with lung, breast, colorectal, prostate or endometrial cancer between 2016 and 2023. The study tracked whether patients received genomic testing (NGS, non-NGS, both or neither) within 180 days of their first cancer diagnosis claim and examined how testing patterns shifted around two Medicare national coverage determinations (NCDs): one covering somatic NGS testing in March 2018 and one extending coverage to germline NGS in January 2020.

“The importance of expanding genomic testing is underscored by the increasing number of FDA-approved therapies that require genomic results for treatment eligibility,” the authors wrote. “Demand is likely to increase as the evidence base for NGS continues to expand.”

Coverage policy tied to broader testing gains

Before the NCDs, coverage decisions for genomic testing were made regionally by individual Medicare administrative contractors, creating inconsistent access across the country. The 2018 and 2020 determinations established uniform national coverage for FDA-approved NGS testing, somatic and germline, when ordered by a treating physician for patients who had not previously been tested.

That shift coincided with substantial growth in testing overall: Any genomic testing use climbed from 6.0% of beneficiaries in 2016 to 16.7% in 2023, with the steepest increase occurring after 2021. Still, 91.4% of patients in the cohort received no genomic testing at all within the six-month window the researchers examined, and NGS specifically was used much less often than non-NGS testing. Just 1.2% of beneficiaries received NGS only, and another 0.5% received both NGS and non-NGS testing, compared with 7.0% who received non-NGS testing exclusively.

Lung cancer drives NGS uptake; breast cancer testing grows without it

Uptake varied widely by cancer type. Beneficiaries with lung cancer had the highest and fastest-growing NGS-only testing rate, rising from 1.6% in 2016 to 9.2% in 2023, which the study's adjusted models linked to a 5.16-percentage-point increase in the probability of NGS testing during the post-germline NCD period alone.

“Heterogeneity in NGS testing uptake across cancer types likely reflects clinical contexts, evidence strength, and guideline recommendations,” the authors wrote. “Patients with lung cancer consistently had the highest testing rates, likely reflecting the availability of multiple actionable targets and clear national guidelines recommending comprehensive somatic NGS for non–small cell lung cancer. However, uptake remained well below guideline expectations.”

Breast cancer followed a different trajectory. By 2023, beneficiaries with breast cancer had the highest rate of any genomic testing among the five cancer types studied, at 28.6%, overtaking lung cancer. But that growth was driven almost entirely by non-NGS testing; NGS-only use in breast cancer stayed below 1% throughout the study period. Colorectal and endometrial cancers showed moderate, more gradual increases in both any testing and NGS specifically, while prostate cancer had the lowest testing rates overall, with any genomic testing use staying below roughly 5% across the study years.

“These differences likely reflect the relatively lower clinical utility of broad NGS in cancers with fewer targetable alterations or FDA-approved therapies,” the authors explained. “We also found the 2020 NCD for germline NGS was associated with greater increases for breast and prostate cancers relative to colorectal cancer, highlighting the combined influence of coverage policy and guideline timing on adoption patterns.”

Persistent gaps despite national coverage

While the national coverage determinations were associated with meaningful gains in testing across nearly all five cancer types, testing overall remained far short of guideline-recommended levels, particularly for NGS, the study concluded.

The authors noted that testing rates in the Medicare population lag those reported in younger, commercially insured populations in prior research, which may partly reflect differences in clinical presentation and treatment patterns among older adults. They also did not find significant differences in NGS uptake by sex or race and ethnicity, which contrasts some earlier studies of germline testing. This may reflect broader Medicare coverage or limitations inherent to claims data, the authors explained.

The study's authors did not have access to detailed clinical information such as tumor stage or biomarker status, limiting their ability to assess whether all untested patients in the cohort were in fact eligible for testing under coverage criteria.

“Although modeling studies have evaluated the cost-effectiveness of NGS, its economic value in clinical practice from a nationally representative sample remains uncertain and likely differs across cancer types depending on the range of available therapies requiring tumor profiling,” the authors wrote. “Further efforts are needed to assess the value of expanding NGS adoption, to investigate whether additional acceleration of uptake is warranted, and to address geographic inequities and patient-level barriers to testing.”