Trends and Disparities in the Use of Next-Generation Sequencing in Patients With Cancer in the United States.

Importance: Life-prolonging targeted therapies are available based on alterations detected on next-generation sequencing (NGS); however, clinical data on NGS adoption are limited. Objective: To assess trends and disparities in NGS among patients with common advanced or metastatic cancers. Design, Setting, and Participants: Retrospective cohort study of 280 US-based cancer clinics (approximately 800 sites of care) using electronic health record-derived deidentified information from Flatiron Health Research Database. Participants were patients diagnosed with metastatic breast (mBC), metastatic prostate (mPC), advanced non-small cell lung (aNSCLC), metastatic colorectal (mCRC), and metastatic pancreatic (mPanC) cancers between January 1, 2018, and December 30, 2022. Data were analyzed from April 2024 to December 2025. Main Outcomes and Measures: Time to NGS from diagnosis, considering death as competing risk. Multivariable cause-specific Weibull accelerated failure time models evaluated association of socioeconomic status (SES), race and ethnicity, insurance type, practice setting, and sex with time to NGS. Results: Overall, 63 294 patients with advanced or metastatic cancer who underwent NGS were eligible and included: 12 085 with mBC (19.1%), 4341 with mPC (6.9%), 27 050 with aNSCLC (42.7%), 13 648 with mCRC (21.6%), and 6170 with mPanC (9.7%). The median (IQR) age was 68 (60-76) years and 33 975 patients (53.7%) were female; 1703 (2.7%) were Asian, 6551 (10.0%) were Black, 3772 (6.0%) were Hispanic, 38 318 (61.0%) were White, and 12 950 (20.3%) were other races and ethnicities. One-year cumulative incidence of NGS increased in patients diagnosed in 2022 compared with 2018 across all cancer types. Significantly longer time to NGS (time ratio [TR]) was observed in those with mBC with low SES (1, lowest: TR, 1.3; 95% CI, 1.1-1.6; 2: TR, 1.3; 95% CI, 1.1-1.5), those who were Hispanic (TR, 1.4; 95% CI, 1.2-1.7), or those on Medicare (TR, 1.5; 95% CI, 1.3-1.8). Longer TRs were also observed in those with mPC and Hispanic ethnicity (TR, 1.6; 95% CI, 1.3-2.1), those on Medicaid (TR, 2.0; 95% CI, 1.2-3.5), those with aNSCLC with low SES (1, lowest: TR, 1.6; 95% CI, 1.5-1.8; 2: TR, 1.4; 95% CI, 1.3-1.6; 3: TR, 1.2; 95% CI, 1.1-1.3), Black patients (TR, 1.4; 95% CI, 1.2-1.5), and those on Medicare (TR, 1.4; 95% CI, 1.3-1.5). For mCRC, TRs were elevated for those with low SES (1, lowest: TR, 1.3; 95% CI, 1.1-1.5; 2: TR, 1.1; 95% CI, 1.0-1.3), Black patients (TR, 1.4; 95% CI, 1.2-1.6), Hispanic patients (TR, 1.4; 95% CI, 1.2-1.6), and those on Medicare (TR, 1.4; 95% CI, 1.3-1.6). Elevated TRs were also observed for mPanC in Black patients (TR, 1.5; 95% CI, 1.2-1.8) and those on Medicare (TR, 1.3; 95% CI, 1.1-1.5). Conclusions and Relevance: In this cohort study, most patients with advanced or metastatic cancers did not undergo tumor genomic testing. Low SES, Black race or Hispanic ethnicity, and Medicaid or Medicare coverage were associated with significantly longer time to NGS, highlighting the need for awareness and health care policies aimed at bridging these gaps.