title: Barriers to the use of personalized medicine in breast cancer.
abstract: OBJECTIVE
  Personalized medicine--the use of genomics and molecular diagnostics to direct care decisions--may improve outcomes by more accurately individualizing treatment to patients. Using qualitative research, we explored care delivery barriers to the use of personalized medicine for patients with breast cancer using examples of BRCA and gene expression profile testing.
  
  
  METHODS
  We conducted 51 interviews with multidisciplinary stakeholders in breast cancer care: clinicians (n = 25) from three academic and nine nonacademic organizations, executives (n = 20) from four major private insurers, and patient advocates (n = 6).
  
  
  RESULTS
  Barriers were common to the BRCA and gene expression profile tests and were classified under two categories: poor coordination of tests relative to treatment decisions and reimbursement-related disincentives. Perception of specific barriers varied across groups. Difficulty coordinating diagnostics relative to decisions was the most frequent concern by clinicians (60%), but only 35% of payers and 17% of advocates noted this barrier. For 60% of payers, drug- and procedure-based reimbursement was a significant barrier, but only 40% of clinicians and none of the advocates expressed the same concern. The opinion that patient out-of-pocket expenses are a barrier varied significantly between advocates and clinicians (83% v 20%, P < .007), and advocates and payers (83% v 15%, P < .004). Barriers were reported to result in postponement or avoidance of tests, delayed treatment decisions, and proceeding with decisions before test results.
  
  
  CONCLUSIONS
  Poorly coordinated diagnostic testing and the current oncology reimbursement model are barriers to the use of genomic and molecular diagnostic tests in cancer care.
authors.affiliation: Center for Business Models in Healthcare, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Christine B
authors.initials: CB
authors.lastname: Weldon
authors.forename: Julia R
authors.initials: JR
authors.lastname: Trosman
authors.forename: William J
authors.initials: WJ
authors.lastname: Gradishar
authors.forename: Al B
authors.initials: AB
authors.lastname: Benson
authors.forename: Julian C
authors.initials: JC
authors.lastname: Schink
mesh_terms: D019313:BRCA1 Protein / Q000235:genetics; D024682:BRCA2 Protein / Q000235:genetics; D001943:Breast Neoplasms / Q000175:diagnosis / Q000188:drug therapy / Q000235:genetics; D003657:Decision Making; D003695:Delivery of Health Care; D005260:Female; D020869:Gene Expression Profiling; D006297:Health Services Accessibility; D006801:Humans; D007349:Insurance, Health, Reimbursement; D025202:Molecular Diagnostic Techniques; D057285:Precision Medicine / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
chemical_list: D019313:BRCA1 Protein; C492913:BRCA1 protein, human; D024682:BRCA2 Protein; C551750:BRCA2 protein, human