Liquid biopsy out of reach for lung cancer patients despite clinical demand

Despite the increasing availability of biomarker testing, access to non-invasive circulating tumour DNA (ctDNA) testing remains alarmingly low for lung cancer patients in Australia and New Zealand, with only 12% currently able to benefit from it, according to new data from the Thoracic Oncology Group Australasia (TOGA).

Conventional tissue-based testing is often hindered by logistical and clinical barriers, creating access disparities that negatively impact those residing in remote regions of ANZ. ctDNA testing may play a pivotal role in overcoming these geographic barriers by enabling molecular testing for patients in remote areas with limited access to hospital-based services.

A survey of TOGA members published by A/Professor Malinda Itchins, thoracic medical oncologist at Chris O’Brien Lifehouse, and Dr Deme Karikos, Department of Medical Oncology at Nepean Hospital, revealed that cost continues to be the major barrier to adoption, with 93% of respondents citing it as the primary obstacle. The lack of government funding is stark, only 8% of ctDNA testing is publicly funded. Most testing is instead financed out-of-pocket by patients (62%) or through clinical trials (58%).

Logistical and operational hurdles compound the challenge. Knowledge gaps also persist, with half of the surveyed clinicians indicating limited understanding of ctDNA, and 40% expressing doubts about the reliability of current assays.

Despite these barriers, the appetite for wider ctDNA adoption is clear. If the technology were readily and equitably accessible, 83% of clinicians said they would use it for advanced disease, with 69% expressing interest in adjuvant settings and 62% in neoadjuvant settings.

Currently, just 33% of clinicians use ctDNA testing in practice, primarily in advanced cases. Usage drops to only 3% in neoadjuvant or adjuvant contexts.

Infrastructure limitations persist beyond testing itself. Thirty percent (30%) of clinicians do not have access to Molecular Tumour Boards, and 70% reported that their patients do not receive pre-test counselling about potential germline findings, highlighting ethical and support gaps in current clinical workflows.

The need for clinician education was also evident. Nearly a quarter had received no formal training on ctDNA testing, while another 23% relied solely on self-directed reading. In-person workshops (77%) and virtual workshops (70%) were the most preferred formats for professional development.

Despite limited uptake, clinical confidence in ctDNA testing is growing. Two-thirds (66%) of clinicians said they would feel comfortable prescribing treatment based solely on ctDNA results if tissue biopsy was unavailable.

Over half (55%) reported that patients had inquired about liquid biopsy, yet fewer than 40% discussed it routinely. Of the 62% who had used liquid biopsy results to guide treatment, 78% observed positive patient outcomes.

More recently, the Australian consensus best practice recommendations have reinforced the role of ctDNA as an appropriate alternative to tissue for molecular testing, particularly when tissue samples are inadequate or unavailable, or in situations of clinical urgency where a ctDNA result can be obtained more rapidly than tissue-based testing. This is especially relevant with the recent launch of the Lung Cancer Screening Program.

“Beyond its diagnostic role, ctDNA has emerging applications in monitoring treatment response, detecting minimal residual disease, and identifying resistance mechanisms to targeted therapy. Longitudinal ctDNA analysis enables real-time adaptation of treatment strategies, potentially improving survival outcomes by guiding therapeutic decision-making in a more dynamic and personalised manner,” the authors wrote.

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