Texas lawmakers push for insurers to cover biomarker testing for cancer

When Rebecca Muñoz was diagnosed at age 29 with breast cancer in 2017, it was a confusing time. She discovered her lump by accident. She knew nothing about breast cancer treatments and biomarker testing or anything that could improve her outcome.

"It's almost like a bomb dropped on you," she said. "I thought it was a death sentence."

She went through six rounds of chemotherapy, a double mastectomy and then immunotherapy before she became cancer-free.

Muñoz was lucky. The biopsy of her tumor was sent out for biomarker testing, which looks at the genes, proteins and other characteristics of that tumor to allow doctors to make more individualized and effective treatment decisions.

Those biomarkers revealed that she had an aggressive form of breast cancer with the HER2 protein. She would need aggressive treatment.

Muñoz didn't have to do anything. Her doctors just did it for her. She had Blue Cross and Blue Shield insurance through her husband's federal job and believes the testing was covered under that plan.

Not everyone with cancer is so lucky. Insurance companies including Medicaid and Medicare do not have to cover biomarker testing in Texas. The American Cancer Society notes that access to biomarker testing in Texas often depends on your insurance, whether you live in a rural or urban area, if you are seen at a nonacademic hospital or one attached to a medical school, and your race.

"It's amazing to witness the standard of care change," said Dr. Debra Patt, a breast cancer specialist and executive vice president of Texas Oncology who focuses on health care policy and strategic initiatives. "People without insurance to cover the biomarker testing, though, don't get to experience that standard of care. The most vulnerable patients are not getting it."

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How could state law change this?

This session the Texas Legislature is considering two bills that would require that biomarker testing be covered by insurance, including government-based plans such as Medicaid and the Children's Health Insurance Program.

Senate Bill 989 is from Sen. Joan Huffman, R-Houston, and House Bill 3188 is from Rep. Greg Bonnen, R-Friendswood. They are identical and say, "A health benefit plan must provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition to guide treatment when the test is supported by medical and scientific evidence."

Some of the things that count as evidence are the Food and Drug Administration requiring biomarker testing to be done before receiving a medication or a test, coverage being approved by the Centers for Medicare and Medicaid Services, nationally recognized clinical practice guidelines, and consensus statements from experts.

Texas would join Arizona, Louisiana, Illinois and Rhode Island in having this law; in 16 other states, legislation has been introduced but not passed.

How much does biomarker testing cost?

Patt said the testing costs about $1,000 out of pocket.

"The costs have come down," she said, noting that it used to be $5,000 several years ago.

Some of the testing companies have charitable programs for people without adequate insurance.

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Why is biomarker testing important?

"Cancer care has evolved tremendously," Patt said. She thinks back to 2006, when all nonsmall cell lung cancer patients got chemo. Now more than 50% have some molecular target therapy, she said.

The American Cancer Society gives these facts: 60% of oncology drugs launched in the past five years need biomarker testing for a patient to use them, and more than half of cancer clinical trials now involve biomarkers.

Patt thinks of cancers as having locks and keys. While there are many different keys — treatments — they might not be effective in that lock — the ultra specific type of cancer.

"If we're trying to open the door taking an ax to it, it's a blunt instrument that affects all cells as opposed to an elegant tool," Patt said in comparing treatments such as a general chemotherapy (the ax) to more precise, targeted treatments (a specific key).

By identifying biomarkers, Patt said, "I can give this therapy that will make them live longer and is less toxic."

"The dream of modern cancer therapy is they get to live their own life with the disease under control," she said.

Patt has seen these targeted therapies really change the life expectancy for the people with breast cancer she works with. A person with metastatic breast cancer (cancer that had spread outside of the breast) used to live on average five years after diagnosis. Now it's 16 years, Patt said.

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Is biomarker testing only about cancer?

No. Biomarker testing is also used in autoimmune disease treatments. More research is being done on how it can be used for heart disease, Alzheimer's, sepsis, respiratory illnesses and infectious diseases.

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What difference does biomarker testing have on individual patients?

Muñoz has a strong family history of cancer, including her grandmother, an aunt and several uncles, all of whom died of the disease and didn't have biomarker testing.

"None of my family has access to this," she said. Muñoz, 35, is celebrating five years of having no evidence of cancer. She said not only did biomarker testing help her doctors identify the right chemo and immunotherapy, but it also gave her more confidence that the treatment matched her cancer and would work. It helped her get through the six rounds of intensive chemo needed to match her aggressive cancer.

"I am here today because I had access to biomarker testing," Muñoz said.

Correction: This story incorrectly stated Munoz's mother and sisters had a history of cancer.

This article originally appeared on Austin American-Statesman: Texas Legislature push for insurance to pay for biomarker testing