KSMO Day 1: Inequities in Access to Cancer Diagnostics and Targeted Treatment in APAC

KSMO 2025 started today, and it kicked things off with an extremely insightful session that had me furiously scribbling notes in my (colourful, handy and free) notebook for 2 hours straight. Those of you who have read previous posts and POVs of mine may know that I am very passionate about the following three topics:

• The cancer management landscape in the immensely heterogeneous region that is APAC
• Molecular diagnostics in oncology
• Inequities in access to cancer treatment and diagnostics

It just so happened that the first session of the conference combined all of the above topics into a highly informative series of lectures that both confirmed and added to my understanding of the barriers to and opportunities for NGS testing in our region.

The power of market research

Dr. Omali Pitiyarachchi from the University of New South Wales set the tone with a presentation that focused on the insights from the 2024 KSMO Young Oncologists forum, which was essentially a market research survey with 14 young oncologists from 11 countries in the region, representing a varied mix of cultures, demographics and - importantly - income categories. Always good to kick things off with a bit of market research.

Genomic technology, in particular next generation sequencing (NGS) and liquid biopsies (LBx), is expensive. This, not surprisingly, leads to significant disparity in access, even within higher-income countries. As the implementation of such technologies has been linked to better patient outcomes in many trials, such unequal access is a major problem. Furthermore, a lot of the data out there that focuses on the utility of NGS and LBx is very US/EU-centric... but over 60% of the global population is in APAC. To address these challenges, the aforementioned survey was conducted by Dr. Pitiyarachchi and her team.

Some of the findings that stood out to me:

• Several respondents (in the Philippines, Thailand and Malaysia) did not have access to NGS at all. This is not surprising, given previous surveys that Ipsos has conducted in this space (e.g. the 2021 Ipsos Oncology MDx Monitor showed that 16% of NSCLC treaters in Thailand were not using NGS testing at all, with the majority of the remainder testing only a small subset of their patients [1])
• No single country has full reimbursement of NGS testing or liquid biopsies. Several have partial government reimbursement of NGS (more on that later), but no private reimbursement. Some have partial private reimbursement, but no government reimbursement. Others (Japan and Taiwan) have both (but again, partial - see later). None of the low-to-middle income countries have any government reimbursement of NGS or LBx. The Philippines has no reimbursement at all (not even private) of either NGS or LBx.
• Again, not surprisingly, cost and lack of reimbursement were the most important barriers to NGS adoption. However, another key barrier was lack of access to targeted therapies. This again confirms what we have observed in our research in low-to-middle income countries: consistently, the main stated barrier to testing for emerging biomarkers such as KRAS G12C or MET exon 14 skipping mutations in NSCLC (even more so than cost of testing) is the cost of targeted therapies associated with that alteration [2].

The power of GOZILA and other MONSTARs

Dr. Tatsunori Shimoi took us through the current state of precision oncology in Japan, and several of the initiatives that aim to improve the situation. He started his presentation with a very familiar (to me) statistic: partly driven by the super-ageing society in Japan, cancer is now by far the leading cause of death in Japan (see my recent paper for a closer look at how the leading causes of death in Japan and other countries have evolved, and the reasons for the rise in cancer over time). He then gave us a summary of the reimbursement landscape:

• Single tests are partially covered by insurance
• Comprehensive genomic profiling (CGP) is partially covered by insurance
• Whole exome sequencing and whole genome sequencing are research use only

The fact that CGP is only partially covered, and is generally significantly more expensive than single tests, leads to continued low adoption. Another data point from a recent Ipsos Laboratory Mapping Survey confirms this: in a surveyed sample of 15 laboratories involved with biomarker testing for CRC, just 27% used NGS, compared to 73% using single-gene or multiplex PCR [3].

In order to address this challenge, several government initiatives have been implemented to increase both NGS uptake and LBx utilisation, such as the SCRUM project, later expanded to SCRUM-GOZILA (got to love clinicians and their trial names...), for NGS-based genomic screening of gastrointestinal tumours (using LBx in the case of GOZILA). A planned future study is called MONSTAR-SCREEN-3 (yes, really).

However, even with these initiatives gradually leading to higher usage of NGS, a low treatment reach based on genomic test results continues to be an issue. In other words, even when actionable mutations are identified, this often does not result in conversion to an appropriate targeted therapy. Hence, platform-type trials are now being run, which assign patients to treatments based on their mutations, regardless of cancer type. One such example is the BELIEVE trial, currently ongoing, which already includes 21 different targeted therapies with over 800 patients recruited to date, which has resulted in expanded indications for multiple targeted drugs.

The power of broad coverage (or lack thereof)

It was then time for a look at the host country: Dr. Hyehyun Jeong, with an overview of the current status of NGS reimbursement in South Korea. What was really interesting to me (and a little depressing in a way) is how things have evolved over time:

• In 2017, the government began conditionally reimbursing NGS, with 50% of the cost covered (with the rest out of pocket, which was roughly USD 550). However, this was applicable to 10 cancer types only, required the inclusion of 14 essential genes, was only available at MFDS-certified institutions, and - crucially - reimbursed only once per diagnosis
• In 2019, reimbursement expanded to advanced, metastatic and recurrent solid tumours (still with an OOP cost of 50%). All other solid tumours only had 10% coverage. It was around this time that we also started seeing significant uptake of NGS in Korea, as observed in the Ipsos Oncology MDx Monitor (although it was still mostly limited to the Big 5 hospitals in Seoul [4])
• In 2023, the impact of the ageing population began making itself felt, and the government decided to reduce reimbursement coverage, maintaining 50% coverage only for advanced lung cancer and certain haematological malignancies, and increasing OOP costs for most cancers to 80%-90%, putting significant financial strain on patients once again

It is clear that there are signficant issues with the NGS reimbursement policy in Korea. While precision medicine continues to expand, NGS reimbursement is going in the opposite direction. In addition, CDx tests and drugs are often not concurrently approved (due to separate review processes, something that can be a major challenge in other markets too). Given the focus on MFDS-certified institutions, the criteria for globally available panels are unclear. In addition, there is a clear regional disparity between Seoul and the rest of the country (a disparity which, incidentally, extends to treatment as well, as we often observed in our Korea Oncology Monitor or Monitors covering other therapeutic categories in Korea).

To add fuel to the proverbial fire, there are studies that show that the total healthcare system cost, while higher in the first year after diagnosis, actually decreases significantly in subsequent years for patients who have had a CGP vs those who didn't, providing a clear rationale for expanded NGS coverage resulting in overall cost savings.

It's not all negative, however. Unlike in some other markets, inequities by income level (in terms of NGS uptake) are relatively low in South Korea. In addition, a large nationwide plaform study (KOSMOS-II) to address the aforementioned disparities is currently ongoing.

The reimbursement situation as it relates to LBx is also rather challenging, unfortunately. While LBx has shown promise for MRD (minimal residual disease monitoring) to track response to treatment, the current reimbursement situation has made this very difficult: current NGS coverage is limited to maximum two tests per patient, with serial testing not reimbursed.

There was much more, but I will leave this for a subsequent post. For now, my room-service meal of dolsot wild vegetables bibimbap is calling me.

References

1. Ipsos Oncology Molecular Diagnostics Monitor in Thailand 2021 Q3; survey conducted online with oncologists and pathologists
2. Ipsos Oncology Molecular Diagnostics Monitor in Thailand 2021 Q3; survey conducted online with oncologists and pathologists
3. Ipsos Laboratory Mapping Study in Japan 2025 Q3; survey conducted online with pathologists and laboratory directors
4. Ipsos Oncology Molecular Diagnostics Monitor in Korea 2020 Q2; survey conducted online with oncologists and pathologists

For additional details on these studies, including methodology and coverage, please contact me.