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Experiences from France

Presented by
Dr Benjamin Besse, Institut Gustave Roussy, France
ELCC 2019
Dr Benjamin Besse (Institut Gustave Roussy, France) talked about the French experience with respect to the implementation of personalised lung cancer care in clinical routine. In France, a top-down strategy was applied. “This was all about politics.”

The first steps were made in 2006, when the Health Ministry and the French National Cancer Institute (NCI) decided to start the French Genetic Centers Network (www.e-cancer.fr). This initiative was aimed to provide nationwide molecular diagnostic tests. The French NCI granted 28 regional centres, roughly covering the whole French territory, based on a cooperation of academic and specialised cancer centres. “This platform is directly paid by the government”, Dr Besse mentioned. “All patients have access to molecular diagnostics, independent of the status of the healthcare institution (public or private).” The high-quality tests are performed for both haematological and solid malignancies.

This national platform was a real success, Dr Besse said. “In 2008, we started to test for EGFR mutations. Subsequently, there was a massive implementation. In 2009, gefitinib was approved for the treatment of EGFR-positive lung cancer, which explains the boom of demands for EGFR mutation tests. However, the capacity was present to perform these molecular tests.” In 2010, the French NCI decided to increase the number of tested genes. Next to EGFR, also KRAS, PI3KCA, HER2 exon 20, BRAF, and EML4-ALK translocation are now tested. The aim was to anticipate on future practices and to improve the French participation in clinical trials. “This was a huge investment, but if you divide the money over the number of patients screened, it is really cost-effective”, Dr Besse reassured. “There was a rapid implementation of EGFR testing. The curve continues to grow with no plateauing in sight.”

The centres report their outcomes to the NCI and are paid based on their activities. There is no private testing, so the NCI knows exactly how many tests are performed each year. Previously, the fees were given to the regional platform of the 28 centres based on its activity. Since 2018, fees are paid to the prescribers. “If you want a small panel, you will get 440 euro per patient by the government. If you want a large panel, the reimbursement can go up to 1,050 euro.” The reimbursement is paid to the hospitals. A prescriber can close a contract either with the national network, i.e. one of the 28 centres in hospitals and cancer centres, or with a private company. This policy has both pros and cons, Dr Besse mentioned: “There are very good private profiles on the market, but by applying those profiles we are losing the benefit of collecting data centrally and knowing exactly the incidence of each molecular alteration in France.”

A -in his view- good initiative that was started in parallel: external quality assessment of the platforms. This national program decided to determine the performance of the laboratories with respect to the diagnosis of solid and haematological malignancies. According to Dr Besse, in the future, whole genome sequencing will be mainstay. “However, that is a political decision. The French government decided that in 2025 a significant number of whole genome sequencing will be performed in cancer patients.

In conclusion, Dr Besse thinks that in France a unique model based on a nationwide access to genotyping, is present. In addition, there is a link to research. However, the impact on survival and economic consequences remain to be demonstrated. A new step was made in 2017 with the implementation of whole genome sequencing.

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