# Pathologists order genomic profiling automatically at diagnosis of advanced cancer

Source: https://onco.cc/ideas/idea-acc-reflex-genomic-profiling-at-diagnosis/  
OnCo record `idea-acc-reflex-genomic-profiling-at-diagnosis` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

A substantial share of patients with advanced non-small-cell lung cancer start first-line treatment before their biomarker results arrive, or without full testing, and so miss targeted therapy. Letting the pathologist order the full genomic panel the moment a cancer of a defined type and stage is confirmed shortens time to result and makes testing complete.

## Summary

Real-world data show that a substantial fraction of patients with advanced NSCLC begin first-line therapy before biomarker results are available or without full testing, forgoing targeted therapy. Reflex testing, ordered by the pathologist at diagnosis on defined tumour types and stages, shortens time to result and increases completeness. Tissue stewardship, funding, and a default panel need agreement. Some regions have adopted reflex testing; most have not.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Reflex comprehensive profiling will increase the proportion of advanced NSCLC and colorectal cancer patients with complete guideline biomarker results before first-line treatment from under 60% to above 90%, and increase targeted-therapy use in eligible patients.
- Rationale: Reflex HER2 and ER testing in breast cancer is universal and uncontroversial; extending the same logic to genomic panels removes an avoidable coordination failure.
- Proposed test: A regional switch to reflex ordering with pre-post measurement of completeness, turnaround, targeted-therapy uptake, and tissue-exhaustion rates.
- Maturity: being-tested-at-scale
- Actor: clinic

## Sources

- Bottleneck evidence (Fragmented care and guideline gaps): Hanna et al., Mortality due to cancer treatment delay: systematic review and meta-analysis (BMJ 2020): https://doi.org/10.1136/bmj.m4087

## Connected records

- cancers: [Colorectal cancer](https://onco.cc/cancers/colorectal/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/)
- technologies: [Companion diagnostics](https://onco.cc/technologies/companion-diagnostic/), [Comprehensive genomic profiling](https://onco.cc/technologies/cgp/)
- drugs: [FoundationOne CDx / Liquid CDx](https://onco.cc/drugs/foundationone-cdx/)
- terms: [Lines of therapy](https://onco.cc/terms/first-line/), [Next-generation sequencing (NGS)](https://onco.cc/terms/ngs/)
- bottlenecks: [Biomarkers are not validated or standardised](https://onco.cc/bottlenecks/b-biomarker-validation/), [Fragmented care and guideline gaps](https://onco.cc/bottlenecks/b-care-fragmentation/)
- key papers: [Mortality due to cancer treatment delay: systematic review and meta-analysis](https://onco.cc/key-papers/paper-hanna-bmj/)
- ideas: [Standing reflex biomarker panels per tumour type, run without an oncologist's order](https://onco.cc/ideas/idea-acc-reflex-biomarker-panels-by-tumour/)

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