Tuesday, I was in a webinar where stakeholders were discussing the badly-outdated Medicare NCD for NGS testing in cancer. Thursday of the same week, more proof of the problem hit my inbox.
See the March 18, 2026, release of new pancreatic cancer management guidelines from the National Cancer Center Network - NCCN. Here. See coverage in Genomeweb, here.
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On Tuesday, I listened to an NCCN webinar on updated pancreatic cancer guidelines. By Thursday, the formal guideline revision was out. The takeaway was clear: NCCN now recommends broad molecular profiling in pancreatic cancer for patients across stages who are candidates for anti-cancer therapy.
That puts fresh pressure on Medicare’s NGS National Coverage Determination. The policy was released in 2018, but it was built around a 2017-era model of cancer genomics. The NCD was a significant and even visionary innovation of the first Trump administration, under Alex Azar and Seema Verma. It gave Medicare a national framework for precision oncology at a time when that was still a fairly bold step.
But a policy can be innovative when issued and still need updating later.
In general terms, the old NCD is framed around patients with recurrent, relapsed, refractory, metastatic, or stage III/IV cancer. That made sense ten, or twenty, years ago.. But NCCN’s pancreatic cancer revision 2026 shows how much the field has moved. The guideline now supports molecular profiling not only for patients with metastatic disease, but also for all patients who are candidates for anti-cancer therapy.
AT this point, there is no doubt hat genomic testing is moving earlier in care, and belongs where treatment decisions are made. And pancreatic cancer is exactly the kind of disease where old stage-based barriers more and more out of date. Clinicians need the actionable information sooner. Guidelines, technology and practice move in that direction.
So the mismatch is becoming pretty obvious. NCCN is operating with a 2026 view of molecular oncology. Medicare national coverage is still substantially shaped by a 2017 framework. And in 2017, he Azar-Verma policy mattered because it was forward-looking. The right way to honor that achievement is not to leave it untouched as it enters a second decade. We must revise it.
And that gives the second Trump administration a real opportunity. Secretary Kennedy, Dr. Oz, Dora Hughe (Chief Medical Officer), and Chris Klomp (Deputy Director, and Advisor to Kennedy) can ensure this policy is updated soon. The 2018 NCD was a smart and ambitious first step. Now it needs its second act.
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SIDEBAR: THE NCCN TEXTS
NCCN is the gold standard in cancer care guidelines. They've updated genomic testing guidance for pancreatic cancer management. Here's the redline:
Here's the new active text, from page 10, "Clinical Presentation and Workup." The same NGS recommendations occur on other pages for other stages or scenarios.
Tumor/somatic molecular profiling, preferably using a next-generation sequencing (NGS) assay, is recommended for all patients who are candidates for anti-cancer therapy to identify clinically actionable and/or emerging alterations.
These alterations include, but are not limited to:
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fusions (ALK, NRG1, NTRK, ROS1, FGFR2, and RET),
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mutations (BRAF, BRCA1/2, KRAS, and PALB2),
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amplifications (HER2),
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microsatellite instability (MSI),
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mismatch repair deficiency (dMMR), or
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tumor mutational burden (TMB)
using comprehensive genomic profiling via an FDA-approved and/or validated NGS-based assay, and HER2 overexpression via immunohistochemistry (IHC) ± fluorescence in situ hybridization (FISH).
In addition to DNA sequencing, RNA sequencing is recommended since it is better at detecting gene fusions.
Testing on tumor tissue is preferred; however, circulating tumor DNA (ctDNA) testing can be considered if tumor tissue testing is not feasible.
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