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Abstract
Lynch syndrome, an autosomal dominant inherited disorder, is caused by inactivating mutations involving DNA mismatch repair (MMR) genes. This leads to profound genetic instability, including microsatellite instability (MSI) and increased risk for cancer development, particularly colon and endometrial malignancies. Clinical testing of tumor tissues for the presence of MMR gene deficiency is standard practice in clinical oncology, with immunohistochemistry and PCR-based microsatellite instability analysis used as screening tests to identify potential Lynch syndrome families. The ultimate diagnosis of Lynch syndrome requires documentation of mutation within one of the four MMR genes (MLH1, PMS2, MSH2 and MSH6) or EPCAM, currently achieved by comprehensive sequencing analysis of germline DNA. In this review, the genetic basis of Lynch syndrome, methodologies of MMR deficiency testing, and current diagnostic algorithms in the clinical management of Lynch syndrome, are discussed.
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Affiliation(s)
- Natalia Buza
- a Department of Pathology, School of Medicine , Yale University , New Haven , CT , USA
| | - James Ziai
- b Genentech Inc ., San Francisco , CA , USA
| | - Pei Hui
- a Department of Pathology, School of Medicine , Yale University , New Haven , CT , USA
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102
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Cost-effectiveness of routine screening for Lynch syndrome in colorectal cancer patients up to 70 years of age. Genet Med 2016; 18:966-73. [DOI: 10.1038/gim.2015.206] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022] Open
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103
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Abstract
Lynch syndrome (LS) is the most common of all inherited cancer syndromes, associated with substantially elevated risks for colonic and extracolonic malignancies, earlier onset and high rates of multiple primary cancers. At the genetic level, it is caused by a defective mismatch repair (MMR) system due to presence of germline defects in at least one of the MMR genes- MLH1, MSH2, MSH6, PMS2 or EPCAM. An impaired MMR function during replication introduces infidelity in DNA sequence and leads to ubiquitous mutations at simple repetitive sequences (microsatellites), causing microsatellite instability (MSI). Although previously, clinicopathological criteria such as Amsterdam I/II and Revised Bethesda Guidelines were commonly used to identify suspected LS mutation carriers, there has been a recent push towards universally testing, especially in case of colorectal cancers (CRCs), through immunohistochemistry for expression of MMR proteins or through molecular tests (polymerase chain reaction, PCR) for MSI, in order to identify LS mutation carriers and subject them to genetic testing to ascertain the specific gene implicated. In this review, we have discussed the latest diagnostic strategies and the current screening and treatment guidelines for colonic and extracolonic cancers in clinically affected and at-risk individuals for LS.
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Affiliation(s)
- A K Tiwari
- From the Section of Gastroenterology, Boston University Medical Center, Boston, MA, USA and
| | - H K Roy
- From the Section of Gastroenterology, Boston University Medical Center, Boston, MA, USA and
| | - H T Lynch
- Department of Preventive Medicine and Public Health, Creighton University, Omaha NE, USA
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104
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Schneider JL, Davis J, Kauffman TL, Reiss JA, McGinley C, Arnold K, Zepp J, Gilmore M, Muessig KR, Syngal S, Acheson L, Wiesner GL, Peterson SK, Goddard KAB. Stakeholder perspectives on implementing a universal Lynch syndrome screening program: a qualitative study of early barriers and facilitators. Genet Med 2016; 18:152-61. [PMID: 25880440 PMCID: PMC4608844 DOI: 10.1038/gim.2015.43] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/23/2015] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Evidence-based guidelines recommend that all newly diagnosed colon cancer be screened for Lynch syndrome (LS), but best practices for implementing universal tumor screening have not been extensively studied. We interviewed a range of stakeholders in an integrated health-care system to identify initial factors that might promote or hinder the successful implementation of a universal LS screening program. METHODS We conducted interviews with health-plan leaders, managers, and staff. Interviews were audio-recorded and transcribed. Thematic analysis began with a grounded approach and was also guided by the Practical Robust Implementation and Sustainability Model (PRISM). RESULTS We completed 14 interviews with leaders/managers and staff representing involved clinical and health-plan departments. Although stakeholders supported the concept of universal screening, they identified several internal (organizational) and external (environment) factors that promote or hinder implementation. Facilitating factors included perceived benefits of screening for patients and organization, collaboration between departments, and availability of organizational resources. Barriers were also identified, including: lack of awareness of guidelines, lack of guideline clarity, staffing and program "ownership" concerns, and cost uncertainties. Analysis also revealed nine important infrastructure-type considerations for successful implementation. CONCLUSION We found that clinical, laboratory, and administrative departments supported universal tumor screening for LS. Requirements for successful implementation may include interdepartmental collaboration and communication, patient and provider/staff education, and significant infrastructure and resource support related to laboratory processing and systems for electronic ordering and tracking.
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Affiliation(s)
| | - James Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Jacob A Reiss
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Cheryl McGinley
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Kathleen Arnold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Jamilyn Zepp
- Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Marian Gilmore
- Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Kristin R Muessig
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise Acheson
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Georgia L Wiesner
- Vanderbilt Hereditary Cancer Program, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Susan K Peterson
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katrina A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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105
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Oosterhoff M, van der Maas ME, Steuten LMG. A Systematic Review of Health Economic Evaluations of Diagnostic Biomarkers. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:51-65. [PMID: 26334528 PMCID: PMC4740568 DOI: 10.1007/s40258-015-0198-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Diagnostic biomarkers have multiple applications along the care process and have a large potential in optimizing treatment decisions. However, many diagnostic biomarkers struggle to gain market access and obtain appropriate coverage because of a lack of evidence on their health economic impact. OBJECTIVES The aim was to review the (methodological) characteristics of recent economic evaluations on diagnostic biomarkers and examine whether these studies dealt with specific issues such as different payer perspectives, preference heterogeneity, and multiple applications in subpopulations. METHODS The PubMed database and the National Health Service Economic Evaluation Database were searched. Full economic evaluations published after 2009 assessing diagnostic biomarkers for the main non-communicable diseases in middle-income or high-income countries were considered eligible. Empirical and methodological study characteristics were summarized, as was the handling of specific issues related to the economic evaluation of personalized medicine. RESULTS Thirty-three economic evaluations were included, of which 25 were model-based analyses. The number of strategies compared ranged from two to 17 per study, and was especially large in studies assessing genetic testing in patients and their relatives. Cost-effectiveness results were most sensitive to test accuracy and costs of the biomarker (N = 7), the relative risk of an event (N = 4), and the proportion of people accepting genetic testing (N = 2). One study incorporated patient preferences, and none of the studies considered different payer perspectives, cost sharing arrangements or variable opportunity costs due to population density variability. CONCLUSIONS Published health economic evaluations of biomarkers used for diagnosing, staging diseases, and guiding treatment selection are characterized by a large number of comparators to model the potential clinical applications and to determine their value. Assessing outcomes beyond health as well as specific issues, such as different payer perspectives and patient preferences, is crucial to fully capture the potential health economic impact of diagnostic biomarkers and to inform value-based reimbursement.
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Affiliation(s)
- Marije Oosterhoff
- Panaxea b.v., Hengelosestraat 221, 7521 AC, Enschede, The Netherlands.
| | | | - Lotte M G Steuten
- Panaxea b.v., Hengelosestraat 221, 7521 AC, Enschede, The Netherlands.
- Fred Hutchinson Cancer Research Center, Seattle, USA.
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106
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Hall MJ, Obeid EI, Schwartz SC, Mantia-Smaldone G, Forman AD, Daly MB. Genetic testing for hereditary cancer predisposition: BRCA1/2, Lynch syndrome, and beyond. Gynecol Oncol 2016; 140:565-74. [PMID: 26812021 DOI: 10.1016/j.ygyno.2016.01.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/11/2016] [Accepted: 01/18/2016] [Indexed: 01/07/2023]
Abstract
Obstetrician/gynecologists and gynecologic oncologists serve an integral role in the care of women at increased hereditary risk of cancer. Their contribution includes initial identification of high risk patients, screening procedures like bimanual exam, trans-vaginal ultrasound and endometrial biopsy, prophylaxis via TAH and/or BSO, and chemoprevention. Further, gynecologists also serve a central role in the management of the secondary repercussions of efforts to mitigate increased cancer risks, including vasomotor symptoms, sexual function, bone health, cardiovascular disease, and mental health. The past several years has seen multiple new high and moderate penetrance genes introduced into the clinical care of women at increased risk of gynecologic malignancy. Awareness of these new genes and the availability of new multi-gene panel tests is critical for providers on the front-line of women's health.
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Affiliation(s)
- M J Hall
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, United States.
| | - E I Obeid
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - S C Schwartz
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, United States; Department of Gynecologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - G Mantia-Smaldone
- Department of Gynecologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - A D Forman
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, United States
| | - M B Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, United States
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107
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Ngeow J, Eng C. Precision medicine in heritable cancer: when somatic tumour testing and germline mutations meet. NPJ Genom Med 2016; 1:15006. [PMID: 29263804 PMCID: PMC5685292 DOI: 10.1038/npjgenmed.2015.6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 01/07/2023] Open
Abstract
Cancer is among the leading causes of death and disfigurement worldwide with an estimated global incidence of 14 million and ~8.2 million cancer-related deaths per annum. An estimated 5-10% of all cancers are hereditary, meaning a single gene mutation contributed to development of the cancer. In other words, inherited cancer has a worldwide incidence of ~1.4 million new cases per annum and a global prevalence of 300 million, and are often poorly recognised. The increase in genetic sequencing capability combined with the decrease in the cost of testing has altered both regulatory policy and clinical oncology practice Well-known examples of clinically important cancer susceptibility syndromes such as those caused by genetic mutations in highly penetrant genes such as BRCA1/2 hereditary breast-ovarian cancer syndrome genes have provided the framework for the practice of clinical cancer genetics. There is no question that these tests have provided clinical benefit to the patient and her/his family. However, with the expanding role of next generation sequencing in tumour profiling as well as in germline testing, clinicians are now faced with significant new challenges and potentially unexpected opportunities. Issues such as determining how best to deal with gene variants of uncertain clinical significance and the issue of incidental findings of hereditary cancer risk may be encountered during tumour genomic testing will require a concerted effort and dialogue on the part of the broad genomic community.
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Affiliation(s)
- Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
- Oncology Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charis Eng
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA
- Germline High Risk Focus Group, Case Comprehensive Cancer Centre, Case Western Reserve University, Cleveland, OH, USA
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108
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Manchanda R, Jacobs I. Genetic screening for gynecological cancer: where are we heading? Future Oncol 2016; 12:207-20. [DOI: 10.2217/fon.15.278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The landscape of cancer genetics in gynecological oncology is rapidly changing. The traditional family history-based approach has limitations and misses >50% mutation carriers. This is now being replaced by population-based approaches. The need for changing the clinical paradigm from family history-based to population-based BRCA1/BRCA2 testing in Ashkenazi Jews is supported by data that demonstrate population-based BRCA1/BRCA2 testing does not cause psychological harm and is cost effective. This article covers various genetic testing strategies for gynecological cancers, including population-based approaches, panel and direct-to-consumer testing as well as the need for innovative approaches to genetic counseling. Advances in genetic testing technology and computational analytics have facilitated an integrated systems medicine approach, providing increasing potential for population-based genetic testing, risk stratification, and cancer prevention. Genomic information along-with biological/computational tools will be used to deliver predictive, preventive, personalized and participatory (P4) and precision medicine in the future.
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Affiliation(s)
- Ranjit Manchanda
- Department of Gynaecological Oncology, Bartshealth NHS Trust, Royal London Hospital, London, E1 1BB, UK
- Barts Cancer Institute, Charter House Square, Queen Mary University of London, London, EC1M 6BQ, UK
- GCRC, Women's Cancer, University College London, London, W1T 7DN, UK
| | - Ian Jacobs
- UNSW Australia, Level 1, Chancellery Building, UNSW Sydney, NSW 2052, Australia
- University College London, Gower Street, London, UK
- University of Manchester, Oxford Road, Manchester, UK
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109
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Cohen SA, Laurino M, Bowen DJ, Upton MP, Pritchard C, Hisama F, Jarvik G, Fichera A, Sjoding B, Bennett RL, Naylor L, Jacobson A, Burke W, Grady WM. Initiation of universal tumor screening for Lynch syndrome in colorectal cancer patients as a model for the implementation of genetic information into clinical oncology practice. Cancer 2015; 122:393-401. [PMID: 26480326 DOI: 10.1002/cncr.29758] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 09/30/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lynch syndrome confers a hereditary predisposition to colorectal and other cancers. Universal tumor screening (UTS) for Lynch syndrome is recommended by several professional societies, but the implementation can be complex. This article describes the evaluation, process development, and initiation of Lynch syndrome UTS at a tertiary referral cancer center. METHODS A multidisciplinary team developed the new process design. Issues in 5 themes were noted: timing, funding, second-opinion patients, result processing, and the role of genetics providers. A committee approach was used to examine each issue for process-improvement development. RESULTS The issues related to testing were addressed individually for the successful implementation of UTS at the institutional level. In the conventional-care period, 9 of 30 cases (30%) received Lynch syndrome screening, and 4 cases were referred to medical genetics. During the 6 months following the implementation of UTS, 32 of 44 patients (73%) received Lynch syndrome screening. The 13 unscreened patients all had identified reasons for nonscreening (eg, financial limitations). Ten patients were referred to medical genetics, which identified no new cases of Lynch syndrome, but a low-risk adenomatous polyposis coli (APC) variant was detected in 1 individual. CONCLUSIONS The implementation of effective Lynch syndrome UTS can feasibly alter practice at the institutional level. This experience with the assessment and management of issues relevant to the successful implementation of a new clinical care paradigm based on emerging technology has implications for the uptake of advances across molecular oncology into clinical practice, and this is highly relevant in the current era of rapidly evolving genomic technology.
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Affiliation(s)
- Stacey A Cohen
- Division of Oncology, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mercy Laurino
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Deborah J Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Melissa P Upton
- Department of Pathology, University of Washington, Seattle, Washington
| | - Colin Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Fuki Hisama
- Division of Medical Genetics, University of Washington, Seattle, Washington
| | - Gail Jarvik
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | | | - Britta Sjoding
- Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Robin L Bennett
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Lorraine Naylor
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Angela Jacobson
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - William M Grady
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Gastroenterology, University of Washington, Seattle, Washington
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110
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Grosse SD. When is Genomic Testing Cost-Effective? Testing for Lynch Syndrome in Patients with Newly-Diagnosed Colorectal Cancer and Their Relatives. Healthcare (Basel) 2015; 3:860-78. [PMID: 26473097 PMCID: PMC4604059 DOI: 10.3390/healthcare3040860] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Varying estimates of the cost-effectiveness of genomic testing applications can reflect differences in study questions, settings, methods and assumptions. This review compares recently published cost-effectiveness analyses of testing strategies for Lynch Syndrome (LS) in tumors from patients newly diagnosed with colorectal cancer (CRC) for either all adult patients or patients up to age 70 along with cascade testing of relatives of probands. Seven studies published from 2010 through 2015 were identified and summarized. Five studies analyzed the universal offer of testing to adult patients with CRC and two others analyzed testing patients up to age 70; all except one reported incremental cost-effectiveness ratios (ICERs) < $ 100,000 per life-year or quality-adjusted life-year gained. Three studies found lower ICERs for selective testing strategies using family history-based predictive models compared with universal testing. However, those calculations were based on estimates of sensitivity of predictive models derived from research studies, and it is unclear how sensitive such models are in routine clinical practice. Key model parameters that are influential in ICER estimates included 1) the number of first-degree relatives tested per proband identified with LS and 2) the cost of gene sequencing. Others include the frequency of intensive colonoscopic surveillance, the cost of colonoscopy, and the inclusion of extracolonic surveillance and prevention options.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA; Tel.: +404-498-3074
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111
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Ladabaum U, Ford JM, Martel M, Barkun AN. American Gastroenterological Association Technical Review on the Diagnosis and Management of Lynch Syndrome. Gastroenterology 2015; 149:783-813.e20. [PMID: 26226576 DOI: 10.1053/j.gastro.2015.07.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology/Hepatology, Stanford University School of Medicine, Stanford, California
| | - James M Ford
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Division of Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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112
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Richman S. Deficient mismatch repair: Read all about it (Review). Int J Oncol 2015; 47:1189-202. [PMID: 26315971 PMCID: PMC4583524 DOI: 10.3892/ijo.2015.3119] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022] Open
Abstract
Defects in the DNA mismatch repair (MMR) proteins, result in a phenotype called microsatellite instability (MSI), occurring in up to 15% of sporadic colorectal cancers. Approximately one quarter of colon cancers with deficient MMR (dMMR) develop as a result of an inherited predisposition syndrome, Lynch syndrome (formerly known as HNPCC). It is essential to identify patients who potentially have Lynch syndrome, as not only they, but also family members, may require screening and monitoring. Diagnostic criteria have been developed, based primarily on Western populations, and several methodologies are available to identify dMMR tumours, including immunohistochemistry and microsatellite testing. These criteria have provided evidence supporting the introduction of reflex testing. Yet, it is becoming increasingly clear that tests have a limited sensitivity and specificity and may yet be superseded by next generation sequencing. In this review, the limitations of diagnostic criteria are discussed, and current and emerging screening technologies explained. There is now useful evidence supporting the prognostic and predictive value of dMMR status in colorectal tumours, but much less is known about their value in extracolonic tumours, that may also feature in Lynch syndrome. This review assesses current literature relating to dMMR in endometrial, ovarian, gastric and melanoma cancers, which it would seem, may benefit from large-scale clinical trials in order to further close the gap in knowledge between colorectal and extracolonic tumours.
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Affiliation(s)
- Susan Richman
- Department of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, St. James University Hospital, Leeds, LS9 7TF, UK
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113
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Stadler ZK. Diagnosis and management of DNA mismatch repair-deficient colorectal cancer. Hematol Oncol Clin North Am 2015; 29:29-41. [PMID: 25475571 DOI: 10.1016/j.hoc.2014.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Colorectal tumors exhibiting defective DNA mismatch repair (MMR-D)/microsatellite instability (MSI-H) form a distinct subgroup of CRCs associated with important clinical and pathologic features. The identification of MMR-D/MSI-H may impact CRC prognosis, prediction of response to chemotherapeutic agents, and may necessitate the need for genetic assessment for Lynch syndrome. Oncologists remain at the forefront of diagnosing, treating, and managing patients with MMR-D/MSI-H CRC and ensuring that the clinical care of these patients reflect our evolving understanding of this unique CRC subtype.
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Affiliation(s)
- Zsofia K Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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114
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Kidambi TD, Blanco A, Myers M, Conrad P, Loranger K, Terdiman JP. Selective Versus Universal Screening for Lynch Syndrome: A Six-Year Clinical Experience. Dig Dis Sci 2015; 60:2463-9. [PMID: 24903654 DOI: 10.1007/s10620-014-3234-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 05/26/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Lynch syndrome is the most common cause of hereditary colorectal cancer (CRC) and confers increased risk of other cancers. Identification of patients improves morbidity and mortality. Screening tumors for absent mismatch repair (MMR) protein expression by immunohistochemistry (IHC) is a recommended approach. Despite guidelines advocating universal screening, significant variation in clinical practice exists. AIMS/METHODS A retrospective study of two different IHC-based Lynch syndrome screening protocols at an urban, university hospital was performed. Outcomes from a "selective" screening strategy utilized from August 2007-July 2010 on CRC tumors from patients with high-risk features were compared with a "universal" strategy of screening all CRC tumors from July 2010-August 2013. Positively screened patients were referred for genetic counseling and offered germline testing. RESULTS A total of 392 patients with CRC were screened: 107 selectively and 285 universally. The prevalence of Lynch syndrome was 3.1 %, with no difference by strategy. There was a trend (p = 0.06) toward fewer universally screened patients agreeing to genetic counseling compared with those selectively screened. Selective criteria failed to identify one of eight cases of Lynch syndrome from the universal group, though the universal strategy screened 166 additional tumors to find this additional patient. CONCLUSIONS Selective screening for Lynch syndrome has similar outcomes as universal screening in terms of identifying Lynch syndrome, despite screening far fewer patients. In addition, fewer eligible patients in our study agreed to undergo genetic counseling and germline testing than in prior studies. These lower rates may better reflect uptake of these services in clinical practice.
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Affiliation(s)
- Trilokesh D Kidambi
- Department of Internal Medicine, University of California, San Francisco, 1701 Divisadero, Suite 120, San Francisco, CA, 94115, USA,
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115
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Knight SJ, Mohamed AF, Marshall DA, Ladabaum U, Phillips KA, Walsh JME. Value of Genetic Testing for Hereditary Colorectal Cancer in a Probability-Based US Online Sample. Med Decis Making 2015; 35:734-744. [PMID: 25589525 PMCID: PMC4501912 DOI: 10.1177/0272989x14565820] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND . While choices about genetic testing are increasingly common for patients and families, and public opinion surveys suggest public interest in genomics, it is not known how adults from the general population value genetic testing for heritable conditions. We sought to understand in a US sample the relative value of the characteristics of genetic tests to identify risk of hereditary colorectal cancer, among the first genomic applications with evidence to support its translation to clinical settings. METHODS . A Web-enabled choice-format conjoint survey was conducted with adults age 50 years and older from a probability-based US panel. Participants were asked to make a series of choices between 2 hypothetical blood tests that differed in risk of false-negative test, privacy, and cost. Random parameters logit models were used to estimate preferences, the dollar value of genetic information, and intent to have genetic testing. RESULTS . A total of 355 individuals completed choice-format questions. Cost and privacy were more highly valued than reducing the chance of a false-negative result. Most (97% [95% confidence interval (CI)], 95%-99%) would have genetic testing to reduce the risk of dying of colorectal cancer in the best scenario (no false negatives, results disclosed to primary care physician). Only 41% (95% CI, 25%-57%) would have genetic testing in the worst case (20% false negatives, results disclosed to insurance company). CONCLUSIONS . Given the characteristics and levels included in the choice, if false-negative test results are unlikely and results are shared with a primary care physician, the majority would have genetic testing. As genomic services become widely available, primary care professionals will need to be increasingly knowledgeable about genetic testing decisions.
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Affiliation(s)
- Sara J. Knight
- Health Services Research and Development Program, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Ateesha F. Mohamed
- CHEOR, Specialty Medicine, Bayer Healthcare Pharmaceuticals Inc., Whippany, New Jersey, United States
| | - Deborah A. Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Uri Ladabaum
- Department of Medicine, Stanford University, Palo Alto, California, United States
| | - Kathryn A. Phillips
- Department of Clinical Pharmacy and Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, United States
| | - Judith M. E. Walsh
- Departments of Medicine and Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California, United States
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Screening for Lynch syndrome among patients with newly diagnosed endometrial cancer: a comprehensive review. TUMORI JOURNAL 2015. [PMID: 26219573 DOI: 10.5301/tj.5000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Lynch syndrome (LS) is an autosomal dominant condition characterized by an increased risk of hereditary colorectal, endometrial, ovarian, pancreatic, urinary tract, and gastric cancer.It is estimated that around 5% of all endometrial cancer (EC) cases are due to an inherited predisposition, of which LS might be the most frequent. The lifetime risk of developing EC in women with LS ranges between 40% and 71% depending on the type of mutation. In many cases, this risk may even exceed their risk of developing colon cancer. Moreover, in 60% of these women, EC will be the first primary malignancy diagnosed and the sentinel diagnosis of the syndrome. Therefore, it is essential to identify which women with EC have LS in order to allow implementation of individualized screening and preventive strategies.
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Abstract
The hereditary colorectal cancer syndromes comprise a heterogeneous group of conditions with varying cancer risks, gastrointestinal polyp types, nonmalignant findings, and inheritance patterns. Although each one is unique in its own right, these syndromes often have overlapping features, making diagnoses difficult in select cases. Obtaining accurate polyp history (histologic type, number, location, and age of onset), cancer history (location, type, and age of onset), and other nonmalignant features is imperative in determining the likely disease diagnosis and thereby the appropriate genetic tests for precise diagnosis in a timely fashion. This process often necessitates collaboration among surgical oncology team members and genetic counselors.
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Affiliation(s)
- Kory Jasperson
- Department of Internal Medicine, Huntsman Cancer Institute, The University of Utah, 2000 Circle of Hope Drive, Room 1166, Salt Lake City, UT 84112, USA.
| | - Randall W Burt
- Department of Internal Medicine, Huntsman Cancer Institute, The University of Utah, 2000 Circle of Hope Drive, Salt Lake City, UT 84112, USA
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Snowsill T, Huxley N, Hoyle M, Jones-Hughes T, Coelho H, Cooper C, Frayling I, Hyde C. A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome. Health Technol Assess 2015; 18:1-406. [PMID: 25244061 DOI: 10.3310/hta18580] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lynch syndrome (LS) is an inherited autosomal dominant disorder characterised by an increased risk of colorectal cancer (CRC) and other cancers, and caused by mutations in the deoxyribonucleic acid (DNA) mismatch repair genes. OBJECTIVE To evaluate the accuracy and cost-effectiveness of strategies to identify LS in newly diagnosed early-onset CRC patients (aged < 50 years). Cascade testing of relatives is employed in all strategies for individuals in whom LS is identified. DATA SOURCES AND METHODS Systematic reviews were conducted of the test accuracy of microsatellite instability (MSI) testing or immunohistochemistry (IHC) in individuals with CRC at risk of LS, and of economic evidence relating to diagnostic strategies for LS. Reviews were carried out in April 2012 (test accuracy); and in February 2012, repeated in February 2013 (economic evaluations). Databases searched included MEDLINE (1946 to April week 3, 2012), EMBASE (1980 to week 17, 2012) and Web of Science (inception to 30 April 2012), and risk of bias for test accuracy was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) quality appraisal tool. A de novo economic model of diagnostic strategies for LS was developed. RESULTS Inconsistencies in study designs precluded pooling of diagnostic test accuracy results from a previous systematic review and nine subsequent primary studies. These were of mixed quality, with significant methodological concerns identified for most. IHC and MSI can both play a part in diagnosing LS but neither is gold standard. No UK studies evaluated the cost-effectiveness of diagnosing and managing LS, although studies from other countries generally found some strategies to be cost-effective compared with no testing. The de novo model demonstrated that all strategies were cost-effective compared with no testing at a threshold of £20,000 per quality-adjusted life-year (QALY), with the most cost-effective strategy utilising MSI and BRAF testing [incremental cost-effectiveness ratio (ICER) = £5491 per QALY]. The maximum health benefit to the population of interest would be obtained using universal germline testing, but this would not be a cost-effective use of NHS resources compared with the next best strategy. When the age limit was raised from 50 to 60 and 70 years, the ICERs compared with no testing increased but remained below £20,000 per QALY (except for universal germline testing with an age limit of 70 years). The total net health benefit increased with the age limit as more individuals with LS were identified. Uncertainty was evaluated through univariate sensitivity analyses, which suggested that the parameters substantially affecting cost-effectiveness: were the risk of CRC for individuals with LS; the average number of relatives identified per index patient; the effectiveness of colonoscopy in preventing metachronous CRC; the cost of colonoscopy; the duration of the psychological impact of genetic testing on health-related quality of life (HRQoL); and the impact of prophylactic hysterectomy and bilateral salpingo-oophorectomy on HRQoL (this had the potential to make all testing strategies more expensive and less effective than no testing). LIMITATIONS The absence of high-quality data for the impact of prophylactic gynaecological surgery and the psychological impact of genetic testing on HRQoL is an acknowledged limitation. CONCLUSIONS Results suggest that reflex testing for LS in newly diagnosed CRC patients aged < 50 years is cost-effective. Such testing may also be cost-effective in newly diagnosed CRC patients aged < 60 or < 70 years. Results are subject to uncertainty due to a number of parameters, for some of which good estimates were not identified. We recommend future research to estimate the cost-effectiveness of testing for LS in individuals with newly diagnosed endometrial or ovarian cancer, and the inclusion of aspirin chemoprevention. Further research is required to accurately estimate the impact of interventions on HRQoL. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002436. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Ian Frayling
- Institute of Medical Genetics, Cardiff University, Cardiff, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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Hunter JE, Zepp JM, Gilmore MJ, Davis JV, Esterberg EJ, Muessig KR, Peterson SK, Syngal S, Acheson LS, Wiesner GL, Reiss JA, Goddard KAB. Universal tumor screening for Lynch syndrome: Assessment of the perspectives of patients with colorectal cancer regarding benefits and barriers. Cancer 2015; 121:3281-9. [PMID: 26036338 PMCID: PMC4560979 DOI: 10.1002/cncr.29470] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/12/2015] [Accepted: 04/21/2015] [Indexed: 12/03/2022]
Abstract
BACKGROUND Universal tumor screening for Lynch syndrome, the most common form of hereditary colorectal cancer (CRC), has been recommended among all patients newly diagnosed with CRC. However, there is limited literature regarding patient perspectives of tumor screening for Lynch syndrome among patients with CRC who are not selected for screening based on family history criteria. METHODS A total of 145 patients aged 39 to 87 years were administered surveys assessing perceived risk, patient perspectives, and potential benefits of and barriers to tumor screening for Lynch syndrome. Associations between patient‐specific and cancer‐specific factors and survey responses were analyzed. RESULTS The majority of participants perceived their risk of developing Lynch syndrome as being low, with 9 participants (6.2%) anticipating an abnormal screening result. However, most participants endorsed the potential benefits of screening for themselves and their families, with 84.8% endorsing ≥6 benefits and 50.3% endorsing all 8 benefits. Participants also endorsed few potential barriers to screening, with 89.4% endorsing ≤4 of 9 potential barriers. A common barrier was worry about the cost of additional testing and surveillance, which was endorsed by 54.5% of participants. The level of distress associated with tumor screening for Lynch syndrome, which was very low, was not associated with age or CRC stage. CONCLUSIONS The results of the current study indicate that patients with CRC overall have a positive attitude toward tumor screening for Lynch syndrome, endorse the benefits of screening, and experience low levels of distress. These findings provide insight into patient attitudes toward tumor screening for Lynch syndrome among unselected patients with CRC to inform educational approaches that assist in patient decision‐making and guide the successful implementation of screening programs. Cancer 2015;121:3281–3289. © 2015 American Cancer Society. In the current study, perspectives among patients newly diagnosed with colorectal cancer are assessed regarding universal tumor screening for Lynch syndrome. The majority of patients appear to have a positive attitude toward screening and endorse the benefits for themselves and their families, whereas potential barriers include concerns over the cost of additional genetic counseling and testing.
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Affiliation(s)
| | - Jamilyn M Zepp
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Mari J Gilmore
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - James V Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Kristin R Muessig
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sapna Syngal
- Division of Medical Oncology, Department of Medicine, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Louise S Acheson
- Department of Family Medicine and Community Health, Department of Reproductive Biology, Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, Ohio
| | - Georgia L Wiesner
- Vanderbilt Hereditary Cancer Program, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee
| | - Jacob A Reiss
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Hereditary Non-polyposis Colorectal Cancer: Prevention and Therapeutic Options. CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-015-0265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Lynch HT, Drescher K, Knezetic J, Lanspa S. Genetics, biomarkers, hereditary cancer syndrome diagnosis, heterogeneity and treatment: a review. Curr Treat Options Oncol 2015; 15:429-42. [PMID: 24827900 DOI: 10.1007/s11864-014-0293-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Molecular genetic pathways that drive the phenotypic and genotypic heterogeneity of hereditary colorectal cancer also can affect response to chemotherapy and chemoprevention. These mutations also can alter patients' response to therapy. Environmental differences can affect this highly complex conundrum. We will use Lynch syndrome as a model to explore this issue. However, to begin with, after more than a century of documentation, we must ask what is meant by the eponym "Lynch syndrome". Germline mutations may act as drivers of chemoprevention and chemotherapy and therein may act positively or conversely they may have a negative effect in terms of inhibiting the inactivation of cancer-causing germline mutations. A relatively new field of hereditary cancer therapeutics has significantly impacted cancer care, from the standpoint of the sensitivity or resistance to a particular form of chemotherapy and/or chemoprevention. The question for the diagnostician and therapist must always concern what is the best possible management approach for the patient, particularly when he or she harbors a cancer-causing germline mutation, which, in this case, causes Lynch syndrome. Continued molecular genetic research might yield a more tailored effective treatment for Lynch syndrome. The ultimate goal of such hereditary oncologic research is to better understand the mutation's therapeutic task, namely, its potential to benefit the patient in terms of its treatment goal, thereby fulfilling the essence of personalized medicine. However, this goal may be exceedingly complicated. For example, in the natural clinical and molecular genetic history of hereditary forms of cancer, there will be a predominance of early-onset cancers of multiple anatomic sites. In our Lynch syndrome model, these will be most commonly colorectal, endometrial, and ovarian cancer. Attention must initially be focused upon cancer's early age of onset coupled with the tendency to multiple primary cancers so that, in the case of CRC, colonoscopic screening must be initiated by age 20-25 years and repeated every other year until age 40 years and then annually thereafter. However, screening will be of limited efficacy in the gynecologic cancers (endometrial and ovarian) so that once the family is completed, particularly by age 35-40 years, careful attention must be given to the option of prophylactic hysterectomy and bilateral salpingo-oophorectomy. Given issues of tumor heterogeneity, selected Lynch syndrome families may show an excess of urologic cancers or cancers of the small bowel, and highly targeted screening should be given serious consideration for these as well as cancers of other anatomic sites in such high-risk, cancer-prone patients.
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Affiliation(s)
- Henry T Lynch
- Department of Preventive Medicine and Public Health, Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA,
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122
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Economic evidence on identifying clinically actionable findings with whole-genome sequencing: a scoping review. Genet Med 2015; 18:111-6. [PMID: 25996638 DOI: 10.1038/gim.2015.69] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/15/2015] [Indexed: 12/25/2022] Open
Abstract
The American College of Medical Genetics and Genomics (ACMG) recommends that mutations in 56 genes for 24 conditions are clinically actionable and should be reported as secondary findings after whole-genome sequencing (WGS). Our aim was to identify published economic evaluations of detecting mutations in these genes among the general population or among targeted/high-risk populations and conditions and identify gaps in knowledge. A targeted PubMed search from 1994 through November 2014 was performed, and we included original, English-language articles reporting cost-effectiveness or a cost-to-utility ratio or net benefits/benefit-cost focused on screening (not treatment) for conditions and genes listed by the ACMG. Articles were screened, classified as targeting a high-risk or general population, and abstracted by two reviewers. General population studies were evaluated for actual cost-effectiveness measures (e.g., incremental cost-effectiveness ratios (ICER)), whereas studies of targeted populations were evaluated for whether at least one scenario proposed was cost-effective (e.g., ICER of ≤$100,000 per life-year or quality-adjusted life-year gained). A total of 607 studies were identified, and 32 relevant studies were included. Identified studies addressed fewer than one-third (7 of 24; 29%) of the ACMG conditions. The cost-effectiveness of screening in the general population was examined for only 2 of 24 conditions (8%). The cost-effectiveness of most genetic findings that the ACMG recommends for return has not been evaluated in economic studies or in the context of screening in the general population. The individual studies do not directly address the cost-effectiveness of WGS.
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Reflex testing for Lynch syndrome: if we build it, will they come? Lessons learned from the uptake of clinical genetics services by individuals with newly diagnosed colorectal cancer (CRC). Fam Cancer 2015; 13:75-82. [PMID: 24002367 PMCID: PMC3927060 DOI: 10.1007/s10689-013-9677-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this qualitative study was to examine the experience of individuals facing a choice about genetic counselling/testing in the context of newly diagnosed colorectal cancer (CRC). Nineteen individuals with newly diagnosed CRC, including 12 individuals who accepted genetic counselling (“acceptors”) and 7 individuals who declined genetic counselling (“refusers”), were interviewed using a standardized questionnaire guide which focused on motivations and barriers experienced in the decision process. Data were analyzed using Karlsson’s Empirical Phenomenological method of data analysis (Karlsson in Psychological qualitative research from a phenomenological perspective. Almgvist and Wiksell International, Stockholm, 1993). Three major themes were identified: facing challenges in health literacy; mapping an unknown territory; and adjusting to cancer. The study participants’ testimonies provided novel insights into potential reasons for patient non-engagement in pilot studies of reflex testing for Lynch syndrome, and allowed us to formulate several recommendations for enhancing patient engagement. Our study findings suggest that patient engagement in clinical cancer genetics services, including reflex testing for Lynch syndrome, can only be achieved by addressing current health literacy issues, by deconstructing current misconceptions related to potential abuses of genetic information, by emphasizing the clinical utility of genetic assessment, and by adapting genetics practices to the specific context of cancer care.
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Gallego CJ, Shirts BH, Bennette CS, Guzauskas G, Amendola LM, Horike-Pyne M, Hisama FM, Pritchard CC, Grady WM, Burke W, Jarvik GP, Veenstra DL. Next-Generation Sequencing Panels for the Diagnosis of Colorectal Cancer and Polyposis Syndromes: A Cost-Effectiveness Analysis. J Clin Oncol 2015; 33:2084-91. [PMID: 25940718 DOI: 10.1200/jco.2014.59.3665] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the cost effectiveness of next-generation sequencing (NGS) panels for the diagnosis of colorectal cancer and polyposis (CRCP) syndromes in patients referred to cancer genetics clinics. PATIENTS AND METHODS We developed a decision model to evaluate NGS panel testing compared with current standard of care in patients referred to a cancer genetics clinic. We obtained data on the prevalence of genetic variants from a large academic laboratory and calculated the costs and health benefits of identifying relatives with a pathogenic variant, in life-years and quality-adjusted life-years (QALYs). We classified the CRCP syndromes according to their type of inheritance and penetrance of colorectal cancer. One-way and probabilistic sensitivity analyses were conducted to assess uncertainty. RESULTS Evaluation with an NGS panel that included Lynch syndrome genes and other genes associated with highly penetrant CRCP syndromes led to an average increase of 0.151 year of life, 0.128 QALY, and $4,650 per patient, resulting in an incremental cost-effectiveness ratio of $36,500 per QALY compared with standard care and a 99% probability that this panel was cost effective at a threshold of $100,000 per QALY. When compared with this panel, the addition of genes with low colorectal cancer penetrance resulted in an incremental cost-effectiveness ratio of $77,300 per QALY. CONCLUSION The use of an NGS panel that includes genes associated with highly penetrant CRCP syndromes in addition to Lynch syndrome genes as a first-line test is likely to provide meaningful clinical benefits in a cost-effective manner at a $100,000 per QALY threshold.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Wylie Burke
- All authors: University of Washington, Seattle, WA
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125
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Snowsill T, Huxley N, Hoyle M, Jones-Hughes T, Coelho H, Cooper C, Frayling I, Hyde C. A model-based assessment of the cost-utility of strategies to identify Lynch syndrome in early-onset colorectal cancer patients. BMC Cancer 2015; 15:313. [PMID: 25910169 PMCID: PMC4428233 DOI: 10.1186/s12885-015-1254-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 03/25/2015] [Indexed: 01/13/2023] Open
Abstract
Background Lynch syndrome is an autosomal dominant cancer predisposition syndrome caused by mutations in the DNA mismatch repair genes MLH1, MSH2, MSH6 and PMS2. Individuals with Lynch syndrome have an increased risk of colorectal cancer, endometrial cancer, ovarian and other cancers. Lynch syndrome remains underdiagnosed in the UK. Reflex testing for Lynch syndrome in early-onset colorectal cancer patients is proposed as a method to identify more families affected by Lynch syndrome and offer surveillance to reduce cancer risks, although cost-effectiveness is viewed as a barrier to implementation. The objective of this project was to estimate the cost–utility of strategies to identify Lynch syndrome in individuals with early-onset colorectal cancer in the NHS. Methods A decision analytic model was developed which simulated diagnostic and long-term outcomes over a lifetime horizon for colorectal cancer patients with and without Lynch syndrome and for relatives of those patients. Nine diagnostic strategies were modelled which included microsatellite instability (MSI) testing, immunohistochemistry (IHC), BRAF mutation testing (methylation testing in a scenario analysis), diagnostic mutation testing and Amsterdam II criteria. Biennial colonoscopic surveillance was included for individuals diagnosed with Lynch syndrome and accepting surveillance. Prophylactic hysterectomy with bilateral salpingo-oophorectomy (H-BSO) was similarly included for women diagnosed with Lynch syndrome. Costs from NHS and Personal Social Services perspective and quality-adjusted life years (QALYs) were estimated and discounted at 3.5% per annum. Results All strategies included for the identification of Lynch syndrome were cost-effective versus no testing. The strategy with the greatest net health benefit was MSI followed by BRAF followed by diagnostic genetic testing, costing £5,491 per QALY gained over no testing. The effect of prophylactic H-BSO on health-related quality of life (HRQoL) is uncertain and could outweigh the health benefits of testing, resulting in overall QALY loss. Conclusions Reflex testing for Lynch syndrome in early-onset colorectal cancer patients is predicted to be a cost-effective use of limited financial resources in England and Wales. Research is recommended into the cost-effectiveness of reflex testing for Lynch syndrome in other associated cancers and into the impact of prophylactic H-BSO on HRQoL. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1254-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tristan Snowsill
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Nicola Huxley
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Martin Hoyle
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Tracey Jones-Hughes
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Helen Coelho
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Chris Cooper
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
| | - Ian Frayling
- Institute of Cancer & Genetics, Cardiff University, Cardiff, UK.
| | - Chris Hyde
- Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK.
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126
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Barzi A, Sadeghi S, Kattan MW, Meropol NJ. Comparative effectiveness of screening strategies for Lynch syndrome. J Natl Cancer Inst 2015; 107:djv005. [PMID: 25794514 DOI: 10.1093/jnci/djv005] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Colorectal cancer is the second leading cause of cancer death in the United States. Approximately 3% of colorectal cancers are associated with Lynch Syndrome. Controversy exists regarding the optimal screening strategy for Lynch Syndrome. METHODS Using an individual level microsimulation of a population affected by Lynch syndrome over several years, effectiveness and cost-effectiveness of 21 screening strategies were compared. Modeling assumptions were based upon published literature, and sensitivity analyses were performed for key assumptions. In a two-step process, the number of Lynch syndrome diagnoses (Step 1) and life-years gained as a result of foreknowledge of Lynch syndrome in otherwise healthy carriers (Step 2) were measured. RESULTS The optimal strategy was sequential screening for probands starting with a predictive model, then immunohistochemistry for mismatch repair protein expression (IHC), followed by germline mutation testing (incremental cost-effectiveness ratio [ICER] of $35 143 per life-year gained). The strategies of IHC + BRAF, germline testing and universal germline testing of colon cancer probands had ICERs of $144 117 and $996 878, respectively. CONCLUSIONS This analysis suggests that the initial step in screening for Lynch Syndrome should be the use of predictive models in probands. Universal tumor testing and general population screening strategies are not cost-effective. When family history is unavailable, alternate strategies are appropriate. Documentation of family history and screening for Lynch Syndrome using a predictive model may be considered a quality-of-care measure for patients with colorectal cancer.
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Affiliation(s)
- Afsaneh Barzi
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Sarmad Sadeghi
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Michael W Kattan
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Neal J Meropol
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
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Bellizzi AM. Screening for Lynch syndrome: a no-brainer: BRAF V600E mutation-specific immunohistochemistry: caveat emptor. Am J Clin Pathol 2015; 143:320-4. [PMID: 25696788 DOI: 10.1309/ajcp3zdd3lthwczk] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Andrew M. Bellizzi
- Department of Pathology, University of Iowa Hospitals and Clinics, University of Iowa Carver College of Medicine, Iowa City
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128
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Kidambi TD, Terdiman JP. Screening for Lynch syndrome: it is time to shift the focus. Dig Dis Sci 2015; 60:586-7. [PMID: 25563721 DOI: 10.1007/s10620-014-3491-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/11/2014] [Indexed: 01/19/2023]
Affiliation(s)
- Trilokesh D Kidambi
- Department of Internal Medicine, University of California, San Francisco, 505 Parnassus Avenue, Room 987, San Francisco, CA, 94143, USA,
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Frolova AI, Babb SA, Zantow E, Hagemann AR, Powell MA, Thaker PH, Gao F, Mutch DG. Impact of an immunohistochemistry-based universal screening protocol for Lynch syndrome in endometrial cancer on genetic counseling and testing. Gynecol Oncol 2015; 137:7-13. [PMID: 25617771 DOI: 10.1016/j.ygyno.2015.01.535] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/14/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Evaluate effects of a Lynch syndrome universal screening protocol in newly diagnosed endometrial cancers on subsequent genetic counseling (GC) and germline testing (GT) referral and acceptance rates. METHODS We performed a retrospective cohort study of women who underwent a hysterectomy for endometrial cancer at Barnes Jewish Hospital in St. Louis, MO between 1/1/2011 and 12/31/2013 (n=637). An immunohistochemistry-based (IHC) universal screening protocol for Lynch syndrome was initiated on 12/17/2012. The cohorts consisted of women presenting prior to (Pre-Em-USP; n=395) and those presenting following (Em-USP; n=242) initiation of the universal screening protocol. GC and GT referrals were based on risk factors and/or IHC results. Comparisons were made using the Fisher's exact test and the Kruskal-Wallis test. RESULTS A greater proportion of individuals in the Em-USP cohort underwent GT than in Pre-Em-USP (9.1% vs 4.8%, p<0.05). Of individuals with an IHC screening result suggestive of LS, those within the Em-USP cohort were significantly more likely to accept GC compared to those in the Pre-Em-USP cohort (95% vs 64%, p=0.02). Specifically within the Em-USP cohort, patients referred to GC due to a concerning IHC screening result, versus those who were referred based on other risk factors, had a higher counseling acceptance rate (95% vs 61%, p=0.03) and underwent genetic testing more readily (76% vs 30%, p<0.001). CONCLUSIONS Implementation of an IHC-based universal screening protocol for LS in endometrial cancer leads to higher acceptance of genetic counseling and higher rates of genetic testing compared to referral based on risk factors alone.
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Affiliation(s)
- Antonina I Frolova
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Sheri A Babb
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Emily Zantow
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Andrea R Hagemann
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew A Powell
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Premal H Thaker
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States
| | - Feng Gao
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - David G Mutch
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, United States.
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130
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Severin F, Stollenwerk B, Holinski-Feder E, Meyer E, Heinemann V, Giessen-Jung C, Rogowski W. Economic evaluation of genetic screening for Lynch syndrome in Germany. Genet Med 2015; 17:765-73. [DOI: 10.1038/gim.2014.190] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/19/2014] [Indexed: 01/13/2023] Open
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131
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Rogowski W, Payne K, Schnell-Inderst P, Manca A, Rochau U, Jahn B, Alagoz O, Leidl R, Siebert U. Concepts of 'personalization' in personalized medicine: implications for economic evaluation. PHARMACOECONOMICS 2015; 33:49-59. [PMID: 25249200 PMCID: PMC4422179 DOI: 10.1007/s40273-014-0211-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
CONTEXT This study assesses if, and how, existing methods for economic evaluation are applicable to the evaluation of personalized medicine (PM) and, if not, where extension to methods may be required. METHODS A structured workshop was held with a predefined group of experts (n = 47), and was run using a modified nominal group technique. Workshop findings were recorded using extensive note taking, and summarized using thematic data analysis. The workshop was complemented by structured literature searches. RESULTS The key finding emerging from the workshop, using an economic perspective, was that two distinct, but linked, interpretations of the concept of PM exist (personalization by 'physiology' or 'preferences'). These interpretations involve specific challenges for the design and conduct of economic evaluations. Existing evaluative (extra-welfarist) frameworks were generally considered appropriate for evaluating PM. When 'personalization' is viewed as using physiological biomarkers, challenges include representing complex care pathways; representing spillover effects; meeting data requirements such as evidence on heterogeneity; and choosing appropriate time horizons for the value of further research in uncertainty analysis. When viewed as tailoring medicine to patient preferences, further work is needed regarding revealed preferences, e.g. treatment (non)adherence; stated preferences, e.g. risk interpretation and attitude; consideration of heterogeneity in preferences; and the appropriate framework (welfarism vs. extra-welfarism) to incorporate non-health benefits. CONCLUSIONS Ideally, economic evaluations should take account of both interpretations of PM and consider physiology and preferences. It is important for decision makers to be cognizant of the issues involved with the economic evaluation of PM to appropriately interpret the evidence and target future research funding.
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Affiliation(s)
- Wolf Rogowski
- Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany,
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132
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Bikhchandani J, Lynch HT. Commentary on 'Colonoscopy screening compliance and outcomes in patients with Lynch syndrome'. Colorectal Dis 2015; 17:46-9. [PMID: 25536883 DOI: 10.1111/codi.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Jai Bikhchandani
- Creighton University, 2500 California Plaza, Omaha, Nebraska, 68102, USA
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133
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Affiliation(s)
- Uri Ladabaum
- Gastrointestinal Cancer Prevention Program, and Clinical Cancer Genetics Program, Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Alway Bldg Rm M211, Stanford, CA, 94305-5187, USA,
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134
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Cost-effectiveness and diagnostic effectiveness analyses of multiple algorithms for the diagnosis of Lynch syndrome. Dig Dis Sci 2014; 59:2913-26. [PMID: 24957400 PMCID: PMC4237622 DOI: 10.1007/s10620-014-3248-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/03/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS The optimal algorithm to identify Lynch syndrome (LS) among patients with colorectal cancer (CRC) is unclear. The definitive test for LS, germline testing, is too expensive to be applied in all cases. Initial screening with the revised Bethesda Guidelines (RBG) cannot be applied in a considerable number of cases due to missing information. METHODS We developed a model to evaluate the cost-effectiveness of 10 strategies for diagnosing LS. Three main issues are addressed: modeling estimates (20-40%) of RBG applicability; comparing sequential or parallel use of microsatellite instability (MSI) and immunohistochemistry (IHC); and a threshold analysis of the charge value below which universal germline testing becomes the most cost-effective strategy. RESULTS LS detection rates in RBG-based strategies decreased to 64.1-70.6% with 20% inapplicable RBG. The strategy that uses MSI alone had lower yield, but also lower cost than strategies that use MSI sequentially or in parallel with IHC. The use of MSI and IHC in parallel was less affected by variations in the sensitivity and specificity of these tests. Universal germline testing had the highest yield and the highest cost of all strategies. The model estimated that if charges for germline testing drop to $633-1,518, universal testing of all newly diagnosed CRC cases becomes the most cost-effective strategy. CONCLUSIONS The low applicability of RBG makes strategies employing initial laboratory-based testing more cost-effective. Of these strategies, parallel testing with MSI and IHC offers the most robust yield. With a considerable drop in cost, universal germline testing may become the most cost-effective strategy for the diagnosis of LS.
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135
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The cost-effectiveness of returning incidental findings from next-generation genomic sequencing. Genet Med 2014; 17:587-95. [PMID: 25394171 DOI: 10.1038/gim.2014.156] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/30/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The American College of Medical Genetics and Genomics (ACMG) recommended that clinical laboratories performing next-generation sequencing analyze and return pathogenic variants for 56 specific genes it considered medically actionable. Our objective was to evaluate the clinical and economic impact of returning these results. METHODS We developed a decision-analytic policy model to project the quality-adjusted life-years and lifetime costs associated with returning ACMG-recommended incidental findings in three hypothetical cohorts of 10,000 patients. RESULTS Returning incidental findings to cardiomyopathy patients, colorectal cancer patients, or healthy individuals would increase costs by $896,000, $2.9 million, and $3.9 million, respectively, and would increase quality-adjusted life-years by 20, 25.4, and 67 years, respectively, for incremental cost-effectiveness ratios of $44,800, $115,020, and $58,600, respectively. In probabilistic analyses, returning incidental findings cost less than $100,000/quality-adjusted life-year gained in 85, 28, and 91%, respectively, of simulations. Assuming next-generation sequencing costs $500, the incremental cost-effectiveness ratio for primary screening of healthy individuals was $133,400 (<$100,000/quality-adjusted life-year gained in 10% of simulations). Results were sensitive to the cohort age and assumptions about gene penetrance. CONCLUSION Returning incidental findings is likely cost-effective for certain patient populations. Screening of generally healthy individuals is likely not cost-effective based on current data, unless next-generation sequencing costs less than $500.
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136
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Cragun D, DeBate RD, Pal T. Applying public health screening criteria: how does universal newborn screening compare to universal tumor screening for Lynch syndrome in adults with colorectal cancer? J Genet Couns 2014; 24:409-20. [PMID: 25323653 DOI: 10.1007/s10897-014-9769-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/27/2014] [Indexed: 12/11/2022]
Abstract
Institutions have increasingly begun to adopt universal tumor screening (UTS) programs whereby tumors from all newly diagnosed patients with colorectal cancer (CRC) are screened to identify who should be offered germline testing for Lynch syndrome (the most common cause of hereditary CRC). Given limited information about the impact of universal screening programs to detect hereditary disease in adults, we apply criteria used to evaluate public health screening programs and compare and contrast UTS with universal newborn screening (NBS) for the purpose of examining ethical implications and anticipating potential outcomes of UTS. Both UTS and a core set of NBS conditions clearly meet most of the Wilson and Jungner screening criteria. However, many state NBS panels include additional conditions that do not meet several of these criteria, and there is currently insufficient data to confirm that UTS meets some of these criteria. Comparing UTS and NBS with regard to newer screening criteria raises additional issues that require attention for both UTS and NBS. Comparisons also highlight the importance of evaluating the implementation of genomic tests to ensure or improve their effectiveness at reducing morbidity and mortality while minimizing potential harms.
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Affiliation(s)
- Deborah Cragun
- Department of Cancer Epidemiology, Moffitt Cancer Center, 12902, Magnolia Drive, Tampa, FL, 33612, USA,
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137
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Cragun D, DeBate RD, Vadaparampil ST, Baldwin J, Hampel H, Pal T. Comparing universal Lynch syndrome tumor-screening programs to evaluate associations between implementation strategies and patient follow-through. Genet Med 2014; 16:773-82. [PMID: 24651603 PMCID: PMC4169758 DOI: 10.1038/gim.2014.31] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 02/20/2014] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Universal tumor screening (UTS) for all colorectal cancer patients can improve the identification of Lynch syndrome, the most common cause of hereditary colorectal cancer. This multiple-case study explored how variability in UTS procedures influenced patient follow-through (PF) with germ-line testing after a screen-positive result. METHODS Data were obtained through Web-based surveys and telephone interviews with institutional informants. Institutions were categorized as Low-PF (≤10% underwent germ-line testing), Medium-PF (11-40%), or High-PF (>40%). To identify implementation procedures (i.e., conditions) unique to High-PF institutions, qualitative comparative analysis was performed. RESULTS Twenty-one informants from 15 institutions completed surveys and/or interviews. Conditions present among all five High-PF institutions included the following: (i) disclosure of screen-positive results to patients by genetic counselors; and (ii) genetic counselors either facilitate physician referrals to genetics professionals or eliminate the need for referrals. Although both of these High-PF conditions were present among two Medium-PF institutions, automatic reflex testing was lacking and difficulty contacting screen-positive patients was a barrier. The three remaining Medium-PF and five Low-PF institutions lacked the conditions found in High-PF institutions. CONCLUSION METHODS for streamlining UTS procedures, incorporating a high level of involvement of genetic counselors in tracking and communication of results and in reducing barriers to patient contact, are reviewed within a broader discussion on maximizing the effectiveness and public health impact of UTS.
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Affiliation(s)
| | | | | | | | | | - Tuya Pal
- Moffitt Cancer Center, Tampa, FL
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138
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Snyder SR, Mitropoulou C, Patrinos GP, Williams MS. Economic Evaluation of Pharmacogenomics: A Value-Based Approach to Pragmatic Decision Making in the Face of Complexity. Public Health Genomics 2014; 17:256-64. [DOI: 10.1159/000366177] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer. Gastroenterology 2014; 147:502-26. [PMID: 25043945 DOI: 10.1053/j.gastro.2014.04.001] [Citation(s) in RCA: 331] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3-6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington, Seattle, Washington
| | | | | | | | | | - Douglas J Robertson
- White River Junction VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | - Sapna Syngal
- Brigham and Women's Hospital, Boston, Massachusetts; Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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140
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2014; 80:197-220. [PMID: 25034835 DOI: 10.1016/j.gie.2014.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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141
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-society Task Force on colorectal cancer. Am J Gastroenterol 2014; 109:1159-79. [PMID: 25070057 DOI: 10.1038/ajg.2014.186] [Citation(s) in RCA: 312] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3,4,5,6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | | | - Jason A Dominitz
- 1] VA Puget Sound Health Care System, Seattle, Washington, USA [2] University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Douglas J Robertson
- 1] White River Junction VA Medical Center, White River Junction, Vermont, USA [2] Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA
| | - Sapna Syngal
- 1] Brigham and Women's Hospital, Boston, Massachusetts, USA [2] Dana Farber Cancer Institute, Boston, Massachusetts, USA [3] Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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142
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Sie AS, Mensenkamp AR, Adang EMM, Ligtenberg MJL, Hoogerbrugge N. Fourfold increased detection of Lynch syndrome by raising age limit for tumour genetic testing from 50 to 70 years is cost-effective. Ann Oncol 2014; 25:2001-2007. [PMID: 25081898 DOI: 10.1093/annonc/mdu361] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recognising colorectal cancer (CRC) patients with Lynch syndrome (LS) can increase life expectancy of these patients and their close relatives. To improve identification of this under-diagnosed disease, experts suggested raising the age limit for CRC tumour genetic testing from 50 to 70 years. The present study evaluates the efficacy and cost-effectiveness of this strategy. METHODS Probabilistic efficacy and cost-effectiveness analyses were carried out comparing tumour genetic testing of CRC diagnosed at age 70 or below (experimental strategy) versus CRC diagnosed at age 50 or below (current practice). The proportions of LS patients identified and cost-effectiveness including cascade screening of relatives, were calculated by decision analytic models based on real-life data. RESULTS Using the experimental strategy, four times more LS patients can be identified among CRC patients when compared with current practice. Both the costs to detect one LS patient (€9437/carrier versus €4837/carrier), and the number needed to test for detecting one LS patient (42 versus 19) doubled. When family cascade screening was included, the experimental strategy was found to be highly cost-effective according to Dutch standards, resulting in an overall ratio of €2703 per extra life-year gained in additionally tested patients. CONCLUSION Testing all CRC tumours diagnosed at or below age 70 for LS is cost-effective. Implementation is important as relatives from the large number of LS patients that are missed by current practice, can benefit from life-saving surveillance.
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Affiliation(s)
- A S Sie
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A R Mensenkamp
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E M M Adang
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M J L Ligtenberg
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.
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143
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Cohen SA, Leininger A. The genetic basis of Lynch syndrome and its implications for clinical practice and risk management. APPLICATION OF CLINICAL GENETICS 2014; 7:147-58. [PMID: 25161364 PMCID: PMC4142571 DOI: 10.2147/tacg.s51483] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Lynch syndrome is the most common cause of hereditary colon cancer, and accounts for as much as 3% of all colon and endometrial cancers. The identification and management of individuals with Lynch syndrome have evolved over the past 20 years, yet the syndrome remains vastly underdiagnosed. It is important for clinicians to recognize individuals and families who are at risk in order to be able to manage them appropriately and reduce their morbidity and mortality from this condition. This review will touch on the history of Lynch syndrome, the current knowledge of genotype–phenotype correlations, the cancers associated with Lynch syndrome, and management of individuals who are gene carriers.
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Affiliation(s)
- Stephanie A Cohen
- Cancer Genetics Risk Assessment Program, St Vincent Health, Indianapolis, IN, USA
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144
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Comparative effectiveness of next generation genomic sequencing for disease diagnosis: design of a randomized controlled trial in patients with colorectal cancer/polyposis syndromes. Contemp Clin Trials 2014; 39:1-8. [PMID: 24997220 DOI: 10.1016/j.cct.2014.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 11/22/2022]
Abstract
Whole exome and whole genome sequencing are applications of next generation sequencing transforming clinical care, but there is little evidence whether these tests improve patient outcomes or if they are cost effective compared to current standard of care. These gaps in knowledge can be addressed by comparative effectiveness and patient-centered outcomes research. We designed a randomized controlled trial that incorporates these research methods to evaluate whole exome sequencing compared to usual care in patients being evaluated for hereditary colorectal cancer and polyposis syndromes. Approximately 220 patients will be randomized and followed for 12 months after return of genomic findings. Patients will receive findings associated with colorectal cancer in a first return of results visit, and findings not associated with colorectal cancer (incidental findings) during a second return of results visit. The primary outcome is efficacy to detect mutations associated with these syndromes; secondary outcomes include psychosocial impact, cost-effectiveness and comparative costs. The secondary outcomes will be obtained via surveys before and after each return visit. The expected challenges in conducting this randomized controlled trial include the relatively low prevalence of genetic disease, difficult interpretation of some genetic variants, and uncertainty about which incidental findings should be returned to patients. The approaches utilized in this study may help guide other investigators in clinical genomics to identify useful outcome measures and strategies to address comparative effectiveness questions about the clinical implementation of genomic sequencing in clinical care.
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145
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Sehgal R, Sheahan K, O'Connell PR, Hanly AM, Martin ST, Winter DC. Lynch syndrome: an updated review. Genes (Basel) 2014; 5:497-507. [PMID: 24978665 PMCID: PMC4198913 DOI: 10.3390/genes5030497] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 04/30/2014] [Accepted: 05/09/2014] [Indexed: 01/05/2023] Open
Abstract
Lynch syndrome is one of the most common cancer susceptibility syndromes. Individuals with Lynch syndrome have a 50%-70% lifetime risk of colorectal cancer, 40%-60% risk of endometrial cancer, and increased risks of several other malignancies. It is caused by germline mutations in the DNA mismatch repair genes MLH1, MSH2, MSH6 or PMS2. In a subset of patients, Lynch syndrome is caused by 3' end deletions of the EPCAM gene, which can lead to epigenetic silencing of the closely linked MSH2. Relying solely on age and family history based criteria inaccurately identifies eligibility for Lynch syndrome screening or testing in 25%-70% of cases. There has been a steady increase in Lynch syndrome tumor screening programs since 2000 and institutions are rapidly adopting a universal screening approach to identify the patients that would benefit from genetic counseling and germline testing. These include microsatellite instability testing and/or immunohistochemical testing to identify tumor mismatch repair deficiencies. However, universal screening is not standard across institutions. Furthermore, variation exists regarding the optimum method for tracking and disclosing results. In this review, we summarize traditional screening criteria for Lynch syndrome, and discuss universal screening methods. International guidelines are necessary to standardize Lynch syndrome high-risk clinics.
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Affiliation(s)
- Rishabh Sehgal
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Kieran Sheahan
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Patrick R O'Connell
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Ann M Hanly
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Sean T Martin
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Desmond C Winter
- Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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146
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Direct-to-patient disclosure of results of mismatch repair screening for Lynch syndrome via electronic personal health record: a feasibility study. Genet Med 2014; 16:854-61. [PMID: 24784156 PMCID: PMC4216634 DOI: 10.1038/gim.2014.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/01/2014] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The adoption of universal mismatch repair screening of colorectal and endometrial cancers has the potential to improve detection of Lynch syndrome, as well as to improve health outcomes among cancer patients and their family members. Electronic patient health records represent an innovative, resource-efficient route of delivering results directly to patients that could be enhanced by multimedia interventions to improve critical downstream outcomes. The current study examines the feasibility and acceptability of this approach. METHODS Patients hospitalized for resection of colorectal or endometrial cancer were recruited to receive their mismatch repair result via institutional electronic patient health record. Baseline and follow-up assessments were conducted. RESULTS In all, 74% (49/66) of eligible patients consented, and 81% (29/36) of participants who had a result posted to their electronic patient health record completed follow-up, surpassing feasibility thresholds, with 14% (5/36) receiving an abnormal result. Ratings of the study approach surpassed the acceptability threshold--97% had a mean score of ≥ 4 on a 7-point scale--and were high, regardless of whether the results were normal or abnormal. Ineligibility was more common among non-white patients (P = 0.009) and patients ≥ 65 of age (P = 0.035) due to either low Internet use or access to the Internet. CONCLUSION Electronic patient health record-based result disclosure for mismatch repair screening is feasible to study and is acceptable to patients, but minority and elderly patients may experience greater barriers to participation.Genet Med 16 11, 854-861.
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147
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Hatz MHM, Schremser K, Rogowski WH. Is individualized medicine more cost-effective? A systematic review. PHARMACOECONOMICS 2014; 32:443-55. [PMID: 24574059 DOI: 10.1007/s40273-014-0143-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Individualized medicine (IM) is a rapidly evolving field that is associated with both visions of more effective care at lower costs and fears of highly priced, low-value interventions. It is unclear which view is supported by the current evidence. OBJECTIVE Our objective was to systematically review the health economic evidence related to IM and to derive general statements on its cost-effectiveness. DATA SOURCES A literature search of MEDLINE database for English- and German-language studies was conducted. STUDY APPRAISAL AND SYNTHESIS METHOD Cost-effectiveness and cost-utility studies for technologies meeting the MEDLINE medical subject headings (MeSH) definition of IM (genetically targeted interventions) were reviewed. This was followed by a standardized extraction of general study characteristics and cost-effectiveness results. RESULTS Most of the 84 studies included in the synthesis were from the USA (n = 43, 51 %), cost-utility studies (n = 66, 79 %), and published since 2005 (n = 60, 71 %). The results ranged from dominant to dominated. The median value (cost-utility studies) was calculated to be rounded $US22,000 per quality-adjusted life year (QALY) gained (adjusted to $US, year 2008 values), which is equal to the rounded median cost-effectiveness in the peer-reviewed English-language literature according to a recent review. Many studies reported more than one strategy of IM with highly varying cost-effectiveness ratios. Generally, results differed according to test type, and tests for disease prognosis or screening appeared to be more favorable than tests to stratify patients by response or by risk of adverse effects. However, these results were not significant. LIMITATIONS Different definitions of IM could have been used. Quality assessment of the studies was restricted to analyzing transparency. CONCLUSIONS IM neither seems to display superior cost-effectiveness than other types of medical interventions nor to be economically inferior. Instead, rather than 'whether' healthcare was individualized, the question of 'how' it was individualized was of economic relevance.
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Affiliation(s)
- Maximilian H M Hatz
- Hamburg Center for Health Economics, University of Hamburg, 20354, Hamburg, Germany,
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148
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Schofield L, Grieu F, Amanuel B, Carrello A, Spagnolo D, Kiraly C, Pachter N, Goldblatt J, Platell C, Levitt M, Stewart C, Salama P, Ee H, Raftopoulous S, Katris P, Threlfall T, Edkins E, Wallace M, Iacopetta B. Population-based screening for Lynch syndrome in Western Australia. Int J Cancer 2014; 135:1085-91. [PMID: 24474394 DOI: 10.1002/ijc.28744] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 12/13/2013] [Indexed: 11/11/2022]
Abstract
We showed earlier that routine screening for microsatellite instability (MSI) and loss of mismatch repair (MMR) protein expression in colorectal cancer (CRC) led to the identification of previously unrecognized cases of Lynch syndrome (LS). We report here the results of screening for LS in Western Australia (WA) during 1994-2012. Immunohistochemistry (IHC) for loss of MMR protein expression was performed in routine pathology laboratories, while MSI was detected in a reference molecular pathology laboratory. Information on germline mutations in MMR genes was obtained from the state's single familial cancer registry. Prior to the introduction of routine laboratory-based screening, an average of 2-3 cases of LS were diagnosed each year amongst WA CRC patients. Following the implementation of IHC and/or MSI screening for all younger (<60 years) CRC patients, this has increased to an average of 8 LS cases diagnosed annually. Based on our experience in WA, we propose three key elements for successful population-based screening of LS. First, for all younger CRC patients, reflex IHC testing should be carried out in accredited pathology services with ongoing quality control. Second, a state- or region-wide reference laboratory for MSI testing should be established to confirm abnormal or suspicious IHC test results and to exclude sporadic cases by carrying out BRAF mutation or MLH1 methylation testing. Finally, a state or regional LS coordinator is essential to ensure that all appropriate cases identified by laboratory testing are referred to and attend a Familial Cancer Clinic for follow-up and germline testing.
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Affiliation(s)
- Lyn Schofield
- School of Surgery, University of Western Australia, Crawley, WA; Genetic Services of Western Australia, King Edward Memorial Hospital, Subiaco, WA; School of Paediatrics and Child Health, University of Western Australia, Crawley, WA
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149
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Hitch K, Joseph G, Guiltinan J, Kianmahd J, Youngblom J, Blanco A. Lynch syndrome patients' views of and preferences for return of results following whole exome sequencing. J Genet Couns 2014; 23:539-51. [PMID: 24449059 DOI: 10.1007/s10897-014-9687-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 01/05/2014] [Indexed: 01/24/2023]
Abstract
Whole exome sequencing (WES) uses next generation sequencing technology to provide information on nearly all functional, protein-coding regions in an individual's genome. Due to the vast amount of information and incidental findings that can be generated from this technology, patient preferences must be investigated to help clinicians consent and return results to patients. Patients (n = 19) who were previously clinically diagnosed with Lynch syndrome, but received uninformative negative Lynch syndrome genetic results through traditional molecular testing methods participated in semi-structured interviews after WES testing but before return of results to explore their views of WES and preferences for return of results. Analyses of interview results found that nearly all participants believed that the benefits of receiving all possible results generated from WES outweighed the undesirable effects. The majority of participants conveyed that relative to coping with a cancer diagnosis, information generated from WES would be manageable. Importantly, participants' experience with Lynch syndrome influenced their notions of genetic determinism, tolerance for uncertain results, and family communication plans. Participants would prefer to receive WES results in person from a genetic counselor or medical geneticist so that an expert could help explain the meaning and implications of the potentially large quantity and range of complicated results. These results underscore the need to study various populations with regard to the clinical use of WES in order to effectively and empathetically communicate the possible implications of this new technology and return results.
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Affiliation(s)
- Kelly Hitch
- California State University, Stanislaus, Turlock, CA, USA,
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150
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Guillén-Ponce C, Molina-Garrido MJ, Carrato A. Follow-up recommendations and risk-reduction initiatives for Lynch syndrome. Expert Rev Anticancer Ther 2014; 12:1359-67. [DOI: 10.1586/era.12.114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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