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Frey MK, Ahsan MD, Bergeron H, Lin J, Li X, Fowlkes RK, Narayan P, Nitecki R, Rauh-Hain JA, Moss HA, Baltich Nelson B, Thomas C, Christos PJ, Hamilton JG, Chapman-Davis E, Cantillo E, Holcomb K, Kurian AW, Lipkin S, Offit K, Sharaf RN. Cascade Testing for Hereditary Cancer Syndromes: Should We Move Toward Direct Relative Contact? A Systematic Review and Meta-Analysis. J Clin Oncol 2022; 40:4129-4143. [PMID: 35960887 PMCID: PMC9746789 DOI: 10.1200/jco.22.00303] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Evidence-based guidelines recommend cascade genetic counseling and testing for hereditary cancer syndromes, providing relatives the opportunity for early detection and prevention of cancer. The current standard is for patients to contact and encourage relatives (patient-mediated contact) to undergo counseling and testing. Direct relative contact by the medical team or testing laboratory has shown promise but is complicated by privacy laws and lack of infrastructure. We sought to compare outcomes associated with patient-mediated and direct relative contact for hereditary cancer cascade genetic counseling and testing in the first meta-analysis on this topic. MATERIALS AND METHODS We conducted a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO No.: CRD42020134276). We searched key electronic databases to identify studies evaluating hereditary cancer cascade testing. Eligible trials were subjected to meta-analysis. RESULTS Eighty-seven studies met inclusion criteria. Among relatives included in the meta-analysis, 48% (95% CI, 38 to 58) underwent cascade genetic counseling and 41% (95% CI, 34 to 48) cascade genetic testing. Compared with the patient-mediated approach, direct relative contact resulted in significantly higher uptake of genetic counseling for all relatives (63% [95% CI, 49 to 75] v 35% [95% CI, 24 to 48]) and genetic testing for first-degree relatives (62% [95% CI, 49 to 73] v 40% [95% CI, 32 to 48]). Methods of direct contact included telephone calls, letters, and e-mails; respective rates of genetic testing completion were 61% (95% CI, 51 to 70), 48% (95% CI, 37 to 59), and 48% (95% CI, 45 to 50). CONCLUSION Most relatives at risk for hereditary cancer do not undergo cascade genetic counseling and testing, forgoing potentially life-saving medical interventions. Compared with patient-mediated contact, direct relative contact increased rates of cascade genetic counseling and testing, arguing for a shift in the care delivery paradigm, to be confirmed by randomized controlled trials.
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Affiliation(s)
| | | | | | - Jenny Lin
- Weill Cornell Medicine, New York, NY
| | - Xuan Li
- Weill Cornell Medicine, New York, NY
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- Memorial Sloan Kettering Cancer Center, New York, NY
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Petersen J, Koptiuch C, Wu YP, Mooney R, Elrick A, Szczotka K, Keener M, Pappas L, Kanth P, Soisson A, Kohlmann W, Kaphingst KA. Patterns of family communication and preferred resources for sharing information among families with a Lynch syndrome diagnosis. PATIENT EDUCATION AND COUNSELING 2018; 101:2011-2017. [PMID: 30097381 PMCID: PMC6179927 DOI: 10.1016/j.pec.2018.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/13/2018] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To explore patterns of communication among families with a Lynch syndrome diagnosis and understand what resources could facilitate family communication. METHODS 127 probands (i.e., first person in family with identified mutation) and family members participated in semi-structured interviews about: how they learned about the Lynch syndrome diagnosis, with whom they shared genetic test results, confidence in sharing results with other family members, and helpfulness of educational resources. RESULTS Both probands and family members were most likely to share genetic test results with parents and siblings, and least likely to share results with aunts, uncles, and cousins. Most participants felt very confident sharing their test results with family members, but reported that certain topics such as cancer risk were challenging to convey. Probands reported the most helpful resources to be access to a specialty clinic or website, while family members described general printed materials as most helpful. CONCLUSIONS Families affected by Lynch syndrome may experience barriers to communication with more distant relatives, and may benefit from receiving specific resources (e.g., websites about Lynch syndrome, print materials) to facilitate family communication. PRACTICE IMPLICATIONS Providers could emphasize the need to share information with more distant family members and provide appropriate supportive resources.
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Affiliation(s)
- Jenna Petersen
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Cathryn Koptiuch
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Yelena P Wu
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA; Department of Dermatology, University of Utah, Salt Lake City, UT, USA.
| | - Ryan Mooney
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Ashley Elrick
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA; Department of Communication, University of Utah, Salt Lake City, UT, USA.
| | - Kathryn Szczotka
- Department of Medicine (Gastroenterology), University of Utah, Salt Lake City, UT, USA.
| | - Megan Keener
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Lisa Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Priyanka Kanth
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA; Department of Medicine (Gastroenterology), University of Utah, Salt Lake City, UT, USA.
| | - Andrew Soisson
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.
| | - Wendy Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Kimberly A Kaphingst
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA; Department of Communication, University of Utah, Salt Lake City, UT, USA.
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Lowery JT, Ahnen DJ, Schroy PC, Hampel H, Baxter N, Boland CR, Burt RW, Butterly L, Doerr M, Doroshenk M, Feero WG, Henrikson N, Ladabaum U, Lieberman D, McFarland EG, Peterson SK, Raymond M, Samadder NJ, Syngal S, Weber TK, Zauber AG, Smith R. Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review. Cancer 2016; 122:2633-45. [PMID: 27258162 PMCID: PMC5575812 DOI: 10.1002/cncr.30080] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/08/2016] [Accepted: 01/15/2016] [Indexed: 12/14/2022]
Abstract
Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2633-2645. © 2016 American Cancer Society.
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Affiliation(s)
- Jan T Lowery
- Colorado School of Public Health, Aurora, Colorado
| | - Dennis J Ahnen
- School of Medicine and Gastroenterology of the Rockies, University of Colorado, Boulder, Colorado
| | - Paul C Schroy
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Heather Hampel
- Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | | | | | - Randall W Burt
- Huntsman Cancer Institute, University of Utah Health Care, Salt Lake City, Utah
| | - Lynn Butterly
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | - W Gregory Feero
- Maine Dartmouth Family Medicine Residency Program, Augusta, Maine
| | | | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, California
| | | | | | - Susan K Peterson
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - N Jewel Samadder
- Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Ann G Zauber
- Memorial Sloan Kettering Cancer Center, New York, New York
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4
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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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5
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Schneider KI, Schmidtke J. Patient compliance based on genetic medicine: a literature review. J Community Genet 2013; 5:31-48. [PMID: 23934761 DOI: 10.1007/s12687-013-0160-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 07/02/2013] [Indexed: 12/19/2022] Open
Abstract
For this literature review, medical literature data bases were searched for studies on patient compliance after genetic risk assessment. The review focused on conditions where secondary or tertiary preventive options exist, namely cancer syndromes (BRCA-related cancer, HNPCC/colon cancer), hemochromatosis, thrombophilia, smoking cessation, and obesity. As a counterpart, patient compliance was assessed regarding medication adherence and medical advice in some of the most epidemiologically important conditions (including high blood pressure, metabolic syndrome, and coronary heart disease) after receiving medical advice based on nongenetic risk information or a combination of genetic and nongenetic risk information. In the majority of studies based on genetic risk assessments, patients were confronted with predictive rather than diagnostic genetic profiles. Most of the studies started from a knowledge base around 10 years ago when DNA testing was at an early stage, limited in scope and specificity, and costly. The major result is that overall compliance of patients after receiving a high-risk estimate from genetic testing for a given condition is high. However, significant behavior change does not take place just because the analyte is "genetic." Many more factors play a role in the complex process of behavioral tuning. Without adequate counseling and guidance, patients may interpret risk estimates of predictive genetic testing with an increase in fear and anxiety.
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Affiliation(s)
- Kai Insa Schneider
- Institute of Human Genetics, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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Bruwer Z, Futter M, Ramesar R. Communicating cancer risk within an African context: experiences, disclosure patterns and uptake rates following genetic testing for Lynch syndrome. PATIENT EDUCATION AND COUNSELING 2013; 92:53-60. [PMID: 23453851 DOI: 10.1016/j.pec.2013.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 01/16/2013] [Accepted: 02/03/2013] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Data pertaining to Lynch syndrome within a developing country are sparse. This study explored the emotional reaction to a mutation-positive test result among a group of individuals from South Africa. As genetic information is not only limited to the individual but extends to the biological family, communication patterns and uptake of testing among at-risk family members was also investigated. METHODS Eighty individuals participated in this qualitative interview study. RESULTS Eight emotional reactions were observed, of which two were of particular concern: (1) secrecy due to disbelief and (2) interpretation of a mutation-positive result as a cancer diagnosis. Disclosure rates of personal genetic test results were high to family members, but low to general healthcare providers. Disclosing the test result was not always followed by a discussion of implications of the genetic information or availability of predictive testing for at-risk family members. The uptake rate of predictive testing among the participants' siblings and children was 97% and 73.6%, respectively. CONCLUSION Awareness of concerning emotional reactions following the delivery of a genetic test result and insight into disclosure patterns, especially the information that is not communicated, will prove beneficial in improving the effectiveness of counselling and management in Lynch syndrome families. PRACTICE IMPLICATIONS Implementation of these findings into the PT programme will have a positive effect on the genetic counseling process.
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Affiliation(s)
- Zandrè Bruwer
- MRC/UCT Human Genetics Research Unit, IIDMM Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
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Burton AM, Hovick SR, Peterson SK. Health behaviors in patients and families with hereditary colorectal cancer. Clin Colon Rectal Surg 2013; 25:111-7. [PMID: 23730226 DOI: 10.1055/s-0032-1313782] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is estimated that 5 to 10% of all colorectal cancer (CRC) cases are attributed to a hereditary cause. The primary hereditary cancer syndromes that confer an increased risk for colorectal cancers are Lynch syndrome/hereditary nonpolyposis colorectal cancer (HNPCC) and familial adenomatous polyposis (FAP). Through genetic testing, health care providers can identify patients and families who carry gene mutations and subsequently are at a substantially greater risk for developing colorectal cancer than the general population. Genetic testing provides risk information not only about an individual patient, but also his or her biological relatives. A variety of risk-reduction behaviors (including screening, surgery, and health and lifestyle behaviors) have been examined in Lynch syndrome and FAP populations. The research indicates that screening behaviors are less than optimal, although the rates vary from study to study. Prophylactic colectomy is the primary course of treatment for individuals who test positive for a FAP mutation, but the results are inconclusive for cancer-unaffected Lynch syndrome mutation carriers. Although research suggests that the adoption of healthy lifestyles and behaviors (e.g., diet, physical activity, weight control, smoking cessation, limited alcohol consumption) could have a favorable impact on colon cancer burden, there is minimal data on how these behaviors may moderate cancer risk among those at risk of hereditary colon cancer. To date, we know very little about the actual health and lifestyle behaviors of those at risk of hereditary colon cancer. Genetic testing and counseling at risk individuals may resolve uncertainty about their personal and familial cancer risk and provide information to guide and personalize decisions about their future health care.
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Affiliation(s)
- Allison M Burton
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
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8
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James AS, Chisholm P, Wolin KY, Baxter M, Kaphingst K, Davidson NO. Screening and Health Behaviors among Persons Diagnosed with Familial Adenomatous Polyposis and Their Relatives. J Cancer Epidemiol 2012; 2012:506410. [PMID: 22899922 PMCID: PMC3414059 DOI: 10.1155/2012/506410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/08/2012] [Accepted: 06/19/2012] [Indexed: 01/02/2023] Open
Abstract
Familial Adenomatous Polyposis (FAP) is a rare autosomal dominantly inherited colorectal cancer syndrome. Individuals with FAP often undergo colectomy and are recommended to follow several surveillance protocols. Biological relatives of persons with FAP may also be at risk and thus should undergo genetic counseling. Screening adherence, genetic testing, and other health behaviors among individuals with FAP and their relatives are not well characterized. We conducted a cross-sectional self-report survey with individuals who have FAP (n = 35) and their biological relatives (n = 15). Respondents were recruited through a cancer center registry for inherited colon cancers. Most relatives had undergone colon cancer screening; 40% had undergone genetic testing. One fifth of respondents with FAP had not undergone an upper endoscopy, contrary to usual recommendations. Cigarette smoking rates were above average and were higher among FAP respondents. Use of vitamin supplements was fairly common, more so among those with FAP. Although most people had been screened, there are areas for improvement, notably for upper endoscopy among individuals with FAP and genetic testing among family members. Several other health-risk behaviors and health concerns other than FAP were identified. Further research into factors contributing to screening rates and other health behaviors in this high-risk population is warranted.
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Affiliation(s)
- Aimee S. James
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, 660 So. Euclid Avenue, P.O. Box 8100, Saint Louis, MO 63110, USA
| | - Phillip Chisholm
- Department of Medicine, Washington University in Saint Louis, 4950 Children's place St. Louis, MO 63110, USA
| | - Kathleen Y. Wolin
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, 660 So. Euclid Avenue, P.O. Box 8100, Saint Louis, MO 63110, USA
| | - Melanie Baxter
- Siteman Cancer Center, Washington University in Saint Louis, 660 So. Euclid Avenue, P.O. Box 8100, Saint Louis, MO 63110, USA
| | - Kimberly Kaphingst
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, 660 So. Euclid Avenue, P.O. Box 8100, Saint Louis, MO 63110, USA
| | - Nicholas O. Davidson
- Division of Gastroenterology, Department of Medicine, Washington University in Saint Louis, 660 So. Euclid Avenue, P.O. Box 8124, Saint Louis, MO 63110, USA
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Esplen MJ, Stuckless N, Gallinger S, Aronson M, Rothenmund H, Semotiuk K, Stokes J, Way C, Green J, Butler K, Petersen HV, Wong J. Development and validation of an instrument to measure the impact of genetic testing on self-concept in Lynch syndrome. Clin Genet 2011; 80:415-23. [PMID: 21883167 DOI: 10.1111/j.1399-0004.2011.01770.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A positive genetic test result may impact on a person's self-concept and affect quality of life. The purpose of the study was to develop a self-concept scale to measure such impact for individuals carrying mutations for a heritable colorectal cancer Lynch syndrome (LS). Two distinct phases were involved: Phase 1 generated specific colorectal self-concept candidate scale items from interviews with eight LS carriers and five genetic counselors, which were added to a previously developed self-concept scale for BRCA1/2 mutation carriers, Phase II had 115 LS carriers complete the candidate scale and a battery of validating measures. A 20-item scale was developed with two dimensions identified through factor analysis: stigma/vulnerability and bowel symptom-related anxiety. The scale showed excellent reliability (Cronbach's α = 0.93), good convergent validity by a high correlation with impact of event scale (r(102) = 0.55, p < 0.001) and Rosenberg self-esteem scale (r(108) = -0.59, p < 0.001), and a low correlation with the Fear questionnaire (r(108) = 0.37, p < 0.001). The scale's performance was stable across participant characteristics. This new scale for measuring self-concept has potential to be used as a clinical tool and as a measure for future studies.
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Affiliation(s)
- M J Esplen
- Behavioral Sciences and Health Research Division, Toronto General Research Institute, University Health Network, Toronto, Canada.
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Ladabaum U, Wang G, Terdiman J, Blanco A, Kuppermann M, Boland CR, Ford J, Elkin E, Phillips KA. Strategies to identify the Lynch syndrome among patients with colorectal cancer: a cost-effectiveness analysis. Ann Intern Med 2011. [PMID: 21768580 DOI: 10.1059/0003-4819-155-2-201107190-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine. OBJECTIVE To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives. DESIGN Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers. DATA SOURCES Published literature. TARGET POPULATION All persons with newly diagnosed colorectal cancer and their relatives. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery. OUTCOME MEASURES Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36,200 per life-year gained. RESULTS OF SENSITIVITY ANALYSIS The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50,000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100,000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44,000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88,700 per incremental life-year gained compared with screening only up to age 70 years. LIMITATION Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered. CONCLUSION Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
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11
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Ladabaum U, Wang G, Terdiman J, Blanco A, Kuppermann M, Boland CR, Ford J, Elkin E, Phillips KA. Strategies to identify the Lynch syndrome among patients with colorectal cancer: a cost-effectiveness analysis. Ann Intern Med 2011; 155:69-79. [PMID: 21768580 PMCID: PMC3793257 DOI: 10.7326/0003-4819-155-2-201107190-00002] [Citation(s) in RCA: 271] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine. OBJECTIVE To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives. DESIGN Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers. DATA SOURCES Published literature. TARGET POPULATION All persons with newly diagnosed colorectal cancer and their relatives. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery. OUTCOME MEASURES Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36,200 per life-year gained. RESULTS OF SENSITIVITY ANALYSIS The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50,000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100,000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44,000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88,700 per incremental life-year gained compared with screening only up to age 70 years. LIMITATION Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered. CONCLUSION Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
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12
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Palmquist AEL, Koehly LM, Peterson SK, Shegog M, Vernon SW, Gritz ER. "The cancer bond": exploring the formation of cancer risk perception in families with Lynch syndrome. J Genet Couns 2010; 19:473-86. [PMID: 20401527 PMCID: PMC2940987 DOI: 10.1007/s10897-010-9299-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 03/23/2010] [Indexed: 12/15/2022]
Abstract
This study explores the social context of hereditary cancer risk perception in three families, an African-American family, a Mexican-American family, and a Caucasian family, each with Lynch Syndrome documented by a mismatch repair gene mutation. Communication network assessments measured family communication about cancer experiences and genetic testing information among a total of 26 participants. Participant narratives were evaluated to gain insight into how family cancer experiences and genetic testing information have shaped perceptions of cancer risk. Analysis of communication networks indicated that some families discussed cancer experiences to a greater extent than genetic testing information, and vice-versa. Interviews elucidated that sharing both types of health information led participants to conceptualize linkages among a strong family history of cancer, genetic testing information, and cancer prevention strategies. Understanding how different types of family communication influence the formation of perceived hereditary disease risk may enhance efforts to tailor genetic counseling services for families.
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Affiliation(s)
- Aunchalee E L Palmquist
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
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13
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Kiviniemi MT, Hay JL, James AS, Lipkus IM, Meissner HI, Stefanek M, Studts JL, Bridges JFP, Close DR, Erwin DO, Jones RM, Kaiser K, Kash KM, Kelly KM, Craddock Lee SJ, Purnell JQ, Siminoff LA, Vadaparampil ST, Wang C. Decision making about cancer screening: an assessment of the state of the science and a suggested research agenda from the ASPO Behavioral Oncology and Cancer Communication Special Interest Group. Cancer Epidemiol Biomarkers Prev 2009; 18:3133-7. [PMID: 19900944 PMCID: PMC2810193 DOI: 10.1158/1055-9965.epi-18-11-aspo] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Marc T Kiviniemi
- Department of Health Behavior, University at Buffalo, Buffalo, New York 14222, USA.
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14
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Ersig AL, Williams JK, Hadley DW, Koehly LM. Communication, encouragement, and cancer screening in families with and without mutations for hereditary nonpolyposis colorectal cancer: a pilot study. Genet Med 2009; 11:728-34. [PMID: 19707152 PMCID: PMC2917812 DOI: 10.1097/gim.0b013e3181b3f42d] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Known and suspected mutation carriers for hereditary nonpolyposis colorectal cancer are advised to have colonoscopies every 1 to 2 years to detect colorectal cancer. Little is known about colonoscopy completion in families suspected of having hereditary nonpolyposis colorectal cancer but without identified mutations. METHODS This study examined the effect of communication and encouragement on colonoscopy in families with and without known mutations. Twenty-three respondents from 11 families with indeterminate genetic test results were matched with 23 respondents from 11 families with mutation-positive results. Hierarchical modeling examined the effects of relational characteristics on time since last colonoscopy in index cases and their first-degree relatives. RESULTS Nearly one fifth of respondents were not screening appropriately. Time since last screening did not differ according to family mutation status. However, respondents who communicated about risk and received encouragement to screen from a greater proportion of named family members, and those who had a greater proportion of named family members involved in both communication and encouragement were significantly more likely to have a shorter time interval since last colonoscopy. CONCLUSION Identifying patterns of interaction within at-risk families, regardless of gene mutation status, may be one avenue for promoting screening adherence.
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Affiliation(s)
- Anne L Ersig
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health Bethesda, Maryland, USA.
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