Suboptimal Adherence in Clinical Practice to Guidelines Recommendation to Screen for Lynch Syndrome

Immunohistochemistry staining for DNA mismatch repair proteins in endoscopic biopsies and the corresponding surgical specimen in colorectal cancer

Microsatellite instability is found in 15% of sporadic colorectal cancers (CRC) and 95% of hereditary CRC cases. Lynch syndrome (LS) diagnosis begins with the analysis of the surgical specimen using methods such as immunohistochemistry (IHC), which identifies changes in the nuclear expression of DNA mismatch repair (MMR) proteins. However, IHC analysis on endoscopic biopsies could provide substantial benefits. Our goal was to assess the accuracy of MMR IHC status on endoscopic biopsies in comparison to corresponding surgical specimen in a series of CRC. We retrospectively selected patients who had undergone CRC surgery between February 2011 and January 2020 and had IHC testing for MMR proteins on the surgical specimen. The study was then performed on the corresponding endoscopic biopsies and results were compared. MMR IHC staining on surgical specimens were available for 361 CRC patients and only in 154 cases for preoperative endoscopic biopsies. The concordance between MMR IHC status of the endoscopic biopsy and the surgical specimen analysis was 98.6% for the MLH1/PMS2 proteins and 100% for MSH2/MSH6. In conclusion, endoscopic biopsies of colorectal tumors serve as a suitable tissue source for the immunohistochemical analysis of DNA repair proteins. The correlation with results from the surgical specimen was notably high and discrepancies were primarily as a result of intratumoral heterogeneity within the same sample. The features of MMR protein loss in endoscopic biopsies can provide clinicians with valuable information for specific therapeutic approaches and genetic counseling.

Creation of a Quality Payment Program Measure for Mismatch Repair or Microsatellite Instability Biomarker Testing Status in Colorectal, Endometrial, Gastroesophageal, or Small Bowel Carcinoma

CONTEXT.—

Quality measures that are supported by evidence-based clinical practice guidelines are preferred for assessing the quality of pathologists' practices. Careful testing of a measure ensures that scores obtained by that measure reflect the quality of a pathologist's practice.

OBJECTIVE.—

To specify a new quality measure and to demonstrate through testing that it is suitable for measuring pathologists' appropriate incorporation of information regarding microsatellite instability (MSI) and/or mismatch repair (MMR) status in pathology reports for colorectal, endometrial, gastroesophageal, and small bowel carcinoma.

DESIGN.—

The College of American Pathologists collaborated with the American Gastroenterological Association to specify and test the new measure. Face validity testing was used to investigate the validity of the measure. Feasibility testing was conducted to understand if data elements required by the measure specification were readily accessible. Signal-to-noise analysis was used to characterize the measure's reliability.

RESULTS.—

Guideline recommendations for MSI and/or MMR testing supported specifications for the measure. Face validity testing indicated that the measure could distinguish the quality of care provided. Data elements required by the measure specification were found to be accessible, which supported the measure's feasibility. Reliability testing showed that differences in measure score were attributable to real differences in performance rather than random variation in scoring.

CONCLUSIONS.—

The Mismatch Repair or Microsatellite Instability Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma measure was appropriately specified, and testing demonstrated that it is well suited for characterizing the quality of pathologists' communication of MMR and/or MSI status.

US physical therapist practice patterns evaluating concussion and clinical practice guideline adherence

OBJECTIVES

To assess the influence of contemporary physical therapy clinical practice guidelines (CPG) on concussion evaluation practice patterns and barriers/facilitators for CPG adherence.

DESIGN

Electronic cross-sectional survey.

SETTING

Online survey platform.

PARTICIPANTS

US licensed physical therapists that manage concussion.

MAIN OUTCOME MEASURES

1) practice patterns 2) knowledge/use of CPG 3) barriers/facilitations to CPG adherence.

RESULTS

Knowledge/use of CPG categories significantly predicted the model (χ²(1) = 10.966, p < .001) of total vignette scores/practice patterns with a statistically significant effect. A Kruskal-Wallis test indicated significant differences in total vignette score means based on knowledge/use between "not aware of the concussion CPG" and "integrated concussion CPG into practice" groups (p < .001, ES = .21). Knowledge/use of the CPG predicted the perceived barriers/facilitators model for three questions: investment in specialized concussion training (χ²(1) = 39.52, p < .001), necessary equipment to complete concussion evaluation (χ²(1) = 16.01, p < .001), and confidence around concussion evaluation knowledge (χ²(1) = 27.46, p < .001) with a significant effect.

CONCLUSION

The results of this study provide support for guiding documents like the CPG to positively influence concussion practice patterns and insight into facilitators for guideline adherence.

Systems approach to enhance Lynch syndrome diagnosis through tumour testing

BACKGROUND

Guidelines recommend universal mismatch repair (MMR) tumour testing of colorectal adenocarcinomas (CRCs) to screen for Lynch syndrome (LS). However, its implementation remains disjointed and referral for genetic testing dismal, particularly among minorities. We aimed to increase referral, cancer genetic testing and eventually LS diagnosis by developing the CLEAR LS (Closed Loop Enhanced Assessment and Referral for Lynch Syndrome) intervention, a systems approach which in the second phase was automated.

METHODS

This is a cohort study of all patients diagnosed with CRC at an academic centre between 1 January 2012, when implementation of universal CRC testing began, and 31 January 2021. The original cohort spanned through 31 May 2015. Tumour testing included MMR immunohistochemistry, followed by BRAF V600E/MLH1 promoter methylation testing when indicated. The intervention included a manual phase (1 June 2015 through 31 July 2018), which systematised pathology screening and cancer genetics (CG) referral mechanisms, and an automated phase (1 August 2018 through 31 January 2021) using computer programming.

RESULTS

A total of 249/1541 CRC (17.38%) had MMR loss of expression and 129 (8.37%) qualified for CG evaluation. Referral was 27.58% in the original cohort and 92.1% in the intervention (p<0.001). Patients seen by CG among referred were 27.58% in the original cohort and 74.3% in the intervention (p two-sided<0.001). The distribution of race/ethnicity among patients qualifying and referred for CG evaluation was not significantly different across cohorts. LS diagnosis increased from 0.56% (original cohort) to 1.43% (intervention). Cost per new diagnosis of LS decreased from US$173 675 to $87 960 from original cohort to intervention.

CONCLUSION

Implementation of systematic case identification and referral support mechanisms significantly increased the proportion of patients undergoing genetic testing and doubled the percentage of patients diagnosed with LS with no referral differences across racial/ethnic groups.

Dynamic serum biomarkers to predict the efficacy of PD-1 in patients with nasopharyngeal carcinoma

Background

There is a lack of effective treatments for recurrent or metastatic nasopharyngeal carcinoma (RM-NPC). Furthermore, the response rate of NPC patients to programmed death 1 (PD-1) inhibitors is approximately 20% to 30%. Thus, we aimed to explore reliable and minimally invasive prognostic indicators to predict the efficacy of PD-1 inhibitors combination therapy in RM-NPC.

Methods

The serum markers of 160 RM-NPC patients were measured before and three weeks after the first anti-PD-1 treatment. The least absolute shrinkage and selection operator (LASSO) logistic regression was carried out to select dynamic serum indicators and construct a prediction model. Furthermore, we carried out univariate, multivariate, nomogram and survival analyses to identify independent prognostic factors that were associated with 1-year progression-free survival (PFS).

Results

Based on two markers that were screened by Lasso logistic regression, we constructed a risk score prediction model for the prediction of anti-PD-1 efficacy at 8–12 weeks with an AUC of 0.737 in the training cohort and 0.723 in the validation cohort. Risk score and metastases were included in the nomogram, and the Kaplan–Meier survival curves demonstrated that the high-risk group has shorter PFS compared to the low-risk group. The concordance index (C-index) of the nomogram for PFS is higher than that of the TNM stage in the training and validation cohort.

Conclusion

We proposed a strategy to monitor dynamic changes in the biochemistry markers and emphasized their importance as potential prognostic biomarkers for the treatment of advanced NPC treated with PD-1 inhibitors. Our risk score prediction model was based on the dynamic change of LDH and AST/ALT, which has predictive and prognostic value for NPC patients who were treated with PD-1 inhibitors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-021-02217-y.

Biomarkers of immune checkpoint inhibitor efficacy in cancer

Immune checkpoint inhibitor-based therapies that target ctla-4, PD-1, or the PD-1 ligand PD-L1 have received approval in Canada and many parts of the world for the treatment of melanoma, renal cell cancer, urothelial cancer, classical Hodgkin lymphoma, and non-small-cell lung cancer. However only a small proportion of patients derive long-term clinical benefit. Here, we describe the biomarkers associated with the complex relationship between tumour-related immune stimulus, T cell-mediated immune response, and immune modulation of the microenvironment that can help to predict improved patient outcomes.

Effective Identification of Lynch Syndrome in Gastroenterology Practice

Purpose of review:

Identification of Lynch syndrome is important from an individual patient and public health standpoint. As paradigms for Lynch syndrome diagnosis have shifted in recent years, this review will discuss rationale and limitations for current strategies as well as provide an overview of future directions in the field.

Recent findings:

In recent years, the use of clinical criteria and risk scores for identification of Lynch syndrome have been augmented by universal testing of all newly diagnosed colorectal cancers with molecular methods to screen for mismatch repair deficiency with high sensitivity and specificity. Studies of implementation and outcomes of universal testing in clinical practice have demonstrated significant heterogeneity that results in suboptimal uptake and contributes to disparities in diagnosis. Emerging technologies, such as next-generation sequencing, hold significant promise as a screening strategy for Lynch syndrome.

Summary:

Universal testing for Lynch syndrome is being performed with increasing frequency, although real-world outcomes have demonstrated room for improvement. Future directions in Lynch syndrome diagnosis will involve optimization of universal testing workflow and application of new genetics technologies.