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Pinto D, Jong MCD, Parameswaran R. Challenges in genetic screening for inherited endocrinopathy affecting the thyroid, parathyroid and adrenal glands in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:253-263. [PMID: 38920182 DOI: 10.47102/annals-acadmedsg.202368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Significant progress has been made in the understand-ing of many human diseases, especially cancers, which has contributed to improved and increased survival. The Human Genome Project and The Cancer Genome Atlas project brought about a new era, with an understanding of inherited diseases at a molecular level, which subsequently facilitated the option of precision medicine. Precision medicine has helped tailor treatment decisions at an individual level, for instance in terms of surgical treatments or targeted therapies in advanced diseases. Despite the increasing advances in genetic-lead precision medicine, this has not translated into increasing uptake among patients. Reasons for this may be potential knowledge gaps among clinicians; on reasons for poor uptake of genetic testing such as for cultural, religious or personal beliefs; and on financial implications such as lack of support from insurance companies. In this review, we look at the current scenario of genetic screening for common inherited endocrine conditions affecting the thyroid, parathyroid and adrenal glands in Singapore, and the implications associated with it.
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Affiliation(s)
- Diluka Pinto
- Division of Endocrine Surgery, National University Hospital, Singapore
| | - Mechteld C de Jong
- Division of Endocrine Surgery, National University Hospital, Singapore
- Division of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Teppala S, Hodgkinson B, Hayes S, Scuffham P, Tuffaha H. A review of the cost-effectiveness of genetic testing for germline variants in familial cancer. J Med Econ 2023; 26:19-33. [PMID: 36426964 DOI: 10.1080/13696998.2022.2152233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Targeted germline testing is recommended for those with or at risk of breast, ovarian, or colorectal cancer. The affordability of genetic sequencing has improved over the past decade, therefore the cost-effectiveness of testing for these cancers is worthy of reassessment. OBJECTIVE To systematically review economic evaluations on cost-effectiveness of germline testing in breast, ovarian, or colorectal cancer. METHODS A search of PubMed and Embase databases for cost-effectiveness studies on germline testing in breast, ovarian, or colorectal cancer, published between 1999 and May 2022. Synthesis of methodology, cost-effectiveness, and reporting (CHEERS checklist) was performed. RESULTS The incremental cost-effectiveness ratios (ICERs; in 2021-adjusted US$) for germline testing versus the standard care option in hereditary breast or ovarian cancer (HBOC) across target settings were as follows: (1) population-wide testing: 344-2.5 million/QALY; (2) women with high-risk: dominant = 78,118/QALY, 8,337-59,708/LYG; (3) existing breast or ovarian cancer: 3,012-72,566/QALY, 39,835/LYG; and (4) metastatic breast cancer: 158,630/QALY. Likewise, ICERs of germline testing for colorectal cancer across settings were: (1) population-wide testing: 132,200/QALY, 1.1 million/LYG; (2) people with high-risk: 32,322-76,750/QALY, dominant = 353/LYG; and (3) patients with existing colorectal cancer: dominant = 54,122/QALY, 98,790-6.3 million/LYG. Key areas of underreporting were the inclusion of a health economic analysis plan (100% of HBOC and colorectal studies), engagement of patients and stakeholders (95.4% of HBOC, 100% of colorectal studies) and measurement of outcomes (18.2% HBOC, 38.9% of colorectal studies). CONCLUSION Germline testing for HBOC was likely to be cost-effective across most settings, except when used as a co-dependent technology with the PARP inhibitor, olaparib in metastatic breast cancer. In colorectal cancer studies, testing was cost-effective in those with high-risk, but inconclusive in other settings. Cost-effectiveness was sensitive to the prevalence of tested variants, cost of testing, uptake, and benefits of prophylactic measures. Policy advice on germline testing should emphasize the importance of these factors in their recommendations.
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Affiliation(s)
- Srinivas Teppala
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
| | - Brent Hodgkinson
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
| | - Sandi Hayes
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
- Menzies Health Institute Queensland, Griffith University, Southport, Australia
| | - Haitham Tuffaha
- Centre for the Business and Economics of Health, The University of Queensland, St. Lucia, Australia
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Chaudhari VS, Hole KC, Issa AM. Evaluating the quality of the economic evidence in colorectal cancer genomics studies. Per Med 2022; 19:361-375. [PMID: 35786999 DOI: 10.2217/pme-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The increase in the use of genome-based screening and diagnostic tests adds to the overall costs of oncologic care for colorectal cancer. This, in turn, has resulted in an increase in published economic analyses. Aim: To perform a systematic literature review of the available economic evidence evaluating the value of genomic testing for colorectal cancer and appraise the quality of the economic studies conducted to date. Methods: A systematic review of the literature for economic studies of colorectal cancer genomics from January 2006 through October 2020, and evaluation of study quality using the Quality of Health Economic Studies (QHES) instrument was conducted. The validated QHES was then applied to a final set of articles that met eligibility criteria. Results: Our search of the literature initially yielded 12,859 records. A final set of 49 articles met our inclusion criteria. The QHES score ranged from 24 to 100, with an average score of 82. Most of the studies (n = 40, 82%) scored above 75 and were considered of good quality. Conclusion: Our analysis revealed that most of the economic analyses of colorectal cancer genomic molecular diagnostics in the literature may be of good quality. There is, however, some variation in methodological rigor between the articles.
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Affiliation(s)
- Vivek S Chaudhari
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA
| | - Kanchan C Hole
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA
| | - Amalia M Issa
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA.,Pharmaceutical Sciences, University of the Sciences, Philadelphia, PA 19104, USA.,Family Medicine, McGill University, Montreal, QC, H3S 1Z1, Canada
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Zischke J, White N, Gordon L. Accounting for Intergenerational Cascade Testing in Economic Evaluations of Clinical Genomics: A Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:944-953. [PMID: 35667782 DOI: 10.1016/j.jval.2021.11.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Clinical genomics is emerging as a diagnostic tool in the identification of blood relatives at risk of developing heritable diseases. Our objective was to identify how genetic cascade screening has been incorporated into health economic evaluations. METHODS A scoping review was conducted to identify how multiple generations of a family were included in economic evaluations of clinical genomic sequencing, how many and which relatives were included, and uptake rates. Databases were searched for full economic evaluations of genetic interventions that screened multiple generations of families and were in English language, and no restrictions were made for disease or publication type. Data were synthesized using a narrative approach. RESULTS Twenty-five studies were included covering a range of diseases in various countries. Markov cohort models were mostly used with hypothetical populations and unsupported by clinical evidence. Cascade testing was either the primary intervention or secondary to the index cases. The number and type of relatives were based on assumptions or identified through population or family records, clinical registry data, or clinical literature. Studies included only immediate family members and the uptake of testing ranged between 20% and 100%. All interventions were reported as cost-effective, and a higher number of relatives was a key driver. CONCLUSIONS Several economic evaluations have considered the impacts of cascade testing interventions within clinical genomics. Ideally, models supported with high-quality clinical data are needed and, in their absence, transparent and justifiable assumptions of uptake rates and choices about including relatives. Consideration of more appropriate modeling types is required.
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Affiliation(s)
- Jason Zischke
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Nicole White
- Centre for Healthcare Transformation, School of Public Health and Social Work and Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
| | - Louisa Gordon
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Nursing, Queensland University of Technology, Brisbane, Australia; School of Public Health, The University of Queensland, Brisbane, Australia
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Validity of a two-antibody testing algorithm for mismatch repair deficiency testing in cancer; a systematic literature review and meta-analysis. Mod Pathol 2022; 35:1775-1783. [PMID: 36104536 PMCID: PMC9708570 DOI: 10.1038/s41379-022-01149-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 12/24/2022]
Abstract
Reflex mismatch repair immunohistochemistry (MMR IHC) testing for MLH1, PMS2, MSH2 and MSH6 is used to screen for Lynch syndrome. Recently MMR-deficiency (MMRd) has been approved as a pan-cancer predictive biomarker for checkpoint inhibitor therapy, leading to a vast increase in the use of MMR IHC in clinical practice. We explored whether immunohistochemical staining with PMS2 and MSH6 can be used as a reliable substitute. This two-antibody testing algorithm has the benefit of saving tissue, cutting costs and saving time. PubMed, Embase and Cochrane library were systematically searched for articles reporting on MMR IHC. The weighed percentage of cases with isolated MLH1 or MSH2 loss or combined MLH1/MSH2 loss alone was analyzed using a random effects model meta-analysis in R. The search yielded 1704 unique citations, of which 131 studies were included, describing 9014 patients. A weighed percentage of 1.1% (95% CI 0.53-18.87, I = 87%) of cases with isolated MLH1 or MSH2 loss or combined MLH1/MSH2 loss alone was observed. In the six articles with the main aim of investigating the two-antibody testing algorithm all MMRd cases were detected with the two-antibody testing algorithm, there were no cases with isolated MLH1 or MSH2 loss or combined MLH1/MSH2 loss alone. This high detection rate of MMRd of the two-antibody testing algorithm supports its use in clinical practice by specialized pathologists. Staining of all four antibodies should remain the standard in cases with equivocal results of the two-antibody testing algorithm. Finally, educational sessions in which staining pattern pitfalls are discussed will continue to be important.
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Aizuddin AN, Ramdzan AR, Syed Omar SA, Mahmud Z, Latiff ZA, Amat S, Teik KW, Siew CG, Rais H, Aljunid SM. Genetic Testing for Cancer Risk: Is the Community Willing to Pay for It? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8752. [PMID: 34444499 PMCID: PMC8392682 DOI: 10.3390/ijerph18168752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/16/2022]
Abstract
With the increasing number of cancer cases worldwide, genetic testing for familiar cancers seems inevitable, yet little is known on population interest and the monetary value for cancer genetic risk information. The current study aimed to determine the willingness to undergo and pay for cancer genetic testing among the Malaysian population. A self-administered questionnaire was distributed to cancer patients and their family members in the oncology and daycare units in several government hospitals. Of 641 respondents (354 patients, 287 family members), 267 (41.7%) were willing to undergo cancer genetic testing. The median that respondents were willing to pay was USD 48.31 (MYR 200.00) IQR USD 96.91 (MYR 400), while 143 (22.3%) respondents were willing to pay a shared cost with the insurance company. Regression analysis identified independent positive predictors of willingness to pay as respondent's status as a family member, high education level, and willingness to undergo cancer genetic testing in general, while in patients, female gender and high level of education were identified as independent positive predictors. Generally, the population needs more information to undergo and pay for cancer genetic testing. This will increase the utilization of the services offered, and with cost-sharing practices with the provider, it can be implemented population-wide.
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Affiliation(s)
- Azimatun Noor Aizuddin
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Abdul Rahman Ramdzan
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
- Department of Public Health Medicine, University of Malaysia Sabah, Jalan UMS, Kota Kinabalu 88400, Malaysia
| | - Sharifah Azween Syed Omar
- Faculty of Education, Universiti Kebangsaan Malaysia, Bangi 43600, Malaysia; (S.A.S.O.); (Z.M.); (S.A.)
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Zuria Mahmud
- Faculty of Education, Universiti Kebangsaan Malaysia, Bangi 43600, Malaysia; (S.A.S.O.); (Z.M.); (S.A.)
| | - Zarina A. Latiff
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Salleh Amat
- Faculty of Education, Universiti Kebangsaan Malaysia, Bangi 43600, Malaysia; (S.A.S.O.); (Z.M.); (S.A.)
| | - Keng Wee Teik
- Genetic Department, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur 50586, Malaysia; (K.W.T.); (C.G.S.)
| | - Ch’ng Gaik Siew
- Genetic Department, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur 50586, Malaysia; (K.W.T.); (C.G.S.)
| | - Haniza Rais
- Department of Education Psychology & Counseling, International Islamic University Malaysia, Jalan Gombak, Selangor 53100, Malaysia;
| | - Syed Mohamed Aljunid
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
- Department of Health Policy and Management, Kuwait University, 320 St, Hawally 13110, Kuwait
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Cost-Effectiveness Analysis of Molecular Screening to Identify Lynch Syndrome in the Patients with Colorectal Cancer. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.108198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Identifying Lynch syndrome (LS) in patients with colorectal cancer (CRC) and monitoring their relatives can increase the life expectancy of these patients. Objectives: The aim of this study was to analyze the cost-effectiveness of 5 molecular testing strategies to screen LS among patients with newly diagnosed CRC and to conduct preventive surveillance in their first-degree relatives. Methods: A decision tree model was designed to identify the number of LS mutations and the related costs in the CRC patients. Five strategies were modeled, i.e., Amsterdam II criteria, microsatellite instability (MSI) testing, immunohistochemistry (IHC), and next-generation sequencing (NGS). A Markov model was also used to estimate the long-term outcome of monitoring (including colonoscopy and taking aspirin) among relatives of those patients with CRC who carried LS. Results: All strategies were cost-effective compared with no testing condition. The 2 most cost-effective strategies were strategy 2 (IHC testing followed by NGS testing) and strategy 4 (MSI testing followed by NGS testing), with the ICER of 4,604$ and 4,748$ per quality-adjusted life year (QALY), respectively. Based on one-way sensitivity analysis of IHC sensitivity, the Cost of colonoscopy, MSI sensitivity, and the number of families who inherited LS had the most effect on the results. Conclusions: The findings suggested that from an Iranian health care system perspective, IHC testing followed by NGS testing could be regarded as the most cost-effective strategy compared to the other strategies. These results can be useful in offering to screen LS in newly diagnosed CRC patients.
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Beard VK, Bedard AC, Nuk J, Lee PWC, Hong Q, Bedard JEJ, Sun S, Schrader KA. Genetic testing in families with hereditary colorectal cancer in British Columbia and Yukon: a retrospective cross-sectional analysis. CMAJ Open 2020; 8:E637-E642. [PMID: 33077534 PMCID: PMC7588261 DOI: 10.9778/cmajo.20190167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Genetic testing in families with hereditary cancer enables identification of people most likely to benefit from intensive screening and preventive measures; however, the uptake of testing in relatives (known as cascade carrier testing) for hereditary colorectal cancer syndromes has been shown to be low. Our objective was to report rates of familial testing for hereditary colorectal cancer syndromes in a publicly funded hereditary cancer clinic in Canada. METHODS A cross-sectional retrospective database review was used to determine testing uptake between 1997 and 2016 for families served by the provincial Hereditary Cancer Program for British Columbia and Yukon. Analyses were conducted for genes associated with syndromes with an increased risk for colorectal cancer, including Lynch syndrome (MLH1, MSH2, MSH6, PMS2 and EPCAM) and familial adenomatous polyposis (APC), and for additional moderate- to high-penetrance genes (STK11, TP53, SMAD4, MUTYH, PTEN and CHEK2). Descriptive statistics were used and all analyses were 2-tailed. RESULTS The study cohort included 245 index patients, with carrier testing performed in 382 relatives. The mean age at family member testing was 41.2 years, and most (61.0%) of the family members who underwent testing were women. The median time between disclosure of index cases and their family member's results was 8.3 months. Among eligible first-degree relatives, 32.6% (268/821) underwent testing in BC. Of 67 cancer diagnoses in family members, most (62.7%) occurred before genetic testing. INTERPRETATION A substantial proportion of people at risk for hereditary colorectal cancer do not undergo genetic testing. This gap highlights the need to explore barriers to testing and to consider interventions to promote uptake; more aggressive efforts by hereditary cancer programs are needed to reach this highest risk population.
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Affiliation(s)
- Vivienne K Beard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Angela C Bedard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Jennifer Nuk
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Petra W C Lee
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Quan Hong
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - James E J Bedard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Sophie Sun
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Kasmintan A Schrader
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
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Xiao B, Luo J, Xie E, Kong L, Tang J, Liu D, Mao L, Sui Q, Li W, Hong Z, Pan Z, Jiang W, Ding PR. Comparisons of screening strategies for identifying Lynch syndrome among patients with MLH1-deficient colorectal cancer. Eur J Hum Genet 2020; 28:1555-1562. [PMID: 32661327 DOI: 10.1038/s41431-020-0687-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/20/2020] [Accepted: 07/01/2020] [Indexed: 11/10/2022] Open
Abstract
BRAF and MLH1 promoter methylation testings have been proven effective prescreens for Lynch Syndrome. We aimed to compare different screening strategies for Lynch Syndrome in patients with MLH1(-) CRC. Patients with MLH1(-) CRC who had been tested for BRAF mutation and germline variants of DNA mismatch repair genes were included. We compared the sensitivities and specificities for identifying Lynch Syndrome and the cost-effectiveness of four screening approaches that used the following tests as prescreens: BRAF testing, MLH1 methylation testing, MLH1 methylation & BRAF testing, and MLH1 methylation testing & Revised Bethesda Criteria. Of 109 patients included, 23 (21.1%) were Lynch Syndrome patients. BRAF mutation and MLH1 methylation occurred in 6 (5.5%) and 40 (36.7%) patients, respectively. The sensitivity for identifying Lynch syndrome of BRAF testing was 100%, but the specificity was only 7%. MLH1 methylation testing had a lower sensitivity than BRAF testing (97.5% vs 100%), but had a markedly higher specificity (45.3% vs 7%). The combination of the two testings had a slightly higher specificity than MLH1 methylation testing alone (47.7% vs 45.3%). The MLH1 methylation testing approach had a 10% lower cost of identifying MLH1(-) Lynch syndrome carriers per case than universal genetic testing, but it missed 4.5% of patients. BRAF and MLH1 promoter methylation testings as prescreens for Lynch syndrome are less effective in Chinese patients with MLH1(-) CRC than in their Western counterparts. Universal genetic testing could be considered an up-front option for this population.
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Affiliation(s)
- Binyi Xiao
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Jun Luo
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences; Cancer Hospital of the University of Chinese Academy of Sciences; Zhejiang Cancer Hospital, Zhejiang, China
| | - E Xie
- Department of General Surgery, the Affiliated Shantou Hospital of Sun Yat-sen University, Guangdong, 515000, China
| | - Lingheng Kong
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Jinghua Tang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Dingxin Liu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Linlin Mao
- Guangzhou Kingmed Diagnostics Group Co., Ltd. Clinical Genome Center, KingMed Center for Clinical Laboratory Co., Ltd., Guangzhou, China
| | - Qiaoqi Sui
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Weirong Li
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Zhigang Hong
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China
| | - Zhizhong Pan
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China.
| | - Wu Jiang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China.
| | - Pei-Rong Ding
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, China.
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Smith H, Varshoei P, Boushey R, Kuziemsky C. Simulation modeling validity and utility in colorectal cancer screening delivery: A systematic review. J Am Med Inform Assoc 2020; 27:908-916. [PMID: 32417894 PMCID: PMC7309251 DOI: 10.1093/jamia/ocaa022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/13/2020] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE This study sought to assess the impact and validity of simulation modeling in informing decision making in a complex area of healthcare delivery: colorectal cancer (CRC) screening. MATERIALS AND METHODS We searched 10 electronic databases for English-language articles published between January 1, 2008, and March 1, 2019, that described the development of a simulation model with a focus on average-risk CRC screening delivery. Included articles were reviewed for evidence that the model was validated, and provided real or potential contribution to informed decision making using the GRADE EtD (Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision) framework. RESULTS A total of 43 studies met criteria. The majority used Markov modeling (n = 31 [72%]) and sought to determine cost-effectiveness, compare screening modalities, or assess effectiveness of screening. No study reported full model validation and only (58%) reported conducting any validation. Majority of models were developed to address a specific health systems or policy question; few articles report the model's impact on this decision (n = 39 [91%] vs. n = 5 [12%]). Overall, models provided evidence relevant to every element important to decision makers as outlined in the GRADE EtD framework. DISCUSSION AND CONCLUSION Simulation modeling contributes evidence that is considered valuable to decision making in CRC screening delivery, particularly in assessing cost-effectiveness and comparing screening modalities. However, the actual impact on decisions and validity of models is lacking in the literature. Greater validity testing, impact assessment, and standardized reporting of both is needed to understand and demonstrate the reliability and utility of simulation modeling.
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Affiliation(s)
- Heather Smith
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peyman Varshoei
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Robin Boushey
- Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Kuziemsky
- Office of Research Services, MacEwan University, Edmonton, Alberta, Canada
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Chin XW, Ang ZLT, Tan RYC, Courtney E, Shaw T, Chen Y, Li S, Ngeow JYY. Use of telephone intake for family history taking at a cancer genetics service in Asia. J Genet Couns 2020; 29:1192-1199. [DOI: 10.1002/jgc4.1286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/30/2020] [Accepted: 04/04/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Xin Wei Chin
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Zoe L. T. Ang
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Ryan Y. C. Tan
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Eliza Courtney
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Tarryn Shaw
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Yanni Chen
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Shao‐Tzu Li
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Joanne Yuen Yie Ngeow
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
- Lee Kong Chian School of Medicine Nanyang Technological University Singapore City Singapore
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Chiang J, Yuen J, Shaw T, Goh HX, Li ST, Courtney E, Ngeow J. Predictive Testing for Tumor Predisposition Syndromes in Pediatric Relatives: An Asian Experience. Front Pediatr 2020; 8:568528. [PMID: 33194895 PMCID: PMC7661469 DOI: 10.3389/fped.2020.568528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/08/2020] [Indexed: 11/17/2022] Open
Abstract
Approximately 10% of pediatric cancer patients possess germline pathogenic/likely pathogenic variants (PV/LPV) in known tumor predisposition genes. Predictive testing is the optimal approach to identify asymptomatic at-risk relatives to guide gene-directed surveillance for early cancer detection and/or risk-reducing strategies. However, the uptake rate for predictive testing remains low in Asian countries. We aim to evaluate the uptake rate of predictive testing in a pediatric population (aged under 21-years-old) in a multi-ethnic Asian cancer center. Our retrospective analysis included families with PV/LPVs identified in genes associated with pediatric tumor predisposition. Of the 83 pediatric first-degree relatives (FDRs) from 49 unrelated families, 20 FDRs (24.1%) originating from 13 families (26.6%) underwent predictive testing. Genes tested in pediatric FDRs were APC, RB1, SBDS, SDHA, SDHB, SDHD, and TP53. All pediatric FDRs of probands with PV/LPVs in RB1 and biallelic PVs in SBDS underwent predictive testing, while <45% of pediatric FDRs had predictive testing for familial PV/LPVs identified in the APC, SDHA, SDHB, SDHD, and TP53 genes. Amongst the 13 families who underwent pre-test counseling, 80% of pediatric FDRs in these families proceeded with predictive testing. Malay pediatric FDRs and siblings of probands were more likely to undergo predictive testing. We conclude that the predictive testing rate in pediatric FDRs is higher than that of adult FDRs in Asia, but still below the global average. We postulate factors that may influence predictive testing uptake in pediatric FDRs includes a lack of genetics awareness, concerns regarding insurance, and genetic discrimination.
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Affiliation(s)
- Jianbang Chiang
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Jeanette Yuen
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Tarryn Shaw
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Hui Xuan Goh
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Shao-Tzu Li
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Eliza Courtney
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Impact of free cancer predisposition cascade genetic testing on uptake in Singapore. NPJ Genom Med 2019; 4:22. [PMID: 31531230 PMCID: PMC6744424 DOI: 10.1038/s41525-019-0096-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Cascade testing for cancer predisposition offers a highly efficient and cost-effective method for identifying individuals at increased risk for cancer, in whom targeted interventions can often improve survival. The aim of this study was to determine the impact of free cascade testing on uptake and identify other associated factors. Demographic and clinical data were gathered prospectively for 183 probands found to have a pathogenic variant associated with cancer predisposition and their 826 first-degree relatives (FDRs). The provision of free cascade testing was significantly associated with uptake (21.6% vs 6.1%; χ 2, P < 0.001). Relationship type between FDR and proband and FDR age also demonstrated significant associations, suggesting greater engagement amongst younger generations. Overall, 29.0% (53/183) of families had at least 1 FDR who underwent cascade testing. Of these families, 67.9% (36/53) had an uptake rate of at least 40.0%. Cost is a significant barrier to cascade testing uptake in Singapore. Tailored interventions targeting underrepresented groups and genetic counseling approaches supporting family communication and decision-making are necessary.
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Shaw T, Metras J, Ting ZAL, Courtney E, Li ST, Ngeow J. Impact of Appointment Waiting Time on Attendance Rates at a Clinical Cancer Genetics Service. J Genet Couns 2018; 27:1473-1481. [PMID: 29799102 DOI: 10.1007/s10897-018-0259-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/04/2018] [Indexed: 12/21/2022]
Abstract
The increase in demand for clinical cancer genetics services has impacted the ability to provide services timeously. Given limited resources, this often results in extended appointment waiting times. Over the last 3 years, the Cancer Genetics Service at the National Cancer Centre Singapore has continued to experience a steady increase in demand for its service. Nevertheless, significant no-show rates have been reported. This study sought to determine whether an association exists between appointment waiting times and attendance rates. Data was gathered for all participants meeting inclusion criteria. Attendance rates and appointment waiting times were calculated. The relationship between mean waiting times for those who did and did not attend their scheduled appointments was evaluated using Welch's t test and linear regression model. The results showed a significant difference in mean appointment waiting times between patients who did and did not attend (32.66 versus 43.50 days respectively; p < 0.0001). Furthermore, patients who waited for longer than 37 days were significantly less likely to attend. No-show rates increased as the waiting time increased, at a rate of 19.60% per 20 days and 21.40% per 30 days. In conclusion, appointment waiting time is a significant predictor for patient attendance. Strategies to ensure patients receive an appointment within the necessary timeframe at the desired setting are important to ensure that individuals at increased cancer risk attend their appointments in order to manage their cancer risks effectively.
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Affiliation(s)
- Tarryn Shaw
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore
| | - Julie Metras
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore
| | - Zoe Ang Li Ting
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore
| | - Eliza Courtney
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore
| | - Shao-Tzu Li
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, 11 Third Hospital Drive, Singapore, 169610, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore. .,Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, 169857, Singapore. .,Institute of Molecular and Cell Biology, Agency for Science Technology and Research (A*Star), Singapore, 138673, Singapore.
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Guglielmo A, Staropoli N, Giancotti M, Mauro M. Personalized medicine in colorectal cancer diagnosis and treatment: a systematic review of health economic evaluations. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:2. [PMID: 29386984 PMCID: PMC5778687 DOI: 10.1186/s12962-018-0085-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/03/2018] [Indexed: 01/03/2023] Open
Abstract
Background Due to its epidemiological relevance, several studies have been performed to assess the cost-effectiveness of diagnostic tests and treatments in colorectal cancer (CRC) patients. Objective We reviewed economic evaluations on diagnosis of inherited CRC-syndromes and genetic tests for the detection of mutations associated with response to therapeutics. Methods A systematic literature review was performed by searching the main literature databases for relevant papers on the field, published in the last 5 years. Results 20 studies were included in the final analysis: 14 investigating the cost-effectiveness of hereditary-CRC screening; 5 evaluating the cost-effectiveness of KRAS mutation assessment before treatment; and 1 study analysing the cost-effectiveness of genetic tests for early-stage CRC patients prognosis. Overall, we found that: (a) screening strategies among CRC patients were more effective than no screening; (b) all the evaluated interventions were cost-saving for certain willingness-to-pay (WTP) threshold; and (c) all new CRC patients diagnosed at age 70 or below should be screened. Regarding patients treatment, we found that KRAS testing is economically sustainable only if anticipated in patients with non-metastatic CRC (mCRC), while becoming unsustainable, due to an incremental cost-effectiveness ratio (ICER) beyond the levels of WTP-threshold, in all others evaluated scenarios. Conclusions The poor evidence in the field, combined to the number of assumptions done to perform the models, lead us to a high level of uncertainty on the cost-effectiveness of genetic evaluations in CRC, suggesting that major research is required in order to assess the best combination among detection tests, type of genetic test screening and targeted-therapy. Electronic supplementary material The online version of this article (10.1186/s12962-018-0085-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annamaria Guglielmo
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Nicoletta Staropoli
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Monica Giancotti
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Marianna Mauro
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
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Which Lynch syndrome screening programs could be implemented in the "real world"? A systematic review of economic evaluations. Genet Med 2018; 20:1131-1144. [PMID: 29300371 PMCID: PMC8660650 DOI: 10.1038/gim.2017.244] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose Lynch syndrome (LS) screening can significantly reduce cancer morbidity and mortality in mutation carriers. Our aim was to identify cost-effective LS screening programs that can be implemented in the “real world.” Methods We performed a systematic review of full economic evaluations of genetic screening for LS in different target populations; health outcomes were estimated in life-years gained or quality-adjusted life-years. Results Overall, 20 studies were included in the systematic review. Based on the study populations, we identified six categories of LS screening program: colorectal cancer (CRC)–based, endometrial cancer–based, general population–based, LS family registry–based, cascade testing–based, and genetics clinic–based screening programs. We performed an in-depth analysis of CRC-based LS programs, classifying them into three additional subcategories: universal, age-targeted, and selective. In five studies, universal programs based on immunohistochemistry, either alone or in combination with the BRAF test, were cost-effective compared with no screening, while in two studies age-targeted programs with a cutoff of 70 years were cost-effective when compared with age-targeted programs with lower age thresholds. Conclusion Universal or <70 years–age-targeted CRC-based LS screening programs are cost-effective and should be implemented in the “real world.”
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Li ST, Yuen J, Zhou K, Binte Ishak ND, Chen Y, Met-Domestici M, Chan SH, Tan YP, Allen JC, Lim ST, Soo KC, Ngeow J. Impact of subsidies on cancer genetic testing uptake in Singapore. J Med Genet 2016; 54:254-259. [DOI: 10.1136/jmedgenet-2016-104302] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 11/04/2022]
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Chen YE, Kao SS, Chung RH. Cost-Effectiveness Analysis of Different Genetic Testing Strategies for Lynch Syndrome in Taiwan. PLoS One 2016; 11:e0160599. [PMID: 27482709 PMCID: PMC4970721 DOI: 10.1371/journal.pone.0160599] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/21/2016] [Indexed: 01/01/2023] Open
Abstract
Patients with Lynch syndrome (LS) have a significantly increased risk of developing colorectal cancer (CRC) and other cancers. Genetic screening for LS among patients with newly diagnosed CRC aims to identify mutations in the disease-causing genes (i.e., the DNA mismatch repair genes) in the patients, to offer genetic testing for relatives of the patients with the mutations, and then to provide early prevention for the relatives with the mutations. Several genetic tests are available for LS, such as DNA sequencing for MMR genes and tumor testing using microsatellite instability and immunohistochemical analyses. Cost-effectiveness analyses of different genetic testing strategies for LS have been performed in several studies from different countries such as the US and Germany. However, a cost-effectiveness analysis for the testing has not yet been performed in Taiwan. In this study, we evaluated the cost-effectiveness of four genetic testing strategies for LS described in previous studies, while population-specific parameters, such as the mutation rates of the DNA mismatch repair genes and treatment costs for CRC in Taiwan, were used. The incremental cost-effectiveness ratios based on discounted life years gained due to genetic screening were calculated for the strategies relative to no screening and to the previous strategy. Using the World Health Organization standard, which was defined based on Taiwan’s Gross Domestic Product per capita, the strategy based on immunohistochemistry as a genetic test followed by BRAF mutation testing was considered to be highly cost-effective relative to no screening. Our probabilistic sensitivity analysis results also suggest that the strategy has a probability of 0.939 of being cost-effective relative to no screening based on the commonly used threshold of $50,000 to determine cost-effectiveness. To the best of our knowledge, this is the first cost-effectiveness analysis for evaluating different genetic testing strategies for LS in Taiwan. The results will be informative for the government when considering offering screening for LS in patients newly diagnosed with CRC.
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Affiliation(s)
- Ying-Erh Chen
- Department of Insurance, Tamkang University, Tamsui Dist., New Taipei City, 251, Taiwan
- * E-mail:
| | - Sung-Shuo Kao
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, 813, Taiwan
| | - Ren-Hua Chung
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, 350, Taiwan
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Bonfanti M, Gambino ML, Pisani S, Carnevali I, Pinotti G, Croce D, Capella C, Sessa F, Tibiletti MG. A cost analysis of inherited colorectal cancer care in Varese Province. J Cancer Policy 2016. [DOI: 10.1016/j.jcpo.2016.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Schlatter RP, Matte U, Polanczyk CA, Koehler-Santos P, Ashton-Prolla P. Costs of genetic testing: Supporting Brazilian Public Policies for the incorporating of molecular diagnostic technologies. Genet Mol Biol 2015; 38:332-7. [PMID: 26500437 PMCID: PMC4612610 DOI: 10.1590/s1415-475738320140204] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 04/23/2015] [Indexed: 01/03/2023] Open
Abstract
This study identifies and describes the operating costs associated with the molecular diagnosis of diseases, such as hereditary cancer. To approximate the costs associated with these tests, data informed by Standard Operating Procedures for various techniques was collected from hospital software and a survey of market prices. Costs were established for four scenarios of capacity utilization to represent the possibility of suboptimal use in research laboratories. Cost description was based on a single site. The results show that only one technique was not impacted by rising costs due to underutilized capacity. Several common techniques were considerably more expensive at 30% capacity, including polymerase chain reaction (180%), microsatellite instability analysis (181%), gene rearrangement analysis by multiplex ligation probe amplification (412%), non-labeled sequencing (173%), and quantitation of nucleic acids (169%). These findings should be relevant for the definition of public policies and suggest that investment of public funds in the establishment of centralized diagnostic research centers would reduce costs to the Public Health System.
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Affiliation(s)
- Rosane Paixão Schlatter
- Programa de Pós-Graduação em Ciências da Saúde Cardiologia e Ciências Cardiovasculares, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. ; Instituto Nacional de Avaliação de Tecnologias em Saúde, CNPq, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ursula Matte
- Departamento de Genética e Programa de Pós-Graduação em Genética e Biologia Molecular, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. ; Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, RS, Brazil
| | - Carisi Anne Polanczyk
- Programa de Pós-Graduação em Ciências da Saúde Cardiologia e Ciências Cardiovasculares, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. ; Instituto Nacional de Avaliação de Tecnologias em Saúde, CNPq, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Patrícia Koehler-Santos
- Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, RS, Brazil
| | - Patricia Ashton-Prolla
- Departamento de Genética e Programa de Pós-Graduação em Genética e Biologia Molecular, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. ; Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, RS, Brazil. ; Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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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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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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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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Matro JM, Ruth KJ, Wong YN, McCully KC, Rybak CM, Meropol NJ, Hall MJ. Cost sharing and hereditary cancer risk: predictors of willingness-to-pay for genetic testing. J Genet Couns 2014; 23:1002-11. [PMID: 24794065 DOI: 10.1007/s10897-014-9724-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 04/09/2014] [Indexed: 12/19/2022]
Abstract
Increasing use of predictive genetic testing to gauge hereditary cancer risk has been paralleled by rising cost-sharing practices. Little is known about how demographic and psychosocial factors may influence individuals' willingness-to-pay for genetic testing. The Gastrointestinal Tumor Risk Assessment Program Registry includes individuals presenting for genetic risk assessment based on personal/family cancer history. Participants complete a baseline survey assessing cancer history and psychosocial items. Willingness-to-pay items include intention for: genetic testing only if paid by insurance; testing with self-pay; and amount willing-to-pay ($25-$2,000). Multivariable models examined predictors of willingness-to-pay out-of-pocket (versus only if paid by insurance) and willingness-to-pay a smaller versus larger sum (≤$200 vs. ≥$500). All statistical tests are two-sided (α = 0.05). Of 385 evaluable participants, a minority (42%) had a personal cancer history, while 56% had ≥1 first-degree relative with colorectal cancer. Overall, 21.3% were willing to have testing only if paid by insurance, and 78.7% were willing-to-pay. Predictors of willingness-to-pay were: 1) concern for positive result; 2) confidence to control cancer risk; 3) fewer perceived barriers to colorectal cancer screening; 4) benefit of testing to guide screening (all p < 0.05). Subjects willing-to-pay a higher amount were male, more educated, had greater cancer worry, fewer relatives with colorectal cancer, and more positive attitudes toward genetic testing (all p < 0.05). Individuals seeking risk assessment are willing-to-pay out-of-pocket for genetic testing, and anticipate benefits to reducing cancer risk. Identifying factors associated with willingness-to-pay for genetic services is increasingly important as testing is integrated into routine cancer care.
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Affiliation(s)
- Jennifer M Matro
- Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA,
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