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Aiob A, Kim YR, Kim K, Kim H, Kim YB, Kim DW, No JH, Seo SH, Suh DH, Park KU. A simplified two-marker immunohistochemistry strategy for Lynch syndrome screening in endometrial cancer patients. Obstet Gynecol Sci 2023; 66:537-544. [PMID: 37839795 PMCID: PMC10663397 DOI: 10.5468/ogs.23124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/22/2023] [Accepted: 08/22/2023] [Indexed: 10/17/2023] Open
Abstract
OBJECTIVE To examine the efficacy of MSH6 and PMS2 immunohistochemistry (IHC) as a screening method for Lynch syndrome in endometrial cancer patients. METHODS Through multidisciplinary discussions, an institutional MSH6 and PMS2 IHC-initiated cascade test (MSH6, PMS2 IHC→microsatellite instability [MSI] assay→germline mismatch repair [MMR] gene sequencing) was developed to screen for Lynch syndrome in endometrial cancer patients. Testing was performed on a consecutive cohort of 218 newly diagnosed endometrial cancer patients who underwent surgery at a tertiary hospital in the Republic of Korea between August 2018 and December 2020. The number of MMR deficiencies (MSH6 or PMS2 loss in IHC) and. RESULTS of subsequent tests (MSI assay and germline MMR gene sequencing) were examined. RESULTS MMR deficiency was detected in 52 of the 218 patients (24.0%). Among these 52 patients, 34 (65.0%) underwent MSI testing, of which 31 (91.0%) exhibited high MSI. Of the 31 patients with MSI-high status, 15 (48.0%) underwent germline MMR gene sequencing. Subsequently, Lynch syndrome was diagnosed in five patients (33.0%). CONCLUSION Lynch syndrome screening using MSH6 and PMS2 IHC-initiated cascade testing is a viable strategy in the management of endometrial cancer. A simplified strategy (MSH6 and PMS2 IHC→germline MMR gene sequencing) was proposed because most women with MMR deficiencies exhibited high MSI.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Azrieli Faculty of Medicine, Bar Ilan University, Safed,
Israel
| | - Yeo Rae Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Hyojin Kim
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Duck Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Jae Hong No
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Soo Hyun Seo
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
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Trujillo-Rojas MA, Ayala-Madrigal MDLL, Gutiérrez-Angulo M, González-Mercado A, Moreno-Ortiz JM. Diagnosis of patients with Lynch syndrome lacking the Amsterdam II or Bethesda criteria. Hered Cancer Clin Pract 2023; 21:21. [PMID: 37864171 PMCID: PMC10589993 DOI: 10.1186/s13053-023-00266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Lynch Syndrome (LS) is an autosomal dominant inheritance disorder characterized by genetic predisposition to develop cancer, caused by pathogenic variants in the genes of the mismatch repair system. Cases are detected by implementing the Amsterdam II and the revised Bethesda criteria, which are based on family history. MAIN BODY Patients who meet the criteria undergo posterior tests, such as germline DNA sequencing, to confirm the diagnosis. However, these criteria have poor sensitivity, as more than one-quarter of patients with LS do not meet the criteria. It is very likely that the lack of sensitivity of the criteria is due to the incomplete penetrance of this syndrome. The penetrance and risk of developing a particular type of cancer are highly dependent on the affected gene and probably of the variant. Patients with variants in low-penetrance genes have a lower risk of developing a cancer associated with LS, leading to families with unaffected generations and showing fewer clear patterns. This study focuses on describing genetic aspects of LS cases that underlie the lack of sensitivity of the clinical criteria used for its diagnosis. CONCLUSION Universal screening could be an option to address the problem of underdiagnosis.
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Affiliation(s)
- Miguel Angel Trujillo-Rojas
- Doctorado en Genética Humana e Instituto de Genética Humana "Dr. Enrique Corona Rivera", Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Sierra Mojada #950, Col. Independencia, Guadalajara, C.P. 44340, Jalisco, México
| | - María de la Luz Ayala-Madrigal
- Instituto de Genética Humana "Dr. Enrique Corona Rivera", Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Sierra Mojada #950, Col. Independencia, Guadalajara, C.P. 44340, Jalisco, México
| | - Melva Gutiérrez-Angulo
- Departamento de Ciencias de la Salud, Centro Universitario de los Altos, Universidad de Guadalajara, Av. Rafael Casillas Aceves #1200. Tepatitlán de Morelos, C.P. 47620, Jalisco, México
| | - Anahí González-Mercado
- Instituto de Genética Humana "Dr. Enrique Corona Rivera", Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Sierra Mojada #950, Col. Independencia, Guadalajara, C.P. 44340, Jalisco, México
| | - José Miguel Moreno-Ortiz
- Instituto de Genética Humana "Dr. Enrique Corona Rivera", Departamento de Biología Molecular y Genómica, Centro Universitario de Ciencias de la Salud, Sierra Mojada #950, Col. Independencia, Guadalajara, C.P. 44340, Jalisco, México.
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Xi Q, Jin S, Morris S. Economic evaluations of predictive genetic testing: A scoping review. PLoS One 2023; 18:e0276572. [PMID: 37531363 PMCID: PMC10395838 DOI: 10.1371/journal.pone.0276572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/03/2023] [Indexed: 08/04/2023] Open
Abstract
Predictive genetic testing can provide information about whether or not someone will develop or is likely to develop a specific condition at a later stage in life. Economic evaluation can assess the value of money for such testing. Studies on the economic evaluation of predictive genetic testing have been carried out in a variety of settings, and this research aims to conduct a scoping review of findings from these studies. We searched the PubMed, Web of Science, Embase, and Cochrane databases with combined search terms, from 2019 to 2022. Relevant studies from 2013 to 2019 in a previous systematic review were also included. The study followed the recommended stages for undertaking a scoping review. A total of 53 studies were included, including 33 studies from the previous review and 20 studies from the search of databases. A significant number of studies focused on the US, UK, and Australia (34%, 23%, and 11%). The most frequently included health conditions were cancer and cardiovascular diseases (68% and 19%). Over half of the studies compared predictive genetic testing with no genetic testing, and the majority of them concluded that at least some type of genetic testing was cost-effective compared to no testing (94%). Some studies stated that predictive genetic testing is becoming more cost-effective with the trend of lowering genetic testing costs. Studies on predictive genetic testing covered various health conditions, particularly cancer and cardiovascular diseases. Most studies indicated that predictive genetic testing is cost-effective compared to no testing.
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Affiliation(s)
- Qin Xi
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Shihan Jin
- Department of Pharmaceutical and Health Economics, Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, United States of America
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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Kansikas M, Vähätalo L, Kantelinen J, Kasela M, Putula J, Døhlen A, Paloviita P, Kärkkäinen E, Lahti N, Arnez P, Kilpinen S, Alcala-Repo B, Pylvänäinen K, Pöyhönen M, Peltomäki P, Järvinen HJ, Seppälä TT, Renkonen-Sinisalo L, Lepistö A, Mecklin JP, Nyström M. Tumor-independent Detection of Inherited Mismatch Repair Deficiency for the Diagnosis of Lynch Syndrome with High Specificity and Sensitivity. CANCER RESEARCH COMMUNICATIONS 2023; 3:361-370. [PMID: 36875157 PMCID: PMC9979712 DOI: 10.1158/2767-9764.crc-22-0384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/20/2022] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
UNLABELLED Lynch syndrome (LS) is the most common hereditary cancer syndrome. Early diagnosis improves prognosis and reduces health care costs, through existing cancer surveillance methods. The problem is finding and diagnosing the cancer predisposing genetic condition. The current workup involves a complex array of tests that combines family cancer history and clinical phenotypes with tumor characteristics and sequencing data, followed by a challenging task to interpret the found variant(s). On the basis of the knowledge that an inherited mismatch repair (MMR) deficiency is a hallmark of LS, we have developed and validated a functional MMR test, DiagMMR, that detects inherited MMR deficiency directly from healthy tissue without need of tumor and variant information. The validation included 119 skin biopsies collected from clinically pathogenic MMR variant carriers (MSH2, MSH6) and controls, and was followed by a small clinical pilot study. The repair reaction was performed on proteins extracted from primary fibroblasts and the interpretation was based on the MMR capability of the sample in relation to cutoff, which distinguishes MMR proficient (non-LS) from MMR deficient (LS) function. The results were compared with the reference standard (germline NGS). The test was shown to have exceptional specificity (100%) with high sensitivity (89%) and accuracy (97%). The ability to efficiently distinguish LS carriers from controls was further shown with a high area under the receiving operating characteristic (AUROC) value (0.97). This test offers an excellent tool for detecting inherited MMR deficiency linked to MSH2 or MSH6 and can be used alone or with conventional tests to recognize genetically predisposed individuals. SIGNIFICANCE Clinical validation of DiagMMR shows high accuracy in distinguishing individuals with hereditary MSH2 or MSH6 MMR deficiency (i.e., LS). The method presented overcomes challenges faced by the complexity of current methods and can be used alone or with conventional tests to improve the ability to recognize genetically predisposed individuals.
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Affiliation(s)
- Minttu Kansikas
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Laura Vähätalo
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Jukka Kantelinen
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Mariann Kasela
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Jaana Putula
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Anni Døhlen
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Pauliina Paloviita
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Emmi Kärkkäinen
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Niklas Lahti
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Philippe Arnez
- LS CancerDiag Ltd., Helsinki, Finland
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | - Sami Kilpinen
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
| | | | - Kirsi Pylvänäinen
- Department of Education and Science, Nova Hospital, Central Finland Health Care District, Jyväskylä, Finland
| | - Minna Pöyhönen
- Department of Genetics, HUSLAB, Helsinki University Hospital Diagnostic Center, Helsinki, Finland
- Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
- Applied Tumor Genomics, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Päivi Peltomäki
- Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
| | | | - Toni T. Seppälä
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
- Applied Tumor Genomics, Research Programs Unit, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Medical Technology, University of Tampere, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Laura Renkonen-Sinisalo
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
- Applied Tumor Genomics, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Anna Lepistö
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
- Applied Tumor Genomics, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Jukka-Pekka Mecklin
- Department of Education and Science, Nova Hospital, Central Finland Health Care District, Jyväskylä, Finland
- Faculty of Sports and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Minna Nyström
- Faculty of Biological and Environmental Sciences, University of Helsinki, Helsinki, Finland
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5
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The Role of Immunohistochemistry Markers in Endometrial Cancer with Mismatch Repair Deficiency: A Systematic Review. Cancers (Basel) 2022; 14:cancers14153783. [PMID: 35954447 PMCID: PMC9367287 DOI: 10.3390/cancers14153783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023] Open
Abstract
The objective of this systematic review was to summarize our current knowledge of the role of immunohistochemistry (IHC) markers for identifying mismatch repair-deficient (MMRd) tumors in endometrial cancer (EC). Identification of MMRd tumors, which occur in 13% to 30% of all ECs, has become critical for patients with colorectal and endometrial cancer for therapeutic management, clinical decision making, and prognosis. This review was conducted by two authors applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following terms: “immunohistochemistry and microsatellite instability endometrial cancer” or “immunohistochemistry and mismatch repair endometrial cancer” or “immunohistochemistry and mismatch repair deficient endometrial cancer”. Among 596 retrieved studies, 161 fulfilled the inclusion criteria. Articles were classified and presented according to their interest for the diagnosis, prognosis, and theragnostics for patients with MMRd EC. We identified 10, 18, and 96 articles using IHC expression of two, three, or four proteins of the MMR system (MLH1, MSH2, MHS6, and PMS2), respectively. MLH1 promoter methylation was analyzed in 57 articles. Thirty-four articles classified MMRd tumors with IHC markers according to their prognosis in terms of recurrence-free survival (RFS), overall survival (OS), stage, grade, and lymph node invasion. Theragnostics were studied in eight articles underlying the important concentration of PD-L1 in MMRd EC. Even though the role of IHC has been challenged, it represents the most common, robust, and cheapest method for diagnosing MMRd tumors in EC and is a valuable tool for exploring novel biotherapies and treatment modalities.
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Pasanen A, Loukovaara M, Kaikkonen E, Olkinuora A, Pylvänäinen K, Alhopuro P, Peltomäki P, Mecklin JP, Bützow R. Testing for Lynch Syndrome in Endometrial Carcinoma: From Universal to Age-Selective MLH1 Methylation Analysis. Cancers (Basel) 2022; 14:cancers14051348. [PMID: 35267656 PMCID: PMC8909331 DOI: 10.3390/cancers14051348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/21/2022] [Accepted: 03/04/2022] [Indexed: 12/13/2022] Open
Abstract
International guidelines recommend universal screening of endometrial carcinoma (EC) patients for Lynch syndrome (LS). This screening is generally based on mismatch repair (MMR) protein immunohistochemistry followed by MLH1 methylation analysis of MLH1-negative cases to exclude the likely sporadic cases from germline testing. As LS-associated EC is uncommon in the elderly, age-selective methylation testing could improve cost-efficiency. We performed MMR immunohistochemistry on 821 unselected ECs (clinic-based cohort) followed by a MLH1 promoter methylation test of all MLH1/PMS2-negative tumors. Non-methylated MLH1-deficient cases underwent NGS and MLPA-based germline analyses to identify MLH1 mutation carriers. A reduction in the test burden and corresponding false negative rates for LS screening were investigated for various age cut-offs. In addition, the age distribution of 132 MLH1 mutation carriers diagnosed with EC (registry-based cohort) was examined. A germline MLH1 mutation was found in 2/14 patients with non-methylated MLH1-deficient EC. When compared to a universal methylation analysis, selective testing with a cut-off age of 65 years, would have reduced the testing effort by 70.7% with a false negative rate for LS detection of 0% and 3% in the clinic and registry-based cohorts, respectively. The use of age-selective methylation analysis is a feasible way of reducing the costs and laboratory burden in LS screening for EC patients.
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Affiliation(s)
- Annukka Pasanen
- Department of Pathology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland;
- Correspondence:
| | - Mikko Loukovaara
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland;
| | - Elina Kaikkonen
- Laboratory of Genetics, HUS Diagnostic Center, Helsinki University Hospital, University of Helsinki, 00209 Helsinki, Finland; (E.K.); (P.A.)
| | - Alisa Olkinuora
- Department of Medical and Clinical Genetics, University of Helsinki, 00014 Helsinki, Finland; (A.O.); (P.P.)
| | - Kirsi Pylvänäinen
- Department of Education and Science, Central Finland Health Care District, 40620 Jyväskylä, Finland;
| | - Pia Alhopuro
- Laboratory of Genetics, HUS Diagnostic Center, Helsinki University Hospital, University of Helsinki, 00209 Helsinki, Finland; (E.K.); (P.A.)
| | - Päivi Peltomäki
- Department of Medical and Clinical Genetics, University of Helsinki, 00014 Helsinki, Finland; (A.O.); (P.P.)
| | - Jukka-Pekka Mecklin
- Department of Surgery, Central Finland Health Care District; 40620 Jyväskylä, Finland;
- Department of Sport and Health Sciences, Jyväskylä University, 40014 Jyväskylä, Finland
| | - Ralf Bützow
- Department of Pathology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland;
- Applied Tumor Genomics Research Program, University of Helsinki, 00290 Helsinki, Finland
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Johnson K, Saylor KW, Guynn I, Hicklin K, Berg JS, Lich KH. A systematic review of the methodological quality of economic evaluations in genetic screening and testing for monogenic disorders. Genet Med 2022; 24:262-288. [PMID: 34906467 PMCID: PMC8900524 DOI: 10.1016/j.gim.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Understanding the value of genetic screening and testing for monogenic disorders requires high-quality, methodologically robust economic evaluations. This systematic review sought to assess the methodological quality among such studies and examined opportunities for improvement. METHODS We searched PubMed, Cochrane, Embase, and Web of Science for economic evaluations of genetic screening/testing (2013-2019). Methodological rigor and adherence to best practices were systematically assessed using the British Medical Journal checklist. RESULTS Across the 47 identified studies, there were substantial variations in modeling approaches, reporting detail, and sophistication. Models ranged from simple decision trees to individual-level microsimulations that compared between 2 and >20 alternative interventions. Many studies failed to report sufficient detail to enable replication or did not justify modeling assumptions, especially for costing methods and utility values. Meta-analyses, systematic reviews, or calibration were rarely used to derive parameter estimates. Nearly all studies conducted some sensitivity analysis, and more sophisticated studies implemented probabilistic sensitivity/uncertainty analysis, threshold analysis, and value of information analysis. CONCLUSION We describe a heterogeneous body of work and present recommendations and exemplar studies across the methodological domains of (1) perspective, scope, and parameter selection; (2) use of uncertainty/sensitivity analyses; and (3) reporting transparency for improvement in the economic evaluation of genetic screening/testing.
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Affiliation(s)
- Karl Johnson
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Katherine W Saylor
- Department of Public Policy, College of Arts and Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Isabella Guynn
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Karen Hicklin
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan S Berg
- Department of Genetics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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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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Abstract
Although endometrial cancer management remains challenging, a deeper understanding of the genetic diversity as well as the drivers of the various pathogenic states of this disease has led to development of divergent management approaches in an effort to improve therapeutic precision in this complex malignancy. This comprehensive review provides an update on the epidemiology, pathophysiology, diagnosis and molecular classification, recent advancements in disease management, as well as important patient quality-of-life considerations and emerging developments in the rapidly evolving therapeutic landscape of endometrial cancers.
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10
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Economic Evaluation of Universal Lynch Syndrome Screening Protocols among Newly Diagnosed Patients with Colorectal Cancer. J Pers Med 2021; 11:jpm11121284. [PMID: 34945755 PMCID: PMC8708954 DOI: 10.3390/jpm11121284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/25/2022] Open
Abstract
We conducted an updated economic evaluation, from a healthcare system perspective, to compare the relative effectiveness and efficiency of eight Lynch syndrome (LS) screening protocols among newly diagnosed colorectal cancer (CRC) patients. We developed decision analytic models for a hypothetical cohort of 1000 patients. Model assumptions and parameter values were based on literature and expert opinion. All costs were in 2018 USD. For identifying LS cases, the direct germline sequencing (DGS) protocol provided the best performance (sensitivity 99.90%, 99.57-99.93%; specificity 99.50%, 97.28-99.85%), followed by the tumor sequencing to germline sequencing (TSGS) protocol (sensitivity, 99.42%, 96.55-99.63%; specificity, 96.58%, 96.46-96.60%). The immunohistochemistry (IHC) protocol was most efficient at $20,082 per LS case identified, compared to microsatellite instability (MSI) ($22,988), DGS ($31,365), and TSGS ($104,394) protocols. Adding double-somatic testing to IHC and MSI protocols did not change sensitivity and specificity, increased costs by 6% and 3.5%, respectively, but reduced unexplained cases by 70% and 50%, respectively. DGS would be as efficient as the IHC protocol when the cost of germline sequencing declines under $368 indicating DGS could be an efficient option in the near future. Until then, IHC and MSI protocols with double-somatic testing would be the optimal choices.
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11
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Gudgeon JM, Wallentine JC, Bonham EM, McLaughlin HD, Dodson MK. Determination of test performance of two contemporary screening tests for Lynch syndrome in endometrial cancer: A clinical trial. Gynecol Oncol 2021; 164:34-38. [PMID: 34689999 DOI: 10.1016/j.ygyno.2021.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Published data on the performance of the immunohistochemistry (IHC) test for mismatch repair (MMR) protein expression to detect Lynch syndrome (LS) index cases suggests it is highly variable; its performance in our system was unknown. Moreover, a brief family history questionnaire (bFHQ) developed by Eiriksson and colleagues in Canada demonstrated 100% sensitivity for LS case identification thus was of interest to us, but its performance outside of its original setting was unknown. Determination of the performance of these tests requires complete LS case identification in the testing population. METHODS Two hundred women were recruited during routine care for endometrial cancer (EC) to administer the bFHQ and perform genetic testing for the LS genes. Independently, the IHC test was performed to screen for presumptive LS cases. We determined the sensitivity, specificity, and positive and negative predictive values of the bFHQ and IHC test as well as simulating outcomes of the complete protocols. RESULTS Genetic testing all participants identified 8 cases of LS out of 200 (4% prevalence), the bFHQ identified 5 of 8 of these cases (62.5%, CI: 31.5%-87.6%), and the IHC test identified 6 or 7 of 8 cases (mean of 75% or 87.5%) depending on interpretation of test results. The specificities of the bFHQ and IHC test were 56.8% (CI: 49.8%-63.7%) and 79.8% (CI: 73.6%-85.1%), respectively. CONCLUSIONS This study is the first, to our knowledge, to test the effectiveness of the bFHQ in an EC population since its original reporting; our results are consistent with many reports of the challenges of collecting family health history. The performance of the IHC test as a screen falls within ranges reported in the literature but do not provide the confidence to drive a decision for or against continued use of this test as a LS screen.
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Affiliation(s)
- James M Gudgeon
- Intermountain Precision Genomics, 383 West Vine Street, Suite 300, Murray, UT 84123, USA.
| | - Jeremy C Wallentine
- Intermountain Central Laboratory, 5252 South Intermountain Drive, Murray, UT 84107, USA.
| | - Emily M Bonham
- Intermountain Precision Genomics, 383 West Vine Street, Suite 300, Murray, UT 84123, USA.
| | - Hannah D McLaughlin
- Department of OB/GYN, Division of Gynecologic Oncology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
| | - Mark K Dodson
- Department of OB/GYN, Division of Gynecologic Oncology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Stinton C, Jordan M, Fraser H, Auguste P, Court R, Al-Khudairy L, Madan J, Grammatopoulos D, Taylor-Phillips S. Testing strategies for Lynch syndrome in people with endometrial cancer: systematic reviews and economic evaluation. Health Technol Assess 2021; 25:1-216. [PMID: 34169821 PMCID: PMC8273681 DOI: 10.3310/hta25420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Lynch syndrome is an inherited genetic condition that is associated with an increased risk of certain cancers. The National Institute for Health and Care Excellence has recommended that people with colorectal cancer are tested for Lynch syndrome. Routine testing for Lynch syndrome among people with endometrial cancer is not currently conducted. OBJECTIVES To systematically review the evidence on the test accuracy of immunohistochemistry- and microsatellite instability-based strategies to detect Lynch syndrome among people who have endometrial cancer, and the clinical effectiveness and the cost-effectiveness of testing for Lynch syndrome among people who have been diagnosed with endometrial cancer. DATA SOURCES Searches were conducted in the following databases, from inception to August 2019 - MEDLINE ALL, EMBASE (both via Ovid), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (both via Wiley Online Library), Database of Abstracts of Reviews of Effects, Health Technology Assessment Database (both via the Centre for Reviews and Dissemination), Science Citation Index, Conference Proceedings Citation Index - Science (both via Web of Science), PROSPERO international prospective register of systematic reviews (via the Centre for Reviews and Dissemination), NHS Economic Evaluation Database, Cost-Effectiveness Analysis Registry, EconPapers (Research Papers in Economics) and School of Health and Related Research Health Utilities Database. The references of included studies and relevant systematic reviews were also checked and experts on the team were consulted. REVIEW METHODS Eligible studies included people with endometrial cancer who were tested for Lynch syndrome using immunohistochemistry- and/or microsatellite instability-based testing [with or without mutL homologue 1 (MLH1) promoter hypermethylation testing], with Lynch syndrome diagnosis being established though germline testing of normal (non-tumour) tissue for constitutional mutations in mismatch repair. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, the Consolidated Health Economic Reporting Standards and the Philips' checklist. Two reviewers independently conducted each stage of the review. A meta-analysis of test accuracy was not possible because of the number and heterogeneity of studies. A narrative summary of test accuracy results was provided, reporting test accuracy estimates and presenting forest plots. The economic model constituted a decision tree followed by Markov models for the impact of colorectal and endometrial surveillance, and aspirin prophylaxis with a lifetime time horizon. RESULTS The clinical effectiveness search identified 3308 studies; 38 studies of test accuracy were included. (No studies of clinical effectiveness of endometrial cancer surveillance met the inclusion criteria.) Four test accuracy studies compared microsatellite instability with immunohistochemistry. No clear difference in accuracy between immunohistochemistry and microsatellite instability was observed. There was some evidence that specificity of immunohistochemistry could be improved with the addition of methylation testing. There was high concordance between immunohistochemistry and microsatellite instability. The economic model indicated that all testing strategies, compared with no testing, were cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. Immunohistochemistry with MLH1 promoter hypermethylation testing was the most cost-effective strategy, with an incremental cost-effectiveness ratio of £9420 per quality-adjusted life-year. The second most cost-effective strategy was immunohistochemistry testing alone, but incremental analysis produced an incremental cost-effectiveness ratio exceeding £130,000. Results were robust across all scenario analyses. Incremental cost-effectiveness ratios ranged from £5690 to £20,740; only removing the benefits of colorectal cancer surveillance produced an incremental cost-effectiveness ratio in excess of the £20,000 willingness-to-pay threshold. A sensitivity analysis identified the main cost drivers of the incremental cost-effectiveness ratio as percentage of relatives accepting counselling and prevalence of Lynch syndrome in the population. A probabilistic sensitivity analysis showed, at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year, a 0.93 probability that immunohistochemistry with MLH1 promoter hypermethylation testing is cost-effective, compared with no testing. LIMITATIONS The systematic review excluded grey literature, studies written in non-English languages and studies for which the reference standard could not be established. Studies were included when Lynch syndrome was diagnosed by genetic confirmation of constitutional variants in the four mismatch repair genes (i.e. MLH1, mutS homologue 2, mutS homologue 6 and postmeiotic segregation increased 2). Variants of uncertain significance were reported as per the studies. There were limitations in the economic model around uncertainty in the model parameters and a lack of modelling of the potential harms of gynaecological surveillance and specific pathway modelling of genetic testing for somatic mismatch repair mutations. CONCLUSION The economic model suggests that testing women with endometrial cancer for Lynch syndrome is cost-effective, but that results should be treated with caution because of uncertain model inputs. FUTURE WORK Randomised controlled trials could provide evidence on the effect of earlier intervention on outcomes and the balance of benefits and harms of gynaecological cancer surveillance. Follow-up of negative cases through disease registers could be used to determine false negative cases. STUDY REGISTRATION This study is registered as PROSPERO CRD42019147185. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 42. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Chris Stinton
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hannah Fraser
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dimitris Grammatopoulos
- Institute of Precision Diagnostics and Translational Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Gudgeon JM, Varner MW, Hao J, Williams MS. Model-Based Re-Examination of the Effectiveness of Tumor/Immunohistochemistry and Direct-to-Sequencing Protocols for Lynch Syndrome Case Finding in Endometrial Cancer. JCO Oncol Pract 2021; 17:e1785-e1793. [PMID: 33886346 DOI: 10.1200/op.20.00988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Despite widespread provision of Lynch syndrome (LS) screening programs, questions remain about the most effective and efficient protocol for LS case finding. The purpose of this study was to explore the performance of the two protocols widely shown to be the most efficient and effective, respectively: immunohistochemical (IHC) staining of tumor and direct-to-sequencing (DtS) in endometrial cancer populations. METHODS Simulation models were developed to explore performance of the IHC and DtS protocols, updated to reflect current evidence. Analyses explicitly account for protocol complexity and failure points, as well as decreased sequencing costs. Key outcomes are percent of LS cases identified, total protocol costs and efficiency, and break-even analyses of sequencing costs. All costs are in 2020 US dollars (USD). RESULTS Under plausible conditions, the IHC protocol is expected to identify 40%-78% of LS cases and DtS protocol from 49% to 97%. When the key variable success in proceeding to sequencing is fixed for both protocols at 50%, 75%, and 100%, the DtS protocol is 9%, 12%, and 16% better at case finding, respectively, than the IHC protocol. The break-even cost of sequencing is about $488 USD when the outcome is total direct testing protocol costs; it is about $670 USD when the outcome is cost per LS case detected. CONCLUSION This study quantifies the plausible differences in the clinical effectiveness and cost-effectiveness of the two LS case-finding protocols. We demonstrate the large influence of success in proceeding to sequencing and potential impact of decreasing sequencing prices.
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Affiliation(s)
| | | | - Jing Hao
- Department of Population Health Sciences, Geisinger, Danville, PA
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14
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Gupta S, Nichols CB, Phillips J, O'Sullivan S, Ayres C, Mohan GR, Leung Y, Stewart CJR, Tan A, Schofield L, Salfinger SG, Kiraly-Borri C, Pachter N, Cohen PA. Lynch syndrome associated endometrial carcinomas in Western Australia: an analysis of universal screening by mismatch repair protein immunohistochemistry. Int J Gynecol Cancer 2021; 31:846-851. [PMID: 33858951 DOI: 10.1136/ijgc-2020-002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In 2016 universal screening with mismatch repair protein immunohistochemistry in all newly diagnosed endometrial carcinomas was introduced in Western Australia. OBJECTIVE To compare the prevalence of Lynch syndrome associated endometrial carcinomas between 2016 and 2019 with a historical control (2015). Additionally, to compare the number of cases appropriately referred for genetic assessment. METHODS A cross-sectional study of cases presented at the Western Australia gynecologic oncology tumor board was carried out. The primary outcome was the prevalence of Lynch syndrome associated endometrial carcinomas. A secondary outcome was the number of cases appropriately referred for genetic assessment. The following variables were extracted: date of birth; age at diagnosis; vital status; tumor mismatch repair protein expression status (retained or lost) and if lost, the specific mismatch repair protein deficiency; patients who were referred to a genetic clinic; and family history, if recorded. Data were collected from the clinical databases of the Familial Cancer Program at Genetic Services of Western Australia and WOMEN Center, to determine whether patients were appropriately referred for genetic evaluation and to ascertain the results of genetic testing. RESULTS Between 2016 and 2019, there were 1040 new endometrial carcinomas. Tumors of 883 (85%) patients underwent mismatch repair protein immunohistochemistry compared with 117 of 199 patients (59%) in 2015 (χ2 73.14, p<0.001). Of 883 tumors tested, 242 (27%) showed loss of mismatch repair protein expression. In 2015, 30 (26%) tumors of 117 tested showed loss of mismatch repair protein expression. During the 4 years of universal screening, 13 (1.5%) of 883 patients screened were diagnosed with Lynch syndrome compared with 2 (1.7%) of 117 in 2015 (Fisher's exact test 0.04, p=0.69). In 2015, 11 (37%) of 30 patients with loss of mismatch repair protein expression were not referred for genetic assessment compared with 36 (17%) of 209 patients in the universal screening group (χ2 6.28, p=0.02). No cases of Lynch syndrome were diagnosed in patients aged over 70 years. CONCLUSIONS Universal immunohistochemical screening did not increase the proportion of Lynch syndrome associated endometrial carcinomas identified, although the study was underpowered to detect small differences. There was an improvement in appropriate referrals for genetic assessment.
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Affiliation(s)
- Surabhi Gupta
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Cassandra B Nichols
- Genetic Services of Western Australia, Subiaco, Western Australia, Australia
| | - Jessica Phillips
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Sarah O'Sullivan
- Genetic Services of Western Australia, Subiaco, Western Australia, Australia.,WOMEN Centre, West Leederville, Western Australia, Australia
| | - Chloe Ayres
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Ganendra Raj Mohan
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia.,Department of Gynaecological Oncology, St John of God Hospital Bendat Family Comprehensive Cancer Centre, Subiaco, Western Australia, Australia
| | - Yee Leung
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia.,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Colin J R Stewart
- PathWest, King Edward Memorial Hospital, Subiaco, Western Australia, Australia
| | - Adeline Tan
- Clinipath Pathology, Osborne Park, Western Australia, Australia
| | - Lyn Schofield
- Genetic Services of Western Australia, Subiaco, Western Australia, Australia
| | - Stuart G Salfinger
- Department of Gynaecological Oncology, St John of God Hospital Bendat Family Comprehensive Cancer Centre, Subiaco, Western Australia, Australia
| | | | - Nicholas Pachter
- Genetic Services of Western Australia, Subiaco, Western Australia, Australia.,Internal Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Paul A Cohen
- Department of Gynaecological Oncology, King Edward Memorial Hospital, Subiaco, Western Australia, Australia .,Department of Gynaecological Oncology, St John of God Hospital Bendat Family Comprehensive Cancer Centre, Subiaco, Western Australia, Australia.,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
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15
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Gallon R, Gawthorpe P, Phelps RL, Hayes C, Borthwick GM, Santibanez-Koref M, Jackson MS, Burn J. How Should We Test for Lynch Syndrome? A Review of Current Guidelines and Future Strategies. Cancers (Basel) 2021; 13:406. [PMID: 33499123 PMCID: PMC7865939 DOI: 10.3390/cancers13030406] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
International guidelines for the diagnosis of Lynch syndrome (LS) recommend molecular screening of colorectal cancers (CRCs) to identify patients for germline mismatch repair (MMR) gene testing. As our understanding of the LS phenotype and diagnostic technologies have advanced, there is a need to review these guidelines and new screening opportunities. We discuss the barriers to implementation of current guidelines, as well as guideline limitations, and highlight new technologies and knowledge that may address these. We also discuss alternative screening strategies to increase the rate of LS diagnoses. In particular, the focus of current guidance on CRCs means that approximately half of Lynch-spectrum tumours occurring in unknown male LS carriers, and only one-third in female LS carriers, will trigger testing for LS. There is increasing pressure to expand guidelines to include molecular screening of endometrial cancers, the most frequent cancer in female LS carriers. Furthermore, we collate the evidence to support MMR deficiency testing of other Lynch-spectrum tumours to screen for LS. However, a reliance on tumour tissue limits preoperative testing and, therefore, diagnosis prior to malignancy. The recent successes of functional assays to detect microsatellite instability or MMR deficiency in non-neoplastic tissues suggest that future diagnostic pipelines could become independent of tumour tissue.
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Affiliation(s)
| | | | | | | | | | | | | | - John Burn
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (P.G.); (R.L.P.); (C.H.); (G.M.B.); (M.S.-K.); (M.S.J.)
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16
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Evaluation of a nationwide Dutch guideline to detect Lynch syndrome in patients with endometrial cancer. Gynecol Oncol 2021; 160:771-776. [PMID: 33419609 DOI: 10.1016/j.ygyno.2020.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In the Netherlands a nationwide guideline was introduced in 2016, which recommended routine Lynch syndrome screening (LSS) for all women with endometrial cancer (EC) <70 years of age. LSS consists of immunohistochemical (IHC) staining for loss of mismatch repair (MMR) protein expression, supplemented with MLH1 methylation analysis if indicated. Test results are evaluated by the treating gynaecologist, who refers eligible patients to a clinical geneticist. We evaluated the implementation of this guideline. METHODS From the nation-wide pathology database we selected all women diagnosed with EC < 70 years of age, treated from 1.6.2016-1.6.2017 in 14 hospitals. We collected data on the results of LSS and follow up of cases with suspected LS. RESULTS In 183 out of 204 tumours (90%) LSS was performed. In 41 cases (22%) MMR protein expression was lost, in 25 cases due to hypermethylation of the MLH1 promotor. One patient was known with a pathogenic MLH1 variant. The option of genetic counselling was discussed with 12 of the 15 remaining patients, of whom three declined. After counselling by the genetic counsellor nine patients underwent germline testing. In two no pathogenic germline variant was detected, two were diagnosed with a pathogenic PMS2 variant, and five with a pathogenic MSH6 variant, in concordance with the IHC profiles. CONCLUSION Coverage of LSS was high (90%), though referral for genetic counselling could be improved. Gynaecologists ought to be aware of the benefits and possible drawbacks of knowing mutational status, and require training in discussing this with their patients.
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Jia S, Wu X, Zhang Y, Zhang M. Chinese Lynch syndrome-associated colorectal cancer patients' self-concept and adherence to surveillance. Eur J Cancer Care (Engl) 2020; 30:e13379. [PMID: 33247511 DOI: 10.1111/ecc.13379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To describe Chinese Lynch syndrome-associated colorectal cancer patients' self-concept and adherence to surveillance and explore the factors influencing patients' adherence to surveillance. METHODS This was a cross-sectional quantitative study of a group of 83 Lynch syndrome-associated colorectal cancer patients, using the Lynch syndrome self-concept scale and medical records. IBM SPSS 20.0 was used for statistical analysis. RESULTS Patients' adherence to surveillance, for colorectal cancer, gastric cancer and small intestinal cancer, endometrial and ovarian cancer, they were 93.2%, 41.8% and 56.7% respectively. Older patients had lower surveillance adherence of colorectal cancer, gastric cancer and small intestinal cancer than younger patients (p < 0.05). Occupation was the major factor influencing their surveillance adherence of endometrial and ovarian cancer (p < 0.05). The score for Lynch syndrome self-concept was 72.23 ± 25.65. CONCLUSION The surveillance adherence of patients is high for colorectal cancer but low for extracolorectal cancers. Low surveillance adherence is associated with old age, living with family members and less secure employment. Chinese patients' self-concept scores were slightly higher than foreign patients. Nurses should pay more attention to the surveillance adherence and self-concept of Lynch syndrome-associated colorectal cancer patients and develop effective interventions to improve their surveillance adherence.
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Affiliation(s)
- Shumin Jia
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiaodan Wu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yiheng Zhang
- School of Nursing, Sun Yat-Sen University, Guangzhou, China
| | - Meifen Zhang
- School of Nursing, Sun Yat-Sen University, Guangzhou, China
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18
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Spinosa D, Acosta T, Wong J, Kurtovic K, Mewshaw J, Collins S, Kauff N, Havrilesky LJ, Strickland KC, Previs RA. Universal screening for Lynch syndrome in uterine cancer patients: A quality improvement initiative. Gynecol Oncol 2020; 160:169-174. [PMID: 33393478 PMCID: PMC7577655 DOI: 10.1016/j.ygyno.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the feasibility and effectiveness of a quality improvement initiative (QI) to adopt universal screening for Lynch syndrome in uterine cancer patients at an institution that previously employed age-based screening. METHODS Prior to the initiative, tumors of patients with uterine cancer diagnosed at age ≤ 60 years were screened for mismatch repair deficiency (MMR) and microsatellite instability (MSI). The QI process change model adopted universal testing of all uterine cancer specimens and implemented provider training, standardized documentation, and enhanced use of the electronic medical record (EMR). We compared screening rates, results of screening, follow up of abnormal results, and final diagnoses from the pre- and post-implementation periods. RESULTS Pre- and post-implementation screening rates for women age ≤ 60 years at the time of diagnosis were 45/78 (57.7%) and 64/68 (94.5%), respectively. The screening rate for all patients with uterine cancer increased from 73/190 (38.4%) to 172/182 (94.5%). The rate of abnormal screening results increased from 15/190 (7.9%) to 44/182 (24.0%) cases. Genetics referral rates among screen positives increased from 3/15 (20.0%) to 16/44 (36.4%). Germline diagnoses increased from 2/190 (1.1%) with two Lynch syndrome diagnoses to 4/182 (2.2%) including three Lynch syndrome diagnoses and one BRCA1 germline diagnosis. The number of patients errantly not screened decreased from at least 32 patients to 3 patients after the intervention. CONCLUSIONS Adherence to screening guidelines significantly improved after interventions involving provider education, optimal use of the EMR, and simplification of screening indications. These interventions are feasible at other institutions and translatable to other screening indications.
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Affiliation(s)
- Daniel Spinosa
- Department of Obstetrics & Gynecology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America.
| | - Tatiana Acosta
- Department of Obstetrics & Gynecology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Janice Wong
- Department of Obstetrics & Gynecology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Kelli Kurtovic
- Department of Obstetrics & Gynecology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Jennifer Mewshaw
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Sarah Collins
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Noah Kauff
- Clinical Cancer Genetics, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Kyle C Strickland
- Department of Pathology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
| | - Rebecca A Previs
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina, United States of America
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Rosa RCA, Santis JO, Teixeira LA, Molfetta GA, Dos Santos JTT, Ribeiro VDS, Chahud F, Ribeiro-Silva A, Brunaldi MO, Silva WA, Ferraz VEDF. Lynch syndrome identification in a Brazilian cohort of endometrial cancer screened by a universal approach. Gynecol Oncol 2020; 159:229-238. [PMID: 32694065 DOI: 10.1016/j.ygyno.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To report the frequency of Lynch syndrome (LS) in a cohort of patients from Southeast Brazil bearing endometrial cancer (EC), using a tumor screening universal approach. METHODS A total of 242 endometrial carcinomas were screened by immunohistochemistry (IHC) and microsatellite instability (MSI) for detection of DNA mismatch repair deficiency (dMMR). MLH1 methylation was assessed to identify sporadic cases. Patients with dMMR tumors were recruited for germline variant analysis by next-generation sequencing of the MLH1, MSH2, MSH6, PMS2, and EPCAM genes. RESULTS Ninety-three out of 242 tumors (38.5%) were classified as dMMR based on MSI and IHC results. Of these, 54 cases were selected for germline analysis, and 37/54 (68.5%) were available for sequencing. Ten patients (10/37, 27%) harbored germline pathogenic or likely pathogenic variants, most of them in the MSH6 gene (4/10, 40%). Seven variants of uncertain significance were found. Eight novel germline variants were identified. The LS prevalence in our cohort was of at least 4.1%. LS patients presented lower mean age at cancer diagnosis compared with patients diagnosed with sporadic EC. Individuals with dMMR tumors, without germline pathogenic variants detected in LS-genes ("Lynch-like" syndrome), had an intermediate mean age at cancer diagnosis between LS and sporadic cases. CONCLUSION This is the first report of the LS prevalence in EC screened by a universal approach in Brazil. Our findings contribute to a better understanding of the mutational landscape of this syndrome in Brazil, which is relevant for improved identification, genetic counseling, prevention and control of cancer in LS.
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Affiliation(s)
- Reginaldo Cruz Alves Rosa
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Jessica Oliveira Santis
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Lorena Alves Teixeira
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Greice Andreotti Molfetta
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | | | - Vanessa Dos Santos Ribeiro
- Inter-institutional Doctoral Program in Nursing, Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, Brazil.
| | - Fernando Chahud
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Alfredo Ribeiro-Silva
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Mariângela Ottoboni Brunaldi
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Wilson Araújo Silva
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Regional Blood Center at University Hospital of the Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Victor Evangelista de Faria Ferraz
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; Center for Medical Genomics at Clinical Hospital of the Ribeirão Preto Medical School, University of São Paulo, Brazil.
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Snowsill TM, Ryan NAJ, Crosbie EJ. Cost-Effectiveness of the Manchester Approach to Identifying Lynch Syndrome in Women with Endometrial Cancer. J Clin Med 2020; 9:E1664. [PMID: 32492863 PMCID: PMC7356917 DOI: 10.3390/jcm9061664] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/16/2022] Open
Abstract
Lynch syndrome (LS) is a hereditary cancer syndrome responsible for 3% of all endometrial cancer and 5% in those aged under 70 years. It is unclear whether universal testing for LS in endometrial cancer patients would be cost-effective. The Manchester approach to identifying LS in endometrial cancer patients uses immunohistochemistry (IHC) to detect mismatch repair (MMR) deficiency, incorporates testing for MLH1 promoter hypermethylation, and incorporates genetic testing for pathogenic MMR variants. We aimed to assess the cost-effectiveness of the Manchester approach on the basis of primary research data from clinical practice in Manchester. The Proportion of Endometrial Tumours Associated with Lynch Syndrome (PETALS) study informed estimates of diagnostic performances for a number of different strategies. A recent microcosting study was adapted and was used to estimate diagnostic costs. A Markov model was used to predict long-term costs and health outcomes (measured in quality-adjusted life years, QALYs) for individuals and their relatives. Bootstrapping and probabilistic sensitivity analysis were used to estimate the uncertainty in cost-effectiveness. The Manchester approach dominated other reflex testing strategies when considering diagnostic costs and Lynch syndrome cases identified. When considering long-term costs and QALYs the Manchester approach was the optimal strategy, costing £5459 per QALY gained (compared to thresholds of £20,000 to £30,000 per QALY commonly used in the National Health Service (NHS)). Cost-effectiveness is not an argument for restricting testing to younger patients or those with a strong family history. Universal testing for Lynch syndrome in endometrial cancer patients is expected to be cost-effective in the U.K. (NHS), and the Manchester approach is expected to be the optimal testing strategy.
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Affiliation(s)
- Tristan M. Snowsill
- Health Economics Group, University of Exeter Medical School, Exeter EX1 2LU, UK
| | - Neil A. J. Ryan
- Division of Evolution and Genomic Medicine, University of Manchester, St Mary’s Hospital, Manchester M13 9WL, UK;
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester M13 9WL, UK;
- Academic Centre for Women’s Health, University of Bristol, Bristol BS8 2PS, UK
| | - Emma J. Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester M13 9WL, UK;
- Division of Gynaecology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
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Guillén-Ponce C, Lastra E, Lorenzo-Lorenzo I, Martín Gómez T, Morales Chamorro R, Sánchez-Heras AB, Serrano R, Soriano Rodríguez MC, Soto JL, Robles L. SEOM clinical guideline on hereditary colorectal cancer (2019). Clin Transl Oncol 2020; 22:201-212. [PMID: 31981079 DOI: 10.1007/s12094-019-02272-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 12/21/2022]
Abstract
In the last 2 decades, clinical genetics on hereditary colorectal syndromes has shifted from just a molecular characterization of the different syndromes to the estimation of the individual risk of cancer and appropriate risk reduction strategies. In the last years, new specific therapies for some subgroups of patients have emerged as very effective alternatives. At the same time, germline multigene panel testing by next-generation sequencing (NGS) technology has become the new gold standard for molecular genetics.
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Affiliation(s)
- C Guillén-Ponce
- Medical Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Carretera de Colmenar Viejo, Km 9,100, 28034, Madrid, Spain.
| | - E Lastra
- Medical Oncology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - I Lorenzo-Lorenzo
- Medical Oncology Department, Complejo Hospitalario Universitario de Vigo (CHUVI), Pontevedra, Spain
| | - T Martín Gómez
- Medical Oncology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - R Morales Chamorro
- Medical Oncology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - A B Sánchez-Heras
- Medical Oncology Department, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - R Serrano
- Medical Oncology Department, Hospital Universitario Reina Sofía, IMIBIC, CIBERONC, Córdoba, Spain
| | | | - J L Soto
- Molecular Genetics Laboratory, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - L Robles
- Medical Oncology Department, Hospital Universitario Doce de Octubre, Madrid, Spain.
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22
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Novinson D, Puckett M, Townsend J, Tortolero-Luna G, Patterson JR, Gelb CA, Stewart SL. Increasing Awareness of Uterine Cancer Risks and Symptoms by Using Campaign Materials from Inside Knowledge: Get the Facts About Gynecologic Cancer. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:1190-1197. [PMID: 30229402 PMCID: PMC6739182 DOI: 10.1007/s13187-018-1427-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Uterine cancer is the fourth most commonly diagnosed cancer among women in the USA. To increase knowledge among women and healthcare providers about uterine cancer, the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) partnered with the Inside Knowledge: Get The Facts About Gynecologic Cancer campaign to present facilitated discussions about uterine cancer with women and providers. After standardized training, local NCCCP grantees developed and led community-based, tailored, facilitated discussions for public participants and providers. Pre- and post-session surveys were administered to assess knowledge of risk factors, symptoms, testing, and diagnostic options for uterine cancer. Following the facilitated sessions, significantly, more public respondents identified uterine cancer risk factors (e.g., advanced age, post-menopausal status). However, they also equally identified factors not associated with uterine cancer (e.g., smoking, HPV). Non-OB/GYN provider knowledge increased, significantly for some risks and symptoms, and their confidence with relaying uterine cancer information to patients significantly increased from 51.4 to 91.0% (P < 0.0001). Relatively low proportions of OB/GYNs (19.3%), other primary care providers (46.2%), and public participants (51.8%) knew post-session that genetic testing for Lynch syndrome can help stratify women for uterine cancer risk. Participant knowledge significantly increased for some risk factors and symptoms following Inside Knowledge educational sessions; however, some knowledge gaps remained. Overall, the Inside Knowledge materials are effective for increasing uterine cancer awareness among providers and women. Additional provider education could include specific resources related to uterine cancer genetic associations, as advancements in genetic testing for all uterine cancers are currently being made.
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Affiliation(s)
- Daniel Novinson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop F-76, Atlanta, GA, 30341, USA
| | - Mary Puckett
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop F-76, Atlanta, GA, 30341, USA.
| | - Julie Townsend
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop F-76, Atlanta, GA, 30341, USA
| | - Guillermo Tortolero-Luna
- Division of Cancer Control and Population Sciences, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | | | - Cynthia A Gelb
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop F-76, Atlanta, GA, 30341, USA
| | - Sherri L Stewart
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mailstop F-76, Atlanta, GA, 30341, USA
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Kasztura M, Richard A, Bempong NE, Loncar D, Flahault A. Cost-effectiveness of precision medicine: a scoping review. Int J Public Health 2019; 64:1261-1271. [PMID: 31650223 PMCID: PMC6867980 DOI: 10.1007/s00038-019-01298-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/19/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives Precision medicine (PM) aims to improve patient outcomes by stratifying or individualizing diagnosis and treatment decisions. Previous reviews found inconclusive evidence as to the cost-effectiveness of PM. The purpose of this scoping review was to describe current research findings on the cost-effectiveness of PM and to identify characteristics of cost-effective interventions.
Methods We searched PubMed with a combination of terms related to PM and economic evaluations and included studies published between 2014 and 2017.
Results A total of 83 articles were included, of which two-thirds were published in Europe and the USA. The majority of studies concluded that the PM intervention was at least cost-effective compared to usual care. However, the willingness-to-pay thresholds varied widely. Key factors influencing cost-effectiveness included the prevalence of the genetic condition in the target population, costs of genetic testing and companion treatment and the probability of complications or mortality. Conclusions This review may help inform decisions about reimbursement, research and development of PM interventions. Electronic supplementary material The online version of this article (10.1007/s00038-019-01298-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miriam Kasztura
- Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.
| | - Aude Richard
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nefti-Eboni Bempong
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dejan Loncar
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Domchek SM, Robson ME. Update on Genetic Testing in Gynecologic Cancer. J Clin Oncol 2019; 37:2501-2509. [PMID: 31403865 PMCID: PMC6754232 DOI: 10.1200/jco.19.00363] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2019] [Indexed: 01/13/2023] Open
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25
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Cost-effectiveness analysis of reflex testing for Lynch syndrome in women with endometrial cancer in the UK setting. PLoS One 2019; 14:e0221419. [PMID: 31469860 PMCID: PMC6716649 DOI: 10.1371/journal.pone.0221419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022] Open
Abstract
Background Lynch syndrome is a hereditary cancer syndrome caused by constitutional pathogenic variants in the DNA mismatch repair (MMR) system, leading to increased risk of colorectal, endometrial and other cancers. The study aimed to identify the incremental costs and consequences of strategies to identify Lynch syndrome in women with endometrial cancer. Methods A decision-analytic model was developed to evaluate the relative cost-effectiveness of reflex testing strategies for identifying Lynch syndrome in women with endometrial cancer taking the NHS perspective and a lifetime horizon. Model input parameters were sourced from various published sources. Consequences were measured using quality-adjusted life years (QALYs). A cost-effectiveness threshold of £20 000/QALY was used. Results Reflex testing for Lynch syndrome using MMR immunohistochemistry and MLH1 methylation testing was cost-effective versus no testing, costing £14 200 per QALY gained. There was uncertainty due to parameter imprecision, with an estimated 42% chance this strategy is not cost-effective compared with no testing. Age had a significant impact on cost-effectiveness, with testing not predicted to be cost-effective in patients aged 65 years and over. Conclusions Testing for Lynch syndrome in younger women with endometrial cancer using MMR immunohistochemistry and MLH1 methylation testing may be cost-effective. Age cut-offs may be controversial and adversely affect implementation.
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Kiyozumi Y, Matsubayashi H, Horiuchi Y, Higashigawa S, Oishi T, Abe M, Ohnami S, Urakami K, Nagashima T, Kusuhara M, Miyake H, Yamaguchi K. Germline mismatch repair gene variants analyzed by universal sequencing in Japanese cancer patients. Cancer Med 2019; 8:5534-5543. [PMID: 31386297 PMCID: PMC6745857 DOI: 10.1002/cam4.2432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/25/2019] [Accepted: 07/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Lynch syndrome (LS) is the commonest inherited cancer syndrome caused by pathogenic variants of germline DNA mismatch repair (g.MMR) genes. Genome‐wide sequencing is now increasingly applied for tumor characterization, but not for g.MMR. The aim of this study was to evaluate the incidence and pathogenicity of g.MMR variants in Japanese cancer patients. Methods Four g.MMR genes (MLH1, MSH2, MSH6, and PMS2) were analyzed by next generation sequencing in 1058 cancer patients (614 male, 444 female; mean age 65.6 years) without past diagnosis of LS. The g.MMR variant pathogenicity was classified based on the ClinVar 2015 database. Tumor MMR immunohistochemistry, microsatellite instability (MSI), and BRAF sequencing were also investigated in specific cases. Results Overall, 46 g.MMR variants were detected in 167 (15.8%) patients, 17 likely benign variants in 119 patients, 24 variants of uncertain significance (VUSs) in 68 patients, two likely pathogenic variants in two patients, and three pathogenic variants in three (0.3%) patients. The three pathogenic variants included two colorectal cancers with MLH1 loss and high MSI and one endometrial cancer with MSH6 loss and microsatellite stability. Two likely pathogenic variants were shifted to VUSs by ClinVar (2018). One colon cancer with a likely benign variant demonstrated MLH1 loss and BRAF mutation, but other nonpathogenic variants showed sustained MMR and microsatellite stability. Conclusions Universal sequencing of g.MMR genes demonstrated sundry benign variants, but only a small proportion of cancer patients had pathogenic variants. Pathogenicity evaluation using the ClinVar database agreed with MSI, MMR immunohistochemistry, and BRAF sequencing.
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Affiliation(s)
- Yoshimi Kiyozumi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Matsubayashi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yasue Horiuchi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan.,Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Satomi Higashigawa
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takuma Oishi
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masato Abe
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sumiko Ohnami
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan
| | | | - Takeshi Nagashima
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan.,SRL Inc., Tokyo, Japan
| | | | - Hidehiko Miyake
- Department of Genetic Counseling, Graduate School of Ochanomizu University, Tokyo, Japan
| | - Ken Yamaguchi
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan
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Chao X, Li L, Wu M, Ma S, Tan X, Zhong S, Bi Y, Lang J. Comparison of screening strategies for Lynch syndrome in patients with newly diagnosed endometrial cancer: a prospective cohort study in China. Cancer Commun (Lond) 2019; 39:42. [PMID: 31307542 PMCID: PMC6628486 DOI: 10.1186/s40880-019-0388-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background The prevalence of Lynch syndrome and screening strategies for this disorder in Chinese patients with endometrial cancer have seldom been investigated. Such data would be essential for the screening, prevention, genetic counseling, and treatment of Lynch syndrome. The purpose of this prospective study was to determine the accuracy of the mismatch repair (MMR) protein immunohistochemistry (IHC), microsatellite instability (MSI) test, and clinical diagnostic criteria in screening for Lynch syndrome-associated endometrial cancer (LS-EC) in a prospective Chinese cohort. Methods All patients with newly diagnosed endometrial cancer (EC) were evaluated using clinical diagnostic criteria (Amsterdam II criteria and the revised Bethesda guidelines), MSI test, and IHC of MMR proteins in tumor tissues. For all patients, the screening results were compared with results of germline sequencing for pathogenic variants of MMR genes. Results Between December 2017 and August 2018, a total of 111 unselected patients with newly diagnosed EC were enrolled. Six patients (5.4%) harbored a pathogenic germline mutation of MMR genes: 1 had a mutation in MutL homolog 1 (MLH1), 2 in MutS homolog 2 (MSH2), and 3 in MutS homolog 6 (MSH6). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for identifying LS-EC were 33.3%, 88.6%, 14.3%, and 95.9%, for the clinical criteria, 66.7%, 75.0%, 14.3%, and 97.3% for IHC of MMR proteins, 100%, 89.9%, 33.3%, and 100% for MSI test, and 100%, 72.4%, 20.0% and 100% for combined IHC and MSI test, respectively. The combination of IHC and MSI test had higher sensitivity and PPV than the clinical criteria (p = 0.030). MSI test and IHC were highly concordant for LS-EC screening (73/77, 94.8%). Conclusion The accuracy of the combination of IHC of MMR proteins and MSI test for screening LS among Chinese patients with EC was superior to that of the clinical criteria. Trial registration NCT03291106. Registered on September 25, 2017
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Affiliation(s)
- Xiaopei Chao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
| | - Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China.
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
| | - Shuiqing Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
| | - Xianjie Tan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
| | - Sen Zhong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
| | - Yalan Bi
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, 100730, P.R. China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, 100730, P.R. China
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Gudgeon JM, Varner MW, Hashibe M, Williams MS. Is immunohistochemistry-based screening for Lynch syndrome in endometrial cancer effective? The consent's the thing. Gynecol Oncol 2019; 154:131-137. [PMID: 31130287 DOI: 10.1016/j.ygyno.2019.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022]
Abstract
PURPOSE To investigate the plausible failure rate of the immunohistochemistry (IHC)-based screening protocol to identify Lynch syndrome (LS) index cases among endometrial cancer (EC) patients. METHODS We developed a simulation model of the IHC protocol in this context. The model was populated from systematic and focused reviews, augmented with local data and expert opinion. The virtual cohort represents the number of women expected to be diagnosed with EC in the U.S. in 2018. The outcomes include protocol failure rates and LS cases missed in a variety of hypothetical scenarios. RESULTS The best estimate of failure rate of the IHC protocol is 58%; minimum and maximum estimates are 33% and 80%, respectively. These failure rates are driven primarily by the high rates of failure to obtain consent from patients for sequencing (25% to 80%). The multiple imperfect tests and potential failure points in this protocol, collectively, make up 7% to 20% of the total failure rate. When consent for sequencing was fixed in the model at 25%, 50%, and 80%; the expected ranges for index case identification failure are 78%-82%, 57%-64%, and 29%-42%, respectively. CONCLUSION The primary driver of failure to identify index cases remains consent for sequencing. Consent rates have shown little improvement since LS screening programs were instituted in the U.S., leaving us to conclude these high failure rates are resistant to substantial improvement. These missed opportunities will be magnified because cascade screening for carrier status among family members will not be pursued.
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Affiliation(s)
- James M Gudgeon
- Intermountain Healthcare, Salt Lake City, UT, United States of America.
| | - Michael W Varner
- University of Utah School of Medicine, Salt Lake City, UT, United States of America; Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT, 30 North 1900 East, Salt Lake City, Utah, 84132.
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, UT, United States of America; Division of Public Health, Department of Family & Preventive Medicine, University of Utah School of Medicine, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT, 84112.
| | - Marc S Williams
- Geisinger Health System, Danville, PA, United States of America; Genomic Medicine Institute, Geisinger Health System, 100 N Academy Dr., Mail Stop 26-20, Danville, PA 17822-2620.
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Yozu M, Kumarasinghe MP, Brown IS, Gill AJ, Rosty C. Australasian Gastrointestinal Pathology Society (AGPS) consensus guidelines for universal defective mismatch repair testing in colorectal carcinoma. Pathology 2019; 51:233-239. [DOI: 10.1016/j.pathol.2018.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/18/2018] [Accepted: 11/25/2018] [Indexed: 01/28/2023]
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30
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Salvador MU, Truelson MR, Mason C, Souders B, LaDuca H, Dougall B, Black MH, Fulk K, Profato J, Gutierrez S, Jasperson K, Tippin-Davis B, Lu HM, Gray P, Shah S, Chao EC, Ghahramani N, Landsverk M, Gau CL, Chen D, Pronold M. Comprehensive Paired Tumor/Germline Testing for Lynch Syndrome: Bringing Resolution to the Diagnostic Process. J Clin Oncol 2019; 37:647-657. [PMID: 30702970 PMCID: PMC6494248 DOI: 10.1200/jco.18.00696] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2018] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The current diagnostic testing algorithm for Lynch syndrome (LS) is complex and often involves multiple follow-up germline and somatic tests. We aimed to describe the results of paired tumor/germline testing performed on a large cohort of patients with colorectal cancer (CRC) and endometrial cancer (EC) to better determine the utility of this novel testing methodology. MATERIALS AND METHODS We retrospectively reviewed a consecutive series of patients with CRC and EC undergoing paired tumor/germline analysis of the LS genes at a clinical diagnostic laboratory (N = 702). Microsatellite instability, MLH1 promoter hypermethylation, and germline testing of additional genes were performed if ordered. Patients were assigned to one of five groups on the basis of prior tumor screening and germline testing outcomes. Results for each group are described. RESULTS Overall results were informative regarding an LS diagnosis for 76.1% and 60.8% of patients with mismatch-repair-deficient (MMRd) CRC and EC without and with prior germline testing, respectively. LS germline mutations were identified in 24.8% of patients in the group without prior germline testing, and interestingly, in 9.5% of patients with previous germline testing; four of these were discordant with prior tumor screening. Upon excluding patients with MLH1 promoter hypermethylation and germline mutations, biallelic somatic inactivation was seen in approximately 50% of patients with MMRd tumors across groups. CONCLUSION Paired testing identified a cause for MMRd tumors in 76% and 61% of patients without and with prior LS germline testing, respectively. Findings support inclusion of tumor sequencing as well as comprehensive LS germline testing in the LS testing algorithm. Paired testing offers a complete, convenient evaluation for LS with high diagnostic resolution.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Elizabeth C. Chao
- Ambry Genetics, Aliso Viejo, CA
- University of California, Irvine, School of Medicine, Irvine, CA
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Ryan NAJ, Davison NJ, Payne K, Cole A, Evans DG, Crosbie EJ. A Micro-Costing Study of Screening for Lynch Syndrome-Associated Pathogenic Variants in an Unselected Endometrial Cancer Population: Cheap as NGS Chips? Front Oncol 2019; 9:61. [PMID: 30863719 PMCID: PMC6399107 DOI: 10.3389/fonc.2019.00061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/21/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Lynch syndrome is the most common inherited cause of endometrial cancer. Identifying individuals affected by Lynch syndrome enables risk-reducing interventions including colorectal surveillance, and cascade testing of relatives. Methods: We conducted a micro-costing study of screening all women with endometrial cancer for Lynch syndrome using one of four diagnostic strategies combining tumor microsatellite instability testing (MSI), immunohistochemistry (IHC), and/or MLH1 methylation testing, and germline next generation sequencing (NGS). Resource use (consumables, capital equipment, and staff) was identified through direct observation and laboratory protocols. Published sources were used to identify unit costs to calculate a per-patient cost (£; 2017) of each testing strategy, assuming a National Health Service (NHS) perspective. Results: Tumor triage with MSI and reflex MLH1 methylation testing followed by germline NGS of women with likely Lynch syndrome was the cheapest strategy at £42.01 per case. Tumor triage with IHC and reflex MLH1 methylation testing of MLH1 protein-deficient cancers followed by NGS of women with likely Lynch syndrome cost £45.68. Tumor triage with MSI followed by NGS of all women found to have tumor microsatellite instability cost £78.95. Immediate germline NGS of all women with endometrial cancer cost £176.24. The cost of NGS was affected by the skills and time needed to interpret results (£44.55/patient). Conclusion: This study identified the cost of reflex screening all women with endometrial cancer for Lynch syndrome, which can be used in a model-based cost-effectiveness analysis to understand the added value of introducing reflex screening into clinical practice.
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Affiliation(s)
- Neil A J Ryan
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Division of Evolution and Genomic Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, St Mary's Hospital, Manchester, United Kingdom
| | - Niall J Davison
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, United Kingdom
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester, United Kingdom
| | - Anne Cole
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - D Gareth Evans
- Division of Evolution and Genomic Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, St Mary's Hospital, Manchester, United Kingdom.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, NIHR Manchester Biomedical Research Centre, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom
| | - Emma J Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,Division of Cancer Sciences, Faculty of Biology, Medicine and Health, NIHR Manchester Biomedical Research Centre, School of Medical Sciences, The University of Manchester, Manchester, United Kingdom.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Nikolaidis C, Ming C, Pedrazzani C, van der Horst T, Kaiser-Grolimund A, Ademi Z, Bührer-Landolt R, Bürki N, Caiata-Zufferey M, Champion V, Chappuis PO, Kohler C, Erlanger TE, Graffeo R, Hampel H, Heinimann K, Heinzelmann-Schwarz V, Kurzeder C, Monnerat C, Northouse LL, Pagani O, Probst-Hensch N, Rabaglio M, Schoenau E, Sijbrands EJG, Taborelli M, Urech C, Viassolo V, Wieser S, Katapodi MC. Challenges and Opportunities for Cancer Predisposition Cascade Screening for Hereditary Breast and Ovarian Cancer and Lynch Syndrome in Switzerland: Findings from an International Workshop. Public Health Genomics 2019; 21:121-132. [PMID: 30695780 DOI: 10.1159/000496495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 01/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An international workshop on cancer predisposition cascade genetic screening for hereditary breast and ovarian cancer (HBOC) and Lynch syndrome (LS) took place in Switzerland, with leading researchers and clinicians in cascade screening and hereditary cancer from different disciplines. The purpose of the workshop was to enhance the implementation of cascade genetic screening in Switzerland. Participants discussed the challenges and opportunities associated with cascade screening for HBOC and LS in Switzerland (CASCADE study); family implications and the need for family-based interventions; the need to evaluate the cost-effectiveness of cascade genetic screening; and interprofessional collaboration needed to lead this initiative. METHODS The workshop aims were achieved through exchange of data and experiences from successful cascade screening programs in the Netherlands, Australia, and the state of Ohio, USA; Swiss-based studies and scientific experience that support cancer cascade screening in Switzerland; programs of research in psychosocial oncology and family-based studies; data from previous cost-effectiveness analyses of cascade genetic screening in the Netherlands and in Australia; and organizational experience from a large interprofessional collaborative. Scientific presentations were recorded and discussions were synthesized to present the workshop findings. RESULTS The key elements of successful implementation of cascade genetic screening are a supportive network of stakeholders and connection to complementary initiatives; sample size and recruitment of relatives; centralized organization of services; data-based cost-effectiveness analyses; transparent organization of the initiative; and continuous funding. CONCLUSIONS This paper describes the processes and key findings of an international workshop on cancer predisposition cascade screening, which will guide the CASCADE study in Switzerland.
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Affiliation(s)
- Christos Nikolaidis
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Chang Ming
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Carla Pedrazzani
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland.,University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Tina van der Horst
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Andrea Kaiser-Grolimund
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | - Zanfina Ademi
- European Center of Pharmaceutical Medicine, University of Basel, Basel, Switzerland.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Nicole Bürki
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | | | - Pierre O Chappuis
- Division of Genetic Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland.,Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Carmen Kohler
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland.,Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias E Erlanger
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Rossella Graffeo
- Institute of Oncology and Breast Unit of Southern Switzerland, Bellinzona, Switzerland
| | - Heather Hampel
- Division of Human Genetics, Department of Internal Medicine, Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Karl Heinimann
- Institute for Medical Genetics and Pathology, University Hospital Basel, and Research Group Human Genomics, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | | | - Olivia Pagani
- Institute of Oncology and Breast Unit of Southern Switzerland, Bellinzona, Switzerland
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Manuela Rabaglio
- University Clinic for Medical Oncology, Inselspital Bern, Bern, Switzerland
| | - Eveline Schoenau
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Eric J G Sijbrands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Monika Taborelli
- Institute of Oncology and Breast Unit of Southern Switzerland, Bellinzona, Switzerland
| | - Corinne Urech
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Valeria Viassolo
- Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Simon Wieser
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Maria C Katapodi
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland, .,University of Michigan School of Nursing, Ann Arbor, Michigan, USA,
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Long B, Lilyquist J, Weaver A, Hu C, Gnanaolivu R, Lee KY, Hart SN, Polley EC, Bakkum-Gamez JN, Couch FJ, Dowdy SC. Cancer susceptibility gene mutations in type I and II endometrial cancer. Gynecol Oncol 2019; 152:20-25. [PMID: 30612635 PMCID: PMC6326093 DOI: 10.1016/j.ygyno.2018.10.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/11/2018] [Accepted: 10/16/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the incidence of germline cancer predisposition gene mutations in patients with endometrial cancer (EC) subtypes. METHODS Germline DNA was extracted from whole blood collected from consenting patients undergoing primary surgery for EC between 5/2005 and 11/2016. DNA samples were evaluated by product sequencing from a targeted multiplex PCR panel including 21 known/suspected cancer predisposition genes. Variants were classified as pathogenic/likely pathogenic based on allele frequency (<0.003), effects on protein function, and ClinVar assertions. RESULTS Germline panel testing was performed on 1170 cases of EC; 849 (72.6%) were type I, and 321 (27.4%) were type II EC, including 135 (11.5%) uterine serous cancers (USC). BRCA1 mutations were enriched in Type II EC compared to Type I EC (0.93% vs. 0.12%, p = 0.07). Lynch Syndrome (LS) mutations were identified in 1.4% of type I and 1.6% of type II EC (p = 0.79), including 1.5% for USC. In total, predisposition gene mutations were present in 4.2% of type I and 5.3% of type II EC, as well as 6.7% of patients with USC). CONCLUSIONS BRCA1/2 and Lynch mutations were rare in this cohort of unselected patients with type I and II EC, including USC. However, the presence of predisposition gene mutations in 4.2% of EC type I, 5.3% of EC type II, and 6.7% of USC suggests that somatic mutation testing should be considered for all EC patients.
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Affiliation(s)
- Beverly Long
- Mayo Clinic, Division of Gynecologic Oncology, United States of America.
| | - Jenna Lilyquist
- Mayo Clinic, Department of Epidemiology, United States of America
| | - Amy Weaver
- Mayo Clinic, Department of Biostatistics, United States of America
| | - Chunling Hu
- Mayo Clinic, Department of Pathology, United States of America
| | - Rohan Gnanaolivu
- Mayo Clinic, Department of Biomedical Statistics and Informatics, United States of America
| | - Kun Y Lee
- Mayo Clinic, Department of Pathology, United States of America
| | - Steven N Hart
- Mayo Clinic, Department of Biomedical Statistics and Informatics, United States of America
| | - Eric C Polley
- Mayo Clinic, Department of Biomedical Statistics and Informatics, United States of America
| | | | - Fergus J Couch
- Mayo Clinic, Department of Epidemiology, United States of America
| | - Sean C Dowdy
- Mayo Clinic, Division of Gynecologic Oncology, United States of America
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Next-Generation Service Delivery: A Scoping Review of Patient Outcomes Associated with Alternative Models of Genetic Counseling and Genetic Testing for Hereditary Cancer. Cancers (Basel) 2018; 10:cancers10110435. [PMID: 30428547 PMCID: PMC6266465 DOI: 10.3390/cancers10110435] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 01/19/2023] Open
Abstract
The combination of increased referral for genetic testing and the current shortage of genetic counselors has necessitated the development and implementation of alternative models of genetic counseling and testing for hereditary cancer assessment. The purpose of this scoping review is to provide an overview of the patient outcomes that are associated with alternative models of genetic testing and genetic counseling for hereditary cancer, including germline-only and tumor testing models. Seven databases were searched, selecting studies that were: (1) full-text articles published ≥2007 or conference abstracts published ≥2015, and (2) assessing patient outcomes of an alternative model of genetic counseling or testing. A total of 79 publications were included for review and synthesis. Data-charting was completed using a data-charting form that was developed by the study team for this review. Seven alternative models were identified, including four models that involved a genetic counselor: telephone, telegenic, group, and embedded genetic counseling models; and three models that did not: mainstreaming, direct, and tumor-first genetic testing models. Overall, these models may be an acceptable alternative to traditional models on knowledge, patient satisfaction, psychosocial measures, and the uptake of genetic testing; however, particular populations may be better served by traditional in-person genetic counseling. As precision medicine initiatives continue to advance, institutions should consider the implementation of new models of genetic service delivery, utilizing a model that will best serve the needs of their unique patient populations.
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Adar T, Rodgers LH, Shannon KM, Yoshida M, Ma T, Mattia A, Lauwers GY, Iafrate AJ, Hartford NM, Oliva E, Chung DC. Universal screening of both endometrial and colon cancers increases the detection of Lynch syndrome. Cancer 2018; 124:3145-3153. [PMID: 29750335 DOI: 10.1002/cncr.31534] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/31/2018] [Accepted: 04/10/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Lynch syndrome (LS) is the most common hereditary cause of colorectal cancer (CRC) and endometrial cancer (EC). Screening of all CRCs for LS is currently recommended, but screening of ECs is inconsistent. The objective of this study was to determine the added value of screening both CRC and EC tumors in the same population. METHODS A prospective, immunohistochemistry (IHC)-based screening program for all patients with newly diagnosed CRCs and ECs was initiated in 2011 and 2013, respectively, at 2 centers (primary and tertiary). Genetic testing was recommended for those who had tumors with absent mutS homolog 2 (MSH2), MSH6, or postmeiotoic segregation increased 2 (PMS2) expression and for those who had tumors with absent mutL homolog 1 (MLH1) expression and no v-Raf murine sarcoma viral oncogene homolog B (BRAF) mutation or MLH1 promoter methylation. Amsterdam II criteria, revised Bethesda criteria, and scores from prediction models for gene mutations (the PREMM1,2,6 and PREMM5 prediction models) were ascertained in patients with LS. RESULTS In total, 1290 patients with CRC and 484 with EC were screened for LS, and genetic testing was recommended for 137 patients (10.6%) and 32 patients (6.6%), respectively (P = .01). LS was identified in 16 patients (1.2%) with CRC and in 8 patients (1.7%) with EC. Among patients for whom genetic testing was recommended, the LS diagnosis rate was higher among those with EC (25.0% vs 11.7%, P = .052). The Amsterdam II criteria, revised Bethesda criteria, and both PREMM calculators would have missed 62.5%, 50.0%, and 12.5% of the identified patients with LS, respectively. CONCLUSIONS Expanding a universal screening program for LS to include patients who had EC identified 50% more patients with LS, and many of these patients would have been missed by risk assessment tools (including PREMM5 ). Universal screening programs for LS should include both CRC and EC. Cancer 2018. © 2018 American Cancer Society.
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Affiliation(s)
- Tomer Adar
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Linda H Rodgers
- Center for Cancer Risk Analysis, Cancer Center, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Kristen M Shannon
- Center for Cancer Risk Analysis, Cancer Center, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Makoto Yoshida
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tianle Ma
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony Mattia
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Pathology, North Shore Medical Center, Danvers, Massachusetts
| | - Gregory Y Lauwers
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anthony J Iafrate
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole M Hartford
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Esther Oliva
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel C Chung
- Gastroenterology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Cancer Risk Analysis, Cancer Center, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
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Petr EJ, Else T. Adrenocortical carcinoma (ACC): When and why should we consider germline testing? Presse Med 2018; 47:e119-e125. [DOI: 10.1016/j.lpm.2018.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Chapel DB, Yamada SD, Cowan M, Lastra RR. Immunohistochemistry for mismatch repair protein deficiency in endometrioid endometrial carcinoma yields equivalent results when performed on endometrial biopsy/curettage or hysterectomy specimens. Gynecol Oncol 2018; 149:570-574. [DOI: 10.1016/j.ygyno.2018.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
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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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Dottino JA, Lu KH. Towards value-based universal Lynch syndrome identification in endometrial cancer patients. Gynecol Oncol 2016; 143:451-452. [PMID: 27865420 DOI: 10.1016/j.ygyno.2016.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Joseph A Dottino
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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