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Lindberg LJ, Wadt KAW, Therkildsen C, Petersen HV. National Experiences from 30 Years of Provider-Mediated Cascade Testing in Lynch Syndrome Families-The Danish Model. Cancers (Basel) 2024; 16:1577. [PMID: 38672659 PMCID: PMC11048852 DOI: 10.3390/cancers16081577] [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: 01/19/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Cascade genetic testing and surveillance reduce morbidity and mortality in Lynch syndrome. However, barriers to conveying information about genetic disorders within families result in low uptake of genetic testing. Provider-mediated interventions may increase uptake but raise legal and ethical concerns. We describe 30 years of national experience with cascade genetic testing combining family- and provider-mediated contact in Lynch syndrome families in the Danish Hereditary Non-Polyposis Colorectal Cancer (HNPCC) Register. We aimed to estimate the added value of information letters to family members in Lynch syndrome families (provider-mediated contact) compared to family members not receiving such letters and thus relying on family-mediated contact. National clinical practice for cascade genetic testing, encompassing infrastructure, legislation, acceptance, and management of the information letters, is also discussed. Cascade genetic testing resulted in 7.3 additional tests per family. Uptake of genetic testing was 54.4% after family-mediated and 64.9% after provider-mediated contact, corresponding to an odds ratio of 1.8 (p < 0.001). The uptake of genetic testing was highest in the first year after diagnosis of Lynch syndrome in the family, with 72.5% tested after provider-mediated contact. In conclusion, the Danish model combining family- and provider-mediated contact can increase the effect of cascade genetic testing.
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Affiliation(s)
- Lars Joachim Lindberg
- The Danish HNPCC Register, Gastrounit, Copenhagen University Hospital—Amager and Hvidovre, DK2650 Hvidovre, Denmark;
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK2200 Copenhagen N, Denmark;
| | - Karin A. W. Wadt
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK2200 Copenhagen N, Denmark;
- Department of Clinical Genetics, Rigshospitalet, DK2100 Copenhagen Ø, Denmark
| | - Christina Therkildsen
- The Danish HNPCC Register, Gastrounit, Copenhagen University Hospital—Amager and Hvidovre, DK2650 Hvidovre, Denmark;
| | - Helle Vendel Petersen
- Medical Department, Zealand University Hospital, DK4800 Nykøbing Falster, Denmark;
- Clinical Research Centre, Copenhagen University Hospital, DK2650 Hvidovre, Denmark
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2
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Etchegary H, Pike A, Puddester R, Watkins K, Warren M, Francis V, Woods M, Green J, Savas S, Seal M, Gao Z, Avery S, Curtis F, McGrath J, MacDonald D, Burry TN, Dawson L. Cancer prevention in cancer predisposition syndromes: A protocol for testing the feasibility of building a hereditary cancer research registry and nurse navigator follow up model. PLoS One 2022; 17:e0279317. [PMID: 36548287 PMCID: PMC9778977 DOI: 10.1371/journal.pone.0279317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Monogenic, high penetrance syndromes, conferring an increased risk of malignancies in multiple organs, are important contributors to the hereditary burden of cancer. Early detection and risk reduction strategies in patients with a cancer predisposition syndrome can save their lives. However, despite evidence supporting the benefits of early detection and risk reduction strategies, most Canadian jurisdictions have not implemented programmatic follow up of these patients. In our study site in the province of Newfoundland and Labrador (NL), Canada, there is no centralized, provincial registry of high-risk individuals. There is no continuity or coordination of care providing cancer genetics expertise and no process to ensure that patients are referred to the appropriate specialists or risk management interventions. This paper describes a study protocol to test the feasibility of obtaining and analyzing patient risk management data, specifically patients affected by hereditary breast ovarian cancer syndrome (HBOC; BRCA 1 and BRCA 2 genes) and Lynch syndrome (LS; MLH1, MSH2, MSH6, and PMS2 genes). Through a retrospective cohort study, we will describe these patients' adherence to risk management guidelines and test its relationship to health outcomes, including cancer incidence and stage. Through a qualitative interviews, we will determine the priorities and preferences of patients with any inherited cancer mutation for a follow up navigation model of risk management. Study data will inform a subsequent funding application focused on creating and evaluating a research registry and follow up nurse navigation model. It is not currently known what proportion of cancer mutation carriers are receiving care according to guidelines. Data collected in this study will provide clinical uptake and health outcome information so gaps in care can be identified. Data will also provide patient preference information to inform ongoing and planned research with cancer mutation carriers.
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Affiliation(s)
- Holly Etchegary
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
- * E-mail:
| | - April Pike
- Faculty of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Rebecca Puddester
- Faculty of Nursing, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Kathy Watkins
- Centre for Nursing and Health Studies, Eastern Health, St. John’s, Newfoundland, Canada
| | - Mike Warren
- Patient Partner, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Vanessa Francis
- Patient Partner, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Michael Woods
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Jane Green
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Sevtap Savas
- Division of Biomedical Sciences, Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Melanie Seal
- Discipline of Oncology, Faculty of Medicine, Memorial University of Newfoundland, Cancer Care Program, Eastern Health, St. John’s, Newfoundland, Canada
| | - Zhiwei Gao
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Susan Avery
- Family Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Fiona Curtis
- Provincial Medical Genetics Program, Eastern Health, St. John’s, Newfoundland, Canada
| | - Jerry McGrath
- Gastroenterology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Donald MacDonald
- Newfoundland and Labrador Centre for Health Information, St. John’s, Newfoundland, Canada
| | - T. Nadine Burry
- Clinical Epidemiology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Lesa Dawson
- Obstetrics and Gynecology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
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Frey MK, Ahsan MD, Bergeron H, Lin J, Li X, Fowlkes RK, Narayan P, Nitecki R, Rauh-Hain JA, Moss HA, Baltich Nelson B, Thomas C, Christos PJ, Hamilton JG, Chapman-Davis E, Cantillo E, Holcomb K, Kurian AW, Lipkin S, Offit K, Sharaf RN. Cascade Testing for Hereditary Cancer Syndromes: Should We Move Toward Direct Relative Contact? A Systematic Review and Meta-Analysis. J Clin Oncol 2022; 40:4129-4143. [PMID: 35960887 PMCID: PMC9746789 DOI: 10.1200/jco.22.00303] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Evidence-based guidelines recommend cascade genetic counseling and testing for hereditary cancer syndromes, providing relatives the opportunity for early detection and prevention of cancer. The current standard is for patients to contact and encourage relatives (patient-mediated contact) to undergo counseling and testing. Direct relative contact by the medical team or testing laboratory has shown promise but is complicated by privacy laws and lack of infrastructure. We sought to compare outcomes associated with patient-mediated and direct relative contact for hereditary cancer cascade genetic counseling and testing in the first meta-analysis on this topic. MATERIALS AND METHODS We conducted a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO No.: CRD42020134276). We searched key electronic databases to identify studies evaluating hereditary cancer cascade testing. Eligible trials were subjected to meta-analysis. RESULTS Eighty-seven studies met inclusion criteria. Among relatives included in the meta-analysis, 48% (95% CI, 38 to 58) underwent cascade genetic counseling and 41% (95% CI, 34 to 48) cascade genetic testing. Compared with the patient-mediated approach, direct relative contact resulted in significantly higher uptake of genetic counseling for all relatives (63% [95% CI, 49 to 75] v 35% [95% CI, 24 to 48]) and genetic testing for first-degree relatives (62% [95% CI, 49 to 73] v 40% [95% CI, 32 to 48]). Methods of direct contact included telephone calls, letters, and e-mails; respective rates of genetic testing completion were 61% (95% CI, 51 to 70), 48% (95% CI, 37 to 59), and 48% (95% CI, 45 to 50). CONCLUSION Most relatives at risk for hereditary cancer do not undergo cascade genetic counseling and testing, forgoing potentially life-saving medical interventions. Compared with patient-mediated contact, direct relative contact increased rates of cascade genetic counseling and testing, arguing for a shift in the care delivery paradigm, to be confirmed by randomized controlled trials.
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Affiliation(s)
| | | | | | - Jenny Lin
- Weill Cornell Medicine, New York, NY
| | - Xuan Li
- Weill Cornell Medicine, New York, NY
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kenneth Offit
- Memorial Sloan Kettering Cancer Center, New York, NY
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Pediatric manifestations of Lynch Syndrome: A single center experience. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022; 86. [PMID: 36313796 PMCID: PMC9609293 DOI: 10.1016/j.epsc.2022.102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Lynch syndrome is an autosomal dominant condition caused by a heterozygous variation in one of the DNA mismatch repair (MMR) genes that pre-disposes individuals to early onset colorectal cancers and other malignancies. Lynch syndrome is generally considered an adult-onset disorder, with malignancy rarely manifesting in childhood. Colorectal cancer is extremely rare in children, but hereditary syndromes including Lynch syndrome are an important cause. We aimed to assess the frequency and clinical course of children with Lynch syndrome associated pediatric colorectal cancers at our institution over the last 20 years. In this retrospective study, we describe four cases of children with Lynch syndrome-associated colorectal cancers age 14–17 years at diagnosis. All patients were diagnosed with Lynch syndrome after diagnosis, despite three of them having family histories consistent with Lynch syndrome. This series highlights a rare but important cause of pediatric malignancy and points to the need for early education on colorectal cancer warning symptoms and open discussion about this condition in affected families. It also illustrates the need for a thorough family history and a high level of suspicion for Lynch syndrome in children based on family background, as early detection may be key to improving cancer outcomes.
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Development of a Secure Website to Facilitate Information Sharing in Families at High Risk of Bowel Cancer-The Familyweb Study. Cancers (Basel) 2021; 13:cancers13102404. [PMID: 34065728 PMCID: PMC8155923 DOI: 10.3390/cancers13102404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Families with an inherited high risk of bowel cancer may struggle to share information about their diagnosis. This means that relatives are not always aware of their increased risk of cancer or able to access screening for the early detection of cancer. Through this study, we aimed to help such families by creating a website where patients could share confidential information with their relatives securely online. Following a survey and telephone interviews with affected individuals, the content of the website was developed to suit the needs of families. Website function was tested with patients to check feasibility and acceptability. Most participants wanted more information to support their adaptation to the diagnosis and help inform their relatives. This study demonstrates how health professionals can improve access to genetic testing and cancer screening in families at high risk of cancer, thus reducing morbidity and mortality. Abstract Individuals with pathogenic variants in genes predisposing to bowel cancer are encouraged to share this information within their families. Close relatives at 50% risk can have access to bowel cancer surveillance. However, many relatives remain unaware of their vulnerability or have insufficient information. We investigated the feasibility and acceptability of using a secure website to support information sharing within families at high risk of bowel cancer. Patients (n = 286) answered an anonymous cross-sectional survey, with 14 participating in telephone interviews. They reported that the diagnosis had a profound effect on them and their family relationships, and consequently desired more support from health professionals. Website content was created in response to the preferences of survey and interview participants. Reactions to the website from 12 volunteers were captured through remote usability testing to guide further refinement of the website. Participants welcomed the opportunity to store and share personal information via the website and wanted more information and help informing their relatives about the diagnosis. Important website topics were: healthy lifestyle; genetic testing; and how to talk to children about the diagnosis. A website providing online access to confidential documents was both feasible and acceptable and could translate into increased uptake of cancer surveillance, resulting in lower morbidity and mortality in these families.
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Dragojlovic N, Kopac N, Borle K, Tandun R, Salmasi S, Ellis U, Birch P, Adam S, Friedman JM, Elliott AM, Lynd LD. Utilization and uptake of clinical genetics services in high-income countries: A scoping review. Health Policy 2021; 125:877-887. [PMID: 33962789 DOI: 10.1016/j.healthpol.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/11/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022]
Abstract
Ongoing rapid growth in the need for genetic services has the potential to severely strain the capacity of the clinical genetics workforce to deliver this care. Unfortunately, assessments of the scale of this health policy challenge and potential solutions are hampered by the lack of a consolidated evidence base on the growth in genetic service utilization. To enable health policy research and strategic planning by health systems in this area, we conducted a scoping review of the literature on the utilization and uptake of clinical genetics services in high-income countries published between 2010 and 2018. One-hundred-and-ninety-five unique studies were included in the review. Most focused on cancer (85/195; 44%) and prenatal care (50/195; 26%), which are consistently the two areas with the greatest volume of genetic service utilization in both the United States and other high-income countries. Utilization and uptake rates varied considerably and were influenced by contextual factors including health system characteristics, provider knowledge, and patient preferences. Moreover, growth in genetic service utilization appears to be driven to a significant degree by technological advances and the integration of new tests into clinical care. Our review highlights both the policy challenge posed by the rapid growth in the utilization of genetic services and the variability in this trend across clinical indications and health systems.
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Affiliation(s)
- Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Nicola Kopac
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Kennedy Borle
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Rachel Tandun
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Shahrzad Salmasi
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Ursula Ellis
- Woodward Library, University of British Columbia, 2198 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Patricia Birch
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Shelin Adam
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Jan M Friedman
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | | | - Alison M Elliott
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada; BC Women's Hospital Research Institute, H214 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, 588-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z 1Y6.
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7
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Beard VK, Bedard AC, Nuk J, Lee PWC, Hong Q, Bedard JEJ, Sun S, Schrader KA. Genetic testing in families with hereditary colorectal cancer in British Columbia and Yukon: a retrospective cross-sectional analysis. CMAJ Open 2020; 8:E637-E642. [PMID: 33077534 PMCID: PMC7588261 DOI: 10.9778/cmajo.20190167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Genetic testing in families with hereditary cancer enables identification of people most likely to benefit from intensive screening and preventive measures; however, the uptake of testing in relatives (known as cascade carrier testing) for hereditary colorectal cancer syndromes has been shown to be low. Our objective was to report rates of familial testing for hereditary colorectal cancer syndromes in a publicly funded hereditary cancer clinic in Canada. METHODS A cross-sectional retrospective database review was used to determine testing uptake between 1997 and 2016 for families served by the provincial Hereditary Cancer Program for British Columbia and Yukon. Analyses were conducted for genes associated with syndromes with an increased risk for colorectal cancer, including Lynch syndrome (MLH1, MSH2, MSH6, PMS2 and EPCAM) and familial adenomatous polyposis (APC), and for additional moderate- to high-penetrance genes (STK11, TP53, SMAD4, MUTYH, PTEN and CHEK2). Descriptive statistics were used and all analyses were 2-tailed. RESULTS The study cohort included 245 index patients, with carrier testing performed in 382 relatives. The mean age at family member testing was 41.2 years, and most (61.0%) of the family members who underwent testing were women. The median time between disclosure of index cases and their family member's results was 8.3 months. Among eligible first-degree relatives, 32.6% (268/821) underwent testing in BC. Of 67 cancer diagnoses in family members, most (62.7%) occurred before genetic testing. INTERPRETATION A substantial proportion of people at risk for hereditary colorectal cancer do not undergo genetic testing. This gap highlights the need to explore barriers to testing and to consider interventions to promote uptake; more aggressive efforts by hereditary cancer programs are needed to reach this highest risk population.
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Affiliation(s)
- Vivienne K Beard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Angela C Bedard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Jennifer Nuk
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Petra W C Lee
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Quan Hong
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - James E J Bedard
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Sophie Sun
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
| | - Kasmintan A Schrader
- Department of Biology (Beard, Lee, J.E.J. Bedard), University of the Fraser Valley, Abbotsford, BC; Hereditary Cancer Program (A.C. Bedard, Nuk, Hong, Sun, Schrader), BC Cancer; Division of Medical Oncology (Sun), University of British Columbia; Department of Molecular Oncology (Schrader), BC Cancer; Department of Medical Genetics (Schrader), University of British Columbia, Vancouver, BC
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Pastorino R, Basile M, Tognetto A, Di Marco M, Grossi A, Lucci-Cordisco E, Scaldaferri F, De Censi A, Federici A, Villari P, Genuardi M, Ricciardi W, Boccia S. Cost-effectiveness analysis of genetic diagnostic strategies for Lynch syndrome in Italy. PLoS One 2020; 15:e0235038. [PMID: 32609729 PMCID: PMC7329085 DOI: 10.1371/journal.pone.0235038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 06/08/2020] [Indexed: 12/20/2022] Open
Abstract
Lynch syndrome (LS) is an autosomal dominant condition caused by pathogenic variants in mismatch repair (MMR) genes that predispose individuals to different malignancies, such as colorectal cancer (CRC) and endometrial cancer. Current guidelines recommended testing for LS in individuals with newly diagnosed CRC to reduce cancer morbidity and mortality in relatives. Economic evaluations in support of such approach, however, are not available in Italy. We developed a decision-analytic model to analyze the cost-effectiveness of LS screening from the perspective of the Italian National Health System. Three testing strategies: the sequencing of all MMR genes without prior tumor analysis (Strategy 1), a sequential IHC and MS-MLPA analysis (Strategy 2), and an age-targeted strategy with a revised Bethesda criteria assessment before IHC and methylation-specific MLPA for patients ≥ than 70 years old (Strategy 3) were analyzed and compared to the “no testing” strategy. Quality Adjusted Life Years (QALYs) in relatives after colonoscopy, aspirin prophylaxis and an intensive gynecological surveillance were estimated through a Markov model. Assuming a CRC incidence rate of 0.09% and a share of patients affected by LS equal to 2.81%, the number of detected pathogenic variants among CRC cases ranges, in a given year, between 910 and 1167 depending on the testing strategy employed. The testing strategies investigated, provided one-time to the entire eligible population (CRC patients), were associated with an overall cost ranging between €1,753,059.93-€10,388,000.00. The incremental cost-effectiveness ratios of the Markov model ranged from €941.24 /QALY to €1,681.93 /QALY, thus supporting that “universal testing” versus “no testing” is cost-effective, but not necessarily in comparison with age-targeted strategies. This is the first economic evaluation on different testing strategies for LS in Italy. The results might support the introduction of cost-effective recommendations for LS screening in Italy.
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Affiliation(s)
- Roberta Pastorino
- Department of Woman and Child Health and Public Health-Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Michele Basile
- Università Cattolica del Sacro Cuore, Alta Scuola di Economia e Management dei Sistemi Sanitari (ALTEMS), Roma, Italia
| | - Alessia Tognetto
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Marco Di Marco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Adriano Grossi
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Emanuela Lucci-Cordisco
- Department of Laboratory and Infectious Sciences, Medical Genetics Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze della Vita e di Sanità Pubblica, Sezione di Medicina Genomica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Franco Scaldaferri
- UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maurizio Genuardi
- Department of Laboratory and Infectious Sciences, Medical Genetics Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento di Scienze della Vita e di Sanità Pubblica, Sezione di Medicina Genomica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Walter Ricciardi
- Department of Woman and Child Health and Public Health-Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Stefania Boccia
- Department of Woman and Child Health and Public Health-Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Roma, Italia
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9
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Menko FH, Jeanson KN, Bleiker EMA, van Tiggelen CWM, Hogervorst FBL, Ter Stege JA, Ait Moha D, van der Kolk LE. The uptake of predictive DNA testing in 40 families with a pathogenic BRCA1/BRCA2 variant. An evaluation of the proband-mediated procedure. Eur J Hum Genet 2020; 28:1020-1027. [PMID: 32300191 DOI: 10.1038/s41431-020-0618-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 02/14/2020] [Accepted: 03/15/2020] [Indexed: 11/09/2022] Open
Abstract
When hereditary breast and ovarian cancer (HBOC) due to a BRCA1/BRCA2 germline pathogenic variant is diagnosed, the proband will be asked to inform other at-risk family members. In the Netherlands, a guideline was introduced in 2012 which provided detailed recommendations regarding this proband-mediated procedure. We now evaluated the uptake of predictive BRCA1/BRCA2 testing in 40 consecutive HBOC families diagnosed in our centre in 2014. We performed a retrospective observational study of all 40 families in which a pathogenic BRCA1/BRCA2 germline variant was identified during 2014. We scored the uptake of predictive and confirmatory testing by the end of 2018 and explored factors associated with the level of uptake. Two families were excluded. In the remaining 38 families, among 239 family members ≥18 years at 50% risk of being a mutation carrier or at 25% risk if the family member at 50% risk was deceased, 102 (43%) were tested. Among 108 females 25-75 years of age at 50% risk, 59 (55%) underwent predictive or confirmatory testing, and among 43 males at 50% risk with daughters ≥18 years, 22 (51%) were tested. Factors which complicated cascade screening included family members living abroad, probands not wanting to share information and limited pedigree information. In conclusion, the standard proband-mediated procedure of informing relatives seems to be far from optimal. We suggest a tailored approach for each family, including the option of a direct approach to at-risk family members by the geneticist. In addition, we suggest detailed monitoring and follow-up of families.
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Affiliation(s)
- Fred H Menko
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
| | - Kiki N Jeanson
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Eveline M A Bleiker
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Carla W M van Tiggelen
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Frans B L Hogervorst
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jacqueline A Ter Stege
- Department of Psychosocial Research and Epidemiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Daoud Ait Moha
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Lizet E van der Kolk
- Family Cancer Clinic, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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Impact of free cancer predisposition cascade genetic testing on uptake in Singapore. NPJ Genom Med 2019; 4:22. [PMID: 31531230 PMCID: PMC6744424 DOI: 10.1038/s41525-019-0096-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Cascade testing for cancer predisposition offers a highly efficient and cost-effective method for identifying individuals at increased risk for cancer, in whom targeted interventions can often improve survival. The aim of this study was to determine the impact of free cascade testing on uptake and identify other associated factors. Demographic and clinical data were gathered prospectively for 183 probands found to have a pathogenic variant associated with cancer predisposition and their 826 first-degree relatives (FDRs). The provision of free cascade testing was significantly associated with uptake (21.6% vs 6.1%; χ 2, P < 0.001). Relationship type between FDR and proband and FDR age also demonstrated significant associations, suggesting greater engagement amongst younger generations. Overall, 29.0% (53/183) of families had at least 1 FDR who underwent cascade testing. Of these families, 67.9% (36/53) had an uptake rate of at least 40.0%. Cost is a significant barrier to cascade testing uptake in Singapore. Tailored interventions targeting underrepresented groups and genetic counseling approaches supporting family communication and decision-making are necessary.
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Menko FH, Ter Stege JA, van der Kolk LE, Jeanson KN, Schats W, Moha DA, Bleiker EMA. The uptake of presymptomatic genetic testing in hereditary breast-ovarian cancer and Lynch syndrome: a systematic review of the literature and implications for clinical practice. Fam Cancer 2019; 18:127-135. [PMID: 29846880 DOI: 10.1007/s10689-018-0089-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Following the identification in a proband of a germline BRCA1/BRCA2 mutation in hereditary breast-ovarian cancer (HBOC) or a DNA mismatch repair gene mutation in Lynch syndrome (LS) he or she will be asked to inform at-risk family members about the option for presymptomatic DNA testing. However, in clinical practice multiple factors may complicate the process of information sharing. We critically evaluated studies on the uptake of presymptomatic genetic testing in both syndromes. A search of relevant MeSH terms and key words in PubMed, Embase and PsycINFO yielded 795 articles published between 2001 and 2017. Thirty of these publications included outcome measures relevant for the current study. Based on information provided by the proband (15 studies) the uptake of presymptomatic genetic testing ranged from 15 to 57% in HBOC, while one study in LS kindreds reported an uptake of 70%. Based on information provided by genetics centres (the remaining 15 studies) the uptake ranged from 21 to 44% in HBOC and from 41 to 94% in LS. However, when genetics centres contacted relatives directly a substantial number of additional family members could be tested. Proband-mediated provision of information to at-risk relatives is a standard procedure in hereditary breast-ovarian cancer and Lynch syndrome. However, the resulting uptake of presymptomatic testing is disappointing-an issue that is now urgent due to the increased use of genetic testing in clinical oncology. We propose that additional strategies should be introduced including the geneticist directly contacting relatives. The outcomes of these strategies should be carefully monitored and evaluated.
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Affiliation(s)
- Fred H Menko
- Family Cancer Clinic, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Jacqueline A Ter Stege
- Department of Psychosocial Research and Epidemiology, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lizet E van der Kolk
- Family Cancer Clinic, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kiki N Jeanson
- Family Cancer Clinic, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Winnie Schats
- Department of Scientific Information Service, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Daoud Ait Moha
- Family Cancer Clinic, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eveline M A Bleiker
- Department of Psychosocial Research and Epidemiology, Antoni van Leeuwenhoek Hospital and The Netherlands Cancer Institute, Amsterdam, The Netherlands
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Petersen HV, Frederiksen BL, Lautrup CK, Lindberg LJ, Ladelund S, Nilbert M. Unsolicited information letters to increase awareness of Lynch syndrome and familial colorectal cancer: reactions and attitudes. Fam Cancer 2018; 18:43-51. [DOI: 10.1007/s10689-018-0083-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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