1
|
Sharaf RN, Udaltsova N, Li D, Pai RK, Sinha S, Li Z, Corley DA. Population-Level Identification of Patients With Lynch Syndrome for Clinical Care, Quality Improvement, and Research. JCO Clin Cancer Inform 2024; 8:e2300157. [PMID: 38838280 DOI: 10.1200/cci.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/02/2023] [Accepted: 03/05/2024] [Indexed: 06/07/2024] Open
Abstract
PURPOSE Identification of those at risk of hereditary cancer syndromes using electronic health record (EHR) data sources is important for clinical care, quality improvement, and research. We describe diagnostic processes, previously seldom reported, for a common hereditary cancer syndrome, Lynch syndrome (LS), using EHR data within a community-based, multicenter, demographically diverse health system. METHODS Within a retrospective cohort enrolled between 2015 and 2020 at Kaiser Permanente Northern California, we assessed electronic diagnostic domains for LS including (1) family history of LS-associated cancer; (2) personal history of LS-associated cancer; (3) LS screening via mismatch repair deficiency (MMRD) testing of newly diagnosed malignancy; (4) germline genetic test results; and (5) clinician-entered diagnostic codes for LS. We calculated proportions and overlap for each diagnostic domain descriptively. RESULTS Among 5.8 million individuals, (1) 28,492 (0.49%) had a family history of LS-associated cancer of whom 3,635 (13%) underwent genetic testing; (2) 100,046 (1.7%) had a personal history of a LS-associated cancer; and (3) 8,711 (0.1%) were diagnosed with colorectal cancer of whom 7,533 (86%) underwent MMRD screening and of the positive screens (486), 130 (27%) underwent germline testing. One thousand seven hundred and fifty-seven (0.03%) were diagnosed with endometrial cancer of whom 1,613 (92%) underwent MMRD screening and of the 195 who screened positive, 55 (28%) underwent genetic testing. (4) 30,790 (0.05%) had LS germline genetic testing with 707 (0.01%) testing positive; and (5) 1,273 (0.02%) had a clinician-entered diagnosis of LS. CONCLUSION It is feasible to electronically characterize the diagnostic processes of LS. No single data source comprehensively identifies all LS carriers. There is underutilization of LS genetic testing for those eligible and underdiagnosis of LS. Our work informs similar efforts in other settings for hereditary cancer syndromes.
Collapse
Affiliation(s)
- Ravi N Sharaf
- Divison of Gastroenterology, Department of Medicine, Weill Cornell Medicine, New York, NY
- Division of Epidemiology, Department of Population Science, Weill Cornell Medicine, New York, NY
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Dan Li
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Gastroenterology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Rish K Pai
- Department of Lab Medicine & Pathology, Mayo Clinic Arizona, Phoenix, AZ
| | - Soham Sinha
- Division of Epidemiology, Department of Population Science, Weill Cornell Medicine, New York, NY
| | - Zixuan Li
- Division of Epidemiology, Department of Population Science, Weill Cornell Medicine, New York, NY
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| |
Collapse
|
2
|
Zhang RY, Cheng K, Huang ZY, Zhang XS, Li Y, Sun X, Yang XQ, Hu YG, Hou XL, Liu B, Chen W, Fan JX, Zhao YD. M1 macrophage-derived exosome for reprograming M2 macrophages and combining endogenous NO gas therapy with enhanced photodynamic synergistic therapy in colorectal cancer. J Colloid Interface Sci 2024; 654:612-625. [PMID: 37862809 DOI: 10.1016/j.jcis.2023.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/19/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
Reprogramming immunosuppressive M2 macrophages into M1 macrophages in tumor site provides a new strategy for the immunotherapy of colorectal cancer. In this study, M1 macrophage-derived exosome nanoprobe (M1UC) with Ce6-loaded upconversion material is designed to enhance the photodynamic performance of Ce6 while reprogramming M2 macrophages at tumor site and producing NO gas for three-mode synergistic therapy. Under the excitation of near-infrared light at 808 nm, the probe can generate 660 nm up-conversion fluorescence, which enables the photosensitizer Ce6 to produce ROS efficiently. In addition, the probe leads the production of NO by nitric oxide synthase on exosomes. Confocal laser and flow cytometry results show that M1UC probe reprograms M2 macrophages into M1 macrophages with an efficiency of 95.12%. The cell experiments show that the apoptosis rate of the three-mode synergistic therapy group is 78.8%, and the therapeutic effect is significantly higher than those of the other single treatment groups. In vivo experiments results show that M1UC probes maximally gather at the tumor site after 12 h of intravenous injection in orthotopic colorectal cancer mice. After 808 nm laser irradiation, the survival rate of mice is 100% and the recurrence rate was 0 within 60 d, and the therapeutic effect is significantly higher than those of other single treatment groups, which is also confirmed by immunohistochemistry. This M1 macrophage-derived exosome nanoplatform which is based on the three modes of immunotherapy, gas therapy and photodynamic therapy, provides a new design idea for the diagnosis and treatment of deep tumors.
Collapse
Affiliation(s)
- Ruo-Yun Zhang
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China; School of Bioengineering and Health, Wuhan Textile University, Wuhan 430200, Hubei, PR China; State Key Laboratory of New Textile Materials and Advanced Processing Technologies, Wuhan Textile University, Wuhan 430200, Hubei, PR China
| | - Kai Cheng
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Zhuo-Yao Huang
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Xiao-Shuai Zhang
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China; Basic Medical Laboratory, General Hospital of Central Theater Command, Wuhan 430081, Hubei, PR China
| | - Yong Li
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Xing Sun
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Xiao-Quan Yang
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Yong-Guo Hu
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Xiao-Lin Hou
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Bo Liu
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Wei Chen
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China
| | - Jin-Xuan Fan
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China.
| | - Yuan-Di Zhao
- Britton Chance Center for Biomedical Photonics at Wuhan National Laboratory for Optoelectronics-Hubei Bioinformatics & Molecular Imaging Key Laboratory, Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, Hubei, PR China.
| |
Collapse
|
3
|
Zhao G, Xiang G, Hu X, Qiao Y, Ma S, Tian Y, Gao X, Liu F, Li X, Shi G. Universal screening for Lynch syndrome in operated colorectal cancer by immunohistochemistry: a cohort of patients in Liaoning province, China. Eur J Cancer Prev 2023; 32:337-347. [PMID: 36942852 DOI: 10.1097/cej.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Lynch syndrome (LS) is the most common hereditary colorectal cancer syndrome worldwide. Due to the decreasing family size in Liaoning province. The Bethesda and Amsterdam II criteria have lower sensitivity and specificity and are not suitable for the local population. Immunohistochemistry screening for mutations in DNA mismatch repair (MMR) in newly diagnosed colorectal cancer can improve the detection rate of LS. METHODS All newly diagnosed colorectal cancer patients who underwent surgery between January 2018 and June 2020 at Cancer Hospital of China Medical University and Shengjing Hospital of China Medical University from Liaoning China were included retrospectively, and the ratio of universal LS screening by immunohistochemistry, MMR protein deficiency (dMMR) ratio, MLH1 loss, MSH2 loss, MSH6 loss, and PMS2 loss was analyzed. The clinicopathological characteristics of patients with pMMR and dMMR were analyzed. RESULTS A total of 7019 colorectal cancer patients underwent surgery and 4802 (68.41%) patients were screened by immunohistochemistry for MMR, 258 (5.37%) cases were reported to have a loss of MMR expression. In the dMMR group, a higher number of patients were under 50 years old, more tumors were located at the right colon, less patients have lymph node metastasis, more tumors were stage II, and histological types of mucinous carcinoma or signet ring carcinoma were more common, compared with the pMMR group. Only 2.71% dMMR patients meet Amsterdam criteria II, 2.71% of patients meet Revised Bethesda guidelines, and 17.83% meet Chinese LS criteria. Twenty-five dMMR patients were confirmed by next-generation sequencing and five families were confirmed as Lynch family. CONCLUSION These data imply that universal screening for LS by immunohistochemistry may be effective in Liaoning province.
Collapse
Affiliation(s)
| | - Guoqing Xiang
- Department of Endoscopy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute
| | - Xiaoru Hu
- Department of Pathology, Shengjing Hospital of China Medical University
| | - Yun Qiao
- Department of Pathology, Shengjing Hospital of China Medical University
| | - Shiyang Ma
- Department of Pathology, Shengjing Hospital of China Medical University
| | - Ye Tian
- Department of Pathology, Shengjing Hospital of China Medical University
| | - Xiaozuo Gao
- Department of Pathology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning Province, P.R. China
| | - Fang Liu
- Department of Pathology, Shengjing Hospital of China Medical University
| | - Xiaohan Li
- Department of Endoscopy, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute
| | - Gang Shi
- Department of Pathology, Shengjing Hospital of China Medical University
| |
Collapse
|
4
|
Kim JJ, Ha BJ, Jeong MS, Yang GE, Yoon SY, Lee YS, Kim MS, Leem SH. Novel strategy of multiple-locus variable number tandem repeats analysis for genetic fingerprinting of human. Genes Genomics 2023; 45:887-899. [PMID: 37133721 DOI: 10.1007/s13258-023-01386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The variable number of tandem repeat (VNTR) analyses are methods based on the detection of repeated sequences within the human genome. In order to perform DNA typing at the personal laboratory, it is necessary to improve the VNTR analysis. OBJECTIVE The VNTR markers were difficult to popularize because PCR amplification was difficult due to its GC-rich and long nucleotide sequence. The aim of this study was to select the multiple VNTR markers that could only be identified by PCR amplification and electrophoresis. METHODS We genotyped each of the 15 VNTR markers using genomic DNA from 260 unrelated individuals by PCR amplification. Differences in the fragment length of PCR products are visualized by agarose gel electrophoresis. To confirm their usefulness as a DNA fingerprint these 15 markers were simultaneously analyzed with the DNA of 213 individuals and verified the statistical significance. In addition, to investigate the usefulness of each of the 15 VNTR markers as paternity markers, Mendelian segregation by meiotic division within a family consisting of two or three generations was confirmed. RESULTS Fifteen VNTR loci selected in this study could be easily amplified by PCR and analyzed by electrophoresis, and were newly named DTM1 ~ 15. The number of total alleles in each VNTR showed from 4 to 16, and 100 to 1600 bp in length, and their heterozygosity ranged from 0.2341 to 0.7915. In simultaneous analysis of 15 markers from 213 DNAs, the probability of chance appearing the same genotype in different individuals was less than 4.09E-12, indicating its usefulness as a DNA fingerprint. These loci were transmitted through meiosis by Mendelian inheritance in families. CONCLUSION Fifteen VNTR markers have been found to be useful as DNA fingerprints for personal identification and kinship analysis that can be used at the personal laboratory level.
Collapse
Affiliation(s)
- Jae-Jun Kim
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea
- Department of Health Sciences, Dong-A University, Busan, 49315, Korea
| | - Byeong Jun Ha
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea
| | - Mi-So Jeong
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea
| | - Gi-Eun Yang
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea
- Department of Health Sciences, Dong-A University, Busan, 49315, Korea
| | - Seo-Yeong Yoon
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea
| | - Young-Shin Lee
- Healthverse Business Division, Beauty Bakery, Seoul, 06167, Korea
| | - Min-Seok Kim
- Healthverse Business Division, Beauty Bakery, Seoul, 06167, Korea
| | - Sun-Hee Leem
- Department of Biomedical Science, Dong-A University, Busan, 49315, Korea.
- Healthverse Business Division, Beauty Bakery, Seoul, 06167, Korea.
| |
Collapse
|
5
|
Dueñas N, Navarro M, Sanjuán X, Ruiz N, Iglesias S, Matias-Guiu X, Guardiola J, Kreisler E, Biondo S, González S, Legido R, Blanco A, Navarro S, Asiain L, Santos C, Capellá G, Pineda M, Brunet J. Lessons learnt from the implementation of a colorectal cancer screening programme for lynch syndrome in a tertiary public hospital. Cancer Epidemiol 2023; 82:102291. [PMID: 36410089 DOI: 10.1016/j.canep.2022.102291] [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: 05/24/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lynch syndrome (LS) is the first cause of inherited colorectal cancer (CRC), being responsible for 2-4% of all diagnoses. Identification of affected individuals is important as they have an increased lifetime risk of multiple CRC and other neoplasms, however, LS is consistently underdiagnosed at the population level. We aimed to evaluate the yield of LS screening in CRC in a single-referral centre and to identify the barriers to its effective implementation. METHODS LS screening programme included individuals with CRC < 70 years, multiple CRC, or endometrial cancer at any age. Mismatch repair (MMR) protein immunohistochemistry (IHC) analysis was performed in routine practice on the surgical specimen and, if MLH1 IHC was altered, MLH1 gene promoter methylation was analysed. Results were collected in the CRC multidisciplinary board database. LS suspected individuals (altered MMR IHC without MLH1 promoter methylation) were referred to the Cancer Genetic Counselling Unit (CGCU). If accepted, a genetic study was performed. Two checkpoints were included: review of the pathology data and verification of patient referral by a genetic counsellor. RESULTS Between 2016 and 2019, 381 individuals were included. MMR IHC analysis was performed in 374/381 (98.2 %) CRC cases and MLH1 promoter methylation in 18/21 (85.7 %). Seventeen of the 20 LS suspected individuals were invited for referral at the CGCU. Two cases were not invited and the remaining patient died of cancer before completion of tumour screening. Fifteen individuals attended and a genetic analysis was performed in 15/20 (75 %) LS suspected individuals. Ten individuals were diagnosed with LS, in concordance with the IHC profile (2.7 % of the total cohort). This led to cascade testing in 58/75 (77.3 %) of the available adult relatives at risk, identifying 26 individuals with LS. CONCLUSIONS Establishing a standardized institutional LS screening programme with checkpoints in the workflow is key to increasing the yield of LS identification.
Collapse
Affiliation(s)
- Nuria Dueñas
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain.
| | - Matilde Navarro
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Hereditary Cancer Program, Catalan Institute of Oncology, Badalona 08916, Barcelona, Spain
| | - Xavier Sanjuán
- Department of Pathology, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Núria Ruiz
- Department of Pathology, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Silvia Iglesias
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Xavier Matias-Guiu
- Department of Pathology, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Jordi Guardiola
- Department of Gastroenterology, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Esther Kreisler
- Department of General Surgery, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Sebastiano Biondo
- Department of General Surgery, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Sara González
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Raquel Legido
- Colorectal Cancer Multidisciplinary Board, Catalan Institute of Oncology, Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Ana Blanco
- Colorectal Cancer Multidisciplinary Board, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Silvia Navarro
- Colorectal Cancer Multidisciplinary Board, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Leyre Asiain
- Department of Radiation Oncology, Catalan Institute of Oncology, Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Cristina Santos
- Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain; Department of Medical Oncology, Catalan Institute of Oncology, Hospitalet de Llobregat, 08908 Barcelona, Spain; Bellvitge Health Sciences Campus, University of Barcelona, Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Gabriel Capellá
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Marta Pineda
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Joan Brunet
- Hereditary Cancer Program, Catalan Institute of Oncology-IDIBELL, ONCOBELL, Hospitalet de Llobregat, 08908 Barcelona, Spain; Biomedical Research Centre Network for Oncology (CIBERONC), Instituto Salud Carlos III, 28029 Madrid, Spain; Hereditary Cancer Program, Catalan Institute of Oncology-IDIBGI, OncoGir-Pro, 17007 Girona, Spain
| |
Collapse
|
6
|
Rustgi SD, Kastrinos F. Screening for Lynch Syndrome: Optimal Strategies and Performance Remain a Moving Target. Am J Gastroenterol 2023; 118:259-260. [PMID: 36735557 PMCID: PMC9907004 DOI: 10.14309/ajg.0000000000002132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Sheila D Rustgi
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York, USA
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Fay Kastrinos
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York, USA
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Cancer and the Vagelos College of Physicians and Surgeons, New York, New York, USA
| |
Collapse
|
7
|
Lahiri S, Pirzadeh-Miller S, Moriarty K, Kubiliun N. Implementation of a Population-Based Cancer Family History Screening Program for Lynch Syndrome. Cancer Control 2023; 30:10732748231175011. [PMID: 37161761 DOI: 10.1177/10732748231175011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
OBJECTIVES Lynch syndrome increases risks for colorectal and other cancers. Though published Lynch syndrome cancer risk-management guidelines are effective for risk-reduction, the condition remains under-recognized. The Cancer Genetics Program at an academic medical center implemented a population-based cancer family history screening program, Detecting Unaffected Individuals with Lynch syndrome, to aid in identification of individuals with Lynch syndrome. METHODS In this retrospective cohort study, simple cancer family history screening questionnaires were used to identify those at risk for Lynch syndrome. Program navigators triaged and educated those who screened positive about hereditary cancer, and genetic counseling and testing services, offering genetic counseling if eligible. Genetic counseling was provided primarily via telephone. Genetic counselors performed hereditary cancer risk assessment and offered genetic testing via hereditary cancer panels to those eligible. Remote service delivery models via telephone genetic counseling and at-home saliva testing were used to increase access to medical genetics services. RESULTS This program screened 212,827 individuals, over half of whom were considered underserved, and identified 133 clinically actionable genetic variants associated with hereditary cancer. Of these, 47 (35%) were associated with Lynch syndrome while notably, 70 (53%) were not associated with hereditary colorectal cancer. Of 3,344 patients offered genetic counseling after initial triage, 2,441 (73%) elected to schedule the appointment and 1,775 individuals (73%) completed genetic counseling. Among underserved patients, telephone genetic counseling completion rates were significantly higher than in-person appointment completion rates (P < .05). While remote service delivery improved appointment completion rates, challenges with genetic test completion using at-home saliva sample collection kits were observed, with 242 of 1592 individuals (15%) not completing testing. CONCLUSION Population-based cancer family history screening and navigation can help identify individuals with hereditary cancer syndromes across diverse patient populations, but logistics of certain downstream service delivery models can impact outcomes.
Collapse
Affiliation(s)
- Sayoni Lahiri
- Department of Cancer Genetics, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Kelsey Moriarty
- Department of Cancer Genetics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nisa Kubiliun
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
8
|
Passero L, Srinivasan S, Grewe ME, Leeman J, Berg J, Reuland D, Roberts MC. Development and initial testing of a multi-stakeholder intervention for Lynch syndrome cascade screening: an intervention mapping approach. BMC Health Serv Res 2022; 22:1411. [PMID: 36434579 PMCID: PMC9694070 DOI: 10.1186/s12913-022-08732-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/25/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Lynch syndrome is an underdiagnosed hereditary condition carrying an increased lifetime risk for colorectal and endometrial cancer and affecting nearly 1 million people in the United States. Cascade screening, systematic screening through family members of affected patients, could improve identification of Lynch syndrome, but this strategy is underused due to multi-level barriers including low knowledge about Lynch syndrome, low access to genetics services, and challenging family dynamics. METHODS We used intervention mapping, a 6-step methodology to create stakeholder-driven interventions that meet the needs of a target population, to develop an intervention to improve cascade screening for Lynch syndrome. The intervention development process was guided by input from key stakeholders in Lynch syndrome care and patients. We conducted usability testing on the intervention with Lynch syndrome patients using qualitative semi-structured interviewing and rapid qualitative analysis. RESULTS We developed a workbook intervention named Let's Talk that addresses gaps in knowledge, skills, self-efficacy, outcome expectancy and other perceived barriers to cascade screening for Lynch syndrome. Let's Talk contained educational content, goal setting activities, communication planning prompts and supplemental resources for patients to plan family communication. Evidence-based methods used in the workbook included information chunking, guided practice, goal setting and gain-framing. We conducted usability testing focused on the complexity and relative advantage of the intervention through 45-min virtual interviews with 10 adult patients with Lynch syndrome recruited from a national advocacy organization in the United States. Usability testing results suggested the intervention was acceptable in terms of complexity and relative advantage to other available resources, but additional information for communication with young or distant family members and a web-based platform could enhance the intervention's usability. CONCLUSIONS Intervention mapping provided a framework for intervention development that addressed the unique needs of Lynch syndrome patients in overcoming barriers to cascade screening. Future work is needed to transform Let's Talk into a web-based tool and evaluate the effectiveness of the intervention in clinical practice with patients and genetic counselors. Intervention mapping can be useful to researchers as an evidence-based technique to develop stakeholder-centered interventions for addressing the needs of other unique populations.
Collapse
Affiliation(s)
- Lauren Passero
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Swetha Srinivasan
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Mary E Grewe
- North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Jonathan Berg
- School of Medicine, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Daniel Reuland
- School of Medicine, University of North Carolina at Chapel Hill, NC, Chapel Hill, US
| | - Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC, Chapel Hill, US.
| |
Collapse
|
9
|
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.
Collapse
|
10
|
Kim SR, Tone A, Kim RH, Cesari M, Clarke BA, Eiriksson L, Hart TL, Aronson M, Holter S, Lytwyn A, Maganti M, Oldfield L, Gallinger S, Bernardini MQ, Oza AM, Djordjevic B, Lerner-Ellis J, Van de Laar E, Vicus D, Pugh TJ, Pollett A, Ferguson SE. Maximizing cancer prevention through genetic navigation for Lynch syndrome detection in women with newly diagnosed endometrial and nonserous/nonmucinous epithelial ovarian cancer. Cancer 2021; 127:3082-3091. [PMID: 33983630 PMCID: PMC8453540 DOI: 10.1002/cncr.33625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/14/2021] [Accepted: 04/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite recommendations for reflex immunohistochemistry (IHC) for mismatch repair (MMR) proteins to identify Lynch syndrome (LS), the uptake of genetic assessment by those who meet referral criteria is low. The authors implemented a comprehensive genetic navigation program to increase the uptake of genetic testing for LS in patients with endometrial cancer (EC) or nonserous/nonmucinous ovarian cancer (OC). METHODS Participants with newly diagnosed EC or OC were prospectively recruited from 3 cancer centers in Ontario, Canada. Family history questionnaires were used to assess LS-specific family history. Reflex IHC for MMR proteins was performed with the inclusion of clinical directives in pathology reports. A trained genetic navigator initiated a genetic referral on behalf of the treating physician and facilitated genetic referrals to the closest genetics center. RESULTS A total of 841 participants (642 with EC, 172 with OC, and 27 with synchronous EC/OC) consented to the study; 194 (23%) were MMR-deficient by IHC. Overall, 170 women (20%) were eligible for a genetic assessment for LS: 35 on the basis of their family history alone, 24 on the basis of their family history and IHC, 82 on the basis of IHC alone, and 29 on the basis of clinical discretion. After adjustments for participants who died (n = 6), 149 of 164 patients (91%) completed a genetic assessment, and 111 were offered and completed genetic testing. Thirty-four women (4.0% of the total cohort and 30.6% of those with genetic testing) were diagnosed with LS: 5 with mutL homolog 1 (MLH1), 9 with mutS homolog 2 (MSH2), 15 with mutS homolog 6 (MSH6), and 5 with PMS2. CONCLUSIONS The introduction of a navigated genetic program resulted in a high rate of genetic assessment (>90%) in patients with gynecologic cancer at risk for LS.
Collapse
Affiliation(s)
- Soyoun Rachel Kim
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Alicia Tone
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada
| | - Raymond H Kim
- Fred A. Litwin Family Centre for Genetic Medicine, University Health Network, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada
| | - Matthew Cesari
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Blaise A Clarke
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lua Eiriksson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Tae L Hart
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Spring Holter
- Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alice Lytwyn
- Division of Anatomical Pathology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Manjula Maganti
- Department of Biostatistics, Princess Margaret Cancer Centre/University Health Network/University of Toronto, Toronto, Ontario, Canada
| | - Leslie Oldfield
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Steven Gallinger
- Division of General Surgery, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Amit M Oza
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada
| | - Bojana Djordjevic
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Lerner-Ellis
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Emily Van de Laar
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada
| | - Danielle Vicus
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.,Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Trevor J Pugh
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, University Health Network, Toronto, Ontario, Canada.,Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada
| | - Aaron Pollett
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sarah E Ferguson
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.,Zane Cohen Centre for Digestive Diseases, Familial Gastrointestinal Cancer Registry, Mount Sinai Hospital, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Reyes-Uribe L, Wu W, Gelincik O, Bommi PV, Francisco-Cruz A, Solis LM, Lynch PM, Lim R, Stoffel EM, Kanth P, Samadder NJ, Mork ME, Taggart MW, Milne GL, Marnett LJ, Vornik L, Liu DD, Revuelta M, Chang K, You YN, Kopelovich L, Wistuba II, Lee JJ, Sei S, Shoemaker RH, Szabo E, Richmond E, Umar A, Perloff M, Brown PH, Lipkin SM, Vilar E. Naproxen chemoprevention promotes immune activation in Lynch syndrome colorectal mucosa. Gut 2021; 70:555-566. [PMID: 32641470 PMCID: PMC7790993 DOI: 10.1136/gutjnl-2020-320946] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Patients with Lynch syndrome (LS) are at markedly increased risk for colorectal cancer. It is being increasingly recognised that the immune system plays an essential role in LS tumour development, thus making an ideal target for cancer prevention. Our objective was to evaluate the safety, assess the activity and discover novel molecular pathways involved in the activity of naproxen as primary and secondary chemoprevention in patients with LS. DESIGN We conducted a Phase Ib, placebo-controlled, randomised clinical trial of two dose levels of naproxen sodium (440 and 220 mg) administered daily for 6 months to 80 participants with LS, and a co-clinical trial using a genetically engineered mouse model of LS and patient-derived organoids (PDOs). RESULTS Overall, the total number of adverse events was not different across treatment arms with excellent tolerance of the intervention. The level of prostaglandin E2 in the colorectal mucosa was significantly decreased after treatment with naproxen when compared with placebo. Naproxen activated different resident immune cell types without any increase in lymphoid cellularity, and changed the expression patterns of the intestinal crypt towards epithelial differentiation and stem cell regulation. Naproxen demonstrated robust chemopreventive activity in a mouse co-clinical trial and gene expression profiles induced by naproxen in humans showed perfect discrimination of mice specimens with LS and PDOs treated with naproxen and control. CONCLUSIONS Naproxen is a promising strategy for immune interception in LS. We have discovered naproxen-induced gene expression profiles for their potential use as predictive biomarkers of drug activity. TRIAL REGISTRATION NUMBER gov Identifier: NCT02052908.
Collapse
Affiliation(s)
- Laura Reyes-Uribe
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wenhui Wu
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Prashant V Bommi
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alejandro Francisco-Cruz
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Luisa M Solis
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick M Lynch
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Clinical Cancer Genetics Program, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ramona Lim
- Department of Gastroenterology, Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elena M Stoffel
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Priyanka Kanth
- Division of Gastroenterology, Department of Medicine, University of Utah/Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - N Jewel Samadder
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Maureen E Mork
- Clinical Cancer Genetics Program, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa W Taggart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ginger L Milne
- Departments of Biochemistry, Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lawrence J Marnett
- Departments of Biochemistry, Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lana Vornik
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Kyle Chang
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Y Nancy You
- Clinical Cancer Genetics Program, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shizuko Sei
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Robert H Shoemaker
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Ellen Richmond
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Asad Umar
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Marjorie Perloff
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland, USA
| | - Powel H Brown
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Eduardo Vilar
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Clinical Cancer Genetics Program, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
12
|
Baroutsou V, Underhill-Blazey ML, Appenzeller-Herzog C, Katapodi MC. Interventions Facilitating Family Communication of Genetic Testing Results and Cascade Screening in Hereditary Breast/Ovarian Cancer or Lynch Syndrome: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040925. [PMID: 33672149 PMCID: PMC7926393 DOI: 10.3390/cancers13040925] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/29/2021] [Accepted: 02/15/2021] [Indexed: 12/19/2022] Open
Abstract
Evidence-based guidelines recommend cascade genetic testing of blood relatives of known Hereditary Breast and Ovarian Cancer (HBOC) or Lynch Syndrome (LS) cases, to inform individualized cancer screening and prevention plans. The study identified interventions designed to facilitate family communication of genetic testing results and/or cancer predisposition cascade genetic testing for HBOC and LS. We conducted a systematic review and meta-analysis of randomized trials that assessed intervention efficacy for these two outcomes. Additional outcomes were also recorded and synthesized when possible. Fourteen articles met the inclusion criteria and were included in the narrative synthesis and 13 in the meta-analysis. Lack of participant blinding was the most common risk of bias. Interventions targeted HBOC (n = 5); both HBOC and LS (n = 4); LS (n = 3); or ovarian cancer (n = 2). All protocols (n = 14) included a psychoeducational and/or counseling component. Additional components were decision aids (n = 4), building communication skills (n = 4), or motivational interviewing (n = 1). The overall effect size for family communication was small (g = 0.085) and not significant (p = 0.344), while for cascade testing, it was small (g = 0.169) but significant (p = 0.014). Interventions show promise for improving cancer predisposition cascade genetic testing for HBOC and LS. Future studies should employ family-based approaches and include racially diverse samples.
Collapse
Affiliation(s)
- Vasiliki Baroutsou
- Department of Clinical Research, Faculty of Medicine, University of Basel, 4055 Basel, Switzerland;
| | - Meghan L. Underhill-Blazey
- School of Nursing, Wilmot Cancer Institute Hereditary Cancer Program, University of Rochester, Rochester, NY 14642, USA;
| | | | - Maria C. Katapodi
- Department of Clinical Research, Faculty of Medicine, University of Basel, 4055 Basel, Switzerland;
- Correspondence: ; Tel.: +41-61-207-04-30
| |
Collapse
|
13
|
Rainone M, Singh I, Salo-Mullen EE, Stadler ZK, O'Reilly EM. An Emerging Paradigm for Germline Testing in Pancreatic Ductal Adenocarcinoma and Immediate Implications for Clinical Practice: A Review. JAMA Oncol 2021; 6:764-771. [PMID: 32053139 DOI: 10.1001/jamaoncol.2019.5963] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Pancreatic ductal adenocarcinoma (PDAC) is a malignant neoplasm with a rising incidence and is a leading public health challenge. Pancreatic ductal adenocarcinoma has been well characterized genomically, with findings of therapeutic actionability that have substantive implications for clinical practice based on recent high-level evidence. Observations Pathogenic germline alterations (PGAs) are relatively common in individuals with PDAC, as evidenced in multiple recent data sets, with a frequency of approximately 10%. The most common PGAs are in BRCA1, BRCA2, and ATM and more rarely in PALB2, MLH1, MSH2, MSH6, PMS2, CDKN2A, and TP53, among others, with an aggregate frequency of 3.8% to 9.7%. These PGAs are of key interest owing to therapeutic actionability and the downstream identification of at-risk family members and possible hereditary cancer syndromes. Approximately 3% to 7% of individuals with PDAC harbor a BRCA1 or BRCA2 mutation, which are among the most frequently mutated genes in PDAC. Recent updates to the American Society of Clinical Oncology and the National Comprehensive Cancer Network guidelines recommend risk assessment for all individuals with PDAC irrespective of personal or family history or ethnicity. Treatment implications include the use of checkpoint inhibitor therapy for mismatch repair-deficient PDAC and the validation of poly-ADP (adenosine diphosphate)-ribose polymerase inhibitor (PARPi) therapy as a maintenance strategy in platinum-sensitive PDAC. Conclusions and Relevance With increasing evidence and slow improvement of outcomes, PDAC has entered the era of precision medicine. Germline mutations have been identified in key genes with an aggregate frequency of 3.8% to 9.7%, several of which are therapeutically actionable with platinum, PARPi, and checkpoint inhibitor therapy. Potential therapeutic targets need to be actively sought and identified.
Collapse
Affiliation(s)
- Michael Rainone
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Isha Singh
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Mount Sinai St Luke's and Mount Sinai West Hospitals, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin E Salo-Mullen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| |
Collapse
|
14
|
Srinivasan S, Hampel H, Leeman J, Patel A, Kulchak Rahm A, Reuland DS, Roberts MC. Stakeholder Perspectives on Overcoming Barriers to Cascade Testing in Lynch Syndrome: A Qualitative Study. Cancer Prev Res (Phila) 2020; 13:1037-1046. [PMID: 32727822 DOI: 10.1158/1940-6207.capr-20-0141] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/15/2020] [Accepted: 07/22/2020] [Indexed: 11/16/2022]
Abstract
Cascade testing (i.e., genetic testing of family members of individuals with disease) among families affected by hereditary cancer disorders, such as Lynch syndrome, is suboptimal and thus represents a missed opportunity in cancer prevention. We aimed to fill a gap in the literature by exploring multilevel barriers and facilitators to the implementation of cascade testing for Lynch syndrome. We conducted semistructured, in-depth interviews guided by the Consolidated Framework for Implementation Research and the Integrated Behavioral Model among key stakeholders (n = 60): Patients with Lynch syndrome and relatives (n = 20), providers (n = 20), and administrators (n = 20). Transcripts were double-coded (20% sample) using template analysis in ATLAS.ti. Barriers identified included (i) low awareness about Lynch syndrome, (ii) psychosocial barriers, (iii) lack of provider follow-up, (iv) accessibility to genetic counseling, and (v) fear of discrimination. Facilitators included (i) motivation to engage in cascade testing and (ii) free genetic testing offered to relatives. Stakeholders also recommended strategies to overcome implementation barriers in the short-term (increasing education, preparing patients for communicating with relatives), medium-term (optimizing clinical workflow and staffing resources), and long-term (nationwide standardization). These findings indicate that modifiable, multilevel barriers to the implementation of cascade testing in Lynch syndrome are experienced across stakeholders. Understanding and targeting implementation barriers is imperative to achieving public health impact of precision health interventions such as cascade testing.
Collapse
Affiliation(s)
- Swetha Srinivasan
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heather Hampel
- Division of Human Genetics, The Ohio State Comprehensive Cancer Center, Columbus, Ohio
| | - Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amit Patel
- Medical Marketing Economics, Oxford, Mississippi
| | | | - Daniel S Reuland
- Division of General Internal Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| |
Collapse
|
15
|
Knerr S, West KM, Angelo FA. Organizational readiness to implement population-based screening and genetic service delivery for hereditary cancer prevention and control. J Genet Couns 2020; 29:867-876. [PMID: 31967362 DOI: 10.1002/jgc4.1216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/15/2019] [Accepted: 12/25/2019] [Indexed: 01/09/2023]
Abstract
Despite clinical guidelines, programs conducting population-based screening and genetic service delivery for hereditary cancer prevention and control are rare in practice. We interviewed individuals (n = 13) instrumental in implementing seven unique clinical programs conducting either universal tumor screening for Lynch Syndrome or routine family history screening and provision of genetic services for hereditary breast and ovarian cancer in the United States. To characterize determinants of readiness to implement population-based cancer genetic service delivery models, interviews and deductive codes drew on Weiner's theory of organizational readiness for change. Qualitative analysis identified themes across programs. The degree to which organizational stakeholders valued moving to a population-based genetic service delivery model depended on the existence of aligned clinical guidelines at the time of program implementation. However, judgments of implementation capacity within the organization, particularly with respect to task demands and resource concerns, were more often barriers to readiness. Program champions were essential to facilitating readiness, frequently taking on substantial uncompensated work. These data suggest that developing interventions targeting change efficacy and cultivating practice change champions may be two promising ways to increase uptake of population-based hereditary cancer screening and genetic service delivery in clinical practice.
Collapse
Affiliation(s)
- Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Kathleen M West
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Frank A Angelo
- Department of Health Services, University of Washington, Seattle, WA, USA
| |
Collapse
|
16
|
Rahm AK, Bellcross C, Cragun D, Duquette D, Hampel H, Heald B. Implementing universal cancer screening programs can help sustain genomic medicine programs. Per Med 2019; 17:9-13. [PMID: 31797715 DOI: 10.2217/pme-2019-0126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Alanna Kulchak Rahm
- Genomic Medicine Institute, Geisinger, 100 N Academy Ave, Danville, PA 17822, USA
| | - Cecelia Bellcross
- Emory University School of Medicine, Department of Human Genetics, 1462 Clifton Road, Suite 310, Atlanta, GA 30322, USA
| | - Deborah Cragun
- USF Genetic Counseling Program, College of Public Health, University of South Florida, Interdisciplinary Research Building, 3720 Spectrum Blvd, Suite 304, Tampa, FL 33612, USA
| | - Debra Duquette
- Graduate Program in Genetic Counseling, Feinberg School of Medicine, Northwestern University, 645 North Michigan Avenue, Suite 630, Chicago, IL 60611, USA
| | - Heather Hampel
- Division of Human Genetics, Department of Internal Medicine & Comprehensive Cancer Center, The Ohio State University, 2012 Kenny Road, Room 257, Columbus, OH 43221, USA
| | - Brandie Heald
- Sanford R Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| |
Collapse
|
17
|
Abstract
Purpose of review: Identification of Lynch syndrome is important from an individual patient and public health standpoint. As paradigms for Lynch syndrome diagnosis have shifted in recent years, this review will discuss rationale and limitations for current strategies as well as provide an overview of future directions in the field. Recent findings: In recent years, the use of clinical criteria and risk scores for identification of Lynch syndrome have been augmented by universal testing of all newly diagnosed colorectal cancers with molecular methods to screen for mismatch repair deficiency with high sensitivity and specificity. Studies of implementation and outcomes of universal testing in clinical practice have demonstrated significant heterogeneity that results in suboptimal uptake and contributes to disparities in diagnosis. Emerging technologies, such as next-generation sequencing, hold significant promise as a screening strategy for Lynch syndrome. Summary: Universal testing for Lynch syndrome is being performed with increasing frequency, although real-world outcomes have demonstrated room for improvement. Future directions in Lynch syndrome diagnosis will involve optimization of universal testing workflow and application of new genetics technologies.
Collapse
|
18
|
Chang K, Taggart MW, Reyes-Uribe L, Borras E, Riquelme E, Barnett RM, Leoni G, San Lucas FA, Catanese MT, Mori F, Diodoro MG, You YN, Hawk ET, Roszik J, Scheet P, Kopetz S, Nicosia A, Scarselli E, Lynch PM, McAllister F, Vilar E. Immune Profiling of Premalignant Lesions in Patients With Lynch Syndrome. JAMA Oncol 2019; 4:1085-1092. [PMID: 29710228 DOI: 10.1001/jamaoncol.2018.1482] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Colorectal carcinomas in patients with Lynch syndrome (LS) arise in a background of mismatch repair (MMR) deficiency, display a unique immune profile with upregulation of immune checkpoints, and response to immunotherapy. However, there is still a gap in understanding the pathogenesis of MMR-deficient colorectal premalignant lesions, which is essential for the development of novel preventive strategies for LS. Objective To characterize the immune profile of premalignant lesions from a cohort of patients with LS. Design, Setting, and Participants Whole-genome transcriptomic analysis using next-generation sequencing was performed in colorectal polyps and carcinomas of patients with LS. As comparator and model of MMR-proficient colorectal carcinogenesis, we used samples from patients with familial adenomatous polyposis (FAP). In addition, a total of 47 colorectal carcinomas (6 hypermutants and 41 nonhypermutants) were obtained from The Cancer Genome Atlas (TCGA) for comparisons. Samples were obtained from the University of Texas MD Anderson Cancer Center and "Regina Elena" National Cancer Institute, Rome, Italy. All diagnoses were confirmed by genetic testing. Polyps were collected at the time of endoscopic surveillance and tumors were collected at the time of surgical resection. The data were analyzed from October 2016 to November 2017. Main Outcomes and Measures Assessment of the immune profile, mutational signature, mutational and neoantigen rate, and pathway enrichment analysis of neoantigens in LS premalignant lesions and their comparison with FAP premalignant lesions, LS carcinoma, and sporadic colorectal cancers from TCGA. Results The analysis was performed in a total of 28 polyps (26 tubular adenomas and 2 hyperplastic polyps) and 3 early-stage LS colorectal tumors from 24 patients (15 [62%] female; mean [SD] age, 48.12 [15.38] years) diagnosed with FAP (n = 10) and LS (n = 14). Overall, LS polyps presented with low mutational and neoantigen rates but displayed a striking immune activation profile characterized by CD4 T cells, proinflammatory (tumor necrosis factor, interleukin 12) and checkpoint molecules (LAG3 [lymphocyte activation gene 3] and PD-L1 [programmed cell death 1 ligand 1]). This immune profile was independent of mutational rate, neoantigen formation, and MMR status. In addition, we identified a small subset of LS polyps with high mutational and neoantigen rates that were comparable to hypermutant tumors and displayed additional checkpoint (CTLA4 [cytotoxic T-lymphocyte-associated protein 4]) and neoantigens involved in DNA damage response (ATM and BRCA1 signaling). Conclusions and Relevance These findings challenge the canonical model, based on the observations made in carcinomas, that emphasizes a dependency of immune activation on the acquisition of high levels of mutations and neoantigens, thus opening the door to the implementation of immune checkpoint inhibitors and vaccines for cancer prevention in LS.
Collapse
Affiliation(s)
- Kyle Chang
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston.,Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston
| | - Melissa W Taggart
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston
| | - Laura Reyes-Uribe
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston
| | - Ester Borras
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston
| | - Erick Riquelme
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston
| | - Reagan M Barnett
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston
| | | | - F Anthony San Lucas
- Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston
| | | | | | - Maria G Diodoro
- Department of Pathology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Y Nancy You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston.,Clinical Cancer Genetics Program, University of Texas MD Anderson Cancer Center, Houston
| | - Ernest T Hawk
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston
| | - Jason Roszik
- Department of Melanoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston.,Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston
| | - Paul Scheet
- Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston.,Department of Epidemiology, University of Texas MD Anderson Cancer Center, Houston
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Alfredo Nicosia
- Nouscom SRL, Rome, Italy.,CEINGE, Naples, Italy.,Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | | | - Patrick M Lynch
- Clinical Cancer Genetics Program, University of Texas MD Anderson Cancer Center, Houston.,Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston
| | - Florencia McAllister
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston.,Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston.,Clinical Cancer Genetics Program, University of Texas MD Anderson Cancer Center, Houston.,Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Eduardo Vilar
- Department of Clinical Cancer Prevention, University of Texas MD Anderson Cancer Center, Houston.,Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston.,Clinical Cancer Genetics Program, University of Texas MD Anderson Cancer Center, Houston.,Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| |
Collapse
|
19
|
Dicks E, Pullman D, Kao K, MacMillan A, Simmonds C, Etchegary H. Universal tumor screening for Lynch syndrome: perspectives of Canadian pathologists and genetic counselors. J Community Genet 2019; 10:335-344. [PMID: 30465127 PMCID: PMC6591350 DOI: 10.1007/s12687-018-0398-9] [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: 04/09/2018] [Accepted: 11/13/2018] [Indexed: 12/31/2022] Open
Abstract
Universal screening of all newly diagnosed colorectal cancer tumors can identify individuals at high risk for Lynch syndrome (LS), a hereditary cancer syndrome predisposing carriers to increased risk of colorectal, endometrial, and other cancers. To inform planning of a universal tumor screening program for LS in our jurisdiction, we undertook online surveys of Canadian pathologists and genetic counselors to describe existing tumor screening programs. Online surveys were hosted on SurveyMonkey between October 2016 and March 2017. Fifty-three pathologists and 66 genetic counselors completed surveys (total n = 119). While attitudes towards tumor screening were positive, considerable variability was observed in the existence of tumor screening, test ordering criteria, and practices. Most respondents indicated consent was not obtained for tumor screening nor were educational materials provided to patients; however, opting out of additional mutation testing in the event of a positive tumor screen was endorsed. Results add to the growing literature on providers' perspectives on population-based tumor screening programs and inform ways to offer these. Findings highlight the need to develop methods of patient education that allow meaningful opt-out decisions. The variability we observed also suggests the need for national standards and guidance on tumor screening for LS.
Collapse
Affiliation(s)
- Elizabeth Dicks
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Daryl Pullman
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Ken Kao
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
- Immunohistochemistry Laboratory, Eastern Regional Health Authority, St. John's, NL, Canada
| | - Andrée MacMillan
- Provincial Medical Genetics Program, Eastern Regional Health Authority, St. John's, NL, Canada
| | | | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John's, NL, Canada.
| |
Collapse
|
20
|
Dicks E, Pullman D, Kao K, MacMillan A, Logan GS, Simmonds C, Etchegary H. Universal tumor screening for Lynch syndrome: Perceptions of Canadian pathologists and genetic counselors of barriers and facilitators. Cancer Med 2019; 8:3614-3622. [PMID: 31102338 PMCID: PMC6601578 DOI: 10.1002/cam4.2182] [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: 01/30/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND People at risk of developing hereditary cancers associated with Lynch Syndrome (LS) can be identified through universal screening of colorectal tumors. However, tumor screening practices are variable across Canada and few studies explore the perspectives of genetic counselors and pathologists about tumor screening. This study was conducted to better understand the barriers and facilitators of implementing universal tumor screening in health centers across Canada. METHODS An online survey about tumor screening programs was administered to genetic counselors and pathologists across Canada through communication channels of professional organizations. It was hosted on SurveyMonkey and accessible from October 2016 to March 2017. RESULTS Barriers to tumor screening included a lack of sustainable resources, including funding and genetic counselors. Respondents strongly identified the need for a coordinated, interdisciplinary approach to program planning with the "right people at the table." Respondents currently with a screening program provided advice such as carefully designing the program structure, developing patient and family follow-up protocols, and ensuring adequate resources (funding, staff, training for providers) were available prior to program initiation. CONCLUSION There is no national approach to universal tumor screening in Canada. However, future efforts can be informed by the experiences of those centers that have already created a universal tumor screening program for LS. These data suggest the need for an interdisciplinary approach, initial and sustained funding, and careful advanced planning of program structures and policies.
Collapse
Affiliation(s)
- Elizabeth Dicks
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Daryl Pullman
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Ken Kao
- Faculty of Medicine, Memorial University, St. John's, NL, Canada.,Immunohistochemistry Laboratory, Eastern Regional Health Authority, St. John's, NL, Canada
| | - Andrée MacMillan
- Provincial Medical Genetics Program, Eastern Regional Health Authority, St. John's, NL, Canada
| | | | | | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| |
Collapse
|
21
|
The Healthcare Systems Research Network (HCSRN) as an Environment for Dissemination and Implementation Research: A Case Study of Developing a Multi-Site Research Study in Precision Medicine. EGEMS 2019; 7:16. [PMID: 30984796 PMCID: PMC6460496 DOI: 10.5334/egems.283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Context: In existence for nearly 25 years, the Healthcare Systems Research Network (HCSRN) is an established and sustainable network of health care systems that serves as a “real world” laboratory to enable the integration of research findings into practice. The objective of this paper is to demonstrate how the HCSRN serves as an ideal environment for studying dissemination and implementation of evidence-based practices into health care systems through the example of developing a multi-site study on the implementation of evidence-based precision medicine practices. Case description: The “Implementing Universal Lynch Syndrome Screening (IMPULSS)” study (NIH R01CA211723) involves seven HCSRN health care systems and two external health care systems. The IMPULSS study will describe and explain organizational variability around Lynch syndrome (LS) screening to identify which factors in different organizational contexts are important for successful implementation of LS screening programs and will create a toolkit to facilitate organizational decision making around implementation and improvement of precision medicine programs in health care systems. Major Themes: The strengths of the HCSRN that facilitate D&I research include: 1) a culture of collaboration, 2) standardization of data and processes across systems, and 3) researchers embedded in diverse health care systems. We describe how these strengths contributed to developing the IMPULSS study. Conclusion: Given the importance of conducting research in real world settings to improve patient outcomes, the unique strengths of the HCSRN are of vital importance. The IMPULSS study is one case example of how the strengths of the HCSRN make it an excellent environment for research on implementing evidence-based precision medicine practices in health care systems.
Collapse
|
22
|
Green RF, Ari M, Kolor K, Dotson WD, Bowen S, Habarta N, Rodriguez JL, Richardson LC, Khoury MJ. Evaluating the role of public health in implementation of genomics-related recommendations: a case study of hereditary cancers using the CDC Science Impact Framework. Genet Med 2019; 21:28-37. [PMID: 29907802 PMCID: PMC6295277 DOI: 10.1038/s41436-018-0028-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/20/2018] [Indexed: 01/21/2023] Open
Abstract
Public health plays an important role in ensuring access to interventions that can prevent disease, including the implementation of evidence-based genomic recommendations. We used the Centers for Disease Control and Prevention (CDC) Science Impact Framework to trace the impact of public health activities and partnerships on the implementation of the 2009 Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Lynch Syndrome screening recommendation and the 2005 and 2013 United States Preventive Services Task Force (USPSTF) BRCA1 and BRCA2 testing recommendations.The EGAPP and USPSTF recommendations have each been cited by >300 peer-reviewed publications. CDC funds selected states to build capacity to integrate these recommendations into public health programs, through education, policy, surveillance, and partnerships. Most state cancer control plans include genomics-related goals, objectives, or strategies. Since the EGAPP recommendation, major public and private payers now provide coverage for Lynch Syndrome screening for all newly diagnosed colorectal cancers. National guidelines and initiatives, including Healthy People 2020, included similar recommendations and cited the EGAPP and USPSTF recommendations. However, disparities in implementation based on race, ethnicity, and rural residence remain challenges. Public health achievements in promoting the evidence-based use of genomics for the prevention of hereditary cancers can inform future applications of genomics in public health.
Collapse
Affiliation(s)
- Ridgely Fisk Green
- Carter Consulting and Office of Public Health Genomics, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | - Mary Ari
- Office of the Director, Office of the Associate Director for Science, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Kolor
- Office of Public Health Genomics, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - W David Dotson
- Office of Public Health Genomics, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Scott Bowen
- Office of Public Health Genomics, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nancy Habarta
- Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Juan L Rodriguez
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Muin J Khoury
- Office of Public Health Genomics, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
23
|
Muller C, Lee SM, Barge W, Siddique SM, Berera S, Wideroff G, Tondon R, Chang J, Peterson M, Stoll J, Katona BW, Sussman DA, Melson J, Kupfer SS. Low Referral Rate for Genetic Testing in Racially and Ethnically Diverse Patients Despite Universal Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2018; 16:1911-1918.e2. [PMID: 30130624 PMCID: PMC6866232 DOI: 10.1016/j.cgh.2018.08.038] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/07/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend that all colorectal tumors be assessed for mismatch repair deficiency, which could increase identification of patients with Lynch syndrome. This is of particular importance for minority populations, in whom hereditary syndromes are under diagnosed. We compared rates and outcomes of testing all tumor samples (universal testing) collected from a racially and ethnically diverse population for features of Lynch syndrome. METHODS We performed a retrospective analysis of colorectal tumors tested from 2012 through 2016 at 4 academic centers. Tumor samples were collected from 767 patients with colorectal cancer (52% non-Hispanic white [NHW], 26% African American, and 17% Hispanic patients). We assessed rates of tumor testing, recommendations for genetic evaluation, rates of attending a genetic evaluation, and performance of germline testing overall and by race/ethnicity. We performed univariate and multivariate regression analyses. RESULTS Overall, 92% of colorectal tumors were analyzed for mismatch repair deficiency without significant differences among races/ethnicities. However, minority patients were significantly less likely to be referred for genetic evaluation (21.2% for NHW patients vs 16.9% for African American patients and 10.9% for Hispanic patients; P = .02). Rates of genetic testing were also lower among minority patients (10.7% for NHW patients vs 6.0% for AA patients and 3.1% for Hispanic patients; P < .01). On multivariate analysis, African American race, older age, and medical center were independently associated with lack of referral for genetic evaluation and genetic testing. CONCLUSION In a retrospective analysis, we found that despite similar rates of colorectal tumor analysis, minority patients are less likely to be recommended for genetic evaluation or to undergo germline testing for Lynch syndrome. Improvements in institutional practices in follow up after tumor testing could reduce barriers to diagnosis of Lynch diagnosis in minorities.
Collapse
Affiliation(s)
- Charles Muller
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sang Mee Lee
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - William Barge
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois
| | - Shazia M Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shivali Berera
- Gastroenterology Division, University of Miami, Miami, Florida
| | - Gina Wideroff
- Gastroenterology Division, University of Miami, Miami, Florida
| | - Rashmi Tondon
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy Chang
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Meaghan Peterson
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jessica Stoll
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Bryson W Katona
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joshua Melson
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois
| | - Sonia S Kupfer
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois.
| |
Collapse
|
24
|
Rahm AK, Cragun D, Hunter JE, Epstein MM, Lowery J, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Burnett-Hartman AN, Gudgeon JM, Hao J, Snyder S, Gogoi R, Ladd I, Williams MS. Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts. BMC Health Serv Res 2018; 18:824. [PMID: 30376847 PMCID: PMC6208012 DOI: 10.1186/s12913-018-3636-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background Systematic screening of all colorectal tumors for Lynch Syndrome (LS) has been recommended since 2009. Currently, implementation of LS screening in healthcare systems remains variable, likely because LS screening involves the complex coordination of multiple departments and individuals across the healthcare system. Our specific aims are to (1) describe variation in LS screening implementation across multiple healthcare systems; (2) identify conditions associated with both practice variation and optimal implementation; (3) determine the relative effectiveness, efficiency, and costs of different LS screening protocols by healthcare system; and (4) develop and test in a real-world setting an organizational toolkit for LS screening program implementation and improvement. This toolkit will promote effective implementation of LS screening in various complex health systems. Methods This study includes eight healthcare systems with 22 clinical sites at varied stages of implementing LS screening programs. Guided by the Consolidated Framework for Implementation Research (CFIR), we will conduct in-depth semi-structured interviews with patients and organizational stakeholders and perform economic evaluation of site-specific implementation costs. These processes will result in a comprehensive cross-case analysis of different organizational contexts. We will utilize qualitative data analysis and configurational comparative methodology to identify facilitators and barriers at the organizational level that are minimally sufficient and necessary for optimal LS screening implementation. Discussion The overarching goal of this project is to combine our data with theories and tools from implementation science to create an organizational toolkit to facilitate implementation of LS screening in various real-world settings. Our organizational toolkit will account for issues of complex coordination of care involving multiple stakeholders to enhance implementation, sustainability, and ongoing improvement of evidence-based LS screening programs. Successful implementation of such programs will ultimately reduce suffering of patients and their family members from preventable cancers, decrease waste in healthcare system costs, and inform strategies to facilitate the promise of precision medicine. Trial registration N/A Electronic supplementary material The online version of this article (10.1186/s12913-018-3636-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Alanna Kulchak Rahm
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA.
| | - Deborah Cragun
- University of South Florida, 3720 Spectrum Blvd, Suite 304, Tampa, FL, 33612, USA
| | - Jessica Ezzell Hunter
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97202, USA
| | - Mara M Epstein
- Department of Medicine and the Meyers Primary Care Institute, University of Massachusetts Medical School, 365 Plantation St. Biotech 1, Suite 100, Worcester, MA, 01605, USA
| | - Jan Lowery
- Colorado Center for Personalized Medicine, University of Colorado, Aurora, CO, 80045, USA
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA
| | | | - Ravi N Sharaf
- Division of Gastroenterology, Department of Medicine, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Andrea N Burnett-Hartman
- Kaiser Permanente Colorado, Institute for Health Research, 2550 S. Parker Rd., Ste 200, Aurora, CO, 80014, USA
| | - James M Gudgeon
- Intermountain Healthcare, Precision Genomics, IMC campus, Bldg. 2, Suite 610, 5121 S. Cottonwood Street, Murray, UT, 84107, USA
| | - Jing Hao
- Geisinger Department of Epidemiology and Health Services Research 100 N, Academy Ave Danville, Mahoning Township, PA, 17822, USA
| | - Susan Snyder
- Geisinger Department of Epidemiology and Health Services Research 100 N, Academy Ave Danville, Mahoning Township, PA, 17822, USA
| | - Radhika Gogoi
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Ilene Ladd
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Marc S Williams
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
| |
Collapse
|
25
|
Palter VN, Baker NA, Rabeneck L, Tinmouth J, Gagliardi AR, Kennedy ED, Carroll JC, Gallinger S, Baxter NN. A framework to build capacity for a reflex-testing program for Lynch syndrome. Genet Med 2018; 21:1381-1389. [PMID: 30349099 DOI: 10.1038/s41436-018-0342-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Lynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada. METHODS We recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed. RESULTS Twenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified. CONCLUSIONS This study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.
Collapse
Affiliation(s)
| | - Natalie A Baker
- St. Michael's Hospital, Toronto, ON, Canada.,Public Health Sciences, University of Toronto, Toronto, ON, Canada
| | | | - Jill Tinmouth
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Erin D Kennedy
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
| | - June C Carroll
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
| | - Steven Gallinger
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Nancy N Baxter
- St. Michael's Hospital, Toronto, ON, Canada.,Public Health Sciences, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
26
|
Mascarenhas L, Shanley S, Mitchell G, Spurdle AB, Macrae F, Pachter N, Buchanan DD, Ward RL, Fox S, Duxbury E, Driessen R, Boussioutas A. Current mismatch repair deficiency tumor testing practices and capabilities: A survey of Australian pathology providers. Asia Pac J Clin Oncol 2018; 14:417-425. [PMID: 30294856 DOI: 10.1111/ajco.13076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 06/17/2018] [Indexed: 12/13/2022]
Abstract
AIM & METHODS An electronic survey of the Royal College of Pathologists of Australasia accredited pathology services was conducted to assess Lynch syndrome tumor screening practices and to identify barriers and capabilities to screen newly diagnosed colorectal and endometrial tumors in Australia. RESULTS Australia lacks a national policy for universal mismatch repair-deficient (dMMR) testing of incident colorectal and endometrial tumors cases. Routine Lynch syndrome tumor screening program for colorectal and/or endometrial tumors was applied by 95% (37/39) of laboratories. Tumor dMMR screening methods varied; MMR protein immunohistochemistry (IHC) alone was undertaken by 77% of 39 laboratories, 18% performed both IHC and microsatellite instability testing, 5% did not have the capacity to perform in-house testing. For colorectal tumors, 47% (17/36) reported following a universal approach without age limit, 30% (11/36) tested only "red flag" cases; 6% (3/36) on clinician request only. For endometrial tumors, 37% (12/33) reported clinician request generated testing, 27% (9/33) were screening only "red flag" cases, and 12% (4/33) carried out universal screening without an age criteria. BRAF V600E mutation testing of colorectal tumors demonstrating aberrant MLH1 protein expression by IHC was the most common secondary tumor test, with 53% of laboratories performing the test; 15% of laboratories also applied the BRAF V600E test to endometrial tumors with aberrant MLH1 expression despite no evidence for its utility. Tumor testing for MLH1 promoter methylation was performed by less than 15% laboratories. CONCLUSION Although use of tumor screening for evidence of dMMR is widely available, protocols for its use in Australia vary widely. This national survey provides a snapshot of the current availability and practice of tumor dMMR screening and identifies the need for a uniform national testing policy.
Collapse
Affiliation(s)
- Lyon Mascarenhas
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Susan Shanley
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Gillian Mitchell
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Amanda B Spurdle
- Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Finlay Macrae
- Department of Colorectal Medicine and Genetics, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia.,School of Medicine & Pharmacology, University of Western Australia, WA, Australia
| | - Daniel D Buchanan
- Colorectal Oncogenomics Group, Department of Clinical Pathology, The University of Melbourne, Parkville, Victoria, Australia.,University of Melbourne Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia.,Genomic Medicine and Family Cancer Clinic, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Robyn L Ward
- Office of Deputy Vice Chancellor (Research), University of Queensland, Brisbane, Queensland, Australia
| | - Stephen Fox
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | | | - Rebecca Driessen
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alex Boussioutas
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
27
|
Palter VN, Baker NA, Pollett A, Daly C, Facey M, Rotenberg C, Rabeneck L, Baxter NN. Learning by Example: An International Perspective on Reflex-Testing for Lynch Syndrome. Ann Surg Oncol 2018; 26:425-436. [DOI: 10.1245/s10434-018-6809-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 01/02/2023]
|
28
|
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.”
Collapse
|
29
|
Khoury MJ, Bowen MS, Clyne M, Dotson WD, Gwinn ML, Green RF, Kolor K, Rodriguez JL, Wulf A, Yu W. From public health genomics to precision public health: a 20-year journey. Genet Med 2017; 20:574-582. [PMID: 29240076 DOI: 10.1038/gim.2017.211] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/20/2017] [Indexed: 12/20/2022] Open
Abstract
In this paper, we review the evolution of the field of public health genomics in the United States in the past two decades. Public health genomics focuses on effective and responsible translation of genomic science into population health benefits. We discuss the relationship of the field to the core public health functions and essential services, review its evidentiary foundation, and provide examples of current US public health priorities and applications. We cite examples of publications to illustrate how Genetics in Medicine reflected the evolution of the field. We also reflect on how public-health genomics is contributing to the emergence of "precision public health" with near-term opportunities offered by the US Precision Medicine (AllofUs) Initiative.
Collapse
Affiliation(s)
- Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M Scott Bowen
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mindy Clyne
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - W David Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marta L Gwinn
- Office of Advanced Molecular Detection, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ridgely Fisk Green
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Kolor
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Juan L Rodriguez
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anja Wulf
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wei Yu
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
30
|
Laurino MY, Truitt AR, Tenney L, Fisher D, Lindor NM, Veenstra D, Jarvik GP, Newcomb PA, Fullerton SM. Clinical verification of genetic results returned to research participants: findings from a Colon Cancer Family Registry. Mol Genet Genomic Med 2017; 5:700-708. [PMID: 29178651 PMCID: PMC5702564 DOI: 10.1002/mgg3.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/23/2017] [Accepted: 07/27/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The extent to which participants act to clinically verify research results is largely unknown. This study examined whether participants who received Lynch syndrome (LS)-related findings pursued researchers' recommendation to clinically verify results with testing performed by a CLIA-certified laboratory. METHODS The Fred Hutchinson Cancer Research Center site of the multinational Colon Cancer Family Registry offered non-CLIA individual genetic research results to select registry participants (cases and their enrolled relatives) from 2011 to 2013. Participants who elected to receive results were counseled on the importance of verifying results at a CLIA-certified laboratory. Twenty-six (76.5%) of the 34 participants who received genetic results completed 2- and 12-month postdisclosure surveys; 42.3% of these (11/26) participated in a semistructured follow-up interview. RESULTS Within 12 months of result disclosure, only 4 (15.4%) of 26 participants reported having verified their results in a CLIA-certified laboratory; of these four cases, all research and clinical results were concordant. Reasons for pursuing clinical verification included acting on the recommendation of the research team and informing future clinical care. Those who did not verify results cited lack of insurance coverage and limited perceived personal benefit of clinical verification as reasons for inaction. CONCLUSION These findings suggest researchers will need to address barriers to seeking clinical verification in order to ensure that the intended benefits of returning genetic research results are realized.
Collapse
Affiliation(s)
- Mercy Y. Laurino
- Cancer Prevention ProgramSeattle Cancer Care AllianceSeattleWashingtonUSA
| | - Anjali R. Truitt
- Department of Rehabilitation MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Lederle Tenney
- Public Health Sciences DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Douglass Fisher
- Public Health Sciences DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | | | - David Veenstra
- Pharmaceutical Outcomes Research and Policy ProgramSchool of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Gail P. Jarvik
- Division of Medical GeneticsDepartment of Genome SciencesUniversity of WashingtonSeattleWashingtonUSA
| | - Polly A. Newcomb
- Public Health Sciences DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | | |
Collapse
|
31
|
Katapodi MC, Viassolo V, Caiata-Zufferey M, Nikolaidis C, Bührer-Landolt R, Buerki N, Graffeo R, Horváth HC, Kurzeder C, Rabaglio M, Scharfe M, Urech C, Erlanger TE, Probst-Hensch N, Heinimann K, Heinzelmann-Schwarz V, Pagani O, Chappuis PO. Cancer Predisposition Cascade Screening for Hereditary Breast/Ovarian Cancer and Lynch Syndromes in Switzerland: Study Protocol. JMIR Res Protoc 2017; 6:e184. [PMID: 28931501 PMCID: PMC5628286 DOI: 10.2196/resprot.8138] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/15/2017] [Accepted: 07/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Breast, colorectal, ovarian, and endometrial cancers constitute approximately 30% of newly diagnosed cancer cases in Switzerland, affecting more than 12,000 individuals annually. Hundreds of these patients are likely to carry germline pathogenic variants associated with hereditary breast ovarian cancer (HBOC) or Lynch syndrome (LS). Genetic services (counseling and testing) for hereditary susceptibility to cancer can prevent many cancer diagnoses and deaths through early identification and risk management. OBJECTIVE Cascade screening is the systematic identification and testing of relatives of a known mutation carrier. It determines whether asymptomatic relatives also carry the known variant, needing management options to reduce future harmful outcomes. Specific aims of the CASCADE study are to (1) survey index cases with HBOC or LS from clinic-based genetic testing records and determine their current cancer status and surveillance practices, needs for coordination of medical care, psychosocial needs, patient-provider and patient-family communication, quality of life, and willingness to serve as advocates for cancer genetic services to blood relatives, (2) survey first- and second-degree relatives and first-cousins identified from pedigrees or family history records of HBOC and LS index cases and determine their current cancer and mutation status, cancer surveillance practices, needs for coordination of medical care, barriers and facilitators to using cancer genetic services, psychosocial needs, patient-provider and patient-family communication, quality of life, and willingness to participate in a study designed to increase use of cancer genetic services, and (3) explore the influence of patient-provider communication about genetic cancer risk on patient-family communication and the acceptability of a family-based communication, coping, and decision support intervention with focus group(s) of mutation carriers and relatives. METHODS CASCADE is a longitudinal study using surveys (online or paper/pencil) and focus groups, designed to elicit factors that enhance cascade genetic testing for HBOC and LS in Switzerland. Repeated observations are the optimal way for assessing these outcomes. Focus groups will examine barriers in patient-provider and patient-family communication, and the acceptability of a family-based communication, coping, and decision-support intervention. The survey will be developed in English, translated into three languages (German, French, and Italian), and back-translated into English, except for scales with validated versions in these languages. RESULTS Descriptive analyses will include calculating means, standard deviations, frequencies, and percentages of variables and participant descriptors. Bivariate analyses (Pearson correlations, chi-square test for differences in proportions, and t test for differences in means) will assess associations between demographics and clinical characteristics. Regression analyses will incorporate generalized estimating equations for pairing index cases with their relatives and explore whether predictors are in direct, mediating, or moderating relationship to an outcome. Focus group data will be transcribed verbatim and analyzed for common themes. CONCLUSIONS Robust evidence from basic science and descriptive population-based studies in Switzerland support the necessity of cascade screening for genetic predisposition to HBOC and LS. CASCADE is designed to address translation of this knowledge into public health interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT03124212; https://clinicaltrials.gov/ct2/show/NCT03124212 (Archived by WebCite at http://www.webcitation.org/6tKZnNDBt).
Collapse
Affiliation(s)
- Maria C Katapodi
- Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland.,University of Michigan School of Nursing, Ann Arbor, MI, United States
| | - Valeria Viassolo
- Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Christos Nikolaidis
- Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Nicole Buerki
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Rossella Graffeo
- Institute of Oncology (IOSI) and Breast Unit (CSSI) of Southern Switzerland, Bellinzona, Switzerland
| | - Henrik Csaba Horváth
- University Clinic for Visceral Surgery and Medicine, Inselspital Bern, Bern, Switzerland
| | - Christian Kurzeder
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuela Rabaglio
- University Clinic for Medical Oncology, Inselspital Bern, Bern, Switzerland
| | - Michael Scharfe
- Clinical Trials Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Corinne Urech
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias E Erlanger
- Clinical Trials Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Karl Heinimann
- Medical Genetics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Olivia Pagani
- Institute of Oncology (IOSI) and Breast Unit (CSSI) of Southern Switzerland, Bellinzona, Switzerland
| | - Pierre O Chappuis
- Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland.,Division of Genetic Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| |
Collapse
|
32
|
Keogh LA, Niven H, Rutstein A, Flander L, Gaff C, Jenkins M. Choosing not to undergo predictive genetic testing for hereditary colorectal cancer syndromes: expanding our understanding of decliners and declining. J Behav Med 2017; 40:583-594. [PMID: 28197815 PMCID: PMC6057776 DOI: 10.1007/s10865-016-9820-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 12/26/2016] [Indexed: 12/23/2022]
Abstract
While medical research continues to investigate the genetic basis of cancer, and personalised prevention gains momentum, little research has been conducted with the individuals who decline predictive genetic testing for cancer. We recruited individuals who had been offered genetic testing for Lynch syndrome or bi-allelic MUTYH mutations due to their participation in a large, population-based, Australia-wide colorectal cancer study. Thirty-three individuals in mutation-carrying families, unaffected by cancer, who had actively or passively declined testing at one of four decision-making points, took part in a qualitative interview about their decision. Data analysis revealed a typology of 'decliners': (1) uninformed about genetic testing; (2) a weak intention to undergo genetic testing; (3) conditionally declining; and (4) unconditionally declining testing. In this population we found substantial barriers to achieving the benefits promised by predictive genetic testing; a lack of knowledge of the availability of genetic testing; a lack of trust in genetic test information; a desire to see a stronger benefit from genetic testing before proceeding; and a sense that there may be more negative than positive outcomes from genetic testing. These discourses must be addressed if medical research on the genetic basis of cancer continues to be funded, and personalised prevention of cancer continues to be recommended by experts.
Collapse
Affiliation(s)
- Louise A Keogh
- Gender and Women's Health Unit, Centre for Health Equity, Melbourne School of Population and Global health, The University of Melbourne, 207 Bouverie St, Carlton, Melbourne, VIC, 3010, Australia.
| | - Heather Niven
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Alison Rutstein
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Louisa Flander
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Clara Gaff
- Walter and Eliza Hall Institute, Melbourne, VIC, Australia
| | - Mark Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
33
|
West KM, Burke W, Korngiebel DM. Identifying "ownership" through role descriptions to support implementing universal colorectal cancer tumor screening for Lynch syndrome. Genet Med 2017; 19:1236-1244. [PMID: 28471433 PMCID: PMC5671377 DOI: 10.1038/gim.2017.39] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/08/2017] [Indexed: 12/31/2022] Open
Abstract
Purpose Lynch Syndrome cases are under-identified, and universal colorectal cancer tumor screening for Lynch Syndrome (UTS) has been recommended. UTS implementation is challenging and few successful examples exist to date, and colorectal cancer patients and at-risk family members exhibit low uptake of genetic services. This study sought to identify the elements that could guide the choice of specialties to implement UTS through three main stages: initiating the screen, returning positive screen results, and providing follow-up. Methods To understand stakeholder views on the UTS process, twenty semi-structured interviews were conducted with clinicians from six medical specialties crucial for implementing UTS. Data were analyzed using directed content analysis and additional thematic analysis across content categories. Results Several clinical specialties could fill necessary roles at each of the main stages of UTS implementation. Participants suggested owners based on attributes of specialty roles, clinical settings, and the routes patients take through the system. Conclusion UTS is considered possible in a range of healthcare settings, with tailoring. Health systems need to choose who best fills the role’s needs based on local resources and processes. These results offer implementation guidance based on role needs, not clinical specialty, in resolving the issue of UTS “ownership.”
Collapse
Affiliation(s)
- Kathleen M West
- Department of Bioethics and Humanities, Institute for Public Health Genetics, University of Washington, Seattle, Washington, USA
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Diane M Korngiebel
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington, USA
| |
Collapse
|
34
|
Yamano T, Hamanaka M, Babaya A, Kimura K, Kobayashi M, Fukumoto M, Tsukamoto K, Noda M, Matsubara N, Tomita N, Sugihara K. Management strategies in Lynch syndrome and familial adenomatous polyposis: a national healthcare survey in Japan. Cancer Sci 2017; 108:243-249. [PMID: 27870147 PMCID: PMC5329156 DOI: 10.1111/cas.13123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/06/2016] [Accepted: 11/17/2016] [Indexed: 12/14/2022] Open
Abstract
Lynch syndrome (LS) and familial adenomatous polyposis (FAP) are major sources of hereditary colorectal cancer (CRC) and are associated with other malignancies. There is some heterogeneity in management strategies in Japan. We undertook a survey of management of hereditary CRC in hospitals that are members of the Japan Society of Colorectal Cancer Research. One hundred and ninety departments responded, of which 127 were from designated cancer care hospitals (DCCHs) according to the Japanese government. There were 25 488 operations for CRC in these departments in 2015. The DCCHs performed better with regard to usage of Japan Society of Colorectal Cancer Research guidelines, referring new CRC patients for LS screening, and having in‐house genetic counselors and knowledge of treatment for LS. There were 174 patients diagnosed with LS and 602 undergoing follow‐up in 2011–2015, which is fewer than the number expected from CRC operations in 2015. These numbers were not affected by whether the institution was a DCCH. Universal screening for LS was carried out in 8% of the departments. In contrast, 541 patients were diagnosed with FAP and 273 received preventive proctocolectomy/colectomy in 2011–2015. The DCCH departments undertook more surgery than non‐DCCH departments, although most of the management, including surgical procedures and use of non‐steroidal anti‐inflammatory drugs, was similar. Management of desmoid tumor in the abdominal cavity differed according to the number of patients treated. In conclusion, there was heterogeneity in management of LS but not FAP. Most patients with LS may be overlooked and universal screening for LS is not common in Japan.
Collapse
Affiliation(s)
- Tomoki Yamano
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Michiko Hamanaka
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akihito Babaya
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masayoshi Kobayashi
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Miki Fukumoto
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kiyoshi Tsukamoto
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masafumi Noda
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nagahide Matsubara
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naohiro Tomita
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | |
Collapse
|
35
|
Abstract
Colorectal cancer affects about 4.4% of the population and is a leading cause of cancer-related death in the United States. Approximately 10% to 20% of cases occur within a familial pattern, and Lynch syndrome is the most common hereditary colorectal cancer syndrome. Lynch syndrome is a hereditary predisposition to forming colorectal and extracolonic cancers, caused by a germline mutation in one of the DNA mismatch repair genes. Identifying at-risk patients and making a correct diagnosis are the keys to successful screening and interventions which will decrease formation of and death from cancers. Knowledge of the genetics and the natural history of Lynch syndrome has continued to be uncovered in recent years, leading to a better grasp on how these patients and their families should be managed. Recent developments include the approach to diagnostic testing, more precise definitions of the syndrome and risk stratification based on gene mutations, surgical decision-making, and chemoprevention.
Collapse
Affiliation(s)
- Sherief Shawki
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
36
|
Parikh AR, Keating NL, Liu PH, Gray SW, Klabunde CN, Kahn KL, Haggstrom DA, Syngal S, Kim B. Oncologists' Selection of Genetic and Molecular Testing in the Evolving Landscape of Stage II Colorectal Cancer. J Oncol Pract 2016; 12:e308-19, 259-60. [PMID: 26962170 DOI: 10.1200/jop.2015.007062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Little is known about the roles of genetic and molecular testing and Lynch syndrome screening in the formulation of predictive and prognostic assessments for patients with stage II colorectal cancer (CRC). METHODS From 2012 to 2013, we surveyed medical oncologists in the Cancer Care Outcomes Research and Surveillance Consortium and evaluated oncologists' selection of microsatellite instability (MSI) and/or immunohistochemistry (IHC) for mismatch repair (MMR) proteins, germline testing for MMR genes, BRAF and KRAS mutation analysis, and Oncotype DX in stage II CRC. Physicians were randomly assigned to receive one of three vignettes that varied by strength of CRC family history. We used multivariable logistic regression to identify physician and practice characteristics associated with test selection. RESULTS Among 327 oncologists, MSI and/or IHC for MMR proteins were most frequently selected (n = 205; 64%), with 82% versus 53% choosing MSI/IHC testing in patients with strong versus no CRC family history, respectively (adjusted odds ratio [OR], 3.87; 95% CI, 2.07 to 7.22). KRAS and Oncotype DX testing were chosen by 24% and 38% of oncologists, respectively. Graduates of non-US and Canadian medical schools and physicians compensated by fee-for-service or on the basis of productivity were more likely to choose KRAS testing versus those receiving salaries not on the basis of productivity (OR, 2.16; 95% CI, 1.17 to 3.99; and OR, 1.94; 95% CI, 1.02 to 3.66, respectively). Fee-for-service or productivity-based salaries were also associated with increased odds of Oncotype DX testing (OR, 2.04; 95% CI, 1.17 to 3.55). CONCLUSION Among surveyed oncologists, we found undertesting and overtesting related to genetic and molecular testing and Lynch syndrome screening for patients with stage II CRC,highlighting the need for improved implementation, targeted education, and evaluation of organizational and financial arrangements to promote the appropriate use of such tests.
Collapse
Affiliation(s)
- Aparna R Parikh
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Nancy L Keating
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Pang-Hsiang Liu
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Stacy W Gray
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Carrie N Klabunde
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Katherine L Kahn
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - David A Haggstrom
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Sapna Syngal
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin Kim
- University of California, San Francisco, San Francisco; University of California, Los Angeles, Los Angeles; RAND Corporation, Santa Monica, CA; Harvard Medical School; Brigham and Women's Hospital; Dana-Farber Cancer Institute, Boston, MA; National Institutes of Health, Bethesda, MD; Richard L. Roudebush Veterans Affairs Medical Center; and Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
37
|
Cragun D, Pal T, Vadaparampil ST, Baldwin J, Hampel H, DeBate RD. Qualitative Comparative Analysis: A Hybrid Method for Identifying Factors Associated with Program Effectiveness. JOURNAL OF MIXED METHODS RESEARCH 2016; 10:251-272. [PMID: 27429602 PMCID: PMC4941817 DOI: 10.1177/1558689815572023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Qualitative comparative analysis (QCA) was developed over 25 years ago to bridge the qualitative and quantitative research gap. Upon searching PubMed and the Journal of Mixed Methods Research, this review identified 30 original research studies that utilized QCA. Perceptions that QCA is complex and provides few relative advantages over other methods may be limiting QCA adoption. Thus, to overcome these perceptions, this article demonstrates how to perform QCA using data from fifteen institutions that implemented universal tumor screening (UTS) programs to identify patients at high risk for hereditary colorectal cancer. In this example, QCA revealed a combination of conditions unique to effective UTS programs. Results informed additional research and provided a model for improving patient follow-through after a positive screen.
Collapse
Affiliation(s)
| | - Tuya Pal
- Moffitt Cancer Center, Tampa, FL, USA
| | | | | | | | | |
Collapse
|
38
|
Djordjevic B, Broaddus RR. Laboratory Assays in Evaluation of Lynch Syndrome in Patients with Endometrial Carcinoma. Surg Pathol Clin 2016; 9:289-99. [PMID: 27241109 DOI: 10.1016/j.path.2016.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This article reviews the main tissue testing modalities for Lynch Syndrome in the pathology laboratory, such as immunohistochemistry and PCR based analyses, and discusses their routine application, interpretation pitfalls, and troubleshooting of common technical performance issues. Discrepancies between laboratory and genetic testing may arise, and are examined in the context of the complexity of molecular abnormalities associated with Lynch Syndrome. The merits of targeted versus universal screening in a changing healthcare climate are addressed. In the absence of comprehensive screening programs, specific tumor topography and histological features that may prompt pathologist-initiated molecular tumor testing are outlined.
Collapse
Affiliation(s)
- Bojana Djordjevic
- Department of Pathology and Laboratory Medicine, University of Ottawa, The Ottawa Hospital, Eastern Ontario Regional Laboratory, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
| | - Russell R Broaddus
- Department of Pathology, Unit 85, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| |
Collapse
|
39
|
Vindigni SM, Kaz AM. Universal Screening of Colorectal Cancers for Lynch Syndrome: Challenges and Opportunities. Dig Dis Sci 2016; 61:969-76. [PMID: 26602911 DOI: 10.1007/s10620-015-3964-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/06/2015] [Indexed: 12/20/2022]
Abstract
Lynch syndrome (LS) is the most common heritable colorectal cancer (CRC) syndrome, accounting for approximately 3 % of CRC cases in the USA each year. LS results from a genetic mutation in one of the four mismatch repair genes, and clinically LS is associated with CRC and other gastrointestinal and extra-gastrointestinal malignancies. In this review, we describe the various clinical criteria utilized for the identification of LS patients and the inherent flaws with these criteria. We discuss the concept of universal testing for LS in all cases of newly diagnosed CRC, along with the potential benefits and challenges of universal testing. Several studies have shown that universal tumor testing is cost-effective and identifies cases of LS that are missed using traditional clinical criteria, which may result in reduced cancer mortality for probands and their families. Yet the full benefits of universal tumor testing may be limited by the availability and patient acceptance of genetic testing, and by logistical obstacles affecting the implementation of universal testing programs. Lastly, we comment on developing technologies such as massively parallel next-generation sequencing, which permits simultaneous sequencing of multiple genes involved in LS and other inherited colon cancer syndromes.
Collapse
Affiliation(s)
- Stephen M Vindigni
- Division of Gastroenterology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356424, Seattle, WA, 98105, USA
| | - Andrew M Kaz
- Division of Gastroenterology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356424, Seattle, WA, 98105, USA. .,VA Puget Sound Health Care System, 1660 S. Columbian Way, S-111-Gastro, Seattle, WA, 98108, USA.
| |
Collapse
|
40
|
Schneider JL, Davis J, Kauffman TL, Reiss JA, McGinley C, Arnold K, Zepp J, Gilmore M, Muessig KR, Syngal S, Acheson L, Wiesner GL, Peterson SK, Goddard KAB. Stakeholder perspectives on implementing a universal Lynch syndrome screening program: a qualitative study of early barriers and facilitators. Genet Med 2016; 18:152-61. [PMID: 25880440 PMCID: PMC4608844 DOI: 10.1038/gim.2015.43] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/23/2015] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Evidence-based guidelines recommend that all newly diagnosed colon cancer be screened for Lynch syndrome (LS), but best practices for implementing universal tumor screening have not been extensively studied. We interviewed a range of stakeholders in an integrated health-care system to identify initial factors that might promote or hinder the successful implementation of a universal LS screening program. METHODS We conducted interviews with health-plan leaders, managers, and staff. Interviews were audio-recorded and transcribed. Thematic analysis began with a grounded approach and was also guided by the Practical Robust Implementation and Sustainability Model (PRISM). RESULTS We completed 14 interviews with leaders/managers and staff representing involved clinical and health-plan departments. Although stakeholders supported the concept of universal screening, they identified several internal (organizational) and external (environment) factors that promote or hinder implementation. Facilitating factors included perceived benefits of screening for patients and organization, collaboration between departments, and availability of organizational resources. Barriers were also identified, including: lack of awareness of guidelines, lack of guideline clarity, staffing and program "ownership" concerns, and cost uncertainties. Analysis also revealed nine important infrastructure-type considerations for successful implementation. CONCLUSION We found that clinical, laboratory, and administrative departments supported universal tumor screening for LS. Requirements for successful implementation may include interdepartmental collaboration and communication, patient and provider/staff education, and significant infrastructure and resource support related to laboratory processing and systems for electronic ordering and tracking.
Collapse
Affiliation(s)
| | - James Davis
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Jacob A Reiss
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Cheryl McGinley
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Kathleen Arnold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Jamilyn Zepp
- Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Marian Gilmore
- Northwest Permanente, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Kristin R Muessig
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Louise Acheson
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Georgia L Wiesner
- Vanderbilt Hereditary Cancer Program, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - Susan K Peterson
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katrina A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| |
Collapse
|
41
|
Expert and Advocacy Group Consensus Findings on the Horizon of Public Health Genetic Testing. Healthcare (Basel) 2016; 4:healthcare4010014. [PMID: 27417602 PMCID: PMC4934548 DOI: 10.3390/healthcare4010014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/18/2015] [Accepted: 01/18/2016] [Indexed: 12/30/2022] Open
Abstract
Description: Among the two leading causes of death in the United States, each responsible for one in every four deaths, heart disease costs Americans $300 billion, while cancer costs Americans $216 billion per year. They also rank among the top three causes of death in Europe and Asia. In 2012 the University of Michigan Center for Public Health and Community Genomics and Genetic Alliance, with the support of the Centers for Disease Control and Prevention Office of Public Health Genomics, hosted a conference in Atlanta, Georgia to consider related action strategies based on public health genomics. The aim of the conference was consensus building on recommendations to implement genetic screening for three major heritable contributors to these mortality and cost figures: hereditary breast and ovarian cancer (HBOC), familial hypercholesterolemia (FH), and Lynch syndrome (LS). Genetic applications for these three conditions are labeled with a “Tier 1” designation by the U.S. Centers for Disease Control and Prevention because they have been fully validated and clinical practice guidelines based on systematic review support them. Methodology: The conference followed a deliberative sequence starting with nationally recognized clinical and public health presenters for each condition, followed by a Patient and Community Perspectives Panel, working group sessions for each of the conditions, and a final plenary session. The 74 conference participants represented disease research and advocacy, public health, medicine and nursing, genetics, governmental health agencies, and industry. Participants drew on a public health framework interconnecting policy, clinical intervention, surveillance, and educational functions for their deliberations. Results: Participants emphasized the importance of collaboration between clinical, public health, and advocacy groups in implementing Tier 1 genetic screening. Advocacy groups could help with individual and institutional buy-in of Tier 1 programs. Groups differed on funding strategies, with alternative options such as large-scale federal funding and smaller scale, incremental funding solutions proposed. Piggybacking on existing federal breast and colorectal cancer control programs was suggested. Public health departments need to assess what information is now being collected by their state cancer registries. The groups advised that information on cascade screening of relatives be included in toolkits for use by states. Participants stressed incorporation of family history into health department breast cancer screening programs, and clinical HBOC data into state surveillance systems. The carrying out of universal LS screening of tumors in those with colorectal cancer was reviewed. Expansion of universal screening to include endometrial tumors was discussed, as was the application of guidelines recommending cholesterol screening of children 9–11 years old. States more advanced in terms of Tier 1 testing could serve as models and partners with other states launching screening and surveillance programs. A multidisciplinary team of screening program champions was suggested as a means of raising awareness among the consumer and health care communities. Participants offered multiple recommendations regarding use of electronic health records, including flagging of at-risk family members and utilization of state-level health information exchanges. The paper contains an update of policy developments and happenings for all three Tier 1 conditions, as well as identified gaps. Conclusions: Implementation of cascade screening of family members for HBOC and FH, and universal screening for LS in CRC tumors has reached a point of readiness within the U.S., with creative solutions at hand. Facilitating factors such as screening coverage through the Patient Protection and Affordable Care Act, and state health information exchanges can be tapped. Collaboration is needed between public health departments, health care systems, disease advocacy groups, and industry to fully realize Tier 1 genetic screening. State health department and disease networks currently engaged in Tier 1 screening can serve as models for the launch of new initiatives.
Collapse
|
42
|
Cragun D, Lewis C, Camperlengo L, Pal T. Hereditary Cancer: Example of a Public Health Approach to Ensure Population Health Benefits of Genetic Medicine. Healthcare (Basel) 2016; 4:healthcare4010006. [PMID: 27417594 PMCID: PMC4934540 DOI: 10.3390/healthcare4010006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/17/2015] [Accepted: 01/06/2016] [Indexed: 11/16/2022] Open
Abstract
This article introduces the identification, prevention, and treatment of hereditary cancer as an important public health concern. Hereditary cancer research and educational outreach activities are used to illustrate how public health functions can help to achieve health benefits of genetic and genomic medicine. First, we evaluate genetic service delivery through triangulating patient and provider survey results which reveal variability among providers in hereditary cancer knowledge and genetic service provision. Second, we describe efforts we have made to assure competency among healthcare providers and to inform, educate and empower patients with regard to the rapidly evolving field of genomics and hereditary cancer. Lastly, key policy-issues raised by our experiences are discussed in the context of how they may help us to more effectively translate future genomic technologies into practice in order to attain population health benefits from genetic and genomic medicine.
Collapse
Affiliation(s)
- Deborah Cragun
- College of Public Health, Department of Global Health, University of South Florida, Tampa, FL 33620, USA.
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| | - Courtney Lewis
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| | | | - Tuya Pal
- Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| |
Collapse
|
43
|
Volmar KE, Idowu MO, Souers RJ, Nakhleh RE. Molecular Testing in Anatomic Pathology and Adherence to Guidelines: A College of American Pathologists Q-Probes Study of 2230 Testing Events Reported by 26 Institutions. Arch Pathol Lab Med 2015; 139:1115-24. [PMID: 26317453 DOI: 10.5858/arpa.2014-0513-cp] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The appropriate and timely performance of molecular testing in anatomic pathology is an indicator of quality. The National Comprehensive Cancer Network (NCCN) publishes a comprehensive treatment guideline that includes recommendations for ancillary testing. OBJECTIVE To establish benchmarks for rates of adherence to NCCN testing recommendations through a multi-institutional study. DESIGN Participants in a 2013 Q-Probes study of the College of American Pathologists reported data from molecular testing on anatomic pathology cases, excluding hematolymphoid neoplasms, breast primary carcinomas, and gynecologic cytology. RESULTS Twenty-six institutions reported data from 2230 molecular testing events. In a retrospective study limited to colon, lung, and melanoma, there was strict adherence to guidelines in a median 71% (10th to 90th percentile range, 33%-90%) and there was at least loose adherence in a median 95% (10th to 90th percentile range, 57%-100%). There was adequate tissue to complete testing in a median 98% (10th to 90th percentile range, 86%-100%); in aggregate the adequacy rate for cell blocks was lower (84%, P < .001). Median test turnaround time was 8 days (10th to 90th percentile range, 4-13 days). In a prospective collection of all organ sites, there was strict adherence to guidelines in a median 53% (10th to 90th percentile range, 20%-71%), and there was at least loose adherence in a median 94% (10th to 90th percentile range, 75%-100%). Adherence to guidelines was higher for lung specimens and in institutions with more multidisciplinary conferences. CONCLUSIONS This multi-institutional study provides benchmarking data on appropriateness and timeliness of molecular testing in anatomic pathology.
Collapse
Affiliation(s)
| | | | | | - Raouf E Nakhleh
- From the Department of Pathology, Rex Pathology Associates, Raleigh, North Carolina (Dr Volmar); the Department of Pathology, Virginia Commonwealth University, Richmond (Dr Idowu); the Department of Biostatistics, College of American Pathologists, Northfield, Illinois (Ms Souers); and the Department of Pathology, Mayo Clinic Jacksonville, Jacksonville, Florida (Dr Nakhleh)
| |
Collapse
|
44
|
Grosse SD. When is Genomic Testing Cost-Effective? Testing for Lynch Syndrome in Patients with Newly-Diagnosed Colorectal Cancer and Their Relatives. Healthcare (Basel) 2015; 3:860-78. [PMID: 26473097 PMCID: PMC4604059 DOI: 10.3390/healthcare3040860] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Varying estimates of the cost-effectiveness of genomic testing applications can reflect differences in study questions, settings, methods and assumptions. This review compares recently published cost-effectiveness analyses of testing strategies for Lynch Syndrome (LS) in tumors from patients newly diagnosed with colorectal cancer (CRC) for either all adult patients or patients up to age 70 along with cascade testing of relatives of probands. Seven studies published from 2010 through 2015 were identified and summarized. Five studies analyzed the universal offer of testing to adult patients with CRC and two others analyzed testing patients up to age 70; all except one reported incremental cost-effectiveness ratios (ICERs) < $ 100,000 per life-year or quality-adjusted life-year gained. Three studies found lower ICERs for selective testing strategies using family history-based predictive models compared with universal testing. However, those calculations were based on estimates of sensitivity of predictive models derived from research studies, and it is unclear how sensitive such models are in routine clinical practice. Key model parameters that are influential in ICER estimates included 1) the number of first-degree relatives tested per proband identified with LS and 2) the cost of gene sequencing. Others include the frequency of intensive colonoscopic surveillance, the cost of colonoscopy, and the inclusion of extracolonic surveillance and prevention options.
Collapse
Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA; Tel.: +404-498-3074
| |
Collapse
|
45
|
Richman S. Deficient mismatch repair: Read all about it (Review). Int J Oncol 2015; 47:1189-202. [PMID: 26315971 PMCID: PMC4583524 DOI: 10.3892/ijo.2015.3119] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022] Open
Abstract
Defects in the DNA mismatch repair (MMR) proteins, result in a phenotype called microsatellite instability (MSI), occurring in up to 15% of sporadic colorectal cancers. Approximately one quarter of colon cancers with deficient MMR (dMMR) develop as a result of an inherited predisposition syndrome, Lynch syndrome (formerly known as HNPCC). It is essential to identify patients who potentially have Lynch syndrome, as not only they, but also family members, may require screening and monitoring. Diagnostic criteria have been developed, based primarily on Western populations, and several methodologies are available to identify dMMR tumours, including immunohistochemistry and microsatellite testing. These criteria have provided evidence supporting the introduction of reflex testing. Yet, it is becoming increasingly clear that tests have a limited sensitivity and specificity and may yet be superseded by next generation sequencing. In this review, the limitations of diagnostic criteria are discussed, and current and emerging screening technologies explained. There is now useful evidence supporting the prognostic and predictive value of dMMR status in colorectal tumours, but much less is known about their value in extracolonic tumours, that may also feature in Lynch syndrome. This review assesses current literature relating to dMMR in endometrial, ovarian, gastric and melanoma cancers, which it would seem, may benefit from large-scale clinical trials in order to further close the gap in knowledge between colorectal and extracolonic tumours.
Collapse
Affiliation(s)
- Susan Richman
- Department of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, St. James University Hospital, Leeds, LS9 7TF, UK
| |
Collapse
|
46
|
Preferences for genetic testing for colorectal cancer within a population-based screening program: a discrete choice experiment. Eur J Hum Genet 2015; 24:361-6. [PMID: 26036860 DOI: 10.1038/ejhg.2015.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 12/17/2022] Open
Abstract
This study explored individuals' preferences for genetic testing for colorectal cancer (CRC) in a screening situation and their willingness to participate in genetic testing for Lynch syndrome, familial adenomatous polyposis (FAP), and familial colorectal cancer (FCC). For that purpose, 532 respondents aged 55-65 years completed a Discrete Choice Experiment. Using panel latent class models, the preferences for two screening situation characteristics (the probability of being genetically predisposed and the probability of developing CRC) and screening test characteristics (the frequency of preventive colonoscopies and CRC survival) were estimated. Based on these preferences, respondents' willingness to participate in the three screening initiatives was estimated. Lower-educated respondents and respondents who express serious anxiety and worries found colonoscopy frequency and the probability of developing CRC relatively more important and survival relatively less important compared with higher-educated respondents and respondents who express no anxiety and worries. These differences in preferences resulted in opposite preferences for participation in FCC and FAP screening. In conclusion, the general population is willing to participate in genetic screening for CRC. If individuals are suspected of genetic or familial CRC, they should at least be informed about their increased risk of being genetically predisposed and about the importance of participating in all preventive follow-up colonoscopies in order to maximize survival.
Collapse
|
47
|
Reflex testing for Lynch syndrome: if we build it, will they come? Lessons learned from the uptake of clinical genetics services by individuals with newly diagnosed colorectal cancer (CRC). Fam Cancer 2015; 13:75-82. [PMID: 24002367 PMCID: PMC3927060 DOI: 10.1007/s10689-013-9677-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this qualitative study was to examine the experience of individuals facing a choice about genetic counselling/testing in the context of newly diagnosed colorectal cancer (CRC). Nineteen individuals with newly diagnosed CRC, including 12 individuals who accepted genetic counselling (“acceptors”) and 7 individuals who declined genetic counselling (“refusers”), were interviewed using a standardized questionnaire guide which focused on motivations and barriers experienced in the decision process. Data were analyzed using Karlsson’s Empirical Phenomenological method of data analysis (Karlsson in Psychological qualitative research from a phenomenological perspective. Almgvist and Wiksell International, Stockholm, 1993). Three major themes were identified: facing challenges in health literacy; mapping an unknown territory; and adjusting to cancer. The study participants’ testimonies provided novel insights into potential reasons for patient non-engagement in pilot studies of reflex testing for Lynch syndrome, and allowed us to formulate several recommendations for enhancing patient engagement. Our study findings suggest that patient engagement in clinical cancer genetics services, including reflex testing for Lynch syndrome, can only be achieved by addressing current health literacy issues, by deconstructing current misconceptions related to potential abuses of genetic information, by emphasizing the clinical utility of genetic assessment, and by adapting genetics practices to the specific context of cancer care.
Collapse
|
48
|
A single institution experience in compliance with universal screening for Lynch syndrome in colorectal cancer. J Gastrointest Surg 2015; 19:543-50. [PMID: 25504462 DOI: 10.1007/s11605-014-2687-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/21/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Detection of Lynch syndrome has the potential to reduce morbidity and mortality among patients and their family members due to beneficial screening and treatment options. Several institutions have begun to adopt universal rather than risk-stratified screening protocols, but the lack of 100 % compliance rates requires identification of system-level interventions to improve screening practices. OBJECTIVE We aimed to identify patient, tumor, and system factors associated with lack of screening and identify system-based interventions to improve Lynch syndrome screening. DESIGN AND SETTINGS This study is a retrospective analysis of Lynch syndrome screening among colorectal cancer patients undergoing surgery in a single healthcare system. PATIENTS Two hundred and sixty-two patients who underwent surgery for colorectal cancer were studied. MAIN OUTCOME MEASURES Rate of Lynch syndrome screening. RESULTS We identified that 75 % of the total cohort was screened for Lynch syndrome. Of patients under the age of 50, 78 % percent were screened. Lower screening rates were found among patients with complete pathologic tumor response and lower pathologic stage of tumor. Higher screening rates were found at the academic hospital and with colorectal surgeons. In multivariable logistic regression analysis, lower screening rates were associated with community hospital location (OR, 0.22; 95 % CI, 0.08-0.56). LIMITATIONS Results may not be generalizable to different hospital settings. CONCLUSIONS Several potential system-level interventions were identified to improve screening rates including an emphasis on improved provider communication.
Collapse
|
49
|
Hereditary colorectal cancer: more common than you think. Curr Probl Cancer 2014; 38:249-61. [PMID: 25497411 DOI: 10.1016/j.currproblcancer.2014.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
50
|
Establishing a clinical and molecular diagnosis for hereditary colorectal cancer syndromes: Present tense, future perfect? Gastrointest Endosc 2014; 80:1145-55. [PMID: 25434663 DOI: 10.1016/j.gie.2014.07.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 07/23/2014] [Indexed: 02/08/2023]
|