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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.
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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
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2
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Underkofler KA, Ring KL. Updates in gynecologic care for individuals with lynch syndrome. Front Oncol 2023; 13:1127683. [PMID: 36937421 PMCID: PMC10014618 DOI: 10.3389/fonc.2023.1127683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/16/2023] [Indexed: 03/05/2023] Open
Abstract
Lynch syndrome is an autosomal dominant hereditary cancer syndrome caused by germline pathogenic variants (PVs) in DNA mismatch repair genes (MLH1, MSH2, PMS2, MSH6) or the EPCAM gene. It is estimated to affect 1 in 300 individuals and confers a lifetime risk of cancer of 10-90%, depending on the specific variant and type of cancer. Lynch syndrome is the most common cause of inherited colorectal cancer, but for women, endometrial cancer is more likely to be the sentinel cancer. There is also evidence that certain PVs causing Lynch syndrome confer an increased risk of ovarian cancer, while the risk of ovarian cancer in others is not well defined. Given this, it is essential for the practicing gynecologist and gynecologic oncologist to remain up to date on the latest techniques in identification and diagnosis of individuals with Lynch syndrome as well as evidence-based screening and risk reduction recommendations for those impacted. Furthermore, as the landscape of gynecologic cancer treatment shifts towards treatment based on molecular classification of tumors, knowledge of targeted therapies well-suited for mismatch repair deficient Lynch tumors will be crucial. The objective of this review is to highlight recent updates in the literature regarding identification and management of individuals with Lynch syndrome as it pertains to endometrial and ovarian cancers to allow gynecologic providers the opportunity to both prevent and identify Lynch-associated cancers earlier, thereby reducing the morbidity and mortality of the syndrome.
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Bartley AN, Mills AM, Konnick E, Overman M, Ventura CB, Souter L, Colasacco C, Stadler ZK, Kerr S, Howitt BE, Hampel H, Adams SF, Johnson W, Magi-Galluzzi C, Sepulveda AR, Broaddus RR. Mismatch Repair and Microsatellite Instability Testing for Immune Checkpoint Inhibitor Therapy: Guideline From the College of American Pathologists in Collaboration With the Association for Molecular Pathology and Fight Colorectal Cancer. Arch Pathol Lab Med 2022; 146:1194-1210. [PMID: 35920830 DOI: 10.5858/arpa.2021-0632-cp] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The US Food and Drug Administration (FDA) approved immune checkpoint inhibitor therapy for patients with advanced solid tumors that have DNA mismatch repair defects or high levels of microsatellite instability; however, the FDA provided no guidance on which specific clinical assays should be used to determine mismatch repair status. OBJECTIVE.— To develop an evidence-based guideline to identify the optimal clinical laboratory test to identify defects in DNA mismatch repair in patients with solid tumor malignancies who are being considered for immune checkpoint inhibitor therapy. DESIGN.— The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Using the National Academy of Medicine-endorsed Grading of Recommendations Assessment, Development and Evaluation approach, the recommendations were derived from available evidence, strength of that evidence, open comment feedback, and expert panel consensus. Mismatch repair immunohistochemistry, microsatellite instability derived from both polymerase chain reaction and next-generation sequencing, and tumor mutation burden derived from large panel next-generation sequencing were within scope. RESULTS.— Six recommendations and 3 good practice statements were developed. More evidence and evidence of higher quality were identified for colorectal cancer and other cancers of the gastrointestinal (GI) tract than for cancers arising outside the GI tract. CONCLUSIONS.— An optimal assay depends on cancer type. For most cancer types outside of the GI tract and the endometrium, there was insufficient published evidence to recommend a specific clinical assay. Absent published evidence, immunohistochemistry is an acceptable approach readily available in most clinical laboratories.
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Affiliation(s)
- Angela N Bartley
- From the Department of Pathology, St. Joseph Mercy Hospital, Ann Arbor, Michigan (Bartley)
| | - Anne M Mills
- From the Department of Pathology, University of Virginia, Charlottesville (Mills)
| | - Eric Konnick
- From the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (Konnick)
| | - Michael Overman
- From the Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston (Overman)
| | - Christina B Ventura
- From Surveys, College of American Pathologists, Northfield, Illinois (Ventura, Colasacco)
| | - Lesley Souter
- From Methodology Consultant, Smithville, Ontario, Canada (Souter)
| | - Carol Colasacco
- From Surveys, College of American Pathologists, Northfield, Illinois (Ventura, Colasacco)
| | - Zsofia K Stadler
- From the Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (Stadler)
| | - Sarah Kerr
- From Hospital Pathology Associates, PA, Minneapolis, Minnesota (Kerr)
| | - Brooke E Howitt
- From the Department of Pathology, Stanford University, Stanford, California (Howitt)
| | - Heather Hampel
- From the Department of Internal Medicine, The Ohio State University, Columbus (Hampel)
| | - Sarah F Adams
- From the Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque (Adams)
| | - Wenora Johnson
- From Fight Colorectal Cancer, Springfield, Missouri (Johnson)
| | - Cristina Magi-Galluzzi
- From the Department of Pathology, University of Alabama at Birmingham, Birmingham (Magi-Galluzzi)
| | - Antonia R Sepulveda
- From the Department of Pathology, George Washington University, Washington, District of Columbia (Sepulveda)
| | - Russell R Broaddus
- From the Department of Pathology & Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill (Broaddus)
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Heald B, Hampel H, Church J, Dudley B, Hall MJ, Mork ME, Singh A, Stoffel E, Stoll J, You YN, Yurgelun MB, Kupfer SS. Collaborative Group of the Americas on Inherited Gastrointestinal Cancer Position statement on multigene panel testing for patients with colorectal cancer and/or polyposis. Fam Cancer 2021; 19:223-239. [PMID: 32172433 DOI: 10.1007/s10689-020-00170-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Multigene panel tests for hereditary cancer syndromes are increasingly utilized in the care of colorectal cancer (CRC) and polyposis patients. However, widespread availability of panels raises a number of questions including which patients should undergo testing, which genes should be included on panels, and the settings in which panels should be ordered and interpreted. To address this knowledge gap, key questions regarding the major issues encountered in clinical evaluation of hereditary CRC and polyposis were designed by the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer Position Statement Committee and leadership. A literature search was conducted to address these questions. Recommendations were based on the best available evidence and expert opinion. This position statement addresses which genes should be included on a multigene panel for a patient with a suspected hereditary CRC or polyposis syndrome, proposes updated genetic testing criteria, discusses testing approaches for patients with mismatch repair proficient or deficient CRC, and outlines the essential elements for ordering and disclosing multigene panel test results. We acknowledge that critical gaps in access, insurance coverage, resources, and education remain barriers to high-quality, equitable care for individuals and their families at increased risk of hereditary CRC.
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Affiliation(s)
- Brandie Heald
- Sanford R Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.
| | - Heather Hampel
- Division of Human Genetics, Department of Internal Medicine and the Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - James Church
- Sanford R Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Beth Dudley
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Hall
- Department of Clinical Genetics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Maureen E Mork
- Department of Clinical Cancer Genetics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aparajita Singh
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Elena Stoffel
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jessica Stoll
- Gastrointestinal Cancer Risk and Prevention Clinic, University of Chicago, Chicago, IL, USA
| | - Y Nancy You
- Department of Clinical Cancer Genetics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew B Yurgelun
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sonia S Kupfer
- Gastrointestinal Cancer Risk and Prevention Clinic, University of Chicago, Chicago, IL, USA
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5
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Evans DG, Lalloo F, Ryan NA, Bowers N, Green K, Woodward ER, Clancy T, Bolton J, McVey RJ, Wallace AJ, Newton K, Hill J, McMahon R, Crosbie EJ. Advances in genetic technologies result in improved diagnosis of mismatch repair deficiency in colorectal and endometrial cancers. J Med Genet 2021; 59:328-334. [PMID: 33452216 PMCID: PMC8961751 DOI: 10.1136/jmedgenet-2020-107542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 11/04/2022]
Abstract
Background Testing cancers for mismatch repair deficiency (dMMR) by immunohistochemistry (IHC) is a quick and inexpensive means of triaging individuals for germline Lynch syndrome testing. The aim of this study was to evaluate tumour dMMR and the prevalence of Lynch syndrome in patients referred to the Manchester Centre for Genomic Medicine, which serves a population of 5.6 million. Methods Tumour testing used IHC for MMR proteins with targeted BRAF and MLH1 promotor methylation testing followed by germline mutation and somatic testing as appropriate. Results In total, 3694 index tumours were tested by IHC (2204 colorectal cancers (CRCs), 739 endometrial cancers (ECs) and 761 other), of which 672/3694 (18.2%) had protein loss, including 348 (9.4%) with MLH1 loss. MLH1 loss was significantly higher for 739 ECs (15%) vs 2204 CRCs (10%) (p=0.0003) and was explained entirely by higher rates of somatic MLH1 promoter hypermethylation (87% vs 41%, p<0.0001). Overall, 65/134 (48.5%) patients with MLH1 loss and no MLH1 hypermethylation or BRAF c.1799T>A had constitutional MLH1 pathogenic variants. Of 456 patients with tumours showing loss of MSH2/MSH6, 216 (47.3%) had germline pathogenic variants in either gene. Isolated PMS2 loss was most suggestive of a germline MMR variant in 19/26 (73%). Of those with no germline pathogenic variant, somatic testing identified likely causal variants in 34/48 (71%) with MLH1 loss and in MSH2/MSH6 in 40/47 (85%) with MSH2/MSH6 loss. Conclusions Reflex testing of EC/CRC leads to uncertain diagnoses in many individuals with dMMR following IHC but without germline pathogenic variants or MLH1 hypermethylation. Tumour mutation testing is effective at decreasing this by identifying somatic dMMR in >75% of cases.
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Affiliation(s)
- D Gareth Evans
- Division of Evolution and Genomic Medicine, The University of Manchester, Manchester, UK.,Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Fiona Lalloo
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Neil Aj Ryan
- Division of Cancer Sciences, The University of Manchester, Manchester, UK.,Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Naomi Bowers
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Kate Green
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Emma R Woodward
- Division of Evolution and Genomic Medicine, The University of Manchester, Manchester, UK.,Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Tara Clancy
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - James Bolton
- Department of Pathology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Rhona J McVey
- Department of Pathology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Andrew J Wallace
- Clinical Genetics Service, Manchester Centre for Genomic Medicine, North-West Genomics Laboratory Hub, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Katy Newton
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - James Hill
- Department of Surgery, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Raymond McMahon
- Department of Pathology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Emma J Crosbie
- Division of Cancer Sciences, The University of Manchester, Manchester, UK .,Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
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Kunnackal John G, Das Villgran V, Caufield-Noll C, Giardiello FM. Comparison of universal screening in major lynch-associated tumors: a systematic review of literature. Fam Cancer 2021; 21:57-67. [PMID: 33426601 DOI: 10.1007/s10689-020-00226-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/23/2020] [Indexed: 01/13/2023]
Abstract
Lynch syndrome (LS) is associated with an increased lifetime risk of several cancers including colorectal (CRC), endometrial (EC), ovarian (OC), urinary (UT) and sebaceous tumors (ST). The benefit for universal screening in CRC and EC is well known. However, this benefit in other major lynch-associated tumors is unclear. We performed a systematic review of all published articles in the MEDLINE database between 2005 to 2017 to identify studies performing universal screening for LS in unselected CRC, EC, OC, UT and ST. All cases with MSI-H (instability in two or more markers) or missing one or more proteins on IHC testing were considered screening positive. Cases with MLH1 promoter hypermethylation or BRAF mutation positive were considered to have somatic mutations. A total of 3788 articles were identified in MEDLINE yielding 129 study arms from 113 studies. The overall pooled yield of universal LS screening and germline mismatch gene mutation was significantly different across the major LS-associated tumors (Mann Whitney test, p < 0.001). The pooled screening yield was highest in ST [52.5% (355/676), 95% CI 48.74-56.26%] followed by EC [22.65% (1142/5041), 95% CI 21.54-23.86%], CRC [11.9% (5649/47,545), 95% CI 11.61-12.19%], OC [11.29% (320/2833), 95% CI 10.13-12.47%] and UT [11.2% (31/276), 95% CI 7.48-14.92%]. ST also had the highest pooled germline positivity for mismatch repair gene mutation [18.8%, 33/176, 95%CI 13.03-24.57], followed by EC [2.6% (97/3765), 95% CI 2.09-3.11], CRC [1.8% (682/37,220), 95% CI 1.66-1.94%], UT [1.8%(3/164), 95% CI - 0.24-3.83%] and OC [0.83%(25/2983), 95% CI 0.48-1.12%]. LS screening in EC yielded significantly higher somatic mutations compared to CRC [pooled percentage 16.94% [(538/3176), 95%CI 15.60-18.20%] vs. 5.23% [(1639/26,152), 95% CI 4.93-5.47%], Mann Whitney test, p < 0.0001. Universal LS testing should be routinely performed in OC, UT and STs in addition to CRC and EC. Our findings also support consideration for IHC and somatic mutation testing before germline testing in EC due to higher prevalence of somatic mutations as well as germline testing in all patients with ST. Our results have implications for future design of LS screening programs and further studies are needed to assess the cost effectiveness and burden on genetic counselling services with expanded universal testing for LS.
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Affiliation(s)
- George Kunnackal John
- Clinical Assistant Professor, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 511 Idlewild Ave, Easton, MD, 21601, USA.
| | - Vipin Das Villgran
- Pulmonary and Critical Care Fellow, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | | | - Francis M Giardiello
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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Worldwide variation in lynch syndrome screening: case for universal screening in low colorectal cancer prevalence areas. Fam Cancer 2020; 20:145-156. [PMID: 32914371 DOI: 10.1007/s10689-020-00206-0] [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: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
To perform a systematic assessment of universal Lynch syndrome (LS) screening yield in colorectal cancer (CRC) patients around the world. Universal screening for LS is recommended in all CRC patients. However, the variation in yield of LS screening in the setting of significant global variation in CRC prevalence is unknown. A systematic review of articles in the MEDLINE database was performed to identify studies performing universal screening for LS. All cases with microsatellite instability (MSI-H) or missing one or more proteins on immunohistochemistry (IHC) were considered screening positive. The overall pooled yield of universal LS screening in 97 study arms from 89 identified studies was 11.9% (5649/47545) and the overall pooled percentage of confirmed LS patients was 1.8% (682/37220). LS screening positivity varied significantly based on geographic region (Kruskal Wallis test, p < 0.001) and reported 5-year CRC prevalence in the country (Fisher's exact, p < 0.001). Significant inverse correlation was found between LS screening positivity and 5-year CRC prevalence (Pearson correlation, r = - 0.56, p < 0.001). The overall yield of LS screening was 15.00% (382/2553) and rate of confirmed LS was 7.7% (113/1475) in LS screening done in patients ≤ 50 years (16 studies). There is significant geographic variation in LS screening positivity with higher yield in countries with lower prevalence of CRC. Our results highlight the importance of universal LS screening in younger patients and low CRC prevalence countries.
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Abstract
For most individuals, cancer development is multifactorial; however, up to 10% of all cancers are related to an inherited genetic mutation. As health care shifts to having a greater emphasis on prevention, care providers, including general surgeons, will need to play a role in identifying patients at high risk for cancer development. Genetic testing provides a tool to determine those patients with a genetic mutation and to whom appropriate preventive care and treatment may be offered. It is imperative for general surgeons to understand the role genetics plays in the care of individual patients and their relatives.
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Affiliation(s)
- Christine Van Cott
- Department of Surgery, St. Vincent's Medical Center, Bridgeport, CT, USA; Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT, USA.
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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.
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Determination of Mismatch Repair Status in Human Cancer and Its Clinical Significance: Does One Size Fit All? Adv Anat Pathol 2019; 26:270-279. [PMID: 30932972 DOI: 10.1097/pap.0000000000000234] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The clinical management of cancers has progressed rapidly into the immunopathology era, with the unprecedented histology-agnostic approval of pembrolizumab in mismatch repair (MMR) deficient tumors. Despite the significant recent achievements in the treatment of these patients, however, the identification of clinically relevant subclasses of cancers based on the MMR status remains a major challenge. Many investigations have assessed the role of different diagnostic tools, including immunohistochemistry, microsatellite instability, and tumor mutational burden in both prognostic and therapeutic settings, with heterogenous results. To date, there are no tumor-specific guidelines or companion diagnostic tests for MMR assessment, and this analysis is often performed with locally developed methods. In this review, we provide a comprehensive overview of the current state-of-knowledge of MMR alterations in syndromic and sporadic tumors and discuss the available armamentarium for MMR pathologic characterization, from morphology to high-throughput molecular tools.
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Cabreira V, Pinto C, Pinheiro M, Lopes P, Peixoto A, Santos C, Veiga I, Rocha P, Pinto P, Henrique R, Teixeira MR. Performance of Lynch syndrome predictive models in quantifying the likelihood of germline mutations in patients with abnormal MLH1 immunoexpression. Fam Cancer 2017; 16:73-81. [PMID: 27581132 DOI: 10.1007/s10689-016-9926-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Lynch syndrome (LS) accounts for up to 4 % of all colorectal cancers (CRC). Detection of a pathogenic germline mutation in one of the mismatch repair genes is the definitive criterion for LS diagnosis, but it is time-consuming and expensive. Immunohistochemistry is the most sensitive prescreening test and its predictive value is very high for loss of expression of MSH2, MSH6, and (isolated) PMS2, but not for MLH1. We evaluated if LS predictive models have a role to improve the molecular testing algorithm in this specific setting by studying 38 individuals referred for molecular testing and who were subsequently shown to have loss of MLH1 immunoexpression in their tumors. For each proband we calculated a risk score, which represents the probability that the patient with CRC carries a pathogenic MLH1 germline mutation, using the PREMM1,2,6 and MMRpro predictive models. Of the 38 individuals, 18.4 % had a pathogenic MLH1 germline mutation. MMRpro performed better for the purpose of this study, presenting a AUC of 0.83 (95 % CI 0.67-0.9; P < 0.001) compared with a AUC of 0.68 (95 % CI 0.51-0.82, P = 0.09) for PREMM1,2,6. Considering a threshold of 5 %, MMRpro would eliminate unnecessary germline mutation analysis in a significant proportion of cases while keeping very high sensitivity. We conclude that MMRpro is useful to correctly predict who should be screened for a germline MLH1 gene mutation and propose an algorithm to improve the cost-effectiveness of LS diagnosis.
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Affiliation(s)
- Verónica Cabreira
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
- Medical Faculty, University of Porto, Porto, Portugal
| | - Carla Pinto
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Manuela Pinheiro
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Paula Lopes
- Department of Pathology, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Ana Peixoto
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Catarina Santos
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Isabel Veiga
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Patrícia Rocha
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Pedro Pinto
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
| | - Rui Henrique
- Department of Pathology, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal
- Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Manuel R Teixeira
- Department of Genetics, Portuguese Oncology Institute of Porto (IPO Porto), Rua Dr. António Bernardino de Almeida, 4200-072, Porto, Portugal.
- Institute of Biomedical Sciences, University of Porto, Porto, Portugal.
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High-risk family colorectal cancer screening service in Ireland: Critical review of clinical outcomes. Cancer Epidemiol 2017; 50:30-38. [PMID: 28783501 DOI: 10.1016/j.canep.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/02/2017] [Accepted: 07/04/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND We present the 15-year experience of a family colorectal cancer screening service in Ireland with emphasis on real life experience and outcomes. METHODS Questionnaires were used to assess family cancer history and assign patients to risk categories; 'Moderate Risk', HNPCC, (suspected) genetic syndrome (non-HNPCC), 'Low Risk'. Screening was by full colonoscopy. We report neoplastic yield, examining effect of risk category, age, gender, and index colonoscopy findings. RESULTS Between 1998 and 2013, 2242 individuals were referred; 57.3% female, 42.7% male, median age 46 years (range9-85yrs). Median follow up time was 7.9yrs (range 0.5-15.3yrs). Follow up data after exclusion (non-compliance, known CRC) was available in 1496 (66.7%): 'Moderate risk' 785 (52.5%), HNPCC 256 (17.1%), (suspected) genetic syndrome (non-HNPCC) 85 (5.7%), 'Low Risk' 370 (24.7%). Screening was performed in 1025(68.5%) patients; colonoscopy data available for 993 (96.9%); total 1914 colonoscopies. At index colonoscopy, 178 (18.0%) patients had adenomas; 56 (5.5%) advanced adenoma. During the entire study period, 240 (24.2%) had an adenoma; 69 (7.0%) advanced adenoma. Cancers were diagnosed on screening in 2 patients. Older age and male gender were associated with higher adenoma detection rate; p<0.001, p=0.01, respectively. Risk category did not affect adenoma yield. Adenoma and advanced adenoma detection at index colonoscopy were associated with detection of same at follow up screening; p<0.001. CONCLUSION Male gender and age (>50) were the core identifiable risk factors for neoplasia at screening colonoscopy in this family screening setting. Our results would support less intensive surveillance in younger patients (<50), particularly where index colonoscopy is normal.
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Brennan B, Hemmings CT, Clark I, Yip D, Fadia M, Taupin DR. Universal molecular screening does not effectively detect Lynch syndrome in clinical practice. Therap Adv Gastroenterol 2017; 10:361-371. [PMID: 28491141 PMCID: PMC5405883 DOI: 10.1177/1756283x17690990] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/04/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Lynch syndrome (LS) due to an inherited damaging mutation in mismatch repair (MMR) genes comprises 3% of all incident colorectal cancer (CRC). Molecular testing using immunohistochemistry (IHC) for MMR proteins is a recommended screening tool to identify LS in incident CRC. This study assessed outcomes of population-based routine molecular screening for diagnosis of LS in a regional center. METHODS We conducted a prospective, consecutive case series study of universal IHC testing on cases of resected CRC from September 2004-December 2013. Referred cases with abnormal IHC results that attended a familial cancer clinic were assessed according to modified Bethesda criteria (until 2009) or molecular criteria (from 2009). RESULTS 1612 individuals underwent resection for CRC in the study period and had MMR testing by IHC. Of these, 274 cases (16.9%) exhibited loss of expression of MMR genes. The mean age at CRC diagnosis was 68.1 years (± standard deviation 12.7) and the mean age of those with an IHC abnormality was 71.6 (± 11.8). A total of 82 (29.9%) patients with an abnormal result were seen in a subspecialty familial cancer clinic. Patients aged under 50 (p = 0.009) and those with loss of MSH6 staining (p = 0.027) were more likely to be referred and to attend. After germ-line sequencing, 0.6% (10 of 82) were identified as having a clinically significant abnormality. A further eight probands with pathogenic germ-line mutations were identified from other referrals to the service over the same time period. CONCLUSIONS While technically accurate, the yield of 'universal' IHC in detecting new Lynch probands is limited by real-world factors that reduce referrals and genetic testing. We propose an alternative approach for universal, incident case detection of Lynch syndrome with 'one-stop' MMR testing and sequencing.
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Affiliation(s)
- Beatrice Brennan
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Garran, ACT, Australia
| | - Christine T. Hemmings
- ACT Pathology, The Canberra Hospital, Garran, ACT, Australia,Current address: Anatomic Pathology (WA) & Head of Molecular Oncology, St John of God Pathology, Subiaco, WA, Australia
| | - Ian Clark
- Capital Pathology, Deakin, ACT, Australia,Current address: Australian Pathology at Sonic Healthcare, Macquarie Park, New South Wales, Australia
| | - Desmond Yip
- Department of Medical Oncology, Canberra and Calvary Hospitals, Garran, Australian Capital Territory, Australia
| | - Mitali Fadia
- ACT Pathology, The Canberra Hospital, Garran, ACT, Australia
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Kastrinos F, Ojha RP, Leenen C, Alvero C, Mercado RC, Balmaña J, Valenzuela I, Balaguer F, Green R, Lindor NM, Thibodeau SN, Newcomb P, Win AK, Jenkins M, Buchanan DD, Bertario L, Sala P, Hampel H, Syngal S, Steyerberg EW. Comparison of Prediction Models for Lynch Syndrome Among Individuals With Colorectal Cancer. J Natl Cancer Inst 2015; 108:djv308. [PMID: 26582061 DOI: 10.1093/jnci/djv308] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 09/25/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent guidelines recommend the Lynch Syndrome prediction models MMRPredict, MMRPro, and PREMM1,2,6 for the identification of MMR gene mutation carriers. We compared the predictive performance and clinical usefulness of these prediction models to identify mutation carriers. METHODS Pedigree data from CRC patients in 11 North American, European, and Australian cohorts (6 clinic- and 5 population-based sites) were used to calculate predicted probabilities of pathogenic MLH1, MSH2, or MSH6 gene mutations by each model and gene-specific predictions by MMRPro and PREMM1,2,6. We examined discrimination with area under the receiver operating characteristic curve (AUC), calibration with observed to expected (O/E) ratio, and clinical usefulness using decision curve analysis to select patients for further evaluation. All statistical tests were two-sided. RESULTS Mutations were detected in 539 of 2304 (23%) individuals from the clinic-based cohorts (237 MLH1, 251 MSH2, 51 MSH6) and 150 of 3451 (4.4%) individuals from the population-based cohorts (47 MLH1, 71 MSH2, 32 MSH6). Discrimination was similar for clinic- and population-based cohorts: AUCs of 0.76 vs 0.77 for MMRPredict, 0.82 vs 0.85 for MMRPro, and 0.85 vs 0.88 for PREMM1,2,6. For clinic- and population-based cohorts, O/E deviated from 1 for MMRPredict (0.38 and 0.31, respectively) and MMRPro (0.62 and 0.36) but were more satisfactory for PREMM1,2,6 (1.0 and 0.70). MMRPro or PREMM1,2,6 predictions were clinically useful at thresholds of 5% or greater and in particular at greater than 15%. CONCLUSIONS MMRPro and PREMM1,2,6 can well be used to select CRC patients from genetics clinics or population-based settings for tumor and/or germline testing at a 5% or higher risk. If no MMR deficiency is detected and risk exceeds 15%, we suggest considering additional genetic etiologies for the cause of cancer in the family.
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Affiliation(s)
- Fay Kastrinos
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB).
| | - Rohit P Ojha
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Celine Leenen
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Carmelita Alvero
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Rowena C Mercado
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Judith Balmaña
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Irene Valenzuela
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Francesc Balaguer
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Roger Green
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Noralane M Lindor
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Stephen N Thibodeau
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Polly Newcomb
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Aung Ko Win
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Mark Jenkins
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Daniel D Buchanan
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Lucio Bertario
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Paola Sala
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Heather Hampel
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Sapna Syngal
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
| | - Ewout W Steyerberg
- Herbert Irving C omprehensive Cancer Center and Division of Digestive and Liver Diseases, Columbia University, Medical Center, New York, NY (FK); Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN (RPO); Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, the Netherlands (CL); Statistical and Data Analysis Center, Harvard School Public Health, Boston, MA (CA); Population Sciences Division, Dana-Farber Cancer Institute, Boston, MA (RCM); Department of Oncology (JB) and Genetics Department (IV), University Hospital Vall d'Hebrón, Barcelona, Spain; Department of Gastroenterology, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain (FB); Discipline of Genetics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada (RG); Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ (NML); Division of Molecular Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN (SNT); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (PN); Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia (AKW, MJ, DDB); Unit of Hereditary Digestive Tract Tumors, Department of Preventive and Predictive Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy (LB, PS); Clinical Cancer Genetics Program, Ohio State University Comprehensive Cancer Center, Columbus, OH (HH); Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA (SS); Harvard Medical School, Boston, MA (SS); Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands (EWS); Oncogenomics Group, Genetic Epidemiology Laboratory, The University of Melbourne, Parkville, Victoria, Australia (DDB)
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16
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Ladabaum U, Ford JM, Martel M, Barkun AN. American Gastroenterological Association Technical Review on the Diagnosis and Management of Lynch Syndrome. Gastroenterology 2015; 149:783-813.e20. [PMID: 26226576 DOI: 10.1053/j.gastro.2015.07.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology/Hepatology, Stanford University School of Medicine, Stanford, California
| | - James M Ford
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Division of Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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17
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Yurgelun MB, Allen B, Kaldate RR, Bowles KR, Judkins T, Kaushik P, Roa BB, Wenstrup RJ, Hartman AR, Syngal S. Identification of a Variety of Mutations in Cancer Predisposition Genes in Patients With Suspected Lynch Syndrome. Gastroenterology 2015; 149:604-13.e20. [PMID: 25980754 PMCID: PMC4550537 DOI: 10.1053/j.gastro.2015.05.006] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 05/06/2015] [Accepted: 05/09/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Multigene panels are commercially available tools for hereditary cancer risk assessment that allow for next-generation sequencing of numerous genes in parallel. However, it is not clear if these panels offer advantages over traditional genetic testing. We investigated the number of cancer predisposition gene mutations identified by parallel sequencing in individuals with suspected Lynch syndrome. METHODS We performed germline analysis with a 25-gene, next-generation sequencing panel using DNA from 1260 individuals who underwent clinical genetic testing for Lynch syndrome from 2012 through 2013. All patients had a history of Lynch syndrome-associated cancer and/or polyps. We classified all identified germline alterations for pathogenicity and calculated the frequencies of pathogenic mutations and variants of uncertain clinical significance (VUS). We also analyzed data on patients' personal and family history of cancer, including fulfillment of clinical guidelines for genetic testing. RESULTS Of the 1260 patients, 1112 met National Comprehensive Cancer Network (NCCN) criteria for Lynch syndrome testing (88%; 95% confidence interval [CI], 86%-90%). Multigene panel testing identified 114 probands with Lynch syndrome mutations (9.0%; 95% CI, 7.6%-10.8%) and 71 with mutations in other cancer predisposition genes (5.6%; 95% CI, 4.4%-7.1%). Fifteen individuals had mutations in BRCA1 or BRCA2; 93% of these met the NCCN criteria for Lynch syndrome testing and 33% met NCCN criteria for BRCA1 and BRCA2 analysis (P = .0017). An additional 9 individuals carried mutations in other genes linked to high lifetime risks of cancer (5 had mutations in APC, 3 had bi-allelic mutations in MUTYH, and 1 had a mutation in STK11); all of these patients met NCCN criteria for Lynch syndrome testing. A total of 479 individuals had 1 or more VUS (38%; 95% CI, 35%-41%). CONCLUSIONS In individuals with suspected Lynch syndrome, multigene panel testing identified high-penetrance mutations in cancer predisposition genes, many of which were unexpected based on patients' histories. Parallel sequencing also detected a high number of potentially uninformative germline findings, including VUS.
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Affiliation(s)
- Matthew B. Yurgelun
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brian Allen
- Myriad Genetic Laboratories, Salt Lake City, Utah, USA
| | | | | | | | | | | | | | | | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Brigham and Women’s Hospital, Boston, Massachusetts, USA
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18
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Ballester V, Boardman L. Next Generation Multigene Panel Testing: The Next Step for Identification of Hereditary Colorectal Cancer Syndromes? Gastroenterology 2015; 149:526-8. [PMID: 26226575 DOI: 10.1053/j.gastro.2015.07.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Veroushka Ballester
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Boardman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Snowsill T, Huxley N, Hoyle M, Jones-Hughes T, Coelho H, Cooper C, Frayling I, Hyde C. A systematic review and economic evaluation of diagnostic strategies for Lynch syndrome. Health Technol Assess 2015; 18:1-406. [PMID: 25244061 DOI: 10.3310/hta18580] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lynch syndrome (LS) is an inherited autosomal dominant disorder characterised by an increased risk of colorectal cancer (CRC) and other cancers, and caused by mutations in the deoxyribonucleic acid (DNA) mismatch repair genes. OBJECTIVE To evaluate the accuracy and cost-effectiveness of strategies to identify LS in newly diagnosed early-onset CRC patients (aged < 50 years). Cascade testing of relatives is employed in all strategies for individuals in whom LS is identified. DATA SOURCES AND METHODS Systematic reviews were conducted of the test accuracy of microsatellite instability (MSI) testing or immunohistochemistry (IHC) in individuals with CRC at risk of LS, and of economic evidence relating to diagnostic strategies for LS. Reviews were carried out in April 2012 (test accuracy); and in February 2012, repeated in February 2013 (economic evaluations). Databases searched included MEDLINE (1946 to April week 3, 2012), EMBASE (1980 to week 17, 2012) and Web of Science (inception to 30 April 2012), and risk of bias for test accuracy was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) quality appraisal tool. A de novo economic model of diagnostic strategies for LS was developed. RESULTS Inconsistencies in study designs precluded pooling of diagnostic test accuracy results from a previous systematic review and nine subsequent primary studies. These were of mixed quality, with significant methodological concerns identified for most. IHC and MSI can both play a part in diagnosing LS but neither is gold standard. No UK studies evaluated the cost-effectiveness of diagnosing and managing LS, although studies from other countries generally found some strategies to be cost-effective compared with no testing. The de novo model demonstrated that all strategies were cost-effective compared with no testing at a threshold of £20,000 per quality-adjusted life-year (QALY), with the most cost-effective strategy utilising MSI and BRAF testing [incremental cost-effectiveness ratio (ICER) = £5491 per QALY]. The maximum health benefit to the population of interest would be obtained using universal germline testing, but this would not be a cost-effective use of NHS resources compared with the next best strategy. When the age limit was raised from 50 to 60 and 70 years, the ICERs compared with no testing increased but remained below £20,000 per QALY (except for universal germline testing with an age limit of 70 years). The total net health benefit increased with the age limit as more individuals with LS were identified. Uncertainty was evaluated through univariate sensitivity analyses, which suggested that the parameters substantially affecting cost-effectiveness: were the risk of CRC for individuals with LS; the average number of relatives identified per index patient; the effectiveness of colonoscopy in preventing metachronous CRC; the cost of colonoscopy; the duration of the psychological impact of genetic testing on health-related quality of life (HRQoL); and the impact of prophylactic hysterectomy and bilateral salpingo-oophorectomy on HRQoL (this had the potential to make all testing strategies more expensive and less effective than no testing). LIMITATIONS The absence of high-quality data for the impact of prophylactic gynaecological surgery and the psychological impact of genetic testing on HRQoL is an acknowledged limitation. CONCLUSIONS Results suggest that reflex testing for LS in newly diagnosed CRC patients aged < 50 years is cost-effective. Such testing may also be cost-effective in newly diagnosed CRC patients aged < 60 or < 70 years. Results are subject to uncertainty due to a number of parameters, for some of which good estimates were not identified. We recommend future research to estimate the cost-effectiveness of testing for LS in individuals with newly diagnosed endometrial or ovarian cancer, and the inclusion of aspirin chemoprevention. Further research is required to accurately estimate the impact of interventions on HRQoL. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002436. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Ian Frayling
- Institute of Medical Genetics, Cardiff University, Cardiff, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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20
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Lee SY, Kim DW, Shin YK, Ihn MH, Lee SM, Oh HK, Ku JL, Jeong SY, Lee JB, Ahn S, Won S, Kang SB. Validation of Prediction Models for Mismatch Repair Gene Mutations in Koreans. Cancer Res Treat 2015; 48:668-75. [PMID: 26044159 PMCID: PMC4843726 DOI: 10.4143/crt.2014.288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 05/05/2015] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Lynch syndrome, the commonest hereditary colorectal cancer syndrome, is caused by germline mutations in mismatch repair (MMR) genes. Three recently developed prediction models for MMR gene mutations based on family history and clinical features (MMRPredict, PREMM(1,2,6), and MMRPro) have been validated only in Western countries. In this study, we propose validating these prediction models in the Korean population. MATERIALS AND METHODS We collected MMR gene analysis data from 188 individuals in the Korean Hereditary Tumor Registry. The probability of gene mutation was calculated using three prediction models, and the overall diagnostic value of each model compared using receiver operator characteristic (ROC) curves and area under the ROC curve (AUC). Quantitative test characteristics were calculated at sensitivities of 90%, 95%, and 98%. RESULTS Of the individuals analyzed, 101 satisfied Amsterdam criteria II, and 87 were suspected hereditary nonpolyposis colorectal cancer. MMR mutations were identified in 62 of the 188 subjects (33.0%). All three prediction models showed a poor predictive value of AUC (MMRPredict, 0.683; PREMM(1,2,6), 0.709; MMRPro, 0.590). Within the range of acceptable sensitivity (> 90%), PREMM(1,2,6) demonstrated higher specificity than the other models. CONCLUSION In the Korean population, overall predictive values of the three models (MMRPredict, PREMM(1,2,6), MMRPro) for MMR gene mutations are poor, compared with their performance in Western populations. A new prediction model is therefore required for the Korean population to detect MMR mutation carriers, reflecting ethnic differences in genotype-phenotype associations.
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Affiliation(s)
- Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Hereditary Tumor Registry, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Kyoung Shin
- Korean Hereditary Tumor Registry, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Myong Hoon Ihn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Min Lee
- Department of Surgery, Chung Hospital, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ja-Lok Ku
- Korean Hereditary Tumor Registry, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Korean Hereditary Tumor Registry, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Bong Lee
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soyeon Ahn
- Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sungho Won
- Department of Public Health Science, Seoul National University, Seoul, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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21
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Barzi A, Sadeghi S, Kattan MW, Meropol NJ. Comparative effectiveness of screening strategies for Lynch syndrome. J Natl Cancer Inst 2015; 107:djv005. [PMID: 25794514 DOI: 10.1093/jnci/djv005] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Colorectal cancer is the second leading cause of cancer death in the United States. Approximately 3% of colorectal cancers are associated with Lynch Syndrome. Controversy exists regarding the optimal screening strategy for Lynch Syndrome. METHODS Using an individual level microsimulation of a population affected by Lynch syndrome over several years, effectiveness and cost-effectiveness of 21 screening strategies were compared. Modeling assumptions were based upon published literature, and sensitivity analyses were performed for key assumptions. In a two-step process, the number of Lynch syndrome diagnoses (Step 1) and life-years gained as a result of foreknowledge of Lynch syndrome in otherwise healthy carriers (Step 2) were measured. RESULTS The optimal strategy was sequential screening for probands starting with a predictive model, then immunohistochemistry for mismatch repair protein expression (IHC), followed by germline mutation testing (incremental cost-effectiveness ratio [ICER] of $35 143 per life-year gained). The strategies of IHC + BRAF, germline testing and universal germline testing of colon cancer probands had ICERs of $144 117 and $996 878, respectively. CONCLUSIONS This analysis suggests that the initial step in screening for Lynch Syndrome should be the use of predictive models in probands. Universal tumor testing and general population screening strategies are not cost-effective. When family history is unavailable, alternate strategies are appropriate. Documentation of family history and screening for Lynch Syndrome using a predictive model may be considered a quality-of-care measure for patients with colorectal cancer.
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Affiliation(s)
- Afsaneh Barzi
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Sarmad Sadeghi
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Michael W Kattan
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
| | - Neal J Meropol
- Department of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (AB, SS); Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH (MWK); Cleveland Clinic Lerner College of Medicine, Cleveland, OH (MWK); Department of Epidemiology and Biostatistics (MWK) and Department of Medicine (NJM), School of Medicine, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH; Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH (NJM)
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Yurgelun MB. Next-generation strategies for hereditary colorectal cancer risk assessment. J Clin Oncol 2015; 33:388-93. [PMID: 25559814 DOI: 10.1200/jco.2014.58.9895] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer. Gastroenterology 2014; 147:502-26. [PMID: 25043945 DOI: 10.1053/j.gastro.2014.04.001] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3-6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; University of Washington, Seattle, Washington
| | | | | | | | | | - Douglas J Robertson
- White River Junction VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | - Sapna Syngal
- Brigham and Women's Hospital, Boston, Massachusetts; Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2014; 80:197-220. [PMID: 25034835 DOI: 10.1016/j.gie.2014.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Giardiello FM, Allen JI, Axilbund JE, Boland CR, Burke CA, Burt RW, Church JM, Dominitz JA, Johnson DA, Kaltenbach T, Levin TR, Lieberman DA, Robertson DJ, Syngal S, Rex DK. Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-society Task Force on colorectal cancer. Am J Gastroenterol 2014; 109:1159-79. [PMID: 25070057 DOI: 10.1038/ajg.2014.186] [Citation(s) in RCA: 312] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3,4,5,6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.
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Affiliation(s)
| | - John I Allen
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | | | - Jason A Dominitz
- 1] VA Puget Sound Health Care System, Seattle, Washington, USA [2] University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Douglas J Robertson
- 1] White River Junction VA Medical Center, White River Junction, Vermont, USA [2] Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA
| | - Sapna Syngal
- 1] Brigham and Women's Hospital, Boston, Massachusetts, USA [2] Dana Farber Cancer Institute, Boston, Massachusetts, USA [3] Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Abstract
Prediction models for the identification of Lynch syndrome have been developed to quantify an individual's risk of carrying a mismatch repair gene mutation and help clinicians decide for whom further risk assessment and genetic testing is necessary. There are diverse clinical settings in which a healthcare provider has the opportunity to assess an individual for Lynch syndrome. Prediction models offer a potentially feasible and useful strategy to systematically identify at-risk individuals, whether they are affected with colorectal cancer or not, and to help with management of the implications of molecular and germline test results. Given the complexity of diagnostic information currently available to clinicians involved in identifying and caring for patients with Lynch syndrome, prediction models provide a useful and complementary aid in medical decision-making. Systematic implementation of prediction models estimates should be considered in routine clinical care and at various stages of cancer risk assessment and prevention. In this manuscript, we review the main prediction models developed for Lynch syndrome, focus on their specific features and performance assessed in several validation studies, compare the models with other clinical and molecular strategies for the diagnosis of Lynch syndrome, and discuss their potential uses in clinical practice.
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Adelson M, Pannick S, East JE, Risby P, Dawson P, Monahan KJ. UK colorectal cancer patients are inadequately assessed for Lynch syndrome. Frontline Gastroenterol 2014; 5:31-35. [PMID: 28839747 PMCID: PMC5369742 DOI: 10.1136/flgastro-2013-100345] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 07/12/2013] [Accepted: 07/15/2013] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To establish whether colorectal cancer patients in two centres in the UK are screened appropriately for Lynch syndrome, in accordance with current international guidance. DESIGN Patients newly diagnosed with colorectal cancer over an 18-month period were identified from the UK National Bowel Cancer Audit Programme. Their records and management were reviewed retrospectively. SETTING Two university teaching hospitals, Imperial College Healthcare and Oxford Radcliffe Hospitals NHS Trusts. OUTCOMES MEASURED Whether patients were screened for Lynch syndrome-and the outcome of that evaluation, if it took place-were assessed from patients' clinical records. The age, tumour location and family history of screened patients were compared to those of unscreened patients. RESULTS Five hundred and fifty three patients with newly diagnosed colorectal cancer were identified. Of these, 97 (17.5%) satisfied the revised Bethesda criteria, and should have undergone further assessment. There was no evidence that those guidelines had been contemporaneously applied to any patient. In practice, only 22 of the 97 (22.7%) eligible patients underwent evaluation. The results for 14 of those 22 (63.6%) supported a diagnosis of Lynch syndrome, but only nine of the 14 (64.3%) were referred for formal mismatch repair gene testing. No factors reliably predicted whether or not a patient would undergo Lynch syndrome screening. CONCLUSIONS Colorectal teams in the UK do not follow international guidance identifying the patients who should be screened for Lynch syndrome. Patients and their families are consequently excluded from programmes reducing colorectal cancer incidence and mortality. Multidisciplinary teams should work with their local genetics services to develop reliable algorithms for patient screening and referral.
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Affiliation(s)
- Maria Adelson
- Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, London, UK
| | - Samuel Pannick
- Department of Gastroenterology, Family History of Bowel Cancer Clinic, West Middlesex University Hospital, London, UK
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Peter Risby
- Department of Clinical Genetics, Churchill Hospital, Oxford, UK
| | - Peter Dawson
- Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, London, UK
| | - Kevin J Monahan
- Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, London, UK,Department of Gastroenterology, Family History of Bowel Cancer Clinic, West Middlesex University Hospital, London, UK
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Win AK, Macinnis RJ, Dowty JG, Jenkins MA. Criteria and prediction models for mismatch repair gene mutations: a review. J Med Genet 2013; 50:785-93. [PMID: 23956446 DOI: 10.1136/jmedgenet-2013-101803] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
One of the strongest predictors of colorectal cancer risk is carrying a germline mutation in a DNA mismatch repair (MMR) gene. Once identified, mutation carriers can be recommended for intensive screening that will substantially reduce their high colorectal cancer risk. Conversely, the relatives of carriers identified as non-carriers can be relieved of the burden of intensive screening. Criteria and prediction models that identify likely mutation carriers are needed for cost-effective, targeted, germline testing for MMR gene mutation. We reviewed 12 criteria/guidelines and 8 prediction models (Leiden, Amsterdam-plus, Amsterdam-alternative, MMRpro, PREMM1,2,6, MMRpredict, Associazione Italiana per lo studio della Familiarità ed Ereditarietà dei tumori Gastrointestinali (AIFEG) and the Myriad Genetics Prevalence table) for identifying mutation carriers. While criteria are only used to identify individuals with colorectal cancer (yes/no for screening followed by germline testing), all prediction models except MMRpredict and Myriad tables can predict the probability of carrying mutations for individuals with or without colorectal cancer. We conducted a meta-analysis of the discrimination performance of 17 studies that validated the prediction models. The pooled estimate for the area under curve was 0.80 (95% CI 0.72 to 0.88) for MMRpro, 0.81 (95% CI 0.73 to 0.88) for MMRpredict, 0.84 (95% CI 0.81 to 0.88) for PREMM, and 0.85 (95% CI 0.78 to 0.91) for Leiden model. Given the high degree of overlap in the CIs, we cannot state that one model has a higher discrimination than any of the others. Overall, the existing statistical models have been shown to be sensitive and specific (at a 5% cut-off) in predicting MMR gene mutation carriers. Future models may need to: provide prediction of PMS2 mutations, take into account a wider range of Lynch syndrome-associated cancers when assessing family history, and be applicable to all people irrespective of any cancer diagnosis.
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Affiliation(s)
- Aung Ko Win
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Parkville, Victoria, Australia
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Abstract
Normal cell function requires strict control over the repair of DNA damage, which prevents excessive mutagenesis. An enhanced accumulation of mutations results in the multistep process generally known as carcinogenesis. Defects in repair pathways fuel such mutagenesis by allowing reiterative cycles of mutation, selection, and clonal expansion that drive cancer progression. The repair of mismatches is an important mechanism in the prevention of such genetic instability. In addition, proteins of this pathway have the unique ability to function in DNA damage response by inducing apoptosis when irreparable damage is encountered. Though originally identified primarily in association with a predisposition to hereditary colon cancer, mismatch repair defects have been identified in many other cancer types, including prostate cancer. From the first discovery of microsatellite instability in prostate cancer cell lines and tumor samples, variations in protein levels and a possible association with recurrence and aggression of disease have been described. Current results suggest that the involvement of mismatch repair proteins in prostate cancer may differ from that found in colorectal cancer, in the type of proteins and protein defects involved and the type of causative mutations. Additional work is clearly needed to investigate this involvement and the possibility that such defects may affect treatment response and androgen independence.
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Affiliation(s)
- John Jarzen
- Department of Biology, College of Science and Technology, Georgia Southern University, Statesboro, Georgia, USA
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Serrano M, Lage P, Belga S, Filipe B, Francisco I, Rodrigues P, Fonseca R, Chaves P, Claro I, Albuquerque C, Pereira AD. Bethesda criteria for microsatellite instability testing: impact on the detection of new cases of Lynch syndrome. Fam Cancer 2013; 11:571-8. [PMID: 22776989 DOI: 10.1007/s10689-012-9550-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In 1997 Bethesda Guidelines (BG) were established and in 2004 those criteria were revised (RBG), with the main goal of selecting colorectal cancers (CRC) that should be subjected to microsatellite instability (MSI) testing. High microsatellite instability (MSI-H) is an intermediate marker for mutational analysis of the mismatch repair (MMR) genes involved in the genesis of Lynch Syndrome (LS). We aimed to evaluate and compare BG/RBG in the detection of MSI-H and subsequent identification of pathogenic MMR genes mutations. We included 174 patients with CRC and indication for MSI analysis according to BG or RBG. MSI testing was performed with the Bethesda markers and mutational analysis of MLH1, MSH2 and MSH6 genes undertaken with DGGE, MLPA and direct sequencing. One hundred fourteen of 174 patients (65.5 %) fulfilled BG and all of them RBG. With the BG, MSI-H was detected in 37/114 (32.5 %) CRCs and mutational analysis was positive in 14/37 (37.8 %) patients. The RBG led to detection of MSI-H in 49/174 (28.2 %) of the CRCs, having the mutational analysis been positive in 16/49 (32.7 %) patients. We could identify 14/114 (12.3 %) new cases of LS, through BG and 16/174 (9.2 %) via RBG. BG presented a similar overall percentage for the detection of MSI-H and mutations when compared with RBG. RBG implicated the analysis of more patients, though they gave rise to detection of two additional LS cases. This difference has a significant impact on the establishment of preventive measures, mainly for CRC, in all the mutation-carriers belonging to these families.
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Affiliation(s)
- Miguel Serrano
- Serviço de Gastrenterologia, Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E., Rua Professor Lima Basto 1099-023, Lisbon, Portugal.
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Moreira L, Balaguer F, Lindor N, de la Chapelle A, Hampel H, Aaltonen LA, Hopper JL, Le Marchand L, Gallinger S, Newcomb PA, Haile R, Thibodeau SN, Gunawardena S, Jenkins MA, Buchanan DD, Potter JD, Baron JA, Ahnen DJ, Moreno V, Andreu M, Ponz de Leon M, Rustgi AK, Castells A. Identification of Lynch syndrome among patients with colorectal cancer. JAMA 2012; 308:1555-65. [PMID: 23073952 PMCID: PMC3873721 DOI: 10.1001/jama.2012.13088] [Citation(s) in RCA: 363] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONTEXT Lynch syndrome is the most common form of hereditary colorectal cancer (CRC) and is caused by germline mutations in DNA mismatch repair (MMR) genes. Identification of gene carriers currently relies on germline analysis in patients with MMR-deficient tumors, but criteria to select individuals in whom tumor MMR testing should be performed are unclear. OBJECTIVE To establish a highly sensitive and efficient strategy for the identification of MMR gene mutation carriers among CRC probands. DESIGN, SETTING, AND PATIENTS Pooled-data analysis of 4 large cohorts of newly diagnosed CRC probands recruited between 1994 and 2010 (n = 10,206) from the Colon Cancer Family Registry, the EPICOLON project, the Ohio State University, and the University of Helsinki examining personal, tumor-related, and family characteristics, as well as microsatellite instability, tumor MMR immunostaining, and germline MMR mutational status data. MAIN OUTCOME Performance characteristics of selected strategies (Bethesda guidelines, Jerusalem recommendations, and those derived from a bivariate/multivariate analysis of variables associated with Lynch syndrome) were compared with tumor MMR testing of all CRC patients (universal screening). RESULTS Of 10,206 informative, unrelated CRC probands, 312 (3.1%) were MMR gene mutation carriers. In the population-based cohorts (n = 3671 probands), the universal screening approach (sensitivity, 100%; 95% CI, 99.3%-100%; specificity, 93.0%; 95% CI, 92.0%-93.7%; diagnostic yield, 2.2%; 95% CI, 1.7%-2.7%) was superior to the use of Bethesda guidelines (sensitivity, 87.8%; 95% CI, 78.9%-93.2%; specificity, 97.5%; 95% CI, 96.9%-98.0%; diagnostic yield, 2.0%; 95% CI, 1.5%-2.4%; P < .001), Jerusalem recommendations (sensitivity, 85.4%; 95% CI, 77.1%-93.6%; specificity, 96.7%; 95% CI, 96.0%-97.2%; diagnostic yield, 1.9%; 95% CI, 1.4%-2.3%; P < .001), and a selective strategy based on tumor MMR testing of cases with CRC diagnosed at age 70 years or younger and in older patients fulfilling the Bethesda guidelines (sensitivity, 95.1%; 95% CI, 89.8%-99.0%; specificity, 95.5%; 95% CI, 94.7%-96.1%; diagnostic yield, 2.1%; 95% CI, 1.6%-2.6%; P < .001). This selective strategy missed 4.9% of Lynch syndrome cases but resulted in 34.8% fewer cases requiring tumor MMR testing and 28.6% fewer cases undergoing germline mutational analysis than the universal approach. CONCLUSION Universal tumor MMR testing among CRC probands had a greater sensitivity for the identification of Lynch syndrome compared with multiple alternative strategies, although the increase in the diagnostic yield was modest.
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Affiliation(s)
- Leticia Moreira
- Department of Gastroenterology, Hospital Clínic, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Institut d’Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Wang G, Kuppermann M, Kim B, Phillips KA, Ladabaum U. Influence of patient preferences on the cost-effectiveness of screening for lynch syndrome. J Oncol Pract 2012; 8:e24s-30s. [PMID: 22942831 DOI: 10.1200/jop.2011.000535] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2012] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Patients and relatives have varying preferences for genetic testing and interventions related to hereditary cancer syndromes. We examined how the impact of these services on quality of life (QoL) affects the cost-effectiveness of screening for Lynch syndrome among probands newly diagnosed with colorectal cancer and their relatives. METHODS We constructed a state-transition model comparing screening strategies (clinical criteria, prediction algorithms, tumor testing, and upfront germline testing) with no screening to identify Lynch syndrome. The model incorporated individuals' health state utilities after screening, germline testing, and risk-reducing surgeries, with utilities persisting for 12 months in the base case. Outcomes consisted of quality-adjusted life-years (QALYs), costs, and cost per QALY gained. Sensitivity analyses assessed how the duration and magnitude of changes in QoL influenced results. RESULTS Multiple screening strategies yielded gains in QALYs at acceptable costs compared with no screening. The preferred strategy-immunohistochemistry of tumors followed by BRAF mutation testing (IHC/BRAF)-cost $59,700 per QALY gained in the base case. The duration and magnitude of decreases in QoL after decisions related to germline testing and surgeries were key determinants of the cost-effectiveness of screening. IHC/BRAF cost > $100,000 per QALY gained when decrements to QoL persisted for 21 months. CONCLUSION Screening for Lynch syndrome in the population is likely to yield long-term gains in life expectancy that outweigh any short-term decreases in QoL, at acceptable costs. Counseling for individuals should aim to mitigate potential negative impact of genetic testing and risk-reducing interventions on QoL.
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Affiliation(s)
- Grace Wang
- American Institutes for Research, Washington, DC; University of California San Francisco, San Francisco; and Stanford University School of Medicine, Stanford, CA
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Castellví-Bel S, Ruiz-Ponte C, Fernández-Rozadilla C, Abulí A, Muñoz J, Bessa X, Brea-Fernández A, Ferro M, Giráldez MD, Xicola RM, Llor X, Jover R, Piqué JM, Andreu M, Castells A, Carracedo A. Seeking genetic susceptibility variants for colorectal cancer: the EPICOLON consortium experience. Mutagenesis 2012; 27:153-9. [PMID: 22294762 DOI: 10.1093/mutage/ger047] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The EPICOLON consortium was initiated in 1999 by the Gastrointestinal Oncology Group of the Spanish Gastroenterology Association. It recruited consecutive, unselected, population-based colorectal cancer (CRC) cases and control subjects matched by age and gender without personal or familial history of cancer all over Spain with the main goal of gaining knowledge in Lynch syndrome and familial CRC. This epidemiological, prospective and multicentre study collected extensive clinical data and biological samples from ∼2000 CRC cases and 2000 controls in Phases 1 and 2 involving 25 and 14 participating hospitals, respectively. Genetic susceptibility projects in EPICOLON have included candidate-gene approaches evaluating single-nucleotide polymorphisms/genes from the historical category (linked to CRC risk by previous studies), from human syntenic CRC susceptibility regions identified in mouse, from the CRC carcinogenesis-related pathways Wnt and BMP, from regions 9q22 and 3q22 with positive linkage in CRC families, and from the mucin gene family. This consortium has also participated actively in the identification 5 of the 16 common, low-penetrance CRC genetic variants identified so far by genome-wide association studies. Finishing their own pangenomic study and performing whole-exome sequencing in selected CRC samples are among EPICOLON future research prospects.
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Affiliation(s)
- Sergi Castellví-Bel
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Villarroel 170, 08036 Barcelona, Catalonia, Spain.
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Performance of PREMM(1,2,6), MMRpredict, and MMRpro in detecting Lynch syndrome among endometrial cancer cases. Genet Med 2012; 14:670-80. [PMID: 22402756 DOI: 10.1038/gim.2012.18] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Lynch syndrome accounts for 2-5% of endometrial cancer cases. Lynch syndrome prediction models have not been evaluated among endometrial cancer cases. METHODS Area under the receiver operating curve (AUC), sensitivity and specificity of PREMM(1,2,6), MMRpredict, and MMRpro scores were assessed among 563 population-based and 129 clinic-based endometrial cancer cases. RESULTS A total of 14 (3%) population-based and 80 (62%) clinic-based subjects had pathogenic mutations. PREMM(1,2,6), MMRpredict, and MMRpro were able to distinguish mutation carriers from noncarriers (AUC of 0.77, 0.76, and 0.77, respectively), among population-based cases. All three models had lower discrimination for the clinic-based cohort, with AUCs of 0.67, 0.64, and 0.54, respectively. Using a 5% cutoff, sensitivity and specificity were as follows: PREMM(1,2,6), 93% and 5% among population-based cases and 99% and 2% among clinic-based cases; MMRpredict, 71% and 64% for the population-based cohort and 91% and 0% for the clinic-based cohort; and MMRpro, 57% and 85% among population-based cases and 95% and 10% among clinic-based cases. CONCLUSION Currently available prediction models have limited clinical utility in determining which patients with endometrial cancer should undergo genetic testing for Lynch syndrome. Immunohistochemical analysis and microsatellite instability testing may be the best currently available tools to screen for Lynch syndrome in endometrial cancer patients.
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Kastrinos F, Syngal S. Screening patients with colorectal cancer for Lynch syndrome: what are we waiting for? J Clin Oncol 2012; 30:1024-7. [PMID: 22355054 DOI: 10.1200/jco.2011.40.7171] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Monteiro Santos EM, Valentin MD, Carneiro F, de Oliveira LP, de Oliveira Ferreira F, Junior SA, Nakagawa WT, Gomy I, de Faria Ferraz VE, da Silva Junior WA, Carraro DM, Rossi BM. Predictive models for mutations in mismatch repair genes: implication for genetic counseling in developing countries. BMC Cancer 2012; 12:64. [PMID: 22321913 PMCID: PMC3305354 DOI: 10.1186/1471-2407-12-64] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 02/09/2012] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Lynch syndrome (LS) is the most common form of inherited predisposition to colorectal cancer (CRC), accounting for 2-5% of all CRC. LS is an autosomal dominant disease characterized by mutations in the mismatch repair genes mutL homolog 1 (MLH1), mutS homolog 2 (MSH2), postmeiotic segregation increased 1 (PMS1), post-meiotic segregation increased 2 (PMS2) and mutS homolog 6 (MSH6). Mutation risk prediction models can be incorporated into clinical practice, facilitating the decision-making process and identifying individuals for molecular investigation. This is extremely important in countries with limited economic resources. This study aims to evaluate sensitivity and specificity of five predictive models for germline mutations in repair genes in a sample of individuals with suspected Lynch syndrome. METHODS Blood samples from 88 patients were analyzed through sequencing MLH1, MSH2 and MSH6 genes. The probability of detecting a mutation was calculated using the PREMM, Barnetson, MMRpro, Wijnen and Myriad models. To evaluate the sensitivity and specificity of the models, receiver operating characteristic curves were constructed. RESULTS Of the 88 patients included in this analysis, 31 mutations were identified: 16 were found in the MSH2 gene, 15 in the MLH1 gene and no pathogenic mutations were identified in the MSH6 gene. It was observed that the AUC for the PREMM (0.846), Barnetson (0.850), MMRpro (0.821) and Wijnen (0.807) models did not present significant statistical difference. The Myriad model presented lower AUC (0.704) than the four other models evaluated. Considering thresholds of ≥ 5%, the models sensitivity varied between 1 (Myriad) and 0.87 (Wijnen) and specificity ranged from 0 (Myriad) to 0.38 (Barnetson). CONCLUSIONS The Barnetson, PREMM, MMRpro and Wijnen models present similar AUC. The AUC of the Myriad model is statistically inferior to the four other models.
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van Lier MGF, Leenen CHM, Wagner A, Ramsoekh D, Dubbink HJ, van den Ouweland AMW, Westenend PJ, de Graaf EJR, Wolters LMM, Vrijland WW, Kuipers EJ, van Leerdam ME, Steyerberg EW, Dinjens WNM. Yield of routine molecular analyses in colorectal cancer patients ≤70 years to detect underlying Lynch syndrome. J Pathol 2012; 226:764-74. [PMID: 22081473 DOI: 10.1002/path.3963] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 11/01/2011] [Accepted: 11/04/2011] [Indexed: 01/26/2023]
Abstract
Although early detection of Lynch syndrome (LS) is important, a considerable proportion of patients with LS remains unrecognized. We aimed to study the yield of LS detection by routine molecular analyses in colorectal cancer (CRC) patients until 70 years of age. We prospectively included consecutive CRC patients ≤70 years. Tumour specimens were analysed for microsatellite instability (MSI), immunohistochemical mismatch-repair protein expression and MLH1-promoter methylation. Tumours were classified as either: (a) likely caused by LS; (b) sporadic microsatellite-unstable (MSI-H); or (c) microsatellite-stable (MSS). Predictors of LS were determined by multivariable logistic regression. A total of 1117 CRC patients (57% males, median age 61 years) were included. Fifty patients (4.5%, 95% CI 3.4-5.9) were likely to have LS, and 71 had a sporadic MSI-H tumour (6.4%, 95% CI 5.1-8.0). Thirty-five patients likely to have LS (70%) were aged > 50 years. A molecular profile compatible with LS was detected in 10% (15/144) of patients aged ≤50, in 4% (15/377) of those aged 51-60 and in 3% (20/596) of patients > 61 years. Compared to MSS cases, patients likely to have LS were significantly younger (OR 3.9, 95% CI 1.7-8.7) and more often had right-sided CRCs (OR 14, 95% CI 6.0-34). In conclusion, molecular screening for LS in CRC patients ≤70 years leads to identification of a molecular profile compatible with LS in 4.5% of patients, with most of them not fulfilling the age criterion (≤50 years) routinely used for LS assessment. Routine use of MSI testing may be considered in CRC patients up to the age of 70 years, with a central role for the pathologist in the selection of patients.
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Affiliation(s)
- Margot G F van Lier
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
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Khan O, Blanco A, Conrad P, Gulden C, Moss TZ, Olopade OI, Kupfer SS, Terdiman J. Performance of Lynch syndrome predictive models in a multi-center US referral population. Am J Gastroenterol 2011; 106:1822-7; quiz 1828. [PMID: 21747416 PMCID: PMC3804147 DOI: 10.1038/ajg.2011.200] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Lynch syndrome is the most common cause of inherited colorectal cancer (CRC) and is due to germline mutations in mismatch repair (MMR) genes. Early Lynch syndrome diagnosis and appropriate CRC surveillance improves mortality. Traditional qualitative clinical criteria including Amsterdam and Bethesda guidelines may miss mutation carriers. Recently, quantitative predictive models including MMRPredict, PREMM(1,2,6), and MMRPro were developed to facilitate diagnosis. However, these models remain to be externally validated in the United States. Therefore, we evaluated the test characteristics of Lynch syndrome predictive models in a tertiary referral group at two US academic centers. METHODS We retrospectively collected data on 230 consecutive individuals who underwent genetic testing for MMR gene mutations at the University of Chicago and University of California at San Francisco's Cancer Risk Clinics. Each individual's risk of mutation was examined using MMRPredict, PREMM(1,2,6), and MMRPro. Amsterdam and Bethesda criteria were also determined. Testing characteristics were calculated for each of the models. RESULTS We included 230 individuals in the combined cohort. In all, 113 (49%) probands were MMR mutation carriers. Areas under the receiver operator characteristic curves were 0.76, 0.78, and 0.82 for MMRPredict, PREMM(1,2,6), and MMRPro, respectively. While similar in overall performance, our study highlights unique test characteristics of these three quantitative models including comparisons of sensitivity and specificity. Moreover, we identify characteristics of mutation carriers who were missed by each model. CONCLUSIONS Overall, all three Lynch syndrome predictive models performed comparably in our multi-center US referral population. These results suggest that Lynch syndrome predictive models can be used to screen for MMR mutation carriers and can provide improved test characteristics compared with traditional clinical criteria. Identification of MMR mutation carriers is paramount as appropriate screening can prevent CRC mortality in this high-risk group.
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Affiliation(s)
- Omar Khan
- Department of Medicine, Section of Gastroenterology, University of Chicago Medical Center, Chicago, IL
| | - Amie Blanco
- University of California San Francisco, Department of Medicine, San Francisco, CA
| | - Peggy Conrad
- University of California San Francisco, Department of Medicine, San Francisco, CA
| | - Cassandra Gulden
- Section of Hematology/Oncology, Center for Clinical Cancer Genetics, University of Chicago Medical Center, Chicago, IL
| | - Tovah Z. Moss
- Department of Medicine, Section of Gastroenterology, University of Chicago Medical Center, Chicago, IL
| | - Olufunmilayo I. Olopade
- Section of Hematology/Oncology, Center for Clinical Cancer Genetics, University of Chicago Medical Center, Chicago, IL
| | - Sonia S. Kupfer
- Department of Medicine, Section of Gastroenterology, University of Chicago Medical Center, Chicago, IL,Section of Hematology/Oncology, Center for Clinical Cancer Genetics, University of Chicago Medical Center, Chicago, IL
| | - Jonathan Terdiman
- University of California San Francisco, Department of Medicine, San Francisco, CA
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Ladabaum U, Wang G, Terdiman J, Blanco A, Kuppermann M, Boland CR, Ford J, Elkin E, Phillips KA. Strategies to identify the Lynch syndrome among patients with colorectal cancer: a cost-effectiveness analysis. Ann Intern Med 2011. [PMID: 21768580 DOI: 10.1059/0003-4819-155-2-201107190-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine. OBJECTIVE To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives. DESIGN Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers. DATA SOURCES Published literature. TARGET POPULATION All persons with newly diagnosed colorectal cancer and their relatives. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery. OUTCOME MEASURES Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36,200 per life-year gained. RESULTS OF SENSITIVITY ANALYSIS The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50,000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100,000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44,000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88,700 per incremental life-year gained compared with screening only up to age 70 years. LIMITATION Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered. CONCLUSION Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
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40
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Tresallet C, Brouquet A, Julié C, Beauchet A, Vallot C, Ménégaux F, Mitry E, Radvanyi F, Malafosse R, Rougier P, Nordlinger B, Laurent-Puig P, Boileau C, Emile JF, Muti C, Penna C, Hofmann-Radvanyi H. Evaluation of predictive models in daily practice for the identification of patients with Lynch syndrome. Int J Cancer 2011; 130:1367-77. [DOI: 10.1002/ijc.26144] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 03/25/2011] [Indexed: 11/11/2022]
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Ladabaum U, Wang G, Terdiman J, Blanco A, Kuppermann M, Boland CR, Ford J, Elkin E, Phillips KA. Strategies to identify the Lynch syndrome among patients with colorectal cancer: a cost-effectiveness analysis. Ann Intern Med 2011; 155:69-79. [PMID: 21768580 PMCID: PMC3793257 DOI: 10.7326/0003-4819-155-2-201107190-00002] [Citation(s) in RCA: 271] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine. OBJECTIVE To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives. DESIGN Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers. DATA SOURCES Published literature. TARGET POPULATION All persons with newly diagnosed colorectal cancer and their relatives. TIME HORIZON Lifetime. PERSPECTIVE Third-party payer. INTERVENTION Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery. OUTCOME MEASURES Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36,200 per life-year gained. RESULTS OF SENSITIVITY ANALYSIS The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50,000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100,000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44,000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88,700 per incremental life-year gained compared with screening only up to age 70 years. LIMITATION Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered. CONCLUSION Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.
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42
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Moussa SAB, Moussa A, Kourda N, Mezlini A, Abdelli N, Zerimech F, Najjar T, Jilani SB, Porchet N, Ayed FB, Manai M, Buisine MP. Lynch syndrome in Tunisia: first description of clinical features and germline mutations. Int J Colorectal Dis 2011; 26:455-67. [PMID: 21311894 DOI: 10.1007/s00384-010-1129-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE High rates of early colorectal cancers (CRC) are observed in Tunisia suggesting genetic susceptibility. Nevertheless, up to now, no molecular study has been performed in the Tunisian population. In our research, we evaluated the clinical characteristics of Tunisian families suspected of Lynch syndrome and the contribution of DNA mismatch repair (MMR) genes. METHODS Thirty-one unrelated families suspected of Lynch syndrome were studied. Probands were tested for the presence of germline mutations in the MMR genes MLH1, MSH2, MSH6 and in MUTYH. Available tumours were analysed for microsatellite instability and expression of MMR proteins. Detailed family and medical histories were collected. RESULTS A total of 134 cancers were noted in the 31 families, the most frequent type of cancer corresponding to CRC (69%), followed by uterine cancer (7.5%). Germline mutations were identified in 11 (35.5%) families (six MSH2, five MLH1, including seven novel mutations), seven of which fulfilled the Amsterdam criteria (sensitivity, 63.6%; positive predictive value, 58.3%). Noteworthy, germline mutations were detected in 52.6% of male patients tested, but in only 8.3% of females (p = 0.02). Moreover, CRC were essentially left sided in families without detected mutation (p = 0.017). Ages of onset of cancers and tumour spectrum were very similar in families with or without MMR germline mutation, contrasting with previous studies performed in other populations. CONCLUSIONS MMR genes contribute significantly to CRC susceptibility in the Tunisian population. However, the cause of early CRC susceptibility remains unknown in most cases, especially in women and in patients with early left colon or rectal cancer.
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Affiliation(s)
- Sana Aissi-Ben Moussa
- Laboratoire de Biochimie et Biologie Moléculaire de Faculté des Sciences de Tunis, Tunis, Tunisia
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43
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Gallagher DJ, Smith JD, Offit K, Stadler ZK. Diagnosing hereditary colorectal cancer. Clin Colorectal Cancer 2011; 9:205-11. [PMID: 20920991 DOI: 10.3816/ccc.2010.n.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Although progress in the treatment of patients with colorectal cancer (CRC) has resulted in improved median survival, most patients with metastatic CRC still die of their disease, and essentially all patients with early-stage disease must undergo surgical resection and subsequently face the possibility of adjuvant chemotherapy. As effective screening and prevention strategies for CRC have been developed, identification of individuals with a hereditary predisposition to developing CRC is especially important and provides the opportunity to reduce disease burden in this high-risk population. Increased awareness and improved diagnostic techniques for hereditary CRC syndromes have facilitated more frequent diagnosis and management of a small number of highly penetrant syndromes within families. However, known high-penetrance genetic predisposition syndromes account for a minority of all familial CRC, leaving much of the genetic basis of CRC unexplained. Recent advances in high-throughput genotyping have made possible genome-wide association studies, which have identified novel genetic variants associated with modest increases in CRC risk. While these associations have helped to identify potentially important pathways in CRC carcinogenesis, at the current time, the clinical use of such genetic risk variants in colon cancer risk stratification remains limited.
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Affiliation(s)
- David J Gallagher
- Department of Medicine, Clinical Genetics Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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44
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Kastrinos F, Steyerberg EW, Mercado R, Balmaña J, Holter S, Gallinger S, Siegmund KD, Church JM, Jenkins MA, Lindor NM, Thibodeau SN, Burbidge LA, Wenstrup RJ, Syngal S. The PREMM(1,2,6) model predicts risk of MLH1, MSH2, and MSH6 germline mutations based on cancer history. Gastroenterology 2011; 140:73-81. [PMID: 20727894 PMCID: PMC3125673 DOI: 10.1053/j.gastro.2010.08.021] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 08/02/2010] [Accepted: 08/12/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS We developed and validated a model to estimate the risks of mutations in the mismatch repair (MMR) genes MLH1, MSH2, and MSH6 based on personal and family history of cancer. METHODS Data were analyzed from 4539 probands tested for mutations in MLH1, MSH2, and MSH6. A multivariable polytomous logistic regression model (PREMM(1,2,6)) was developed to predict the overall risk of MMR gene mutations and the risk of mutation in each of the 3 genes. The discriminative ability of the model was validated in 1827 population-based colorectal cancer (CRC) cases. RESULTS Twelve percent of the original cohort carried pathogenic mutations (204 in MLH1, 250 in MSH2, and 71 in MSH6). The PREMM(1,2,6) model incorporated the following factors from the probands and first- and second-degree relatives (odds ratio; 95% confidence intervals [CIs]): male sex (1.9; 1.5-2.4), a CRC (4.3; 3.3-5.6), multiple CRCs (13.7; 8.5-22), endometrial cancer (6.1; 4.6-8.2), and extracolonic cancers (3.3; 2.4-4.6). The areas under the receiver operating characteristic curves were 0.86 (95% CI, 0.82-0.91) for MLH1 mutation carriers, 0.87 (95% CI, 0.83-0.92) for MSH2, and 0.81 (95% CI, 0.69-0.93) for MSH6; in validation, they were 0.88 for the overall cohort (95% CI, 0.86-0.90) and the population-based cases (95% CI, 0.83-0.92). CONCLUSIONS We developed the PREMM(1,2,6) model, which incorporates information on cancer history from probands and their relatives to estimate an individual's risk of mutations in the MMR genes MLH1, MSH2, and MSH6. This Web-based decision making tool can be used to assess risk of hereditary CRC and guide clinical management.
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Affiliation(s)
- Fay Kastrinos
- Herbert Irving Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York 10032, USA.
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rowena Mercado
- Population Sciences Division, Dana-Farber Cancer Institute, Spain
| | - Judith Balmaña
- Department of Medical Oncology, Hospital Vall d’Hebrón, Medical Department of Universitat Autònoma de Barcelona, Spain
| | - Spring Holter
- Dr. Zane Cohen Digestive Diseases Clinical Research Centre, Mount Sinai Hospital, University of Toronto, ON, Canada
| | - Steven Gallinger
- Dr. Zane Cohen Digestive Diseases Clinical Research Centre, Mount Sinai Hospital, University of Toronto, ON, Canada,Department of Surgery, University Health Network, University of Toronto, ON, Canada
| | | | - James M. Church
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mark A. Jenkins
- Cancer Epidemiology Centre, Victorian Cancer Registry, Carlton, Victoria, Australia
| | | | | | | | | | - Sapna Syngal
- Population Sciences Division, Dana-Farber Cancer Institute, Spain,Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
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Gupta S, Ashfaq R, Kapur P, Afonso BB, Nguyen TPT, Ansari F, Boland CR, Goel A, Rockey DC. Microsatellite instability among individuals of Hispanic origin with colorectal cancer. Cancer 2010; 116:4965-72. [PMID: 20665498 DOI: 10.1002/cncr.25486] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the presence of microsatellite instability (MSI) in patients with colorectal cancer (CRC) may have implications for prognosis, therapy, and family counseling, to the authors' knowledge, the prevalence of MSI has not been well described among individuals of Hispanic origin with CRC residing in the United States. METHODS A retrospective cohort study using a hospital-based tumor registry to identify individuals of Hispanic origin who were diagnosed with CRC was conducted. Clinical data and tumor samples were retrieved. Molecular analyses included testing for MSI using a panel of 5 mononucleotide markers (BAT25, BAT26, NR21, NR24, and NR27) in a pentaplex polymerase chain reaction assay, as well as immunohistochemistry for the mismatch repair (MMR) proteins mutL homolog (MLH) 1, mutS homolog (MSH) 2, MSH6, and postmeiotic segregation increased 2 (PMS2) 2 on representative tissue. RESULTS A total of 111 individuals of Hispanic origin with CRC were identified. Approximately 41.4% were women, and the median age was 57 years (interquartile range [IQR], 47.1-63.5 years). Eleven patients (9.9%; 95% confidence interval [95% CI], 4.2%-15.6%) had MSI CRC, whereas 14 patients (12.6%; 95% CI, 7.3%-21.8%) had CRC with ≥1 MMR protein abnormality. Ten of 11 individuals with MSI had clinical or molecular characteristics suspicious for Lynch syndrome such as abnormal expression of MSH2 and/or MSH6 (n=7) or age<50 years at the time of diagnosis (n=7). CONCLUSIONS The prevalence of MSI CRC among Hispanic individuals may be similar to that of other races and ethnicities, but clinicopathological characteristics, including age at diagnosis and pattern of abnormal MMR protein expression, suggest that sporadic MSI CRC may be less common in individuals of Hispanic origin, and that much of the MSI observed in this situation may be attributable to Lynch syndrome. Further exploration of the causes of disparate presentations of CRC by ethnicity and race is warranted.
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Affiliation(s)
- Samir Gupta
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA.
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Stoffel EM, Chittenden A. Genetic testing for hereditary colorectal cancer: challenges in identifying, counseling, and managing high-risk patients. Gastroenterology 2010; 139:1436-41, 1441.e1. [PMID: 20858494 DOI: 10.1053/j.gastro.2010.09.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Elena M Stoffel
- Cancer Risk and Prevention Clinic, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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47
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De Jesus-Monge WE, Gonzalez-Keelan C, Zhao R, Hamilton SR, Rodriguez-Bigas M, Cruz-Correa M. Mismatch repair protein expression and colorectal cancer in Hispanics from Puerto Rico. Fam Cancer 2010; 9:155-66. [PMID: 20012372 DOI: 10.1007/s10689-009-9310-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Colorectal cancer (CRC) is a leading cause of morbidity and mortality and alterations in mismatch repair (MMR) genes, leading to absent protein (negative) expression, are responsible for approximately 20% of CRC cases. Immunohistochemistry is a tool for prescreening of MMR protein expression in CRC but the literature on its use on Hispanics is scarce. However, Hispanics represent the second leading ethnicity in the United States (US) and CRC is a public health burden in this group. Our objectives were to determine the frequency of MMR protein-negative CRC and to evaluate its association with clinical and pathological characteristics among Hispanics from Puerto Rico, for the first time to our knowledge. A retrospective observational study of unselected CRC patients from the Puerto Rico Medical Center from 2001 to 2005 was done. MLH1 and MSH2, the most commonly altered MMR genes, protein expression was evaluated using immunohistochemistry, with microsatellite instability (MSI) and BRAF gene analyses in the absence of MLH1 protein expression. One-hundred sixty-four CRC patients were evaluated: the overall MMR protein-negative frequency was 4.3%, with 0.6% frequency of co-occurrence of MLH1-protein negative expression, MSI-high, and normal BRAF gene. MMR protein-negative expression was associated with proximal colon location (P = 0.02) and poor histological tumor differentiation (P = 0.001), but not with other characteristics. The frequency of MMR protein-negative CRC in Hispanics from Puerto Rico was lower than reported in other populations. This finding may explain the lower CRC incidence rate among US Hispanics as compared to US non-Hispanic whites and blacks.
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Boland CR, Shike M. Report from the Jerusalem workshop on Lynch syndrome-hereditary nonpolyposis colorectal cancer. Gastroenterology 2010; 138:2197.e1-7. [PMID: 20416305 PMCID: PMC3032350 DOI: 10.1053/j.gastro.2010.04.024] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
A Workshop was held in Jerusalem, Israel, on October 26 and 27, 2009 to discuss the management of Lynch syndrome-hereditary nonpolyposis colorectal cancer (CRC), with the primary goal to develop consensus for the optimal management of this disease. A second goal was to identify areas of research with the potential to advance the clinical management of Lynch syndrome. The perspectives and recommendations from the workshop are meant to be a platform for discussion and deliberation. The Workshop was organized by Moshe Shike (Memorial Sloan Kettering Cancer Center, New York) and sponsored by The Colon Cancer Foundation. More details of each presentation are available in an on-line supplement.
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Affiliation(s)
| | - Moshe Shike
- Memorial Sloan Kettering Cancer Center, New York, New York
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49
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Quispe I, Balmaña J. Desarrollo y aplicación de modelos predictivos en el síndrome de Lynch. Med Clin (Barc) 2010; 134:412-7. [DOI: 10.1016/j.medcli.2009.02.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Accepted: 02/12/2009] [Indexed: 12/20/2022]
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50
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Monzon JG, Cremin C, Armstrong L, Nuk J, Young S, Horsman DE, Garbutt K, Bajdik CD, Gill S. Validation of predictive models for germline mutations in DNA mismatch repair genes in colorectal cancer. Int J Cancer 2010; 126:930-9. [PMID: 19653273 DOI: 10.1002/ijc.24808] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lynch syndrome is defined by the presence of germline mutations in mismatch repair (MMR) genes. Several models have been recently devised that predict mutation carrier status (Myriad Genetics, Wijnen, Barnetson, PREMM and MMRpro models). Families at moderate-high risk for harboring a Lynch-associated mutation, referred to the BC Cancer Agency (BCCA) Hereditary Cancer Program (HCP), underwent mutation analysis, immunohistochemistry and/or microsatellite testing. Seventy-two tested cases were included. Twenty-five patients were mutation positive (34.7%) and 47 were mutation negative (65.3%). Nineteen of 43 patients who were both microsatellite stable and normal on immunohistochemistry for MLH1 and MSH2 were also genotyped for mutations in these genes; all 19 were negative for MMR gene mutations. Model-derived probabilities of harboring a MMR gene mutation in the proband were calculated and compared to observed results. The area under the ROC curves were 0.75 (95%CI; 0.63-0.87), 0.86 (0.7-0.96), 0.89 (0.82-0.97), 0.89 (0.81-0.98) and 0.93 (0.86-0.99) for the Myriad, Barnetson, Wijnen, MMRpro and PREMM models, respectively. The Amsterdam II criteria had a sensitivity and specificity of 0.76 and 0.74, respectively, in this cohort. The PREMM model demonstrated the best performance for predicting carrier status based on the positive likelihood ratios at the >10%, >20% and >30% probability thresholds. In this referred cohort, the PREMM model had the most favorable concordance index and predictive performance for carrier status based on the positive LR. These prediction models (PREMM, MMRPro and Wijnen) may soon replace the Amsterdam II and revised Bethesda criteria as a prescreening tool for Lynch mutations.
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Affiliation(s)
- Jose G Monzon
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada
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