ACG Clinical Report and Recommendations on Transition of Care in Children and Adolescents With Hereditary Polyposis Syndromes

Transition of care in pediatric hereditary polyposis: the why, how and to whom

INTRODUCTION

Transition of care (TOC) is a process that must be planned and executed in a coordinated manner factoring patient, family, disease, and healthcare system. Among youth with gastrointestinal hereditary polyposis syndromes (HPS), poorly planned TOC can have devastating consequences from poor engagement in necessary medical care. This results in increased risk of cancer and related mortality. This review aims to emphasize unique aspects of HPS relevant to TOC, related barriers/challenges, and outline current best practice recommendations.

AREAS COVERED

A review was undertaken of transition-focused practice guidelines among youth with chronic conditions, as well as literature from major pediatric gastroenterology societies on the ideal approach for managing polyposis syndromes. Literature from PubMed and Medline, including conference abstracts and proceedings, was reviewed and in the absence of empirically supported evidence, recommendations reflect the opinion of the author experts involved in the care of adolescents and young adults (AYA) with HPS.

EXPERT OPINION

Effective TOC requires a structured, patient-centered, individualized process that includes early engagement, incremental education, and multidisciplinary collaboration. Given the unique aspects of HPS, including complex psychosocial and medical needs, there is urgent need for research toward evidence-based strategies enhancing continuity, and mitigating socio-cultural and financial barriers to care.

Health Care Transition Programs for Adolescents and Young Adults With Hereditary Cancer Predisposition: A Scoping Review

Adolescents and young adults (AYA) with increased risk for cancer due to hereditary predisposition, previous cancer treatment, or both are eligible for increased surveillance, chemoprevention, and prophylactic surgery that can improve early detection and prevention of cancers. One way to ensure continuity of cancer prevention care is to support adolescents through the transition from pediatric to adult health care. Yet, there are limited data on the impl ementation of health care transition (HCT) programs for AYA with increased risk for cancer. We conducted a scoping review of the literature on transition programs for AYA at increased risk of cancer due to known germline risk or prior cancer diagnosis, with a focus on implementation factors relevant to designing, implementing, and sustaining a new program. Data from 54 articles were extracted and analyzed using the RE-AIM implementation science framework. Few HCT programs have been implemented for AYA with hereditary cancer syndromes. Several groups have done preimplementation work for future hereditary cancer programs, but programs for cancer survivors are farther along the translational spectrum. We identified implementation factors along the five RE-AIM dimensions to assist preimplementation planning for HCT programs for AYA with increased risk for cancer.

Cold Snare Polypectomy in Pediatric Polyposis: A Multicenter Experience

Background: Cold snare polypectomy (CSP) is a well-established and recommended technique in adult gastroenterology for the safe, efficient and complete removal of nonpedunculated lesions up to 10 mm, with piecemeal excision possible for larger lesions. However, the application of CSP in pediatric patients remains underexplored. This study summarizes a multicenter experience of CSP in pediatric polyposis patients, focusing on safety, efficacy and clinical outcomes. Methods: This retrospective study was conducted at two pediatric tertiary centers, encompassing patients aged 1 to 21 years with polyposis who underwent colonoscopy with CSP and hot snare polypectomy (HSP) between January 2022 and January 2023. Patient demographics, procedure characteristics, polyp details and clinical outcomes were analyzed. Results: A total of 477 CSPs were performed in 63 colonoscopies. Satisfactory bowel preparation was noted in 79% of procedures, with a pooled mean procedure duration of 52 min and cecal intubation achieved in 98%. Polyps resected by CSP ranged from 3 to 70 mm in size and were predominantly left-sided. Tissue retrieval was complete in 94% of cases and partial in 5%. Mild intraprocedural bleeding occurred in 25% of CSP cases, requiring endoclip placement in 19%, with no post-procedural bleeding or significant complications observed. Comparatively, CSP demonstrated favorable bleeding rates relative to HSP. At two-week follow-up, four patients required emergency evaluation for unrelated complaints, but with no adverse events attributed to CSP. Conclusions: CSP is a safe and effective technique for the removal of sessile polyps in pediatric patients with polyposis. Mild intraprocedural bleeding, when observed, was effectively managed with standard hemostatic techniques. These findings support the potential of CSP as a preferred modality for sessile polyp removal in pediatric patients, though further research is warranted to define its role across broader pediatric populations and practice settings.

Clinician perspectives on designing and implementing a hereditary cancer transition clinic

Early identification of hereditary cancer predisposition in adolescents and young adults represents a unique opportunity to target cancer prevention and improve survival in a population at risk for adverse health outcomes. However, adolescents and young adults face challenges unique to their stage of life that can undermine their transition from pediatric to adult healthcare and lead to interruptions in preventative care. The purpose of this study was to understand expert perspectives on factors relevant to designing and implementing a transition clinic for adolescents and young adults with hereditary cancer predisposition. We used qualitative methods informed by human-centered design and implementation science to identify implementation considerations rooted in clinician experience. To understand clinic design and clinician experience at Geisinger transition clinics, we conducted a contextual inquiry using clinic observations and follow-up interviews of clinicians. To learn about designing and implementing a transition program, we also conducted in-depth interviews with national transition experts actively involved in developing, implementing, or participating in transition clinics around the United States. The contextual inquiry resulted in three diagrams depicting the following common elements of transition clinics at our institution: relationship building with patients, care coordination, stepwise transition education, communication between providers, and a sustainable clinic home. Interviews were analyzed deductively using thematic analysis to learn clinician perspectives about program implementation specific to each domain of the RE-AIM theoretical framework: reach, effectiveness, adoption, implementation, and maintenance.

Transitions of care for adolescents with disorders of gut-brain interaction

OBJECTIVES

Little is known about the experience of adolescents and young adults (AYA) with disorders of gut-brain interaction (DGBI) who transition from pediatric to adult gastroenterology care. In this two-part study, we used quantitative and qualitative methods to: (1) assess incidence of optimal versus suboptimal transitions of care for AYA with DGBI, (2) characterize health and quality of life effects of the transition, and (3) identify barriers and facilitators for optimal transition of care.

METHODS

In Part 1, we conducted a retrospective review of AYA referrals to our adult neurogastroenterology clinic who had transitioned from pediatric gastroenterology care (N = 109, 17-23 years, 72% female). We collected demographic, psychosocial, and healthcare utilization data to determine rate and risk factors for suboptimal transitions. In Part 2, we recruited 24 AYA and parents (n = 19 AYA, n = 5 parents) for completion of a survey and semistructured interview, which was analyzed using validated rapid qualitative analysis method.

RESULTS

In Part 1, 20% (22/109) of AYA met the criteria for suboptimal transition of care, which was associated with treatment adherence concern and functional impairment. In Part 2, we identified two principal themes: (1) AYA's health and quality of life are impacted during the transition, and (2) parental involvement and collaboration with pediatric gastrointestinal are facilitators to successful transitions, whereas access to care and practice style change are barriers.

CONCLUSION

AYA with DGBI have high rates of suboptimal care transitions, affecting their health and quality of life. Our study highlights the need for a comprehensive approach that incorporates parents and pediatric providers.

Endoscopy in pediatric polyposis syndromes: why, when and how

Single or multiple polyps are frequently encountered during colonoscopy among children and adolescents and may be indicative of hereditary polyposis syndrome (HPS). The management of children with single or multiple polyps is guided by the number of polyps, their distribution and the histological findings. Children with HPS carry a high risk of complications, including intestinal and extra-intestinal malignancies. The goals of surveillance in pediatric HPS are to treat symptoms, monitor the burden of polyps and prevent short- and long-term complications. Therefore, the management of children with HPS is based on therapeutic endoscopy. The strategy of therapeutic endoscopy is a careful assessment and characterization of the polyps and performing polypectomies using advanced endoscopic techniques. A multidisciplinary approach, comprising clinical, interventional endoscopy, cancer surveillance and support of familial and emotional aspects is essential in the management of children with HPS.

Polyps and Polyposis Syndromes in Children: Novel Endoscopic Considerations

Polypectomy is the most common therapeutic endoscopic intervention in children. Management of sporadic juvenile polyps is limited to polypectomy to resolve symptoms, whereas polyposis syndromes pose a multidisciplinary challenge with broader ramifications. In preparation for polypectomy, there are key patient, polyp, endoscopy unit, and provider characteristics that factor into the likelihood of success. Younger age and multiple medical comorbidities increase the risk of adverse outcomes, classified as intraoperative, immediate postoperative, and delayed postoperative complications. Novel techniques, including cold snare polypectomy, can significantly decrease adverse events but a more structured training process for polypectomy in pediatric gastroenterology is needed.

Diagnosis and Management of Cancer Risk in the Gastrointestinal Hamartomatous Polyposis Syndromes: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

The gastrointestinal hamartomatous polyposis syndromes are rare, autosomal dominant disorders associated with an increased risk of benign and malignant intestinal and extraintestinal tumors. They include Peutz-Jeghers syndrome, juvenile polyposis syndrome, the PTEN hamartoma tumor syndrome (including Cowden's syndrome and Bannayan-Riley-Ruvalcaba syndrome), and hereditary mixed polyposis syndrome. Diagnoses are based on clinical criteria and, in some cases, confirmed by demonstrating the presence of a germline pathogenic variant. The best understood hamartomatous polyposis syndrome is Peutz-Jeghers syndrome, caused by germline pathogenic variants in the STK11 gene. The management is focused on prevention of bleeding and mechanical obstruction of the small bowel by polyps and surveillance of organs at increased risk for cancer. Juvenile polyposis syndrome is caused by a germline pathogenic variant in either the SMAD4 or BMPR1A genes, with differing clinical courses. Patients with SMAD4 pathogenic variants may have massive gastric polyposis, which can result in gastrointestinal bleeding and/or protein-losing gastropathy. Patients with SMAD4 mutations usually have the simultaneous occurrence of hereditary hemorrhagic telangiectasia (juvenile polyposis syndrome-hereditary hemorrhagic telangiectasia overlap syndrome) that can result in epistaxis, gastrointestinal bleeding from mucocutaneous telangiectasias, and arteriovenous malformations. Germline pathogenic variants in the PTEN gene cause overlapping clinical phenotypes (known as the PTEN hamartoma tumor syndromes), including Cowden's syndrome and related disorders that are associated with an increased risk of gastrointestinal and colonic polyposis, colon cancer, and other extraintestinal manifestations and cancers. Due to the relative rarity of the hamartomatous polyposis syndromes, recommendations for management are based on few studies. This U.S Multi-Society Task Force on Colorectal Cancer consensus statement summarizes the clinical features, assesses the current literature, and provides guidance for diagnosis, assessment, and management of patients with the hamartomatous polyposis syndromes, with a focus on endoscopic management.

Diagnosis and management of cancer risk in the gastrointestinal hamartomatous polyposis syndromes: recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer

The gastrointestinal hamartomatous polyposis syndromes are rare, autosomal dominant disorders associated with an increased risk of benign and malignant intestinal and extraintestinal tumors. They include Peutz-Jeghers syndrome, juvenile polyposis syndrome, the PTEN hamartoma tumor syndrome (including Cowden's syndrome and Bannayan-Riley-Ruvalcaba syndrome), and hereditary mixed polyposis syndrome. Diagnoses are based on clinical criteria and, in some cases, confirmed by demonstrating the presence of a germline pathogenic variant. The best understood hamartomatous polyposis syndrome is Peutz-Jeghers syndrome, caused by germline pathogenic variants in the STK11 gene. The management is focused on prevention of bleeding and mechanical obstruction of the small bowel by polyps and surveillance of organs at increased risk for cancer. Juvenile polyposis syndrome is caused by a germline pathogenic variant in either the SMAD4 or BMPR1A genes, with differing clinical courses. Patients with SMAD4 pathogenic variants may have massive gastric polyposis, which can result in gastrointestinal bleeding and/or protein-losing gastropathy. Patients with SMAD4 mutations usually have the simultaneous occurrence of hereditary hemorrhagic telangiectasia (juvenile polyposis syndrome-hereditary hemorrhagic telangiectasia overlap syndrome) that can result in epistaxis, gastrointestinal bleeding from mucocutaneous telangiectasias, and arteriovenous malformations. Germline pathogenic variants in the PTEN gene cause overlapping clinical phenotypes (known as the PTEN hamartoma tumor syndromes), including Cowden's syndrome and related disorders that are associated with an increased risk of gastrointestinal and colonic polyposis, colon cancer, and other extraintestinal manifestations and cancers. Due to the relative rarity of the hamartomatous polyposis syndromes, recommendations for management are based on few studies. This U.S. Multi-Society Task Force on Colorectal Cancer consensus statement summarizes the clinical features, assesses the current literature, and provides guidance for diagnosis, assessment, and management of patients with the hamartomatous polyposis syndromes, with a focus on endoscopic management.

Diagnosis and Management of Cancer Risk in the Gastrointestinal Hamartomatous Polyposis Syndromes: Recommendations From the US Multi-Society Task Force on Colorectal Cancer

The gastrointestinal hamartomatous polyposis syndromes are rare, autosomal dominant disorders associated with an increased risk of benign and malignant intestinal and extraintestinal tumors. They include Peutz-Jeghers syndrome, juvenile polyposis syndrome, the PTEN hamartoma tumor syndrome (including Cowden's syndrome and Bannayan-Riley-Ruvalcaba syndrome), and hereditary mixed polyposis syndrome. Diagnoses are based on clinical criteria and, in some cases, confirmed by demonstrating the presence of a germline pathogenic variant. The best understood hamartomatous polyposis syndrome is Peutz-Jeghers syndrome, caused by germline pathogenic variants in the STK11 gene. The management is focused on prevention of bleeding and mechanical obstruction of the small bowel by polyps and surveillance of organs at increased risk for cancer. Juvenile polyposis syndrome is caused by a germline pathogenic variant in either the SMAD4 or BMPR1A genes, with differing clinical courses. Patients with SMAD4 pathogenic variants may have massive gastric polyposis, which can result in gastrointestinal bleeding and/or protein-losing gastropathy. Patients with SMAD4 mutations usually have the simultaneous occurrence of hereditary hemorrhagic telangiectasia (juvenile polyposis syndrome-hereditary hemorrhagic telangiectasia overlap syndrome) that can result in epistaxis, gastrointestinal bleeding from mucocutaneous telangiectasias, and arteriovenous malformations. Germline pathogenic variants in the PTEN gene cause overlapping clinical phenotypes (known as the PTEN hamartoma tumor syndromes), including Cowden's syndrome and related disorders that are associated with an increased risk of gastrointestinal and colonic polyposis, colon cancer, and other extraintestinal manifestations and cancers. Due to the relative rarity of the hamartomatous polyposis syndromes, recommendations for management are based on few studies. This US Multi-Society Task Force on Colorectal Cancer consensus statement summarizes the clinical features, assesses the current literature, and provides guidance for diagnosis, assessment, and management of patients with the hamartomatous polyposis syndromes, with a focus on endoscopic management.

Evaluation of Classic, Attenuated, and Oligopolyposis of the Colon

The goal of this review is to provide an overview of evaluating patients with adenomatous polyposis of the colon, including elements such as generating a differential diagnosis, referral considerations for genetic testing, genetic testing options, and expected outcomes from genetic testing in these individuals. In more recent years, adenomatous colonic polyposis has evolved beyond the more robustly characterized familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP) now encompassing more newly described genes and associated syndromes. Technological innovation, from whole-exome sequencing to multigene panel testing, has dramatically increased the amount of genotypic and phenotypic data amassed in adenomatous polyposis cohorts, which has contributed greatly to informing diagnosis and clinical management of affected individuals and their families.

Chemoprevention Considerations in Patients with Hereditary Colorectal Cancer Syndromes

Secondary prevention of colorectal neoplasia with chemoprevention is long-studied area of research and clinical use in patients with the 2 most common hereditary colorectal cancer syndromes including Lynch syndrome and familial adenomatous polyposis. No medication is currently approved for use for the prevention of colorectal polyps or cancer in either the general population or individuals with the hereditary colorectal cancer syndromes. Emerging data in animal models and limited data in humans suggest vaccines may be the next breakthrough for neoplasia prevention in patients with hereditary colorectal cancer. Clinicians must acknowledge chemoprevention is an adjunct and does not supplant endoscopic surveillance.