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Potter AJ, Colebatch AJ, Rawson RV, Ferguson PM, Cooper WA, Gupta R, O'Toole S, Saw RPM, Ch'ng S, Menzies AM, Long GV, Scolyer RA. Pathologist initiated reflex BRAF mutation testing in metastatic melanoma: experience at a specialist melanoma treatment centre. Pathology 2022; 54:526-532. [PMID: 35249747 DOI: 10.1016/j.pathol.2021.12.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 11/28/2022]
Abstract
Testing for BRAF mutations in metastatic melanoma is pivotal to identifying patients suitable for targeted therapy and influences treatment decisions regarding single agent versus combination immunotherapy. Knowledge of BRAF V600E immunohistochemistry (IHC) results can streamline decisions during initial oncology consultations, prior to DNA-based test results. In the absence of formal guidelines that require pathologist initiated ('reflex') BRAF mutation testing, our institution developed a local protocol to perform BRAF V600E IHC on specimens from all stage III/IV melanoma patients when the status is otherwise unknown. This study was designed to evaluate the application of this protocol in a tertiary referral pathology department. A total of 408 stage III/IV melanoma patients had tissue specimens accessioned between 1 January and 31 March in three consecutive years (from 2019 to 2021), reported by 32 individual pathologists. The BRAF mutation status was established by pathologists in 87% (352/408) of cases. When a prior BRAF mutation status was previously known, as confirmed in linked electronic records (202/408), this status had been communicated by the clinician on the pathology request form in 1% of cases (3/202). Pathologists performed BRAF V600E IHC in 153 cases (74% of cases where the status was unknown, 153/206) and testing was duplicated in 5% of cases (20/408). Reflex BRAF IHC testing was omitted in 26% of cases (53/206), often on specimens with small volume disease (cytology specimens or sentinel node biopsies) despite adequate tissue for testing. Incorporating BRAF IHC testing within routine diagnostic protocols of stage III/IV melanoma was both feasible and successful in most cases. Communication of a patient's BRAF mutation status via the pathology request form will likely improve implementation of pathologist initiated BRAF mutation testing and may result in a reduction of duplicate tests. To improve pathologist reflex testing rates, we advocate for the use of an algorithmic approach to pathologist initiated BRAF mutation testing utilising both IHC and DNA-based methodologies for stage III/IV melanoma patients.
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Affiliation(s)
- Alison J Potter
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J Colebatch
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia
| | - Robert V Rawson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter M Ferguson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Wendy A Cooper
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Western Sydney University, Campbelltown, NSW, Australia
| | - Ruta Gupta
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sandra O'Toole
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Western Sydney University, Campbelltown, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Mater Hospital, North Sydney, NSW, Australia
| | - Sydney Ch'ng
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Mater Hospital, North Sydney, NSW, Australia; Chris O'Brien Lifehouse, Camperdown, NSW, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Mater Hospital, North Sydney, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Mater Hospital, North Sydney, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Snedden TW, McCracken A, Vaidyanathan A, Taranova A, Villarreal R, Qamar S, Arora SP. Implementation of Universal Tumor Screening of Colorectal Cancer for Detection of Lynch Syndrome at a Hispanic-Rich County Hospital. JCO Oncol Pract 2020; 16:e948-e957. [PMID: 32452745 DOI: 10.1200/jop.19.00508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In 2014, a reflexive screening protocol for Lynch syndrome (LS) via an immunohistochemistry (IHC) assay was shown to be cost-effective; however, the screening rates at a predominant Hispanic-rich institution are unclear. We hypothesized that implementation of a universal tumor screening (UTS) protocol requiring screening for LS via IHC in patients with newly diagnosed colorectal cancer (CRC) at our Hispanic-rich institution would improve detection of LS by increasing screening rates. METHODS AND MATERIALS This is a retrospective analysis of screening rates of 3 sequential cohorts of newly diagnosed patients with CRC between January 2012 and April 2016 at the University Health System and with follow-up at National Cancer Institute-designated Mays Cancer Center at University of Texas Health San Antonio. Cohort 1 consisted of patients screened using old screening guidelines (PRE). Cohort 2 consisted of patients screened when treating clinicians were receiving education on the new protocol (PERI). Cohort 3 consisted of patients screened after implementation of the UTS protocol (POST). RESULTS The majority of 312 patients were Hispanic (62.5%), 18.1% were < 50 years, and 81.9% were ≥ 50 years of age (median age, 57 years). Of patients with CRC screened for LS via IHC, the PRE, PERI, and POST cohorts had screening rates of 31%, 64%, and 58%, respectively. We found significant differences when comparing the PRE with POST sequential cohorts (P < .01). CONCLUSION The quality of Lynch syndrome-related family histories and screening rates were significantly improved after implementation in our Hispanic-rich population. Future studies are warranted to provide insight into clinical effects of increased screening, provider and patient surveillance, and screening-related systemic barriers.
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Affiliation(s)
- Tyler W Snedden
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX
| | | | | | | | | | - Samina Qamar
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX
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Powers EM, Shiffman RN, Melnick ER, Hickner A, Sharifi M. Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review. J Am Med Inform Assoc 2019; 25:1556-1566. [PMID: 30239810 DOI: 10.1093/jamia/ocy112] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/26/2018] [Indexed: 11/13/2022] Open
Abstract
Objective Clinical decision support (CDS) hard-stop alerts-those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party-are increasingly common but can be problematic. To understand their appropriate application, we asked 3 key questions: (1) To what extent are hard-stop alerts effective in improving patient health and healthcare delivery outcomes? (2) What are the adverse events and unintended consequences of hard-stop alerts? (3) How do hard-stop alerts compare to soft-stop alerts? Methods and Materials Studies evaluating computerized hard-stop alerts in healthcare settings were identified from biomedical and computer science databases, gray literature sites, reference lists, and reviews. Articles were extracted for process outcomes, health outcomes, unintended consequences, user experience, and technical details. Results Of 32 studies, 15 evaluated health outcomes, 16 process outcomes only, 10 user experience, and 4 compared hard and soft stops. Seventy-nine percent showed improvement in health outcomes and 88% in process outcomes. Studies reporting good user experience cited heavy user involvement and iterative design. Eleven studies reported on unintended consequences including avoidance of hard-stopped workflow, increased alert frequency, and delay to care. Hard stops were superior to soft stops in 3 of 4 studies. Conclusions Hard stops can be effective and powerful tools in the CDS armamentarium, but they must be implemented judiciously with continuous user feedback informing rapid, iterative design. Investigators must report on associated health outcomes and unintended consequences when implementing IT solutions to clinical problems.
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Affiliation(s)
- Emily M Powers
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Richard N Shiffman
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Hickner
- Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mona Sharifi
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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Renshaw AA, Gould EW. Improving Discrete Data Capture in Synoptic Reports With Optional Free-Text Modifiers. JCO Clin Cancer Inform 2019; 2:1-6. [PMID: 30652544 DOI: 10.1200/cci.17.00127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Upfront, discrete data capture in synoptic reporting fails when pathologists choose a response not associated with discrete data. We sought to determine the factors associated with this event. METHODS The results of all "Other" entries in four common tumor sites in synoptic reports were reviewed. RESULTS "Other" entries occurred in 329 of 13,421 questions (2.5%). In 306 of these 329 questions (93.0%), the pathologist appeared to choose this response because they wished to add additional information to an already existing response that was associated with discrete data capture. As a result, the addition of a free-text modifiers to existing responses would allow pathologist to add this additional information while still selecting a response associated with discrete data capture, significantly improving the total discrete data capture (13,092 of 13,421 questions [97.5%] v 13,398 of 13,421 questions [99.8%]; P < .001). CONCLUSION The addition of free-text modifiers to structured responses in synoptic reports could significantly improve the discrete data capture rate.
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Affiliation(s)
- Andrew A Renshaw
- Andrew A. Renshaw and Edwin W. Gould, Miami Cancer Institute and Baptist Hospital, Miami, FL
| | - Edwin W Gould
- Andrew A. Renshaw and Edwin W. Gould, Miami Cancer Institute and Baptist Hospital, Miami, FL
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Renshaw AA, Mena-Allauca M, Gould EW, Sirintrapun SJ. Synoptic Reporting: Evidence-Based Review and Future Directions. JCO Clin Cancer Inform 2018; 2:1-9. [PMID: 30652566 PMCID: PMC6873952 DOI: 10.1200/cci.17.00088] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Andrew A. Renshaw
- Andrew A. Renshaw, Mercy Mena-Allauca, and Edwin W. Gould, Baptist Health South Florida, Miami, FL; and S. Joseph Sirintrapun, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mercy Mena-Allauca
- Andrew A. Renshaw, Mercy Mena-Allauca, and Edwin W. Gould, Baptist Health South Florida, Miami, FL; and S. Joseph Sirintrapun, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edwin W. Gould
- Andrew A. Renshaw, Mercy Mena-Allauca, and Edwin W. Gould, Baptist Health South Florida, Miami, FL; and S. Joseph Sirintrapun, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S. Joseph Sirintrapun
- Andrew A. Renshaw, Mercy Mena-Allauca, and Edwin W. Gould, Baptist Health South Florida, Miami, FL; and S. Joseph Sirintrapun, Memorial Sloan Kettering Cancer Center, New York, NY
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