Low Rates of Genetic Counseling and Testing in Individuals at Risk for Lynch Syndrome Reported in the National Health Interview Survey

Genetic testing decision-making experiences within families of colorectal cancer patients: A qualitative study

PURPOSE

Genetic testing is the gold standard for the diagnosis of hereditary colorectal cancer syndromes but is currently inadequate and nonideal. The decision-making processes regarding genetic testing are even less well known. The present study aims to explore the decision-making experience of genetic testing for colorectal cancer patients and their family members.

METHOD

A descriptive qualitative study was employed. Data were collected using individual semi-structured interviews with 5 colorectal cancer patients and 20 family members from November 2020 to April 2021. Interviews were transcribed and analysed using inductive content analysis.

RESULTS

Four categories were identified: 1) the source of information for genetic testing, 2) the differentiated attitudes towards genetic testing, 3) genetic testing decisional needs, and 4) the factors influencing genetic testing decision-making. Colorectal cancer patients and their families engaged in two distinct pathways to genetic testing decisions: direct decision-making and indirect decision-making. Throughout these processes, due to the limited source of information, they had information needs that were met and facilitated genetic testing decision-making.

CONCLUSIONS

Colorectal cancer patients and family members need knowledge related to genetic testing, but they have limited access to information, which prevents them from making informed decisions. Providing decision aid interventions and informational support are significant steps towards addressing the support needs of this population.

Lynch syndrome cancer vaccines: A roadmap for the development of precision immunoprevention strategies

Hereditary cancer syndromes (HCS) account for 5~10% of all cancer diagnosis. Lynch syndrome (LS) is one of the most common HCS, caused by germline mutations in the DNA mismatch repair (MMR) genes. Even with prospective cancer surveillance, LS is associated with up to 50% lifetime risk of colorectal, endometrial, and other cancers. While significant progress has been made in the timely identification of germline pathogenic variant carriers and monitoring and early detection of precancerous lesions, cancer-risk reduction strategies are still centered around endoscopic or surgical removal of neoplastic lesions and susceptible organs. Safe and effective cancer prevention strategies are critically needed to improve the life quality and longevity of LS and other HCS carriers. The era of precision oncology driven by recent technological advances in tumor molecular profiling and a better understanding of genetic risk factors has transformed cancer prevention approaches for at-risk individuals, including LS carriers. MMR deficiency leads to the accumulation of insertion and deletion mutations in microsatellites (MS), which are particularly prone to DNA polymerase slippage during DNA replication. Mutations in coding MS give rise to frameshift peptides (FSP) that are recognized by the immune system as neoantigens. Due to clonal evolution, LS tumors share a set of recurrent and predictable FSP neoantigens in the same and in different LS patients. Cancer vaccines composed of commonly recurring FSP neoantigens selected through prediction algorithms have been clinically evaluated in LS carriers and proven safe and immunogenic. Preclinically analogous FSP vaccines have been shown to elicit FSP-directed immune responses and exert tumor-preventive efficacy in murine models of LS. While the immunopreventive efficacy of "off-the-shelf" vaccines consisting of commonly recurring FSP antigens is currently investigated in LS clinical trials, the feasibility and utility of personalized FSP vaccines with individual HLA-restricted epitopes are being explored for more precise targeting. Here, we discuss recent advances in precision cancer immunoprevention approaches, emerging enabling technologies, research gaps, and implementation barriers toward clinical translation of risk-tailored prevention strategies for LS carriers. We will also discuss the feasibility and practicality of next-generation cancer vaccines that are based on personalized immunogenic epitopes for precision cancer immunoprevention.

Public Awareness of Colorectal Cancer Screening in the Al-Baha Region, Saudi Arabia, 2022

BACKGROUND

According to the WHO, cancer is ranked as the second leading cause of death, accounting for an estimated 9.6 million deaths in 2018. This study aimed to assess public awareness about colorectal cancer (CRC) screening and the barriers that prevent Saudi individuals from undergoing CRC screening.  Materials and methods: A cross-sectional study was conducted in the Prince Mishari Bin Saud General Baljurashi Hospital, and a supervised self-administered questionnaire was utilized. Sociodemographic data, knowledge about colorectal cancer, and attitude toward screening were included in the survey. Data were analyzed using IBM SPSS Version 23 (SPSS Inc., Chicago, IL, USA) and Pearson's chi-square test. A P<0.05 was considered statistically significant.

RESULTS

A total of 396 eligible participants completed the survey. About 209 (52%) were female, and 124 (31.3%) belonged to the age group of 18-29 years. Nearly (49.7%) knew that detecting colorectal cancer before symptoms appear is possible. About 64% of the participants cited colonoscopy as the screening method for CRC. More than half of the participants (58.1%) expressed their willingness to be screened for colorectal cancer, while only 2.8% reported that they had undergone screening before. Participants with higher educational status demonstrated better knowledge regarding CRC than others (p<0.05).

CONCLUSION

 The overall knowledge of CRC was found to be poor in Al-Baha residents, irrespective of age. Implementing new strategies to increase public awareness about colorectal cancer will aid in the early diagnosis of CRC. We recommend targeted education and screening programs to improve the level of screening awareness and aid in the early diagnosis of colorectal cancer.

Systems approach to enhance Lynch syndrome diagnosis through tumour testing

BACKGROUND

Guidelines recommend universal mismatch repair (MMR) tumour testing of colorectal adenocarcinomas (CRCs) to screen for Lynch syndrome (LS). However, its implementation remains disjointed and referral for genetic testing dismal, particularly among minorities. We aimed to increase referral, cancer genetic testing and eventually LS diagnosis by developing the CLEAR LS (Closed Loop Enhanced Assessment and Referral for Lynch Syndrome) intervention, a systems approach which in the second phase was automated.

METHODS

This is a cohort study of all patients diagnosed with CRC at an academic centre between 1 January 2012, when implementation of universal CRC testing began, and 31 January 2021. The original cohort spanned through 31 May 2015. Tumour testing included MMR immunohistochemistry, followed by BRAF V600E/MLH1 promoter methylation testing when indicated. The intervention included a manual phase (1 June 2015 through 31 July 2018), which systematised pathology screening and cancer genetics (CG) referral mechanisms, and an automated phase (1 August 2018 through 31 January 2021) using computer programming.

RESULTS

A total of 249/1541 CRC (17.38%) had MMR loss of expression and 129 (8.37%) qualified for CG evaluation. Referral was 27.58% in the original cohort and 92.1% in the intervention (p<0.001). Patients seen by CG among referred were 27.58% in the original cohort and 74.3% in the intervention (p two-sided<0.001). The distribution of race/ethnicity among patients qualifying and referred for CG evaluation was not significantly different across cohorts. LS diagnosis increased from 0.56% (original cohort) to 1.43% (intervention). Cost per new diagnosis of LS decreased from US$173 675 to $87 960 from original cohort to intervention.

CONCLUSION

Implementation of systematic case identification and referral support mechanisms significantly increased the proportion of patients undergoing genetic testing and doubled the percentage of patients diagnosed with LS with no referral differences across racial/ethnic groups.

Point/Counterpoint: Is It Time for Universal Germline Genetic Testing for all GI Cancers?

Use of germline genetic testing among patients with cancer is increasing because of (1) the availability of multigene panel tests that include multiple cancer susceptibility genes in a single test, (2) decreased costs of these tests and improvements in insurance coverage, and (3) US Food and Drug Administration-approval of genotype-directed therapies such as poly(ADP-ribose) polymerase inhibitors for individuals with certain cancers and pathogenic germline variants in BRCA1 and BRCA2 (with possible benefits with other genes in the homologous repair deficiency pathway). In addition, National Comprehensive Cancer Network guidelines have already endorsed germline genetic testing for all patients with certain cancer types (epithelial ovarian cancer, exocrine pancreatic cancer, and high-grade/metastatic prostate cancer), regardless of age or personal/family history of cancer. Herein, we debate the pros and cons of offering germline multigene panel testing to all patients diagnosed with any GI cancer. The authors agree that it may just be a matter of time before germline multigene panel testing is offered to all patients with cancer; however, this article will highlight some of the benefits, risks, and limitations of this approach so that research can help fill some of the gaps to ensure that genetic medicine continues to be implemented in ways that improve real-world patient care and outcomes.

Uptake of Genetic Testing Among Patients with Cancer At Risk for Lynch Syndrome in the National Health Interview Survey

Lynch syndrome is the most common inherited cancer syndrome that increases the risk of developing colorectal and endometrial cancer. Universal screening guidelines were first recommended by the Centers for Disease Control and Prevention (CDC) in 2009 and are updated annually by multiple societies. Therefore, one would expect genetic testing rates to increase over time. But testing remains underutilized among those with colorectal or endometrial cancer, even though early detection can improve prognosis and survival rates. In this study, we aimed to understand differences in genetic testing uptake among those with colorectal cancer or endometrial cancer from 2005, 2010, 2015, using data from the National Health Interview Survey (NHIS). We examined genetic testing uptake across cancer-type, age (≤50 or ≥51), sex, race, insurance, and education using a χ² statistical analysis. Despite an upward genetic testing trend in 2010, we found no significant differences in genetic testing uptake over time. In 2010, non-White individuals experienced the highest increase from 2005 in comparison with White individuals. However, genetic testing rates declined for both groups by 2015. Our findings show that genetic testing for colorectal cancer and endometrial cancer did not increase over a 10-year period in spite of guidelines that recommend testing. PREVENTION RELEVANCE: Genetic testing uptake for colorectal cancer and endometrial cancer has not increased over a 10-year period in spite of universal screening guidelines. More genetic testing education is needed at the provider and patient level to improve screening strategies for cancer patients who are most at risk for Lynch syndrome.

Model-Based Re-Examination of the Effectiveness of Tumor/Immunohistochemistry and Direct-to-Sequencing Protocols for Lynch Syndrome Case Finding in Endometrial Cancer

PURPOSE

Despite widespread provision of Lynch syndrome (LS) screening programs, questions remain about the most effective and efficient protocol for LS case finding. The purpose of this study was to explore the performance of the two protocols widely shown to be the most efficient and effective, respectively: immunohistochemical (IHC) staining of tumor and direct-to-sequencing (DtS) in endometrial cancer populations.

METHODS

Simulation models were developed to explore performance of the IHC and DtS protocols, updated to reflect current evidence. Analyses explicitly account for protocol complexity and failure points, as well as decreased sequencing costs. Key outcomes are percent of LS cases identified, total protocol costs and efficiency, and break-even analyses of sequencing costs. All costs are in 2020 US dollars (USD).

RESULTS

Under plausible conditions, the IHC protocol is expected to identify 40%-78% of LS cases and DtS protocol from 49% to 97%. When the key variable success in proceeding to sequencing is fixed for both protocols at 50%, 75%, and 100%, the DtS protocol is 9%, 12%, and 16% better at case finding, respectively, than the IHC protocol. The break-even cost of sequencing is about $488 USD when the outcome is total direct testing protocol costs; it is about $670 USD when the outcome is cost per LS case detected.

CONCLUSION

This study quantifies the plausible differences in the clinical effectiveness and cost-effectiveness of the two LS case-finding protocols. We demonstrate the large influence of success in proceeding to sequencing and potential impact of decreasing sequencing prices.

Effectiveness of patient-targeted interventions to inform decision making and improve uptake of colorectal cancer genetic evaluation for at-risk individuals: A systematic review

BACKGROUND

Inherited colorectal cancer syndromes increase the risk of contracting colorectal and other cancers. International guidelines recommend the identification of individuals with hereditary colorectal cancer and the supervision of asymptomatic individuals with a family history. However, detection of hereditary colorectal cancer is suboptimal. The prevalence of genetic counselling and testing for individuals with high genetic risk is low.

OBJECTIVE

To identify, characterize and summarize patient-targeted interventions on improving the uptake of colorectal cancer genetic evaluation for at-risk individuals and enhancing their informed decision making.

DESIGN

Systematic review.

DATA SOURCES

Six electronic databases (PubMed, CINAHL, Web of Science, Embase, PsycINFO, and Cochrane library) were searched to identify eligible clinical trials from each database's inception to March 25, 2020. The reference lists of the included studies and reviews were checked for additional articles.

REVIEW METHODS

Studies were screened and independently appraised by two reviewers using the standardized critical appraisal checklist for randomized controlled trials and quasi-experimental studies from the Joanna Briggs Institute. The results were tabulated and reported in descriptive format.

RESULTS

Based on the inclusion criteria, 8 articles satisfied the inclusion criteria and were included. The studies examined patient-targeted intervention strategies related to risk assessment, education, and decision aids. Outcomes included (1) informed decisions regarding microsatellite instability testing, (2) informed decisions concerning genetic testing, (3) genetic counselling and testing. Most of the included studies revealed that interventions had positive effects on the uptake of colorectal cancer genetic evaluation for at-risk individuals and their informed decision making.

CONCLUSIONS

There were few studies included in this review, and the results were inconsistent. Based on this review, the conclusion cannot be made that interventions for risk assessment, education, and decision aids have positive effects on the uptake of colorectal cancer genetic evaluation for at-risk individuals and their informed decision making. However, to our knowledge, this is the first systematic review to summarize the effectiveness of patient-targeted interventions to inform decision making and improve uptake of colorectal cancer genetic evaluation for at-risk individuals. This review provides important evidence for related topics. Future studies with rigorous designs are recommended. Nurses have a crucial role in personalized health care. The involvement of nurses in collaboration with all the stakeholders in the development, implementation and evaluation of cancer genetic screening programs to improve genetic referral of individual at risk.