1
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Chaudhari VS, Hole KC, Issa AM. Evaluating the quality of the economic evidence in colorectal cancer genomics studies. Per Med 2022; 19:361-375. [PMID: 35786999 DOI: 10.2217/pme-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The increase in the use of genome-based screening and diagnostic tests adds to the overall costs of oncologic care for colorectal cancer. This, in turn, has resulted in an increase in published economic analyses. Aim: To perform a systematic literature review of the available economic evidence evaluating the value of genomic testing for colorectal cancer and appraise the quality of the economic studies conducted to date. Methods: A systematic review of the literature for economic studies of colorectal cancer genomics from January 2006 through October 2020, and evaluation of study quality using the Quality of Health Economic Studies (QHES) instrument was conducted. The validated QHES was then applied to a final set of articles that met eligibility criteria. Results: Our search of the literature initially yielded 12,859 records. A final set of 49 articles met our inclusion criteria. The QHES score ranged from 24 to 100, with an average score of 82. Most of the studies (n = 40, 82%) scored above 75 and were considered of good quality. Conclusion: Our analysis revealed that most of the economic analyses of colorectal cancer genomic molecular diagnostics in the literature may be of good quality. There is, however, some variation in methodological rigor between the articles.
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Affiliation(s)
- Vivek S Chaudhari
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA
| | - Kanchan C Hole
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA
| | - Amalia M Issa
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA.,Pharmaceutical Sciences, University of the Sciences, Philadelphia, PA 19104, USA.,Family Medicine, McGill University, Montreal, QC, H3S 1Z1, Canada
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2
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Zischke J, White N, Gordon L. Accounting for Intergenerational Cascade Testing in Economic Evaluations of Clinical Genomics: A Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:944-953. [PMID: 35667782 DOI: 10.1016/j.jval.2021.11.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Clinical genomics is emerging as a diagnostic tool in the identification of blood relatives at risk of developing heritable diseases. Our objective was to identify how genetic cascade screening has been incorporated into health economic evaluations. METHODS A scoping review was conducted to identify how multiple generations of a family were included in economic evaluations of clinical genomic sequencing, how many and which relatives were included, and uptake rates. Databases were searched for full economic evaluations of genetic interventions that screened multiple generations of families and were in English language, and no restrictions were made for disease or publication type. Data were synthesized using a narrative approach. RESULTS Twenty-five studies were included covering a range of diseases in various countries. Markov cohort models were mostly used with hypothetical populations and unsupported by clinical evidence. Cascade testing was either the primary intervention or secondary to the index cases. The number and type of relatives were based on assumptions or identified through population or family records, clinical registry data, or clinical literature. Studies included only immediate family members and the uptake of testing ranged between 20% and 100%. All interventions were reported as cost-effective, and a higher number of relatives was a key driver. CONCLUSIONS Several economic evaluations have considered the impacts of cascade testing interventions within clinical genomics. Ideally, models supported with high-quality clinical data are needed and, in their absence, transparent and justifiable assumptions of uptake rates and choices about including relatives. Consideration of more appropriate modeling types is required.
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Affiliation(s)
- Jason Zischke
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Nicole White
- Centre for Healthcare Transformation, School of Public Health and Social Work and Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
| | - Louisa Gordon
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Nursing, Queensland University of Technology, Brisbane, Australia; School of Public Health, The University of Queensland, Brisbane, Australia
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3
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Cernat A, Hayeems RZ, Prosser LA, Ungar WJ. Incorporating Cascade Effects of Genetic Testing in Economic Evaluation: A Scoping Review of Methodological Challenges. CHILDREN-BASEL 2021; 8:children8050346. [PMID: 33925765 PMCID: PMC8145875 DOI: 10.3390/children8050346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/26/2022]
Abstract
Cascade genetic testing is indicated for family members of individuals testing positive on a genetic test, and is particularly relevant for child health because of their vulnerability and the long-term health and economic implications. Cascade testing has patient- and health system-level implications; however cascade costs and health effects are not routinely considered in economic evaluation. The methodological challenges associated with incorporating cascade effects in economic evaluation require examination. The purpose of this scoping review was to identify published economic evaluations that considered cascade genetic testing. Citation databases were searched for English-language economic evaluations reporting on cascade genetic testing. Nineteen publications were included. In four, genetic testing was used to identify new index patients—cascade effects were also considered; thirteen assessed cascade genetic testing strategies for the identification of at-risk relatives; and two calculated the costs of cascade genetic testing as a secondary objective. Methodological challenges associated with incorporating cascade effects in economic evaluation are related to study design, costing, measurement and valuation of health outcomes, and modeling. As health economic studies may currently be underestimating both the cost and health benefits attributable to genetic technologies through omission of cascade effects, development of methods to address these difficulties is required.
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Affiliation(s)
- Alexandra Cernat
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (A.C.); (R.Z.H.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 1P8, Canada
| | - Robin Z. Hayeems
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (A.C.); (R.Z.H.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 1P8, Canada
| | - Lisa A. Prosser
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Wendy J. Ungar
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (A.C.); (R.Z.H.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 1P8, Canada
- Correspondence:
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4
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Washington MK, Goldberg RM, Chang GJ, Limburg P, Lam AK, Salto-Tellez M, Arends MJ, Nagtegaal ID, Klimstra DS, Rugge M, Schirmacher P, Lazar AJ, Odze RD, Carneiro F, Fukayama M, Cree IA. Diagnosis of digestive system tumours. Int J Cancer 2021; 148:1040-1050. [PMID: 32674220 DOI: 10.1002/ijc.33210] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 12/12/2022]
Abstract
The WHO Classification of Tumours provides the international standards for the classification and diagnosis of tumours. It enables direct comparisons to be made between different countries. In the new fifth edition, the series has gone digital with the launch of a website as well as a series of books, known widely as the WHO Blue Books. The first volume to be produced is on the classification of Digestive System tumours, replacing the successful 2010 version. It has been rewritten and updated accordingly. This article summarises the major diagnostic innovations that have occurred over the last decade and that have now been incorporated in the classification. As an example, it incorporates the recently proposed classification of neuroendocrine tumours, based on the recognition that neuroendocrine tumours and carcinomas differ substantially in the genetic abnormalities that drive their growth, findings relevant to treatment selection and outcome prediction. Several themes have emerged during the production process. One is the importance of the progression from hyperplasia to dysplasia to carcinoma in the evolution of the malignant process. Advances in imaging techniques and endoscopy have resulted in enhanced access to precancerous lesions in the gastrointestinal and biliary tract, necessitating both changes in classification schema and clinical practice. Diagnosis of tumours is no longer the sole purview of pathologists, and some patients now receive treatment before tissue is obtained, based on clinical, radiological and liquid biopsy results. This makes the classification relevant to many disciplines involved in the care of patients with tumours of the digestive system.
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Affiliation(s)
| | - Richard M Goldberg
- West Virginia University Cancer Institute and the Mary Babb Randolph Cancer Center, Morgantown, West Virginia, USA
| | - George J Chang
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Paul Limburg
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alfred K Lam
- Pathology, School of Medicine, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia
| | - Manuel Salto-Tellez
- Queen's Precision Medicine Centre of Excellence, Queen's University Belfast, Belfast Health & Social Care Trust, Belfast, UK
| | - Mark J Arends
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics & Molecular Medicine, The University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David S Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | | | - Alexander J Lazar
- Departments of Pathology, Genomic Medicine, and Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Masashi Fukayama
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ian A Cree
- WHO Classification of Tumours Group, International Agency for Research on Cancer (IARC), World Health Organization, Lyon, France
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5
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Cerretelli G, Ager A, Arends MJ, Frayling IM. Molecular pathology of Lynch syndrome. J Pathol 2020; 250:518-531. [PMID: 32141610 DOI: 10.1002/path.5422] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/18/2022]
Abstract
Lynch syndrome (LS) is characterised by predisposition to colorectal, endometrial, and other cancers and is caused by inherited pathogenic variants affecting the DNA mismatch repair (MMR) genes MLH1, MSH2, MSH6, and PMS2. It is probably the most common predisposition to cancer, having an estimated prevalence of between 1/100 and 1/180. Resources such as the International Society for Gastrointestinal Hereditary Cancer's MMR gene variant database, the Prospective Lynch Syndrome Database (PLSD), and the Colon Cancer Family Register (CCFR), as well as pathological and immunological studies, are enabling advances in the understanding of LS. These include defined criteria by which to interpret gene variants, the function of MMR in the normal control of apoptosis, definition of the risks of the various cancers, and the mechanisms and pathways by which the colorectal and endometrial tumours develop, including the critical role of the immune system. Colorectal cancers in LS can develop along three pathways, including flat intramucosal lesions, which depend on the underlying affected MMR gene. This gives insights into the limitations of colonoscopic surveillance and highlights the need for other forms of anti-cancer prophylaxis in LS. Finally, it shows that the processes of autoimmunisation and immunoediting fundamentally constrain the development of tumours in LS and explain the efficacy of immune checkpoint blockade therapy in MMR-deficient tumours. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Guia Cerretelli
- Division of Pathology, Cancer Research UK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Ann Ager
- Division of Infection and Immunity, School of Medicine and Systems Immunity Research Institute, Cardiff University, Cardiff, UK
| | - Mark J Arends
- Division of Pathology, Cancer Research UK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Ian M Frayling
- Inherited Tumour Syndromes Research Group, Institute of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, UK
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6
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Dabir PD, Bruggeling CE, van der Post RS, Dutilh BE, Hoogerbrugge N, Ligtenberg MJL, Boleij A, Nagtegaal ID. Microsatellite instability screening in colorectal adenomas to detect Lynch syndrome patients? A systematic review and meta-analysis. Eur J Hum Genet 2019; 28:277-286. [PMID: 31695176 DOI: 10.1038/s41431-019-0538-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 10/01/2019] [Accepted: 10/13/2019] [Indexed: 11/09/2022] Open
Abstract
The colorectal cancer spectrum has changed due to population screening programs, with a shift toward adenomas and early cancers. Whether it would be a feasible option to test these adenomas for detection of Lynch syndrome (LS) patients is unclear. Through meta-analysis and systematic review, risk factors for DNA mismatch repair deficiency (dMMR) and microsatellite instability (MSI) in adenomas were identified in LS and unselected patient cohorts. Data were extracted for patient age and MMR variant together with adenoma type, grade, size, and location. A total of 41 studies were included, and contained more than 519 LS patients and 1698 unselected patients with 1142 and 2213 adenomas respectively. dMMR/MSI was present in 69.5% of conventional adenomas in LS patients, compared with 2.8% in unselected patients. In the LS cohort, dMMR/MSI was more frequently present in patients older than 60 years (82% versus 54%). dMMR/MSI was also more common in villous adenomas (84%), adenomas over 1 cm (81%), and adenomas with high grade dysplasia (88%). No significant differences were observed for dMMR/MSI in relation to MMR variants and location of adenomas. In the context of screening, we conclude that detection of dMMR/MSI in conventional adenomas of unselected patients is uncommon and might be considered as indication for LS testing. Within the LS cohort, 69.5% of LS patients could have been detected through dMMR/MSI screening of their conventional adenomas.
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Affiliation(s)
- Parag D Dabir
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Carlijn E Bruggeling
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas E Dutilh
- Theoretical Biology and Bioinformatics, Utrecht University, Utrecht, The Netherlands.,Centre for Molecular and Biomolecular Informatics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjolijn J L Ligtenberg
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemarie Boleij
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.
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7
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Li D, Hoodfar E, Jiang SF, Udaltsova N, Pham NP, Jodesty Y, Armstrong MA, Hung YY, Baker RJ, Postlethwaite D, Ladabaum U, Levin TR, Corley DA, Bergoffen J. Comparison of Universal Versus Age-Restricted Screening of Colorectal Tumors for Lynch Syndrome Using Mismatch Repair Immunohistochemistry: A Cohort Study. Ann Intern Med 2019; 171:19-26. [PMID: 31181578 DOI: 10.7326/m18-3316] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend screening all patients with newly diagnosed colorectal cancer (CRC) for Lynch syndrome (LS). However, the efficiency of universal LS screening in elderly populations has not been well studied. OBJECTIVE To compare the performance of age-restricted and universal LS screening using reflex mismatch repair (MMR) immunohistochemistry (IHC) of CRC tumors. DESIGN Retrospective cohort study. SETTING A large, diverse, community-based health care system. PARTICIPANTS 3891 persons with newly diagnosed CRC who had LS screening between 2011 and 2016. MEASUREMENTS Diagnostic yield of different LS screening strategies. RESULTS Sixty-three LS cases (diagnostic yield, 1.62%) were identified by universal screening, with only 5 (7.9%) detected after age 70 years and 1 (1.6%) detected after age 80 years. When all patients with CRC who had universal screening were used as the denominator, 58 LS cases (diagnostic yield, 1.49% [95% CI, 1.13% to 1.92%]) were identified in patients with CRC diagnosed at or before age 70 years, 60 LS cases (diagnostic yield, 1.54% [CI, 1.18% to 1.98%]) were identified in those with CRC diagnosed at or before age 75 years, and 62 LS cases (diagnostic yield, 1.59% [CI, 1.22% to 2.04%]) were identified in those with CRC diagnosed at or before age 80 years. Using 75 years as the upper age limit for screening missed 3 of 63 (4.8%) LS cases but resulted in 1053 (27.1%) fewer cases requiring tumor MMR IHC. Using 80 years as the upper age limit missed 1 of 63 (1.6%) LS cases and resulted in 668 (17.2%) fewer cases requiring tumor MMR IHC. LIMITATION Persons who were eligible for but did not complete germline analysis were excluded from calculations of performance characteristics. CONCLUSION The incremental diagnostic yield decreased substantially after age 70 to 75 years. Stopping reflex CRC screening for LS after age 80 years may be reasonable because of very low efficiency, particularly in resource-limited settings, but this merits further investigation. Studies evaluating the effect of diagnosing LS in elderly persons on their family members are needed. PRIMARY FUNDING SOURCE Kaiser Permanente Northern California Division of Research.
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Affiliation(s)
- Dan Li
- Kaiser Permanente Northern California, Santa Clara, California, and Kaiser Permanente Northern California, Oakland, California (D.L.)
| | | | - Sheng-Fang Jiang
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - Natalia Udaltsova
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - Nhung P Pham
- Kaiser Permanente Northern California, Santa Clara, California (N.P.P., Y.J.)
| | - Yves Jodesty
- Kaiser Permanente Northern California, Santa Clara, California (N.P.P., Y.J.)
| | - Mary Anne Armstrong
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - Yun-Yi Hung
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - Robin J Baker
- Kaiser Permanente Northern California, San Francisco, California (R.J.B.)
| | - Debbie Postlethwaite
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, California (U.L.)
| | - Theodore R Levin
- Kaiser Permanente Northern California, Walnut Creek, California (T.R.L.)
| | - Douglas A Corley
- Kaiser Permanente Northern California, Oakland, California (S.J., N.U., M.A.A., Y.H., D.P., D.A.C.)
| | - JoAnn Bergoffen
- Kaiser Permanente Northern California, San Jose, California (J.B.)
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8
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Vos JR, Giepmans L, Röhl C, Geverink N, Hoogerbrugge N. Boosting care and knowledge about hereditary cancer: European Reference Network on Genetic Tumour Risk Syndromes. Fam Cancer 2019; 18:281-284. [PMID: 30302652 PMCID: PMC6449296 DOI: 10.1007/s10689-018-0110-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Approximately 27-36 million patients in Europe have one of the ~ 5.000-8.000 known rare diseases. These patients often do not receive the care they need or they have a substantial delay from diagnosis to treatment. In March 2017, twenty-four European Reference Networks (ERNs) were launched with the aim to improve the care for these patients through cross border healthcare, in a way that the medical knowledge and expertise travels across the borders, rather than the patients. It is expected that through the ERNs, European patients with a rare disease get access to expert care more often and more quickly, and that research and guideline development will be accelerated resulting in improved diagnostics and therapies. The ERN on Genetic Tumour Risk Syndromes (ERN GENTURIS) aims to improve the identification, genetic diagnostics, prevention of cancer, and treatment of European patients with a genetic predisposition for cancer. The ERN GENTURIS focuses on syndromes such as hereditary breast cancer, hereditary colorectal cancer and polyposis, neurofibromatosis and more rare syndromes e.g. PTEN Hamartoma Tumour Syndrome, Li Fraumeni Syndrome and hereditary diffuse gastric cancer.
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Affiliation(s)
- Janet R Vos
- Department of Human Genetics, Radboud University Medical Center, P.O. box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Lisette Giepmans
- Research B.V, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Claas Röhl
- Patient representative, European Patient Advocacy Group, European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Vienna, Austria
| | - Nicoline Geverink
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, P.O. box 9101, 6500 HB, Nijmegen, The Netherlands.
- Coordinator European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands.
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9
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Keränen A, Ghazi S, Carlson J, Papadogiannakis N, Lagerstedt-Robinson K, Lindblom A. Testing strategies to reduce morbidity and mortality from Lynch syndrome. Scand J Gastroenterol 2018; 53:1535-1540. [PMID: 30572730 DOI: 10.1080/00365521.2018.1542453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Lynch syndrome (LS) has an autosomal dominant inheritance pattern and is associated with increased risk for colorectal cancer (CRC) and other cancers. Various strategies are used to identify patients at risk and offer surveillance and preventive programs, the cost effectiveness of which is much dependent on the prevalence of LS in a population. Universal testing (UT) is proposed as an effective measure, targeting all newly diagnosed CRC patients under a certain age. MATERIALS AND METHODS LS cases were identified in a cohort of 572 consecutive CRC patients. Immunohistochemistry was performed in 539 cases, using antibodies against mismatch repair proteins MLH1, PMS2, MSH2, and MSH6. Microsatellite instability and gene mutation screening were performed in 57 cases. RESULTS In total 11 pathogenic variants were detected, identifying LS in 1.9% of new CRC cases. Comparing the results with current clinical methods, 2 pathogenic variants were found with Amsterdam criteria and 9 when using either Bethesda guidelines or our institution's prior clinical criteria. Pathogenic variants in MSH6 were the most common in our series. We also found different outcomes using different age cut offs. CONCLUSION Our study demonstrates that UT of tumors before age on onset at 75 years would most likely be cost-efficient and essentially equivalent to applying the Bethesda guidelines or our institution's prior clinical criteria on all new CRC.
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Affiliation(s)
- Anne Keränen
- a Department of Laboratory Medicine, Division of Pathology , Karolinska Institutet , Karolinska University Hospital, Stockholm , Sweden
| | - Sam Ghazi
- a Department of Laboratory Medicine, Division of Pathology , Karolinska Institutet , Karolinska University Hospital, Stockholm , Sweden
| | - Joseph Carlson
- a Department of Laboratory Medicine, Division of Pathology , Karolinska Institutet , Karolinska University Hospital, Stockholm , Sweden
| | - Nikos Papadogiannakis
- a Department of Laboratory Medicine, Division of Pathology , Karolinska Institutet , Karolinska University Hospital, Stockholm , Sweden
| | - Kristina Lagerstedt-Robinson
- b Department of Molecular Medicine and Surgery , and Department of Clinical Genetics, Karolinska Institutet, Karolinska University Hospital, Solna , Stockholm , Sweden
| | - Annika Lindblom
- b Department of Molecular Medicine and Surgery , and Department of Clinical Genetics, Karolinska Institutet, Karolinska University Hospital, Solna , Stockholm , Sweden
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10
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Leicher LW, Lammertink MHA, Offerman SR, Morreau H, de Jong MM, de Groot JWB, van Westreenen HL, Vasen HFA, de Vos Tot Nederveen Cappel WH. Consequences of testing for mismatch repair deficiency of colorectal cancer in clinical practice. Scand J Gastroenterol 2018; 53:632-636. [PMID: 29161904 DOI: 10.1080/00365521.2017.1406534] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Mismatch repair deficiency (dMMR) can be found in Lynch syndrome (LS)-associated colorectal carcinoma and in 15% of sporadic colorectal cancer (CRC). Outcome of MMR-deficiency testing is important for surgical decisions as extended colectomy is recommended in young LS-patients with CRC. Moreover, the finding of a dMMR tumour has consequences for the choices of adjuvant chemotherapy as MMR-deficient CRC is resistant to 5-fluorouracil (5-FU) monotherapy. Aims of our study are to evaluate whether MMR-deficiency testing leads to (1) identification of LS, (2) change in surgical treatment and (3) adjustment of systemic therapy in patients with dMMR CRC. METHODS We performed a multicentre, retrospective study, in a community hospital and a University Medical Centre. We included all CRC-patients between 2012 and 2016 who were tested for microsatellite instability. We collected clinical data such as gender, age, referral to clinical geneticist, surgical procedure and choice of chemotherapy. RESULTS We analysed 225 CRCs. Twenty-four (10.7%) of 225 CRC were MMR-deficient. Of the 24 patients with dMMR CRC, 18 (75%) were referred to the clinical geneticist and in nine (37%) patients a MMR mutation was identified. In one (4%) of the 24 patients, a subtotal colectomy was performed. In seven (35%) out of 20 MMR deficient patients, the chemotherapy regimen was adjusted. CONCLUSIONS The finding of a dMMR CRC had consequences for decisions on chemotherapy in a relative high proportion of patients. We recommend testing in all patients with CRC independent of age at diagnosis, as proper treatment decisions and genetic counselling are very important.
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Affiliation(s)
- L W Leicher
- a Department of Gastroenterology and Hepatology , Isala , Zwolle , The Netherlands
| | - M H A Lammertink
- a Department of Gastroenterology and Hepatology , Isala , Zwolle , The Netherlands
| | - S R Offerman
- b Department of Pathology , Isala , Zwolle , The Netherlands
| | - H Morreau
- c Department of Pathology , Leiden University Medical Centre , Leiden , The Netherlands
| | - M M de Jong
- d Department of Genetics , University Medical Centre Groningen , Groningen , The Netherlands
| | - J W B de Groot
- e Department of Oncology , Isala , Zwolle , The Netherlands
| | | | - H F A Vasen
- g Department of Gastroenterology , Leiden University Medical Centre , Leiden , The Netherlands.,h The Netherlands Foundation for the Detection of Hereditary Tumors , Leiden , The Netherlands
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11
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Guglielmo A, Staropoli N, Giancotti M, Mauro M. Personalized medicine in colorectal cancer diagnosis and treatment: a systematic review of health economic evaluations. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:2. [PMID: 29386984 PMCID: PMC5778687 DOI: 10.1186/s12962-018-0085-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/03/2018] [Indexed: 01/03/2023] Open
Abstract
Background Due to its epidemiological relevance, several studies have been performed to assess the cost-effectiveness of diagnostic tests and treatments in colorectal cancer (CRC) patients. Objective We reviewed economic evaluations on diagnosis of inherited CRC-syndromes and genetic tests for the detection of mutations associated with response to therapeutics. Methods A systematic literature review was performed by searching the main literature databases for relevant papers on the field, published in the last 5 years. Results 20 studies were included in the final analysis: 14 investigating the cost-effectiveness of hereditary-CRC screening; 5 evaluating the cost-effectiveness of KRAS mutation assessment before treatment; and 1 study analysing the cost-effectiveness of genetic tests for early-stage CRC patients prognosis. Overall, we found that: (a) screening strategies among CRC patients were more effective than no screening; (b) all the evaluated interventions were cost-saving for certain willingness-to-pay (WTP) threshold; and (c) all new CRC patients diagnosed at age 70 or below should be screened. Regarding patients treatment, we found that KRAS testing is economically sustainable only if anticipated in patients with non-metastatic CRC (mCRC), while becoming unsustainable, due to an incremental cost-effectiveness ratio (ICER) beyond the levels of WTP-threshold, in all others evaluated scenarios. Conclusions The poor evidence in the field, combined to the number of assumptions done to perform the models, lead us to a high level of uncertainty on the cost-effectiveness of genetic evaluations in CRC, suggesting that major research is required in order to assess the best combination among detection tests, type of genetic test screening and targeted-therapy. Electronic supplementary material The online version of this article (10.1186/s12962-018-0085-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annamaria Guglielmo
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Nicoletta Staropoli
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Monica Giancotti
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
| | - Marianna Mauro
- Department of Clinical and Experimental Medicine, "Magna Græcia" University, Viale Europa 88100, Catanzaro, Italy
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Which Lynch syndrome screening programs could be implemented in the "real world"? A systematic review of economic evaluations. Genet Med 2018; 20:1131-1144. [PMID: 29300371 PMCID: PMC8660650 DOI: 10.1038/gim.2017.244] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/17/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose Lynch syndrome (LS) screening can significantly reduce cancer morbidity and mortality in mutation carriers. Our aim was to identify cost-effective LS screening programs that can be implemented in the “real world.” Methods We performed a systematic review of full economic evaluations of genetic screening for LS in different target populations; health outcomes were estimated in life-years gained or quality-adjusted life-years. Results Overall, 20 studies were included in the systematic review. Based on the study populations, we identified six categories of LS screening program: colorectal cancer (CRC)–based, endometrial cancer–based, general population–based, LS family registry–based, cascade testing–based, and genetics clinic–based screening programs. We performed an in-depth analysis of CRC-based LS programs, classifying them into three additional subcategories: universal, age-targeted, and selective. In five studies, universal programs based on immunohistochemistry, either alone or in combination with the BRAF test, were cost-effective compared with no screening, while in two studies age-targeted programs with a cutoff of 70 years were cost-effective when compared with age-targeted programs with lower age thresholds. Conclusion Universal or <70 years–age-targeted CRC-based LS screening programs are cost-effective and should be implemented in the “real world.”
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Coelho H, Jones-Hughes T, Snowsill T, Briscoe S, Huxley N, Frayling IM, Hyde C. A systematic review of test accuracy studies evaluating molecular micro-satellite instability testing for the detection of individuals with lynch syndrome. BMC Cancer 2017; 17:836. [PMID: 29221446 PMCID: PMC5723028 DOI: 10.1186/s12885-017-3820-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 11/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A systematic review was conducted to assess the diagnostic test accuracy of polymerase chain reaction (PCR)-based microsatellite instability (MSI) testing for identifying Lynch syndrome in patients with colorectal cancer (CRC). Unlike previous reviews, this was based on assessing MSI testing against best practice for the reference standard, and included CRC populations that were unselected, age-limited or high-risk for Lynch syndrome. METHODS Single- and two-gate diagnostic test accuracy studies, or similar, were identified, assessed for inclusion, data extracted and quality appraised by two reviewers according to a pre-specified protocol. Sensitivity of MSI testing was estimated for all included studies. Specificity, likelihood ratios and predictive values were estimated for studies that were not based on high-risk samples. Narrative synthesis was conducted. RESULTS Nine study samples were included. When MSI-Low results were considered to be negative, sensitivity estimates ranged from 67% (95% CI 47, 83) to 100% (95% CI 94, 100). Three studies contributed to estimates of both sensitivity and specificity, with specificity ranging from 61% (95% CI 57, 65), to 93% (95% CI 89, 95). Good sensitivity was achieved at the expense of specificity. When MSI-L was considered to be positive (effectively lowering the threshold for a positive index test result) sensitivity increased and specificity decreased. Between-study heterogeneity in both the MSI and reference standard testing, combined with the low number of studies contributing to both sensitivity and specificity estimates, precluded pooling by meta-analysis. CONCLUSIONS MSI testing is an effective screening test for Lynch syndrome. However, there is significant uncertainty surrounding what balance of sensitivity and specificity will be achieved in clinical practice and how this relates to specific characteristics of the test (such as the panel of markers used or the thresholds used to denote a positive test).
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Affiliation(s)
- Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
| | - Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
| | - Simon Briscoe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
| | - Ian M. Frayling
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, South Cloisters, St Lukes Campus, Heavitree Road, Exeter, Devon EX1 2LU UK
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14
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Katapodi MC, Viassolo V, Caiata-Zufferey M, Nikolaidis C, Bührer-Landolt R, Buerki N, Graffeo R, Horváth HC, Kurzeder C, Rabaglio M, Scharfe M, Urech C, Erlanger TE, Probst-Hensch N, Heinimann K, Heinzelmann-Schwarz V, Pagani O, Chappuis PO. Cancer Predisposition Cascade Screening for Hereditary Breast/Ovarian Cancer and Lynch Syndromes in Switzerland: Study Protocol. JMIR Res Protoc 2017; 6:e184. [PMID: 28931501 PMCID: PMC5628286 DOI: 10.2196/resprot.8138] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/15/2017] [Accepted: 07/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Breast, colorectal, ovarian, and endometrial cancers constitute approximately 30% of newly diagnosed cancer cases in Switzerland, affecting more than 12,000 individuals annually. Hundreds of these patients are likely to carry germline pathogenic variants associated with hereditary breast ovarian cancer (HBOC) or Lynch syndrome (LS). Genetic services (counseling and testing) for hereditary susceptibility to cancer can prevent many cancer diagnoses and deaths through early identification and risk management. OBJECTIVE Cascade screening is the systematic identification and testing of relatives of a known mutation carrier. It determines whether asymptomatic relatives also carry the known variant, needing management options to reduce future harmful outcomes. Specific aims of the CASCADE study are to (1) survey index cases with HBOC or LS from clinic-based genetic testing records and determine their current cancer status and surveillance practices, needs for coordination of medical care, psychosocial needs, patient-provider and patient-family communication, quality of life, and willingness to serve as advocates for cancer genetic services to blood relatives, (2) survey first- and second-degree relatives and first-cousins identified from pedigrees or family history records of HBOC and LS index cases and determine their current cancer and mutation status, cancer surveillance practices, needs for coordination of medical care, barriers and facilitators to using cancer genetic services, psychosocial needs, patient-provider and patient-family communication, quality of life, and willingness to participate in a study designed to increase use of cancer genetic services, and (3) explore the influence of patient-provider communication about genetic cancer risk on patient-family communication and the acceptability of a family-based communication, coping, and decision support intervention with focus group(s) of mutation carriers and relatives. METHODS CASCADE is a longitudinal study using surveys (online or paper/pencil) and focus groups, designed to elicit factors that enhance cascade genetic testing for HBOC and LS in Switzerland. Repeated observations are the optimal way for assessing these outcomes. Focus groups will examine barriers in patient-provider and patient-family communication, and the acceptability of a family-based communication, coping, and decision-support intervention. The survey will be developed in English, translated into three languages (German, French, and Italian), and back-translated into English, except for scales with validated versions in these languages. RESULTS Descriptive analyses will include calculating means, standard deviations, frequencies, and percentages of variables and participant descriptors. Bivariate analyses (Pearson correlations, chi-square test for differences in proportions, and t test for differences in means) will assess associations between demographics and clinical characteristics. Regression analyses will incorporate generalized estimating equations for pairing index cases with their relatives and explore whether predictors are in direct, mediating, or moderating relationship to an outcome. Focus group data will be transcribed verbatim and analyzed for common themes. CONCLUSIONS Robust evidence from basic science and descriptive population-based studies in Switzerland support the necessity of cascade screening for genetic predisposition to HBOC and LS. CASCADE is designed to address translation of this knowledge into public health interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT03124212; https://clinicaltrials.gov/ct2/show/NCT03124212 (Archived by WebCite at http://www.webcitation.org/6tKZnNDBt).
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Affiliation(s)
- Maria C Katapodi
- Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland.,University of Michigan School of Nursing, Ann Arbor, MI, United States
| | - Valeria Viassolo
- Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Christos Nikolaidis
- Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Nicole Buerki
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Rossella Graffeo
- Institute of Oncology (IOSI) and Breast Unit (CSSI) of Southern Switzerland, Bellinzona, Switzerland
| | - Henrik Csaba Horváth
- University Clinic for Visceral Surgery and Medicine, Inselspital Bern, Bern, Switzerland
| | - Christian Kurzeder
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuela Rabaglio
- University Clinic for Medical Oncology, Inselspital Bern, Bern, Switzerland
| | - Michael Scharfe
- Clinical Trials Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Corinne Urech
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tobias E Erlanger
- Clinical Trials Unit, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Karl Heinimann
- Medical Genetics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Women's Clinic and Gynecological Oncology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Olivia Pagani
- Institute of Oncology (IOSI) and Breast Unit (CSSI) of Southern Switzerland, Bellinzona, Switzerland
| | - Pierre O Chappuis
- Unit of Oncogenetics and Cancer Prevention, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland.,Division of Genetic Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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15
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Goverde A, Spaander MC, van Doorn HC, Dubbink HJ, van den Ouweland AM, Tops CM, Kooi SG, de Waard J, Hoedemaeker RF, Bruno MJ, Hofstra RM, de Bekker-Grob EW, Dinjens WN, Steyerberg EW, Wagner A. Cost-effectiveness of routine screening for Lynch syndrome in endometrial cancer patients up to 70years of age. Gynecol Oncol 2016; 143:453-459. [PMID: 27789085 DOI: 10.1016/j.ygyno.2016.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE To assess cost-effectiveness of routine screening for Lynch Syndrome (LS) in endometrial cancer (EC) patients ≤70years of age. METHODS Consecutive EC patients ≤70years of age were screened for LS by analysis of microsatellite instability, immunohistochemistry and MLH1 hypermethylation. Costs and health benefit in life years gained (LYG) included surveillance for LS carriers among EC patients and relatives. We calculated incremental cost-effectiveness ratios (ICERs) comparing LS screening among EC patients ≤70years with ≤50years and the revised Bethesda guidelines. RESULTS Screening for LS in 179 EC patients identified 7 LS carriers; 1 was ≤50 and 6 were 51-70years. Per age category 18 and 9 relatives were identified as LS carrier. Screening resulted in 74,7 LYG (45,4 and 29,3 LYG per age category). The ICER for LS screening in EC patients ≤70 compared with ≤50years was €5,252/LYG. The revised Bethesda guidelines missed 4/7 (57%) LS carriers among EC patients. The ICER for LS screening in EC patients ≤70years of age compared with the revised Bethesda guidelines was €6,668/LYG. Both ICERs remained <€16,000/LYG in sensitivity analyses. CONCLUSION Routine LS screening in EC patients ≤70years is a cost-effective strategy, allowing colorectal cancer prevention in EC patients and their relatives.
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Affiliation(s)
- Anne Goverde
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Manon Cw Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Helena C van Doorn
- Department of Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hendrikus J Dubbink
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ans Mw van den Ouweland
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Carli M Tops
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sjarlot G Kooi
- Department of Gynaecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Judith de Waard
- Department of Gynaecology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Robert Mw Hofstra
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Esther W de Bekker-Grob
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Winand Nm Dinjens
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Anja Wagner
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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16
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Cost-effectiveness of routine screening for Lynch syndrome in colorectal cancer patients up to 70 years of age. Genet Med 2016; 18:966-73. [DOI: 10.1038/gim.2015.206] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022] Open
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17
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Grosse SD. When is Genomic Testing Cost-Effective? Testing for Lynch Syndrome in Patients with Newly-Diagnosed Colorectal Cancer and Their Relatives. Healthcare (Basel) 2015; 3:860-78. [PMID: 26473097 PMCID: PMC4604059 DOI: 10.3390/healthcare3040860] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Varying estimates of the cost-effectiveness of genomic testing applications can reflect differences in study questions, settings, methods and assumptions. This review compares recently published cost-effectiveness analyses of testing strategies for Lynch Syndrome (LS) in tumors from patients newly diagnosed with colorectal cancer (CRC) for either all adult patients or patients up to age 70 along with cascade testing of relatives of probands. Seven studies published from 2010 through 2015 were identified and summarized. Five studies analyzed the universal offer of testing to adult patients with CRC and two others analyzed testing patients up to age 70; all except one reported incremental cost-effectiveness ratios (ICERs) < $ 100,000 per life-year or quality-adjusted life-year gained. Three studies found lower ICERs for selective testing strategies using family history-based predictive models compared with universal testing. However, those calculations were based on estimates of sensitivity of predictive models derived from research studies, and it is unclear how sensitive such models are in routine clinical practice. Key model parameters that are influential in ICER estimates included 1) the number of first-degree relatives tested per proband identified with LS and 2) the cost of gene sequencing. Others include the frequency of intensive colonoscopic surveillance, the cost of colonoscopy, and the inclusion of extracolonic surveillance and prevention options.
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Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA; Tel.: +404-498-3074
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18
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Richman S. Deficient mismatch repair: Read all about it (Review). Int J Oncol 2015; 47:1189-202. [PMID: 26315971 PMCID: PMC4583524 DOI: 10.3892/ijo.2015.3119] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/29/2015] [Indexed: 12/20/2022] Open
Abstract
Defects in the DNA mismatch repair (MMR) proteins, result in a phenotype called microsatellite instability (MSI), occurring in up to 15% of sporadic colorectal cancers. Approximately one quarter of colon cancers with deficient MMR (dMMR) develop as a result of an inherited predisposition syndrome, Lynch syndrome (formerly known as HNPCC). It is essential to identify patients who potentially have Lynch syndrome, as not only they, but also family members, may require screening and monitoring. Diagnostic criteria have been developed, based primarily on Western populations, and several methodologies are available to identify dMMR tumours, including immunohistochemistry and microsatellite testing. These criteria have provided evidence supporting the introduction of reflex testing. Yet, it is becoming increasingly clear that tests have a limited sensitivity and specificity and may yet be superseded by next generation sequencing. In this review, the limitations of diagnostic criteria are discussed, and current and emerging screening technologies explained. There is now useful evidence supporting the prognostic and predictive value of dMMR status in colorectal tumours, but much less is known about their value in extracolonic tumours, that may also feature in Lynch syndrome. This review assesses current literature relating to dMMR in endometrial, ovarian, gastric and melanoma cancers, which it would seem, may benefit from large-scale clinical trials in order to further close the gap in knowledge between colorectal and extracolonic tumours.
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Affiliation(s)
- Susan Richman
- Department of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, St. James University Hospital, Leeds, LS9 7TF, UK
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19
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Kumamoto K, Ishida H, Suzuki O, Tajima Y, Chika N, Kuwabara K, Ishibashi K, Saito K, Nagata K, Eguchi H, Tamaru J, Iwama T. Lower prevalence of Lynch syndrome in colorectal cancer patients in a Japanese hospital-based population. Surg Today 2015; 46:713-20. [PMID: 26249337 DOI: 10.1007/s00595-015-1232-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/21/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study was to investigate the prevalence of Lynch syndrome among Japanese patients with surgically resected colorectal cancer at a single institution. METHODS Of 616 colorectal cancer patients who underwent surgical operation in our institution from January 2005 to August 2010, immunohistochemistry analyses for mismatch repair proteins (MLH1, MSH2, MSH6, and PMS2) and microsatellite instability (MSI) testing for surgically resected, formalin-fixed paraffin-embedded colorectal cancer specimens from 138 colorectal cancer patients under 60 years of age were undertaken. Hypermethylation of the MLH1 promoter and BRAF mutation were analyzed where necessary. RESULTS Seven patients were identified as candidates for genetic testing by mismatch repair protein loss (n = 7) or MSI-H (n = 6). Methylation of MLH1 was detected in one case. Three patients were diagnosed with Lynch syndrome, comprising 2.2 % of the total colorectal cancer patients younger than 60 years of age. CONCLUSION The prevalence of Lynch syndrome among hospital-based diagnosed cancer patients may therefore be lower than expected in Japan compared with Western populations.
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Affiliation(s)
- Kensuke Kumamoto
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan.
- Department of Organ Regulatory Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Hideyuki Ishida
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Okihide Suzuki
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Yusuke Tajima
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Noriyasu Chika
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Koki Kuwabara
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Keiichiro Ishibashi
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Katsuharu Saito
- Department of Organ Regulatory Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Koji Nagata
- Department of Pathology, Saitama International Medical Center, Saitama Medical University, Saitama, 350-1298, Japan
| | - Hidetaka Eguchi
- Division of Translational Research, Research Center for Genomic Medicine, Saitama Medical University, Saitama, 350-1241, Japan
| | - Junichi Tamaru
- Department of Pathology, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
| | - Takeo Iwama
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, 350-8550, Japan
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Economic evidence on identifying clinically actionable findings with whole-genome sequencing: a scoping review. Genet Med 2015; 18:111-6. [PMID: 25996638 DOI: 10.1038/gim.2015.69] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/15/2015] [Indexed: 12/25/2022] Open
Abstract
The American College of Medical Genetics and Genomics (ACMG) recommends that mutations in 56 genes for 24 conditions are clinically actionable and should be reported as secondary findings after whole-genome sequencing (WGS). Our aim was to identify published economic evaluations of detecting mutations in these genes among the general population or among targeted/high-risk populations and conditions and identify gaps in knowledge. A targeted PubMed search from 1994 through November 2014 was performed, and we included original, English-language articles reporting cost-effectiveness or a cost-to-utility ratio or net benefits/benefit-cost focused on screening (not treatment) for conditions and genes listed by the ACMG. Articles were screened, classified as targeting a high-risk or general population, and abstracted by two reviewers. General population studies were evaluated for actual cost-effectiveness measures (e.g., incremental cost-effectiveness ratios (ICER)), whereas studies of targeted populations were evaluated for whether at least one scenario proposed was cost-effective (e.g., ICER of ≤$100,000 per life-year or quality-adjusted life-year gained). A total of 607 studies were identified, and 32 relevant studies were included. Identified studies addressed fewer than one-third (7 of 24; 29%) of the ACMG conditions. The cost-effectiveness of screening in the general population was examined for only 2 of 24 conditions (8%). The cost-effectiveness of most genetic findings that the ACMG recommends for return has not been evaluated in economic studies or in the context of screening in the general population. The individual studies do not directly address the cost-effectiveness of WGS.
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21
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Gallego CJ, Shirts BH, Bennette CS, Guzauskas G, Amendola LM, Horike-Pyne M, Hisama FM, Pritchard CC, Grady WM, Burke W, Jarvik GP, Veenstra DL. Next-Generation Sequencing Panels for the Diagnosis of Colorectal Cancer and Polyposis Syndromes: A Cost-Effectiveness Analysis. J Clin Oncol 2015; 33:2084-91. [PMID: 25940718 DOI: 10.1200/jco.2014.59.3665] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the cost effectiveness of next-generation sequencing (NGS) panels for the diagnosis of colorectal cancer and polyposis (CRCP) syndromes in patients referred to cancer genetics clinics. PATIENTS AND METHODS We developed a decision model to evaluate NGS panel testing compared with current standard of care in patients referred to a cancer genetics clinic. We obtained data on the prevalence of genetic variants from a large academic laboratory and calculated the costs and health benefits of identifying relatives with a pathogenic variant, in life-years and quality-adjusted life-years (QALYs). We classified the CRCP syndromes according to their type of inheritance and penetrance of colorectal cancer. One-way and probabilistic sensitivity analyses were conducted to assess uncertainty. RESULTS Evaluation with an NGS panel that included Lynch syndrome genes and other genes associated with highly penetrant CRCP syndromes led to an average increase of 0.151 year of life, 0.128 QALY, and $4,650 per patient, resulting in an incremental cost-effectiveness ratio of $36,500 per QALY compared with standard care and a 99% probability that this panel was cost effective at a threshold of $100,000 per QALY. When compared with this panel, the addition of genes with low colorectal cancer penetrance resulted in an incremental cost-effectiveness ratio of $77,300 per QALY. CONCLUSION The use of an NGS panel that includes genes associated with highly penetrant CRCP syndromes in addition to Lynch syndrome genes as a first-line test is likely to provide meaningful clinical benefits in a cost-effective manner at a $100,000 per QALY threshold.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Wylie Burke
- All authors: University of Washington, Seattle, WA
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