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Macrae F. Balancing the burden and benefits of colonoscopy in Lynch Syndrome. Fam Cancer 2023; 22:399-401. [PMID: 37713026 DOI: 10.1007/s10689-023-00347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Finlay Macrae
- Department of Colorectal Medicine and Genetics, The Royal Melbourne Hospital, and Dept of Medicine, University of Melbourne, Melbourne, Australia, PO Box 2010 Royal Melbourne Hospital, 3050, Melbourne, Victoria, Australia.
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Morrow A, Steinberg J, Chan P, Tiernan G, Kennedy E, Egoroff N, Hilton D, Sankey L, Venchiarutti R, Hayward A, Pearn A, McKay S, Debono D, Hogden E, Taylor N. In person and virtual process mapping experiences to capture and explore variability in clinical practice: application to genetic referral pathways across seven Australian hospital networks. Transl Behav Med 2023; 13:561-570. [PMID: 37036763 PMCID: PMC10415733 DOI: 10.1093/tbm/ibad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Genetic referral for Lynch syndrome (LS) exemplifies complex clinical pathways. Identifying target behaviours (TBs) for change and associated barriers requires structured group consultation activities with busy clinicians - consolidating implementation activities whilst retaining rigour is crucial. This study aimed to: i) use process mapping to gain in-depth understandings of site-specific LS testing and referral practices in Australian hospitals and support identification of TBs for change, ii) explore if barriers to identified TBs could be identified through process mapping focus-group data, and iii) demonstrate pandemic-induced transition from in-person to virtual group interactive process mapping methods. LS clinical stakeholders attended interactive in-person or virtual focus groups to develop site-specific "process maps" visually representing referral pathways. Content analysis of transcriptions informed site-specific process maps, then clinical audit data was compared to highlight TBs for change. TBs were reviewed in follow-up focus groups. Secondary thematic analysis explored barriers to identified TBs, coded against the Theoretical Domains Framework (TDF). The transition from in-person to pandemic-induced virtual group interactive process mapping methods was documented. Process mapping highlighted six key areas of clinical practice variation across sites and site-specific TBs for change were identified. Key barriers to identified TBs emerged, categorised to seven TDF domains. Process mapping revealed variations in clinical practices surrounding LS referral between sites. Incorporating qualitative perspectives enhances process mapping by facilitating identification of TBs for change and barriers, providing a pathway to developing targeted interventions. Virtual process mapping activities produced detailed data and enabled comprehensive map development.
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Affiliation(s)
- April Morrow
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Priscilla Chan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Gabriella Tiernan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Elizabeth Kennedy
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Desiree Hilton
- Familial Cancer Service, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | | | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amy Pearn
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Skye McKay
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, University of Technology Sydney, New South Wales, Australia
| | - Emily Hogden
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography. J Adv Nurs 2020; 76:3548-3562. [PMID: 32996620 DOI: 10.1111/jan.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
AIM To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. DESIGN Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. METHODS An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. RESULTS Observation was conducted for 300 hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. CONCLUSION Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. IMPACT Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City University of London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Judith Dyson
- School of Health Sciences, City University of London, London, UK
| | - Jillian Hartin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Leanne M Aitken
- School of Health Sciences, City University of London, London, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
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Churruca K, Ludlow K, Taylor N, Long JC, Best S, Braithwaite J. The time has come: Embedded implementation research for health care improvement. J Eval Clin Pract 2019; 25:373-380. [PMID: 30632246 DOI: 10.1111/jep.13100] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 12/23/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The field of implementation science has developed in response to slow and inconsistent translation of evidence into practice. Despite utilizing increasingly sophisticated approaches to implementation, including applying a complexity science lens and conducting realist evaluations, challenges remain to getting the kinds of outcomes hoped for by implementation efforts. These include gaining access and buy-in from those implementing the change and accounting for the influence of local context. One emerging approach to address these challenges is embedded implementation research-a collaborative, adaptive approach to improvement. It involves researchers and implementers working together in situ from the outset of, and throughout, an implementation project. Both groups can benefit from the collaboration: it increases the rigor of evaluation, provides opportunities to improve the intervention through direct feedback, and promotes better on-the-ground understanding of the change process. We aimed to examine the potential benefits, and some of the challenges, of increased embeddedness. METHOD We performed a multi-case analysis of implementation research projects that varied by degree of embeddedness. RESULTS Embedded implementation research may offer a range of advantages over dichotomized research-practice designs, including better understanding of local context and direct feedback to improve the implementation along the way. We present a model that spans four approaches: dichotomized research-practice, collaborative linking-up, partially-embedded, and deep immersion. CONCLUSION Embedded implementation research approaches hold promise in comparison to traditional dichotomized-research practice designs, where the research is external to the implementation and conducts a summative evaluation. We are only beginning to understand how such partnerships operate in practice and what makes them successful. Our analysis suggests the time has come to consider such approaches.
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Affiliation(s)
- Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Stephanie Best
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Long JC, Winata T, Debono D, Phan-Thien KC, Zhu C, Taylor N. Process evaluation of a behaviour change approach to improving clinical practice for detecting hereditary cancer. BMC Health Serv Res 2019; 19:180. [PMID: 30894169 PMCID: PMC6425681 DOI: 10.1186/s12913-019-3985-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This retrospective process evaluation reports on the application of a 1-year implementation program to increase identification and management of patients at high risk of a hereditary cancer syndrome. The project used the Theoretical Domains Framework Implementation (TDFI) approach, a promising implementation methodology, used successfully in the United Kingdom to address patient safety issues. This Australian project run at two large public hospitals aimed to increase referrals of patients flagged as being at risk of Lynch syndrome on the basis of a screening test to genetic services. At the end of the project, the pathologists' processes had changed, but the referral rate remained inconsistent and low. METHODS Semi-structured interviews explored participants' perceptions of the TDFI approach and Health services researchers wrote structured reflections. Interview transcripts and reflections were coded initially against implementation outcomes for the various TDFI approach activities: acceptability, appropriateness, feasibility, value for time cost, and adoption. On a second pass, themes were coded around challenges to the approach. RESULTS Interviews were held with nine key project participants including pathologists, oncologists, surgeons, genetic counsellors and an administrative officer. Two health services researchers wrote structured reflections. The first of two major themes was 'Theory-related challenges', with subthemes of accessibility of theory underpinning the TDFI, commitment to that theory-based approach, and the problem of complexity. The second theme was 'Practical challenges' with subthemes of stakeholder management, navigating the system, and perceptions of the problem. Health services researchers reflected on the benefits of bridging professional divides and facilitating collective learning and problem solving, but noted frustrations around clinicians' time constraints that led to sparse interactions with the team, and lack of authority to effect change themselves. CONCLUSIONS Mixed success of adoption as an outcome was attributed to the complexity and highly nuanced nature of the setting. This made identifying the target behaviour, a key step in the TDFI approach, challenging. Introduced changes in the screening process led to new, unexpected issues yet to be addressed. Strategies to address challenges are presented, including using an internal facilitator with a focus on applying a theory-based implementation approach.
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Affiliation(s)
- Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Teresa Winata
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Deborah Debono
- Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, NSW, 2007, Australia
| | - Kim-Chi Phan-Thien
- St George and Sutherland Clinical School, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - Christine Zhu
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia. .,Cancer Research Division, Cancer Council NSW, 153 Dowling St, Woolloomooloo, NSW, 2011, Australia. .,Faculty of Health Sciences, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia.
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Taylor N, Best S, Martyn M, Long JC, North KN, Braithwaite J, Gaff C. A transformative translational change programme to introduce genomics into healthcare: a complexity and implementation science study protocol. BMJ Open 2019; 9:e024681. [PMID: 30842113 PMCID: PMC6429849 DOI: 10.1136/bmjopen-2018-024681] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/21/2018] [Accepted: 11/08/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Translating scientific advances in genomic medicine into evidence-based clinical practice is challenging. Studying the natural translation of genomics into 'early-adopting' health system sectors is essential. We will (a) examine 29 health systems (Australian and Melbourne Genomics Health Alliance flagships) integrating genomics into practice and (b) combine this learning to co-design and test an evidence-based generalisable toolkit for translating genomics into healthcare. METHODS AND ANALYSIS Twenty-nine flagships integrating genomics into clinical settings are studied as complex adaptive systems to understand emergent and self-organising behaviours among inter-related actors and processes. The Effectiveness-Implementation Hybrid approach is applied to gather information on the delivery and potential for real-world implementation. Stages '1' and '2a' (representing hybrid model 1) are the focus of this protocol. The Translation Science to Population Impact (TSci Impact) framework is used to study policy decisions and service provision, and the Theoretical Domains Framework (TDF) is used to understand individual level behavioural change; both frameworks are applied across stages 1 and 2a. Stage 1 synthesises interview data from 32 participants involved in developing the genomics clinical practice systems and approaches across five 'demonstration-phase' (early adopter) flagships. In stage 2a, stakeholders are providing quantitative and qualitative data on process mapping, clinical audits, uptake and sustainability (TSci Impact), and psychosocial and environmental determinants of change (TDF). Findings will be synthesised before codesigning an intervention toolkit to facilitate implementation of genomic testing. Study methods to simultaneously test the comparative effectiveness of genomic testing and the implementation toolkit (stage 2b), and the refined implementation toolkit while simply observing the genomics intervention (stage 3) are summarised. ETHICS AND DISSEMINATION Ethical approval has been granted. The results will be disseminated in academic forums and used to refine interventions to translate genomics evidence into healthcare. Non-traditional academic dissemination methods (eg, change in guidelines or government policy) will also be employed.
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Affiliation(s)
- Natalie Taylor
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Stephanie Best
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Australian Genomics, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Melissa Martyn
- Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics and Medicine, University of Melbourne, Melbourne, UK
| | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kathryn N North
- Australian Genomics, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Australian Genomics, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Clara Gaff
- Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Paediatrics and Medicine, University of Melbourne, Melbourne, UK
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Long JC, Debono D, Williams R, Salisbury E, O'Neill S, Eykman E, Butler J, Rawson R, Phan-Thien KC, Thompson SR, Braithwaite J, Chin M, Taylor N. Using behaviour change and implementation science to address low referral rates in oncology. BMC Health Serv Res 2018; 18:904. [PMID: 30486812 PMCID: PMC6263048 DOI: 10.1186/s12913-018-3653-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022] Open
Abstract
Background Patients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach. Methods Multidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates. Results Teams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: ‘environmental context;’ ‘memory and decision making;’ ‘skills;’ and ‘beliefs about capabilities.’ Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation. Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later. Conclusion Lynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions. Electronic supplementary material The online version of this article (10.1186/s12913-018-3653-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, Australia.
| | - Deborah Debono
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, Australia.,Faculty of Health, University of Technology, Sydney, Australia
| | - Rachel Williams
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Sharron O'Neill
- School of Business, University of NSW, Campbell, ACT, Australia
| | - Elizabeth Eykman
- NSW Pathology (SEALS), St George Hospital, Kogarah, NSW, Australia
| | - Jordan Butler
- NSW Pathology (SEALS), Prince of Wales Hospital, Randwick, NSW, Australia
| | - Robert Rawson
- Anatomical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kim-Chi Phan-Thien
- St George and Sutherland Clinical School, University of New South Wales, Randwick, NSW, Australia
| | - Stephen R Thompson
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, Australia
| | - Melvin Chin
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
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Brennan B, Hemmings CT, Clark I, Yip D, Fadia M, Taupin DR. Universal molecular screening does not effectively detect Lynch syndrome in clinical practice. Therap Adv Gastroenterol 2017; 10:361-371. [PMID: 28491141 PMCID: PMC5405883 DOI: 10.1177/1756283x17690990] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 01/04/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Lynch syndrome (LS) due to an inherited damaging mutation in mismatch repair (MMR) genes comprises 3% of all incident colorectal cancer (CRC). Molecular testing using immunohistochemistry (IHC) for MMR proteins is a recommended screening tool to identify LS in incident CRC. This study assessed outcomes of population-based routine molecular screening for diagnosis of LS in a regional center. METHODS We conducted a prospective, consecutive case series study of universal IHC testing on cases of resected CRC from September 2004-December 2013. Referred cases with abnormal IHC results that attended a familial cancer clinic were assessed according to modified Bethesda criteria (until 2009) or molecular criteria (from 2009). RESULTS 1612 individuals underwent resection for CRC in the study period and had MMR testing by IHC. Of these, 274 cases (16.9%) exhibited loss of expression of MMR genes. The mean age at CRC diagnosis was 68.1 years (± standard deviation 12.7) and the mean age of those with an IHC abnormality was 71.6 (± 11.8). A total of 82 (29.9%) patients with an abnormal result were seen in a subspecialty familial cancer clinic. Patients aged under 50 (p = 0.009) and those with loss of MSH6 staining (p = 0.027) were more likely to be referred and to attend. After germ-line sequencing, 0.6% (10 of 82) were identified as having a clinically significant abnormality. A further eight probands with pathogenic germ-line mutations were identified from other referrals to the service over the same time period. CONCLUSIONS While technically accurate, the yield of 'universal' IHC in detecting new Lynch probands is limited by real-world factors that reduce referrals and genetic testing. We propose an alternative approach for universal, incident case detection of Lynch syndrome with 'one-stop' MMR testing and sequencing.
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Affiliation(s)
- Beatrice Brennan
- Gastroenterology and Hepatology Unit, The Canberra Hospital, Garran, ACT, Australia
| | - Christine T. Hemmings
- ACT Pathology, The Canberra Hospital, Garran, ACT, Australia,Current address: Anatomic Pathology (WA) & Head of Molecular Oncology, St John of God Pathology, Subiaco, WA, Australia
| | - Ian Clark
- Capital Pathology, Deakin, ACT, Australia,Current address: Australian Pathology at Sonic Healthcare, Macquarie Park, New South Wales, Australia
| | - Desmond Yip
- Department of Medical Oncology, Canberra and Calvary Hospitals, Garran, Australian Capital Territory, Australia
| | - Mitali Fadia
- ACT Pathology, The Canberra Hospital, Garran, ACT, Australia
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