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Allen CG, Hunt K, Jackson A, Baierl J, McMahon L, Judge D. Applying the R = MC 2 implementation science heuristic to assess the impact of readiness on reach and implementation of a population-wide genomic screening program. J Genet Couns 2023:10.1002/jgc4.1775. [PMID: 37732417 PMCID: PMC10954584 DOI: 10.1002/jgc4.1775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/30/2023] [Accepted: 08/14/2023] [Indexed: 09/22/2023]
Abstract
Population-wide genomic screening for genes that have high penetrance and clinical actionability enhances the opportunity to identify individuals at risk for developing hereditary conditions. Organizational readiness has been shown to influence the likelihood of successful implementation of complex initiatives such as the integration of population-wide genomic screening in clinical settings. We use the organizational readiness heuristic R = MC2 to better understand three factors that influence readiness for implementation of In Our DNA SC, a population-wide genomic screening program: motivation to implement, general capacity of an organization, and innovation-specific capacities. We then assessed the influence of these readiness factors on implementation outcomes of reach (measured through enrollment rate) and implementation (measured through the number of DNA samples collected). Data were collected pre-implementation and captured during the three-month pilot phase of the In Our DNA SC program. We collected administrative data from the electronic health record and quantitatively captured elements of readiness through surveys distributed to provider champions and clinical administrative champions at the 10 sites implementing the population-wide genomic screening program. We facilitated innovation-specific capacity through training offered at each site, as well as technical assistance through weekly meetings with other implementing sites, and resources available to all staff. Forty percent of provider champions attended training and 80% of administrative champions attended training. An average of 3.7 additional staff were trained at each implementing site. Satisfaction with training positively influenced reach (β = 0.0121, p = 0.0271) but did not impact implementation. Provider engagement (innovation capabilities) was associated with reach (β = 0.0020, p = 0.0251) and clinical administrator engagement was associated with sample collection rate (β = 0.2599, β = 0.038). Readiness to change is considered one of the most important factors in understanding the potential opportunity for implementation. We found that motivation to adopt a population-wide genomic screening program positively impacted the program's reach. The type of champion influenced discrete outcomes, with provider champions positively impacting reach and administrative champions influencing implementation (assessed through sample collection rate). As genomics continues to be integrated into clinical practice, it will be important to understand the contextual factors that influence readiness for implementation and design support throughout the life-course of implementation to ensure the success of large-scale, complex initiatives.
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Affiliation(s)
- Caitlin G. Allen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kelly Hunt
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amy Jackson
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Baierl
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lori McMahon
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel Judge
- Medical University of South Carolina, Charleston, South Carolina, USA
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Witjes VM, Braspenning JCC, Hoogerbrugge N, Smolders YHCM, Hermkens DMA, Mourits MJE, Ligtenberg MJL, Ausems MGEM, de Hullu JA. Healthcare professionals' perspectives on implementation of universal tumor DNA testing in ovarian cancer patients: multidisciplinary focus groups. Fam Cancer 2023; 22:1-11. [PMID: 35570228 PMCID: PMC9829642 DOI: 10.1007/s10689-022-00294-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/19/2022] [Indexed: 01/13/2023]
Abstract
Universal tumor DNA testing in epithelial ovarian cancer patients can function not only as an efficient prescreen for hereditary cancer testing, but may also guide treatment choices. This innovation, introduced as Tumor-First workflow, offers great opportunities, but ensuring optimal multidisciplinary collaboration is a challenge. We investigated factors that were relevant and important for large-scale implementation. In three multidisciplinary online focus groups, healthcare professionals (gynecologic oncologists, pathologists, clinical geneticists, and clinical laboratory specialists) were interviewed on factors critical for the implementation of the Tumor-First workflow. Recordings were transcribed for analysis in Atlas.ti according to the framework of Flottorp that categorizes seven implementation domains. Healthcare professionals from all disciplines endorse implementation of the Tumor-First workflow, but more detailed standardization and advice regarding the logistics of the workflow were needed. Healthcare professionals explored ways to stay informed about the different phases of the workflow and the results. They emphasized the importance of including all epithelial ovarian cancer patients in the workflow and monitoring this inclusion. Overall, healthcare professionals would appreciate supporting material for the implementation of the Tumor-First workflow in the daily work routine. Focus group discussions have revealed factors for developing a tailored implementation strategy for the Tumor-First workflow in order to optimize care for epithelial ovarian cancer patients. Future innovations affecting multidisciplinary oncology teams including clinical geneticists can benefit from the lessons learned.
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Affiliation(s)
- Vera M. Witjes
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jozé C. C. Braspenning
- grid.10417.330000 0004 0444 9382Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne H. C. M. Smolders
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dorien M. A. Hermkens
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marian J. E. Mourits
- grid.4494.d0000 0000 9558 4598Department of Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolijn J. L. Ligtenberg
- grid.10417.330000 0004 0444 9382Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Pathology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Margreet G. E. M. Ausems
- grid.7692.a0000000090126352Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joanne A. de Hullu
- grid.10417.330000 0004 0444 9382Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Yambert J, Henricksen LA, Clements J, Hannon A, Jordan A, Singh S, Dvorak K, Pritchard CC, Konnick EQ. DNA Mismatch Repair Proteins and BRAF V600E Detection by Immunohistochemistry in Colorectal Cancer Demonstrates Concordance with Next Generation Sequencing. JMP 2022; 3:339-354. [DOI: 10.3390/jmp3040029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Aims: Multiple laboratory methods are used to screen patients with colorectal cancer (CRC) for mismatch repair (MMR) protein deficiency to identify possible Lynch syndrome patients. The goal of this study was to compare the agreement between ready-to-use immunohistochemistry (IHC) assays for MLH-1, PMS-2, MSH-2, MSH-6, and mutated BRAF at V600E and molecular methods in CRC cases. The inclusion of the BRAF V600E mutation testing is important for the identification of patients with sporadic CRC, as the BRAF V600E mutation is very rarely observed in patients with Lynch syndrome tumors. Methods: CRC cases were analyzed by ColoSeqTM tumor sequencing assay and VENTANA MMR IHC Panel that included anti-MLH1, anti-PMS2, anti-MSH2, anti-MSH6, and anti-BRAF V600E antibodies. Additionally, CRC cases with MLH1 IHC loss were evaluated for MLH1 promoter hypermethylation. Results: One hundred and eighteen cases were analyzed. The overall percent agreement (OPA) for each evaluated marker status compared to next-generation sequencing (NGS) exceeded 96%. Twenty-three cases were positive for the BRAF V600E mutation by IHC and NGS, and twenty cases showed loss of MLH1 protein and were positive for MLH1 hypermethylation. Samples with loss of MMR protein expression by IHC demonstrated genetic and/or epigenetic alterations that were consistent with the observed protein expression patterns. Conclusions: The results of this study indicate that ready-to-use IHC assays can correctly identify the loss of MMR proteins and the presence of mutated BRAF V600E protein, supporting the utility of the VENTANA MMR IHC Panel as an aid to stratify patients with sporadic CRC vs. potential Lynch syndrome.
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Rabin BA, Cakici J, Golden CA, Estabrooks PA, Glasgow RE, Gaglio B. A citation analysis and scoping systematic review of the operationalization of the Practical, Robust Implementation and Sustainability Model (PRISM). Implement Sci 2022; 17:62. [PMID: 36153628 PMCID: PMC9509575 DOI: 10.1186/s13012-022-01234-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background The Practical, Robust Implementation and Sustainability Model (PRISM) was developed in 2008 as a contextually expanded version of the broadly used Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. PRISM provides researchers a pragmatic and intuitive model to improve translation of research interventions into clinical and community practice. Since 2008, the use of PRISM increased across diverse topics, populations, and settings. This citation analysis and scoping systematic review aimed to assess the use of the PRISM framework and to make recommendations for future research. Methods A literature search was conducted using three databases (PubMed, Web of Science, Scopus) for the period of 2008 and September 2020. After exclusion, reverse citation searches and invitations to experts in the field were used to identify and obtain recommendations for additional articles not identified in the original search. Studies that integrated PRISM into their study design were selected for full abstraction. Unique research studies were abstracted for information on study characteristics (e.g., setting/population, design), PRISM contextual domains, and RE-AIM outcomes. Results A total of 180 articles were identified to include PRISM to some degree. Thirty-two articles representing 23 unique studies integrated PRISM within their study design. Study characteristics varied widely and included studies conducted in diverse contexts, but predominately in high-income countries and in clinical out-patient settings. With regards to use, 19 used PRISM for evaluation, 10 for planning/development, 10 for implementation, four for sustainment, and one for dissemination. There was substantial variation across studies in how and to what degree PRISM contextual domains and RE-AIM outcomes were operationalized and connected. Only two studies directly connected individual PRISM context domains with RE-AIM outcomes, and another four included RE-AIM outcomes without direct connection to PRISM domains. Conclusions This is the first systematic review of the use of PRISM in various contexts. While there were low levels of ‘integrated’ use of PRISM and few reports on linkage to RE-AIM outcomes, most studies included important context domains of implementation and sustainability infrastructure and external environment. Recommendations are provided for more consistent and comprehensive use of and reporting on PRISM to inform both research and practice on contextual factors in implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01234-3.
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Squires JE, Hutchinson AM, Coughlin M, Bashir K, Curran J, Grimshaw JM, Dorrance K, Aloisio L, Brehaut J, Francis JJ, Ivers N, Lavis J, Michie S, Hillmer M, Noseworthy T, Vine J, Graham ID. Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis. Int J Health Policy Manag 2022; 11:1373-1390. [PMID: 34060269 PMCID: PMC9808341 DOI: 10.34172/ijhpm.2021.32] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 03/13/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare. METHODS A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role. RESULTS A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes). CONCLUSION The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.
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Affiliation(s)
- Janet E. Squires
- Department of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alison M. Hutchinson
- Monash Health, Melbourne, VIC, Australia
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Mary Coughlin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kainat Bashir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Janet Curran
- Faculty of Health, School of Nursing, Dalhousie University, Halifax, NS, Canada
- IWK Health Centre, Halifax, NS, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Laura Aloisio
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jill J. Francis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Noah Ivers
- Women’s College Hospital, Toronto, ON, Canada
| | - John Lavis
- McMaster University, Hamilton, ON, Canada
| | | | - Michael Hillmer
- Ontario Ministry of Health and Long-Term Care, Toronto, ON, Canada
| | | | | | - Ian D. Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Zhou J, Pu J, Wang Q, Zhang R, Liu S, Wang G, Zhang T, Chen Y, Xing W, Liu J, Hu D, Li Y. Tuberculosis treatment management in primary healthcare sectors: a mixed-methods study investigating delivery status and barriers from organisational and patient perspectives. BMJ Open 2022; 12:e053797. [PMID: 35443945 PMCID: PMC9021800 DOI: 10.1136/bmjopen-2021-053797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) treatment management services (TTMSs) are crucial for improving patient treatment adherence. Under the TB integrated control model in China, healthcare workers (HCWs) in the primary healthcare (PHC) sectors are responsible for TTMS delivery. This mixed-method study aimed to explore the status of and barriers to TTMS delivery faced by HCWs in PHC sectors from the health organisational and patient perspectives. DESIGN We completed a questionnaire survey of 261 TB healthcare workers (TB HCWs) and 459 patients with TB in the PHC sector and conducted 20 semistructured interviews with health organisational leaders, TB HCWs and patients with TB. SPSS V.22.0 and the framework approach were used for data analysis. SETTING PHC sectors in Southwest China. RESULTS Our results showed that TTMS delivery rate by HCWs in PHC sectors was <90% (88.4%) on average, and the delivery rates of intensive and continuation phase directly observed therapy (DOT) were only 54.7% and 53.0%, respectively. HCWs with high work satisfaction and junior titles were more likely to deliver first-time home visits and DOT services. Our results suggest that barriers to TTMS delivery at the organisational level include limited patient-centred approaches, inadequate resources and incentives, insufficient training, poor cross-sectional coordination, and strict performance assessment. At the patient level, barriers include low socioeconomic status, poor health literacy and TB-related social stigma. CONCLUSION TTMSs in Southwest China still need further improvement, and this study highlighted specific barriers to TTMS delivery in the PHC sector. Comprehensive measures are urgently needed to address these barriers at the organisational and patient levels to promote TB control in Southwest China.
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Affiliation(s)
- Jiani Zhou
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Jie Pu
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Qingya Wang
- Department of Districts and Counties, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Rui Zhang
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Shili Liu
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Geng Wang
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Ting Zhang
- Department of Districts and Counties, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Yong Chen
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Wei Xing
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Jiaqing Liu
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
| | - Daiyu Hu
- Department of Districts and Counties, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Ying Li
- Department of Social Medicine and Health Service Management, Army Medical University, Chongqing, China
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Crain PR, Zepp JM, Gille S, Jenkins L, Kauffman TL, Shuster E, Goddard KAB, Wilfond BS, Hunter JE. Identifying patients with Lynch syndrome using a universal tumor screening program in an integrated healthcare system. Hered Cancer Clin Pract 2022; 20:17. [PMID: 35436948 PMCID: PMC9014602 DOI: 10.1186/s13053-022-00217-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 03/01/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Lynch syndrome (LS) is associated with an increased risk of colorectal (CRC) and endometrial (EC) cancers. Universal tumor screening (UTS) of all individuals diagnosed with CRC and EC is recommended to increase identification of LS. Kaiser Permanente Northwest (KPNW) implemented a UTS program for LS among individuals newly diagnosed with CRC in January 2016 and EC in November 2016. UTS at KPNW begins with immunohistochemistry (IHC) of tumor tissue to determine loss of mismatch repair proteins associated with LS (MLH1, MSH2, MSH6, and PMS2)., IHC showing loss of MLH1 is followed by reflex testing (automatic testing) to detect the presence of the BRAF V600E variant (in cases of CRC) and MLH1 promoter hypermethylation to rule out likely sporadic cases. Materials and methods Individuals newly diagnosed with CRC and EC were identified between the initiation of the respective UTS programs and July 2018. Electronic medical records were reviewed to extract patient data related to UTS, including IHC and reflex testing results, date of referrals to the genetics department, and results of germline genetic testing for LS. Results 313 out of 362 individuals diagnosed with CRC and 61 out of 64 individuals diagnosed with EC who were eligible were screened by IHC for LS. Most (47/52 or 90%, including 46/49 CRC and 1/3 EC) individuals that were not screened by IHC only had a biopsy sample available. Fourteen individuals (3.7% overall, including 13/313 CRC and 1/61 EC) received an abnormal result after reflex testing and were referred for genetic counseling. Of these, 10 individuals (71% overall, including 9/13 CRC and 1/1 EC) underwent germline genetic testing for LS. Five individuals diagnosed with CRC were found to have pathogenic variants. in PMS2 (n = 3), MLH1 (n = 1), and MSH6 (n = 1). No pathogenic variants were identified in individuals diagnosed with EC. Conclusions UTS identified individuals at risk for LS. Most individuals who screened positive for LS had follow-up germline genetic testing for LS. The consistent use of biopsy samples is an opportunity to improve UTS.
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Affiliation(s)
- Philip R Crain
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jamilyn M Zepp
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Sara Gille
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Lindsay Jenkins
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Tia L Kauffman
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Elizabeth Shuster
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Katrina A B Goddard
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Department of Pediatrics, Seattle Children's Research Institute and Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Jessica Ezzell Hunter
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.
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Pollard S, Dunne J, Costa S, Regier DA. Stakeholder Perspectives on Navigating Evidentiary and Decision Uncertainty in Precision Oncology. J Pers Med 2022; 12:22. [PMID: 35055337 PMCID: PMC8778253 DOI: 10.3390/jpm12010022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022] Open
Abstract
(1) Background: Precision oncology has the potential to improve patient health and wellbeing through targeted prevention and treatment. Owing to uncertain clinical and economic outcomes, reimbursement has been limited. The objective of this pan-Canadian qualitative study was to investigate barriers to precision oncology implementation from the perspectives of health system stakeholders. (2) Methods: We conducted 32 semi-structured interviews with health technology decision makers (n = 14) and clinicians (n = 18) experienced with precision oncology. Participants were recruited using a purposive sampling technique. Interviews were analyzed using thematic analysis. Recruitment continued until two qualitative analysts reached agreement that thematic saturation was reached. (3) Results: While cautiously optimistic about the potential for enhanced therapeutic alignment, participants identified multiple decisional challenges under conditions of evidentiary uncertainty. Decision makers voiced concern over resource requirements alongside small benefitting patient populations and limited evidence supporting patient and health system impacts. Clinicians were comparatively tolerant of evidentiary uncertainty guiding clinical decision-making practices. Clinicians applied a broader definition of patient benefit, focusing on the ability to assist patients making informed clinical decisions. (4) Conclusions: Sustainable precision oncology must balance demand with evidence demonstrating benefit. We show that clinicians and decision makers vary in their tolerance for evolving knowledge, suggesting a need to establish evidentiary standards supporting precision oncology reimbursement decisions.
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Affiliation(s)
- Samantha Pollard
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Jessica Dunne
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Sarah Costa
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Dean A. Regier
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
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O'Shea R, Rankin NM, Kentwell M, Gleeson M, Tucker KM, Hampel H, Taylor N, Lewis S. Stakeholders' views of integrating universal tumour screening and genetic testing for colorectal and endometrial cancer into routine oncology. Eur J Hum Genet 2021; 29:1634-1644. [PMID: 33811254 PMCID: PMC8560784 DOI: 10.1038/s41431-021-00871-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/07/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022] Open
Abstract
Mainstream genetic testing in routine oncology care requires implementation research to inform intervention design. In Australia, funding is available for oncology health professionals (OHP) to organise genetic testing (GT) for eligible colorectal and endometrial cancer patients as part of their routine care. To assess the health system ability to incorporate this practice change, we conducted an implementation survey using the Consolidated Framework for Implementation Research (CFIR). The online survey was available from April to September 2020 to OHP and genetic health professional (GHP). In total, 198 respondents attempted the survey, with 158 completed and 27 partial responses: 26% were GHP, 66% OHP and 8% pathologists. Of all responders, 50% were female, mainly practicing in public hospital settings (57%) in an urban location (80%) and with an 18-60 years plus age range. The majority of respondents saw the relative advantage of aligning GT to abnormal universal tumour screening (UTS) results, with 77% of GHP and 78% of OHP agreeing it would streamline care for patients. There was disagreement across healthcare professional groups about knowledge and self-efficacy, with 45% of GHP not viewing oncologists as 'feeling confident' to use genetic test results for treatment management decisions, while 62% of OHP felt confident in their ability. Both OHP and GHP's indicated embedding a genetic counsellor in oncology or having a genetics point of contact to support integrating of GT through UTS as favourable interventions. Implementation research findings allow for the design of targeted interventions and a model for GT integration into oncology.
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Affiliation(s)
- Rosie O'Shea
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Nicole M Rankin
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Maira Kentwell
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Oncology, Royal Women's Hospital Parkville, Melbourne, VIC, Australia
| | | | - Katherine M Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Heather Hampel
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Natalie Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Cancer Research Division, Cancer Council, Sydney, NSW, Australia
| | - Sarah Lewis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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10
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Dixon K, Asrat MJ, Bedard AC, Binnington K, Compton K, Cremin C, Heidary N, Lohn Z, Lovick N, McCullum M, Mindlin A, O'Loughlin M, Petersen T, Portigal-Todd C, Scott J, St-Martin G, Thompson J, Turnbull R, Mung SW, Hong Q, Bezeau M, Bosdet I, Tucker T, Young S, Yip S, Aubertin G, Blood KA, Nuk J, Sun S, Schrader KA. Integrating Tumor Sequencing Into Clinical Practice for Patients With Mismatch Repair-Deficient Lynch Syndrome Spectrum Cancers. Clin Transl Gastroenterol 2021; 12:e00397. [PMID: 34397043 PMCID: PMC8373535 DOI: 10.14309/ctg.0000000000000397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Uninformative germline genetic testing presents a challenge to clinical management for patients suspected to have Lynch syndrome, a cancer predisposition syndrome caused by germline variants in the mismatch repair (MMR) genes or EPCAM. METHODS Among a consecutive series of MMR-deficient Lynch syndrome spectrum cancers identified through immunohistochemistry-based tumor screening, we investigated the clinical utility of tumor sequencing for the molecular diagnosis and management of suspected Lynch syndrome families. MLH1-deficient colorectal cancers were prescreened for BRAF V600E before referral for genetic counseling. Microsatellite instability, MLH1 promoter hypermethylation, and somatic and germline genetic variants in the MMR genes were assessed according to an established clinical protocol. RESULTS Eighty-four individuals with primarily colorectal (62%) and endometrial (31%) cancers received tumor-normal sequencing as part of routine clinical genetic assessment. Overall, 27% received a molecular diagnosis of Lynch syndrome. Most of the MLH1-deficient tumors were more likely of sporadic origin, mediated by MLH1 promoter hypermethylation in 54% and double somatic genetic alterations in MLH1 (17%). MSH2-deficient, MSH6-deficient, and/or PMS2-deficient tumors could be attributed to pathogenic germline variants in 37% and double somatic events in 28%. Notably, tumor sequencing could explain 49% of cases without causal germline variants, somatic MLH1 promoter hypermethylation, or somatic variants in BRAF. DISCUSSION Our findings support the integration of tumor sequencing into current Lynch syndrome screening programs to improve clinical management for individuals whose germline testing is uninformative.
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Affiliation(s)
- Katherine Dixon
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Mary-Jill Asrat
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Angela C. Bedard
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Kristin Binnington
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Katie Compton
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Carol Cremin
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Nili Heidary
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Zoe Lohn
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Niki Lovick
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Mary McCullum
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Allison Mindlin
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Melanie O'Loughlin
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Tammy Petersen
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | | | - Jenna Scott
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada;
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | | | - Jennifer Thompson
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Ruth Turnbull
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Sze Wing Mung
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Quan Hong
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Marjorie Bezeau
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
- Laboratory of Transdisciplinary Research in Genetics, Medicines and Social Sciences, Sherbrooke's University Hospital Center of Clinical Research, Quebec, Canada;
| | - Ian Bosdet
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Tracy Tucker
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Sean Young
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Stephen Yip
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
| | - Gudrun Aubertin
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
- Department of Medical Genetics, Vancouver Island Health Authority, Victoria, British Columbia, Canada;
| | - Katherine A. Blood
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada;
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
- Department of Medical Genetics, Vancouver Island Health Authority, Victoria, British Columbia, Canada;
| | - Jennifer Nuk
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada;
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
| | - Sophie Sun
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
- Department of Medical Oncology, BC Cancer, Vancouver, British Columbia, Canada.
| | - Kasmintan A. Schrader
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada;
- Hereditary Cancer Program, BC Cancer, Vancouver, British Columbia, Canada;
- Department of Medical Oncology, BC Cancer, Vancouver, British Columbia, Canada.
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11
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Allen CG, Peterson S, Khoury MJ, Brody LC, McBride CM. A scoping review of social and behavioral science research to translate genomic discoveries into population health impact. Transl Behav Med 2021; 11:901-911. [PMID: 32902617 PMCID: PMC8240657 DOI: 10.1093/tbm/ibaa076] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Since the completion of the Human Genome Project, progress toward translating genomic research discoveries to address population health issues has been limited. Several meetings of social and behavioral scientists have outlined priority research areas where advancement of translational research could increase population health benefits of genomic discoveries. In this review, we track the pace of progress, study size and design, and focus of genomics translational research from 2012 to 2018 and its concordance with five social and behavioral science recommended priorities. We conducted a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines for Scoping Reviews. Steps involved completing a search in five databases and a hand search of bibliographies of relevant literature. Our search (from 2012 to 2018) yielded 4,538 unique studies; 117 were included in the final analyses. Two coders extracted data including items from the PICOTS framework. Analysis included descriptive statistics to help identify trends in pace, study size and design, and translational priority area. Among the 117 studies included in our final sample, nearly half focused on genomics applications that have evidence to support translation or implementation into practice (Centers for Disease Control and Prevention Tier 1 applications). Common study designs were cross-sectional (40.2%) and qualitative (24.8%), with average sample sizes of 716 across all studies. Most often, studies addressed public understanding of genetics and genomics (33.3%), risk communication (29.1%), and intervention development and testing of interventions to promote behavior change (19.7%). The number of studies that address social and behavioral science priority areas is extremely limited and the pace of this research continues to lag behind basic science advances. Much of the research identified in this review is descriptive and related to public understanding, risk communication, and intervention development and testing of interventions to promote behavior change. The field has been slow to develop and evaluate public health-friendly interventions and test implementation approaches that could enable health benefits and equitable access to genomic discoveries. As the completion of the human genome approaches its 20th anniversary, full engagement of transdisciplinary efforts to address translation challenges will be required to close this gap.
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Affiliation(s)
- Caitlin G Allen
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
| | - Shenita Peterson
- Woodruff Health Science Center Library, Emory University, Atlanta, GA, USA
| | - Muin J Khoury
- Office of Genomics and Precision Public Health, Office of Science, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence C Brody
- Gene and Environment Interaction Section, National Human Genome Research Institute, Bethesda, MD, USA
| | - Colleen M McBride
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
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12
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Li D, Udaltsova N, Layefsky E, Doan C, Corley DA. Natural Language Processing for the Accurate Identification of Colorectal Cancer Mismatch Repair Status in Lynch Syndrome Screening. Clin Gastroenterol Hepatol 2021; 19:610-612.e1. [PMID: 32036042 DOI: 10.1016/j.cgh.2020.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/18/2020] [Accepted: 01/24/2020] [Indexed: 02/07/2023]
Abstract
Lynch syndrome (LS) is the most common type of hereditary colorectal cancer (CRC) syndrome caused by pathogenic variants in mismatch repair (MMR) genes.1 Current multisociety guidelines recommend screening all CRC tumors for LS.2,3 The most widely adopted screening method is MMR immunohistochemistry (IHC) followed by germline analysis if indicated.2,3 However, the text-based nature of pathology and IHC reports used for LS screening results impedes creation of an efficient tracking system for identifying affected patients and screening outcomes.4 In this study, we developed and validated a natural language processing (NLP) tool for extracting MMR IHC results in LS screening in a large, diverse, multicenter, community-based setting.5.
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Affiliation(s)
- Dan Li
- Department of Gastroenterology, Kaiser Permanente Medical Center, Santa Clara, California; Division of Research, Kaiser Permanente Northern California, Oakland, California.
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Evan Layefsky
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Cecilia Doan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Gastroenterology, Kaiser Permanente Medical Center, San Francisco, California
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13
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O'Shea R, Rankin NM, Kentwell M, Gleeson M, Salmon L, Tucker KM, Lewis S, Taylor N. How can Australia integrate routine genetic sequencing in oncology: a qualitative study through an implementation science lens. Genet Med 2020; 22:1507-1516. [PMID: 32461668 DOI: 10.1038/s41436-020-0838-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/04/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study sought to determine genetics and oncology specialists' views of integrating BRCA1 and BRCA2 testing in epithelial ovarian and breast cancer into routine practice. METHODS Qualitative interviews were designed using the Consolidated Framework for Implementation Research. Questions included experiences or views of the BRCA testing processes, implementation needs of oncology health professionals, perceived challenges, and future ideas for interventions to integrate genetic testing into oncology. RESULTS Twenty-two participants were interviewed from twelve health organizations and four themes were identified: (1) embracing the shift to mainstream genetic testing, with the majority of participants viewing BRCA testing as clinically useful and routine use important for maintaining a patient centered process; (2) the need for communication networks and role delineation to integrate routine genetic testing; (3) factors that influence sustaining routine genetic testing, including ongoing training, resources and funding, real-world adaptation, system complexity, and champions; and (4) variation in system interventions for integrating routine genetic testing align to organizational context. CONCLUSION Findings illustrate the need for integrating genetic testing into routine oncology, and that adaptation of interventions and processes is essential to sustain a feasible model. An understanding of individual and organizational implementation factors will help to prepare for future integration of routine genetic testing in other cancers.
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Affiliation(s)
- Rosie O'Shea
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia. .,Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Nicole M Rankin
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Maira Kentwell
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Oncology, Royal Women's Hospital Parkville, Parkville, VIC, Australia
| | | | - Lucinda Salmon
- Department of Clinical Genetics, Austin Health, Melbourne, VIC, Australia
| | - Katherine M Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, University of New South Wales, UNSW, Sydney, NSW, Australia
| | - Sarah Lewis
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Natalie Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia
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14
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Pollard S, Kalloger S, Weymann D, Sun S, Nuk J, Schrader KA, Regier DA. Genetic testing for hereditary cancer syndromes: patient recommendations for improved risk communication. Health Expect 2020; 23:884-892. [PMID: 32338425 PMCID: PMC7495068 DOI: 10.1111/hex.13062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/18/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Background Multi‐gene panel testing is replacing single‐gene testing for patients with suspected hereditary cancer syndromes. The detection of a hereditary cancer syndrome allows tested individuals to initiate enhanced primary and secondary prevention efforts—where available—with a view to reduce disease burden. Current policy prevents testing programmes from communicating genetic test results with potentially affected family members, yet it is well documented that tested individuals face multiple challenges in initiating such discussions with relatives. Objective In response to this challenge, we sought patient recommendations about how to improve genetic risk communication to enhance interfamilial discussions about primary and secondary disease prevention. Design We conducted 25 semi‐structured interviews with individuals who received genetic testing through British Columbia’s Hereditary Cancer Program between 2017 and 2018. Interviews were professionally transcribed and analysed using a constant comparative approach. Results Participants described difficulty engaging in conversations with relatives who were resistant to receiving genetic risk information, when communicating with younger relatives and where participants reported strained familial relationships. Participants recommended that testing facilities provide a summary of results and implications and that resources be made available to prepare patients for challenging discussions with family members. Discussion Our study demonstrates that individuals undergoing genetic testing for suspected hereditary cancer syndromes would benefit from additional supportive resources alongside genetic counselling. Providing this on‐going support will enhance the accurate and transparent communication of risk to facilitate the uptake of cascade testing and enhanced prevention strategies.
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Affiliation(s)
- Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Steve Kalloger
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Sophie Sun
- Hereditary Cancer Program, BC Cancer, Vancouver, BC, Canada.,Division of Medical Oncology, BC Cancer, Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Nuk
- Hereditary Cancer Program, BC Cancer, Vancouver, BC, Canada.,Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kasmintan A Schrader
- Hereditary Cancer Program, BC Cancer, Vancouver, BC, Canada.,Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Molecular Oncology, BC Cancer, Vancouver, BC, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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15
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Zhang R, Chen Y, Liu S, Liang S, Wang G, Li L, Luo X, Li Y. Progress of equalizing basic public health services in Southwest China--- health education delivery in primary healthcare sectors. BMC Health Serv Res 2020; 20:247. [PMID: 32209085 PMCID: PMC7092608 DOI: 10.1186/s12913-020-05120-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Equalizing basic public health services (BPHS) for all has been one goal of the health system reform in China since 2009. At the end of the 12th five-year plan, we conducted a series of surveys to understand BPHS implementation in Southwest China, and firstly reported implementation of health education (HE) and explore the barriers to HE delivery. Methods Mixed research methods were used to investigate achievement in and barriers to HE in Southwest China. SPSS 22.0 was used for data analysis. Results Nine hundred and eighty-nine residents were surveyed by questionnaire. 16 health care workers (HCWs) and 16 directors from 16 PHC sectors were included in the in-depth interviews. Less than 50% of residents who knew or utilized some item of HE. Age, residence, region (Chongqing or Guizhou), marital status, education, occupation, type and quality of primary health care (PHC) sectors to deliver BPHS, self-reported health and status of chronic diseases were associated with knowledge or utilization of HE. Distance to PHC sectors was associated with the knowledge of HE, gender and health insurance were associated with utilization of HE. Age, marital status, occupation region and self-reported health were associated with satisfaction regarding HE. Barriers to HE delivery included defects in HE design, weak capacity in PHC sectors to provide HE, residents’ poor cooperation, lack of multi-sector cooperation, poor equipment and weak health system. Conclusions Southwest China delivered HE in all PHC sectors. However, our study underlined many barriers to equalization of HE. To address those barriers and achieve HE quality improvement, comprehensive measures to improve capacity of PHC sectors, enhance multi-sector cooperation and strengthen health information systems are all urgent needs.
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Affiliation(s)
- Rui Zhang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Yong Chen
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Shili Liu
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Shengxiang Liang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Geng Wang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Li Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Xingneng Luo
- Tuwai community health service center, Shapingba District, Chongqing, China
| | - Ying Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.
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16
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Li L, Zhang R, Chen Y, Deng H, Liu S, Wang G, Wang M, Liang S, Xing W, Lin H, Li Y. Achievements and challenges in health management for aged individuals in primary health care sectors: a survey in Southwest China. BMC Public Health 2020; 20:338. [PMID: 32178646 PMCID: PMC7077106 DOI: 10.1186/s12889-020-8210-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND China has rapidly transformed into an ageing nation and will be one of the countries with the highest percentage of aged people in 2050. Healthcare management for the aged (HMA) in basic public health service (BPHS), which is delivered by lay healthcare workers (LHWs) in primary health care (PHC) sectors, is an important strategy to address the healthcare challenges that have resulted from ageing in China since 2009. This survey aimed to understand the achievements made and challenges faced by HMA in Southwest China. METHODS A multilevel stratified random and consecutive sampling method was used to select study places and participants respectively, and mixed research methods were used to collect data from the aged individuals, LHWs and leaders in PHC sectors. SPSS 21.0 was used for data analysis. RESULTS Seven hundred seventy-two surveys with aged people (over 60 years old), 16 focus group discussions (FGDs) with 96 aged people, and 32 in-depth interviews with 16 LHWs and 16 leaders were completed in PHC sectors. More than 85% of aged individuals had knowledge and utilization of HMA, and over 94% of these respondents were satisfied with HMA. Meanwhile, challenges in HMA delivery included weakness (unmet items and lack of appropriate assessment indicators) in HMA design, low capacity of PHC sectors and competency of LHWs to deliver HMA, poor health literacy of aged individuals, insufficient funds and a lack of multi-sector cooperation. CONCLUSIONS Though significant achievements in HMA were observed, this study highlighted the challenges in further quality improvement of HMA delivery program in Southwest China. The "older-person-centered and integrated care" model provided a good theory to improve the quality of HMA by reinforcing the needs-based HMA design, building a comprehensive assessment strategy, improving the capacity of PHC sectors and the LHWs' competency, and strengthening multi-sector cooperation.
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Affiliation(s)
- Li Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.,Chongqing City Management College, Chongqing, China
| | - Rui Zhang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Yong Chen
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Haoyue Deng
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Shili Liu
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Geng Wang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Mei Wang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Shengxiang Liang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Wei Xing
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Hai Lin
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.
| | - Ying Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.
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17
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Dong L, Jin X, Wang W, Ye Q, Li W, Shi S, Guo L, Ying J, Zou S. Distinct clinical phenotype and genetic testing strategy for Lynch syndrome in China based on a large colorectal cancer cohort. Int J Cancer 2020; 146:3077-3086. [PMID: 32030746 DOI: 10.1002/ijc.32914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/19/2020] [Accepted: 01/29/2020] [Indexed: 02/06/2023]
Abstract
Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) predisposition syndrome. We performed a large-scale study to assess a screening strategy for identifying LS in Chinese CRC patients in routine clinical testing. A total of 4,195 eligible CRCs were universally screened. Then, 8.7% of CRCs were detected with dMMR. The incidence of LS was 2.7% (115 of 4,195) in this cohort; among patients over 70 years of age, only 0.3% (2 of 678) were diagnosed as LS. Then, 17.4% of LS cases showed large genomic deletions/duplications. LS probands developed CRCs predominantly at proximal colon location. The frequency of BRAF V600E mutation among Chinese CRCs was significantly lower than that among Western populations, and MLH1 promoter methylation significantly improved the efficiency of genetic screening for LS among MLH1-deficient patients. A comprehensive molecular testing strategy that includes detection of large genomic rearrangements is imperative for the diagnosis of LS. Among CRC patients aged 70 years or younger, a selective strategy for LS screening might be considered for routine clinical testing.
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Affiliation(s)
- Lin Dong
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianglan Jin
- Department of Pathology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Wenmiao Wang
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiurong Ye
- Department of Pathology, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Weihua Li
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Susheng Shi
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Guo
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianming Ying
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuangmei Zou
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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18
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Knerr S, West KM, Angelo FA. Organizational readiness to implement population-based screening and genetic service delivery for hereditary cancer prevention and control. J Genet Couns 2020; 29:867-876. [PMID: 31967362 DOI: 10.1002/jgc4.1216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 12/15/2019] [Accepted: 12/25/2019] [Indexed: 01/09/2023]
Abstract
Despite clinical guidelines, programs conducting population-based screening and genetic service delivery for hereditary cancer prevention and control are rare in practice. We interviewed individuals (n = 13) instrumental in implementing seven unique clinical programs conducting either universal tumor screening for Lynch Syndrome or routine family history screening and provision of genetic services for hereditary breast and ovarian cancer in the United States. To characterize determinants of readiness to implement population-based cancer genetic service delivery models, interviews and deductive codes drew on Weiner's theory of organizational readiness for change. Qualitative analysis identified themes across programs. The degree to which organizational stakeholders valued moving to a population-based genetic service delivery model depended on the existence of aligned clinical guidelines at the time of program implementation. However, judgments of implementation capacity within the organization, particularly with respect to task demands and resource concerns, were more often barriers to readiness. Program champions were essential to facilitating readiness, frequently taking on substantial uncompensated work. These data suggest that developing interventions targeting change efficacy and cultivating practice change champions may be two promising ways to increase uptake of population-based hereditary cancer screening and genetic service delivery in clinical practice.
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Affiliation(s)
- Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Kathleen M West
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Frank A Angelo
- Department of Health Services, University of Washington, Seattle, WA, USA
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Abstract
Purpose of review: Identification of Lynch syndrome is important from an individual patient and public health standpoint. As paradigms for Lynch syndrome diagnosis have shifted in recent years, this review will discuss rationale and limitations for current strategies as well as provide an overview of future directions in the field. Recent findings: In recent years, the use of clinical criteria and risk scores for identification of Lynch syndrome have been augmented by universal testing of all newly diagnosed colorectal cancers with molecular methods to screen for mismatch repair deficiency with high sensitivity and specificity. Studies of implementation and outcomes of universal testing in clinical practice have demonstrated significant heterogeneity that results in suboptimal uptake and contributes to disparities in diagnosis. Emerging technologies, such as next-generation sequencing, hold significant promise as a screening strategy for Lynch syndrome. Summary: Universal testing for Lynch syndrome is being performed with increasing frequency, although real-world outcomes have demonstrated room for improvement. Future directions in Lynch syndrome diagnosis will involve optimization of universal testing workflow and application of new genetics technologies.
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Dicks E, Pullman D, Kao K, MacMillan A, Simmonds C, Etchegary H. Universal tumor screening for Lynch syndrome: perspectives of Canadian pathologists and genetic counselors. J Community Genet 2019; 10:335-344. [PMID: 30465127 PMCID: PMC6591350 DOI: 10.1007/s12687-018-0398-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 11/13/2018] [Indexed: 12/31/2022] Open
Abstract
Universal screening of all newly diagnosed colorectal cancer tumors can identify individuals at high risk for Lynch syndrome (LS), a hereditary cancer syndrome predisposing carriers to increased risk of colorectal, endometrial, and other cancers. To inform planning of a universal tumor screening program for LS in our jurisdiction, we undertook online surveys of Canadian pathologists and genetic counselors to describe existing tumor screening programs. Online surveys were hosted on SurveyMonkey between October 2016 and March 2017. Fifty-three pathologists and 66 genetic counselors completed surveys (total n = 119). While attitudes towards tumor screening were positive, considerable variability was observed in the existence of tumor screening, test ordering criteria, and practices. Most respondents indicated consent was not obtained for tumor screening nor were educational materials provided to patients; however, opting out of additional mutation testing in the event of a positive tumor screen was endorsed. Results add to the growing literature on providers' perspectives on population-based tumor screening programs and inform ways to offer these. Findings highlight the need to develop methods of patient education that allow meaningful opt-out decisions. The variability we observed also suggests the need for national standards and guidance on tumor screening for LS.
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Affiliation(s)
- Elizabeth Dicks
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Daryl Pullman
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Ken Kao
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
- Immunohistochemistry Laboratory, Eastern Regional Health Authority, St. John's, NL, Canada
| | - Andrée MacMillan
- Provincial Medical Genetics Program, Eastern Regional Health Authority, St. John's, NL, Canada
| | | | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John's, NL, Canada.
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21
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Dicks E, Pullman D, Kao K, MacMillan A, Logan GS, Simmonds C, Etchegary H. Universal tumor screening for Lynch syndrome: Perceptions of Canadian pathologists and genetic counselors of barriers and facilitators. Cancer Med 2019; 8:3614-3622. [PMID: 31102338 PMCID: PMC6601578 DOI: 10.1002/cam4.2182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND People at risk of developing hereditary cancers associated with Lynch Syndrome (LS) can be identified through universal screening of colorectal tumors. However, tumor screening practices are variable across Canada and few studies explore the perspectives of genetic counselors and pathologists about tumor screening. This study was conducted to better understand the barriers and facilitators of implementing universal tumor screening in health centers across Canada. METHODS An online survey about tumor screening programs was administered to genetic counselors and pathologists across Canada through communication channels of professional organizations. It was hosted on SurveyMonkey and accessible from October 2016 to March 2017. RESULTS Barriers to tumor screening included a lack of sustainable resources, including funding and genetic counselors. Respondents strongly identified the need for a coordinated, interdisciplinary approach to program planning with the "right people at the table." Respondents currently with a screening program provided advice such as carefully designing the program structure, developing patient and family follow-up protocols, and ensuring adequate resources (funding, staff, training for providers) were available prior to program initiation. CONCLUSION There is no national approach to universal tumor screening in Canada. However, future efforts can be informed by the experiences of those centers that have already created a universal tumor screening program for LS. These data suggest the need for an interdisciplinary approach, initial and sustained funding, and careful advanced planning of program structures and policies.
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Affiliation(s)
- Elizabeth Dicks
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Daryl Pullman
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
| | - Ken Kao
- Faculty of Medicine, Memorial University, St. John's, NL, Canada.,Immunohistochemistry Laboratory, Eastern Regional Health Authority, St. John's, NL, Canada
| | - Andrée MacMillan
- Provincial Medical Genetics Program, Eastern Regional Health Authority, St. John's, NL, Canada
| | | | | | - Holly Etchegary
- Faculty of Medicine, Memorial University, St. John's, NL, Canada
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Rahm AK, Ladd I, Burnett-Hartman AN, Epstein MM, Lowery JT, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Hunter JE. The Healthcare Systems Research Network (HCSRN) as an Environment for Dissemination and Implementation Research: A Case Study of Developing a Multi-Site Research Study in Precision Medicine. EGEMS (Wash DC) 2019; 7:16. [PMID: 30984796 DOI: 10.5334/egems.283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Context: In existence for nearly 25 years, the Healthcare Systems Research Network (HCSRN) is an established and sustainable network of health care systems that serves as a “real world” laboratory to enable the integration of research findings into practice. The objective of this paper is to demonstrate how the HCSRN serves as an ideal environment for studying dissemination and implementation of evidence-based practices into health care systems through the example of developing a multi-site study on the implementation of evidence-based precision medicine practices. Case description: The “Implementing Universal Lynch Syndrome Screening (IMPULSS)” study (NIH R01CA211723) involves seven HCSRN health care systems and two external health care systems. The IMPULSS study will describe and explain organizational variability around Lynch syndrome (LS) screening to identify which factors in different organizational contexts are important for successful implementation of LS screening programs and will create a toolkit to facilitate organizational decision making around implementation and improvement of precision medicine programs in health care systems. Major Themes: The strengths of the HCSRN that facilitate D&I research include: 1) a culture of collaboration, 2) standardization of data and processes across systems, and 3) researchers embedded in diverse health care systems. We describe how these strengths contributed to developing the IMPULSS study. Conclusion: Given the importance of conducting research in real world settings to improve patient outcomes, the unique strengths of the HCSRN are of vital importance. The IMPULSS study is one case example of how the strengths of the HCSRN make it an excellent environment for research on implementing evidence-based precision medicine practices in health care systems.
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23
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Rahm AK, Cragun D, Hunter JE, Epstein MM, Lowery J, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Burnett-Hartman AN, Gudgeon JM, Hao J, Snyder S, Gogoi R, Ladd I, Williams MS. Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts. BMC Health Serv Res 2018; 18:824. [PMID: 30376847 PMCID: PMC6208012 DOI: 10.1186/s12913-018-3636-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 10/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background Systematic screening of all colorectal tumors for Lynch Syndrome (LS) has been recommended since 2009. Currently, implementation of LS screening in healthcare systems remains variable, likely because LS screening involves the complex coordination of multiple departments and individuals across the healthcare system. Our specific aims are to (1) describe variation in LS screening implementation across multiple healthcare systems; (2) identify conditions associated with both practice variation and optimal implementation; (3) determine the relative effectiveness, efficiency, and costs of different LS screening protocols by healthcare system; and (4) develop and test in a real-world setting an organizational toolkit for LS screening program implementation and improvement. This toolkit will promote effective implementation of LS screening in various complex health systems. Methods This study includes eight healthcare systems with 22 clinical sites at varied stages of implementing LS screening programs. Guided by the Consolidated Framework for Implementation Research (CFIR), we will conduct in-depth semi-structured interviews with patients and organizational stakeholders and perform economic evaluation of site-specific implementation costs. These processes will result in a comprehensive cross-case analysis of different organizational contexts. We will utilize qualitative data analysis and configurational comparative methodology to identify facilitators and barriers at the organizational level that are minimally sufficient and necessary for optimal LS screening implementation. Discussion The overarching goal of this project is to combine our data with theories and tools from implementation science to create an organizational toolkit to facilitate implementation of LS screening in various real-world settings. Our organizational toolkit will account for issues of complex coordination of care involving multiple stakeholders to enhance implementation, sustainability, and ongoing improvement of evidence-based LS screening programs. Successful implementation of such programs will ultimately reduce suffering of patients and their family members from preventable cancers, decrease waste in healthcare system costs, and inform strategies to facilitate the promise of precision medicine. Trial registration N/A Electronic supplementary material The online version of this article (10.1186/s12913-018-3636-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alanna Kulchak Rahm
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA.
| | - Deborah Cragun
- University of South Florida, 3720 Spectrum Blvd, Suite 304, Tampa, FL, 33612, USA
| | - Jessica Ezzell Hunter
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97202, USA
| | - Mara M Epstein
- Department of Medicine and the Meyers Primary Care Institute, University of Massachusetts Medical School, 365 Plantation St. Biotech 1, Suite 100, Worcester, MA, 01605, USA
| | - Jan Lowery
- Colorado Center for Personalized Medicine, University of Colorado, Aurora, CO, 80045, USA
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA
| | | | - Ravi N Sharaf
- Division of Gastroenterology, Department of Medicine, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, CA, 94301, USA
| | - Andrea N Burnett-Hartman
- Kaiser Permanente Colorado, Institute for Health Research, 2550 S. Parker Rd., Ste 200, Aurora, CO, 80014, USA
| | - James M Gudgeon
- Intermountain Healthcare, Precision Genomics, IMC campus, Bldg. 2, Suite 610, 5121 S. Cottonwood Street, Murray, UT, 84107, USA
| | - Jing Hao
- Geisinger Department of Epidemiology and Health Services Research 100 N, Academy Ave Danville, Mahoning Township, PA, 17822, USA
| | - Susan Snyder
- Geisinger Department of Epidemiology and Health Services Research 100 N, Academy Ave Danville, Mahoning Township, PA, 17822, USA
| | - Radhika Gogoi
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Ilene Ladd
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - Marc S Williams
- Geisinger Genomic Medicine Institute, 100 N. Academy Ave, Danville, PA, 17822, USA
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24
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Palter VN, Baker NA, Rabeneck L, Tinmouth J, Gagliardi AR, Kennedy ED, Carroll JC, Gallinger S, Baxter NN. A framework to build capacity for a reflex-testing program for Lynch syndrome. Genet Med 2018; 21:1381-1389. [PMID: 30349099 DOI: 10.1038/s41436-018-0342-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/05/2018] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Lynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada. METHODS We recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed. RESULTS Twenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified. CONCLUSIONS This study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.
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Affiliation(s)
| | - Natalie A Baker
- St. Michael's Hospital, Toronto, ON, Canada.,Public Health Sciences, University of Toronto, Toronto, ON, Canada
| | | | - Jill Tinmouth
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Erin D Kennedy
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
| | - June C Carroll
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada
| | - Steven Gallinger
- Public Health Sciences, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Nancy N Baxter
- St. Michael's Hospital, Toronto, ON, Canada.,Public Health Sciences, University of Toronto, Toronto, ON, Canada
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25
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Palter VN, Baker NA, Pollett A, Daly C, Facey M, Rotenberg C, Rabeneck L, Baxter NN. Learning by Example: An International Perspective on Reflex-Testing for Lynch Syndrome. Ann Surg Oncol 2018; 26:425-436. [DOI: 10.1245/s10434-018-6809-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 01/02/2023]
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26
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Schneider JL, Goddard KAB, Muessig KR, Davis JV, Rope AF, Hunter JE, Peterson SK, Acheson LS, Syngal S, Wiesner GL, Reiss JA. Patient and provider perspectives on adherence to and care coordination of lynch syndrome surveillance recommendations: findings from qualitative interviews. Hered Cancer Clin Pract 2018; 16:11. [PMID: 29760830 PMCID: PMC5946437 DOI: 10.1186/s13053-018-0090-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/26/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with a genetic variant associated with Lynch syndrome (LS) are recommended to undergo frequent and repeated cancer surveillance activities to minimize cancer-related morbidity and mortality. Little is known about how patients and primary care providers (PCPs) track and manage these recommendations. We conducted a small exploratory study of patient and PCP experiences with recommended LS surveillance activities and communication with family members in an integrated health care system. METHODS We used in-depth interviews with patients and providers to understand how surveillance is coordinated and monitored following confirmation of LS. We recruited patients with a range of ages/gender, and providers with at least at least one patient with a molecular diagnosis of LS. All interviews were recorded, transcribed, and content analyzed by a trained qualitative methodologist. RESULTS Twenty-two interviews were completed with 12 patients and 10 providers. Most patients (10) had detailed knowledge of surveillance recommendations, but were less sure of time intervals. While all patients reported receiving initial education about their surveillance recommendations from a genetic counselor, seven did not follow-up with a genetic counselor in subsequent years. A third of patients described taking sole responsibility for managing their LS surveillance care. Lack of routine communication from the health system (e.g., prompts for surveillance activities), and provider engagement were surveillance barriers. PCPs were generally aware of LS, but had limited familiarity with surveillance recommendations. Most PCPs (7) viewed LS as rare and relied on patient and specialist expertise and support. Providers typically had 1 patient with LS in a panel of 1800 patients overall. Providers felt strongly that management of LS should be coordinated by a dedicated team of specialists. Most patients (92%) had at least one family member that sought LS testing, and common barriers for family members included lack of insurance, affordability, and fear of result. CONCLUSION The maximal benefits of screening for confirmation of LS will only be realized with adherence to recommended preventive care. Important factors to ensure patients receive recommended LS care include a comprehensive and coordinated monitoring program that includes reminder prompts, and increased PCP education of LS and associated surveillance recommendations.
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Affiliation(s)
- Jennifer L. Schneider
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Katrina A. B. Goddard
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Kristin R. Muessig
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - James V. Davis
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Alan F. Rope
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Jessica E. Hunter
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Susan K. Peterson
- 0000 0001 2291 4776grid.240145.6Department of Behavioral Science, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Louise S. Acheson
- 0000 0000 9149 4843grid.443867.aCase Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Sapna Syngal
- 0000 0001 2106 9910grid.65499.37Dana-Farber Cancer Institute, Boston, MA USA
| | - Georgia L. Wiesner
- 0000 0001 2264 7217grid.152326.1Vanderbilt Hereditary Cancer Program, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, TN USA
| | - Jacob A. Reiss
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
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27
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Di Marco M, DAndrea E, Panic N, Baccolini V, Migliara G, Marzuillo C, De Vito C, Pastorino R, Boccia S, Villari P. Which Lynch syndrome screening programs could be implemented in the "real world"? A systematic review of economic evaluations. Genet Med 2018; 20:1131-44. [PMID: 29300371 DOI: 10.1038/gim.2017.244] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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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28
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Ryan E, Sheahan K, Creavin B, Mohan HM, Winter DC. The current value of determining the mismatch repair status of colorectal cancer: A rationale for routine testing. Crit Rev Oncol Hematol. 2017;116:38-57. [PMID: 28693799 DOI: 10.1016/j.critrevonc.2017.05.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/02/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Colorectal Cancer (CRC) is the third most prevalent cancer in men and women. Up to 15% of CRCs display microsatellite instability (MSI). MSI is reflective of a deficient mismatch repair (MMR) system and is most commonly caused by hypermethylation of the MLH1 promoter. However, it may also be due to autosomal dominant constitutional mutations in DNA MMR, termed Lynch Syndrome. MSI may be diagnosed via polymerase chain reaction (PCR) or alternatively, immunohistochemistry (IHC) can identify MMR deficiency (dMMR). Many institutions now advocate universal tumor screening of CRC via either PCR for MSI or IHC for dMMR to guide Lynch Syndrome testing. The association of sporadic MSI with methylation of the MLH1 promoter and an activating BRAF mutation may offer further exclusion criteria for genetic testing. Aside from screening for Lynch syndrome, MMR testing is important because of its prognostic and therapeutic implications. Several studies have shown MSI CRCs exhibit different clinicopathological features and prognosis compared to microsatellite-stable (MSS) CRCs. For example, response to conventional chemotherapy has been reported to be less in MSI tumours. More recently, MSI tumours have been shown to be responsive to immune-checkpoint inhibition providing a novel therapeutic strategy. This provides a rationale for routine testing for MSI or dMMR in CRC.
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29
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West KM, Burke W, Korngiebel DM. Identifying "ownership" through role descriptions to support implementing universal colorectal cancer tumor screening for Lynch syndrome. Genet Med 2017; 19:1236-1244. [PMID: 28471433 PMCID: PMC5671377 DOI: 10.1038/gim.2017.39] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/08/2017] [Indexed: 12/31/2022] Open
Abstract
Purpose Lynch Syndrome cases are under-identified, and universal colorectal cancer tumor screening for Lynch Syndrome (UTS) has been recommended. UTS implementation is challenging and few successful examples exist to date, and colorectal cancer patients and at-risk family members exhibit low uptake of genetic services. This study sought to identify the elements that could guide the choice of specialties to implement UTS through three main stages: initiating the screen, returning positive screen results, and providing follow-up. Methods To understand stakeholder views on the UTS process, twenty semi-structured interviews were conducted with clinicians from six medical specialties crucial for implementing UTS. Data were analyzed using directed content analysis and additional thematic analysis across content categories. Results Several clinical specialties could fill necessary roles at each of the main stages of UTS implementation. Participants suggested owners based on attributes of specialty roles, clinical settings, and the routes patients take through the system. Conclusion UTS is considered possible in a range of healthcare settings, with tailoring. Health systems need to choose who best fills the role’s needs based on local resources and processes. These results offer implementation guidance based on role needs, not clinical specialty, in resolving the issue of UTS “ownership.”
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Affiliation(s)
- Kathleen M West
- Department of Bioethics and Humanities, Institute for Public Health Genetics, University of Washington, Seattle, Washington, USA
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Diane M Korngiebel
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, Washington, USA
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30
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Bombard Y, Rozmovits L, Sorvari A, Daly C, Carroll JC, Kennedy E, Rabeneck L, Baxter NN. Universal tumor screening for Lynch syndrome: health-care providers' perspectives. Genet Med 2017; 19:568-74. [PMID: 27711070 DOI: 10.1038/gim.2016.150] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/03/2016] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Population-based reflex testing of colorectal tumors can identify individuals with Lynch syndrome (LS), but there is debate regarding the type of patient discretion such a program warrants. We examined health-care providers' views and experiences to inform the design of a reflex-testing program and their perspectives regarding an opt-out option. METHODS We interviewed providers managing LS or colorectal cancer patients, including surgeons, genetic counselors, oncologists, primary-care physicians, and gastroenterologists. Qualitative data were analyzed thematically using constant comparison techniques. RESULTS Providers supported a reflex-testing program because of the current lack of coordinated immunohistochemistry (IHC) testing and underascertainment of LS patients as well as the opportunity to standardize the increasing use of genomic tests in practice. Most supported an opt-out after reflex testing because they felt that IHC is akin to other pathology tests, which are not optional. Some favored an opt-out before testing because of concern for patients experiencing distress, insurance discrimination, or a diagnostic odyssey that may be inconclusive. CONCLUSION Providers support a reflex-testing program to improve the identification and management of suspected LS patients. However, how to support meaningful information provision to enable an opt-out without jeopardizing testing uptake and the anticipated public health benefits remains a policy challenge.Genet Med advance online publication 06 October 2016.
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31
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Sperber NR, Andrews SM, Voils CI, Green GL, Provenzale D, Knight S. Barriers and Facilitators to Adoption of Genomic Services for Colorectal Care within the Veterans Health Administration. J Pers Med 2016; 6:E16. [PMID: 27136589 DOI: 10.3390/jpm6020016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/15/2016] [Accepted: 04/22/2016] [Indexed: 11/17/2022] Open
Abstract
We examined facilitators and barriers to adoption of genomic services for colorectal care, one of the first genomic medicine applications, within the Veterans Health Administration to shed light on areas for practice change. We conducted semi-structured interviews with 58 clinicians to understand use of the following genomic services for colorectal care: family health history documentation, molecular and genetic testing, and genetic counseling. Data collection and analysis were informed by two conceptual frameworks, the Greenhalgh Diffusion of Innovation and Andersen Behavioral Model, to allow for concurrent examination of both access and innovation factors. Specialists were more likely than primary care clinicians to obtain family history to investigate hereditary colorectal cancer (CRC), but with limited detail; clinicians suggested templates to facilitate retrieval and documentation of family history according to guidelines. Clinicians identified advantage of molecular tumor analysis prior to genetic testing, but tumor testing was infrequently used due to perceived low disease burden. Support from genetic counselors was regarded as facilitative for considering hereditary basis of CRC diagnosis, but there was variability in awareness of and access to this expertise. Our data suggest the need for tools and policies to establish and disseminate well-defined processes for accessing services and adhering to guidelines.
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32
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Modell SM, Greendale K, Citrin T, Kardia SL. Expert and Advocacy Group Consensus Findings on the Horizon of Public Health Genetic Testing. Healthcare (Basel) 2016; 4:E14. [PMID: 27417602 DOI: 10.3390/healthcare4010014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 12/18/2015] [Accepted: 01/18/2016] [Indexed: 12/30/2022] Open
Abstract
Description: Among the two leading causes of death in the United States, each responsible for one in every four deaths, heart disease costs Americans $300 billion, while cancer costs Americans $216 billion per year. They also rank among the top three causes of death in Europe and Asia. In 2012 the University of Michigan Center for Public Health and Community Genomics and Genetic Alliance, with the support of the Centers for Disease Control and Prevention Office of Public Health Genomics, hosted a conference in Atlanta, Georgia to consider related action strategies based on public health genomics. The aim of the conference was consensus building on recommendations to implement genetic screening for three major heritable contributors to these mortality and cost figures: hereditary breast and ovarian cancer (HBOC), familial hypercholesterolemia (FH), and Lynch syndrome (LS). Genetic applications for these three conditions are labeled with a “Tier 1” designation by the U.S. Centers for Disease Control and Prevention because they have been fully validated and clinical practice guidelines based on systematic review support them. Methodology: The conference followed a deliberative sequence starting with nationally recognized clinical and public health presenters for each condition, followed by a Patient and Community Perspectives Panel, working group sessions for each of the conditions, and a final plenary session. The 74 conference participants represented disease research and advocacy, public health, medicine and nursing, genetics, governmental health agencies, and industry. Participants drew on a public health framework interconnecting policy, clinical intervention, surveillance, and educational functions for their deliberations. Results: Participants emphasized the importance of collaboration between clinical, public health, and advocacy groups in implementing Tier 1 genetic screening. Advocacy groups could help with individual and institutional buy-in of Tier 1 programs. Groups differed on funding strategies, with alternative options such as large-scale federal funding and smaller scale, incremental funding solutions proposed. Piggybacking on existing federal breast and colorectal cancer control programs was suggested. Public health departments need to assess what information is now being collected by their state cancer registries. The groups advised that information on cascade screening of relatives be included in toolkits for use by states. Participants stressed incorporation of family history into health department breast cancer screening programs, and clinical HBOC data into state surveillance systems. The carrying out of universal LS screening of tumors in those with colorectal cancer was reviewed. Expansion of universal screening to include endometrial tumors was discussed, as was the application of guidelines recommending cholesterol screening of children 9–11 years old. States more advanced in terms of Tier 1 testing could serve as models and partners with other states launching screening and surveillance programs. A multidisciplinary team of screening program champions was suggested as a means of raising awareness among the consumer and health care communities. Participants offered multiple recommendations regarding use of electronic health records, including flagging of at-risk family members and utilization of state-level health information exchanges. The paper contains an update of policy developments and happenings for all three Tier 1 conditions, as well as identified gaps. Conclusions: Implementation of cascade screening of family members for HBOC and FH, and universal screening for LS in CRC tumors has reached a point of readiness within the U.S., with creative solutions at hand. Facilitating factors such as screening coverage through the Patient Protection and Affordable Care Act, and state health information exchanges can be tapped. Collaboration is needed between public health departments, health care systems, disease advocacy groups, and industry to fully realize Tier 1 genetic screening. State health department and disease networks currently engaged in Tier 1 screening can serve as models for the launch of new initiatives.
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Cohen SA, Laurino M, Bowen DJ, Upton MP, Pritchard C, Hisama F, Jarvik G, Fichera A, Sjoding B, Bennett RL, Naylor L, Jacobson A, Burke W, Grady WM. Initiation of universal tumor screening for Lynch syndrome in colorectal cancer patients as a model for the implementation of genetic information into clinical oncology practice. Cancer 2015; 122:393-401. [PMID: 26480326 DOI: 10.1002/cncr.29758] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/11/2015] [Accepted: 09/30/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lynch syndrome confers a hereditary predisposition to colorectal and other cancers. Universal tumor screening (UTS) for Lynch syndrome is recommended by several professional societies, but the implementation can be complex. This article describes the evaluation, process development, and initiation of Lynch syndrome UTS at a tertiary referral cancer center. METHODS A multidisciplinary team developed the new process design. Issues in 5 themes were noted: timing, funding, second-opinion patients, result processing, and the role of genetics providers. A committee approach was used to examine each issue for process-improvement development. RESULTS The issues related to testing were addressed individually for the successful implementation of UTS at the institutional level. In the conventional-care period, 9 of 30 cases (30%) received Lynch syndrome screening, and 4 cases were referred to medical genetics. During the 6 months following the implementation of UTS, 32 of 44 patients (73%) received Lynch syndrome screening. The 13 unscreened patients all had identified reasons for nonscreening (eg, financial limitations). Ten patients were referred to medical genetics, which identified no new cases of Lynch syndrome, but a low-risk adenomatous polyposis coli (APC) variant was detected in 1 individual. CONCLUSIONS The implementation of effective Lynch syndrome UTS can feasibly alter practice at the institutional level. This experience with the assessment and management of issues relevant to the successful implementation of a new clinical care paradigm based on emerging technology has implications for the uptake of advances across molecular oncology into clinical practice, and this is highly relevant in the current era of rapidly evolving genomic technology.
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Affiliation(s)
- Stacey A Cohen
- Division of Oncology, University of Washington, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mercy Laurino
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Deborah J Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Melissa P Upton
- Department of Pathology, University of Washington, Seattle, Washington
| | - Colin Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Fuki Hisama
- Division of Medical Genetics, University of Washington, Seattle, Washington
| | - Gail Jarvik
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Department of Genome Sciences, University of Washington, Seattle, Washington
| | | | - Britta Sjoding
- Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Robin L Bennett
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Lorraine Naylor
- Division of Medical Genetics, University of Washington, Seattle, Washington.,Genetic Counseling, Seattle Cancer Care Alliance, Seattle, Washington
| | - Angela Jacobson
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - William M Grady
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Gastroenterology, University of Washington, Seattle, Washington
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