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Kim HM, Kim TI. Screening and surveillance for hereditary colorectal cancer. Intest Res 2024; 22:119-130. [PMID: 38311713 PMCID: PMC11079514 DOI: 10.5217/ir.2023.00112] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/08/2023] [Accepted: 11/27/2023] [Indexed: 02/06/2024] Open
Abstract
Hereditary colorectal cancer is a type of cancer that is caused by a genetic mutation. Individuals with a family history of colorectal cancer, or who have a known hereditary syndrome, are at an increased risk of developing the disease. Screening and surveillance are important tools for managing the risk of hereditary colorectal cancer. Screening involves a combination of tests that can detect precancerous or cancerous changes in the colon and rectum. Surveillance involves regular follow-up examinations to monitor disease progression and to identify new developments. The frequency and type of screening and surveillance tests may vary depending on an individual's risk factors, genetic profile, and medical history. However, early detection and treatment of hereditary colorectal cancer can significantly improve patient outcomes and reduce mortality rates. By implementing comprehensive screening and surveillance strategies, healthcare providers can help individuals at risk of hereditary colorectal cancer to receive timely interventions and make informed decisions about their health. Specific examples of screening and surveillance tests for hereditary colorectal cancer include colonoscopy, genetic testing, and imaging tests. In this review article, we will discuss detailed screening and surveillance of hereditary colorectal cancer.
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Affiliation(s)
- Hee Man Kim
- Cancer Prevention Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Cancer Prevention Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Santoro A, Bragantini E, Castiglione F, Ganesan R, Matias-Guiu X, Frattini M, Gallotta V, Garcia P, Pattni Y, Tsiampali-Laprell J, Bisaro B, Barbareschi M, Zannoni GF. Biomarker characterization in endometrial cancer in Europe: first survey data analysis from 69 pathological academic and hospital labs. Pathologica 2024; 116:32-45. [PMID: 38482673 PMCID: PMC10938279 DOI: 10.32074/1591-951x-926] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/21/2023] [Indexed: 03/17/2024] Open
Abstract
Introduction Endometrial carcinoma (EC) is the commonest gynecological cancer affecting women in Western populations. To predict patient risk, the 2020 edition of the World Health Organization (WHO) Classification of Tumors of the Female Genital Tract stressed the importance of integrated histo-molecular classification of the disease. This survey analysis poses attention on the most frequently used immunohistochemical and molecular markers adopted in daily categorization of ECs in European laboratories. Methods We analyzed data collected through questionnaires administered to 40 Italian, 20 Spanish, 3 Swiss and 6 United Kingdom (UK) laboratories. We collected information regarding daily practice in EC evaluation, specifically concerning mismatch repair status (MMR) and microsatellite instability (MSI). Summary and descriptive statistical analyses were carried out to evaluate the current practice of each laboratory. Results The results show that MMR status is mainly evaluated by using immunohistochemistry (IHC) on most EC samples. The most frequent approach for the analysis of MMR status is IHC of four proteins (PMS2, MSH6, MSH2, MLH1). MSI analysis by molecular methods is uncommon but useful as a supplemental tool in specific conditions. MLH1 promoter hypermethylation and BRAF V600 mutations analysis are performed in case of negative expression of MLH1/PMS2. Other markers (mainly p53 followed by POLE and PTEN) are investigated in particular in Spain and Switzerland in a consistent number of cases. Conclusion Guidelines consultation and standardization of laboratory procedures are efficient means for EC prognostic risk stratification and improving the quality of care.
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Affiliation(s)
- Angela Santoro
- Department of Women, Children and Public Health Sciences, General Pathology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Francesca Castiglione
- Histopathology and Molecular Diagnostics, Careggi University Hospital, Florence, Italy
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women’s and Childrens Hospital, Birmingham, UK
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital U de Bellvitge and Hospital U Arnau de Vilanova, Universities of Lleida and Barcelona, Institut de Recerca Biomèdica de Lleida, Instituto de Investigación Biomédica de Bellvitge, Centro de Investigación Biomédica en Red de Cáncer, Barcelona, Spain
| | - Milo Frattini
- Institute of Pathology, Ente Ospedaliero Cantonale (EOC), Locarno, Italy
| | - Valerio Gallotta
- Department of Women, Children and Public Health Sciences, Oncological Gynecology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Yu J, Ding PR, Jiang W. Screening and Management of Lynch Syndrome: The Chinese Experience. Clin Colon Rectal Surg 2023; 36:369-377. [PMID: 37795465 PMCID: PMC10547539 DOI: 10.1055/s-0043-1767706] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Lynch syndrome (LS), caused by germline mutations in the mismatch repair genes, is the most common hereditary colorectal cancer. While LS is also associated with various cancers, early detection of the proband is meaningful for tumor prevention, treatment, and familial management. It has been a dramatic shift on the screening approaches for LS. As the rapid development of the molecular biological methods, a comprehensive understanding of the LS screening strategies will help to improve the clinical care for this systematic disease. The current screening strategies have been well validated but mainly by evidence derived from western population, lacking consideration of the ethnic heterogeneity, which hampers the universality and clinical application in China. Hence, this review will focus on the Chinese experience in LS screening, aiming to help better understand the ethnic diversity and further optimize the screening strategies.
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Affiliation(s)
- Jiehai Yu
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou Guangdong, P. R. China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou Guangdong, P. R. China
| | - Wu Jiang
- Department of Colorectal Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou Guangdong, P. R. China
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Morrow A, Steinberg J, Chan P, Tiernan G, Kennedy E, Egoroff N, Hilton D, Sankey L, Venchiarutti R, Hayward A, Pearn A, McKay S, Debono D, Hogden E, Taylor N. In person and virtual process mapping experiences to capture and explore variability in clinical practice: application to genetic referral pathways across seven Australian hospital networks. Transl Behav Med 2023; 13:561-570. [PMID: 37036763 PMCID: PMC10415733 DOI: 10.1093/tbm/ibad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Genetic referral for Lynch syndrome (LS) exemplifies complex clinical pathways. Identifying target behaviours (TBs) for change and associated barriers requires structured group consultation activities with busy clinicians - consolidating implementation activities whilst retaining rigour is crucial. This study aimed to: i) use process mapping to gain in-depth understandings of site-specific LS testing and referral practices in Australian hospitals and support identification of TBs for change, ii) explore if barriers to identified TBs could be identified through process mapping focus-group data, and iii) demonstrate pandemic-induced transition from in-person to virtual group interactive process mapping methods. LS clinical stakeholders attended interactive in-person or virtual focus groups to develop site-specific "process maps" visually representing referral pathways. Content analysis of transcriptions informed site-specific process maps, then clinical audit data was compared to highlight TBs for change. TBs were reviewed in follow-up focus groups. Secondary thematic analysis explored barriers to identified TBs, coded against the Theoretical Domains Framework (TDF). The transition from in-person to pandemic-induced virtual group interactive process mapping methods was documented. Process mapping highlighted six key areas of clinical practice variation across sites and site-specific TBs for change were identified. Key barriers to identified TBs emerged, categorised to seven TDF domains. Process mapping revealed variations in clinical practices surrounding LS referral between sites. Incorporating qualitative perspectives enhances process mapping by facilitating identification of TBs for change and barriers, providing a pathway to developing targeted interventions. Virtual process mapping activities produced detailed data and enabled comprehensive map development.
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Affiliation(s)
- April Morrow
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Priscilla Chan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Gabriella Tiernan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Elizabeth Kennedy
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Desiree Hilton
- Familial Cancer Service, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | | | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amy Pearn
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Skye McKay
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, University of Technology Sydney, New South Wales, Australia
| | - Emily Hogden
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Tatsuta K, Sakata M, Iwaizumi M, Kojima R, Yamanaka K, Baba S, Suzuki K, Morita Y, Kikuchi H, Hiramatsu Y, Kurachi K, Takeuchi H. Using a multistep approach with multidisciplinary team to increase the diagnosis rate of Lynch syndrome-associated colorectal cancer after universal screening: a single-center study in Japan. Hered Cancer Clin Pract 2023; 21:14. [PMID: 37460934 PMCID: PMC10351164 DOI: 10.1186/s13053-023-00258-0] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 07/11/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUNDS This study aimed to evaluate the changes in the rates of genetic counseling and genetic testing as well as the diagnosis rate of Lynch syndrome (LS)-associated colorectal cancer before and after multistep approach with multidisciplinary team in Japanese. METHODS In September 2016, we started universal screening for LS by mismatch repair protein immunohistochemistry and prospectively collected the records. Following patient interviews, we started multistep approach with multidisciplinary team (MA) in January 2020. MA consists of six surgeons, one genetic counselor, one medical geneticist, and six pathologists. MA is set up to compensate for patients' lack of knowledge about genetic diseases and make case selection for elderly colorectal cancer patients with deficient mismatch repair (dMMR). MA is designed as a system that could be performed by a small number of medical genetic specialists. A total of 522 patients were included during the study duration, 323 and 199 patients in the pre-MA (P-MA) and MA groups, respectively. RESULTS The frequency of dMMR in all patients was 10.0%. The patient interview results indicated a significant lack of patient education regarding genetic diseases. The rates of genetic counseling and genetic testing was significantly higher in MA group than in P-MA group (genetic counseling: MA 34.6% vs. P-MA 7.7%, p = 0.04; genetic testing: MA 30.8% vs. P-MA 3.8%, p = 0.02). Moreover, the diagnosis rate of LS-associated colorectal cancer was significantly higher in MA group (2.5%) than in P-MA group (0.3%) (P = 0.03). In addition, MA could be performed without problems despite the small number of medical and human genetics specialists. CONCLUSIONS MA has achieved appropriate pickup of suspected hereditary colorectal cancer patients and complemented the lack of knowledge about genetic diseases. The introduction of MA increased LS-associated colorectal cancer after universal screening. MA is an appropriate LS screening protocol for Japanese patients who lag behind in medical and human genetics education.
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Affiliation(s)
- Kyota Tatsuta
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Mayu Sakata
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan.
| | - Moriya Iwaizumi
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Risa Kojima
- Clinical & Molecular Genetics Center, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Katsumasa Yamanaka
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Satoshi Baba
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Katsunori Suzuki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
- Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Kiyotaka Kurachi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
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Kim MH, Kim DW, Lee HS, Bang SK, Seo SH, Park KU, Oh HK, Kang SB. Universal Screening for Lynch Syndrome Compared with Pedigree-Based Screening: 10-Year Experience in a Tertiary Hospital. Cancer Res Treat 2023; 55:179-188. [PMID: 35313100 PMCID: PMC9873326 DOI: 10.4143/crt.2021.1512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 11/18/2021] [Accepted: 03/20/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Universal screening for Lynch syndrome (LS) refers to routine tumor testing for microsatellite instability (MSI) among all patients with colorectal cancer (CRC). Despite its widespread adoption, real-world data on the yield is lacking in Korean population. We studied the yield of adopting universal screening for LS in comparison with pedigree-based screening in a tertiary center. MATERIALS AND METHODS CRC patients from 2007-2018 were reviewed. Family histories were obtained and were evaluated for hereditary nonpolyposis colorectal cancer (HNPCC) using Amsterdam II criteria. Tumor testing for MSI began in 2007 and genetic testing was offered using all available clinicopathologic data. Yield of genetic testing for LS was compared for each approach and step. RESULTS Of the 5,520 patients, tumor testing was performed in 4,701 patients (85.2%) and family histories were obtained from 4,241 patients (76.8%). Hereditary CRC (LS or HNPCC) was present in 69 patients (1.3%). MSI-high was present in 6.9%, and 25 patients had confirmed LS. Genetic testing was performed in 41.2% (47/114) of MSI-high patients, out of which 40.4% (19/47) were diagnosed with LS. There were six additional LS patients found outside of tumor testing. For pedigree-based screening, Amsterdam II criteria diagnosed 55 patients with HNPCC. Fifteen of these patients underwent genetic testing, and 11 (73.3%) were diagnosed with LS. Two patients without prior family history were diagnosed with LS and relied solely on tumor testing results. CONCLUSION Despite widespread adoption of routine tumor testing for MSI, this is not a fail-safe approach to screen all LS patients. Obtaining a thorough family history in combination with universal screening provides a more comprehensive 'universal' screening method for LS.
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Affiliation(s)
- Min Hyun Kim
- Department of Surgery, Uijeongbu Eulji Medical Center, Uijeongbu,
Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Hye Seung Lee
- Department of Pathology, Seoul National University Hospital, Seoul,
Korea
| | - Su Kyung Bang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Soo Hyun Seo
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Kyung Un Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam,
Korea
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Primiero CA, Finnane A, Yanes T, Peach B, Soyer HP, McInerney-Leo AM. Protocol to evaluate a pilot program to upskill clinicians in providing genetic testing for familial melanoma. PLoS One 2022; 17:e0275926. [PMID: 36477719 PMCID: PMC9728910 DOI: 10.1371/journal.pone.0275926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/22/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Genetic testing for hereditary cancers can improve long-term health outcomes through identifying high-risk individuals and facilitating targeted prevention and screening/surveillance. The rising demand for genetic testing exceeds the clinical genetic workforce capacity. Therefore, non-genetic specialists need to be empowered to offer genetic testing. However, it is unknown whether patient outcomes differ depending on whether genetic testing is offered by a genetics specialist or a trained non-genetics clinician. This paper describes a protocol for upskilling non-genetics clinicians to provide genetic testing, randomise high-risk individuals to receive testing from a trained clinician or a genetic counsellor, and then determine whether patient outcomes differed depending on provider-type. METHODS An experiential training program to upskill dermatologically-trained clinicians to offer genetic testing for familial melanoma is being piloted on 10-15 clinicians, prior to wider implementation. Training involves a workshop, comprised of a didactic learning presentation, case studies, simulated sessions, and provision of supporting documentation. Clinicians later observe a genetic counsellor led consultation before being observed leading a consultation. Both sessions are followed by debriefing with a genetic counsellor. Thereafter, clinicians independently offer genetic testing in the clinical trial. Individuals with a strong personal and/or family history of melanoma are recruited to a parallel-group trial and allocated to receive pre- and post- genetic testing consultation from a genetic counsellor, or a dermatologically-trained clinician. A mixed method approach measures psychosocial and behavioural outcomes. Longitudinal online surveys are administered at five timepoints from baseline to one year post-test disclosure. Semi-structured interviews with both patients and clinicians are qualitatively analysed. SIGNIFICANCE This is the first program to upskill dermatologically-trained clinicians to provide genetic testing for familial melanoma. This protocol describes the first clinical trial to compare patient-reported outcomes of genetic testing based on provider type (genetic counsellors vs trained non-genetic clinicians).
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Affiliation(s)
- Clare A. Primiero
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
| | - Anna Finnane
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Tatiane Yanes
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
| | - Betsy Peach
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
| | - H. Peter Soyer
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Aideen M. McInerney-Leo
- The University of Queensland Diamantina Institute, The University of Queensland, Dermatology Research Centre, Brisbane, Australia
- * E-mail:
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Primiero CA, Baker AM, Wallingford CK, Maas EJ, Yanes T, Fowles L, Janda M, Young MA, Nisselle A, Terrill B, Lodge JM, Tiller JM, Lacaze P, Andersen H, McErlean G, Turbitt E, Soyer HP, McInerney-Leo AM. Attitudes of Australian dermatologists on the use of genetic testing: A cross-sectional survey with a focus on melanoma. Front Genet 2022; 13:919134. [PMID: 36353112 PMCID: PMC9638172 DOI: 10.3389/fgene.2022.919134] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Melanoma genetic testing reportedly increases preventative behaviour without causing psychological harm. Genetic testing for familial melanoma risk is now available, yet little is known about dermatologists’ perceptions regarding the utility of testing and genetic testing ordering behaviours. Objectives: To survey Australasian Dermatologists on the perceived utility of genetic testing, current use in practice, as well as their confidence and preferences for the delivery of genomics education. Methods: A 37-item survey, based on previously validated instruments, was sent to accredited members of the Australasian College of Dermatologists in March 2021. Quantitative items were analysed statistically, with one open-ended question analysed qualitatively. Results: The response rate was 56% (256/461), with 60% (153/253) of respondents between 11 and 30 years post-graduation. While 44% (112/252) of respondents agreed, or strongly agreed, that genetic testing was relevant to their practice today, relevance to future practice was reported significantly higher at 84% (212/251) (t = -9.82, p < 0.001). Ninety three percent (235/254) of respondents reported rarely or never ordering genetic testing. Dermatologists who viewed genetic testing as relevant to current practice were more likely to have discussed (p < 0.001) and/or offered testing (p < 0.001). Respondents indicated high confidence in discussing family history of melanoma, but lower confidence in ordering genetic tests and interpreting results. Eighty four percent (207/247) believed that genetic testing could negatively impact life insurance, while only 26% (63/244) were aware of the moratorium on using genetic test results in underwriting in Australia. A minority (22%, 55/254) reported prior continuing education in genetics. Face-to-face courses were the preferred learning modality for upskilling. Conclusion: Australian Dermatologists widely recognise the relevance of genetic testing to future practice, yet few currently order genetic tests. Future educational interventions could focus on how to order appropriate genetic tests and interpret results, as well as potential implications on insurance.
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Affiliation(s)
- Clare A. Primiero
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Amy M. Baker
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Courtney K. Wallingford
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Ellie J. Maas
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Tatiane Yanes
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Lindsay Fowles
- Genetic Health Queensland, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia
| | - Mary-Anne Young
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Sydney, NSW, Australia
- Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Amy Nisselle
- Australian Genomics Health Alliance, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Bronwyn Terrill
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Sydney, NSW, Australia
- Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Jason M. Lodge
- School of Education, The University of Queensland, Brisbane, QLD, Australia
| | - Jane M. Tiller
- Public Health Genomics, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul Lacaze
- Public Health Genomics, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Hayley Andersen
- Melanoma and Skin Cancer Advocacy Network, Carlton, VIC, Australia
| | - Gemma McErlean
- SWS Nursing and Midwifery Research Alliance, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
| | - Erin Turbitt
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - H. Peter Soyer
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Department of Dermatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Aideen M. McInerney-Leo
- The University of Queensland Diamantina Institute, Dermatology Research Centre, The University of Queensland, Brisbane, QLD, Australia
- *Correspondence: Aideen M. McInerney-Leo,
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Singh V, Mezzacappa C, Gershkovich P, Di Giovanna J, Ganzak A, Gibson J, Sinard J, Xicola RM, Llor X. Systems approach to enhance Lynch syndrome diagnosis through tumour testing. J Med Genet 2022; 60:533-539. [PMID: 36115663 PMCID: PMC10020126 DOI: 10.1136/jmg-2022-108770] [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: 06/16/2022] [Accepted: 09/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Guidelines recommend universal mismatch repair (MMR) tumour testing of colorectal adenocarcinomas (CRCs) to screen for Lynch syndrome (LS). However, its implementation remains disjointed and referral for genetic testing dismal, particularly among minorities. We aimed to increase referral, cancer genetic testing and eventually LS diagnosis by developing the CLEAR LS (Closed Loop Enhanced Assessment and Referral for Lynch Syndrome) intervention, a systems approach which in the second phase was automated. METHODS This is a cohort study of all patients diagnosed with CRC at an academic centre between 1 January 2012, when implementation of universal CRC testing began, and 31 January 2021. The original cohort spanned through 31 May 2015. Tumour testing included MMR immunohistochemistry, followed by BRAF V600E/MLH1 promoter methylation testing when indicated. The intervention included a manual phase (1 June 2015 through 31 July 2018), which systematised pathology screening and cancer genetics (CG) referral mechanisms, and an automated phase (1 August 2018 through 31 January 2021) using computer programming. RESULTS A total of 249/1541 CRC (17.38%) had MMR loss of expression and 129 (8.37%) qualified for CG evaluation. Referral was 27.58% in the original cohort and 92.1% in the intervention (p<0.001). Patients seen by CG among referred were 27.58% in the original cohort and 74.3% in the intervention (p two-sided<0.001). The distribution of race/ethnicity among patients qualifying and referred for CG evaluation was not significantly different across cohorts. LS diagnosis increased from 0.56% (original cohort) to 1.43% (intervention). Cost per new diagnosis of LS decreased from US$173 675 to $87 960 from original cohort to intervention. CONCLUSION Implementation of systematic case identification and referral support mechanisms significantly increased the proportion of patients undergoing genetic testing and doubled the percentage of patients diagnosed with LS with no referral differences across racial/ethnic groups.
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Affiliation(s)
- Vinit Singh
- Department of Medicine, Yale University, New Haven, Connecticut, USA
| | | | - Peter Gershkovich
- Department of Pathology, Yale University, New Haven, Connecticut, USA
| | - Jessica Di Giovanna
- Cancer Genetics and Prevention Program, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Amanda Ganzak
- Cancer Genetics and Prevention Program, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Joanna Gibson
- Department of Pathology, Yale University, New Haven, Connecticut, USA
| | - John Sinard
- Department of Pathology, Yale University, New Haven, Connecticut, USA
| | - Rosa M Xicola
- Department of Medicine, Yale University, New Haven, Connecticut, USA
| | - Xavier Llor
- Department of Medicine, Yale University, New Haven, Connecticut, USA
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10
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Steinberg J, Chan P, Hogden E, Tiernan G, Morrow A, Kang YJ, He E, Venchiarutti R, Titterton L, Sankey L, Pearn A, Nichols C, McKay S, Hayward A, Egoroff N, Engel A, Gibbs P, Goodwin A, Harris M, Kench JG, Pachter N, Parkinson B, Pockney P, Ragunathan A, Smyth C, Solomon M, Steffens D, Toh JWT, Wallace M, Canfell K, Gill A, Macrae F, Tucker K, Taylor N. Lynch syndrome testing of colorectal cancer patients in a high-income country with universal healthcare: a retrospective study of current practice and gaps in seven australian hospitals. Hered Cancer Clin Pract 2022; 20:18. [PMID: 35509103 PMCID: PMC9066828 DOI: 10.1186/s13053-022-00225-1] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To inform effective genomic medicine strategies, it is important to examine current approaches and gaps in well-established applications. Lynch syndrome (LS) causes 3-5% of colorectal cancers (CRCs). While guidelines commonly recommend LS tumour testing of all CRC patients, implementation in health systems is known to be highly variable. To provide insights on the heterogeneity in practice and current bottlenecks in a high-income country with universal healthcare, we characterise the approaches and gaps in LS testing and referral in seven Australian hospitals across three states. METHODS We obtained surgery, pathology, and genetics services data for 1,624 patients who underwent CRC resections from 01/01/2017 to 31/12/2018 in the included hospitals. RESULTS Tumour testing approaches differed between hospitals, with 0-19% of patients missing mismatch repair deficiency test results (total 211/1,624 patients). Tumour tests to exclude somatic MLH1 loss were incomplete at five hospitals (42/187 patients). Of 74 patients with tumour tests completed appropriately and indicating high risk of LS, 36 (49%) were missing a record of referral to genetics services for diagnostic testing, with higher missingness for older patients (0% of patients aged ≤ 40 years, 76% of patients aged > 70 years). Of 38 patients with high-risk tumour test results and genetics services referral, diagnostic testing was carried out for 25 (89%) and identified a LS pathogenic/likely pathogenic variant for 11 patients (44% of 25; 0.7% of 1,624 patients). CONCLUSIONS Given the LS testing and referral gaps, further work is needed to identify strategies for successful integration of LS testing into clinical care, and provide a model for hereditary cancers and broader genomic medicine. Standardised reporting may help clinicians interpret tumour test results and initiate further actions.
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Affiliation(s)
- Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia.
| | - Priscilla Chan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily Hogden
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Gabriella Tiernan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Yoon-Jung Kang
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily He
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leanna Titterton
- NSW Health, Western Sydney Local Health District, Westmead, NSW, Australia
| | | | - Amy Pearn
- Cancer Council NSW, Sydney, NSW, Australia
| | - Cassandra Nichols
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Skye McKay
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Alexander Engel
- The University of Sydney, Northern Clinical School Royal North Shore Hospital, Sydney, NSW, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Annabel Goodwin
- Cancer Genetics Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | | | - James G Kench
- Department of Tissue Pathology & Diagnostic Oncology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western, Australia
| | - Bonny Parkinson
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Peter Pockney
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Abiramy Ragunathan
- Westmead Familial Cancer Services, The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
| | | | - Michael Solomon
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, The University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Marina Wallace
- Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, Western Australia, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anthony Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, Department of Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kathy Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
- School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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11
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Reed AK, Kohn MJ, Stayman S, Cole AM, Ko CW, Konnick EQ, Swanson PE, Zhang Y, Knerr S. Patient navigation for hereditary colorectal cancer: Design of a randomized controlled trial to determine the effectiveness of pathways to genetic counseling. Contemp Clin Trials 2022;:106735. [PMID: 35331945 DOI: 10.1016/j.cct.2022.106735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosis of Lynch and other hereditary colorectal cancer (CRC) syndromes through germline genetic testing has important implications for treatment and risk-management, yet guideline-recommended genetic counseling referral and attendance is suboptimal. METHODS Our team developed an adapted patient navigation program-Pathways to Genetic Counseling-to address multilevel barriers to genetic counseling referral and receipt. This paper describes the methods of a randomized controlled trial (RCT) testing Pathways to Genetic Counseling's effectiveness at increasing genetic counseling attendance in the University of Washington Medicine health system. We will identify CRC patients eligible for genetic counseling (diagnosed before age 50 or at any age with evidence of inherited mismatch repair deficiency) through a combination of structured electronic health record queries and manual chart review. Patients will be randomized 1:1 prior to consent and receive either care as usual (no contact) or be invited to participate in patient navigation. We will use chart review to compare rates of genetic counseling referral and attendance within six months of randomization, regardless of patients' engagement with navigation. We plan to identify and randomize 161 eligible CRC patients over a nine-month period beginning in late 2021. DISCUSSION Our pragmatic RCT design will provide real-world data on the potential for patient navigation to address longstanding care gaps in preventive genomic medicine. If effective, we hope to pilot Pathways to Genetic Counseling in additional settings with a long-term goal of improving appropriate diagnosis of hereditary CRC syndromes and subsequent cascade screening of eligible family members.
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12
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Kozak VN, de Souza Fonseca Ribeiro EM, Kozonoe MM, Ioshii SO, Casali da Rocha JC. When guidelines face reality - Lynch syndrome screening in the setting of public health system in a developing country. J Community Genet 2021. [PMID: 34623598 DOI: 10.1007/s12687-021-00549-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022] Open
Abstract
Lynch syndrome (LS) is the most common cause of hereditary colorectal cancer (CRC); however, it is still underrecognized and underdiagnosed. While international guidelines gravitate towards universal screening, the underuse of screening methods has been reported in real-world scenarios. This study aims to evaluate screening for LS among patients diagnosed with CRC in a public cancer center in Brazil and evaluate access to genetic counseling and testing for abnormal screens. For that purpose, all patients with CRC registered in our institution from July 2012 to December 2018 had their charts reviewed. Demographic and clinical characteristics were noted, as well as immunohistochemistry and microsatellite instability analysis results, when available. After applying exclusion criteria, a total of 1234 charts were reviewed. Among these, 257 patients were screened for LS, making up a 20.8% screening rate; when considering Jerusalem criteria, screening rate was 24.5%; for Bethesda criteria, it was 35.1%. Almost 80% of patients fulfilling Amsterdam criteria I/II were screened. There were 64 abnormal screens, from which 40 (62.5%) underwent genetic counseling and 12 (18.7%) underwent genetic testing. We concluded that overall screening rates for LS among CRC patients in a public cancer center in Brazil are low, and still very guided by stringent clinical criteria. Referral to genetic counseling and access to testing is limited, calling the whole process into question. Public policies aiming to raise awareness on hereditary cancer and include genetic testing in the public health system could help improve this scenario.
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13
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Stinton C, Jordan M, Fraser H, Auguste P, Court R, Al-Khudairy L, Madan J, Grammatopoulos D, Taylor-Phillips S. Testing strategies for Lynch syndrome in people with endometrial cancer: systematic reviews and economic evaluation. Health Technol Assess 2021; 25:1-216. [PMID: 34169821 PMCID: PMC8273681 DOI: 10.3310/hta25420] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Lynch syndrome is an inherited genetic condition that is associated with an increased risk of certain cancers. The National Institute for Health and Care Excellence has recommended that people with colorectal cancer are tested for Lynch syndrome. Routine testing for Lynch syndrome among people with endometrial cancer is not currently conducted. OBJECTIVES To systematically review the evidence on the test accuracy of immunohistochemistry- and microsatellite instability-based strategies to detect Lynch syndrome among people who have endometrial cancer, and the clinical effectiveness and the cost-effectiveness of testing for Lynch syndrome among people who have been diagnosed with endometrial cancer. DATA SOURCES Searches were conducted in the following databases, from inception to August 2019 - MEDLINE ALL, EMBASE (both via Ovid), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (both via Wiley Online Library), Database of Abstracts of Reviews of Effects, Health Technology Assessment Database (both via the Centre for Reviews and Dissemination), Science Citation Index, Conference Proceedings Citation Index - Science (both via Web of Science), PROSPERO international prospective register of systematic reviews (via the Centre for Reviews and Dissemination), NHS Economic Evaluation Database, Cost-Effectiveness Analysis Registry, EconPapers (Research Papers in Economics) and School of Health and Related Research Health Utilities Database. The references of included studies and relevant systematic reviews were also checked and experts on the team were consulted. REVIEW METHODS Eligible studies included people with endometrial cancer who were tested for Lynch syndrome using immunohistochemistry- and/or microsatellite instability-based testing [with or without mutL homologue 1 (MLH1) promoter hypermethylation testing], with Lynch syndrome diagnosis being established though germline testing of normal (non-tumour) tissue for constitutional mutations in mismatch repair. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, the Consolidated Health Economic Reporting Standards and the Philips' checklist. Two reviewers independently conducted each stage of the review. A meta-analysis of test accuracy was not possible because of the number and heterogeneity of studies. A narrative summary of test accuracy results was provided, reporting test accuracy estimates and presenting forest plots. The economic model constituted a decision tree followed by Markov models for the impact of colorectal and endometrial surveillance, and aspirin prophylaxis with a lifetime time horizon. RESULTS The clinical effectiveness search identified 3308 studies; 38 studies of test accuracy were included. (No studies of clinical effectiveness of endometrial cancer surveillance met the inclusion criteria.) Four test accuracy studies compared microsatellite instability with immunohistochemistry. No clear difference in accuracy between immunohistochemistry and microsatellite instability was observed. There was some evidence that specificity of immunohistochemistry could be improved with the addition of methylation testing. There was high concordance between immunohistochemistry and microsatellite instability. The economic model indicated that all testing strategies, compared with no testing, were cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. Immunohistochemistry with MLH1 promoter hypermethylation testing was the most cost-effective strategy, with an incremental cost-effectiveness ratio of £9420 per quality-adjusted life-year. The second most cost-effective strategy was immunohistochemistry testing alone, but incremental analysis produced an incremental cost-effectiveness ratio exceeding £130,000. Results were robust across all scenario analyses. Incremental cost-effectiveness ratios ranged from £5690 to £20,740; only removing the benefits of colorectal cancer surveillance produced an incremental cost-effectiveness ratio in excess of the £20,000 willingness-to-pay threshold. A sensitivity analysis identified the main cost drivers of the incremental cost-effectiveness ratio as percentage of relatives accepting counselling and prevalence of Lynch syndrome in the population. A probabilistic sensitivity analysis showed, at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year, a 0.93 probability that immunohistochemistry with MLH1 promoter hypermethylation testing is cost-effective, compared with no testing. LIMITATIONS The systematic review excluded grey literature, studies written in non-English languages and studies for which the reference standard could not be established. Studies were included when Lynch syndrome was diagnosed by genetic confirmation of constitutional variants in the four mismatch repair genes (i.e. MLH1, mutS homologue 2, mutS homologue 6 and postmeiotic segregation increased 2). Variants of uncertain significance were reported as per the studies. There were limitations in the economic model around uncertainty in the model parameters and a lack of modelling of the potential harms of gynaecological surveillance and specific pathway modelling of genetic testing for somatic mismatch repair mutations. CONCLUSION The economic model suggests that testing women with endometrial cancer for Lynch syndrome is cost-effective, but that results should be treated with caution because of uncertain model inputs. FUTURE WORK Randomised controlled trials could provide evidence on the effect of earlier intervention on outcomes and the balance of benefits and harms of gynaecological cancer surveillance. Follow-up of negative cases through disease registers could be used to determine false negative cases. STUDY REGISTRATION This study is registered as PROSPERO CRD42019147185. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 42. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Chris Stinton
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hannah Fraser
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Dimitris Grammatopoulos
- Institute of Precision Diagnostics and Translational Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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14
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O’Shea R, Taylor N, Crook A, Jacobs C, Jung Kang Y, Lewis S, Rankin NM. Health system interventions to integrate genetic testing in routine oncology services: A systematic review. PLoS One 2021; 16:e0250379. [PMID: 34010335 PMCID: PMC8133413 DOI: 10.1371/journal.pone.0250379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Integration of genetic testing into routine oncology care could improve access to testing. This systematic review investigated interventions and the tailored implementation strategies aimed at increasing access to genetic counselling and testing and identifying hereditary cancer in oncology. METHODS The search strategy results were reported using the PRISMA statement and four electronic databases were searched. Eligible studies included routine genetic testing for breast and ovarian cancer or uptake after universal tumour screening for colorectal or endometrial cancer. The titles and abstracts were reviewed and the full text articles screened for eligibility. Data extraction was preformed using a designed template and study appraisal was assessed using an adapted Newcastle Ottawa Scale. Extracted data were mapped to Proctor's et al outcomes and the Consolidated Framework for Implementation Research and qualitatively synthesised. RESULTS Twenty-seven studies, published up to May 2020, met the inclusion criteria. Twenty-five studies ranged from poor (72%), fair to good (28%) quality. Most interventions identified were complex (multiple components) such as; patient or health professional education, interdisciplinary practice and a documentation or system change. Forty-eight percent of studies with complex interventions demonstrated on average a 35% increase in access to genetic counselling and a 15% increase in testing completion. Mapping of study outcomes showed that 70% and 32% of the studies aligned with either the service and client or the implementation level outcome and 96% to the process or inner setting domains of the Consolidated Framework for Implementation Research. CONCLUSION Existing evidence suggests that complex interventions have a potentially positive effect towards genetic counselling and testing completion rates in oncology services. Studies of sound methodological quality that explore a greater breadth of pre and post implementation outcomes and informed by theory are needed. Such research could inform future service delivery models for the integration of genetics into oncology services.
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Affiliation(s)
- Rosie O’Shea
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Natalie Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Ashley Crook
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Chris Jacobs
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Yoon Jung Kang
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Sarah Lewis
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole M. Rankin
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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15
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Gallon R, Gawthorpe P, Phelps RL, Hayes C, Borthwick GM, Santibanez-Koref M, Jackson MS, Burn J. How Should We Test for Lynch Syndrome? A Review of Current Guidelines and Future Strategies. Cancers (Basel) 2021; 13:406. [PMID: 33499123 PMCID: PMC7865939 DOI: 10.3390/cancers13030406] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 12/23/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
International guidelines for the diagnosis of Lynch syndrome (LS) recommend molecular screening of colorectal cancers (CRCs) to identify patients for germline mismatch repair (MMR) gene testing. As our understanding of the LS phenotype and diagnostic technologies have advanced, there is a need to review these guidelines and new screening opportunities. We discuss the barriers to implementation of current guidelines, as well as guideline limitations, and highlight new technologies and knowledge that may address these. We also discuss alternative screening strategies to increase the rate of LS diagnoses. In particular, the focus of current guidance on CRCs means that approximately half of Lynch-spectrum tumours occurring in unknown male LS carriers, and only one-third in female LS carriers, will trigger testing for LS. There is increasing pressure to expand guidelines to include molecular screening of endometrial cancers, the most frequent cancer in female LS carriers. Furthermore, we collate the evidence to support MMR deficiency testing of other Lynch-spectrum tumours to screen for LS. However, a reliance on tumour tissue limits preoperative testing and, therefore, diagnosis prior to malignancy. The recent successes of functional assays to detect microsatellite instability or MMR deficiency in non-neoplastic tissues suggest that future diagnostic pipelines could become independent of tumour tissue.
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Affiliation(s)
| | | | | | | | | | | | | | - John Burn
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 3BZ, UK; (P.G.); (R.L.P.); (C.H.); (G.M.B.); (M.S.-K.); (M.S.J.)
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16
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Lawrence J, Richer L, Arseneau J, Zeng X, Chong G, Weber E, Foulkes W, Palma L. Mismatch Repair Universal Screening of Endometrial Cancers (MUSE) in a Canadian Cohort. ACTA ACUST UNITED AC 2021; 28:509-522. [PMID: 33467402 PMCID: PMC7903281 DOI: 10.3390/curroncol28010052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Abstract
Background: Approximately 2–6% of endometrial cancers (ECs) are due to Lynch Syndrome (LS), a cancer predisposition syndrome caused by germline pathogenic variants (PVs) affecting the DNA mismatch repair (MMR) pathway. Increasingly, universal tissue-based screening of ECs has been proposed as an efficient and cost-effective way to identify families with LS, though few studies have been published on Canadian cohorts. The purpose of this study was to evaluate the feasibility and overall performance of a universal immunohistochemistry (IHC) screening program for women with EC within a single Canadian university hospital centre. Methods and Results: From 1 October 2015 to 31 December 2017, all newly diagnosed ECs (n = 261) at our centre were screened for MMR protein deficiency by IHC. MMR deficiency was noted in 69 tumours (26.4%), among which 53 had somatic MLH1 promoter hypermethylation and were considered “screen-negative”. The remaining MMR-deficient cases (n = 16) were considered “screen-positive” and were referred for genetic counselling and testing. Germline PVs were identified in 12/16 (75%). One additional PV was identified in a screen-negative individual who was independently referred to the Genetics service. This corresponds to an overall LS frequency of 5.0% among unselected women with EC, and 6.4% among women diagnosed under age 70 years. Our algorithm detected MMR gene pathogenic variants in 4.6% and 6.2% of unselected individuals and individuals under age 70 years, respectively. Four germline PVs (30.8%) were identified in individuals who did not meet any traditional LS screening criteria. Conclusions: Universal IHC screening for women with EC is an effective and feasible method of identifying individuals with LS in a Canadian context.
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Affiliation(s)
- Jessica Lawrence
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada; (W.F.); (L.P.)
- Correspondence:
| | - Lara Richer
- Department of Pathology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; (L.R.); (J.A.)
| | - Jocelyne Arseneau
- Department of Pathology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; (L.R.); (J.A.)
| | - Xing Zeng
- Division of Gynecologic Oncology, Departments of Obstetrics and Gynecology, Oncology, and Pathology, McGill University and McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - George Chong
- Department of Pathology, Jewish General Hospital, Montreal, QC H3T 1E2, Canada;
| | - Evan Weber
- Division of Medical Genetics, Department of Specialized Medicine, McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
| | - William Foulkes
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada; (W.F.); (L.P.)
- Division of Medical Genetics, Department of Specialized Medicine, McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
- Cancer Research Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
| | - Laura Palma
- Department of Human Genetics, McGill University, Montreal, QC H3A 0C7, Canada; (W.F.); (L.P.)
- Division of Medical Genetics, Department of Specialized Medicine, McGill University Health Centre, Montreal, QC H4A 3J1, Canada;
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Kunnackal John G, Das Villgran V, Caufield-Noll C, Giardiello FM. Comparison of universal screening in major lynch-associated tumors: a systematic review of literature. Fam Cancer 2021; 21:57-67. [PMID: 33426601 DOI: 10.1007/s10689-020-00226-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/23/2020] [Indexed: 01/13/2023]
Abstract
Lynch syndrome (LS) is associated with an increased lifetime risk of several cancers including colorectal (CRC), endometrial (EC), ovarian (OC), urinary (UT) and sebaceous tumors (ST). The benefit for universal screening in CRC and EC is well known. However, this benefit in other major lynch-associated tumors is unclear. We performed a systematic review of all published articles in the MEDLINE database between 2005 to 2017 to identify studies performing universal screening for LS in unselected CRC, EC, OC, UT and ST. All cases with MSI-H (instability in two or more markers) or missing one or more proteins on IHC testing were considered screening positive. Cases with MLH1 promoter hypermethylation or BRAF mutation positive were considered to have somatic mutations. A total of 3788 articles were identified in MEDLINE yielding 129 study arms from 113 studies. The overall pooled yield of universal LS screening and germline mismatch gene mutation was significantly different across the major LS-associated tumors (Mann Whitney test, p < 0.001). The pooled screening yield was highest in ST [52.5% (355/676), 95% CI 48.74-56.26%] followed by EC [22.65% (1142/5041), 95% CI 21.54-23.86%], CRC [11.9% (5649/47,545), 95% CI 11.61-12.19%], OC [11.29% (320/2833), 95% CI 10.13-12.47%] and UT [11.2% (31/276), 95% CI 7.48-14.92%]. ST also had the highest pooled germline positivity for mismatch repair gene mutation [18.8%, 33/176, 95%CI 13.03-24.57], followed by EC [2.6% (97/3765), 95% CI 2.09-3.11], CRC [1.8% (682/37,220), 95% CI 1.66-1.94%], UT [1.8%(3/164), 95% CI - 0.24-3.83%] and OC [0.83%(25/2983), 95% CI 0.48-1.12%]. LS screening in EC yielded significantly higher somatic mutations compared to CRC [pooled percentage 16.94% [(538/3176), 95%CI 15.60-18.20%] vs. 5.23% [(1639/26,152), 95% CI 4.93-5.47%], Mann Whitney test, p < 0.0001. Universal LS testing should be routinely performed in OC, UT and STs in addition to CRC and EC. Our findings also support consideration for IHC and somatic mutation testing before germline testing in EC due to higher prevalence of somatic mutations as well as germline testing in all patients with ST. Our results have implications for future design of LS screening programs and further studies are needed to assess the cost effectiveness and burden on genetic counselling services with expanded universal testing for LS.
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Affiliation(s)
- George Kunnackal John
- Clinical Assistant Professor, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 511 Idlewild Ave, Easton, MD, 21601, USA.
| | - Vipin Das Villgran
- Pulmonary and Critical Care Fellow, Allegheny Health Network, Pittsburgh, PA, 15212, USA
| | | | - Francis M Giardiello
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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Jacobi EM, Landon G, Broaddus RR, Roy-Chowdhuri S. Evaluating Mismatch Repair/Microsatellite Instability Status Using Cytology Effusion Specimens to Determine Eligibility for Immunotherapy. Arch Pathol Lab Med 2021; 145:46-54. [PMID: 33367660 PMCID: PMC7529913 DOI: 10.5858/arpa.2019-0398-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2020] [Indexed: 01/28/2023]
Abstract
CONTEXT.— The approval of pembrolizumab for treatment of patients with microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) advanced cancers has led to increased requests for MSI and/or MMR immunoperoxidase (IPOX) testing. Diagnoses for patients with advanced-stage cancer are frequently made from cytology specimens. OBJECTIVE.— To investigate the feasibility of using cell block (CB) preparations of effusions for MMR IPOX evaluation. DESIGN.— Surgical pathology cases of colorectal and endometrial carcinomas with known MMR/MSI status and matched effusions with available CBs were identified. Cell block sections were evaluated for adequacy and stained with MMR IPOX (MSH2, MSH6, MLH1, and PMS2). The CBs were reviewed, the number of tumor cells quantified, and MMR IPOX was interpreted as retained, lost, suboptimal, or noncontributory. RESULTS.— We identified 748 cases with MMR/MSI testing on surgical specimens having matched effusions. Of these, 131 cases (17.5%) had an available CB and 53 were deemed adequate for MMR IPOX staining. MMR IPOX results between effusion CBs and surgical pathology specimens were concordant in 45 of 53 (85%), inconclusive in 6 of 53 (11%), and discordant in 2 of 53 (4%) cases. CONCLUSIONS.— There was high concordance of MMR IPOX testing between cytologic and surgical specimens, with no false-positive and 2 false-negative CB results. Limited tumor cells, staining in cells indefinite as tumor, tumor staining heterogeneity, and lack of internal control staining were problematic in some cases. Our findings indicate that cytologic effusion specimens may be suitable substrates for MMR IPOX biomarker testing; however, inconclusive cases need to be interpreted with caution.
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Affiliation(s)
- Elizabeth M Jacobi
- The Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston
- Jacobi is currently in the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Gene Landon
- The Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Russell R Broaddus
- The Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston
- Broaddus is currently in the Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill
| | - Sinchita Roy-Chowdhuri
- The Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston
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Mannucci A, Furniss CS, Ukaegbu C, Horiguchi M, Fehlmann T, Uno H, Yurgelun MB, Syngal S. Comparison of Colorectal and Endometrial Microsatellite Instability Tumor Analysis and Premm 5 Risk Assessment for Predicting Pathogenic Germline Variants on Multigene Panel Testing. J Clin Oncol 2020; 38:4086-4094. [PMID: 32997573 PMCID: PMC7768341 DOI: 10.1200/jco.20.01470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Tumor testing for microsatellite instability and/or mismatch repair-deficiency (MSI/IHC) and clinical prediction models effectively screen for Lynch syndrome (LS)-associated colorectal cancer (CRC) and endometrial cancer (EC), but they have not been assessed for their ability to identify non-LS forms of inherited risk. The aim of this study was to compare MSI/IHC and the PREMM5 prediction model to identify carriers of LS and non-LS pathogenic variants (PVs) among patients with CRC and EC. PATIENTS AND METHODS Data were retrospectively analyzed from two single-institution cohorts: 706 patients with CRC and/or EC referred for genetic evaluation/testing (high-risk cohort) and 1,058 consecutively ascertained patients with CRC (oncology clinic cohort), unselected for familial risk. All participants underwent germline multigene panel testing. PREMM5 scores were calculated from personal/family cancer history. The primary outcome was the proportion of individuals with germline PVs (LS PVs, high-penetrance PVs, and any PVs) who had abnormal MSI/IHC testing and/or PREMM5 score ≥ 2.5%. RESULTS MSI/IHC and PREMM5 had comparable sensitivity for identifying LS carriers in high-risk (89.3% v 85.7%; P = .712) and oncology clinic patients (96.6% v 96.6%; P = 1.000), although MSI/IHC had significantly superior specificity for LS (81.3% v 20.1%; P < .001; 92.3% v 24.3%; P < .001). In both cohorts, PREMM5 had superior sensitivity to MSI/IHC at identifying patients with any high-penetrance PVs and any low-, moderate-, and high-penetrance PVs. Among patients with normal MSI/IHC, PREMM5 identified 84.2% and 83.3% of high-risk patients with CRC/EC and oncology clinic CRC patients with high-penetrance PVs, respectively. CONCLUSION MSI/IHC and PREMM5 effectively identify patients with CRC and/or EC with LS, although MSI/IHC has better specificity for LS. Because PREMM5 identifies non-LS, high-penetrance germline PVs, patients with CRC and/or EC with PREMM5 score ≥ 2.5%, including those with normal MSI/IHC, should be offered multigene panel testing.
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Affiliation(s)
- Alessandro Mannucci
- IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy
- Dana-Farber Cancer Institute, Boston, MA
| | - C. Sloane Furniss
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Miki Horiguchi
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Hajime Uno
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew B. Yurgelun
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women’s Hospital, Boston, MA
| | - Sapna Syngal
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women’s Hospital, Boston, MA
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20
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Morrow A, Parkinson B, Kang YJ, Hogden E, Canfell K, Taylor N. The health and economic impact of implementation strategies for improving detection of hereditary cancer patients—protocol for an in-depth cost-effectiveness evaluation with microsimulation modelling. Implement Sci Commun 2020. [DOI: 10.1186/s43058-020-00058-w] [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: 11/10/2022] Open
Abstract
Abstract
Background
Patients with Lynch syndrome (an inherited cancer predisposition syndrome) remain largely underdiagnosed despite clinically and cost-effective testing strategies to detect patients. This is largely due to poor referral rates for high-risk patients for consideration of genetic testing. Targeted approaches to improve the implementation of guidelines and thus uptake rates of genetic testing require the use of limited and valuable healthcare resources. Decision makers must carefully balance the potential health impacts of implementation approaches against the associated costs, similar to when assessing the direct impact of health interventions. This protocol outlines the methods used to conduct an economic evaluation of different implementation approaches aimed at improving referral rates of high-risk patients, including estimating implementation approach costs.
Methods
A cluster randomised controlled trial (the Hide and Seek Project, HaSP) is underway to compare two different implementation approaches aimed at improving referral rates, and thus detection, of Lynch syndrome among colorectal cancer patients across eight Australian hospital networks. An in-depth process evaluation is being conducted alongside the trial and includes measures to collect comprehensive data on both implementation and intervention costs. These costs, in addition to HaSP outcome data, will be incorporated as inputs into an existing microsimulation model—Policy1-Lynch—to project the downstream economic and health impacts and determine the more cost-effective implementation approach from the Australian healthcare perspective.
Discussion
The ability to model the impact of different implementation approaches will enable the most efficient way of improving Lynch syndrome detection. The approach used in this study could also be applied to assess other implementation approaches aimed at increasing the uptake of cost-effective health interventions.
Trial registration
ANZCTR, ACTRN12618001072202. Registered on 27 June 2018.
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21
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Sherman SK, Schuitevoerder D, Chan CHF, Turaga KK. Metastatic Colorectal Cancers with Mismatch Repair Deficiency Result in Worse Survival Regardless of Peritoneal Metastases. Ann Surg Oncol 2020; 27:5074-5083. [PMID: 32583196 PMCID: PMC9782694 DOI: 10.1245/s10434-020-08733-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mismatch-repair deficiency (dMMR) predicts worse chemoresponsiveness but better survival in early-stage colorectal adenocarcinoma. This study examined metastatic colorectal and appendix cancers with and without peritoneal metastasis (PM) in the National Cancer Database (NCDB), hypothesizing that dMMR tumors show better survival. METHODS Stage 4 colon, rectum, and appendix cancers (2010-2016) were identified in the NCDB (including goblet cell carcinoids, excluding neuroendocrine tumors). Stage 4 disease without liver, bone, brain, lung, or distant nodal metastases defined PM. Fisher's exact tests were used to compare proportions, and Kaplan-Meier analysis was used to evaluate survival. RESULTS Of 130,125 stage 4 colon, rectum, and appendix cancers, 27,848 (21.4%) had PM. Appendix primary tumors had PM more commonly than colon or rectum cancer (83.6% vs. 20.6% and 12.1% of stage 4 cases; p < 0.0001). More PM patients had MMR testing than patients with other metastasis (OM) (21.4% vs. 16.1%), and testing increased from 9.6% in 2010 to 26.3% in 2016 (both p < 0.0001). Among the PM patients, MMR testing was least common for appendix cancers (9.0%). When tested, PM patients more often had dMMR (22.9% [1122/4900] vs. 15.4% [2532/16,495] of OM patients; p < 0.0001). Colon primary tumor had dMMR most frequently (25.0% vs. 14.6% and 14.5% for rectal and appendix tumor; p < 0.0001). Most PM patients received chemotherapy (66.2%). Immunotherapy use increased over time (1.1% of PM diagnoses in 2010 vs. 20.8% in 2016). For MMR-tested stage 4 patients, dMMR correlated with worse survival (median OM, 19.7 vs. 23.9 months, p < 0.0001; median PM, 19.9 vs. 24.6 months, p = 0.035). CONCLUSIONS The NCDB showed dMMR predicting worse survival for stage 4 colorectal cancers with and without PM and dMMR existing in 14.5-25% of tested patients, suggesting that increased attention to MMR testing in stage 4 colorectal and appendix cancers can identify many patients who could potentially benefit from immunotherapy.
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Affiliation(s)
- Scott K. Sherman
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Carlos H. F. Chan
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
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22
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Heald B, Keel E, Marquard J, Burke CA, Kalady MF, Church JM, Liska D, Mankaney G, Hurley K, Eng C. Using chatbots to screen for heritable cancer syndromes in patients undergoing routine colonoscopy. J Med Genet 2020; 58:807-814. [PMID: 33168571 DOI: 10.1136/jmedgenet-2020-107294] [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: 06/23/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hereditary colorectal cancer (HCRC) syndromes account for 10% of colorectal cancers but remain underdiagnosed. This feasibility project tested the utility of an artificial intelligence-based chatbot deployed to patients scheduled for colonoscopy to identify HCRC risk factors, educate participants about HCRC and obtain consent to genetic testing as an extension of genetic counselling of appropriate subjects. Genetic counsellor (GC) and genetic counselling assistant (GCA) time spent per subject was also measured. METHODS Patients scheduled for colonoscopy at Cleveland Clinic were invited via electronic medical record patient portal or letter prior to colonoscopy with a link to a chatbot administering the Colon Cancer Risk Assessment Tool (CCRAT) to screen for HCRC syndromes. Those with ≥1 positive response to a CCRAT question received chatbot-deployed genetic education and the option to receive genetic testing. An order for a 55-gene pan-cancer panel was placed for those consenting, and the subject had blood drawn on the day of colonoscopy. Results were disclosed by a GC or GCA by telephone. Subject demographics, progression through the chat, responses to CCRAT, personal and family history, genetic test results and communication with the subject were recorded. Descriptive statistics and two-tailed unpaired t-test and Fisher's exact test were used. RESULTS 506/4254 (11.9%) initiated and 487 (96.2%) completed the chat with the chatbot. 215 (44.1%) answered 'yes' to ≥1 CCRAT question and all completed pretest education. 129/181 (71.3%) subjects who consented completed testing, and 12 (9.3%) were found to have a germline pathogenic variant. Per subject, the GC spent a mean of 14.3 (SD 7.3) and the GCA a mean of 19.2 (SD 9.8) minutes. CONCLUSION The use of a chatbot in this setting was a novel and feasible method, with the potential of increasing genetic screening and testing in individuals at risk of HCRC syndromes.
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Affiliation(s)
| | - Emma Keel
- Cleveland Clinic, Cleveland, Ohio, USA
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23
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Peterse EF, Naber SK, Daly C, Pollett A, Paszat LF, Spaander MC, Aronson M, Gryfe R, Rabeneck L, Lansdorp-Vogelaar I, Baxter NN. Cost-effectiveness of Active Identification and Subsequent Colonoscopy Surveillance of Lynch Syndrome Cases. Clin Gastroenterol Hepatol 2020; 18:2760-2767.e12. [PMID: 31629885 PMCID: PMC7162709 DOI: 10.1016/j.cgh.2019.10.021] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 10/02/2019] [Accepted: 10/11/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS The province of Ontario, Canada is considering immunohistochemical followed by cascade analyses of all patients who received a diagnosis of colorectal cancer (CRC) at an age younger than 70 years to identify individuals with Lynch syndrome. We evaluated the costs and benefits of testing for Lynch syndrome and determined the optimal surveillance interval for first-degree relatives (FDRs) found to have Lynch syndrome. METHODS We developed a patient flow diagram to determine costs and yield of immunohistochemical testing for Lynch syndrome in CRC cases and, for those found to have Lynch syndrome, their FDRs, accounting for realistic uptake. Subsequently, we used the MISCAN-colon model to compare costs and benefits of annual, biennial, and triennial surveillance in FDRs identified with Lynch syndrome vs colonoscopy screening every 10 years (usual care for individuals without a diagnosis of Lynch syndrome). RESULTS Testing 1000 CRC cases was estimated to identify 20 CRC index cases and 29 FDRs with Lynch syndrome at a cost of $310,274. Despite the high cost of Lynch syndrome tests, offering the FDRs with Lynch syndrome biennial colonoscopy surveillance was cost-effective at $8785 per life-year gained compared with usual care because of a substantial increase in life-years gained (+122%) and cost savings in CRC care. Triennial surveillance was more costly and less effective, and annual surveillance showed limited additional benefit compared with biennial surveillance. CONCLUSIONS Immunohistochemical testing for Lynch syndrome in persons younger than 70 years who received a diagnosis of CRC and then testing FDRs of those found to have Lynch syndrome provide a good balance between costs and long-term benefits. Colonoscopy surveillance every 2 years is the optimal surveillance interval for patients with Lynch syndrome.
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Affiliation(s)
- Elisabeth F.P. Peterse
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Steffie K. Naber
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Corinne Daly
- Strategy Division, Canadian Partnership Against Cancer, Toronto, Canada
| | - Aaron Pollett
- Pathology & Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada,Laboratory Medicine & Pathobiology, University of Toronto, Canada
| | | | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Melyssa Aronson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada
| | - Robert Gryfe
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada,Department of Surgery, Mount Sinai Hospital, Toronto, Canada
| | - Linda Rabeneck
- Prevention and Cancer Control, Cancer Care Ontario and Department of Medicine, University of Toronto, Toronto, Canada
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nancy N. Baxter
- Department of Surgery, LiKaShing Knowledge Institute St. Michael’s Hospital, Toronto, Canada
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24
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Jiang W, Sui QQ, Li WL, Ke CF, Ling YH, Liao LE, Zhu Z, Cai MY, Luo J, Mao LL, Zhang HZ, Wan DS, Pan ZZ, Ju HX, Ding PR. Low prevalence of mismatch repair deficiency in Chinese colorectal cancers: a multicenter study. Gastroenterol Rep (Oxf) 2020; 8:399-403. [PMID: 33163196 PMCID: PMC7603866 DOI: 10.1093/gastro/goaa006] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although universal testing for mismatch repair deficiency (dMMR) has been recommended to all colorectal cancer (CRC) patients, related evidence for the Chinese population is lacking. Here, we investigated the prevalence and clinicopathological features of dMMR patients in a large Chinese CRC cohort. METHODS We included 7,373 CRC patients treated at four Chinese medical centers between August 2010 and September 2016. Patients' baseline characteristics and pathological features were recorded. The clinicopathological features were compared between patients with MLH1/PMS2 deficiency (dMLH1/PMS2) and MSH2/MSH6 deficiency (dMSH2/MSH6). RESULTS Among the investigated patients, 654 (8.9%) were identified with dMMR CRCs and, of them, 401 (61.3%) were males, with a median age of 55 years (range, 22-87 years); 355 (54.3%) had stage II CRC based on American Joint Committee on Cancer 8th edition. The prevalence of the dMLH1/PMS2 group and the dMSH2/MSH6 group were 51.5% (337/654) and 25.1% (164/654), respectively. Compared with dMSH2/MSH6 patients, those with dMLH1/PMS2 were older (57 vs 52 years, P < 0.001), more likely to be female (45.7% vs 31.5%, P = 0.004), prone to having tumors located in the right-hand side of the colon (59.0% vs 47.6%, P = 0.015), and less likely to have a family history of tumors (29.7% vs 43.3%, P = 0.003). CONCLUSIONS The prevalence of dMMR in Chinese CRC patients was low, especially in the dMLH1/PMS2 group. The clinicopathological features were different between dMMR subgroups.
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Affiliation(s)
- Wu Jiang
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
| | - Qiao-Qi Sui
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
| | - Wen-Liang Li
- Department of Surgical Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P. R. China
| | - Chuan-Feng Ke
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P. R. China
| | - Yi-Hong Ling
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
| | - Le-En Liao
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
| | - Zhu Zhu
- Department of Surgical Oncology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, P. R. China
| | - Mu-Yan Cai
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
| | - Jun Luo
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, P. R. China
| | - Lin-Lin Mao
- Department of Clinical Genome Center, Guangzhou KingMed Diagnostics Group Co., Ltd, Guangzhou, Guangdong, P. R. China
| | - Hui-Zhong Zhang
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
| | - De-Sen Wan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
| | - Zhi-Zhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
| | - Hai-Xing Ju
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, P. R. China
| | - Pei-Rong Ding
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, P. R. China
- Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, P. R. China
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Dondi G, Coluccelli S, De Leo A, Ferrari S, Gruppioni E, Bovicelli A, Godino L, Coadă CA, Morganti AG, Giordano A, Santini D, Ceccarelli C, Turchetti D, De Iaco P, Perrone AM. An Analysis of Clinical, Surgical, Pathological and Molecular Characteristics of Endometrial Cancer According to Mismatch Repair Status. A Multidisciplinary Approach. Int J Mol Sci 2020; 21:E7188. [PMID: 33003368 DOI: 10.3390/ijms21197188] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 09/09/2020] [Revised: 09/25/2020] [Accepted: 09/26/2020] [Indexed: 12/17/2022] Open
Abstract
Since 2016, our hospital has applied tumor testing with immunohistochemistry (IHC) in endometrial cancer in order to detect mutations of mismatch repair genes (MMR). All cases with MMR deficiency proteins expression are sent for genetic testing, except those with MLH1 protein deficiency, in which case genetic testing is performed if negative for promoter hypermethylation. The primary aim of this study was to investigate the ability of our algorithm to identify Lynch syndrome (LS). The Secondary aims were to investigate the relationship between MMR status and clinicopathological features and prognosis of primary endometrial cancer (EC). From January 2016 to December 2018, 239 patients with EC were retrospectively analyzed and subdivided according to MMR status. Patients were divided in three groups: MMR proficient, LS and Lynch-like cancer (LLC). LS was characterized by a lower age and BMI, more use of contraceptive and less use of hormonal replacement therapy, nulliparity and a trend versus a better prognosis. LLC appeared more related to MMR proficient than LS and exhibited a more aggressive behavior. Our multidisciplinary approach permitted a correct diagnosis of germline mutation in patients with newly diagnosis EC and it confirmed clinicopathologic and prognostic characteristics of LS.
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Gomes AAD, Macedo MP, Torrezan GT, Zenun GR, Aguiar S, Begnami MD, Carraro DM, Formiga MN. DNA Mismatch Repair-Deficient Colorectal Carcinoma: Referral Rate for Genetic Cancer Risk Assessment in a Brazilian Cancer Center. J Gastrointest Cancer 2020; 52:997-1002. [PMID: 32974876 DOI: 10.1007/s12029-020-00467-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Approximately 15% of colorectal cancers (CRCs) are deficient in DNA mismatch repair proteins (dMMR), a characteristic that can occur in both sporadic and hereditary CRC. Due to sparse studies on dMMR CRC in the Brazilian population, we conducted a retrospective analysis of referral rates for Genetic Cancer Risk Assessment of this population and also describing clinical and molecular characterization of these tumors. METHODS A retrospective, longitudinal, and unicenter study that included patients with dMMR CRC detected by IHC analysis from Pathology Database of our institution, from January 2015 to July 2017. RESULTS MMR IHC testing was performed in 998 CRC tumors, and 78 tumors (7.8%) had dMMR. The mean age at diagnosis was 56.8 years (17-90), and most patients were female (41 out of 78, 52.6%). Of the 52 patients with right-sided CRC, 40 tumors (77%) had loss of the MLH1 and/or PMS2 expression, and 12 tumors (23%) had loss of MSH2 and/or MSH6 expression (p = 0.005). From 78 patients with dMMR CRC, only 43 patients (55.1%) were referred for genetic counseling (GC), and of them, only 33 patients (76.7%) really went to GC consultation. A total of 21 patients with dMMR CRC performed genetic testing. CONCLUSION Overall, genetic referral was less than expected in our population. Most of dMMR CRC patients did not receive GC, even in a cancer center, either due to the absence of referral or personal decision and few patients who pursued genetic counseling performed genetic testing.
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Affiliation(s)
- A A D Gomes
- Medical Oncology Department, A.C.Camargo Cancer Center, Sao Paulo, Brazil
| | - M P Macedo
- Anatomic Pathology Department, Hospital Sirio Libanes, Sao Paulo, Brazil
| | - G T Torrezan
- Laboratory of Genomics and Molecular Biology, International Research Center/CIPE-A.C. Camargo Cancer Center, National Institute of Science and Technology in Oncogenomics (INCITO), São Paulo, Brazil
| | - G R Zenun
- Laboratorio LAPACI, Pocos de Caldas, Brazil
| | - S Aguiar
- Department of Colorectal Tumors, A.C.Camargo Cancer Center, Sao Paulo, Brazil
| | - M D Begnami
- Anatomic Pathology Department, Hospital Sirio Libanes, Sao Paulo, Brazil
| | - D M Carraro
- Laboratory of Genomics and Molecular Biology, International Research Center/CIPE-A.C. Camargo Cancer Center, National Institute of Science and Technology in Oncogenomics (INCITO), São Paulo, Brazil
| | - M N Formiga
- Medical Oncology Department, A.C.Camargo Cancer Center, Sao Paulo, Brazil. .,Department of Oncogenetics, A.C.Camargo Cancer Center, 211, Professor Antonio Prudente Street - Liberdade, Sao Paulo, SP, 01509-900, Brazil.
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Kunnackal John G, Das Villgran V, Caufield-Noll C, Giardiello F. Worldwide variation in lynch syndrome screening: case for universal screening in low colorectal cancer prevalence areas. Fam Cancer 2021; 20:145-56. [PMID: 32914371 DOI: 10.1007/s10689-020-00206-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
To perform a systematic assessment of universal Lynch syndrome (LS) screening yield in colorectal cancer (CRC) patients around the world. Universal screening for LS is recommended in all CRC patients. However, the variation in yield of LS screening in the setting of significant global variation in CRC prevalence is unknown. A systematic review of articles in the MEDLINE database was performed to identify studies performing universal screening for LS. All cases with microsatellite instability (MSI-H) or missing one or more proteins on immunohistochemistry (IHC) were considered screening positive. The overall pooled yield of universal LS screening in 97 study arms from 89 identified studies was 11.9% (5649/47545) and the overall pooled percentage of confirmed LS patients was 1.8% (682/37220). LS screening positivity varied significantly based on geographic region (Kruskal Wallis test, p < 0.001) and reported 5-year CRC prevalence in the country (Fisher's exact, p < 0.001). Significant inverse correlation was found between LS screening positivity and 5-year CRC prevalence (Pearson correlation, r = - 0.56, p < 0.001). The overall yield of LS screening was 15.00% (382/2553) and rate of confirmed LS was 7.7% (113/1475) in LS screening done in patients ≤ 50 years (16 studies). There is significant geographic variation in LS screening positivity with higher yield in countries with lower prevalence of CRC. Our results highlight the importance of universal LS screening in younger patients and low CRC prevalence countries.
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Lee PWC, Bedard AC, Samimi S, Beard VK, Hong Q, Bedard JEJ, Gilks B, Schaeffer DF, Wolber R, Kwon JS, Lim HJ, Sun S, Schrader KA. Evaluating the impact of universal Lynch syndrome screening in a publicly funded healthcare system. Cancer Med 2020; 9:6507-6514. [PMID: 32700475 PMCID: PMC7520344 DOI: 10.1002/cam4.3279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/23/2020] [Revised: 05/08/2020] [Accepted: 06/12/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Referrals for Lynch syndrome (LS) assessment have traditionally been based on personal and family medical history. The introduction of universal screening practices has allowed for referrals based on immunohistochemistry tests for mismatch repair (MMR) protein expression. This study aims to characterize the effect of universal screening in a publicly funded healthcare system with comparison to patients referred by traditional criteria, from January 2012 to March 2017. METHODS Patient files from the time of initiation of universal screening from 2012 to 2017 were reviewed. Patients were sorted into two groups: (a) universally screened and (b) referred by traditional methods. Mutation detection rates, analysis of traditional testing criteria met, and cascade carrier testing were evaluated. RESULTS The mutation detection rate of the universal screening group was higher than the traditionally referred group (45/228 (19.7%) vs 50/390 (12.5%), P = .05), though each were able to identify unique patients. An analysis of testing criteria met by each patient showed that half of referred patients from the universal screening group could not meet any traditional testing criteria. CONCLUSION The implementation of universal screening in a publicly funded system will increase efficiency in detecting patients with LS. The resources available for genetic testing and counseling may be more limited in public systems, thus inclusion of secondary screening with BRAF and MLH1 promoter hypermethylation testing is key to further optimizing efficiency.
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Affiliation(s)
- Petra W C Lee
- Department of Biology, University of the Fraser Valley, Abbotsford, BC, Canada
| | | | - Setareh Samimi
- Hematologie et Oncologie Departement, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada
| | - Vivienne K Beard
- Department of Biology, University of the Fraser Valley, Abbotsford, BC, Canada
| | - Quan Hong
- BC Cancer, Hereditary Cancer Program, Vancouver, BC, Canada
| | - James E J Bedard
- Department of Biology, University of the Fraser Valley, Abbotsford, BC, Canada
| | - Blake Gilks
- Department of Pathology, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - David F Schaeffer
- Department of Pathology, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Robert Wolber
- Department of Pathology, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Janice S Kwon
- Division of Gynecology Oncology, BC Cancer, Vancouver, BC, Canada
| | - Howard J Lim
- Department of Medical Oncology, BC Cancer, Vancouver, BC, Canada
| | - Sophie Sun
- BC Cancer, Hereditary Cancer Program, Vancouver, BC, Canada.,Department of Medical Oncology, BC Cancer, Vancouver, BC, Canada
| | - Kasmintan A Schrader
- BC Cancer, Hereditary Cancer Program, Vancouver, BC, Canada.,Department of Medical Genetics, The University of British Columbia, Vancouver, BC, Canada.,Department of Molecular Oncology, BC Cancer, Vancouver, BC, Canada
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Morrow A, Tucker KM, Shaw TJ, Parkinson B, Abraham C, Wolfenden L, Taylor N. Understanding implementation success: protocol for an in-depth, mixed-methods process evaluation of a cluster randomised controlled trial testing methods to improve detection of Lynch syndrome in Australian hospitals. BMJ Open 2020; 10:e033552. [PMID: 32540886 PMCID: PMC7299044 DOI: 10.1136/bmjopen-2019-033552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/01/2023] Open
Abstract
INTRODUCTION In multisite intervention trials, implementation success often varies widely across settings. Process evaluations are crucial to interpreting trial outcomes and understanding contextual factors and causal chains necessary for successful implementation. Lynch syndrome is a hereditary cancer predisposition conferring an increased risk of colorectal, endometrial and other cancer types. Despite systematic screening protocols to identify Lynch syndrome, the condition remains largely underdiagnosed. The Hide and Seek Project ('HaSP') is a cluster randomised controlled trial determining the effectiveness of two approaches to improving Lynch syndrome detection at eight Australian hospital networks. To enhance widespread implementation of optimal Lynch syndrome identification, there is a need to understand not only what works, but also why, in what contexts, and at what costs. Here we describe an in-depth investigation of factors influencing successful implementation of procedures evaluated in the HaSP trial. METHODS AND ANALYSIS A mixed-methods, theory-driven process evaluation will be undertaken in parallel to the HaSP trial. Data will include: interviews of Implementation Leads and Lynch syndrome stakeholders, pre-post implementation questionnaires, audio analysis of meetings and focus groups, observation of multidisciplinary team meetings, fidelity checklists and project log analysis. Results will be triangulated and coded, drawing on the Theoretical Domains Framework, Consolidated Framework for Implementation Research and Proctor's implementation outcomes. ETHICS AND DISSEMINATION Use of a theory-based process evaluation will enhance interpretation and generalisability of HaSP trial findings, and contribute to the implementation research field by furthering understanding of the conditions necessary for implementation success. Ethical approval has been granted and results will be disseminated via publications in peer-reviewed journals and conference presentations. At trial completion, key findings will be fed back to sites to enable refinement of intervention strategies, both in the context of Lynch syndrome and for the possible generalisability of intervention components in other genetic and broader clinical specialties. HASP TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (Identifier: ACTRN12618001072202). Registered 27 June 2018. http://www.ANZCTR.org.au/ACTRN12618001072202.aspx.
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Affiliation(s)
- April Morrow
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Katherine M Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
- UNSW Prince of Wales Clinical School, Randwick, New South Wales, Australia
| | - Tim J Shaw
- Research in Implementation Science and eHealth (RISe), Faculty of Health Sciences, University of Sydney, Camperdown, New South Wales, Australia
| | - Bonny Parkinson
- The Macquarie University Centre for the Health Economy, Macquarie University, Macquarie, New South Wales, Australia
| | - Charles Abraham
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Natalie Taylor
- Cancer Council New South Wales, Woolloomooloo, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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Luchini C, Bibeau F, Ligtenberg MJL, Singh N, Nottegar A, Bosse T, Miller R, Riaz N, Douillard JY, Andre F, Scarpa A. ESMO recommendations on microsatellite instability testing for immunotherapy in cancer, and its relationship with PD-1/PD-L1 expression and tumour mutational burden: a systematic review-based approach. Ann Oncol 2020; 30:1232-1243. [PMID: 31056702 DOI: 10.1093/annonc/mdz116] [Citation(s) in RCA: 527] [Impact Index Per Article: 131.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cancers with a defective DNA mismatch repair (dMMR) system contain thousands of mutations most frequently located in monomorphic microsatellites and are thereby defined as having microsatellite instability (MSI). Therefore, MSI is a marker of dMMR. MSI/dMMR can be identified using immunohistochemistry to detect loss of MMR proteins and/or molecular tests to show microsatellite alterations. Together with tumour mutational burden (TMB) and PD-1/PD-L1 expression, it plays a role as a predictive biomarker for immunotherapy. METHODS To define best practices to implement the detection of dMMR tumours in clinical practice, the ESMO Translational Research and Precision Medicine Working Group launched a collaborative project, based on a systematic review-approach, to generate consensus recommendations on the: (i) definitions related to the concept of MSI/dMMR; (ii) methods of MSI/dMMR testing and (iii) relationships between MSI, TMB and PD-1/PD-L1 expression. RESULTS The MSI-related definitions, for which a consensus frame-work was used to establish definitions, included: 'microsatellites', 'MSI', 'DNA mismatch repair' and 'features of MSI tumour'. This consensus also provides recommendations on MSI testing; immunohistochemistry for the mismatch repair proteins MLH1, MSH2, MSH6 and PMS2 represents the first action to assess MSI/dMMR (consensus with strong agreement); the second method of MSI/dMMR testing is represented by polymerase chain reaction (PCR)-based assessment of microsatellite alterations using five microsatellite markers including at least BAT-25 and BAT-26 (strong agreement). Next-generation sequencing, coupling MSI and TMB analysis, may represent a decisive tool for selecting patients for immunotherapy, for common or rare cancers not belonging to the spectrum of Lynch syndrome (very strong agreement). The relationships between MSI, TMB and PD-1/PD-L1 expression are complex, and differ according to tumour types. CONCLUSIONS This ESMO initiative is a response to the urgent questions raised by the growing success of immunotherapy and provides also important insights on the relationships between MSI, TMB and PD-1/PD-L1.
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Affiliation(s)
- C Luchini
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - F Bibeau
- Department of Pathology, Caen University Hospital, Caen, France
| | - M J L Ligtenberg
- Departments of Human Genetics Radboud university medical center, Nijmegen, The Netherlands; Departments of Pathology, Radboud university medical center, Nijmegen, The Netherlands
| | - N Singh
- Department of Cellular Pathology, Barts Health NHS Trust, London, UK
| | - A Nottegar
- Department of Surgery, San Bortolo Hospital, Vicenza, Italy
| | - T Bosse
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - R Miller
- Department of Oncology, University College London, London, UK
| | - N Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J-Y Douillard
- European Society for Medical Oncology, Lugano, Switzerland
| | - F Andre
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France.
| | - A Scarpa
- ARC-Net Research Centre, University of Verona, Verona, Italy
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Snedden TW, McCracken A, Vaidyanathan A, Taranova A, Villarreal R, Qamar S, Arora SP. Implementation of Universal Tumor Screening of Colorectal Cancer for Detection of Lynch Syndrome at a Hispanic-Rich County Hospital. JCO Oncol Pract 2020; 16:e948-e957. [PMID: 32452745 DOI: 10.1200/jop.19.00508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In 2014, a reflexive screening protocol for Lynch syndrome (LS) via an immunohistochemistry (IHC) assay was shown to be cost-effective; however, the screening rates at a predominant Hispanic-rich institution are unclear. We hypothesized that implementation of a universal tumor screening (UTS) protocol requiring screening for LS via IHC in patients with newly diagnosed colorectal cancer (CRC) at our Hispanic-rich institution would improve detection of LS by increasing screening rates. METHODS AND MATERIALS This is a retrospective analysis of screening rates of 3 sequential cohorts of newly diagnosed patients with CRC between January 2012 and April 2016 at the University Health System and with follow-up at National Cancer Institute-designated Mays Cancer Center at University of Texas Health San Antonio. Cohort 1 consisted of patients screened using old screening guidelines (PRE). Cohort 2 consisted of patients screened when treating clinicians were receiving education on the new protocol (PERI). Cohort 3 consisted of patients screened after implementation of the UTS protocol (POST). RESULTS The majority of 312 patients were Hispanic (62.5%), 18.1% were < 50 years, and 81.9% were ≥ 50 years of age (median age, 57 years). Of patients with CRC screened for LS via IHC, the PRE, PERI, and POST cohorts had screening rates of 31%, 64%, and 58%, respectively. We found significant differences when comparing the PRE with POST sequential cohorts (P < .01). CONCLUSION The quality of Lynch syndrome-related family histories and screening rates were significantly improved after implementation in our Hispanic-rich population. Future studies are warranted to provide insight into clinical effects of increased screening, provider and patient surveillance, and screening-related systemic barriers.
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Affiliation(s)
- Tyler W Snedden
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX
| | | | | | | | | | - Samina Qamar
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX
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Lentz SE, Salyer CV, Dontsi M, Armstrong MA, Hoodfar E, Alvarado MM, Avila M, Nguyen NT, Powell CB. Comparison of two Lynch screening strategies in endometrial cancer in a California health system. Gynecol Oncol 2020; 158:158-166. [PMID: 32386910 DOI: 10.1016/j.ygyno.2020.04.692] [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: 02/11/2020] [Accepted: 04/16/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Compare detection of Lynch syndrome in endometrial cancer between regions of a health care system with different screening strategies. METHODS A retrospective study of endometrial cancer (EC) cases from 2 regions of an integrated health care system (Kaiser Permanente Northern (KPNC) and Southern (KPSC) California). Within KPNC, immunohistochemistry tumor screening (IHC) was physician ordered and risk-based; within KPSC, IHC was universal and automated. Clinical risk factors associated with abnormal IHC and Lynch Syndrome (LS) were identified. RESULTS During the study, there were 2045 endometrial cancers: 1399 in the physician-order group and 646 in the universal testing group. In the physician-order group: among women < age 60, 34% underwent IHC; 9.6% were abnormal, and 3% were possible LS after methylation testing; among women ≥60, 11% underwent IHC, 3% were abnormal and <1% were possible LS. In the universal group, 87% of women age <60 had IHC, 19.4% were abnormal, and 6% were possible LS; Among women age ≥60, 82% underwent IHC, 26% were abnormal, and 2% were possible LS. There were no differences in LS cases between the physician-order group and the universal group in either age strata (<60: 3% vs. 3.6%, p=0.62; ≥60: <1% vs. 1%, p=0.63) Factors associated with LS were younger age (odds ratio (OR) 0.11, 95% confidence interval (CI) 0.04-0.29) and lower body mass index (BMI), (OR 0.38 95% CI 0.18-0.80). CONCLUSIONS Universal IHC screening did not result in increased LS detection in EC.
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Affiliation(s)
- Scott E Lentz
- Kaiser Permanente Southern California Gynecologic Oncology Program, United States of America
| | - Chelsea V Salyer
- Kaiser Permanente Oakland Ob/Gyn Residency Program, United States of America
| | - Makdine Dontsi
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Mary Anne Armstrong
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Elizabeth Hoodfar
- Kaiser Permanente Northern California Genetics Department, United States of America
| | - Monica M Alvarado
- Kaiser Permanente Southern California Regional Genetics Department, United States of America
| | - Monica Avila
- Kaiser Permanente Southern California Gynecologic Oncology Program, United States of America
| | - Nancy T Nguyen
- Kaiser Permanente Oakland Ob/Gyn Residency Program, United States of America
| | - C Bethan Powell
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America; Northern California Gynecologic Cancer Program, San Francisco, CA, United States of America.
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DeSouza B, Georgiou D. Advances in Hereditary Colorectal Cancer: Opportunities and Challenges for Clinical Translation. Curr Genet Med Rep 2020. [DOI: 10.1007/s40142-020-00183-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tognetto A, Pastorino R, Castorina S, Condorelli DF, DeCensi A, De Vito C, Magnano A, Scaldaferri F, Villari P, Genuardi M, Boccia S. The Current Practice of Lynch Syndrome Diagnosis and Management in Italy: A Qualitative Assessment. Public Health Genomics 2019; 22:189-207. [PMID: 31805557 DOI: 10.1159/000504305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 04/10/2019] [Accepted: 10/22/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lynch syndrome (LS) is the most frequent form of hereditary colorectal cancer (CRC; up to 3-5% of the total CRC burden) and predisposes to the development of other cancers. Multidisciplinary diagnostic strategies are relevant both to the index cases and to their at-risk relatives, but their implementation is still limited. Our study aimed to explore LS testing practices in Italy. METHODS In order to ascertain the current practice of LS diagnosis and management, we conducted a qualitative assessment by sending a questionnaire to health care professionals at 4 Italian hospitals selected as "models" representing different hospital settings. Based on the surveys, we reconstructed the management pathways for CRC patients in terms of diagnostic strategies and health professionals involved. RESULTS Seven of the 8 invited professionals filled in the questionnaire. Noncompliance with the latest guidelines was reported, as no tumor "screening" was performed on CRC cases. The lack of a structured multidisciplinary team who manages CRC patients from risk assessment to diagnosis and follow-up was reported. The availability of professionals and laboratory technologies differ widely between hospitals. As for cascade testing of at-risk relatives, a systematic and active approach was absent in all the considered hospitals. CONCLUSIONS Our study shows that no structured and standardized pathways for the diagnosis and management of LS patients are currently in place in Italy. We envisage that by extending our research to further experiences and countries, an increasing awareness of the topic can be translated into a health gain for hereditary CRC patients and their at-risk relatives.
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Affiliation(s)
- Alessia Tognetto
- Sezione di Igiene, Istituto di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Pastorino
- Department of Woman and Child Health and Public Health - Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,
| | - Sergio Castorina
- Department of Medical and Surgical Sciences and Advanced Technologies, G.F. Ingrassia, Catania University, Catania, Italy
| | - Daniele Filippo Condorelli
- Section of Medical Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | | | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonio Magnano
- UOC Gastroenterologia, AOU Policlinico VE - Catania, Catania, Italy
| | - Franco Scaldaferri
- UOC Medicina Interna, Gastroenterologia e Malattie del Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maurizio Genuardi
- UOC Genetica Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Medicina Genomica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefania Boccia
- Sezione di Igiene, Istituto di Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Woman and Child Health and Public Health - Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Borowsky J, Setia N, Rosty C, Conrad R, Susman R, Misdraji J, Hart J, Lauwers GY, Brown IS. Spectrum of gastrointestinal tract pathology in a multicenter cohort of 43 Cowden syndrome patients. Mod Pathol 2019; 32:1814-22. [PMID: 31273317 DOI: 10.1038/s41379-019-0316-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/08/2022]
Abstract
Most patients with Cowden syndrome have lesions in the gastrointestinal tract, characterized by multiple polyps of various histologic types in the large bowel, polyps in the upper gastrointestinal tract, and esophageal glycogenic acanthosis. However, pathologists are often unaware of the distinctive polyposis phenotype of Cowden syndrome. In this multicenter study, we report the spectrum of gastrointestinal manifestations in a series of 43 Cowden syndrome patients who had at least one endoscopy. The median age at the first endoscopy was 46 years and 58% were women. In 24 of 29 (83%) tested patients, a pathogenic germline mutation in PTEN was identified. The histology from 199 endoscopy procedures (67 upper gastrointestinal endoscopy and 132 colonoscopies) was reviewed. Hamartomatous polyps of the large bowel were the most common lesions, present in 85% of patients. Hamartomatous polyps showed varied histology, including lymphoid aggregates in 55% of patients, a lipomatous component in 52%, a ganglioneuromatous component in 52%, and a fibrous-rich component in 14%. Polyps with at least two different stromal components were found in 55% of patients. Inflammatory polyps were present in 21% of patients. Conventional adenomas and serrated polyps were identified in 48% and 62% of patients, respectively. In the upper gastrointestinal tract, the most common lesions were esophageal glycogenic acanthosis (37%), gastric hamartomatous polyps (47%), and duodenal hamartomatous polyps (20%). All patients with glycogenic acanthosis who had a colonoscopy had hamartomatous polyps of the large bowel. In five patients, the diagnosis of Cowden syndrome was established after the pathology report raised suspicion for the diagnosis. Pathologists who are aware of the characteristic admixture of lesions in Cowden syndrome can play an essential role in recommending referral to genetic counseling and gene testing. Early diagnosis of Cowden syndrome is important, as these patients and their relatives are at increased risk for developing multiple cancers.
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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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Snowsill TM, Ryan NAJ, Crosbie EJ, Frayling IM, Evans DG, Hyde CJ. Cost-effectiveness analysis of reflex testing for Lynch syndrome in women with endometrial cancer in the UK setting. PLoS One. 2019;14:e0221419. [PMID: 31469860 PMCID: PMC6716649 DOI: 10.1371/journal.pone.0221419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022] Open
Abstract
Background Lynch syndrome is a hereditary cancer syndrome caused by constitutional pathogenic variants in the DNA mismatch repair (MMR) system, leading to increased risk of colorectal, endometrial and other cancers. The study aimed to identify the incremental costs and consequences of strategies to identify Lynch syndrome in women with endometrial cancer. Methods A decision-analytic model was developed to evaluate the relative cost-effectiveness of reflex testing strategies for identifying Lynch syndrome in women with endometrial cancer taking the NHS perspective and a lifetime horizon. Model input parameters were sourced from various published sources. Consequences were measured using quality-adjusted life years (QALYs). A cost-effectiveness threshold of £20 000/QALY was used. Results Reflex testing for Lynch syndrome using MMR immunohistochemistry and MLH1 methylation testing was cost-effective versus no testing, costing £14 200 per QALY gained. There was uncertainty due to parameter imprecision, with an estimated 42% chance this strategy is not cost-effective compared with no testing. Age had a significant impact on cost-effectiveness, with testing not predicted to be cost-effective in patients aged 65 years and over. Conclusions Testing for Lynch syndrome in younger women with endometrial cancer using MMR immunohistochemistry and MLH1 methylation testing may be cost-effective. Age cut-offs may be controversial and adversely affect implementation.
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Kiyozumi Y, Matsubayashi H, Horiuchi Y, Higashigawa S, Oishi T, Abe M, Ohnami S, Urakami K, Nagashima T, Kusuhara M, Miyake H, Yamaguchi K. Germline mismatch repair gene variants analyzed by universal sequencing in Japanese cancer patients. Cancer Med 2019; 8:5534-5543. [PMID: 31386297 PMCID: PMC6745857 DOI: 10.1002/cam4.2432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 02/05/2019] [Revised: 06/25/2019] [Accepted: 07/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Lynch syndrome (LS) is the commonest inherited cancer syndrome caused by pathogenic variants of germline DNA mismatch repair (g.MMR) genes. Genome‐wide sequencing is now increasingly applied for tumor characterization, but not for g.MMR. The aim of this study was to evaluate the incidence and pathogenicity of g.MMR variants in Japanese cancer patients. Methods Four g.MMR genes (MLH1, MSH2, MSH6, and PMS2) were analyzed by next generation sequencing in 1058 cancer patients (614 male, 444 female; mean age 65.6 years) without past diagnosis of LS. The g.MMR variant pathogenicity was classified based on the ClinVar 2015 database. Tumor MMR immunohistochemistry, microsatellite instability (MSI), and BRAF sequencing were also investigated in specific cases. Results Overall, 46 g.MMR variants were detected in 167 (15.8%) patients, 17 likely benign variants in 119 patients, 24 variants of uncertain significance (VUSs) in 68 patients, two likely pathogenic variants in two patients, and three pathogenic variants in three (0.3%) patients. The three pathogenic variants included two colorectal cancers with MLH1 loss and high MSI and one endometrial cancer with MSH6 loss and microsatellite stability. Two likely pathogenic variants were shifted to VUSs by ClinVar (2018). One colon cancer with a likely benign variant demonstrated MLH1 loss and BRAF mutation, but other nonpathogenic variants showed sustained MMR and microsatellite stability. Conclusions Universal sequencing of g.MMR genes demonstrated sundry benign variants, but only a small proportion of cancer patients had pathogenic variants. Pathogenicity evaluation using the ClinVar database agreed with MSI, MMR immunohistochemistry, and BRAF sequencing.
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Affiliation(s)
- Yoshimi Kiyozumi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Matsubayashi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yasue Horiuchi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan.,Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Satomi Higashigawa
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takuma Oishi
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masato Abe
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sumiko Ohnami
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan
| | | | - Takeshi Nagashima
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan.,SRL Inc., Tokyo, Japan
| | | | - Hidehiko Miyake
- Department of Genetic Counseling, Graduate School of Ochanomizu University, Tokyo, Japan
| | - Ken Yamaguchi
- Shizuoka Cancer Center Research Institute, Shizuoka, Japan
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Cavazza A, Radia C, Harlow C, Monahan KJ. Experience of the implementation and outcomes of universal testing for Lynch syndrome in the United Kingdom. Colorectal Dis 2019; 21:760-766. [PMID: 30815953 DOI: 10.1111/codi.14597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
AIM Colorectal cancer (CRC) is diagnosed in approximately 45 000 people annually in the UK, and it is estimated that Lynch syndrome (LS) accounts for 3.1% of these cases. In February 2017, National Institute for Health and Care Excellence (NICE guideline DG27 recommended universal testing of new cases of CRC for mismatch repair (MMR) status. The aim of this study was to implement universal testing for LS in CRC patients in a secondary care setting. METHOD We prospectively collected data on consecutive newly diagnosed CRC patients at our centre from November 2016 to August 2018, including evidence of MMR status determined by immunohistochemistry. We recorded clinicopathological data including age at diagnosis, stage, tumour site, reported histological findings and MMR tumour status. Statistical analysis was performed using the chi-square test and the two-tailed t-test for binary and continuous variables, respectively. RESULTS A cohort of 203 consecutive patients were diagnosed with CRC during this period. Universal MMR testing was performed for the 198 CRC patients in whom a diagnosis of adenocarcinoma was confirmed, with colonoscopic biopsy used as the source material in 68.6% of cases. Twenty-three CRCs (11.6%) were MMR deficient (dMMR). Most dMMR CRCs (21/23) were early stage tumours (Dukes A or B, P = 0.002). In 39 Dukes B CRCs in patients under 70 years of age, the result of MMR testing influenced decision-making about personalized treatment with 5-fluorouracil based chemotherapy. CONCLUSION Our results demonstrate that universal testing of all new cases of CRC for features suggestive of LS is feasible and effective in the UK. Our data also indicate the importance of genetic testing and personalized oncological care.
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Affiliation(s)
- A Cavazza
- Imperial College London and The Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, Chelsea and Westminster Hospitals NHS Trust, London, UK
| | - C Radia
- Imperial College London and The Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, Chelsea and Westminster Hospitals NHS Trust, London, UK
| | - C Harlow
- Imperial College London and The Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, Chelsea and Westminster Hospitals NHS Trust, London, UK
| | - K J Monahan
- Imperial College London and The Family History of Bowel Cancer Clinic, Department of Gastroenterology, West Middlesex University Hospital, Chelsea and Westminster Hospitals NHS Trust, London, UK
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Bai W, Ma J, Liu Y, Liang J, Wu Y, Yang X, Xu E, Li Y, Xi Y. Screening of MSI detection loci and their heterogeneity in East Asian colorectal cancer patients. Cancer Med 2019; 8:2157-2166. [PMID: 30945461 PMCID: PMC6536949 DOI: 10.1002/cam4.2111] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 11/13/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE This study aims to screen the MSI detection loci suitable for the East Asian colorectal cancer patients. and explore its intratumoral heterogeneity. METHODS A total of 271 pathological tissues specimens of colorectal cancer were collected. The MSI status was detected using different PCR reagent kits with different detection loci. Then, the results were compared with the immunohistochemical (IHC) staining results. Microdissection of pathological tissues specimens detected to be MSI-H was performed to examine whether there was intratumoral heterogeneity of MSI status. RESULTS Thirty-nine out of 271 cases were dMMR. dMMR occurred mostly in patients with right-hemi colon cancer (P < 0.0001). Compared with dMMR patients, the clinical stages of pMMR patients were more inclined to be in the late stage with lymph node metastasis (P < 0.0001). MSI-H tumors were significantly associated with KRAS mutation (P = 0.036) and PD-L1 expression (P = 0.038). Compared with Promega panel and 24-locus detection, the consistency between NCI MSI panel and IHC staining results were the highest with the Kappa value of 0.850. The sensitivity of detection decreased from 87.18% to 56.41% with the increase in detection loci. Single locus analysis showed that the first two loci with the highest sensitivity were both mononucleotide loci, namely, BAT-26 (95.45%) and BAT-25 (86.36%). The dinucleotide locus with highest sensitivity was D2S123 (50%). The main detection loci of MSI-H showed no intratumoral heterogeneity. CONCLUSION The combination of 2 mononucleotide loci (BAT25, BAT26) and 3 dinucleotide loci (D2S123, D5S346, D17S250) might be the most suitable loci for MSI detection in East Asian population. There is no intratumoral heterogeneity in the main MSI loci.
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Affiliation(s)
- Wenqi Bai
- Department of Colorectal Surgery, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
| | - Jinfeng Ma
- Department of General Surgery, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
| | - Yangyang Liu
- Department of Oncology, Union hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, P.R. China
| | - Jing Liang
- Graduate School of Shanxi Medical University, Taiyuan, Shanxi, P.R. China
| | - Yueqin Wu
- Department of Pathology, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
| | - Xuanqin Yang
- Department of Pathology, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
| | - Enwei Xu
- Department of Pathology, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
| | - Yan Li
- Department of Pathology, Union hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, P.R. China
| | - Yanfeng Xi
- Department of Pathology, Shanxi Cancer Hospital, Taiyuan, Shanxi, P.R. China
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Abstract
Lynch syndrome is a hereditary cancer predisposition syndrome caused by germline alterations in the mismatch repair genes and is the most common etiology of hereditary colorectal cancer. While Lynch syndrome was initially defined by the clinical Amsterdam criteria, these criteria lack the sensitivity needed for clinical utility. This review covers the evolution of screening for Lynch syndrome from the use of tumor microsatellite instability and/or somatic alterations in mismatch repair protein expression by immunohistochemistry to the newest methods using next-generation sequencing. Additionally, it discusses the clinical implications of the diagnosis of Lynch syndrome as it affects cancer therapeutics and the role of screening in noncolorectal Lynch-associated cancers. As molecular oncology continues to evolve, it is crucial to remain current on the increasing complexity of Lynch syndrome diagnostics and treatment options.
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Affiliation(s)
- Stacey A Cohen
- Division of Oncology, University of Washington, Seattle, Washington 98109, USA; .,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Colin C Pritchard
- Department of Laboratory Medicine, University of Washington, Seattle, Washington 98195, USA
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington 98195, USA.,Department of Genome Sciences, University of Washington, Seattle, Washington 98195, USA
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Danaher P, Warren S, Ong S, Elliott N, Cesano A, Ferree S. A gene expression assay for simultaneous measurement of microsatellite instability and anti-tumor immune activity. J Immunother Cancer 2019; 7:15. [PMID: 30665466 PMCID: PMC6341623 DOI: 10.1186/s40425-018-0472-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 07/26/2018] [Accepted: 11/30/2018] [Indexed: 12/21/2022] Open
Abstract
Background Clinical benefit from checkpoint inhibitors has been associated in a tumor-agnostic manner with two main tumor traits. The first is tumor antigenicity, which is typically measured by tumor mutation burden, microsatellite instability (MSI), or Mismatch Repair Deficiency using gene sequence platforms and/or immunohistochemistry. The second is the presence of a pre-existing adaptive immune response, typically measured by immunohistochemistry (e.g. single analyte PD-L1 expression) and/or gene expression signatures (e.g. tumor “inflamed” phenotype). These two traits have been shown to provide independent predictive information. Here we investigated the potential of using gene expression to predict tumor MSI, thus enabling the measurement of both tumor antigenicity and the level of tumor inflammation in a single assay, possibly reducing sample requirement, turn-around time, and overall cost. Methods Using The Cancer Genome Atlas RNA-seq datasets with the greatest MSI-H incidence, i.e. those from colon (n = 208), stomach (n = 269), and endometrial (n = 241) cancers, we trained an algorithm to predict tumor MSI from under-expression of the mismatch repair genes MLH1, PMS2, MSH2, and MSH6 and from 10 additional genes with strong pan-cancer associations with tumor hypermutation. The algorithms were validated on the NanoString nCounter™ platform in independent cohorts of colorectal (n = 52), endometrial (n = 11), and neuroendocrine (n = 4) tumors pre-characterized using the MMR immunohistochemistry assay. Results In the validation cohorts, the algorithm showed high prediction accuracy of tumor MSI status, with sensitivity of at least 88% attained at thresholds chosen to achieve 100% specificity. Furthermore, MSI status was compared to the Tumor Inflammation Signature (TIS), an analytically validated diagnostic assay which measures a suppressed adaptive immune response in the tumor and enriches for response to immune checkpoint blockade. TIS score was largely independent of MSI status, suggesting that measuring both parameters may identify more patients that would respond to immune checkpoint blockade than either assay alone. Conclusions Development of a gene expression signature of MSI status raises the possibility of a combined diagnostic assay on a single platform which measures both tumor antigenicity and presence of a suppressed adaptive immune response. Such an assay would have significant advantages over multi-platform assays for both ease of use and turnaround time and could lead to a diagnostic test with improved clinical performance. Electronic supplementary material The online version of this article (10.1186/s40425-018-0472-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick Danaher
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA
| | - Sarah Warren
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA.
| | - SuFey Ong
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA
| | - Nathan Elliott
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA
| | - Alessandra Cesano
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA
| | - Sean Ferree
- NanoString Technologies®, Inc, 530 Fairview Ave. N, Seattle, Washington, 98109, USA
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Jiang W, Cai MY, Li SY, Bei JX, Wang F, Hampel H, Ling YH, Frayling IM, Sinicrope FA, Rodriguez-Bigas MA, Dignam JJ, Kerr DJ, Rosell R, Mao M, Li JB, Guo YM, Wu XY, Kong LH, Tang JH, Wu XD, Li CF, Chen JR, Ou QJ, Ye MZ, Guo FM, Han P, Wang QW, Wan DS, Li L, Xu RH, Pan ZZ, Ding PR. Universal screening for Lynch syndrome in a large consecutive cohort of Chinese colorectal cancer patients: High prevalence and unique molecular features. Int J Cancer 2019; 144:2161-2168. [PMID: 30521064 DOI: 10.1002/ijc.32044] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 06/26/2018] [Accepted: 10/04/2018] [Indexed: 12/31/2022]
Abstract
The prevalence of Lynch syndrome (LS) varies significantly in different populations, suggesting that ethnic features might play an important role. We enrolled 3330 consecutive Chinese patients who had surgical resection for newly diagnosed colorectal cancer. Universal screening for LS was implemented, including immunohistochemistry for mismatch repair (MMR) proteins, BRAFV600E mutation test and germline sequencing. Among the 3250 eligible patients, MMR protein deficiency (dMMR) was detected in 330 (10.2%) patients. Ninety-three patients (2.9%) were diagnosed with LS. Nine (9.7%) patients with LS fulfilled Amsterdam criteria II and 76 (81.7%) met the revised Bethesda guidelines. Only 15 (9.7%) patients with absence of MLH1 on IHC had BRAFV600E mutation. One third (33/99) of the MMR gene mutations have not been reported previously. The age of onset indicates risk of LS in patients with dMMR tumors. For patients older than 65 years, only 2 patients (5.7%) fulfilling revised Bethesda guidelines were diagnosed with LS. Selective sequencing of all cases with dMMR diagnosed at or below age 65 years and only of those dMMR cases older than 65 years who fulfill revised Bethesda guidelines results in 8.2% fewer cases requiring germline testing without missing any LS diagnoses. While the prevalence of LS in Chinese patients is similar to that of Western populations, the spectrum of constitutional mutations and frequency of BRAFV600E mutation is different. Patients older than 65 years who do not meet the revised Bethesda guidelines have a low risk of LS, suggesting germline sequencing might not be necessary in this population.
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Affiliation(s)
- Wu Jiang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Mu-Yan Cai
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Shi-Yong Li
- BGI-Guangzhou Medical Laboratory, BGI-Shenzhen, People's Republic of China
| | - Jin-Xin Bei
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Fang Wang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Heather Hampel
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Yi-Hong Ling
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ian M Frayling
- Institute of Cancer and Genetics, Cardiff University, Cardiff, United Kingdom.,All-Wales Medical Genetics Service, Institute of Medical Genetics, University Hospital of Wales, Cardiff, United Kingdom
| | | | | | - James J Dignam
- Department of Public Health Sciences, The University of Chicago Biological Sciences, Chicago, IL
| | - David J Kerr
- Department of Clinical Pharmacology, OCRB, Churchill Campus, Headington, University of Oxford, Oxford, United Kingdom
| | - Rafael Rosell
- Catalan Institute of Oncology, Germans Trias i Pujol Health Sciences Institute and Hospital, Badalona, Barcelona, Spain
| | - Mao Mao
- BGI-Guangzhou Medical Laboratory, BGI-Shenzhen, People's Republic of China
| | - Ji-Bin Li
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yun-Miao Guo
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Xiao-Yan Wu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Molecular Diagnostics, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ling-Heng Kong
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jing-Hua Tang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Xiao-Dan Wu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Chao-Feng Li
- Department of Information Technology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Jie-Rong Chen
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Qing-Jian Ou
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China.,Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Ming-Zhi Ye
- BGI-Guangzhou Medical Laboratory, BGI-Shenzhen, People's Republic of China
| | - Feng-Ming Guo
- BGI-Guangzhou Medical Laboratory, BGI-Shenzhen, People's Republic of China
| | - Peng Han
- BGI-Guangzhou Medical Laboratory, BGI-Shenzhen, People's Republic of China
| | - Qi-Wei Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - De-Sen Wan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Li Li
- Imaging Diagnosis and Interventional Center, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Rui-Hua Xu
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Zhi-Zhong Pan
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
| | - Pei-Rong Ding
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, Guangzhou, People's Republic of China
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Muller C, Lee SM, Barge W, Siddique SM, Berera S, Wideroff G, Tondon R, Chang J, Peterson M, Stoll J, Katona BW, Sussman DA, Melson J, Kupfer SS. Low Referral Rate for Genetic Testing in Racially and Ethnically Diverse Patients Despite Universal Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2018; 16:1911-1918.e2. [PMID: 30130624 PMCID: PMC6866232 DOI: 10.1016/j.cgh.2018.08.038] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/07/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines recommend that all colorectal tumors be assessed for mismatch repair deficiency, which could increase identification of patients with Lynch syndrome. This is of particular importance for minority populations, in whom hereditary syndromes are under diagnosed. We compared rates and outcomes of testing all tumor samples (universal testing) collected from a racially and ethnically diverse population for features of Lynch syndrome. METHODS We performed a retrospective analysis of colorectal tumors tested from 2012 through 2016 at 4 academic centers. Tumor samples were collected from 767 patients with colorectal cancer (52% non-Hispanic white [NHW], 26% African American, and 17% Hispanic patients). We assessed rates of tumor testing, recommendations for genetic evaluation, rates of attending a genetic evaluation, and performance of germline testing overall and by race/ethnicity. We performed univariate and multivariate regression analyses. RESULTS Overall, 92% of colorectal tumors were analyzed for mismatch repair deficiency without significant differences among races/ethnicities. However, minority patients were significantly less likely to be referred for genetic evaluation (21.2% for NHW patients vs 16.9% for African American patients and 10.9% for Hispanic patients; P = .02). Rates of genetic testing were also lower among minority patients (10.7% for NHW patients vs 6.0% for AA patients and 3.1% for Hispanic patients; P < .01). On multivariate analysis, African American race, older age, and medical center were independently associated with lack of referral for genetic evaluation and genetic testing. CONCLUSION In a retrospective analysis, we found that despite similar rates of colorectal tumor analysis, minority patients are less likely to be recommended for genetic evaluation or to undergo germline testing for Lynch syndrome. Improvements in institutional practices in follow up after tumor testing could reduce barriers to diagnosis of Lynch diagnosis in minorities.
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Affiliation(s)
- Charles Muller
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sang Mee Lee
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - William Barge
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois
| | - Shazia M Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shivali Berera
- Gastroenterology Division, University of Miami, Miami, Florida
| | - Gina Wideroff
- Gastroenterology Division, University of Miami, Miami, Florida
| | - Rashmi Tondon
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy Chang
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Meaghan Peterson
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jessica Stoll
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Bryson W Katona
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joshua Melson
- Division of Digestive Diseases and Nutrition, Rush University, Chicago, Illinois
| | - Sonia S Kupfer
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago, Chicago, Illinois.
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McCuaig JM, Armel SR, Care M, Volenik A, Kim RH, Metcalfe KA. Next-Generation Service Delivery: A Scoping Review of Patient Outcomes Associated with Alternative Models of Genetic Counseling and Genetic Testing for Hereditary Cancer. Cancers (Basel) 2018; 10:E435. [PMID: 30428547 DOI: 10.3390/cancers10110435] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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: 10/12/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 01/19/2023] Open
Abstract
The combination of increased referral for genetic testing and the current shortage of genetic counselors has necessitated the development and implementation of alternative models of genetic counseling and testing for hereditary cancer assessment. The purpose of this scoping review is to provide an overview of the patient outcomes that are associated with alternative models of genetic testing and genetic counseling for hereditary cancer, including germline-only and tumor testing models. Seven databases were searched, selecting studies that were: (1) full-text articles published ≥2007 or conference abstracts published ≥2015, and (2) assessing patient outcomes of an alternative model of genetic counseling or testing. A total of 79 publications were included for review and synthesis. Data-charting was completed using a data-charting form that was developed by the study team for this review. Seven alternative models were identified, including four models that involved a genetic counselor: telephone, telegenic, group, and embedded genetic counseling models; and three models that did not: mainstreaming, direct, and tumor-first genetic testing models. Overall, these models may be an acceptable alternative to traditional models on knowledge, patient satisfaction, psychosocial measures, and the uptake of genetic testing; however, particular populations may be better served by traditional in-person genetic counseling. As precision medicine initiatives continue to advance, institutions should consider the implementation of new models of genetic service delivery, utilizing a model that will best serve the needs of their unique patient populations.
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Wong HL, Christie M, Gately L, Tie J, Lee B, Semira C, Lok SW, Wong R, Gibbs P. Mismatch repair deficiency assessment by immunohistochemistry: for Lynch syndrome screening and beyond. Future Oncol 2018; 14:2725-2739. [DOI: 10.2217/fon-2018-0319] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
While mismatch repair (MMR) deficiency has been studied extensively, the assessment of MMR status in colorectal and other cancers remains highly relevant, particularly in light of recent data demonstrating that MMR deficiency is a strong predictor for treatment benefit with immune checkpoint inhibitors across multiple tumor types. In colorectal cancer, there is a growing consensus in support of routine MMR testing for Lynch syndrome screening, to inform prognosis and adjuvant chemotherapy use in early stage disease, and to predict response to immunotherapy in advanced disease. Here, we provide a review of the Ventana MMR Immunohistochemistry Panel, which was recently approved by the US FDA for use in Lynch syndrome screening.
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Affiliation(s)
- Hui-li Wong
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael Christie
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Pathology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lucy Gately
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, St. Vincent's Health, Fitzroy, Victoria, Australia
| | - Jeanne Tie
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Department of Medical Oncology, Western Health Medical School, University of Melbourne, Footscray, Victoria, Australia
| | - Belinda Lee
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
- Department of Medical Oncology, Northern Health, Epping, Victoria, Australia
| | - Christine Semira
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Sheau Wen Lok
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Rachel Wong
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, Eastern Health, Box Hill, Victoria, Australia
| | - Peter Gibbs
- Systems Biology & Personalised Medicine Division, The Walter & Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Medical Oncology, Western Health Medical School, University of Melbourne, Footscray, Victoria, Australia
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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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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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Cragun DL, Kechik J, Pal T. Complexities of genetic screening and testing in hereditary colorectal cancer. Seminars in Colon and Rectal Surgery 2018. [DOI: 10.1053/j.scrs.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Signoroni S, Tibiletti MG, Ricci MT, Milione M, Perrone F, Pensotti V, Chiaravalli AM, Carnevali I, Morabito A, Bertario L, Vitellaro M. Performance of tumor testing for Lynch syndrome identification in patients with colorectal cancer: A retrospective single-center study. Tumori 2018; 105:76-83. [DOI: 10.1177/0300891618792460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: To investigate the performance of tumor testing approaches in the identification of Lynch syndrome (LS) in a single-center cohort of people with colorectal cancer (CRC). Methods: A retrospective analysis of data stored in a dedicated database was carried out to identify patients with CRC suspected for LS who were referred to Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, between 1999 and 2014. The sensitivity and specificity of immunohistochemistry (IHC) for mismatch repair (MMR) proteins and microsatellite instability (MSI) analysis (alone or combined) were calculated with respect to the presence of causative MMR germline variants. Results: A total of 683 patients with CRC suspected for LS were identified. IHC results of MMR protein analysis and MSI were assessed in 593 and 525 CRCs, respectively, while germline analysis was performed in 418 patients based on the IHC or MSI test result and/or clinical features. Univariate and multivariate analysis revealed a significant correlation of pathogenic MMR germline variants with all clinicopathologic features including Amsterdam criteria, presence of endometrial cancer, CRC site, age at onset, stage, and grade. The highest odds ratio values were observed for IHC and MSI (17.1 and 8.8, respectively). The receiver operating characteristic curve and area under the curve values demonstrated that IHC alone or combined with other clinicopathologic parameters was an excellent test for LS identification. Conclusions: This study confirms the effectiveness of tumor testing to identify LS among patients with CRC. Although IHC and MSI analysis were similarly effective, IHC could be a better strategy for LS identification as it is less expensive and more feasible.
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Affiliation(s)
- Stefano Signoroni
- Unit of Hereditary Digestive Tract Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | - Maria Teresa Ricci
- Unit of Hereditary Digestive Tract Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Massimo Milione
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Federica Perrone
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Valeria Pensotti
- IFOM, Institute of Molecular Oncology, Italian Foundation for Cancer Research, Milan, Italy
- Cancer Genetic Test Laboratory, Cogentech, Milan, Italy
| | | | | | | | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marco Vitellaro
- Unit of Hereditary Digestive Tract Tumors, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
- Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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