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Underutilization of Lynch Syndrome Screening at Two Large Veterans Affairs Medical Centers

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Abstract

Background

Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome, yet is grossly under-recognized. Multiple professional societies recommend screening all CRCs for LS by performing tumor testing. The veterans affairs system has not adopted universal tumor testing as a national performance metric and leaves screening for LS to clinical care at individual sites.

Aims

Describe adherence to LS screening in the VA system.

Methods

Dual-center, retrospective review of all CRCs diagnosed between 2010 and 2016. Rates of tumor testing, personal and family history of cancer were extracted from the medical record. Univariate and multivariate regression analysis was performed to determine predictors of tumor-based screening for LS.

Results

A total of 421 cancers were reviewed. 15.1% of all cancers underwent either MSI and/or IHC for LS screening over the study period. There was improvement in LS screening from 3% of all CRCs in 2010 to 45% of all CRCs in 2016. 34% and 70% of patients did not have documentation of CRC in first- and second-degree relatives, respectively. Of the 73 patients who met one of the Revised Bethesda Criteria or had a PREMM1,2,6 score of ≥ 5, 34% and 56% underwent tumor testing, respectively. Younger age, non-Caucasian race, meeting Bethesda or PREMM1,2,6 criteria and right-sided tumor location were predictors of undergoing tumor testing.

Conclusions

CRC tumor screening for LS is grossly inadequate when left to routine clinical care. Our results lend support to implementation of reflexive universal tumor testing within the VA system.

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Abbreviations

CRC:

Colorectal cancer

LS:

Lynch syndrome

MSI:

Microsatellite instability

IHC:

Immunohistochemistry

MMR:

Mismatch repair

EGAPP:

Evaluation of genomic applications in practice and prevention

MSTF:

Multi-society task force

VA:

Veterans affairs

GMS:

Genomics medicine service

PCR:

Polymerase chain reaction

FDR:

First-degree relative

SDR:

Second-degree relative

VISN:

Veterans integrated services network

LAC:

Lynch-associated cancer

BMI:

Body mass index

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Authors and Affiliations

  1. University of Colorado Anschutz Medical Center, 12631 E 17th Avenue, Room 7614, Campus Box 158, 80045, Aurora, CO, USA

    Chetan Mittal, Frank I. Scott, Dennis Ahnen & Swati G. Patel

  2. Parkview Cancer Institute, Fort Wayne, IN, USA

    Chetan Mittal

  3. Veterans Affairs Hospital, Ann Arbor, MI, USA

    Duyen Dang & Stacy Menees

  4. Henry Ford Medical Center, Detroit, MI, USA

    Duyen Dang

  5. University of Michigan, Ann Arbor, MI, USA

    Elena Stoffel & Stacy Menees

  6. Veterans Affairs Hospital, Aurora, CO, USA

    Swati G. Patel

Authors
  1. Chetan Mittal
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  2. Duyen Dang
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  3. Elena Stoffel
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  4. Stacy Menees
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  5. Frank I. Scott
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  6. Dennis Ahnen
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  7. Swati G. Patel
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Contributions

C. Mittal involved in study conception and design; generation, collection, assembly, analysis and interpretation of data; drafting, critical revision and final approval of the manuscript; D. Dang involved in study conception and design; generation, collection, assembly, analysis and interpretation of data; drafting, critical revision and final approval of the manuscript; E. Stoffel involved in analysis and interpretation of data; drafting, critical revision and final approval of the manuscript; S. Menees involved in collection, analysis and interpretation of data, critical revision and final approval of the manuscript; F. Scott involved in assembly, statistical analysis and interpretation of data; critical revision and final approval of the manuscript; D. Ahnen involved in analysis and interpretation of data; drafting, critical revision and final approval of the manuscript; S. Patel involved in study conception and design; generation, collection, assembly, analysis and interpretation of data; drafting, critical revision and final approval of the manuscript; study supervision

Corresponding author

Correspondence to Swati G. Patel.

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Mittal, C., Dang, D., Stoffel, E. et al. Underutilization of Lynch Syndrome Screening at Two Large Veterans Affairs Medical Centers. Dig Dis Sci 65, 3305–3315 (2020). https://doi.org/10.1007/s10620-020-06340-0

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  • DOI: https://doi.org/10.1007/s10620-020-06340-0

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