Reports From the Field

Screening for Lynch Syndrome Among Patients with Colorectal Cancer: Experiences from a Multihospital Health System

Journal of Clinical Outcomes Management. 2018 December;25(10):451-455

References

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There has been some debate as to whether CRC tumor screening requires consent from the patient.¹⁴ Without a clear standard of care for CRC cases, MMR IHC testing might not be ordered if a pathologist deems it necessary for the surgeon to obtain patient consent to the test. When the discrepancy in MMR IHC testing among the hospitals was investigated, we learned that one pathologist performed MMR testing only if a signed patient consent was provided. This revealed a deviation from our CRC protocol and a deficiency of communication within the HHC network. In addition, only 3 of our 5 hospitals routinely had genetic counselors present during the study period, requiring travel for patients at the other 2 hospitals and thus creating a potential barrier to the genetic consultation.

Based on the results of this study and other studies in the literature, we estimated that approximately 7 to 10 MMR-positive cases and 5 to 7 patients with LS may have been missed within the HHC network during the 2 study years as a result of suboptimal MMR testing, genetic counseling, and genetic testing.^14-18 These potentially missed cases and diagnoses underscore the importance of implementing a unified standard of care across all large health care organizations. Individualized care, genetic testing, and counseling for patients and families affected by LS lead to more effective monitoring of these patients for disease.

However, our project showed that effective implementation of a standard of care for universal tumor screening for patients with CRC can modify institutional cancer care.¹⁵ Notably, hospitals that tested a lower percentage of patients overall improved their MMR testing drastically from 2014 to 2015. This significant increase in MMR testing shows the impact of measuring and disseminating compliance performance information following the institution of a new quality standard within a health care system. Further audits have revealed universal acceptance and use of this testing.

General patient perception of universal tumor screening is positive, and patients understand and endorse the benefits of screening for LS.¹⁶ In our study, patients with LS were on average 21 years younger at diagnosis compared to patients who were MMR-negative. Because LS patients are younger at diagnosis of CRC compared to patients who do not have MMR gene mutations and because colonoscopy typically is not initiated until age 50 years, molecular screening and genetic testing of MMR-positive patients is important. Identifying the presence of LS is important for both the patient and their family. Specifically, patients with LS are recommended to receive a screening colonoscopy every 1 to 2 years beginning at age 20 to 25 years.¹³ Personalizing care and increasing surveillance for patients with LS can help to reduce the morbidity and mortality of CRC and potentially other cancers.

Conclusion

As a result of this study, we recognized that inclusion of pathologists in the discussion is essential but not enough to ensure that all cases will be screened. Rather, a much more detailed series of steps is necessary to ensure compliance, including:

Gain consensus among clinical leadership in CRC (including surgery, medical oncology, and pathology) that universal screening is necessary.
Bring the appropriate strategy to pathology department operational managers to ensure that policy is transmitted to all appropriate staff.
Ensure that involved individuals at newer hospitals in the system have access to the details of cultural discussions that have occurred to develop consensus and the policies and procedures that followed.
Develop policies and procedures to assure that all appropriate patients are tested, including those who present outside normal hours for emergency surgery (ie, bowel obstruction).
Develop an audit process to ensure that all patients have been screened and determine where any exceptions might be present.
Present audit data back to the pathology team and Cancer Institute leadership team, and consider any strategy or operational modifications if needed.

The results of this study also highlight the important role quality studies play in informing health care organizations and improving clinical care. Quality studies assist in changing the culture and practice of institutions and guide the development and implementation of a unified standard of care.

Corresponding author: Andrew L. Salner, MD, Hartford HealthCare Cancer Institute, 80 Seymour Street, Hartford, CT 06102; andrew.salner@hhchealth.org.

Financial disclosures: None.

Funding: This study was funded internally as a quality improvement study.