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Wu R, McNeil R, Green G, Abbott D, Thomas C, Morris S, Knight S, Provenzale D. Incorporating genomic services into routine clinical care for Veterans with colorectal cancer. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
Research Objective: The evidence for incorporation of genomics into routine clinical care is increasing. A prime example of this is screening for hereditary nonpolyposis colorectal cancer (HNPCC). HNPCC is the cause of 3-5% of all colorectal cancers (CRC).(1) Since the release of the revised Bethesda guidelines (2) in 2004, numerous organizations (3-6) have recommended that CRC patients, diagnosed under the age of fifty, should be tested for HNPCC for the purposes of individual and familial risk stratification. In 2011, VHA launched an initiative to perform molecular testing of CRC tumors for HNPCC, regardless of patient age, based on economic analyses demonstrating the cost-effectiveness of molecular testing in all CRC cases. (7, 8) The goal of our study was to determine the degree to which such recommendations were being practiced with the Veterans Health Administration (VHA) prior to the new initiative. This abstract describes the utilization of screening for HNPCC within the VHA. Study Design: We performed an observational study that integrated multiple national VHA databases with electronic medical records to collect patient, provider, and facility characteristics of CRC cases. Primary endpoints included assessment of family health history (FHH) of HNPCC related cancers, ordering of molecular analyses for HNPCC, and referral for genetic counseling and genetic testing. Population Studied: All CRC cases in patients less than 50 years old diagnosed between fiscal year 2003-2009 within the VHA. Principal Findings: We abstracted data from 1,003 patient charts from 103 VHA facilities. The following descriptors are based on 889 documented cases of CRC. Median age was 48 (20-55). 92% (N = 815) were male. Race was largely Caucasian (58%) or Black (34%). The majority (63%) did not have supplemental insurance (private, Medicare or Medicaid). Tumor stages were: Stage 0 (4%), Stage I (18%), Stage 2 (22%), Stage 3 (26%), and Stage IV (20%). (9% had incomplete data for staging.) 89% were diagnosed within a VHA facility. Twenty-five percent (N = 219) of cases were discussed at a multidisciplinary tumor board meeting. FHH of CRC or any Lynch syndrome related cancer was documented in 29% of cases. MSI or IHC testing was evident in the medical record for 8% of cases. Genetic counseling referrals were made for 5% of cases, mostly by oncologists (35%) or gastroenterologists (28%). Of those referred, 51% completed genetic counselling. Genetic counselling was completed at: academic affiliates (30%), VA (19%), other non-VA clinics (16%), or unknown locations (35%). Twenty cases (2%) completed genetic sequencing, of which 25% were confirmed to have Lynch syndrome. Conclusion: While evidence for routine screening for HNPCC within CRC patients is emerging, adoption of such practices within the high-risk population of CRC patients under the age of 50 within VHA through 2009 was not widespread. Given that 46% of cases were Stage III or IV, understandably immediate treatment of the cancer was likely of more pressing importance. Implications for Policy or Practice: Further research will evaluate the impact that VHA's initiative to introduce universal screening has had and the barriers and facilitators to widespread implementation. Policies of reflexive molecular testing of all CRC across the VHA could be instituted to increase adherence to guidelines.
