Background & Aims The optimal algorithm to identify Lynch syndrome (LS) among patients with colorectal cancer (CRC) is unclear. The definitive test for LS, germline testing, is too expensive to be applied in all cases. Initial screening with the Revised Bethesda Guidelines (RBG) cannot be applied in a considerable number of cases due to missing information. Methods We developed a model to evaluate the cost-effectiveness of 10 strategies for diagnosing LS. Three main issues are addressed: modeling estimates (20–40%) of RBG applicability; comparing sequential or parallel use of MSI and IHC; and a threshold analysis of the charge value below which universal germline testing becomes the most cost effective strategy. Results LS detection rates in RBG-based strategies decreased to 64.1%-70.6% with 20% inapplicable RBG. The strategy that uses MSI alone had lower yield but also lower cost than strategies that use MSI sequentially or in parallel with IHC. The use of MSI and IHC in parallel was less affected by variations in the sensitivity and specificity of these tests. Universal germline testing had the highest yield and the highest cost of all strategies. The model estimated that if charges for germline testing drop to $633–1518, universal testing of all newly diagnosed CRC cases becomes the most cost effective strategy. Conclusions The low applicability of RBG makes strategies employing initial laboratory based testing more cost effective. Of these strategies, parallel testing with MSI and IHC offers the most robust yield. With a considerable drop in cost, universal germline testing may become the most cost effective strategy for the diagnosis of LS.
Introduction: Screening for cervical, colorectal, and breast cancer is an evidence-based strategy to reduce the morbidity and mortality from these cancers. However a large proportion of medically underserved individuals do not obtain regular screening. Using the Quality in the Continuum of Cancer Care (QCCC) framework, we developed and implemented a comprehensive systems design intervention to improve the delivery, uptake, and follow-up of cervical, colorectal, and breast cancer screening within a network of healthcare institutions that serve the medically underserved in Harris County, Texas. Methods: An academic-community partnership, the Community Network for Cancer Prevention, was established between an academic cancer center, the county's safety net healthcare system, and several academic and community-based healthcare institutions. Clinical advisory boards, comprised of physicians, nurses, and public health professionals, were established for each cancer line. The QCCC framework was used to identify system-level failures that impede processes and transitions in the continuum of care from risk assessment to detection and from detection to diagnosis. Project components were developed to address the identified failures. Results: System failures identified at the risk assessment to detection phases included 1) failure to identify individuals in need of screening, 2) inadequate capacity to screen, and 3) inadequate access to care. Failures identified at the detection to diagnosis phases included 1) failures in the screening test results notification system, 2) failures in inter-provider communication, 3) failures in inter-institutional referrals for clinical follow-up, 4) patient non-adherence, and 5) inadequate access to care. Project components to address the identified failures include community outreach, patient education, and patient navigation. Community outreach involves a community theater program aimed to increase awareness of cancer risk and the current cancer screening guidelines among medically underserved individuals in the larger community; healthcare access navigators available at each performance assist audience members in applying for healthcare coverage through the safety net healthcare system. Patient education involves using the electronic medical record to identify patients due or past due for cervical, colorectal, and/or breast cancer screening. These patients are then targeted for a video-based patient education intervention while they wait to be seen by their healthcare provider. Motivational messaging in the videos encourages patients to discuss the particular screening test with their provider. Finally, patient navigation involves a team of navigators who actively communicate with patients and providers to ensure follow-up among patients with an abnormal screening test result. A real-time tracking database is used to monitor all screen-test positive patients as they move through the different stages of diagnostic and therapeutic follow-up. Conclusion: The QCCC provides a systematic approach for assessing factors that influence cancer care processes at the risk assessment, screening, detection, and diagnosis phases, as well as transitions between them. Focusing on transitions between phases is particularly useful for developing systems-level interventions to improve the delivery, uptake, and follow-up of cancer screening. Citation Format: Jane R. Montealegre, Loretta Hanser, Maria Daheri, Roshanda Chenier, Ivan Valverde, Glori S. Chauca, Luis O. Rustveld, Matthew L. Anderson, Lois Ramondetta, Milena Gould-Suarez, Musher L. Benjamin, Larry D. Scott, Juli R. Nangia, Brian C. Reed, Janet Hoagland-Sorensen, Alyssa Rieber, Maria L. Jibaja-Weiss. Using the Quality in the Continuum of Cancer Care framework to develop a multilevel intervention to improve cancer screening and follow-up among the medically underserved. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B78.
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