From diagnosis of colorectal cancer to diagnosis of Lynch syndrome: The RM Partners quality improvement project

Abstract

AimThe UK National Institute for Health and Care Excellence guideline DG27 recommends universal testing for Lynch syndrome (LS) in all newly diagnosed colorectal cancer (CRC) patients. However, DG27 guideline implementation varies significantly by geography. This quality improvement project (QIP) was developed to measure variation and deliver an effective diagnostic pathway from diagnosis of CRC to diagnosis of LS within the RM Partners (RMP) West London cancer alliance.MethodRM Partners includes a population of 4 million people and incorporates nine CRC multidisciplinary teams (MDTs), overseen by a Pathway Group, and three regional genetic services, managing approximately 1500 new CRC cases annually. A responsible LS champion was nominated within each MDT. A regional project manager and nurse practitioner were appointed to support the LS champions, to develop online training packages and patient consultation workshops. MDTs were supported to develop an ‘in‐house’ mainstreaming service to offer genetic testing in their routine oncology clinics. Baseline data were collected through completion of the LS pathway audit of the testing pathway in 30 consecutive CRC patients from each CRC MDT, with measurement of each step of the testing pathway. Areas for improvement in each MDT were identified, delivered by the local champion and supported by the project team.ResultsOverall, QIP measurables improved following the intervention. The Wilcoxon signed rank test revealed significant differences with strong effect sizes on the percentile of CRC cases undergoing mismatch repair (MMR) testing in endoscopic biopsies (p = 0.008), further testing with either methylation or BRAF V600E (p = 0/03) and in effective referral for genetic testing (from 10% to 74%; p = 0.02). During the QIP new mainstreaming services were developed, alongside the implementation of systematic and robust testing pathways. These pathways were tailored to the needs of each CRC team to ensure that patients with a diagnosis of CRC had access to testing for LS. Online training packages were produced which remain freely accessible for CRC teams across the UK.ConclusionThe LS project was completed by April 2022. We have implemented a systematic approach with workforce transformation to facilitate identification and ‘mainstreamed’ genetic diagnosis of LS. This work has contributed to the development of a National LS Transformation Project in England which recommends local leadership within cancer teams to ensure delivery of diagnosis of LS and integration of genomics into clinical practice.

A novel colorectal cancer test combining microsatellite instability and BRAF/RAS analysis: Clinical validation and impact on Lynch syndrome screening

“…This improvement will be related to several key advantages, such as its low cost, scalability, clarity of results, and delivery by technologists rather than senior scientists or pathologists, that address the previously identified barriers to LS screening [ 11 – 13 ]. However, it has also been shown that LS screening quality improvement programmes that focus on educating healthcare providers and connecting clinical services, rather than employing new technologies, significantly increase tumour testing [ 37 ]. Therefore, the improved testing observed here at the regional-level will also reflect the impact of the English National Lynch Syndrome transformation project, which has appointed over 200 local LS Champions across England and established a national forum and data service to monitor LS screening, among other advances [ 35 ].…”

“…These downstream barriers are also being targeted by the English National Lynch Syndrome transformation project [ 35 ], including updates to molecular reporting to ease clinical interpretation, education of multi-disciplinary teams on results interpretation and germline testing referral, and the mainstreaming of genetic testing. As shown for increased MMR deficiency testing rates, such programmes have increased referrals for germline analysis [ 37 ].…”

The English National Lynch Syndrome transformation project: an NHS Genomic Medicine Service Alliance (GMSA) programme

“…The number of patients eligible for constitutional (germline) testing for LS who were identified and effectively referred increased from 10% to 74% across the life cycle of this QIP. 42 These data formed the basis for a successful bid to NHS England to fund a national transformational project.…”