Background: Colorectal cancer (CRC) is a common cancer and tumor analysis to screen for Lynch syndrome is recommended by several organizations. The Genomic Medicine Service (GMS) at the VHA has been charged with implementing a universal Lynch screening program within the VHA. Colorectal cancer is the third most common cancer and second most common cause of cancer death in the United States. Lynch syndrome, the most common inherited colon cancer predisposition syndrome, may be responsible for 3% of all CRCs, and increases an individual’s risks of colorectal, endometrial, ovarian, and stomach cancers. In 2009, the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) working group found sufficient evidence to recommend using tumor analysis to screen for Lynch syndrome in all individuals newly diagnosed with CRC, regardless of age or family history, to reduce cancer morbidity and mortality. The NCCN guidelines now also recommend routine tumor testing for all patients diagnosed with CRC. Universal Lynch syndrome screening is also a goal of the CDC initiative, Healthy People 2020. As an integrated, nationwide health care system with over 7 million users and at least 4,000 CRC diagnoses a year, the VHA is in a unique position to identify an estimated 120 to 150 new cases of Lynch syndrome per year. Following these individuals with Lynch syndrome with appropriate screening will decrease the risk of subsequent cancers. In addition, education and cascade testing for relatives will increase the impact of a screening program. The GMS is a relatively new national service, which provides genetic counseling and diagnostic services to our nation’s veterans, using the VA’s telehealth infrastructure. In 2010, the Genomic Medicine Program Advisory Committee recommended that Lynch screening be implemented in the VHA. In 2011, the VHA and GMS began implementation with the following algorithm: MSI by PCR, with MSI-high tumors moving forward to IHC and BRAF if indicated and finally, germline testing after genetic counseling and informed consent.
Purpose: To evaluate the process of implementing universal Lynch screening in VAMCs with which GMS is aligned.
Methods: Empirical data collected during implementation in 8 sites. As many as 70 different VHA facilities perform colon resections; this translates to a significant coordination of effort to implement screening by 1 centralized program. The GMS is only aligned with about 60 sites nationally, and not all of them perform colon resections; 45 sites in which we are providing service perform colon resections. The GMS reached out to 13 of these sites.
Results: While there are national infrastructure tools, such as a single EHR, which improve care for veterans, the individual culture within each VAMC creates a myriad of challenges in defining one workable national protocol. Unique challenges have been identified in implementing a national program in numerous facilities. The greatest barriers to implementation include funding concerns, coordination of key players in multiple departments (GI, surgery, pathology, and hem/onc) and identification of a local clinical champion to manage the cases. Other barriers include coordination of follow-up after positive tumor screening results and program staff turnover.
Conclusions: Despite these barriers, genomic medicine has facilitated the establishment of universal Lynch screening in 8 VHA facilities. The GMS continues outreach to VAMCs that use our services to expand the Lynch screening program. Increased education regarding national guidelines as well as collaboration between multiple stakeholders will be necessary to accomplish VHA-wide implementation of universal Lynch syndrome screening.
