Colorectal cancer (CRC) is highly prevalent among Veterans cared for within the Veterans Health Administration (VHA). The most common hereditary CRC syndrome is hereditary non-polyposis colon cancer (HNPCC). Despite long-standing published guidelines on routine screening for HNPCC among CRC patients and VHA interest in implementing these standards of care, there is limited knowledge of how these guidelines are being incorporated in the care of Veterans. As an evidence-based application of genomics, HNPCC screening provides an exceptional opportunity to understand delivery patterns for genomic services within VHA.
1) To characterize how genomic information related to HNPCC is integrated into CRC care for Veterans age 50 and younger within VHA based on medical record abstraction, and 2) To examine barriers and facilitators of the incorporation of genomic information into CRC care based on key informant interviews.
We used a mixed methods approach based on secondary data analysis, medical record review, and key informant interviews. Via retrospective cohort study, we examined current patterns of care for Veterans under age 50 diagnosed with CRC, all of whom should have documentation of genomic services in their medical records based on current guidelines, as well as uptake of HNPCC screening guidelines within the VHA over time. To assess facilitators and barriers to delivery of genomic services within VHA, we conducted semi-structured interviews with clinicians at 14 VHA facilities with a high volume of oncology cases and 9 VHA facilities with a low volume of oncology cases. Interviews were transcribed and analyzed using qualitative analysis software and techniques.
We abstracted data from 1,003 patient charts from 103 VHA facilities. The following descriptive findings are based on 886 documented cases of CRC within this cohort of Veterans whose age at diagnosis was less than 50 years old, all of whom would be expected to receive one or more genomic services: Family history of CRC or any HNPCC-related cancer was documented in 29%; Molecular tumor analysis was evident in the medical record for 8%; Genetic counseling referrals were made for 5%; Of those referred, 65% completed genetic counseling; Twelve cases (1%) completed genetic sequencing, of which 25% were confirmed to have HNPCC. No record of molecular analysis of tumor tissue or genetic counseling was present for 62% and 69%, respectively, of facilities that treated Veterans age 50 and under with CRC. VHA adoption of molecular tumor analysis and genetic counseling trended upward in 2009 and 2010, but rates of these services for Veterans with CRC remained well below what is have been recommended by guidelines.
We conducted 58 key informant interviews with clinicians at 23 VA facilities between July 2013 and September 2014. Interview respondents were clinicians who were considered to be knowledgeable of CRC surveillance and treatment within VHA, specifically primary care providers (n=11), oncologists (n=13), surgeons (n=7), gastroenterologists (n=18), and pathologists (n=9). According to qualitative analysis of interview transcripts, clinical stakeholders would like a template to facilitate systematic family history documentation and retrieval. Gastroenterologists and surgeons reported obtaining family history to screen for hereditary CRC at time of colonoscopy or surgery, particularly with younger patients, but with limited detail due to lack of time and open-access scheduling. Clinician awareness of genomic services for CRC varied by specialty. Generally, primary care providers reported that they lacked information about services to evaluate hereditary CRC; in contrast, gastroenterologists and oncologists were generally aware of genomic services for CRC. Molecular tumor testing for HNPCC was regarded as available and advantageous prior to genetic sequencing, though seldom used. A frequently cited barrier to testing for HNPCC within VHA was that clinicians see few cases that raise suspicion of familial CRC, because the patient population tends to be older. Among specialists who were aware of the VA telegenomic service, some said that having that this service within VA facilitated referrals for genetic counseling, whereas others were unable to connect. Some, who were unaware of the VA telegenomic service, said that they would like VA resources to support use of genomics for detection of familial cancer syndromes. Clinicians at two centers reported routine molecular testing for new CRC diagnoses.
Our work to understand the application of genomic services for HNPCC within VHA has the potential to improve how VHA integrates genomic information into the clinical care of Veterans. We are working closely with VHA Genomic Medicine Services and VHA Oncology to ensure that our results will inform improvements in policy and in the delivery of clinical care in the VHA for Veterans diagnosed with CRC.
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Health Systems, Cancer
Diagnosis, Treatment - Observational, Genomics
Genomics, Organizational issues, Practice patterns