A Comparison of Gynecologic Cancer Risk Management in Lynch Syndrome Patients Between a Safety-Net Hospital and University Medical Center
Cancer Genetics and Therapeutics
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Primary Categories:
- Cancer
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Secondary Categories:
- Cancer
Introduction:
Guidelines for the management of gynecologic cancer risk in patients with Lynch syndrome (LS) currently include consideration of screening and surgical risk-reduction. These guidelines have changed over time and require individualized care coordination. Little is known about decision-making surrounding screening and risk-reducing surgery and how the clinical care setting may influence management.
Methods:
Medical records were reviewed from patients with LS who underwent genetic counseling from 2012-2024 and were followed for risk management at Keck Medical Center of USC (Keck, a university medical center) or at Los Angeles General Medical Center (LA General, a safety-net hospital). Both facilities are staffed by many of the same attending physicians and genetic counseling practices are aligned. Eligible patients had no prior uterine or ovarian cancer and an intact uterus and/or ovaries at receipt of their LS diagnosis. Descriptive statistics of the two groups were reported and a multivariable logistic regression model was used to analyze the likelihood of undergoing risk-reducing surgery between the two hospital populations, while adjusting for potential confounding variables including age and previous cancer diagnosis.
Results:
Seventy patients with a median age of 39 years (range 19-73) at the time of LS diagnosis were identified, with 42 (60%) from Keck with median age of 33 years (range 19-73) and 28 (40%) from LA General with a median age of 45 (range 28-57). The majority of Keck patients were white, non-Hispanic (28/42, 67%) and most LA General patients were Hispanic (23/28, 82%). Pathogenic variants were identified in the following Lynch-associated genes: MLH1 (29, 41%), PMS2 (18, 26%), MSH2 (16, 23%), MSH6 (5, 7.0%), and EPCAM (2, 3.0%). More than half (37/70) of patients had at least one prior cancer diagnosis, most commonly colorectal cancer (24/37, 65%). After receiving their diagnosis of LS, most patients were followed by gynecologic oncologists (44/70, 63%) or by gynecologists (18/70, 26%). Almost half (33/70) pursued gynecologic cancer screening, including 21/42 (50%) of Keck patients and 12/28 (43%) of LA General patients. Screening consisted of endometrial biopsy (25/33, 76%), transvaginal ultrasound (24/33, 73%) and CA-125 (10/33, 30%). Several patients started or continued taking oral contraceptives for risk reduction (12/70, 17%) or had an IUD (6/70, 8.6%). In total, 31/70 (46%) completed any risk-reducing surgery with a median age of 45 years at first surgery (range 33-60); 12/42 (29%) of Keck patients and 19/28 (68%) of LA General patients with a median age of 42 years (range 34-60) and 46 years (range 33-57), respectively. Controlling for age and history of cancer, LA General patients were more likely to undergo risk-reducing surgery compared to patients from Keck (OR = 3.72, 95% CI = 1.23-11.8, p = 0.02). Six patients (8.6%) declined risk-reducing surgery, and surgery was not recommended for one patient due to a complicated cancer medical history. One Keck patient was diagnosed with early-stage endometrial cancer after symptomatic screening and underwent surgery for treatment. Two LA General patients were diagnosed with gynecologic cancers after symptomatic presentation without screening; one with primary peritoneal cancer who underwent surgery, adjuvant chemotherapy and immunotherapy and another with metastatic endometrial cancer who died shortly after her diagnosis. The median age of the 37/70 (53%) LS patients who have not undergone risk-reducing surgery was 36 years (range 20-75) at last follow up.
Conclusion:
LS patients at the safety-net hospital were more likely to undergo any gynecologic risk-reducing surgery than patients at the university medical center. Further studies are needed to explore patient, provider, and system-level factors that may influence uptake of and preferences for screening and risk-reduction.
Guidelines for the management of gynecologic cancer risk in patients with Lynch syndrome (LS) currently include consideration of screening and surgical risk-reduction. These guidelines have changed over time and require individualized care coordination. Little is known about decision-making surrounding screening and risk-reducing surgery and how the clinical care setting may influence management.
Methods:
Medical records were reviewed from patients with LS who underwent genetic counseling from 2012-2024 and were followed for risk management at Keck Medical Center of USC (Keck, a university medical center) or at Los Angeles General Medical Center (LA General, a safety-net hospital). Both facilities are staffed by many of the same attending physicians and genetic counseling practices are aligned. Eligible patients had no prior uterine or ovarian cancer and an intact uterus and/or ovaries at receipt of their LS diagnosis. Descriptive statistics of the two groups were reported and a multivariable logistic regression model was used to analyze the likelihood of undergoing risk-reducing surgery between the two hospital populations, while adjusting for potential confounding variables including age and previous cancer diagnosis.
Results:
Seventy patients with a median age of 39 years (range 19-73) at the time of LS diagnosis were identified, with 42 (60%) from Keck with median age of 33 years (range 19-73) and 28 (40%) from LA General with a median age of 45 (range 28-57). The majority of Keck patients were white, non-Hispanic (28/42, 67%) and most LA General patients were Hispanic (23/28, 82%). Pathogenic variants were identified in the following Lynch-associated genes: MLH1 (29, 41%), PMS2 (18, 26%), MSH2 (16, 23%), MSH6 (5, 7.0%), and EPCAM (2, 3.0%). More than half (37/70) of patients had at least one prior cancer diagnosis, most commonly colorectal cancer (24/37, 65%). After receiving their diagnosis of LS, most patients were followed by gynecologic oncologists (44/70, 63%) or by gynecologists (18/70, 26%). Almost half (33/70) pursued gynecologic cancer screening, including 21/42 (50%) of Keck patients and 12/28 (43%) of LA General patients. Screening consisted of endometrial biopsy (25/33, 76%), transvaginal ultrasound (24/33, 73%) and CA-125 (10/33, 30%). Several patients started or continued taking oral contraceptives for risk reduction (12/70, 17%) or had an IUD (6/70, 8.6%). In total, 31/70 (46%) completed any risk-reducing surgery with a median age of 45 years at first surgery (range 33-60); 12/42 (29%) of Keck patients and 19/28 (68%) of LA General patients with a median age of 42 years (range 34-60) and 46 years (range 33-57), respectively. Controlling for age and history of cancer, LA General patients were more likely to undergo risk-reducing surgery compared to patients from Keck (OR = 3.72, 95% CI = 1.23-11.8, p = 0.02). Six patients (8.6%) declined risk-reducing surgery, and surgery was not recommended for one patient due to a complicated cancer medical history. One Keck patient was diagnosed with early-stage endometrial cancer after symptomatic screening and underwent surgery for treatment. Two LA General patients were diagnosed with gynecologic cancers after symptomatic presentation without screening; one with primary peritoneal cancer who underwent surgery, adjuvant chemotherapy and immunotherapy and another with metastatic endometrial cancer who died shortly after her diagnosis. The median age of the 37/70 (53%) LS patients who have not undergone risk-reducing surgery was 36 years (range 20-75) at last follow up.
Conclusion:
LS patients at the safety-net hospital were more likely to undergo any gynecologic risk-reducing surgery than patients at the university medical center. Further studies are needed to explore patient, provider, and system-level factors that may influence uptake of and preferences for screening and risk-reduction.