Invited comment on Warrier et al.: hereditary colorectal cancer screening and management practices by colorectal surgeons

Excerpt

Despite a low survey response rate of 10 % and the potential for non-response bias, the Warrier study in this month’s issue raises significant issues about genetic evaluation and surgical management in young patients suspected of having hereditary colorectal cancer (CRC)/polyposis syndromes [1]. Perhaps most important is the fact that there is great heterogeneity among colorectal surgeons in the preoperative, operative and postoperative management practices of these patients. For example, in patients with CRC under age 50 without a family history of CRC, 33.1 % of surgeons would proceed to definitive surgery without a preoperative genetic evaluation, while 48.9 % would request some form of tumor analysis to help risk stratify the patient. In this latter group, there was again significant heterogeneity with differing practices regarding the ordering of microsatellite instability (MSI), immunohistochemistry (IHC) or combination (MSI/IHC) testing. The key question, which is not answered by this study, is what underlies the difference in approach among surgeons. As the National Comprehensive Cancer Network (NCCN) guidelines recommend mismatch repair (MMR) protein testing in all patients with CRC under the age of 50, regardless of family history, it would be important to distinguish whether the surveyed physicians are not aware of this recommendation or simply disagree with the recommendation and chose not follow it [2]. The former may signify a lack of provider education. With the later, it would be important to ascertain the physician-related factors associated with medical decision making in this high-risk patient group (e.g., the belief that there is an inadequate evidence base upon which to build a recommendation). Alternatively, there may be patient-related factors, including patient preference, insurance status and concerns of being labeled as having a genetic disease, which can either facilitate or impede effective management. For example, with regard to patient preference, some individuals may be unwilling to wait for tumor analysis or formal genetic testing results and desire surgery immediately. Clearly, in all cases, an important goal should be to better understand the driving forces and obstacles that underlie medical decision making. This will help create standardized patient care practices and may ultimately optimize clinical outcomes. …