Delivery of a comprehensive service for the detection of Lynch syndrome
About Lynch Syndrome
Lynch Syndrome (LS) is an inherited condition which results in an increased risk of certain cancer types. The main concerns are colorectal and endometrial cancer. There is also an increased risk to other cancers, but they are less frequent. People with LS have up to an 80% risk of developing colorectal cancer in their lifetime and, in women, up to a 60% risk of developing endometrial cancer.
In total LS affects approximately 1 in 350 to 1 in 400 people, with 200,000-300,000 people likely to have this condition in the UK. However, it is estimated that only 5% of people with LS in the UK have been diagnosed.
Identifying people with LS provides the opportunity to detect cancers at an earlier stage through enrolment into screening programmes, and prevent cancers through risk reduction techniques including colonoscopy, prophylactic surgery and chemoprophylaxis with aspirin.
A diagnosis of LS can also influence management plans for people who develop cancer, including impacting the surgical approaches chosen and the use of specific immunotherapy and chemotherapy treatments, and may impact access to emerging therapies.
In addition to preventing cancer and maintaining the health and quality of life of patients and families with LS, there is consistent evidence of the cost-effectiveness of a structured diagnostic pathway in patients with LS following a diagnosis of cancer, linked to cascade testing in families.
Led by the North Thames and South East GMSAs, the NHS GMS National Lynch Syndrome project is working to improve the identification and management of Lynch Syndrome, bridging the gap in testing and diagnosis of Lynch Syndrome and supporting the early detection of cancer and access to personalised care. The project will initially focus on colorectal and endometrial cancer patients and over time the programme will aim to extend LS screening across relevant tumour types.
The GMSAs are collaborating closely with the Cancer Alliances, National Disease Registry Service (NDRS), National Cancer Registration and Analysis Service (NCRAS), and the NHS England Cancer Programme to:
- Establish a Lynch MDT Champion within each Colorectal and Gynae Cancer MDT
- Upskill the workforce to identify eligible patients for testing and deliver mainstreamed constitutional gene testing
- Develop Regional Expert Networks to embed standardised and equitable testing pathways for LS across England and monitor and address any geographical variation in testing
Progress to date
Nationally, over 200 MDT Lynch Champions have been appointed to be responsible for Lynch testing pathways across their geographies. These Champions are supported by a network of Regional Lynch Nurses and Clinical Project Leads and are a central member of the Regional Expert Networks that are being established.
A national forum with regional project teams, MDT Champions, Cancer Alliance representatives and other key stakeholders convenes on a regular basis to facilitate discussion of common issues and shared solutions.
The national project leadership team have collaborated with the NDRS to deliver a Lynch data dashboard on CancerStats2, linking national dataset to provide regional and Provider level performance monitoring at each stage of the Lynch testing pathway, including MMR, BRAF and MLH and germline genetic testing. The current full complement of NDRS data includes all patients diagnosed in 2019 with endometrial or colorectal cancers. Although this baseline data shows low access to testing, more recent self-reported data collected by this project via a national survey indicates that this will have increased over the past few years. The NDRS plan to provide more contemporary data for Lynch Syndrome testing and GMSAs are working with GLHs to access other datasets and MDTs are completing local audits to continue monitoring geographical variation and measure impact of project activities on equity of access to testing and appropriate interventions.
National guidance for implementing testing strategies:
Additional guidance documents for healthcare professionals:
Online training courses for healthcare professionals:
Information for patients and family members:
National Transformation Project Leadership team:
Consultant in Clinical Genetics Guy’s and St Thomas’ NHS Foundation Trust
Kevin Monahan (North Thames GMSA)
Consultant Gastroenterologist, Lynch Syndrome and Family Cancer Clinic, St Mark’s Hospital
Laura Monje-Garcia (North Thames GMSA)
Nurse Practitioner and Clinical Research Fellow, Lynch Syndrome and Family Cancer Clinic, St Mark’s Hospital
Lynch syndrome is caused by a genetic change in one of the DNA mismatch repair genes called MLH1, MSH2, MSH6 and PMS2. There is a fifth gene involved called the EPCAM gene because it turns off the neighbouring MSH2 gene. EPCAM alterations are very rare and only account for 6% of Lynch syndrome cases.
The function of DNA mismatch repair genes is to repair errors that may arise in the DNA code, which in turn protect people from developing cancer.
No. Lynch syndrome does not always lead to or cause cancer, but the inherited genetic change that causes Lynch syndrome increases a person’s lifetime risk of developing certain cancer types. The risk of developing cancer from Lynch syndrome depends on the gene affected. The risks associated with variants in PMS2 are much lower than the risks associated with variants in MLH1.
If you believe that your patient may be at risk of developing Lynch syndrome i.e., a strong family history of cancer or family members diagnosed with cancer before the age of 50, then you should recommend referral for a genetic assessment. During the consultation, a family history will be taken and draw a family tree, to assess the risk of an inherited condition in the family.
The national Lynch project’s aim is to test every patient who develops bowel or endometrial cancer for Lynch syndrome.
Patients with diagnosed cancer should have further testing (immunohistochemistry, or IHC) to inform the appropriate diagnostic pathway.
Those with a family history of cancer should be directed to the regional genetics’ units for a family history assessment. Genetic counselling helps patients, and their families better understand their risk for hereditary cancer in order that they can make informed decisions about screening, genetic testing, and follow-on care.
The term ‘mainstreaming’ refers to the shift of genomic testing away from Clinical Genetics to other clinics and specialities. Within the Lynch Syndrome testing pathway, this means healthcare professionals in the oncology MDTs becoming directly involved in the consenting of patients for germline genetic testing, the requesting of the test and in communicating the result. A goal of the national GMSA transformation project is to upskill oncology MDTs to provide a mainstream testing service for Lynch Syndrome. This will help ensure all eligible patients receive germline testing without delay and results can effectively inform management.