Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Nov 24, 2021; 12(11): 1023-1036
Published online Nov 24, 2021. doi: 10.5306/wjco.v12.i11.1023
Uptake and outcomes of small intestinal and urinary tract cancer surveillance in Lynch syndrome
Jeshua DeJesse, Ravy K Vajravelu, Christina Dudzik, Gillain Constantino, Jessica M Long, Kirk J Wangensteen, Kathleen D Valverde, Bryson W Katona
Jeshua DeJesse, Kathleen D Valverde, Department of Genetics, University of Pennsylvania, Philadelphia, PA 19104, United States
Ravy K Vajravelu, Christina Dudzik, Gillain Constantino, Kirk J Wangensteen, Bryson W Katona, Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
Jessica M Long, Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA 19104, United States
Author contributions: All the authors solely contributed to this paper.
Supported by NIH, No. 5R03DK120946-02.
Institutional review board statement: This study was granted a Waiver of Informed Consent from the University of Pennsylvania IRB. They deemed the study minimal risk for patients.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: BWK – Janssen Pharmaceuticals (travel) and Exact Sciences (consulting).
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Bryson W Katona, MD, PhD, Assistant Professor, Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, 751 South Pavilion, Philadelphia, PA 19104, United States.
Received: April 13, 2021
Peer-review started: April 13, 2021
First decision: July 3, 2021
Revised: July 26, 2021
Accepted: October 14, 2021
Article in press: October 14, 2021
Published online: November 24, 2021

Lynch syndrome (LS) is a hereditary cancer predisposition syndrome associated with increased risk of multiple cancers. While colorectal cancer surveillance decreases mortality in LS and is recommended by guidelines, there is lack of evidence for the efficacy of surveillance for extra-colonic cancers associated with LS, including small intestinal cancer (SIC) and urinary tract cancer (UTC). Given the limited evidence, guidelines do not consistently recommend surveillance for SIC and UTC, and it remains unclear how often individuals will choose to undergo and follow through with extra-colonic surveillance recommendations.


To study factors associated with SIC and UTC surveillance uptake and outcomes in LS.


This is an IRB-approved retrospective analysis of individuals with LS seen at a tertiary care referral center. Included individuals had a pathogenic or likely pathogenic variant in MLH1, MSH2, MSH6, PMS2, or EPCAM, or were a confirmed obligate carrier, and had at least one documented visit to our center. Information regarding SIC and UTC surveillance was captured for each individual, and detailed personal and family history was obtained for individuals who had an initial LS management visit in our center’s dedicated high-risk LS clinic between January 1, 2017 and October 29, 2020. During these initial management visits, all patients had in-depth discussions of SIC and UTC surveillance with 1 of 3 providers experienced in LS management to promote informed decision-making about whether to pursue SIC and/or UTC surveillance. Statistical analysis using Pearson’s chi-squared test and Wilcoxon rank-sum test was completed to understand the factors associated with pursuit and completion of SIC and UTC surveillance, and a P value below 0.05 was deemed statistically significant.


Of 317 individuals with LS, 86 (27%) underwent a total of 105 SIC surveillance examinations, with 5 leading to additional work-up and no SICs diagnosed. Additionally, 99 (31%) patients underwent a total of 303 UTC surveillance examinations, with 19 requiring further evaluation and 1 UTC identified. Of 155 individuals who had an initial LS management visit between January 1, 2017 and October 29, 2020, 63 (41%) chose to undergo SIC surveillance and 58 (37%) chose to undergo UTC surveillance. However, only 26 (41%) and 32 (55%) of those who initially chose to undergo SIC or UTC surveillance, respectively, successfully completed their surveillance examinations. Individuals with a pathogenic variant in MSH2 or EPCAM were more likely to initially choose to undergo SIC surveillance (P = 0.034), and older individuals were more likely to complete SIC surveillance (P = 0.007). Choosing to pursue UTC surveillance was more frequent among older individuals (P = 0.018), and females more frequently completed UTC surveillance (P = 0.002). Personal history of cancer and family history of SIC or UTC were not significantly associated with electing nor completing surveillance. Lastly, the provider discussing SIC/UTC surveillance was significantly associated with subsequent surveillance choices.


Pursuing and completing SIC/UTC surveillance in LS is influenced by several factors, however broad incorporation in LS management is likely unhelpful due to low yield and frequent false positive results.

Keywords: Lynch syndrome, Urinary tract cancer, Intestinal neoplasms, Early diagnosis of cancer, Patient preference, Gastrointestinal surgical procedure

Core Tip: This retrospective study of a Lynch syndrome (LS) cohort measured the uptake and outcome of small intestinal cancer (SIC) and urinary tract cancer (UTC) surveillance. When given the option of surveillance, a minority of patients elected surveillance, and patient completion of surveillance exams was suboptimal. Completed surveillance exams rarely detected SIC/UTC and resulted in multiple false positives that led to additional follow-up procedures. Pursuing and completing SIC/UTC surveillance in LS was influenced by several factors, however given the low yield and positive predictive value, broad incorporation of SIC/UTC surveillance in LS management is unlikely to be helpful.