A Quality Improvement Initiative to Improve Implementation of Guideline-Concordant Hereditary Myeloid Malignancy Syndrome Evaluation

Background: Myeloid malignancies such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are traditionally thought of as sporadic disorders. Recently, there has been increasing awareness of hereditary myeloid malignancy syndromes (HMMS) and their impact on MDS/AML treatment decisions, other organ and cancer surveillance, and at-risk family member management. Detection of patients with an HMMS is challenging due to variable expressivity, lack of physical signs, incomplete family history information, and limited provider awareness. In 2021, the National Comprehensive Cancer Network (NCCN) guidelines added recommendations for genetic evaluation of patients with MDS/AML meeting certain clinical or molecular criteria to facilitate identification of patients with an HMMS. The impact of utilizing these criteria on the proportions of patients with MDS/AML needing germline genetic evaluation and their efficacy in detecting the subset with an HMMS have not been studied. We established a quality improvement (QI) committee to implement and test the utility and efficacy of NCCN MDS/AML referral criteria.

Methods: A QI committee, including a cancer geneticist, a molecular pathologist, hematology faculty and fellows, clinical pharmacists, research coordinators, and a genetic counselor, was formed to implement NCCN recommendations and evaluate patients with MDS/AML for referral to the UW Hereditary Hematology Clinic. At each monthly meeting, clinical and family history and molecular data are reviewed for patients with MDS/AML who had a next-generation sequencing panel performed in the prior month. Patients meeting criteria for referral are identified, and an HMMS evaluation referral recommendation note is written in the electronic medical record and routed to the patient's primary hematologist. To assess the impact of implementing these guidelines on need for HMMS evaluations in routine MDS/AML care, we compared the proportion of patients meeting criteria and referral rates before (1/2019-8/2021) and after (9/2021-4/2022) our intervention.

Results: From 9/1/21 through 4/31/22, 42 patients (20 AML, 22 MDS) were reviewed by the committee. 34 patients had a new diagnosis, whereas eight had an established diagnosis but had molecular data obtained for the first time after 9/1/2021. Overall, 23 patients (55%) met criteria for referral. Six patients met clinical criteria, seven patients met molecular criteria, and 10 patients met both clinical and molecular criteria. Eight patients were ultimately referred for HMMS evaluation, corresponding to a referral rate of 35%. Two patients were found to have a pathogenic variant in DDX41, two patients had at least one variant of unknown significance (VUS), one patient had negative testing, and three patients have pending results. For the 15 patients who were not referred, three were deceased at the time of committee meeting, two were pursuing hospice, one patient declined, and one patient was lost to follow-up; the remaining eight patients were not referred for unknown reasons. In the pre-intervention cohort, 71 of 114 patients met criteria for referral (63%), and 8 were ultimately referred for HMMS evaluation, corresponding to a referral rate of 11%. One patient had a pathogenic variant in ANKRD26, two patients had at least one VUS, four patients had negative testing, and one patient declined genetic evaluation.

Conclusion: Implementation of current NCCN germline genetic testing criteria for MDS/AML resulted in ~60% of unselected MDS/AML patients meeting referral criteria for HMMS evaluation. Formalized referral recommendations in the form of a QI committee referral note in the medical record increased provider referrals from 11% to 35% in those meeting criteria. Clinical acuity and patient mortality were the largest barriers to referral for HMMS evaluation in this patient population. Among the small proportion actually referred, 5% of patients in the intervention cohort and 1% of patients in the pre-intervention cohort were found to have an HMMS. This experience demonstrates that implementing current NCCN guidelines via a QI committee will significantly increase the proportion of patients recommended to have HMMS evaluation and increases detection of patients with HMMS. Whether these criteria can be refined to maximize detection while minimizing burden on patient care and the healthcare system warrants further investigation.

Churpek:UpToDate, Inc.: Honoraria.