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Comparison of predictive models, clinical criteria and molecular tumour screening for the identification of patients with Lynch syndrome in a population-based cohort of colorectal cancer patients
  1. J Balmaña1,
  2. F Balaguer2,
  3. S Castellví-Bel2,
  4. E W Steyerberg3,
  5. M Andreu4,
  6. X Llor5,
  7. R Jover6,
  8. A Castells2,
  9. S Syngal7,
  10. for the Gastrointestinal Oncology Group of the Spanish Gastroenterological Association
  1. 1
    Department of Medical Oncology, Hospital Vall d’Hebron, Medical Department of Universitat Autònoma de Barcelona, Spain
  2. 2
    Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
  3. 3
    Department of Public Health, Erasmus Medical Center-University MC Rotterdam, The Netherlands
  4. 4
    Department of Gastroenterology, Hospital del Mar, Barcelona, Spain
  5. 5
    Section of Digestive Diseases and Nutrition, University of Illinois at Chicago, Illinois, USA
  6. 6
    Department of Gastroenterology, Hospital General Universitario de Alicante, Alicante, Spain
  7. 7
    Division of Gastroenterology, Brigham and Women’s Hospital, Population Sciences Division, Dana-Farber Cancer Institute, and Harvard Medical School, Boston, Massachusetts, USA
  1. Dr J Balmaña, Medical Oncology Department, Hospital Universitari Vall d’Hebron. Paseo Vall d’hebron 119-129, Barcelona 08035, Spain; jbalmana{at}


Background: Several models have recently been developed to predict mismatch repair (MMR) gene mutations. Their comparative performance with clinical criteria or universal molecular screening in a population based colorectal cancer (CRC) cohort has not been assessed.

Methods: All 1222 CRC from the EPICOLON cohort underwent tumour MMR testing with immunohistochemistry and microsatellite instability, and those with MMR deficiency (n = 91) underwent MLH1/MSH2 germline testing. Sensitivity, specificity and positive predictive value (PPV) of the PREMM1,2 and the Barnetson models for identification of MLH1/MSH2 mutation carriers were evaluated and compared with the revised Bethesda guidelines (RBG), Amsterdam II criteria, and tumour analysis for MMR deficiency. Overall discriminative ability was quantified by the area under the ROC curve (AUC), and calibration was assessed by comparing the average predictions versus the observed prevalence.

Results: Both models had similar AUC (0.93 and 0.92, respectively). Sensitivity of the RBG and a PREMM1,2 score ⩾5% was 100% (95% CI 71% to 100%); a Barnetson score >0.5% missed one mutation carrier (sensitivity 87%, 95% CI 51% to 99%). PPVs of all three strategies were 2–3%. Presence of MMR deficiency increased specificity and PPV of predictive scores (97% and 21% for PREMM1,2 score ⩾5%, and 98% and 21% for Barnetson ⩾0.5%, respectively).

Conclusions: The PREMM1,2 and the Barnetson models offer a quantitative systematic approach to select CRC patients for identification of MLH1/MSH2 mutation carriers with a similar performance to the RBG.

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  • Funding: This work was supported by grants from the Fondo de Investigación Sanitaria (FIS 01/0104, 03/0070 and 05/0071), the Ministerio de Educación y Ciencia (SAF 04-07190 and SAF 07-64873) and the Asociación Española contra el Cáncer. Francesc Balaguer received a research grant from the Hospital Clínic and the Instituto de Salud Carlos III, and Sergi Castellví-Bel is supported by a contract from the Fondo de Investigación Sanitaria. CIBERehd is funded by the Instituto de Salud Carlos III. The work was also supported by the US National Cancer Institute grant CA 113433 (Dr Syngal).

  • Competing interests: None declared.

  • Ethics approval: The study was approved by the institutional ethics committee of each participating hospital.

  • Patient consent: Obtained.