Variation in physician-directed immunohistochemistry screening among women with endometrial cancer.

OBJECTIVE: Immunohistochemistry screening is a reliable method for identifying women with endometrial cancer who are at risk for Lynch syndrome, but clinical workflows used to implement immunohistochemistry screening protocols can vary by institution. The goal of this study was to investigate variation in performance of immunohistochemistry screening when a physician order is required. METHODS: Retrospective study from an integrated healthcare system with a risk-based immunohistochemistry screening policy for Lynch syndrome from January 2015 to December 2016. Immunohistochemistry screening was indicated for all women with endometrial cancer aged <60 years and women with endometrial cancer aged ≥60 years who had a personal/family history suggestive of Lynch syndrome. However, a physician order was needed to have immunohistochemistry screening performed on the tumor specimen as our health system did not have reflex screening in the clinical workflow. Demographics and tumor characteristics were reviewed, and patients were stratified by immunohistochemistry screening status. Multivariable regression was performed to identify factors associated with immunohistochemistry performance and reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: There were 1399 eligible patients in the study. With a required physician order, immunohistochemistry screening rates (20% overall, 34% aged <60 years) were significantly lower than previous reports (36% overall, 90% aged <60 years, p≤0.0001 for both comparisons). Significant factors associated with immunohistochemistry screening performance identified by multivariable analysis included age, race, body mass index, personal/family cancer history, diabetes, endometrioid histology, and tumor grade. Asian women were most likely to have immunohistochemistry screening (OR 1.58, 95% CI 1.07 to 2.34) whereas black women were least likely (OR 0.43, 95% CI 0.22 to 0.91). CONCLUSIONS: Immunohistochemistry screening rates in women with endometrial cancer were lower in our health system compared with prior reports in the literature, and there were variations in screening performance according to patient age, race, and body mass index. Requiring a physician order for immunohistochemistry screening likely creates a barrier in screening uptake, therefore automated immunohistochemistry screening is recommended.