see related editorial on page x nature publishing group 1 © 2016 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY THE RED SECTION DIGITAL DIALOGUE Colorectal cancer (CRC) is the second leading cause of cancer- related mortality in the U.S. (1). Approximately 5–6% of people with CRC have hereditary cancer syndromes, including Lynch syndrome, familial adenomatous polyposis (FAP), or MUTYH- associated polyposis (MAP) (2). Tese people are ofen not identi- fed in routine practice (3). Families with inherited cancer syndromes were traditionally identifed through clinical criteria. Tere is growing enthusiasm for refex colorectal tumor screening for Lynch syndrome (4–6). Cancer gene panel testing is being used increasingly (7,8). How- ever, these strategies do not address the question of risk assessment in people without cancer or outside the setting of a cancer genetics consultation. A three-question CRC Risk-Assessment Tool deve- loped to identify people at very high risk for CRC who might beneft from further risk assessment and genetic evaluation (9) could be useful in routine practice. Open-access colonoscopy (i.e., no preceding ofce visit) has become widely accepted in the U.S. Tis presents an opportunity to screen patients for genetic CRC syndromes. Our aim was to assess the feasibility and yield of establishing a system for identify- ing people at high risk for CRC in a busy community-based, open- access colonoscopy setting. METHODS Huron Gastroenterology Associates, a private community-based practice with sixteen gastroenterologists, is part of the Saint Joseph Mercy Health System in Ann Arbor, MI. We perform >10,000 colonoscopies annually. Saint Joseph Mercy Health System has a Cancer Genetics Program (CGP) stafed by one full-time genetic counselor. An Electronic Health Records-Based Risk-Assessment System (EHR-RAS) was implemented in our open-access colonoscopy practice. Te screen was applied to all patients referred for open- access colonoscopy from September 2012 to March 2013, and their subsequent management was ascertained prospectively. To com- pare the yield of the EHR-RAS with routine care, a retrospective chart review was performed for patients referred for open-access colonoscopy from March to August 2012. Saint Joseph Mercy Health System’s Institutional Review Board approved the study protocol. Te three -question CRC Risk-Assessment Tool developed by Kastrinos et al. (9) ( Figure 1) was incorporated into the electronic template used during our routine scheduling process. If a patient answered “Yes” to at least one screening question, an automated EHR-RAS alert was sent instantly to the patient’s endoscopist ( Figure 2), and at the time of colonoscopy the endoscopist was provided with a printed form to encourage discussion with the patient ( Figure 3). Te decision to refer a patient to the CGP was lef to the endoscopist. All schedulers were trained in the administration of the ques- tions, and all endoscopists were educated on the EHR-RAS and the role of the CGP. A direct referral system to the CGP was established, and endoscopists were encouraged to refer all high-risk patients. Upon referral, a detailed questionnaire was sent to patients. Question- naire completion was used as a marker of patient motivation to pursue genetic counseling, and people who completed the ques- tionnaire were ofered a counseling appointment. Te appoint- ment included risk evaluation, discussion, and recommendations. Among patients with possible Lynch syndrome, those who met the Revised Bethesda guidelines or Amsterdam II criteria or had a calculated risk of carrying a Lynch syndrome-associated muta- tion of >7% using the MMRPro model or >5% using the PREMM (1,2,6) model were ofered further testing. Tumor testing for microsatellite instability or for the Lynch syndrome gene protein Screening for Cancer Genetic Syndromes With a Simple Risk-Assessment Tool in a Community-Based Open-Access Colonoscopy Practice Naresh T. Gunaratnam, MD 1, 2 , Mehmet Akce, MD 2 , Riad Al Natour, MD 2 , Angela N. Bartley, MD 3 , Ann F. Fioritto, BS 1 , Kristen Hanson, MS, CGC 4 and Uri Ladabaum, MD, MS 5 Am J Gastroenterol advance online publication, 29 March 2016; doi:10.1038/ajg.2016.84 1 Huron Gastroenterology Associates, Ypsilanti, Michigan, USA; 2 Department of Internal Medicine, Saint Joseph Mercy Hospital System, Ann Arbor, Michigan, USA; 3 Department of Pathology, Saint Joseph Mercy Hospital System, Ann Arbor, Michigan, USA; 4 Division of Oncology, Saint Joseph Mercy Hospital System, Ann Arbor, Michigan, USA; 5 Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA. Correspondence: Naresh T. Gunaratnam, MD, Huron Gastroenterology Associates, 5300 Elliott Drive, Ypsilanti, Michigan 48197, USA. E-mail: gunaratnamn@hurongastro.com