Carol Christianson, MS, CGC Genetic Counselor West Michigan Cancer Center

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1 Carol Christianson, MS, CGC Genetic Counselor West Michigan Cancer Center

2 Following this presentation you will be able to: Identify cancer survivors in your practice who might benefit from genetic counseling Discuss the pros and cons of next generation sequencing with your patients Apply adult learning theory to facilitate referrals and cascade screening

importance of collecting health history information from

3 Effective tool to identify patients at increased risk for adult onset diseases Communicates to your patients the importance of collecting health history information from relatives Communicates the importance of sharing health history information

4 Data to collect on all first and second degree relatives: Gender Current age or age at death If deceased, cause of death History of significant illnesses, including cancer Age of onset Whether they are maternal or paternal relatives

5 50-year-old, G2,P2, post menopausal, Caucasian female Past Medical History: Stage IA breast cancer diagnosed age 48 Radiation Therapy & Tamoxifen HTN Past Surgical History: Right breast biopsy age 48 Right breast lumpectomy age 48 Tonsillectomy age 7

8 20-25% ~70%

10 Breast cancer diagnosed at age 45 or younger Ovarian cancer Multiple primary breast cancers either in the same breast or opposite breast Both breast and ovarian cancer in the same person Male breast cancer Triple-negative (estrogen receptor negative, progesterone receptor negative, and HER2/neu [human epidermal growth factor receptor 2] negative) breast cancer under age 60 Pancreatic cancer with breast or ovarian cancer in the same individual or on the same side of the family Ashkenazi Jewish ancestry Two or more relatives with breast cancer, one under age 50 Three or more relatives with breast cancer at any age A previously identified BRCA1 or BRCA2 mutation in the family

12 Do you have a formal process in place to update your patients family histories? If yes, Does it involve more than asking your patients Are there any changes in your family health history?

13 If you were asked right now to tell me what changes have occurred in your own family s health history, what comes to mind? Did your grandparents, or aunts, uncles, nieces and nephews automatically come to mind? Did you think about people with health conditions not related to those that concern you?

18 Cancer Type Population Risk BRCA1 BRCA2 Breast 12% 50% - 80% 40% - 70% Second Primary Breast Cancer 3.5% within 5 years 27% within 5 years 12% within 5 years Ovarian Cancer 1% - 2% 24% - 40% 11% - 18% Male Breast Cancer 0.1% 1% - 2% 5% - 10% Prostate 15% (N. European) 18% (African Am) <30% <39% Pancreatic 0.5% 1% - 3% 2% - 7% Petrucelli N, Daly MB, Feldman GL. BRCA1 and BRCA2 Hereditary Breast and Ovarian Cancer Sep 4 [Updated 2013 Sep 26]. In: Pagon RA, Adam MP, Bird TD, et al., editors. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; Available from:

19 Cancer Type Population Risk Risk Mean Age of Onset Colon 5.5% 52% - 82% years Endometrium 2.7% 25% - 60% years Stomach <1% 6% - 13% 56 years Ovary 1.6% 4% - 12 % 42.5 years Small bowel <1% 3% - 6% 49 years Hepatobiliary tract <1% 1.4% - 4% Not reported Urinary tract <1% 1% - 4% ~55 years Brain/CNS <1% 1% - 3% ~50 years Sebaceous neoplasms <1% 1% - 9% Not reported Kohlmann W, Gruber SB. Lynch Syndrome Feb 5 [Updated 2012 Sep 20]. In: Pagon RA, Adam MP, Bird TD, et al., editors. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; Available from:

20 Facial papules Acral keratoses, palmo-plantar keratoses Lipomas, Fibromas Oral papillomas Macrocephaly (>97 th percentile) Goiter, thyroid nodules Hamartomatous intestinal polyps Intellectual disability (IQ 75) Freckling on the lips Sebaceous adenomas

21 Associated with Cowden syndrome 97 th percentile Women 58 cm Men 60 cm

22 To identify cancer survivors in your practice who may benefit from genetic counseling: Take a detailed family history every one to two years Look for patterns of cancer in families suggestive of a hereditary cancer syndrome Do a detailed physical examination Use the list of Red Flags as a guideline for referral

23 35-year-old, premenopausal Caucasian female Past Medical History: Stage II breast cancer diagnosed age 27 Radiation and Chemotherapy BRCA1/2 negative Past Surgical History: Left breast biopsy age 27 Left breast lumpectomy age 27

26 Sanger Sequencing Single gene sequencing Duplications/Deletions CGH arrays MLPA Next Generation Sequencing (NGS) Sequencing multiple genes at once AND identifying small and large duplications and deletions

27 Multiple genes can be sequenced simultaneously Cost effective - can sequence multiple genes that when mutated result in overlapping phenotypes (e.g., Hereditary breast and ovarian cancer syndrome, Li-Fraumeni syndrome, Cowden syndrome, etc. )

28 Test Name (no. of genes) BRCA1/2 Gene Sequencing and Deletion/Duplication Analyses (2) Breast Cancer High Risk Panel (6) Breast Cancer Panel (16) Breast/Ovarian Cancer Panel (26) Genes BRCA1, BRCA2 BRCA1, BRCA2, CDH1, PTEN, TP53, STK11 BRCA1, BRCA2, ATM, BARD1, BRIP1, MRE11A, NGN, PALB2, RAD50, RAD51C, CDH1, CHEK2, MUTYH, PTEN, TP53, STK11 BRCA1, BRCA2, ATM, BARD1, BRIP1, BLM, EPCAM, FAM175A, FANCC, HOXB13, MLH1, MSH2, MSH6, MRE11A, NGN, PALB2, PMS2, RAD50, RAD51C, RAD51D, CDH1, CHEK2, MUTYH, PTEN, TP53, STK11, XRCC2

29 High-Risk Genes Moderate-Risk Genes Newer Genes Well studied Lifetime risk of developing breast cancer 50% and/or ovarian cancer 6% Can increase risk for other cancers Guidelines for screening and prevention established Well studied Lifetime risk of developing breast cancer 24% - 49% and/or ovarian cancer 3-6% Can increase risk for other cancers Consensus guidelines for screening and prevention not yet established Not well studied, data based on small number of patients or patients within a specific ethnicity Precise lifetime risks not yet determined May increase risk for other cancers Guidelines for screening and prevention not yet established

30 An alteration in the normal sequence of a gene, the significance of which is unclear until further study of the genotype and corresponding phenotype in a sufficiently large population; complete gene sequencing often identifies numerous (sometimes hundreds) allelic variants for a given gene. Definition from: GeneReviews from the University of Washington and the National Center for Biotechnology Information A variation in a genetic sequence whose association with disease risk is unknown. Also called variant of uncertain significance, unclassified variant, and VUS. Definition from: National Cancer Institute dictionary

31 Test Variants of Uncertain Significance TAT BRAC1/2 2-3% 2-3 weeks High Risk Panel 6-7% ~4 weeks Large Panels 33% weeks Interpreting test results Mutations in unexpected genes Mutations in more than one gene

33 Female breast cancer (28 38%) Male breast cancer (1%) Colon cancer (~10%) Prostate cancer (24-50%) Thyroid Renal Uterine (serous) Ovarian

34 Annual Breast MRI Annual Mammogram Stagger exams at 6 month intervals CA Cancer J Clin 2007;57:75-89 Other screening guidelines based on family history

35 The available genetic tests continue to change If a cancer survivor in your practice was tested and is negative for a BRCA1 or BRCA2 gene mutation, they may still benefit from a genetic counseling referral if they: Were diagnosed under age 35 Have a suspicious family history If they develop physical characteristics associated with a known hereditary cancer syndrome

37 65-year-old, post menopausal, Caucasian female Past Medical History Stage 1C Breast Cancer age 58 Radiation therapy and aromatase Inhibitor Hyperlipidemia Diabetes Past Surgical History TAH BSO age 45 (uterine fibroids) Bilateral Mastectomies age 58 Knee replacement age 65

39 Adults will learn/internalize educational messages best when: Messages are relevant to their life & Practical, goal-oriented solutions are presented

40 Motivated to collect family history information and determine why they have cancer Want to know if they have a gene mutation to make surgical decisions Diagnosis raises concerns for other family members

41 Patients are: Overwhelmed with doctor s appointments, information, the need to make decisions Preoccupied with other events in life and not focused on more than just getting through each day Worried they will test positive and experience feelings of guilt Feeling fatalistic, like their test results will make no difference to them. Etc.

42 Marriage Birth of a child or grandchild Diagnosis, or suspicion of cancer in another family member Death of a family member Imminent death Etc

43 TM heuristic suggests three domains underlie whether an event is significant enough to be a TM for changing behavior: the extent to which the event: increases perceptions of personal risk and outcome expectancies, prompts strong affective or emotional responses, and redefines self-concept or social role. Time to bring up again the possibility of a genetic referral and the option of testing

44 Adults will learn/internalize educational messages best when: Messages are relevant to their life & Practical, goal-oriented solutions are presented

45 For patients who test positive for a gene mutation, the results of their genetic test will: Change their medical management NCCN guidelines American Cancer Society guidelines Make cascade screening possible Identify family members at risk for disease and allow them to take steps to reduce their risk Those who did not inherit the mutation can be reassured that they are not at increased risk and can follow the routine American Cancer Society screening guidelines

GYNplus: A Genetic Test for Hereditary Ovarian and/or Uterine Cancer

GYNplus: A Genetic Test for Hereditary Ovarian and/or Uterine Cancer Causes of Hereditary Ovarian and Uterine Cancer uterine cancer ovarian cancer Sporadic 75-90% Sporadic 70-80% Hereditary, 5% Lynch syndrome