Protocol. Genetic Testing for Hereditary Breast and/or Ovarian Cancer

Transcription

1 Protocol Genetic Testing for Hereditary Breast and/or Ovarian Cancer (20402) Medical Benefit Effective Date: 07/01/14 Next Review Date: 05/15 Preauthorization Yes Review Dates: 02/07, 01/08, 11/08, 09/09, 05/10, 05/11, 01/12, 01/13, 01/14, 05/14 The following Protocol contains medical necessity criteria that apply for this service. It is applicable to Medicare Advantage products unless separate Medicare Advantage criteria are indicated. If the criteria are not met, reimbursement will be denied and the patient cannot be billed. Preauthorization is required. Please note that payment for covered services is subject to eligibility and the limitations noted in the patient s contract at the time the services are rendered. Description Hereditary breast and ovarian cancer (HBOC) syndrome describes the familial cancer syndromes that are related to mutations in the BRCA genes (BRCA1 located on chromosome 17q21 and BRCA2 located on chromosome 13q12-13). Identification of patients with BRCA mutations may lead to enhanced screening and/or surveillance that could lead to improved outcomes. Background Several genetic syndromes with an autosomal dominant pattern of inheritance that feature breast cancer have been identified. Of these, hereditary breast and ovarian cancer (HBOC) and some cases of hereditary sitespecific breast cancer have in common causative mutations in BRCA (breast cancer susceptibility) genes. Families suspected of having HBOC syndrome are characterized by an increased susceptibility to breast cancer occurring at a young age, bilateral breast cancer, male breast cancer, ovarian cancer at any age, as well as cancer of the fallopian tube and primary peritoneal cancer. Other cancers, such as prostate cancer, pancreatic cancer, gastrointestinal cancers, melanoma, and laryngeal cancer, occur more frequently in HBOC families. Hereditary site-specific breast cancer families are characterized by early onset breast cancer with or without male cases, but without ovarian cancer. For this Protocol, both will be referred to collectively as hereditary breast and/or ovarian cancer. Germline mutations in the BRCA1 and BRCA2 genes are responsible for the cancer susceptibility in the majority of HBOC families, especially if ovarian cancer or male breast cancer are features. However, in site-specific breast cancer, BRCA mutations are responsible only for a proportion of affected families, and research to date has not yet identified other moderate or high-penetrance gene mutations that account for disease in these families. BRCA gene mutations are inherited in an autosomal dominant fashion through either the maternal or paternal lineage. It is possible to test for abnormalities in BRCA1 and BRCA2 genes to identify the specific mutation in cancer cases and to identify family members with increased cancer risk. Family members without existing cancer who are found to have BRCA mutations can consider preventive interventions for reducing risk and mortality. CHEK2 (cell cycle checkpoint kinase2) is also involved with DNA repair and human cancer predisposition, like BRCA1 andbrca2. CHEK2 is normally activated in response to DNA double-stranded breaks. CHEK2 regulates the function of BRCA1 protein in DNA repair and also exerts critical roles in cell cycle control and apoptosis. The CHEK2 mutation, 1100delC in exon 10 has been associated with familial breast cancers. Related Protocol Genetic Cancer Susceptibility Panels Using Next Generation Sequencing Page 1 of 9

2 Policy (Formerly Corporate Medical Guideline) Genetic testing should be performed in a setting that has suitably trained healthcare providers who can give appropriate pre- and posttest counseling and that has access to a Clinical Laboratory Improvement Amendments (CLIA) licensed laboratory that offers comprehensive mutation analysis (see Policy Guidelines: Comprehensive mutation analysis). Patients with Cancer Genetic testing for BRCA1 and BRCA2 mutations in cancer-affected individuals may be considered medically necessary under any of the following circumstances: Individual from a family with a known BRCA1/BRCA2 mutation Personal history of breast cancer and 1 of the following: Diagnosed age 45 years Two primary breast cancers when first breast cancer diagnosis occurred age 50 years Diagnosed age 50 years AND: o o 1 1st-, 2nd-, or 3rd-degree relative a with breast cancer at any age, or Unknown or limited family history Diagnosed age 60 years with a triple negative (ER, PR, HER2 ) breast cancer Diagnosed any age AND 1 1st-, 2nd-, or 3rd-degree relative a with breast cancer diagnosed 50 years Diagnosed any age AND 2 1st-, 2nd-, or 3rd-degree relatives a with breast cancer at any age Diagnosed any age AND 1 1st-, 2nd-, or 3rd-degree relative a with epithelial ovarian/fallopian tube/primary peritoneal CA Diagnosed any age AND 2 1st-, 2nd-, or 3rd-degree relatives a with pancreatic cancer or prostate cancer b at any age 1st-, 2nd-, or 3rd-degree male relative with breast cancer Ethnicity associated with deleterious founder mutations, e.g., Ashkenazi Jewish descent c Personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer Personal history of male breast cancer Personal history of pancreatic cancer or prostate cancer b at any age AND 2 1st-, 2nd-, or 3rd-degree relatives a with any of the following at any age. For pancreatic cancer, if Ashkenazi Jewish ancestry, only one additional affected relative is needed. Breast cancer Ovarian/fallopian tube/primary peritoneal cancer Pancreatic or prostate cancer b Patients without cancer (see Policy Guidelines: Testing unaffected individuals) Genetic testing for BRCA1 and BRCA2 mutations of cancer-unaffected individuals may be considered medically necessary under any of the following circumstances: Individual from a family with a known BRCA1/BRCA2 mutation 1st- or 2nd-degree blood relative meeting any criterion listed above for Patients with Cancer 3rd-degree blood relative with breast cancer and/or ovarian/fallopian tube/primary peritoneal cancer AND 2 1st-, 2nd-, or 3rd-degree relatives a with breast cancer ( 1 at age 50 years) and/or ovarian/fallopian tube/primary peritoneal cancer Page 2 of 9

3 a For the purpose of familial assessment, 1st-, 2nd-, and 3rd-degree relatives are blood relatives on the same side of the family (maternal or paternal). 1st-degree relatives are parents, siblings, and children. 2nd-degree relatives are grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings. 3rd-degree relatives are great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins. b For the purpose of familial assessment, prostate cancer is defined as Gleason score 7. c Testing for Ashkenazi Jewish or other founder mutation(s) should be performed first (see Policy Guidelines: High risk ethnic groups). Testing for genomic rearrangements of the BRCA1 and BRCA2 genes may be considered medically necessary in patients who meet criteria for BRCA testing, whose testing for point mutations is negative. Unless they meet the criteria above, genetic testing for either those affected with breast, ovarian, fallopian tube, or primary peritoneal cancer or for unaffected individuals, including those with a family history of pancreatic cancer, is considered investigational. Testing for CHEK2 abnormalities (mutations, deletions, etc.) is considered investigational in affected and unaffected patients with breast cancer, irrespective of the family history. Genetic testing in minors for BRCA1 and BRCA2 mutations is investigational. Policy Guideline The Policy Statements above are based on current guidelines from the National Comprehensive Cancer Network (NCCN) (1) (see Practice Guidelines and Position Statements section). Current U.S. Preventive Services Task Force (USPSTF) guidelines recommend screening women with any family history of breast, ovarian, tubal, or peritoneal cancer. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. (2) (Grade B Recommendation) Recommended screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in BRCA1 or BRCA2 are: Ontario Family History Assessment Tool (FHAT) Manchester Scoring System Referral Screening Tool (RST) Pedigree Assessment Tool (PAT) FHS-7 Comprehensive mutation analysis. Comprehensive BRCA mutation analysis should be performed in patients with breast cancer, ovarian cancer, cancer of the fallopian tube, or primary peritoneal cancer who are: Eligible for testing, and From families without a known deleterious BRCA1 or BRCA2 mutation, and Not from ethnic groups with known founder mutations. Comprehensive mutation analysis currently includes sequencing the coding regions and intron/exon splice sites, as well as tests to detect common large deletions and rearrangements that can be missed with sequence analysis alone. In addition, before August 2006, testing for large deletions and rearrangements was not Page 3 of 9

4 performed, thus some patients with familial breast cancer who had negative BRCA testing before this time may consider repeat testing for the rearrangements (see Policy Statements for criteria). High-risk ethnic groups. Testing in eligible individuals who belong to ethnic populations in which there are wellcharacterized founder mutations should begin with tests specifically for these mutations. For example, founder mutations account for approximately three quarters of the BRCA mutations found in Ashkenazi Jewish populations. When testing for founder mutations is negative, comprehensive mutation analysis should then be performed. Testing unaffected individuals. In unaffected family members of potential BRCA mutation families, most test results will be negative and uninformative. Therefore, it is strongly recommended that an affected family member be tested first whenever possible to adequately interpret the test. Should a BRCA mutation be found in an affected family member(s), DNA from an unaffected family member can be tested specifically for the same mutation of the affected family member without having to sequence the entire gene. Interpreting test results for an unaffected family member without knowing the genetic status of the family may be possible in the case of a positive result for an established disease-associated mutation but leads to difficulties in interpreting negative test results (uninformative negative) or mutations of uncertain significance because the possibility of a causative BRCA mutation is not ruled out. Prostate cancer. Patients with BRCA mutations have an increased risk of prostate cancer, and patients with known BRCA mutations may therefore consider more aggressive screening approaches for prostate cancer. However, the presence of prostate cancer in an individual, or in a family, is not itself felt to be sufficient justification for BRCA testing. Medicare Advantage For Medicare Advantage, this testing is considered medically necessary for members personally affected by a cancer who meet one of the following: 1. Personal history of breast cancer + one or more of the following: Diagnosed age 45 y, with or without family history Diagnosed age 50 y or two breast primaries, with 1 close blood relative(s) with breast cancer 50 y and/or 1 close blood relative(s) with epithelial ovarian/fallopian tube/primary peritoneal cancer Two breast primaries when first breast cancer diagnosis occurred prior to age 50 Diagnosed age < 60 y with a triple negative breast cancer (ER-, PR-, HER2-) Diagnosed age < 50 y with a limited family history, defined as fewer than two first- or second-degree female relatives or female relatives surviving beyond 45 years in either lineage Diagnosed at any age, with 2 close blood relatives with breast and/or epithelial ovarian/fallopian tube/primary peritoneal cancer, at any age Close male blood relative with breast cancer Personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer If of certain ethnicity associated with higher mutation frequency, (e.g., Ashkenazi Jewish) no additional family history required a close relative with a known BRCA1 or BRCA2 gene mutation 2. Personal history of epithelial ovarian/fallopian tube/primary peritoneal cancer. 3. Personal history of male breast cancer. In addition, limited family history is defined as fewer than two first- or second-degree female relatives or female relatives surviving beyond 45 years in either lineage. The results of the genetic testing must potentially affect at Page 4 of 9

5 least one of the management options considered by the referring physician in accordance with accepted standards of care (e.g., surgery, the extent of surgery, a change in surveillance, hormonal manipulation, or a change from standard therapeutic or adjuvant chemotherapy). Testing of unaffected family members or other individuals is screening and not medically necessary. Services that are the subject of a clinical trial do not meet our Technology Assessment Protocol criteria and are considered investigational. For explanation of experimental and investigational, please refer to the Technology Assessment Protocol. It is expected that only appropriate and medically necessary services will be rendered. We reserve the right to conduct prepayment and postpayment reviews to assess the medical appropriateness of the above-referenced procedures. Some of this Protocol may not pertain to the patients you provide care to, as it may relate to products that are not available in your geographic area. References We are not responsible for the continuing viability of web site addresses that may be listed in any references below. 1. NCCN Clinical Practice Guidelines in Oncology. Genetic/familial high-risk assessment: breast and ovarian, v Available online at: Last accessed March U.S. Preventive Services Task Force. Risk assessment, Genetic Counseling, and Genetic Testing for BRCA- Related Cancer in Women, December Available online at: Last accessed March Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). BRCA1 and BRCA2 testing to determine the risk of breast and ovarian cancer. TEC Assessments 1997; volume 12, tab Begg CB. On the use of familial aggregation in population-based case probands for calculating penetrance. J Natl Cancer Inst 2002; 94(16): Moslehi R, Chu W, Karlan B et al. BRCA1 and BRCA2 mutation analysis of 208 Ashkenazi Jewish women with ovarian cancer. Am J Hum Genet 2000; 66(4): Satagopan JM, Offit K, Foulkes W et al. The lifetime risks of breast cancer in Ashkenazi Jewish carriers of BRCA1 and BRCA2 mutations. Cancer Epidemiol Biomarkers Prev 2001; 10(5): Thorlacius S, Struewing JP, Hartge P et al. Population-based study of risk of breast cancer in carriers of BRCA2 mutation. Lancet 1998; 352(9137): Warner E, Foulkes W, Goodwin P et al. Prevalence and penetrance of BRCA1 and BRCA2 gene mutations in unselected Ashkenazi Jewish women with breast cancer. J Natl Cancer Inst 1999; 91(14): King MC, Marks JH, Mandell JB. Breast and ovarian cancer risks due to inherited mutations in BRCA1 and BRCA2. Science 2003; 302(5645): Metcalfe K, Lynch HT, Ghadirian P et al. Contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. J Clin Oncol 2004; 22(12): Page 5 of 9

6 11. Mavaddat N, Peock S, Frost D et al. Cancer risks for BRCA1 and BRCA2 mutation carriers: results from prospective analysis of EMBRACE. J Natl Cancer Inst 2013; 105(11): Grann VR, Whang W, Jacobson JS et al. Benefits and costs of screening Ashkenazi Jewish women for BRCA1 and BRCA2. J Clin Oncol 1999; 17(2): Hartmann LC, Schaid DJ, Woods JE et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 1999; 340(2): Menkiszak J, Rzepka-Gorska I, Gorski B et al. Attitudes toward preventive oophorectomy among BRCA1 mutation carriers in Poland. Eur J Gynaecol Oncol 2004; 25(1): Moller P, Borg A, Evans DG et al. Survival in prospectively ascertained familial breast cancer: analysis of a series stratified by tumour characteristics, BRCA mutations and oophorectomy. Int J Cancer 2002; 101(6): Olopade OI, Artioli G. Efficacy of risk-reducing salpingo-oophorectomy in women with BRCA-1 and BRCA-2 mutations. Breast J 2004; 10 Suppl 1:S Rebbeck TR, Lynch HT, Neuhausen SL et al. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002; 346(21): Scheuer L, Kauff N, Robson M et al. Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol 2002; 20(5): Weitzel JN, McCaffrey SM, Nedelcu R et al. Effect of genetic cancer risk assessment on surgical decisions at breast cancer diagnosis. Arch Surg 2003; 138(12):1323-8; discussion Malone KE, Daling JR, Doody DR et al. Prevalence and predictors of BRCA1 and BRCA2 mutations in a population-based study of breast cancer in white and black American women ages 35 to 64 years. Cancer Res 2006; 66(16): Rennert G, Bisland-Naggan S, Barnett-Griness O et al. Clinical outcomes of breast cancer in carriers of BRCA1 and BRCA2 mutations. N Engl J Med 2007; 357(2): Winchester DP. Breast cancer in young women. Surg Clin North Am 1996; 76(2): Frank TS, Deffenbaugh AM, Reid JE et al. Clinical characteristics of individuals with germline mutations in BRCA1 and BRCA2: analysis of 10,000 individuals. J Clin Oncol 2002; 20(6): Langston AA, Malone KE, Thompson JD et al. BRCA1 mutations in a population-based sample of young women with breast cancer. N Engl J Med 1996; 334(3): Malone KE, Daling JR, Thompson JD et al. BRCA1 mutations and breast cancer in the general population: analyses in women before age 35 years and in women before age 45 years with first-degree family history. JAMA 1998; 279(12): Ford D, Easton DF, Stratton M et al. Genetic heterogeneity and penetrance analysis of the BRCA1 and BRCA2 genes in breast cancer families. The Breast Cancer Linkage Consortium. Am J Hum Genet 1998; 62(3): Gershoni-Baruch R, Patael Y, Dagan et al. Association of the I1307K APC mutation with hereditary and sporadic breast/ovarian cancer: more questions than answers. Br J Cancer 2000; 83(2): Hartge P, Struewing JP, Wacholder S et al. The prevalence of common BRCA1 and BRCA2 mutations among Ashkenazi Jews. Am J Hum Genet 1999; 64(4): Hodgson SV, Heap E, Cameron J et al. Risk factors for detecting germline BRCA1 and BRCA2 founder mutations in Ashkenazi Jewish women with breast or ovarian cancer. J Med Genet 1999; 36(5): Page 6 of 9

7 30. de Ruijter TC VJ, de Hoon JPJ et al. Characteristics of triple-negative breast cancer. J Cancer Res Clin Oncol 2011; 137: Kandel MJ SD, Masciari S et al. Prevalence of BRCA1 mutations in triple negative breast cancer (BC). J Clin Onc 2006; 24(18S): Young SR, Pilarski RT, Donenberg T et al. The prevalence of BRCA1 mutations among young women with triple-negative breast cancer. BMC Cancer 2009; 9: Gonzalez-Angulo AM, Timms KM, Liu S et al. Incidence and outcome of BRCA mutations in unselected patients with triple receptor-negative breast cancer. Clin Cancer Res 2011; 17(5): Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994 and beyond. Nat Rev Cancer 2004; 4(9): Hruban RH, Canto MI, Goggins M et al. Update on familial pancreatic cancer. Adv Surg 2010; 44: Couch FJ, Johnson MR, Rabe KG et al. The prevalence of BRCA2 mutations in familial pancreatic cancer. Cancer Epidemiol Biomarkers Prev 2007; 16(2): Ferrone CR, Levine DA, Tang LH et al. BRCA germline mutations in Jewish patients with pancreatic adenocarcinoma. J Clin Oncol 2009; 27(3): Trainer AH, Meiser B, Watts K et al. Moving toward personalized medicine: treatment-focused genetic testing of women newly diagnosed with ovarian cancer. Int J Gynecol Cancer 2010; 20(5): Zhang S, Royer R, Li S et al. Frequencies of BRCA1 and BRCA2 mutations among 1,342 unselected patients with invasive ovarian cancer. Gynecol Oncol 2011; 121(2): Hirst JE, Gard GB, McIllroy K et al. High rates of occult fallopian tube cancer diagnosed at prophylactic bilateral salpingo-oophorectomy. Int J Gynecol Cancer 2009; 19(5): Powell CB, Swisher EM, Cass I et al. Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy. Gynecol Oncol 2013; 129(2): Robson M, Offit K. Clinical practice. Management of an inherited predisposition to breast cancer. N Engl J Med 2007; 357(2): Phillips KA, Jenkins MA, Lindeman GJ et al. Risk-reducing surgery, screening and chemoprevention practices of BRCA1 and BRCA2 mutation carriers: a prospective cohort study. Clin Genet 2006; 70(3): Lesnock JL, Darcy KM, Tian C et al. BRCA1 expression and improved survival in ovarian cancer patients treated with intraperitoneal cisplatin and paclitaxel: a Gynecologic Oncology Group Study. Br J Cancer 2013; 108(6): Gallagher DJ, Gaudet MM, Pal P et al. Germline BRCA mutations denote a clinicopathologic subset of prostate cancer. Clin Cancer Res 2010; 16(7): Kirchhoff T, Kauff ND, Mitra N et al. BRCA mutations and risk of prostate cancer in Ashkenazi Jews. Clin Cancer Res 2004; 10(9): Castro E, Goh C, Olmos D et al. Germline BRCA mutations are associated with higher risk of nodal involvement, distant metastasis, and poor survival outcomes in prostate cancer. J Clin Oncol 2013; 31(14): Mitra AV, Bancroft EK, Barbachano Y et al. Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study. BJU Int 2011; 107(1): Page 7 of 9

8 49. Antoniou AC, Beesley J, McGuffog L et al. Common breast cancer susceptibility alleles and the risk of breast cancer for BRCA1 and BRCA2 mutation carriers: implications for risk prediction. Cancer Res 2010; 70(23): Casadei S, Norquist BM, Walsh T et al. Contribution of inherited mutations in the BRCA2-interacting protein PALB2 to familial breast cancer. Cancer Res 2011; 71(6): Cox DG, Simard J, Sinnett D et al. Common variants of the BRCA1 wild-type allele modify the risk of breast cancer in BRCA1 mutation carriers. Hum Mol Genet 2011l 20(23): Engel C, Versmold B, Wappenschmidt B et al. Association of the variants CASP8 D302H and CASP10 V410I with breast and ovarian cancer risk in BRCA1 and BRCA2 mutation carriers. Cancer Epidemiol Biomarkers Prev 2010; 19(11): Kleibl Z, Havranek O, Kormunda S et al. The AIB1 gene polyglutamine repeat length polymorphism and the risk of breast cancer development. J Cancer Res Clin Oncol 2011; 137(2): Osorio A, Milne RL, Alonso R et al. Evaluation of the XRCC1 gene as a phenotypic modifier in BRCA1/2 mutation carriers. Results from the consortium of investigators of modifiers of BRCA1/BRCA2. Br J Cancer 2011; 104(8): Ramus SJ, Kartsonaki C, Gayther SA et al. Genetic variation at 9p22.2 and ovarian cancer risk for BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst 2011; 103(2): Bianco A, Quaresima B, Pileggi C et al. Polymorphic repeat length in the AIB1 gene and breast cancer risk in BRCA1 and BRCA2 mutation carriers: a meta-analysis of observational studies. PloS One 2013; 8(3):e Zhou GW, Hu J, Peng XD et al. RAD51 135G>C polymorphism and breast cancer risk: a meta-analysis. Breast Cancer Res Treat 2011; 125(2): Metcalfe K, Lubinski J, Lynch HT et al. Family history of cancer and cancer risks in women with BRCA1 or BRCA2 mutations. J Natl Cancer Inst 2010; 102(24): Walsh T, Casadei S, Coats KH et al. Spectrum of mutations in BRCA1, BRCA2, CHEK2, and TP53 in families at high risk of breast cancer. JAMA 2006; 295(12): Palma MD, Domchek SM, Stopfer J et al. The relative contribution of point mutations and genomic rearrangements in BRCA1 and BRCA2 in high-risk breast cancer families. Cancer Res 2008; 68(17): Myriad Genetics Laboratories. BRACAnalysis Large Rearrangement Test (BART). Available online at: Last accessed September Weischer M, Bojesen SE, Ellervik C et al. CHEK2*1100delC genotyping for clinical assessment of breast cancer risk: meta-analyses of 26,000 patient cases and 27,000 controls. J Clin Oncol 2008; 26(4): Offit K, Garber JE. Time to check CHEK2 in families with breast cancer? J Clin Oncol 2008; 26(4): Myszka A, Karpinski P, Slezak R et al. Irrelevance of CHEK2 variants to diagnosis of breast/ovarian cancer predisposition in Polish cohort. J Appl Genet 2011; 52(2): Zhang B, Beeghly-Fadiel A, Long J et al. Genetic variants associated with breast-cancer risk: comprehensive research synopsis, meta-analysis, and epidemiological evidence. Lancet Oncol 2011; 12(5): Peng S, Lu B, Ruan W et al. Genetic polymorphisms and breast cancer risk: evidence from meta-analyses, pooled analyses, and genome-wide association studies. Breast Cancer Res Treat 2011; 127(2): American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 2003; 21(12): Page 8 of 9

9 68. Robson ME, Storm CD, Weitzel J et al. American Society of Clinical Oncology Policy Statement Update: Genetic and Genomic Testing for Cancer Susceptibility. J Clin Oncol 2010; 28(5): Genetic Susceptibility to Breast and Ovarian Cancer: Assessment, Counseling and Testing Guidelines. The American College of Medical Genetics, Practice Guideline: Available online at: Last accessed September Page 9 of 9