Expert Interview: Inherited Susceptibility to Cancer with Dr. Nicoleta Voian

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1 Expert Interview: Inherited Susceptibility to Cancer with Dr. Nicoleta Voian ANNOUNCER OPEN: Welcome to CME on ReachMD. This segment, entitled Inherited Susceptibility to Cancer: What Do Primary Care Providers Need to Know? is provided by Prova Education and the Roswell Park Cancer Institute. Please be sure to review the faculty and commercial support disclosure statements as well as the Learning Objectives. Dr. Voian: Hi, my name is Nicoleta Voian. I'm the Director of Clinical Genetics at Roswell Park Cancer Institute. Today we'll talk about Inherited Susceptibility to Cancer. After listening to this module, you will be able to efficiently use a patient's family history to accurately identify those patients with increased cancer risk, appropriately refer patients to Cancer Genetics services, personalize the medical management of individuals with an increased risk of cancer due to genetic findings, understand the importance of continued education to keep up with the new advancements in genetics. Most of the cancers, about 70% of them, are sporadic, thought to be due to environmental factors. In about 20 to 25% of the cases, the cancer is due to a combination of environmental and inherited factors. We d call it familial. In about 5 to 10%, the cancer is due to an inherited genetic mutation that runs in the family, giving individuals predisposition to cancer. Hereditary cancer syndromes is a key component of public health and preventive medicine. Why? Because it accounts for about 5 to 10% of all cancers, and it confers a high risk to develop multiple primaries at a younger age. Multiple family members could also carry the same familial mutation; thus, they can be affected. And early identification would benefit patients and families linking them with preventive care options that are available. Common hereditary cancer syndromes: There are many hereditary cancer syndromes, and I have listed here most common cancer syndromes that we usually see in our clinic. Hereditary breast and ovarian cancer syndrome is associated with mutations in the BRC1 1

2 and BRC2 genes conferring an increased risk for breast, ovarian, prostate and pancreatic cancer. Lynch Syndrome is associated with mutations in the MLH1, MSH2, MSH6, PMS2 and EPCAM gene. People who have Lynch Syndrome have an increased risk of colorectal cancer, endometrial cancer, ovarian cancer and other cancers. Familial adenomatous polyposis is associated with mutations in APC gene. People who have FAP have an increased risk of developing multiple colonic polyps, adenomatous colon cancer and other cancers. MUTYHassociated Polyposis, abbreviated MAP, it's a recessive condition. People who have mutations in both copies of the MYH gene have an increased risk to develop colorectal polyps and colorectal cancer. Hereditary Diffuse Gastric Cancer is associated with mutations in the CDH1 gene, confer an increased risk for hereditary diffuse gastric cancer and lobular breast cancer. Familial atypical multiple mole and melanoma syndrome is associated with mutations in the CDKN2A gene and also in the CDK4 gene. People who have this syndrome have an increased risk of melanoma and pancreatic cancer. Paraganglioma syndromes are associated with mutations in genes that affect (inaudible 3:29) and some cause succinate dehydrogenase. People who have these syndromes have an increased risk to develop paragangliomas and pheochromocytomas. Von Hippel Lindau Syndrome is associated with VHL gene mutations. People who have Von Hippel Lindau Syndrome have an increased risk to develop cysts in multiple organs, and they also have an increased risk to develop renal cancer and pancreatic neuroendocrine cancers. Cowden Syndrome is associated with PTEN gene mutations. People who have Cowden Syndrome have an increased risk to develop breast cancer, endometrial cancer and other cancers. Li-Fraumeni Syndrome is associated with mutations in TP53 gene. People who have Li-Fraumeni Syndrome have an increased risk to develop multiple cancers like soft tissue sarcomas, early-onset breast cancer, adrenal cortical carcinomas and other cancers, many of them occurring at very young age. Recording and maintaining a patient's family history of cancer is very important in identifying who has an increased risk and who needs to be referred to Cancer Genetics services. Family history should include first-degree and second-degree relatives. As you know, first-degree relatives are parents, siblings and children. Second-degree relatives are grandparents, grandchildren, nephews and nieces, aunts and uncles. Family history should also include ethnicity, should include the type of cancer they have had and also the ages of their diagnoses. Sometimes for different reasons patients have limited or no family history information. In those situations, it's very important to record the patient's personal history. In order to qualify for genetics counseling for cancer risk, patients need to have features suggested* 5:22 in their personal history or their family history. 2

3 Here are listed red flags, and if you see those red flags in your patient's personal or family history, it should prompt a genetic referral: early onset of cancer, for example, breast, colorectal or endometrial cancer developing before age 50; more than one primary cancer in your patient or family members; multiple -- usually more than gastrointestinal polyps (adenomas) or rare types of polyps like serrated, juvenile or hamartomatous polyps; cancer occurring in multiple generations on the same side of the family; constellation of cancers consistent with specific cancer syndromes, for example, breast and ovarian, colorectal cancer and endometrial, or melanoma and pancreatic cancer; rare cancers with or without family history, for example, ovarian cancer or adrenal cortical carcinoma; unusual presentation, male breast cancer; uncommon tumor histology, medullary thyroid cancer. We know that all people who are identified with medullary thyroid cancer should be referred for genetic testing because about 30% of them they may have a RET gene mutation. Another uncommon tumor histology is the cribriform-morular papillary thyroid cancer. When this is revealed in one of your patients, they have to be referred, because many times this histology is associated with FAP, familial adenomatous polyposis. Ethnic populations known to be at risk of hereditary cancer syndromes, for example, Ashkenazi Jewish heritage, have an increased risk to carry a BRC1 and BRC2 mutation compared with general population. A known gene mutation, thus meaning a confirmation of a hereditary cancer syndrome in the family. I've listed here additional resources to help you identify patients who may benefits from Genetics Cancer Risk Assessment. What are the benefits of genetic testing? Genetic testing may identify a cause of a cancer that was diagnosed. Also, genetic testing may identify other family members who would be at risk to carry the same mutation. Genetic testing can bring additional information in order for our patients to make an informed decision in regards of their medical management. For example, women who are diagnosed with breast cancer and either at earlier age or with strong family history, before having surgery they may want to know if they carry BRC mutation before making those decisions because having a gene mutation will increase their risk for a contralateral breast cancer. Many times people who have a family history of cancer have anxiety, and having genetic testing, this may reduce the anxiety because they will have a clear estimate of their cancer risk and they will have a personalized medical management. Limitations, we know that genetic testing will not detect all causes of cancer. 3

4 A negative result is more helpful where there is a known familial mutation. And we need to know that even if a negative result is the case, one will never be cancer free. Let's talk about genetic counseling. Medical geneticists and genetic counselors work often in the same healthcare team. Medical geneticists are medical doctors. Genetic counselors have genetic training with a Master's degree. Both have expertise in genetic counseling designed to helping people understand and adapt to the medical, psychological and familial implications of genetics disease. Medical geneticists and genetic counselors are certified by specific boards. Genetic counseling usually involves 2 visits. First visit is called pre-test genetic counseling. During this visit, the patient will meet with the genetic provider, and at that time personal history and family history will be recorded, a genetic pedigree will be generated, and it will be established if genetic testing is appropriate or not. If patient is deemed to be appropriate for genetic testing, he or she will have genetic counseling to learn about the type of the test, the limitations, the risks, the benefits, before he or she will proceed with the genetic testing. We'll also learn about the implications for other family members based on different types of results, and also we'll learn about medical management based on different types of possible results. Genetic testing: Before genetic testing every patient needs to sign an informed consent. Signing the informed consent, patients acknowledge that they are aware about the limitations, the benefits and the risks involved in genetic testing. Genetic testing usually is a blood sample that will be sent to a qualified laboratory. Most insurance carriers will cover genetic testing if that is deemed to be appropriate and certain criteria are met. Post-test genetic counseling: After results are available, patients will be scheduled an appointment to have the results disclosed and to discuss the impact of those results for their medical management and their family member's medical management. Also, their primary care providers and the referring physicians will receive medical management plans for every case. Genetic testing results: For every gene that is analyzed, there are 3 possible results. A positive result means that a gene mutation or alteration in that gene is identified confirming increased risk for cancer for that patient, also means that other family members are at 4

5 increased risk to carry the gene mutation; thus, referral for those family members is very appropriate. Medical management in this situation will follow established guidelines for that specific hereditary cancer syndrome. A negative result, there are 2 distinct situations. If a mutation is known in the family and the patient does not carry the same mutation, he or she will not be considered at risk to develop those cancers associated with that gene mutation. In that situation, their medical management will follow screenings or guidelines for general population based on their age and gender. The second distinct situation when there is not known a mutation in that family and our patient is negative, we call it uninformative. In this situation their medical management will be based on their personal history and their family history. Other family members may be appropriate for testing. The third possible result is called a variant of unknown significance. In that situation the laboratory identifies a change in the gene, but its clinical significance is unknown. There is no indication to clinically test other family members. In that situation medical management will be based on personal and family history. Medical management based on the cancer risk: People who have average cancer risk will be monitored based on general population screenings based on their age and gender, and primary care providers will monitor their screenings. For people who have moderate and high risk, the situation is different. We call moderate risk people who have either strong family history of cancer or they have a mutation in a moderate penetrant gene. We call high risk for cancer people who have a gene mutation in BRC1 or 2 or any aforementioned syndromes. In those situations the screenings will be usually offered in high-risk clinics or in community followed by providers who have expertise and experience in hereditary cancer syndromes. For example, medical management for high-risk population will include enhanced screenings, medication, or risk-reducing surgeries. Last decade alone brought a lot of new advancements in genetics. It brought identification of new hereditary cancer susceptibility genes, also significant advancements in genetic testing technology, and continuous changes in guidelines regarding genetic testing and medical management. This means that patients who were not previously eligible for genetic may now be eligible. Patients who were tested in the past and the test failed to identify 5

6 gene mutation may be now candidates to test either the same gene or for other hereditary cancer syndromes. For example, people who have been tested before 2012 for BRC1 and BRC2 mutation may have an incomplete test because assessing for deletion duplication in both BRC1 and BRC2 was provided only in selected cases. Testing for Lynch Syndrome now includes 5 genes. In the past it was mostly 3 genes. Young women with breast cancer who were diagnosed before age 35 and are negative for BRC1 or BRC2 mutation are now appropriate for testing for Li-Fraumeni Syndrome. If you have patients that need to be referred for Genetics Service, here I have listed additional resources for you to find a genetics professional in your area. I'm Dr. Nicoleta Voian. Thank you for listening. ANNOUNCER CLOSE: You have been listening to CME on ReachMD. This segment, entitled Inherited Susceptibility to Cancer: What Do Primary Care Providers Need to Know? was provided by Prova Education and the Roswell Park Cancer Institute. To earn your CME credit, please take the post-test and activity evaluation by clicking on the post-test button below. Or if you re listening to this as a podcast, go to ReachMD-dot-comforward slash-projectoncology. 6

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