1. Gene$c
tes$ng
for
breast
&
ovarian
cancer
Ephrat
Levy-­‐Lahad,
MD
Shaare
Zedek
Medical
Center
Jerusalem,
Israel
Israeli-­‐French
Breast
Cancer
Update,
Jerusalem
May
1,
2014

2. Disclosures
-­‐
none
Our
research
is
supported
by
:
• The
Israel
Cancer
Associa:on
• The
Breast
Cancer
Research
Founda:on
(NY,
USA)

3. Gene$c
tes$ng
for
breast
and
ovarian
cancer:
Who
should
be
tested
and
for
what
genes?

4. Why
perform
gene$c
tes$ng?
Unaffected
women
–
defining
risk
• Prevent
breast
&
ovarian
cancer
(in
carriers)
• Avoid
unnecessary
preven:on/surveillance
measures
(in
non-­‐carriers)
• Enable
tes:ng
in
rela:ves.
Affected
women
(breast
or
ovarian
cancer)
• Prevent
addi:onal
cancers
(ovarian,
contralateral
breast)
• Enable
tes:ng
in
rela:ves
•
Therapeu$c
implica$ons
–
chemotherapy,
radiotherapy,
targeted
therapy
(incl.
clinical
trials).
Therapeu$c
implica$ons
are
a
game
changer:
Timeline;
Scope
of
tes:ng:
pa:ents
&
genes

5. Who
to
test?
Current
guidelines
• This
recommenda$on
applies
to
asymptoma$c
women
who
have
not
been
diagnosed
with
BRCA-­‐related
cancer.
• USPSTF
recognizes
the
poten$al
importance
of
further
evalua$ng
women
who
have
a
diagnosis
of
breast
or
ovarian
cancer.
Some
women
receive
gene:c
tes:ng
as
part
of
a
cancer
evalua:on
at
the
:me
of
diagnosis
of
breast
cancer.
• The
USPSTF
did
not
review
the
appropriate
use
of
BRCA
tes$ng
in
the
evalua$on
of
women
who
are
newly
diagnosed
with
breast
cancer.
That
assessment
is
part
of
disease
management
and
is
beyond
the
scope
of
this
recommenda$on.

6. USPSTF
–
Test
asymptoma$c
only
with
sugges$ve
family
history
Family
history
sugges:ve
of
BRCA
muta:ons
includes:
• Breast
cancer
diagnosis
at
age
<50
years,
• Bilateral
breast
cancer
• Individual
with
2
primary
tumors:
breast&
ovarian/
fallopian/peritoneal
cancer
• Male
breast
cancer
• Mul:ple
cases
of
breast
cancer
in
the
family,
Rela:ves
with
2
primary
BRCA-­‐related
cancers
• Ashkenazi
Jewish
ethnicity.

7. Insufficient
evidence
to
support
a
specific
risk
threshold
for
referral
for
tes$ng,
or
a
specific
carrier
probability
model.
Recommend
tes$ng
women
with
sugges:ve
family
history
Recommend
against
tes:ng
women
without
family
history
USPSTF
–
Tes$ng
only
for
sugges$ve
family
history

8. Who
to
test?
Addi:onal
guidelines
• ACOG
(2009),
SGO
(2007)
20-­‐25%
cancer
risk
threshold,
suggest
tes:ng
could
be
helpful
for
those
with
>
5-­‐10%
chance
of
inherited
cancer
predisposi:on.
(prior
probability
approach)
• ASCO
(2010),
NSGC
(2013)–
no
threshold,
emphasize
counseling
and
impera:ve
that
test
results
affect
pa:ent
management.
• ESMO
(2011)
–
pretest
&
post-­‐test
counseling,
informed
consent.
(emphasis
on
process
and
clinical
u$lity)

9. NCCN
Guidelines
-­‐
2014
Affected
persons
–
detailed
criteria
for
breast
cancer
+
• All
breast
cancer
<
45
• Early
onset
(<50
yrs)
breast
cancer+
• Triple
nega:ve
breast
cancer
–
all
<
60,
over
60
if
+
• All
mul:ple
primaries
• All
ovarian
cancer
• All
male
breast
cancer

10. NICE
Guidelines
(UK)
June
2013
• Carrier
probability
at
which
gene$c
tes$ng
should
be
offered
• Breast/ovarian
cancer
cases
with
combined
BRCA1/BRCA2
muta-on
carrier
probability
of
>10%
(based
on
acceptable
methods)
• Person
with
no
personal
history
of
breast
or
ovarian
cancer:
1. If
they
have
a
combined
BRCA1/BRCA2
muta-on
carrier
probability
>
10%.
2. If
they
have
an
an
affected
rela-ve
with
carrier
probability
>
10%
who
is
available
for
tes-ng.

11. Should
all
women
with
breast
or
ovarian
cancer
undergo
germline
gene$c
tes$ng?

12. Ashkenazi
Women
with
Breast
Cancer
IBCS
(Israel
Breast
Cancer
Study)
–Results
NYBCS
(King
et
al.
Science
2003)
N=1008
42
25
37
104
4.2%
2.5%
3.7%
10.3%
BRCA1
BRCA1
BRCA2
Total
185delAG
5382insC
6174delT
44
20
48
112
4.2%
1.9%
4.5%
10.6%
N=1,046
consecu:ve,
Ashkenazi
Jewish
women
with
breast
cancer

13. 83
52 48Br 39
79
*
BRCA1
5382 insC
84 74
48Br 42
*
BRCA2
6174 ΔT
VN" VN"
VN" VN"NN" NN" NN"
NN" NN"
Small families"
Paternal inheritance"
Female relatives carry wildtype alleles by Mendelian chance"
50% of patients with BRCA1 or BRCA2 mutations"
No close family history of breast or ovarian cancer"
V – Variant
(mutation)
N- normal
Courtesy of MC King, UW

14. Carriers
Non-carrier
controls
Family History-
How suggestive?
77* (45%)119 (70%)Not
31 (18%)32 (19%)Low
34** (20%)15 (9%)Moderate
25 (15%)4 (2%)High
3 (2%)0 (0%)Lack of information
170 (100%)170 (100%)Total
Do carriers have family history?
Carriers vs. Non-carriers – p<.001
BRCA2 vs. BRCA1 p=0.015
Assessment of family history in BRCA1/2 and control families
*one double heterozygote
** two double heterozygotes

15. Should
all
women
with
ovarian
cancer
undergo
germline
gene$c
tes$ng?

16. Hirsch-Yecehzkel et al, Gyn Oncol 2003
BRCA1/BRCA2
muta$ons
in
ovarian
cancer
NISOC
study
–
all
ovarian
cancer
cases
in
Israel
3/1994-­‐6/1999
–
779
invasive
epithelial
ovarian
cancers.

17. TP53
BRCA1
BRCA2
BRIP1
CHEK2
BARD1
MRE11
MSH6
NBN
PALB2
RAD51C
RAD50
40
23
1
4
5
1
2
1
2
1 2 3
Ovarian cancer:
BRCA1/BRCA2
mutations in 63/360
(18%) patients not
selected for family
history or age at
onset
Walsh, Swisher et al. PNAS 2011
BRCA1/BRCA2
muta$ons
in
ovarian
cancer
(UW,
Seaile,
USA)
Courtesy of MC King, UW

18. Should
all
women
with
breast
or
ovarian
cancer
undergo
germline
gene$c
tes$ng?
BRCA1/BRCA2
Ovarian
cancer
–
Yes
>
10%
probability
Breast
cancer–
Ashkenazi
Jews
–
Yes
~10%
probability
other
founder
popula$ons,
all?
(7-­‐8%)

19. Advantages
and
disadvantages
of
general
tes$ng
in
affected
women
Advantages
• Management
–
planning
surgery
and
radia:on,
chemotherapy
choice
• Preven:on/early
detec:on
of
second
primary
• Clinical
trials
Disadvantages
• Variants
of
unknown
significance
10-­‐15%

20. For
what
genes?
• BRCA1/BRCA2
• Syndrome
specific
–
PTEN
(Cowden/PTEN
hamartoma
synd.),
TP53,
CDH1
• Popula:on
specific
–
PALB2
in
Finland
Game
changer
–
mul$-­‐gene
panels
Available
as
a
consequence
of
NGS
(next
genera:on
sequencing).
Most
now
include
BRCA1/BRCA2

21. Hereditary
breast/ovarian
gene
panels
–
Gene
list
Hiraki
S,
et
al,
J
Genet
Counsel,
2014

22. Hiraki
S,
et
al,
J
Genet
Counsel,
2014

23. Panel
genes:
pathways
and
risk
categories

24. Panel
genes:
pathways
and
risk
categories
Hiraki
S,
et
al,
J
Genet
Counsel,
2014

25. Mul$-­‐gene
panel
tes$ng
-­‐
results
1.
Deleterious
muta$ons
in
high-­‐risk
genes
2.
Deleterious
muta$ons
in
moderate-­‐risk
genes?
• No
clinical
guidelines
for
management
of
moderate
penetrance
genes.
• Life:me
breast
cancer
risk
>
20%,
breast
MRI
• Risk
reducing
surgeries????
3.
Variants
of
unknown
signficance
(VOUS)

26. What
is
the
added
yield
of
mul$-­‐gene
panels?

27. TP53
BRCA1
BRCA2
BRIP1
CHEK2
BARD1
MRE11
MSH6
NBN
PALB2
RAD51C
RAD50
40
23
1
4
5
1
2
1
2
1 2 3
Ovarian
cancer:
BRCA1/BRCA2
muta:ons
in
63/360
(18%)
pa:ents
not
selected
for
family
history
or
age
at
onset
Muta$ons
in
10
other
genes:
19/360
–
5%
Walsh,
Swisher
et
al.
PNAS
2011
BRCA1/BRCA2
muta$ons
in
ovarian
cancer
(UW,
Seaile,
USA)
Courtesy
of
MC
King,
UW

28. Patient’s genotype determines treatment
Implications for relatives
Almost all these cases are preventable
Patients w ovarian cancer
BRCA1/BRCA2
Other genes
Total with inherited risk
360
63
19
82
0.18
0.05
0.23
N Proportion
Walsh, Swisher et al. PNAS 2011
Ovarian cancer:
Inherited mutations in 12 genes in 23% of unselected patients

29. 18 genes with actionable mutations in 191 breast cancer families
25% of families negative by commercial BRCA1 and BRCA2 testing
Courtesy of MC King, UW

30. Families with negative results from commercial BRCA1 and BRCA2
testing – Sequencing 20 breast cancer genes
0
0.1
0.2
0.3
All
families
(N = 741)
Female and
male breast
cancer
(N = 83)
Breast and
ovarian
cancer
(N = 279)
Female
breast
cancer only
(N = 401)
Proportionoffamiliesresolved
Courtesy of MC King, UW

31. NGS
panels
in
“real
life”
(Mauer
CB,
et
al,
GIM
2013)
Retrospec:ve
review
of
all
NGS
cancer
panels
ordered
by
a
large
academic
cancer
gene:cs
program
(University
of
Texas,
Dallas)
4/2012
-­‐1/
2013
Various
panels
(not
including
BRCA1/2)
• 1,233/1,521
(81.1%)
new
cancer
gene:cs
pa:ents
evaluated
had
gene:c
tes:ng.
• NGS
panels
were
ordered
on
60
(4.9%)
of
these
pa:ents.

32. • Breast
cancer
pa:ents
–
36/37
previously
nega:ve
BRCA1/BRCA2
tes:ng.
• Most
other
tested
pa:ents
were
also
personally
affected
with
cancer
• Deleterious
results:
• 5/50
(10%)
of
those
who
had
an
NGS
panel
•
Compare
to:
131/1,233
(10.6%)
single-­‐gene
tests
ordered
at
the
same
center
in
the
study
:me
frame-­‐deleterious
result
NGS
panels
in
“real
life”
(Mauer
CB,
et
al,
GIM
2013)

35. Clinical
U$lity
of
NGS
panels
(Mauer
CB,
et
al,
GIM
2013)
30
(60%)
–
no
effect
on
management
decisions.
15
(30%)
introduced
uncertainty
regarding
the
pa:ents’
cancer
risks.
5
(10%)-­‐
directly
influenced
management
decisions.
“The
CHEK2
posi-ve
pa-ents
were
counseled
according
to
the
management
guideline
previously
established
at
our
ins:tu:on.”
“The
RAD51C,
ATM,
and
MUTYH
muta:on
results
prompted
a
thorough
review
of
the
literature”

36. Suggested
Criteria
for
NGS
–
Breast
cancer
(aper
nega$ve
BRCA1/2
tes$ng)

37. Criteria
for
NGS
–
Ovarian
cancer
(aper
nega$ve
BRCA1/2
tes$ng)

38. Conclusions
• Who
–
all
women
with
ovarian
cancer,
and
probably
all
women
with
breast
cancer.
• What
–
Ideally
–
BRCA1/BRCA2
+
syndromic
genes
separately,
NGS
as
research.
(NCCN
–
NGS
as
second
:er,
with
gene:cist)
• Not
clearly
possible
as
BRCA1/BRCA2
are
incorporated
into
NGS
panels.
• DATA
COLLECTION
–
reclassify
VUS,
understand
cancer
risks.

39. Institute of Medical Genetics, Shaare Zedek Medical Center:
Sari Lieberman, Ariela Tomer, Vered Koltuv, Carmit Cohen
Dr. Efrat Gabai-Kapara , Chaya Hackett,
Lab: Dr. Rachel Beeri, Doris Goldschmidt, Dr. Esther Korzin-Bez,
GCs: Hila Fridman, Sivan Koka, Dr. Adi Ben-Yehuda, Dr. Galit Lazer-
Derbeko, Shachar Zuckerman, Yulia Grinshpun-Cohen.
CoordinationL Sara Ribak, Liora Bruchim, Ronit Eliahu, Noam Zaslansky
Dr. Avraham Ben-Chetrit, Dr. Oded Olsha, Dr. Amnon Lahad
Sheba Medical Center, Tel Hashomer
Prof. Bella Kaufman, Dr. Shlomo Segev, Michal Chami, Prof. Raphael
Catane, Dr. Miri Sklair, Prof. Eitan Friedman
Terem Medical Center Hala Breast Clinic
Dr. Keren Djemal, Toby Davidian Dr. Strano, Judy Kopp
Efrat Medical Center Terem Modiin Medical Center
Dr. Ben Zev, Dr. Yitchak Glick Dr. Todd Zalut, Chaviv Gabai
Thank you:
Supported
by
the
Breast
Cancer
Research
Founda$on,
(BCRF),
NY,
USA
Israel
Cancer
Associa$on
(Israel
Breast
Cancer
Consor$um)

40. Which
genes?
NICE
Recommenda:on
(2013,
unchanged
from
2004)
• Muta$on
tests
• 1.5.5
Tests
aimed
at
muta:on
finding
should
first
be
carried
out
on
an
affected
family
member
where
possible.
[2004]
• 1.5.6
If
possible,
the
development
of
a
gene:c
test
for
a
family
should
usually
start
with
the
tes:ng
of
an
affected
individual
(muta:on
searching/screening)
to
try
to
iden:fy
a
muta:on
in
the
appropriate
gene
(such
as
BRCA1,
BRCA2
or
TP53)
(see
recommenda-ons
1.5.8–1.5.13).
[2004]
• 1.5.7
A
search/screen
for
a
muta:on
in
a
gene
(such
as
BRCA1,
BRCA2
or
TP53)
should
aim
for
as
close
to
100%
sensi-vity
as
possible
for
detec-ng
coding
altera-ons
and
the
whole
gene(s)
should
be
searched.
[2004]

41. In
the
American
College
of
Medical
Gene:cs
and
Genomics
(ACMG)
recommenda:ons
(1)
sequence
varia$on
is
previously
reported
and
is
a
recognized
cause
of
the
disorder.
(2)
sequence
varia:on
is
previously
unreported
and
is
of
the
type
which
is
expected
to
cause
the
disorder.
(3)
sequence
varia:on
is
previously
unreported
and
is
of
the
type
which
may
or
may
not
be
causa:ve
of
the
disorder.
(4)
sequence
varia:on
is
previously
unreported
and
is
probably
not
causa:ve
of
disease.
(5)
sequence
varia$on
is
previously
reported
and
is
a
recognized
neutral
variant.
(6)
sequence
varia:on
is
previously
not
known
or
expected
to
be
causa:ve
of
disease,
but
is
found
to
be
associated
with
a
clinical
presenta:on

42. ACMG
results
report
guideline
• (1)
the
gene
• analyzed
and
the
presence
or
absence
of
a
variant,
the
nature
• of
the
muta:on,
and
whether
it
is
conserva:ve
or
nonconserva:ve;
• (2)
The
category
(1–6)
within
which
the
variants
• falls;
(3)
The
basis
upon
which
this
classifica:on
was
made;
• (4)
Tes:ng
methodology
and
analy:c
sensi:vity;
(5)
Available
• data
on
penetrance
and
expressivity
of
previously
reported
• variants;
(6)
Strategies
for
further
classifica:on
of
novel
• variants
(Richards
et
al.
2008).
It
is
recommended
that
novel
• variants
with
unknown
pathogenicity
not
be
reported
to
the
• pa:ent,
but
be
studied
within
the
research
context
in
efforts
to
• further
refine
the
classifica:on
(Berg
et
al.
2011).

43. • GeneDx
categorizes
genes
based
on
level
of
risk,
with
“Significantly
• Increased
Risk”
genes
having
a
rela:ve
risk≥4,
• “Moderately
Increased
Risk”
genes
having
a
rela:ve
risk
of
• 2–4,
and
genes
that
confer
an
increased
risk,
the
exact
magnitude
• of
which
is
unknown
due
to
lack
of
data.