This document summarizes highlights from the Ohio Colorectal Cancer Prevention Initiative. The initiative screened over 3,300 colorectal cancer patients and found that 15.9% had defective DNA mismatch repair (dMMR). Further testing identified 4% as having Lynch syndrome (LS) and 2% as having double somatic mutations. Similar results were found in screening over 300 endometrial cancer patients. Cascade genetic testing of relatives identified over 180 additional individuals with LS. The initiative demonstrated the value of universal tumor screening in identifying hereditary cancer cases and facilitating prevention through genetic testing of relatives.

1. Heather Hampel, MS, CGC
Associate Director, Division of Clinical Cancer Genomics
Professor, Department of Medical Oncology & Therapeutics Research
Twitter: @HHampel1 Email: hhampel@coh.org
Highlights from the Ohio Colorectal
Cancer Prevention Initiative
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Disclosures
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 Scientific Advisory Board
• Invitae Genetics
• Genome Medical
• Promega
• Natera
 Consulting
• 23andMe
• GI OnDemand
 Stock/Stock Options
• Genome Medical
• GI OnDemand
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Outline
Highlights from the Ohio Colorectal Cancer Prevention Initiative
Lynch Syndrome
 Common
Ohio Colorectal Cancer Prevention Initiative
 Study design
 Overall results
Ohio Prevention and Treatment of Endometrial Cancer Study
 Study design
 Overall results
Highlights
 Cascade Testing
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Lynch Syndrome
Cancer Genetic Counseling & Testing
 Over 1.2 million individuals in the United States have Lynch
syndrome
 Inherited condition that causes high risks for colorectal cancer,
endometrial cancer, and other cancers
 Preventable cancers with early and more frequent screening
 95% of affected individuals do not know they have Lynch
syndrome

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Normal Male Karyotype
Cancer Genetic Counseling & Testing
Sex chromosomes

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Sporadic Inherited
• Later age at onset (60s or 70s)
• Little or no family history of cancer
• Single or unilateral tumors
•Early age at onset (<50)
•Multiple generations with cancer
•Bilateral or multiple primary cancers
•Clustering of certain cancers (i.e. colon/uterine)
Normal genes
Somatic mutation
Somatic mutation
Germline mutation
Somatic mutation
Cancer Genetic Counseling & Testing

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Carrier Parent Non-carrier Parent
Aa aa
Aa Aa aa aa
Carrier Carrier Non-carrier Non-carrier
Cancer Genetic Counseling & Testing
Autosomal Dominant Inheritance
1/2 1/2

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Lynch Syndrome Cancer Risks
NCCN Guidelines Version 1.2022; Genetic/Familial High-Risk Assessment: Colorectal
Cancer Type MLH1 and MSH2 MSH6 PMS2 General Public
Colon cancer 33%-61% 10%-44% 8.7%-20% 4.2%
Endometrial cancer 21%-57% 16%-49% 13-26% 3.1%
Stomach 0.2%-9% ≤1-7.9% ND < 1%
Ovarian 4%-38% ≤1%-13% 1.3-3% 1.3 %

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Intervention Recommendation
Colon Cancer MLH1 & MSH2: Colonoscopy every 1-2 y beginning at age 20-25 (or 2-5 years
younger than earliest diagnosis if <25
MSH6 & PMS2: Colonoscopy every 1-2 y beginning at age 30-35 (or 2-5
years younger than earliest diagnosis if <25
Endometrial Cancer Education regarding symptoms
Consideration of hysterectomy after childbearing
Endometrial biopsy every 1-2 y beginning at age 30-35 can be considered
Ovarian Cancer Education regarding symptoms
TVUS and CA-125 surveillance could be considered by no evidence of efficacy
BSO can be considered after childbearing
Gastric & Small Bowel
Cancer
EGD every 2-4 y starting at age 40
Lynch Syndrome Surveillance Options
NCCN v1.2022

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Intervention Recommendation
Urothelial cancer No clear evidence to support. Consider in select individuals with a family history of
urothelial cancer and individuals with MSH2 pathogenic variants (especially males).
Annual urinalysis starting at age 30-35
Pancreatic Cancer Consider pancreatic cancer screening beginning at age 50 or 10 years younger than
the earliest dx in family.
Annual contrast-enhanced MRI/MRCP and/or EUS with consideration of shorter
screening intervals for individuals found to have worrisome abnormalities on
screening.
Most small cystic lesions found on screening will not warrant biopsy, surgical
resection, or any intervention.
Prostate Cancer General population screening
Breast Cancer General population screening
Brain Cancer Annual physical/neurologic examination starting at age 25-30y
Reproductive Risks Advise about prenatal diagnosis and assisted reproduction including preimplantation
genetic testing
Advise about risk of rare recessive syndrome called CMMR deficiency if both
partners are carriers of pathogenic variants in the same MMR gene
Lynch Syndrome Surveillance Options
NCCN v1.2022

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Baron JA. N Engl J Med 348(10):2003; Sandler RS. NEJM 348(10):2003; Cole BF. JNCI 101(4):2009; Arber N. NEJM 355(9):2006; Burn J. Lancet 378(9809): 2011.
Cancer Genetic Counseling & Testing
 Numerous studies have demonstrated benefit of aspirin and COX-2 inhibition in adenoma and CRC
prevention
o USPSTF recommends ASA 81mg for adults age 50-59 for primary CRC prevention (and CV
disease prevention)
 CaPP2 study
o Patients with Lynch syndrome randomized 2x2 factorial to ASA 600 mg/day and resistant
starch (or placebo)
o Early adenoma outcomes = no difference
o At >4 years follow-up, those who took ASA for at least 2 years experienced reduction in CRC
(Incidence rate ratio/IRR 0.37) and non-CRC LS cancers (IRR 0.49)
 Expert groups have awaited follow-up confirmatory studies before endorsing these data (CaPP3)
o Also concern for toxicities associated with this dose of ASA
Aspirin as chemoprevention for CRC

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CRC
dx 45
Ovarian
Ca, dx 64
CRC
dx 50s
CRC
dx 61
CRC
dx 75
CRC
dx 48
CRC
dx 52
Endometrial
Ca, dx 59
CRC
dx 42
45
Family History Used to be the Key to Diagnosing Lynch
Syndrome
Cancer Genetic Counseling & Testing

13. CITY OF HOPE Universal Tumor Screening for Lynch Syndrome: From Population Studies to Prevention
Genetic Features of Lynch Syndrome
 Genes belong to DNA mismatch repair (MMR) family
 Mutations in MMR genes lead to microsatellite instability (MSI)
 Test is positive in 15% of colorectal and
24% of endometrial tumors
 Sensitivity is 77-89% for Lynch Syndrome
 MMR proteins missing in tumor tissue making
Immunohistochemical (IHC) staining useful
 1-2 proteins absent in 20% of colorectal and 25% of
endometrial tumors
 Sensitivity is 83% for Lynch Syndrome
 Immune therapy very effective in treating patients whose
tumors have defective MMR
MLH1 MSH2
MSH6 PMS2
Le DT et al. N Engl J Med. 2015;372(26):2509-20.

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Highlights from the Ohio Colorectal Cancer Prevention Initiative
Ohio Colorectal Cancer Prevention Initiative (OCCPI)
 Statewide initiative included 50 hospitals
 Establish prevalence of hereditary
CRC
 Increase colonoscopy compliance
among relatives
 Establish research infrastructure
 Accrual for 4 years (2013-2016)
 Patients enrolled from all 88
counties
Ohio
Columbus
Cleveland
Cincinnati
Toledo
Dayton
Akron

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Eligibility
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 3,310 Patients diagnosed with a primary invasive colorectal adenocarcinoma with surgical resection* in Ohio
between 1/1/2013 and 12/31/2016
o All ages (>18 years of age at accrual)
o All stages
o Resection at any hospital in Ohio, enrolled at a collaborating hospital
 Bonus: 341 Patients diagnosed with a primary invasive endometrial cancer (excluding sarcomas) with
hysterectomy at OSUMC between 1/1/2013 and 12/31/2016
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Highlights from the Ohio Colorectal Cancer Prevention Initiative
Results
7.1% of all patients had a PGV in a CSG; 16% of those tested. Pearlman R, JCO Precis Oncol 2021;5:779-91.
64.7% of
dMMR cases +
7.5% of
pMMR
cases +
4.0% of
methylated
cases +

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Results
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 76/86 (88.4%) patients with unexplained dMMR tumors had double somatic MMR gene mutations
 Among all CRC patients:
 Among dMMR CRC patients without MLH1 promoter methylation:
 Testing for only MMR genes in dMMR would have missed 18 PGV is in other CSG (7.3% of total)
 UTS only would have missed 91/236 (38.6%) PGVs, including 9/144) 6.3% of those with LS.
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60% (135/224) had LS
32% (76/224) double somatic
5% (11/224) unexplained
15.9% (525/3,310) dMMR
9.2% (301/3,310) methylation
4% (135/3,310) had LS
2% (76/3,310) double somatic
0.3% (11/3,310) unexplained
Pearlman R, JCO Precis Oncol 2021;5:779-91.

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Highlights from the Ohio Colorectal Cancer Prevention Initiative
Results
Hampel H et al. Gynecol Oncol. 2021 Jan;160(1):161-168.

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Results
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 Among all EC patients:
 Among dMMR EC patients without MLH1 promoter methylation:
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45.5% (10/22) had LS
54.5% (12/22) double somatic
26.7% (91/341) dMMR
20.2% (69/341) methylation
2.9% (10/341) had LS
3.5% (12/341) double somatic
Hampel H et al. Gynecol Oncol. 2021 Jan;160(1):161-168.; Levine M et al. JCO PO. 2021

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Study Design
 963 Endometrial cancer patients were prospectively enrolled at 9 Ohio institutions from 10/1/2017 – 12/31/2020
 All patients received germline multi-gene panel testing with a 47 gene panel (Common Hereditary Cancers panel)
 All patients received tumor sequencing with a test designed specifically for the study that included MSI by NGS,
sequencing of the four MMR genes (MLH1, MSH2, MSH6, and PMS2) to assess for germline versus double somatic MMR
mutations, and sequencing of PTEN and
 Aims:
o Determine the prevalence of hereditary cancer susceptibility syndromes among newly diagnosed EC patients
o Determine if a tumor sequencing first approach could replace traditional MSI/IHC screening and germline testing
o Determine the cost-effectiveness of all approaches
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Prevalence of Hereditary Cancer Syndromes
3% 7.1%

22. LYNCH SYNDROME
• 29/961 (3%; 95% CI 2.1 - 4.3) patients with LP/PVs in
MMR gene consistent with LS diagnosis
• PMS2 most common (11), then MSH6 (10), MSH2 (6),
MLH1 (2)
• Clinicopathologic features similar to overall
population
• Most early stage endometrioid
• Except
• Younger age at diagnosis (mean 55.5 vs. 61.6y; P = .002)
• Lower BMIs (29.1 vs. 36.8; P ≤ .001)
• When considered by gene, nonsignificant trend
towards higher BMIs for PMS2 heterozygotes.

23. LYNCH SYNDROME – IHC FINDINGS
*MGPT identified 10 patients with LS (34.5%
of all LS cases) that would not otherwise
have been recognized*
• All MLH1 and MSH2 cases had abnormal IHC as expected.
• 9/10 MSH6 cases has IHC as expected.
• Screening IHC results for PMS2 cases were highly variable.
• 1 with no residual tumor for testing
• Only 5/10 had isolated PMS2 absence initially
• 2 cases had normal staining for all four proteins
• 3 cases with MLH1 abnormalities
• 1 case absent MLH1 and PMS2 and no MLH1 PH.
Repeat: loss of PMS2
• 1 case focal/weak MLH1, loss of PMS2 and no MLH1
PH. Repeat: same
• 1 case absent PMS2, partial absent MLH1 and partial
absent MSH6. Repeat: loss of MSH6 and PMS2 with
MLH1 PH.

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Cascade Testing
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Highlights from the Ohio Colorectal Cancer Prevention Initiative
Cascade Testing Results
CRC patients with Lynch
syndrome = 132*
EC patients with Lynch
syndrome = 10
Genetic Counseling
Cascade Test Family
184 Positive 345 Negative
554 Relatives Tested
Receive intensive
surveillance and prevention
Receive general
population screening
*Includes the 2 patients with germline methylation

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Cascade Testing: Opportunities for Future Research
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 Average number of relatives tested per proband: 4
 Number of families with cascade testing: 95/142 (67%)
 Average number of relatives tested per proband in families with cascade testing: 6
 Gold star family: 131 relatives tested
….how did we do that?
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The Lima Story
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 EC patient “EC1” from Van Wert OH diagnosed at 44, enrolled at OSU September 2013.
o Tumor screening: Discordant
• MSS, absent MSH6
o Germline testing: Uncertain Variant
• MSH6 VUS c.1109T>C, p.L370S
o Tumor testing: Inconclusive
• MSH6 pathogenic c.3647-5 to c.3649delAACAGGAA and MSH6 VUS (c.1671T>C,G557G). Known germline MSH6 VUS detected at heterozygous levels.
• Which MSH6 VUS is likely pathogenic??
o Fhx: Maternal aunt EC (d.44); maternal grandfather CRC 60s
 Counseled her to follow LS guidelines for now
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The Lima Story
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 CRC patient “CRC1” from Lima OH diagnosed at 42, enrolled at OSU April 2015.
o Tumor screening: Insufficient tumor for MSI, absent MSH2/MSH6
o Germline testing: Uncertain Variant
• MSH6 VUS c.1109T>C, p.L370S
o Tumor testing: Insufficient for NGS
o Fhx: Father CaSU 40s, prostate 60s; paternal grandmother ovarian 60s; Mother EC 52 (on 9909),
maternal uncle “liver” (d.47), maternal uncle abdominal ca 76 (d.76)
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Geneaology Work
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 CRC1 and EC1 are 5th cousins!
 Reclassification of MSH6 VUS c.1109T>C, p.L370S from uncertain to pathogenic
 Cascade testing for relatives!
 CRC1 branch first, siblings, parents and 20+ maternal relatives…
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+ +
-

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More Genealogy Work…
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 CRC1’s father tested positive
 CRC1’s parents are actually 4th cousins
 CRC1 and EC1 are 3rd and 5th cousins!
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+
+
+
+
+
+
+ +
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Highlights from the Ohio Colorectal Cancer Prevention Initiative
CRC1 Pedigree

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EC1 Pedigree
Highlights from the Ohio Colorectal Cancer Prevention Initiative 32

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Successful Cascade Testing
Highlights from the Ohio Colorectal Cancer Prevention Initiative
 These two seemingly separate families had 20 and
29 first- and second-degree relatives ascertained
from a standard three-generation pedigree,
respectively.
 Once linked as distant cousins, 6 additional
branches of 3rd cousins were identified, with
hundreds of at-risk relatives.
o 4th and 5th cousins also identified using
Ancestry.com
o Thousands of at-risk relatives
 So far, 131 have tested, 42 positive, and a whole
other branch with the mutation was identified.
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New Approach to Cascade Testing
We have 25 recurrent mutations identified
through OCCPI, 12 other probands have been
connected so far.
By identifying the furthest common ancestor,
families can be alerted of their risk.
Plan to submit grants capitalizing on this
approach.
 25 recurrent mutations identified through
OCCPI, 12 other probands have been
connected so far.
 By identifying the furthest common ancestor,
families can be alerted of their risk.
 Plan to submit grants capitalizing on this
approach.

35. Ohio State University
Rachel Pearlman
Albert de la Chapelle
Wendy Frankel
Dan Jones
Ahmet Yilmaz
Jason Bacher
Kristin Miller
Chris Bigley
Lori Nelson
Michael Bigley
Ilene Lattimer
Paul Goodfellow
Peter Stanich
OSU cancer genetics
team
OCCPI hospital network
University of Washington
Colin Pritchard
Brian Shirts
Angie Jacobson
Andrew McFaddin
Myriad Genetics
Other key players
Sisi Haraldsdottir
Richard Goldberg
Christina Wu