genetics: for this generation and the next andrea forman, ms, lcgc fox chase cancer center risk...
TRANSCRIPT
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Genetics: For this Generation and the Next
Andrea Forman, MS, LCGC Fox Chase Cancer Center
Risk Assessment ProgramDepartment of Clinical Genetics
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Common Diseases
• Cancer
• Heart disease
• Diabetes
• Hypertension
• Stroke
• Alzheimer's
• Arthritis
• Osteoporosis
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Common Risk Factors
• Age
• Family history
• Ethnicity
• Lifestyle
• Diet
• Alcohol
• Smoking
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Top 5 Reasons to Know Your Family History
5. Family recipes should be kept secret — family medical history should not.
4. Knowing your risk might save your life.
3. It’s free and you don’t have to leave home.
2. It’s a priceless gift to leave to your children.
1. Because every family has a story, but not every family has YOUR story.
https://www.yahoo.com/health/10-reasons-you-should-dig-into-your-family-medical-118232923367.html
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Genetic information is key
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What is a Gene?
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DAD MOM
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Cancer and Genetics
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Fortune Cookie Tip #1
Family history was the first genetic test
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Clues:Genetic Risk for Cancer
• YOUNG– Breast <45, Colon <50
• RARE– Examples include Ovarian, Male Breast, Pancreatic
• MULTIPLE– Two or more different cancers in the same person
• FAMILY– Two or more family members with the same or related types
of cancer. • Breast/Ovary. Breast/Thyroid/Uterine. Breast/Sarcoma/Brain
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Colon, 72
Sporadic Family History
Risk for cancer is AVERAGE
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Familial Family History
Prostate, 75
Lung, 65coal miner
Stomach, 55H. pylori
Liver, 50alcohol abuse
CervixHPV, smoker
Lung, 58smokerBasal Cell
sun exposure
Risk for cancer is MODERATE
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Hereditary Family History
Breast, 55
Ovarian, 44
Breast, 34
Prostate,59
Breast, 50
Risk for cancer is HIGH
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Fortune Cookie Tip #2
Don’t forget to look at both sides of the
family!
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Why would I want to know?
• Possible risk of another, new cancer
• Risks to your children
• Risks to other family members
• Screening and prevention are often available and may save a life
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Family history of breast cancer? Who is the best person to test?
New yellow apple
Red apple tree growing one yellow apple
Courtesy of Kallie Weinan, MS, CGC
Red apple tree growing red apples
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Fortune Cookie Tip #3
When searching for something rare, start the search with the
most likely target.
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BRCA1 +BRCA1 -
Does not want testing
BRCA1 +BRCA1 -
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Breast Ovary Prostate (male) Breast (male) Pancreas
Gen. Population BRCA Carrier
Cancer Risks with HBOC
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What Can You Do?
Increased screening
• Start Earlier– 25yo for breast screening
• More Often– Alternating imaging every
6 months
• More Aggressive– Mammogram
+
Breast MRI
Prevention
• Medication– Tamoxifen (breast
cancer risk)– Birth control pills (ovarian
cancer risk)
• Surgery– Risk reducing mastectomy– Salpingo-oophorectomy
(removal of ovaries and fallopian tubes)
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Guess what?
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You won’t be seeing many tests
for just BRCA1/2 anymore
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Multi-Gene (NGS) Panels
• Genetic tests to look at dozens of genes related to cancer
• Similar cost and turn around time as gene specific testing
• Higher risk of uncertain results
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NGS Panels- Breast
Walsh et. al. 2013 (ASHG Platform Presentation)
•800 families with negative BRCA1/2 testing– 206 tested positive with NGS BROCA panel (26%)
•Of the 26% with a new positive results–39% (80/206) had BRCA1/2 mutations–37% carried mutations in CHEK2, PALB2, or TP53–20% carried mutations in 10 less characterized genes
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Ms. Smith
• 46 year old woman with a newly diagnosed left breast cancer– ER/PR+ invasive ductal carcinoma
• Referred to Risk Assessment as patient wants risk estimate to help her make a decision about bilateral mastectomy
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NGS Test Result
Positive for a gene mutation
• CHEK2
Variants of Uncertain Significance
• BRCA 2
• STK11
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Fortune Cookie Tip #4
Sometimes, in our quest for answers, we end up with
more questions
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Moderate Risk Genes
• Cancer risks may not be very high– How high does risk need to be before we
pursue surgery or medications?
• Cancer risks may be unclear– How do we make medical decisions when we
don’t know the risks?
• We’re still learning– The recommendations you get today may be
different in 5 years
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NGS Test Result
Positive for a gene mutation
• CHEK2
Variants of Uncertain Significance
• BRCA 2
• STK11
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N=398
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Rates of Uncertain Variants
Eggington et. al. Current Variant of Uncertain Significance Rates in BRCA1/2 and Lynch Syndrome Testing (MLH1, MSH2, MSH6, PMS2, EPCAM), March 2012, ACMG Poster Presentation.
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Isn’t it just a blood test?
• Positive results with limited information
• Inconclusive results
• Results that don’t “fit”
• Worry/anxiety
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Consider This…
• Unclear results
• Limited data• Limited
usefulness • Changes in
technology
BENEFITS
• Anxiety/ distress
• Privacy• Appropriate
follow-up?
• Clarification of risk
• Guidance for medical management
• Information for family
RISKS LIMITATIONS
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What can you do?
• Know your family history
• Educate your family about its history
• Talk to your doctor or a genetic counselor
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What is a Genetic Counselor?
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I am a translator
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NSGC: www.nsgc.org
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Questions?
Andrea Forman, MS, LCGCGenetic Counselor
Department of Clinical Genetics, Fox Chase Cancer Center
1-877-627-9684
www.fccc.edu/rap