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Health Disparities in Germline Genetic Testing for Cancer Susceptibility. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00354-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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52
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Napoli M, Lewis J, Hopper J, Widmeyer K. Factors that impact risk management decisions among women with pathogenic variants in moderate penetrance genes associated with hereditary breast cancer. J Genet Couns 2020; 29:960-970. [PMID: 32012395 DOI: 10.1002/jgc4.1220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/25/2019] [Accepted: 12/26/2019] [Indexed: 11/09/2022]
Abstract
There is limited information known about how women with pathogenic variants (PV) in moderate penetrance genes make decisions to manage their increased risk of breast cancer. This study analyzed factors that may impact decision-making surrounding management for increased breast cancer risk. Women with a PV in a moderate penetrance gene associated with increased risk for breast cancer were identified from an institutional database. Semi-structured, qualitative interviews were conducted to analyze decision-making factors. Themes were developed using deductive codes based on previous literature and inductive codes based on interviewee responses. The 16 participants (mean age = 55.9 years) included 12 women with a breast cancer diagnosis. Six women (37.5%) chose bilateral mastectomy (BM), and 10 women (62.5%) chose surveillance as management. Of the 12 women with a personal history of breast cancer, four chose to have BM (33.3%). Two women without a personal history of breast cancer chose to have BM (50.0%). Transcriptions revealed seven comprehensive themes, as well as themes unique to affected and unaffected women (Cohen's kappa = 0.80). Physician opinion was the only factor present in all interviews reported to influence risk management decision-making. Several themes were consistent with prior BRCA1/BRCA2 research (family history, risk perception, sibling influence, and physician opinions). Autonomy and insurance/finances were also important factors to participants. There were certain differences in decision-making factors between affected and unaffected women, such as partner influence. Results indicate an opportunity for providers to engage their patients in a decision-making process.
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Affiliation(s)
- Melissa Napoli
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Jaime Lewis
- Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH
| | - Jennifer Hopper
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kimberly Widmeyer
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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53
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Ye F, Huang L, Lang G, Hu X, Di G, Shao Z, Cao A. Outcomes and risk of subsequent breast events in breast-conserving surgery patients with BRCA1 and BRCA2 mutation. Cancer Med 2020; 9:1903-1910. [PMID: 31912664 PMCID: PMC7050073 DOI: 10.1002/cam4.2836] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 12/18/2019] [Accepted: 12/26/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose Previous studies provide inconsistent interpretations of the effect of inherited genetic factors on the survival and prognosis of patients with breast cancer. The aim of this study was to examine the effect of germline BRCA1 and BRCA2 mutation on survival and subsequent breast events in Chinese women who underwent breast‐conserving surgery. Methods A retrospective review of the clinical and pathological records was performed in patients diagnosed with primary invasive breast cancer between 2005 and 2018 in the cancer registry database. Clinicopathological data and data regarding treatment and outcomes, including date and site of disease progression, were collected. The survival outcomes and independent risk factors were conducted using SPSS. Results Overall, a total of 501 patients who underwent breast‐conserving surgery were identified and subjected to analyses, of which 63 cases with BRCA1 or BRCA2 mutation. The median age at diagnosis was 41 (range, 24‐74) for carriers and 37 (range, 17‐84) for noncarriers. After a median follow‐up time of 61 months (range, 8‐161) and 70 months (range, 0‐153), respectively, in carriers and noncarriers, the overall survival (P = .173) and disease‐free survival (P = .424) were not significantly different. Analogously, there was no significant difference between the two groups about the outcomes of ipsilateral breast tumor recurrence (P = .348), yet the contralateral breast cancer (CBC) was overt worse than noncarriers (P < .001). When adjusted to confounding factors, BRCA mutation was the only independent risk factors to CBC (HR = 7.89, P = .01). Conclusion In this study, BRCA mutation carriers have higher risk of CBC. And, BRCA mutation is the only independent risk factor to CBC. Therefore, intensive surveillance and follow‐up as well as more effective individual prevention are urgent. Decisions on alternatively effective prevention, especially the prevention of CBC, are urgent and should take into account patient prognosis and preferences.
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Affiliation(s)
- Fugui Ye
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Liang Huang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Guantian Lang
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin Hu
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Genhong Di
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Zhimin Shao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Ayong Cao
- Key Laboratory of Breast Cancer in Shanghai, Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
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54
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Sun L, Brentnall A, Patel S, Buist DSM, Bowles EJA, Evans DGR, Eccles D, Hopper J, Li S, Southey M, Duffy S, Cuzick J, dos Santos Silva I, Miners A, Sadique Z, Yang L, Legood R, Manchanda R. A Cost-effectiveness Analysis of Multigene Testing for All Patients With Breast Cancer. JAMA Oncol 2019; 5:1718-1730. [PMID: 31580391 PMCID: PMC6777250 DOI: 10.1001/jamaoncol.2019.3323] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023]
Abstract
Importance Moving to multigene testing for all women with breast cancer (BC) could identify many more mutation carriers who can benefit from precision prevention. However, the cost-effectiveness of this approach remains unaddressed. Objective To estimate incremental lifetime effects, costs, and cost-effectiveness of multigene testing of all patients with BC compared with the current practice of genetic testing (BRCA) based on family history (FH) or clinical criteria. Design, Setting, and Participants This cost-effectiveness microsimulation modeling study compared lifetime costs and effects of high-risk BRCA1/BRCA2/PALB2 (multigene) testing of all unselected patients with BC (strategy A) with BRCA1/BRCA2 testing based on FH or clinical criteria (strategy B) in United Kingdom (UK) and US populations. Data were obtained from 11 836 patients in population-based BC cohorts (regardless of FH) recruited to 4 large research studies. Data were collected and analyzed from January 1, 2018, through June 8, 2019. The time horizon is lifetime. Payer and societal perspectives are presented. Probabilistic and 1-way sensitivity analyses evaluate model uncertainty. Interventions In strategy A, all women with BC underwent BRCA1/BRCA2/PALB2 testing. In strategy B, only women with BC fulfilling FH or clinical criteria underwent BRCA testing. Affected BRCA/PALB2 carriers could undertake contralateral preventive mastectomy; BRCA carriers could choose risk-reducing salpingo-oophorectomy (RRSO). Relatives of mutation carriers underwent cascade testing. Unaffected relative carriers could undergo magnetic resonance imaging or mammography screening, chemoprevention, or risk-reducing mastectomy for BC risk and RRSO for ovarian cancer (OC) risk. Main Outcomes and Measures Incremental cost-effectiveness ratio (ICER) was calculated as incremental cost per quality-adjusted life-year (QALY) gained and compared with standard £30 000/QALY and $100 000/QALY UK and US thresholds, respectively. Incidence of OC, BC, excess deaths due to heart disease, and the overall population effects were estimated. Results BRCA1/BRCA2/PALB2 multigene testing for all patients detected with BC annually would cost £10 464/QALY (payer perspective) or £7216/QALY (societal perspective) in the United Kingdom or $65 661/QALY (payer perspective) or $61 618/QALY (societal perspective) in the United States compared with current BRCA testing based on clinical criteria or FH. This is well below UK and US cost-effectiveness thresholds. In probabilistic sensitivity analysis, unselected multigene testing remained cost-effective for 98% to 99% of UK and 64% to 68% of US health system simulations. One year's unselected multigene testing could prevent 2101 cases of BC and OC and 633 deaths in the United Kingdom and 9733 cases of BC and OC and 2406 deaths in the United States. Correspondingly, 8 excess deaths due to heart disease occurred in the United Kingdom and 35 in the United States annually. Conclusions and Relevance This study found unselected, high-risk multigene testing for all patients with BC to be extremely cost-effective compared with testing based on FH or clinical criteria for UK and US health systems. These findings support changing current policy to expand genetic testing to all women with BC.
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Affiliation(s)
- Li Sun
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Adam Brentnall
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Shreeya Patel
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Diana S. M. Buist
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - D. Gareth R. Evans
- Genomic Medicine, Manchester Academic Health Science Centre, Manchester Universities Foundation Trust, St Mary’s Hospital, The University of Manchester, Manchester, United Kingdom
| | - Diana Eccles
- Cancer Sciences Academic Unit, Faculty of Medicine and Cancer Sciences, University of Southampton, Southampton, United Kingdom
| | - John Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Shuai Li
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Melissa Southey
- Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
- Department of Clinical Pathology, Melbourne Medical School, Melbourne University, Melbourne, Australia
- Cancer Epidemiology Division, Cancer Council Victoria, Victoria, Australia
| | - Stephen Duffy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
| | - Isabel dos Santos Silva
- Department of Noncommunicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Li Yang
- School of Public Health, Peking University, Beijing, China
| | - Rosa Legood
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ranjit Manchanda
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom
- Department of Gynaecological Oncology, Barts Health National Health System Trust, Royal London Hospital, London, United Kingdom
- MRC (Medical Research Counsel) Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, Faculty of Population Health Sciences, University College London, London, United Kingdom
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55
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Powell CB, Alabaster A, Le A, Stoller N, Armstrong MA, Raine‐Bennett T. Sexual function, menopausal symptoms, depression and cancer worry in women with BRCA mutations. Psychooncology 2019; 29:331-338. [DOI: 10.1002/pon.5253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/13/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022]
Affiliation(s)
- C. Bethan Powell
- Kaiser Permanente Northern California Gynecologic Cancer Program California United States of America
- Division of Research Kaiser Permanente Northern California California United States of America
| | - Amy Alabaster
- Division of Research Kaiser Permanente Northern California California United States of America
| | - Amy Le
- Kaiser Permanente Ob/Gyn Residency Program California United States of America
| | - Nicole Stoller
- Division of Research Kaiser Permanente Northern California California United States of America
| | - Mary Anne Armstrong
- Division of Research Kaiser Permanente Northern California California United States of America
| | - Tina Raine‐Bennett
- Division of Research Kaiser Permanente Northern California California United States of America
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56
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Breast cancer surveillance for BRCA1/2 mutation carriers - is "early detection" early enough? Breast 2019; 49:81-86. [PMID: 31760168 PMCID: PMC7375664 DOI: 10.1016/j.breast.2019.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 11/18/2022] Open
Abstract
Background Annual MRI screening is associated with a significant reduction in advanced-stage breast cancer diagnosis in BRCA1/2 mutation carriers. The impact that early detection has on subsequent oncological treatment is less frequently reported. In this study we compared disease stage and therapeutic approaches in BRCA1/2 mutation carriers who developed breast cancer while adhering to the recommended surveillance scheme (“known carriers”), with women who became aware of their BRCA mutation status after breast cancer diagnosis (“latent carriers"). Methods Data on tumor characteristics, disease stage, and therapeutic decisions were collected on BRCA1/2 mutation carriers treated for breast cancer at the Chaim Sheba Medical Center. Results Data were available for 298 BRCA1/2 carriers. Median follow-up was 77.4 months (range, 3.5–520). Age at diagnosis was not statistically different between known carriers (n = 96; median age at diagnosis 44.7 years) and latent carriers (n = 202; 43.7 years); p = 0.8284. Of known carriers, 19.8% were diagnosed with carcinoma in situ vs. 5% of latent carriers (p = 0.0012). Stage T1N0 disease was diagnosed in 54/96 (56.3%) of known carriers vs. 59/202 (29.2%) of latent carriers (p < 0.00001). Neoadjuvant or adjuvant chemotherapy was administered to 46/96 (47.9%) of known carriers compared with 162/202 (80.2%) of latent carriers (p < 0.00001). Conclusions While early stage breast cancer was diagnosed frequently among known BRCA1/2 carriers under tight surveillance, almost half of these women were treated with chemotherapy. Healthy BRCA1/2 mutation carriers should be informed about these rates while discussing risk-reducing surgical options. Annual MRI screening is recommended to healthy BRCA1/2 mutation carriers. Intensive surveillance enables breast cancer diagnosis at early stages. In this study ∼50% of early stage diagnosed patients received chemotherapy. This rate should be discussed with BRCA carriers considering risk-reducing options.
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57
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Conley CC, Kasting ML, Augusto BM, Garcia JD, Cragun D, Gonzalez BD, Kim J, Ashing KT, Knott CL, Hughes-Halbert C, Pal T, Vadaparampil ST. Impact of Genetic Testing on Risk-Management Behavior of Black Breast Cancer Survivors: A Longitudinal, Observational Study. Ann Surg Oncol 2019; 27:1659-1670. [PMID: 31677107 DOI: 10.1245/s10434-019-07982-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Black women are overrepresented among premenopausal breast cancer (BC) survivors. These patients warrant genetic testing (GT) followed by risk-reducing behaviors. This study documented patterns and predictors of cancer risk-management behaviors among young black BC survivors after GT. METHODS Black women (n = 143) with a diagnosis of BC at the age of 50 years or younger received GT. At 1 year after GT, participants reported receipt of risk-reducing mastectomy, risk-reducing salpingo-oophorectomy, mammogram, breast magnetic resonance imaging (MRI), CA125 test, and transvaginal/pelvic ultrasound. Logistic regression was used to examine predictors of BC risk management (risk-reducing mastectomy or breast MRI) and ovarian cancer risk management (risk-reducing salpingo-oophorectomy, CA125 test, or transvaginal/pelvic ultrasound). RESULTS Of the study participants, 16 (11%) were BRCA1/2-positive, 43 (30%) had a variant of uncertain significance, and 84 (59%) were negative. During the 12 months after GT, no women received risk-reducing mastectomy. The majority (93%) received a mammogram, and a smaller proportion received breast MRI (33%), risk-reducing salpingo-oophorectomy (10%), CA125 test (11%), or transvaginal/pelvic ultrasound (34%). Longer time since the BC diagnosis predicted lower likelihood of BC risk management (odds ratio [OR] 0.54). BRCA1/2 carrier status (OR 4.57), greater perceived risk of recurrence (OR 8.03), and more hereditary breast and ovarian cancer knowledge (OR 1.37) predicted greater likelihood of ovarian cancer risk management. CONCLUSIONS Young black BC survivors appropriately received mammograms and ovarian cancer risk management based on their BRCA1/2 test result. However, the low usage of MRI among BRCA1/2 carriers contrasts with national guidelines. Future research should examine barriers to MRI among black BC survivors. Finally, modifiable variables predicting risk management after GT were identified, providing implications for future interventions.
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Affiliation(s)
- Claire C Conley
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Monica L Kasting
- Department of Health and Kinesiology, Purdue University, West Lafayette, IN, USA
| | - Bianca M Augusto
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Jennifer D Garcia
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Deborah Cragun
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Jongphil Kim
- Division of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Kimlin Tam Ashing
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Cheryl L Knott
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Chanita Hughes-Halbert
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Tuya Pal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan T Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
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58
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Lammert J, Skandarajah AR, Shackleton K, Calder P, Thomas S, Lindeman GJ, Mann GB. Outcomes of women at high familial risk for breast cancer: An 8-year single-center experience. Asia Pac J Clin Oncol 2019; 16:e27-e37. [PMID: 31657879 DOI: 10.1111/ajco.13274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The value of a high-risk surveillance program for mutation carriers and women at high familial breast cancer risk has not been extensively studied. A Breast and Ovarian Cancer Risk Management Clinic (BOCRMC) was established at the Royal Melbourne Hospital in 2010 to provide multimodality screening and risk management strategies for this group of women. The aims of this study were to evaluate the program and describe breast cancer diagnoses for BRCA1, BRCA2, and other germline mutation carriers as well as high-risk noncarriers attending the BOCRMC. METHODS Clinical data from mutation carriers and noncarriers with a ≥25% lifetime risk of developing breast cancer who attended between 2010 and 2018 were extracted from clinic records and compared. The pattern and mode of detection of cancer were determined. RESULTS A total of 206 mutation carriers and 305 noncarriers attended the BOCRMC and underwent screening on at least one occasion. Median age was 37 years. After a median follow-up of 34 months, 15 (seven invasive) breast cancers were identified in mutation carriers, with seven (six invasive) breast cancers identified in noncarriers. Of these, 20 (90.9%) were detected by annual screening, whereas two (9.1%) were detected as interval cancers (both in BRCA1 mutation carriers). Median size of the invasive breast cancers was 11 mm (range: 1.5-30 mm). The majority (76.9%) were axillary node negative. In women aged 25-49 years, the annualized cancer incidence was 1.6% in BRCA1, 1.4% in BRCA2 mutation carriers, and 0.5% in noncarriers. This compares to 0.06% annualized cancer incidence in the general Australian population. CONCLUSIONS Screening was effective at detecting early-stage cancers. The incidence of events in young noncarriers was substantially higher than in the general population. This potentially justifies ongoing management through a specialty clinic, although further research to better personalize risk assessment in noncarriers is required.
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Affiliation(s)
- Jacqueline Lammert
- Department of Gynecology and Center for Hereditary Breast and Ovarian Cancer, University Hospital rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - Anita R Skandarajah
- Breast Service, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia.,Department of Surgery, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kylie Shackleton
- Breast Service, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia.,Familial Cancer Centre, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,ACRF Cancer Biology and Stem Cells Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Patricia Calder
- Familial Cancer Centre, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Susan Thomas
- Breast Service, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia.,Familial Cancer Centre, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Geoffrey J Lindeman
- Breast Service, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia.,Familial Cancer Centre, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,ACRF Cancer Biology and Stem Cells Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Gregory Bruce Mann
- Breast Service, The Royal Melbourne and Royal Women's Hospitals, Parkville, Victoria, Australia.,Department of Surgery, The University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Kotsopoulos J, Gronwald J, Karlan BY, Huzarski T, Tung N, Moller P, Armel S, Lynch HT, Senter L, Eisen A, Singer CF, Foulkes WD, Jacobson MR, Sun P, Lubinski J, Narod SA. Hormone Replacement Therapy After Oophorectomy and Breast Cancer Risk Among BRCA1 Mutation Carriers. JAMA Oncol 2019; 4:1059-1065. [PMID: 29710224 DOI: 10.1001/jamaoncol.2018.0211] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Prophylactic bilateral salpingo-oophorectomy is recommended for BRCA1 mutation carriers to prevent ovarian cancer. Whether or not hormone replacement therapy (HRT) initiated after oophorectomy is associated with an increased risk of breast cancer has not been evaluated in a prospective study. Objective To determine the association between HRT use and BRCA1-associated breast cancer. Design, Setting, and Participants A prospective, longitudinal cohort study of BRCA1 and BRCA2 mutation carriers from 80 participating centers in 17 countries was conducted between 1995 and 2017 with a mean follow-up of 7.6 years. Participants had sought genetic testing for a BRCA1 or BRCA2 mutation because of a personal or family history of breast and/or ovarian cancer. Carriers of BRCA1 mutation with no personal medical history of cancer who underwent bilateral oophorectomy following enrollment were eligible for the cohort study. Exposures A follow-up questionnaire was administered every 2 years to obtain detailed information on HRT use. A left-truncated Cox proportional hazard analysis was used to estimate the hazard ratios (HRs) and 95% CIs associated with the initiation of HRT use postoophorectomy. Main Outcomes and Measures Incident breast cancer. Results A total of 872 BRCA1 mutation carriers with a mean postoophorectomy follow-up period of 7.6 years (range, 0.4-22.1) were included in this study. Mean (SD) age of participants was 43.4 (8.5) years. Among these, 92 (10.6%) incident breast cancers were diagnosed. Overall, HRT use after oophorectomy was not associated with an increased risk of breast cancer. The HR was 0.97 (95% CI, 0.62-1.52; P = .89) for ever use of any type of HRT vs no use; however, the effects of estrogen alone and combination hormonal therapy were different. After 10 years of follow-up, the cumulative incidence of breast cancer among women who used estrogen-alone HRT was 12% compared with 22% among women who used estrogen plus progesterone HRT (absolute difference, 10%; log rank P = .04). Conclusions and Relevance These findings suggest that use of estrogen after oophorectomy does not increase the risk of breast cancer among women with a BRCA1 mutation and should reassure BRCA1 mutation carriers considering preventive surgery that HRT is safe. The possible adverse effect of progesterone-containing HRT warrants further study.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jacek Gronwald
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Beth Y Karlan
- Gynecology Oncology, Cedars Sinai Medical Center, Los Angeles, California
| | - Tomasz Huzarski
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Nadine Tung
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Pal Moller
- Inherited Cancer Research Group, The Norwegian Radium Hospital, Department for Medical Genetics, Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital; Oslo University Hospital, Oslo, Norway
| | - Susan Armel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | - Henry T Lynch
- Department of Preventive Medicine and Public Health, Creighton University School of Medicine, Omaha, Nebraska
| | - Leigha Senter
- Division of Human Genetics, the Ohio State University Medical Center, Comprehensive Cancer Center, Columbus
| | - Andrea Eisen
- Toronto-Sunnybrook Regional Cancer Center, Toronto, Ontario, Canada
| | - Christian F Singer
- Department of Obstetrics and Gynecology and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - William D Foulkes
- Program in Cancer Genetics, Department of Oncology and Human Genetics, McGill University, Montréal, Quebec, Canada
| | - Michelle R Jacobson
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Ping Sun
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Jan Lubinski
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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60
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Kurian AW, Ward KC, Hamilton AS, Deapen DM, Abrahamse P, Bondarenko I, Li Y, Hawley ST, Morrow M, Jagsi R, Katz SJ. Uptake, Results, and Outcomes of Germline Multiple-Gene Sequencing After Diagnosis of Breast Cancer. JAMA Oncol 2019; 4:1066-1072. [PMID: 29801090 DOI: 10.1001/jamaoncol.2018.0644] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Low-cost sequencing of multiple genes is increasingly available for cancer risk assessment. Little is known about uptake or outcomes of multiple-gene sequencing after breast cancer diagnosis in community practice. Objective To examine the effect of multiple-gene sequencing on the experience and treatment outcomes for patients with breast cancer. Design, Setting, and Participants For this population-based retrospective cohort study, patients with breast cancer diagnosed from January 2013 to December 2015 and accrued from SEER registries across Georgia and in Los Angeles, California, were surveyed (n = 5080, response rate = 70%). Responses were merged with SEER data and results of clinical genetic tests, either BRCA1 and BRCA2 (BRCA1/2) sequencing only or including additional other genes (multiple-gene sequencing), provided by 4 laboratories. Main Outcomes and Measures Type of testing (multiple-gene sequencing vs BRCA1/2-only sequencing), test results (negative, variant of unknown significance, or pathogenic variant), patient experiences with testing (timing of testing, who discussed results), and treatment (strength of patient consideration of, and surgeon recommendation for, prophylactic mastectomy), and prophylactic mastectomy receipt. We defined a patient subgroup with higher pretest risk of carrying a pathogenic variant according to practice guidelines. Results Among 5026 patients (mean [SD] age, 59.9 [10.7] years), 1316 (26.2%) were linked to genetic results from any laboratory. Multiple-gene sequencing increasingly replaced BRCA1/2-only testing over time: in 2013, the rate of multiple-gene sequencing was 25.6% and BRCA1/2-only testing, 74.4%; in 2015 the rate of multiple-gene sequencing was 66.5% and BRCA1/2-only testing, 33.5%. Multiple-gene sequencing was more often ordered by genetic counselors (multiple-gene sequencing, 25.5% and BRCA1/2-only testing, 15.3%) and delayed until after surgery (multiple-gene sequencing, 32.5% and BRCA1/2-only testing, 19.9%). Multiple-gene sequencing substantially increased rate of detection of any pathogenic variant (multiple-gene sequencing: higher-risk patients, 12%; average-risk patients, 4.2% and BRCA1/2-only testing: higher-risk patients, 7.8%; average-risk patients, 2.2%) and variants of uncertain significance, especially in minorities (multiple-gene sequencing: white patients, 23.7%; black patients, 44.5%; and Asian patients, 50.9% and BRCA1/2-only testing: white patients, 2.2%; black patients, 5.6%; and Asian patients, 0%). Multiple-gene sequencing was not associated with an increase in the rate of prophylactic mastectomy use, which was highest with pathogenic variants in BRCA1/2 (BRCA1/2, 79.0%; other pathogenic variant, 37.6%; variant of uncertain significance, 30.2%; negative, 35.3%). Conclusions and Relevance Multiple-gene sequencing rapidly replaced BRCA1/2-only testing for patients with breast cancer in the community and enabled 2-fold higher detection of clinically relevant pathogenic variants without an associated increase in prophylactic mastectomy. However, important targets for improvement in the clinical utility of multiple-gene sequencing include postsurgical delay and racial/ethnic disparity in variants of uncertain significance.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and Health Research and Policy, Stanford University, Stanford, California
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Dennis M Deapen
- Department of Preventive Medicine in the Keck School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Abrahamse
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Irina Bondarenko
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Sarah T Hawley
- Department of Internal Medicine, Division of General Medicine, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, and Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor
| | - Monica Morrow
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, New York, New York
| | - Reshma Jagsi
- Center for Bioethics and Social Science in Medicine, Oncology, Department of Radiation, University of Michigan, Ann Arbor
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Kotsopoulos J, Hall E, Finch A, Hu H, Murphy J, Rosen B, Narod SA, Cheung AM. Changes in Bone Mineral Density After Prophylactic Bilateral Salpingo-Oophorectomy in Carriers of a BRCA Mutation. JAMA Netw Open 2019; 2:e198420. [PMID: 31390031 PMCID: PMC6686775 DOI: 10.1001/jamanetworkopen.2019.8420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Preventive surgery is strongly recommended for individuals with a BRCA mutation at a young age to prevent ovarian cancer and improve overall survival. The overall effect of early surgical menopause on various health outcomes, including bone health, has not been clearly elucidated. OBJECTIVE To evaluate the association of prophylactic bilateral salpingo-oophorectomy with bone mineral density (BMD) loss among individuals with a BRCA mutation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of participants with a BRCA mutation who underwent oophorectomy through the University Health Network, Toronto, Ontario, Canada, recruited participants from January 2000 to May 2013. Eligibility criteria included having a BRCA mutation, at least 1 ovary intact prior to surgery, and no history of any cancer other than breast cancer. Bone mineral density was measured using dual-energy x-ray absorptiometry before and after surgery. Data analysis began in December 2018 and finished in January 2019. MAIN OUTCOMES AND MEASURES The annual change in BMD from baseline to follow-up was calculated for the following 3 anatomical locations: (1) lumbar spine, (2) femoral neck, and (3) total hip. RESULTS A total of 95 women had both a baseline and postsurgery BMD measurement with a mean (SD) follow-up period of 22.0 (12.7) months. The mean (SD) age at oophorectomy was 48.0 (7.4) years. Among women who were premenopausal at time of surgery (50 [53%]), there was a decrease in BMD from baseline to follow-up across the lumbar spine (annual change, -3.45%; 95% CI, -4.61% to -2.29%), femoral neck (annual change, -2.85%; 95% CI, -3.79% to -1.91%), and total hip (annual change, -2.24%; 95% CI, -3.11% to -1.38%). Self-reported hormone therapy use was associated with significantly less bone loss at the lumbar spine (-2.00% vs -4.69%; P = .02) and total hip (-1.38% vs -3.21; P = .04) compared with no hormone therapy use. Among postmenopausal women at time of surgery (45 [47%]), there was also a significant decrease in BMD across the lumbar spine (annual change, -0.82%; 95% CI, -1.42% to -0.23%) and femoral neck (annual change, -0.68%; 95% CI, -1.33% to -0.04%) but not total hip (annual change, -0.18%; 95% CI, -0.82% to 0.46%). CONCLUSIONS AND RELEVANCE This study found that oophorectomy was associated with postoperative bone loss, especially among women who were premenopausal at the time of surgery. Targeted management strategies should include routine BMD assessment and hormone therapy use to improve management of bone health in this population.
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Affiliation(s)
- Joanne Kotsopoulos
- Women’s College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Hall
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Amy Finch
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Hanxian Hu
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
| | - Joan Murphy
- Department of Gynecology Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Barry Rosen
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Narod
- Women’s College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Angela M. Cheung
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
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Petelin L, Hossack L, Mitchell G, Liew D, Trainer AH, James PA. A Microsimulation Model for Evaluating the Effectiveness of Cancer Risk Management for BRCA Pathogenic Variant Carriers: miBRovaCAre. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:854-862. [PMID: 31426925 DOI: 10.1016/j.jval.2019.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/20/2019] [Accepted: 03/05/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To develop a validated model for evaluating the real-world effectiveness of long-term clinical management strategies for women with germline BRCA1 or BRCA2 pathogenic variants. METHODS A microsimulation model was developed that included a BRCA-specific natural history for breast and ovarian cancer, a clinical framework for carrier follow-up, and cancer risk management strategies (breast screening, risk-reducing mastectomy, and bilateral salpingo-oophorectomy). Adherence rates and outcomes for breast screening and risk-reducing surgery were obtained from BRCA carriers seen through a familial cancer service in Melbourne, Australia. The model was assessed for internal and external validity. The model was used to compare women perfectly adhering to screening recommendations versus actual adherence of the clinical cohort. RESULTS The model accurately predicted cancer incidence, pathology, and mortality. Using actual adherence for breast screening resulted in additional breast cancer deaths (per 1000 women: BRCA1, 2.7; BRCA2, 1.6) compared with perfect screening adherence. This decreased average life expectancy by 0.30 life-years for BRCA1 and 0.07 life-years for BRCA2. When carriers had access to risk-reducing mastectomy, the benefit from improved screening adherence was not significant. CONCLUSIONS The developed model is a good descriptor of BRCA carriers' lifetime trajectory and its modification by use of risk management strategies alone or in combination. Evaluations of breast screening in BRCA carriers may overestimate the benefits of screening programs unless adherence is considered. By incorporating real-world clinical practice and patient behavior, this model can assist in developing clinical services and improving clinical outcomes for carriers.
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Affiliation(s)
- Lara Petelin
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Lucinda Hossack
- Clinical Genetics, Austin Health, Austin Hospital, Melbourne, Victoria, Australia
| | - Gillian Mitchell
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alison H Trainer
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul A James
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Manoukian S, Alfieri S, Bianchi E, Peissel B, Azzollini J, Borreani C. Risk‐reducing surgery in
BRCA1
/
BRCA2
mutation carriers: Are there factors associated with the choice? Psychooncology 2019; 28:1871-1878. [DOI: 10.1002/pon.5166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Siranoush Manoukian
- Unit of Medical Genetics, Department of Medical Oncology and HematologyFondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Sara Alfieri
- Clinical Psychlogy UnitFondazione IRCSS Istituto Nazionale dei Tumori Milan Italy
| | - Elisabetta Bianchi
- Clinical Psychlogy UnitFondazione IRCSS Istituto Nazionale dei Tumori Milan Italy
| | - Bernard Peissel
- Unit of Medical Genetics, Department of Medical Oncology and HematologyFondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Jacopo Azzollini
- Unit of Medical Genetics, Department of Medical Oncology and HematologyFondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Claudia Borreani
- Clinical Psychlogy UnitFondazione IRCSS Istituto Nazionale dei Tumori Milan Italy
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Rebitschek FG, Pashayan N, Widschwendter M, Wegwarth O. Do cancer risk and benefit-harm ratios influence women's consideration of risk-reducing mastectomy? A scenario-based experiment in five European countries. PLoS One 2019; 14:e0218188. [PMID: 31188874 PMCID: PMC6561593 DOI: 10.1371/journal.pone.0218188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 05/28/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Personal cancer risk assessments enable stratified care, for example, offering preventive surgical measures such as risk-reducing mastectomy (RRM) to women at high risk for breast cancer. In scenario-based experiments, we investigated whether different benefit-harm ratios of RRM influence women's consideration of this, whether this consideration is influenced by women's perception of and desire to know their personal cancer risk, or by their intention to take a novel cancer risk-predictive test, and whether consideration varies across different countries. METHOD In January 2017, 1,675 women 40 to 75 years of age from five European countries-Czech Republic, Germany, UK, Italy, and Sweden-took part in an online scenario-based experiment. Six different scenarios of hypothetical benefit-harm ratios of RRM were presented in accessible fact box formats: Baseline risk/risk reduction pairings were 20/16, 20/4, 10/8, 10/2, 5/4, and 5/1 out of 1,000 women dying from breast cancer. RESULTS Varying the baseline risk of dying from breast cancer and the extent of risk reduction influenced the decision to consider RRM for 23% of women. Decisions varied by country, risk perception, and the intention to take a cancer risk-predictive test. Women who expressed a stronger intention to take such a test were more likely to consider having RRM. The desire to know one's risk of developing any female cancer in general moderated women's decisions, whereas the specific desire to know the risk of breast cancer did not. CONCLUSIONS In this hypothetical scenario-based study, only for a minority of women did the change in benefit-harm ratio inform their consideration of RRM. Because this consideration is influenced by risk perception and the intention to learn one's cancer risks via a cancer risk-predictive test, careful disclosure of different potential preventive measures and their benefit-harm ratios is necessary before testing for individual risk. Furthermore, information on risk testing should acknowledge country-specific sensitivities for benefit-harm ratios.
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Affiliation(s)
- Felix G. Rebitschek
- Harding Center for Risk Literacy, Max Planck Institute for Human Development, Berlin, Germany
- * E-mail:
| | - Nora Pashayan
- Department of Applied Health Research, University College London, London, United Kingdom
| | | | - Odette Wegwarth
- Harding Center for Risk Literacy, Max Planck Institute for Human Development, Berlin, Germany
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
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Cancer screening and prevention in BRCA mutation carriers: a missed opportunity? Br J Cancer 2019; 121:1-2. [PMID: 31171836 PMCID: PMC6738056 DOI: 10.1038/s41416-019-0484-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/03/2019] [Indexed: 11/26/2022] Open
Abstract
While the elevated lifetime risk of breast and ovarian cancer is well recognised for patients with a BRCA mutation, the implementation of effective risk reduction strategies has been fraught with challenges. This report from an international database and published in the British Journal of Cancer reveals suboptimal rates of utilisation of surveillance/preventative measures globally.
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Samadder NJ, Giridhar KV, Baffy N, Riegert-Johnson D, Couch FJ. Hereditary Cancer Syndromes-A Primer on Diagnosis and Management: Part 1: Breast-Ovarian Cancer Syndromes. Mayo Clin Proc 2019; 94:1084-1098. [PMID: 31171119 DOI: 10.1016/j.mayocp.2019.02.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 02/05/2019] [Accepted: 02/14/2019] [Indexed: 12/12/2022]
Abstract
Cancer is the second leading cause of death in both men and women in the United States, with colorectal cancer and breast cancer being two of the most frequent cancer types. Hereditary causes occurring due to pathogenic sequence variants and defects in certain genes makes up roughly 5% of all colorectal cancers and breast-ovarian cancers. High-risk hereditary predisposition syndromes have been associated with a substantially increased lifetime risk for the development of colorectal cancers and breast-ovarian cancers depending on the genetic syndrome, and many people also carry an increased risk of several other cancers compared with the general population. The aim of this review was to provide comprehensive literature on the most commonly encountered hereditary predisposition syndromes, including Lynch syndrome, familial adenomatous polyposis, MUTYH-associated polyposis, hamartomatous polyposis, and breast-ovarian cancer conditions. This will be presented as a 2-part series: the first part will cover the breast-ovarian cancer syndromes, and the second will focus on the inherited colorectal cancer and polyposis conditions.
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Affiliation(s)
- N Jewel Samadder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ; Department of Clinical Genomics, Mayo Clinic, Scottsdale, AZ; Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL.
| | | | - Noemi Baffy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ
| | - Douglas Riegert-Johnson
- Department of Clinical Genomics, Mayo Clinic, Scottsdale, AZ; Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL; Department of Clinical Genomics, Mayo Clinic, Jacksonville, FL
| | - Fergus J Couch
- Department of Laboratory Medicine, Mayo Clinic, Rochester, MN
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Kehm RD, Hopper JL, John EM, Phillips KA, MacInnis RJ, Dite GS, Milne RL, Liao Y, Zeinomar N, Knight JA, Southey MC, Vahdat L, Kornhauser N, Cigler T, Chung WK, Giles GG, McLachlan SA, Friedlander ML, Weideman PC, Glendon G, Nesci S, Andrulis IL, Buys SS, Daly MB, Terry MB. Regular use of aspirin and other non-steroidal anti-inflammatory drugs and breast cancer risk for women at familial or genetic risk: a cohort study. Breast Cancer Res 2019; 21:52. [PMID: 30999962 PMCID: PMC6471793 DOI: 10.1186/s13058-019-1135-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/05/2019] [Indexed: 01/23/2023] Open
Abstract
Background The use of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with reduced breast cancer risk, but it is not known if this association extends to women at familial or genetic risk. We examined the association between regular NSAID use and breast cancer risk using a large cohort of women selected for breast cancer family history, including 1054 BRCA1 or BRCA2 mutation carriers. Methods We analyzed a prospective cohort (N = 5606) and a larger combined, retrospective and prospective, cohort (N = 8233) of women who were aged 18 to 79 years, enrolled before June 30, 2011, with follow-up questionnaire data on medication history. The prospective cohort was further restricted to women without breast cancer when medication history was asked by questionnaire. Women were recruited from seven study centers in the United States, Canada, and Australia. Associations were estimated using multivariable Cox proportional hazards regression models adjusted for demographics, lifestyle factors, family history, and other medication use. Women were classified as regular or non-regular users of aspirin, COX-2 inhibitors, ibuprofen and other NSAIDs, and acetaminophen (control) based on self-report at follow-up of ever using the medication for at least twice a week for ≥1 month prior to breast cancer diagnosis. The main outcome was incident invasive breast cancer, based on self- or relative-report (81% confirmed pathologically). Results From fully adjusted analyses, regular aspirin use was associated with a 39% and 37% reduced risk of breast cancer in the prospective (HR = 0.61; 95% CI = 0.33–1.14) and combined cohorts (HR = 0.63; 95% CI = 0.57–0.71), respectively. Regular use of COX-2 inhibitors was associated with a 61% and 71% reduced risk of breast cancer (prospective HR = 0.39; 95% CI = 0.15–0.97; combined HR = 0.29; 95% CI = 0.23–0.38). Other NSAIDs and acetaminophen were not associated with breast cancer risk in either cohort. Associations were not modified by familial risk, and consistent patterns were found by BRCA1 and BRCA2 carrier status, estrogen receptor status, and attained age. Conclusion Regular use of aspirin and COX-2 inhibitors might reduce breast cancer risk for women at familial or genetic risk. Electronic supplementary material The online version of this article (10.1186/s13058-019-1135-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca D Kehm
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Esther M John
- Department of Medicine and Stanford Cancer Institute, Stanford University School of Medicine, 780 Welch Road, Stanford, CA, 94304, USA
| | - Kelly-Anne Phillips
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Robert J MacInnis
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Gillian S Dite
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, 3168, Australia
| | - Yuyan Liao
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - Nur Zeinomar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA
| | - Julia A Knight
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario, M5T3M7, Canada
| | - Melissa C Southey
- Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Linda Vahdat
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA.,C Anthony and Jean Whittingham Cancer Center, 34 Maple Street, Norwalk, CT, 06856, USA
| | - Naomi Kornhauser
- Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10065, USA
| | - Tessa Cigler
- Weill Cornell Medicine Breast Center, 428 E 72nd St, New York, NY, 10021, USA
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, 1150 St Nicholas Ave, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA
| | - Graham G Giles
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia.,Cancer Epidemiology, Cancer Council Victoria, 615 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, St Vincent's Hospital, The University of Melbourne, Parkville, VIC, 3010, Australia.,Department of Medical Oncology, St Vincent's Hospital, 41 Victoria St, Fitzroy, VIC, 3065, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, 2052, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Barker St, Randwick, NSW, 2031, Australia
| | - Prue C Weideman
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Gord Glendon
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada
| | - Stephanie Nesci
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia
| | | | - Irene L Andrulis
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 600 University Ave, Toronto, Ontario, M5G 1X5, Canada.,Departments of Molecular Genetics and Laboratory Medicine and Pathobiology, University of Toronto, 164 College Street, Toronto, ON, M5S 3G9, Canada
| | - Saundra S Buys
- Department of Medicine and Huntsman Cancer Institute, University of Utah Health, 2000 Cir of Hope Dr, Salt Lake City, UT, 84103, USA
| | - Mary B Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, 10032, USA. .,Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, 1130 St Nicholas Ave, New York, NY, 10032, USA.
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Zhang X, Wang Y, Chiang HC, Hsieh YP, Lu C, Park BH, Jatoi I, Jin VX, Hu Y, Li R. BRCA1 mutations attenuate super-enhancer function and chromatin looping in haploinsufficient human breast epithelial cells. Breast Cancer Res 2019; 21:51. [PMID: 30995943 PMCID: PMC6472090 DOI: 10.1186/s13058-019-1132-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/27/2019] [Indexed: 01/07/2023] Open
Abstract
Background BRCA1-associated breast cancer originates from luminal progenitor cells. BRCA1 functions in multiple biological processes, including double-strand break repair, replication stress suppression, transcriptional regulation, and chromatin reorganization. While non-malignant cells carrying cancer-predisposing BRCA1 mutations exhibit increased genomic instability, it remains unclear whether BRCA1 haploinsufficiency affects transcription and chromatin dynamics in breast epithelial cells. Methods H3K27ac-associated super-enhancers were compared in primary breast epithelial cells from BRCA1 mutation carriers (BRCA1mut/+) and non-carriers (BRCA1+/+). Non-tumorigenic MCF10A breast epithelial cells with engineered BRCA1 haploinsufficiency were used to confirm the H3K27ac changes. The impact of BRCA1 mutations on enhancer function and enhancer-promoter looping was assessed in MCF10A cells. Results Here, we show that primary mammary epithelial cells from women with BRCA1 mutations display significant loss of H3K27ac-associated super-enhancers. These BRCA1-dependent super-enhancers are enriched with binding motifs for the GATA family. Non-tumorigenic BRCA1mut/+ MCF10A cells recapitulate the H3K27ac loss. Attenuated histone mark and enhancer activity in these BRCA1mut/+ MCF10A cells can be partially restored with wild-type BRCA1. Furthermore, chromatin conformation analysis demonstrates impaired enhancer-promoter looping in BRCA1mut/+ MCF10A cells. Conclusions H3K27ac-associated super-enhancer loss is a previously unappreciated functional deficiency in ostensibly normal BRCA1 mutation-carrying breast epithelium. Our findings offer new mechanistic insights into BRCA1 mutation-associated transcriptional and epigenetic abnormality in breast epithelial cells and tissue/cell lineage-specific tumorigenesis. Electronic supplementary material The online version of this article (10.1186/s13058-019-1132-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaowen Zhang
- Department of Biochemistry & Molecular Medicine, School of Medicine & Health Sciences, The George Washington University, Washington, DC, 20037, USA
| | - Yao Wang
- Department of Molecular Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Huai-Chin Chiang
- Department of Biochemistry & Molecular Medicine, School of Medicine & Health Sciences, The George Washington University, Washington, DC, 20037, USA
| | - Yuan-Pang Hsieh
- Department of Chemical Engineering, Virginia Tech, Blacksburg, VA, 24061, USA
| | - Chang Lu
- Department of Chemical Engineering, Virginia Tech, Blacksburg, VA, 24061, USA
| | - Ben Ho Park
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Ismail Jatoi
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Victor X Jin
- Department of Molecular Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA.
| | - Yanfen Hu
- Department of Anatomy & Cell Biology, School of Medicine & Health Sciences, The George Washington University, Washington, DC, 20037, USA.
| | - Rong Li
- Department of Biochemistry & Molecular Medicine, School of Medicine & Health Sciences, The George Washington University, Washington, DC, 20037, USA.
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Metcalfe K, Eisen A, Senter L, Armel S, Bordeleau L, Meschino WS, Pal T, Lynch HT, Tung NM, Kwong A, Ainsworth P, Karlan B, Moller P, Eng C, Weitzel JN, Sun P, Lubinski J, Narod SA. International trends in the uptake of cancer risk reduction strategies in women with a BRCA1 or BRCA2 mutation. Br J Cancer 2019; 121:15-21. [PMID: 30971774 PMCID: PMC6738089 DOI: 10.1038/s41416-019-0446-1] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Women with a BRCA1 or BRCA2 mutation face high risks of breast and ovarian cancer. In the current study, we report on uptake of cancer screening and risk-reduction options in a cohort of BRCA mutation carriers from ten countries over two time periods (1995 to 2008 and 2009 to 2017). METHODS Eligible subjects were identified from an international database of female BRCA mutation carriers and included women from 59 centres from ten countries. Subjects completed a questionnaire at the time of genetic testing, which included past use of cancer prevention options and screening tests. Biennial follow-up questionnaires were administered. RESULTS Six-thousand two-hundred and twenty-three women were followed for a mean of 7.5 years. The mean age at last follow-up was 52.1 years (27-96 years) and 42.3% of the women had a prior diagnosis of breast cancer. In all, 27.8% had a prophylactic bilateral mastectomy and 64.7% had a BSO. Screening with breast MRI increased from 70% before 2009 to 81% at or after 2009. There were significant differences in uptake of all options by country. CONCLUSION For women who received genetic testing more recently, uptake of prophylactic mastectomy and breast MRI is significantly higher than those who received genetic testing more than 10 years ago. However, uptake of both BSO and breast MRI is not optimal, and interventions to increase uptake are needed.
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Affiliation(s)
- Kelly Metcalfe
- Women's College Research Institute, Toronto, ON, Canada.,Bloomberg, Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Andrea Eisen
- Toronto-Sunnybrook Regional Cancer Center, Toronto, ON, Canada
| | - Leigha Senter
- Division of Human Genetics, The Ohio State University Medical Center, Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan Armel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | | | | | - Tuya Pal
- Vanderbilt-Ingram Cancer Center/Vanderbilt University Medical Center, Nashville, TN, USA
| | - Henry T Lynch
- Hereditary Cancer Center, Creighton University School of Medicine, Omaha, NE, USA
| | - Nadine M Tung
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ava Kwong
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong SAR.,Department of Surgery, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong SAR.,Hong Kong Hereditary Breast Cancer Family Registry, Happy Valley, Hong Kong SAR
| | - Peter Ainsworth
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Beth Karlan
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, West Hollywood, CA, USA
| | - Pal Moller
- Research Group Inherited Cancer, Department of Medical, Genetics, Oslo University Hospital, Oslo, Norway.,Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway.,Center for Hereditary Tumors, HELIOS-Klinikum Wuppertal, University of Witten-Herdecke, Wuppertal, Germany
| | - Charis Eng
- Genomic Medicine Institute, Center for Personalised Genetic Healthcare, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ping Sun
- Women's College Research Institute, Toronto, ON, Canada
| | - Jan Lubinski
- International Hereditary Cancer Center, Department of Genetics and Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Steven A Narod
- Women's College Research Institute, Toronto, ON, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Kwon JS, Tinker AV, Hanley GE, Pansegrau G, Sun S, Carey MS, Schrader I. BRCA mutation testing for first-degree relatives of women with high-grade serous ovarian cancer. Gynecol Oncol 2019; 152:459-464. [DOI: 10.1016/j.ygyno.2018.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/25/2018] [Accepted: 10/15/2018] [Indexed: 12/20/2022]
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71
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Asphaug L, Melberg HO. The Cost-Effectiveness of Multigene Panel Testing for Hereditary Breast and Ovarian Cancer in Norway. MDM Policy Pract 2019; 4:2381468318821103. [PMID: 30746499 PMCID: PMC6360477 DOI: 10.1177/2381468318821103] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/21/2018] [Indexed: 12/20/2022] Open
Abstract
Background. Expansion of routine genetic testing for hereditary breast and ovarian cancer from conventional BRCA testing to a multigene test could improve diagnostic yield and increase the opportunity for cancer prevention in both identified carriers and their relatives. We use an economic decision model to assess whether the current knowledge on non-BRCA mutation prevalence, cancer risk, and patient preferences justifies switching to a multigene panel for testing of early-onset breast cancer patients. Methods. We evaluated routine testing by BRCA testing, a 7-gene panel, and a 14-gene panel using individual-level simulations of annual health state transitions over a lifetime perspective. Breast and ovarian cancer incidence is reduced and posttreatment survival is improved when high-risk mutations are detected and risk-reducing treatment offered. Most model inputs were synthesized from published literature. Intermediate health outcomes included breast and ovarian cancer incidence rates, along with organ-specific cancer mortality. Cost-effectiveness outcomes were health sector costs and quality-adjusted life years. Results. Intermediate health outcomes improved by testing with multigene panels. At a cost-effectiveness threshold of $77,000, a 7-gene panel test with five non-BRCA genes was the optimal strategy with an incremental cost-effectiveness ratio of $53,310 per quality-adjusted life year compared to BRCA-only testing. Limitations. Unable to stratify carriers to specific mutations within genes, we can only make predictions on the gene level, with combined risk estimates for known variants. As mutation prevalence is the absolute upper bound of returns to more expansive testing, the rarity of modelled mutations makes analysis outcomes sensitive to model implementation. Conclusions. A 7-gene panel to diagnose hereditary breast and ovarian cancer in early-onset breast cancer patients can be a cost-effective alternative to current BRCA-only testing in Norway.
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Affiliation(s)
- Lars Asphaug
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Hans Olav Melberg
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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72
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Best AF, Tucker MA, Frone MN, Greene MH, Peters JA, Katki HA. A Pragmatic Testing-Eligibility Framework for Population Mutation Screening: The Example of BRCA1/2. Cancer Epidemiol Biomarkers Prev 2019; 28:293-302. [PMID: 30692095 DOI: 10.1158/1055-9965.epi-18-0584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/07/2018] [Accepted: 10/19/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Eligibility guidelines for genetic testing may be revisited, given technological advances, plummeting costs, and proposals for population mutation screening. A key property of eligibility criteria is the tradeoff between the number of mutation carriers identified versus population members tested. We assess the fractions of mutation carriers identified, versus women undergoing mutation testing, for BRCA1/2 founder mutation screening in U.S. Ashkenazi-Jewish women. METHODS BRCA1/2 carrier probabilities, based on personal/family history, were calculated using the risk-prediction tool BRCAPRO for 4,589 volunteers (102 mutation carriers) in the population-based Washington Ashkenazi Study. For each carrier-probability threshold between 0% and 10%, we compared the percentage of founder mutations detected versus the percentage of women requiring mutation testing. PCR mutation testing was conducted at the NIH for the 3 Ashkenazi-Jewish founder mutations (5382insC and 185delAG in BRCA1, and 6174delT in BRCA2). RESULTS Identifying 90% of BRCA1/2 founder mutations required testing the 60% of Ashkenazi-Jewish women with carrier probabilities exceeding 0.56%, potentially avoiding mutation testing for approximately 0.7 to 1.1 million U.S. Ashkenazi-Jewish women. Alternatively, testing the 44% whose carrier probability exceeded 0.78% identified 80% of mutation carriers, increasing to 89% of mutation carriers when accounting for cascade testing triggered after mutation-positive daughters were identified by screening. We present data on all carrier-probability thresholds, e.g., a 5% threshold identified 46% of mutation carriers while testing 10% of women. CONCLUSIONS Different carrier-probability thresholds offered diverse tradeoffs between numbers of identified mutation carriers versus women tested. Low carrier-probability thresholds identified 90% of BRCA1/2 founder mutation carriers, without testing approximately 1 million U.S. Ashkenazi-Jewish women with lowest carrier probabilities. IMPACT In general, this risk-based framework could provide useful new options to consider during eligibility-criteria development for population mutation screening.
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Affiliation(s)
- Ana F Best
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - Margaret A Tucker
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - Megan N Frone
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - Mark H Greene
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - June A Peters
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - Hormuzd A Katki
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland.
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73
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Peccatori FA, Mangili G, Bergamini A, Filippi F, Martinelli F, Ferrari F, Noli S, Rabaiotti E, Candiani M, Somigliana E. Fertility preservation in women harboring deleterious BRCA mutations: ready for prime time? Hum Reprod 2019; 33:181-187. [PMID: 29207007 DOI: 10.1093/humrep/dex356] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 11/09/2017] [Indexed: 12/31/2022] Open
Abstract
Fertility issues have become critical in the management and counseling of BRCA mutation carriers. In this setting four points deserve consideration. (1) Women in general lose their ability to conceive at a mean age of 41 years, thus the suggested policy of prophylactic bilateral salpingo-oophorectomy at age 40 for BRCA mutation carriers does not affect the chances of natural pregnancy. Conversely, if the procedure is chosen at 35 years old, oocyte cryopreservation prior to surgery should be considered. (2) Some evidence suggests that ovarian reserve may actually be partly reduced in BRCA mutations carriers and that the mutation may affect ovarian responsiveness to stimulation. However, these findings are still controversial. (3) Breast cancer is not rare before the age of 40 and fertility preservation after diagnosis can be requested in a significant proportion of BRCA mutation carriers. Thus, a policy of oocyte cryopreservation in young healthy carriers deserves consideration. The procedure could be considered at a young age and in an elective setting, when ovarian stimulation may yield more oocytes of better quality. (4) Preimplantation genetic diagnosis (PGD) could be considered in BRCA mutations carriers, particularly when good quality oocytes have been stored at a young age. Based on the current knowledge, a univocal approach cannot be recommended; in depth patient counseling is warranted.
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Affiliation(s)
- Fedro Alessandro Peccatori
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, Via S. Luca 8, 20122 Milan, Italy
| | - Giorgia Mangili
- Department of Obstetrics and Gynecology, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Alice Bergamini
- Department of Obstetrics and Gynecology, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Francesca Filippi
- Obstetrics and Gynecology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 12, 20122 Milan, Italy
| | - Fabio Martinelli
- Gynecologic Oncology Unit, Fondazione IRCCS National Cancer Institute, Via G. Venezian, 1, 20133 Milan, Italy
| | - Federica Ferrari
- Applied Research Division for Cognitive and Psychological Science, European Institute of Oncology, Via S. Luca 8, 20122 Milan, Italy
| | - Stefania Noli
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology, Via S. Luca 8, 20122 Milan, Italy.,Obstetrics and Gynecology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milan, Italy
| | - Emanuela Rabaiotti
- Department of Obstetrics and Gynecology, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Massimo Candiani
- Department of Obstetrics and Gynecology, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Edgardo Somigliana
- Obstetrics and Gynecology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 12, 20122 Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 20122 Milan, Italy
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74
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Kotsopoulos J. BRCA Mutations and Breast Cancer Prevention. Cancers (Basel) 2018; 10:E524. [PMID: 30572612 PMCID: PMC6315560 DOI: 10.3390/cancers10120524] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/05/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Women who inherit a deleterious BRCA1 or BRCA2 mutation face substantially increased risks of developing breast cancer, which is estimated at 70%. Although annual screening with magnetic resonance imaging (MRI) and mammography promotes the earlier detection of the disease, the gold standard for the primary prevention of breast cancer remains bilateral mastectomy. In the current paper, I review the evidence regarding the management of healthy BRCA mutation carriers, including key risk factors and protective factors, and also discuss potential chemoprevention options. I also provide an overview of the key findings from the literature published to date, with a focus on data from studies that are well-powered, and preferably prospective in nature.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, 6th Floor, Toronto, ON M5S 1B2, Canada.
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada.
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75
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Oliveri S, Ferrari F, Manfrinati A, Pravettoni G. A Systematic Review of the Psychological Implications of Genetic Testing: A Comparative Analysis Among Cardiovascular, Neurodegenerative and Cancer Diseases. Front Genet 2018; 9:624. [PMID: 30619456 PMCID: PMC6295518 DOI: 10.3389/fgene.2018.00624] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/23/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Genetic testing is performed for different purposes, such as identifying carriers, predicting a disease onset in presymptomatic individuals or confirming a diagnosis. However, these tests may have notable psychological effects, such as generating anxiety and depression. These effects may depend on people's perception of risk, severity, and controllability of the disease; and the availability of treatments. To date, there are no reports that analyze these factors specifically, and their role in influencing genetic test users' experience. Methods: We performed a systematic review of the psychological implication of undergoing genetic testing for cardiovascular, neurodegenerative and cancer diseases. Articles were searched on PubMed, Google Scholar, and PsychInfo. Results: 47 studies were included, 9 concerning cardiovascular disease, 18 neurodegenerative disorders, and 20 for cancer disease. According to the reviewed studies, people experience no significant increase in distress and anxiety, or adverse impacts on quality of life, except the Huntington disease, which is characterized by depressive symptoms, suicidal ideations, and hopelessness in gene carriers. People tend to consider genetic tests as valid information to take important preventive decisions. Genetic risk for cardiovascular disease is perceived to be manageable; genetic analysis for some neurodegenerative diseases (e.g., Alzheimer) or cancer (breast cancer in particular) is considered useful because the problem could be addressed in advance with preventive behaviors. Conclusions: Genetic tests should be proposed along with proper psychological support and counseling focused on users' genetic health literacy; perception of risk, beliefs about disease controllability, in order to foster fruitful medical decisions.
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Affiliation(s)
- Serena Oliveri
- Department of Oncology and Hematoncology, Interdisciplinary Research Center on Decision Making Processes, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Federica Ferrari
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Andrea Manfrinati
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hematoncology, Interdisciplinary Research Center on Decision Making Processes, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
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76
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A clinically structured and partnered approach to genetic testing in Trinidadian women with breast cancer and their families. Breast Cancer Res Treat 2018; 174:469-477. [PMID: 30515680 DOI: 10.1007/s10549-018-5045-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Breast cancer (BC) is the leading cause of cancer death in Caribbean women. Across the Caribbean islands, the prevalence of hereditary breast cancer among unselected breast cancer patients ranges from 5 to 25%. Moreover, the prevalence of BC among younger women and the high mortality in the Caribbean region are notable. This BC burden presents an opportunity for cancer prevention and control that begins with genetic testing among high-risk women. Measured response to positive genetic test results includes the number of preventive procedures and cascade testing in family members. We previously reported data on an active approach to promote cascade testing in the Bahamas and report on preventive procedures showing moderate uptake. Here, we describe a clinically structured and community-partnered approach to the dissemination and follow-up of genetic test results including family counseling for the promotion of risk mitigation strategies and cascade testing in our Trinidadian cohort of patients tested positive for BC predisposition genes. METHODS As a part of our initial study of BC genetic testing in Trinidad and Tobago, all participants received pre-test counseling including three-generation pedigree and genetic testing for BRCA1/2, PALB2, and RAD51C. The study was approved by the University of Miami IRB and the Ethics Committee of the Ministry of Health, Trinidad and Tobago. We prospectively evaluated a clinically structured approach to genetic counseling and follow-up of BC mutation carriers in Trinidad and Tobago in 2015. The intervention consisted of (1) engaging twenty-nine BC patients with a deleterious gene mutation (probands), and (2) invitation of their at-risk relatives to attend to a family counseling session. The session included information on the meaning of their results, risk of inheritance, risk of cancer, risk-reduction options, offering of cascade testing to family members, and follow-up of proband decision-making over two years. RESULTS Twenty-four of twenty-nine mutation carriers (82.8%) consented to enroll in the study. At initial pedigree review, we identified 125 at-risk relatives (ARR). Seventy-seven ARR (62%) attended the family counseling sessions; of these, 76 ARR (99%) consented to be tested for their family gene mutation. Genetic sequencing revealed that of the 76 tested, 35 (46%) ARR were carriers of their family mutation. The ARR received their results and were urged to take preventative measures at post-test counseling. At 2-year follow-up, 6 of 21 probands with intact breasts elected to pursue preventive mastectomy (28.5%) and 4 of 20 women with intact ovaries underwent RRSO (20%). CONCLUSIONS In Trinidad and Tobago, a clinically structured and partnered approach to our testing program led to a significant rate of proband response by completing the intervention counseling session, executing risk-reducing procedures as well as informing and motivating at-risk relatives, thereby demonstrating the utility and efficacy of this BC control program.
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Ramos MCDA, Folgueira MAAK, Maistro S, Campolina AG, de Soárez PC, de Bock GH, Novaes HMD, Diz MDPE. Cost effectiveness of the cancer prevention program for carriers of the BRCA1/2 mutation. Rev Saude Publica 2018; 52:94. [PMID: 30517521 PMCID: PMC6280621 DOI: 10.11606/s1518-8787.2018052000643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/04/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To analyze the cost effectiveness of the diagnostic program for the germline mutation in BRCA1/2 genes and of preventative strategies for the relatives of patients diagnosed with ovarian cancer associated with this mutation. METHODS The study analyzed the cost effectiveness by developing an analysis of the Markov decision process from the perspective of the National Health System. The strategies compared reflect upon the adoption of genetic testing and preventative strategies for relatives or the usual care currently proposed. The incremental cost-effectiveness ratio was expressed in terms of cost per case avoided. The sensitivity analysis was performed in a univariate and deterministic manner. RESULTS The study showed increments for effectiveness and for costs when performing genetic testing and adopting prophylactic measures for family members. The incremental cost-effectiveness ratio was estimated at R$908.58 per case of cancer avoided, a figure considered lower than the study's cost-effectiveness threshold (R$7,543.50). CONCLUSIONS The program analyzed should be considered a cost-effective strategy for the national situation. Studies in various other countries have reached similar conclusions. One possible ramification of this research might the need to perform a budgetary-impact analysis of making the program one of the country's health policies.
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Affiliation(s)
| | - Maria Aparecida Azevedo Koike Folgueira
- Universidade de São Paulo. Faculdade de Medicina. Hospital das Clínicas. Instituto do Câncer do Estado de São Paulo. Centro de Investigação Translacional em Oncologia. São Paulo, SP, Brasil
| | - Simone Maistro
- Universidade de São Paulo. Faculdade de Medicina. Hospital das Clínicas. Instituto do Câncer do Estado de São Paulo. Centro de Investigação Translacional em Oncologia. São Paulo, SP, Brasil
| | - Alessandro Gonçalves Campolina
- Universidade de São Paulo. Faculdade de Medicina. Hospital das Clínicas. Instituto do Câncer do Estado de São Paulo. Centro de Investigação Translacional em Oncologia. São Paulo, SP, Brasil
| | - Patricia Coelho de Soárez
- Universidade de São Paulo. Faculdade de Medicina. Departamento de Medicina Preventiva. São Paulo, SP, Brasil
| | - Geertruida Hendrika de Bock
- University of Groningen. University Medical Center Groningen. Department of Epidemiology. Groningen, The Netherlands
| | | | - Maria Del Pilar Estevez Diz
- Universidade de São Paulo. Faculdade de Medicina. Hospital das Clínicas. Instituto do Câncer do Estado de São Paulo. Divisão de Oncologia Clínica. São Paulo, SP, Brasil
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78
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Giannakeas V, Cadarette SM, Ban JK, Lipscombe L, Narod SA, Kotsopoulos J. Denosumab and breast cancer risk in postmenopausal women: a population-based cohort study. Br J Cancer 2018; 119:1421-1427. [PMID: 30420611 PMCID: PMC6265331 DOI: 10.1038/s41416-018-0225-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Denosumab inhibits the receptor activator of nuclear factor κB (RANK) pathway and is used to treat osteoporosis. Emerging evidence suggests RANK-blockade may play a role in mammary tumourigenesis. Thus, we undertook a population-based study of denosumab use and breast cancer risk in a large cohort of postmenopausal women. METHODS We included women 67+ years with prior bisphosphonate use who filled a first prescription for denosumab. They were matched on age, date, cumulative prior use of and time since last use of a bisphosphonate to women with no history of denosumab. Cox proportional hazards was used to estimate the hazard ratio (HR) of breast cancer with denosumab use. RESULTS A total of 100,368 women were included in the analysis with 1271 incident breast cancer events. Denosumab use was associated with a 13% decreased breast cancer risk (HR = 0.87; 95% CI 0.76-1.00). There was no relationship between increasing number of denosumab doses and breast cancer risk (P-trend = 0.15). CONCLUSION These findings suggest a potential protective effect of ever denosumab use on breast cancer risk in a cohort of older women previously treated with bisphosphonates.
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Affiliation(s)
- Vasily Giannakeas
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Suzanne M Cadarette
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Joann K Ban
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Lorraine Lipscombe
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Steven A Narod
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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79
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Kim J, Park EY, Kim O, Schilder JM, Coffey DM, Cho CH, Bast RC. Cell Origins of High-Grade Serous Ovarian Cancer. Cancers (Basel) 2018; 10:cancers10110433. [PMID: 30424539 PMCID: PMC6267333 DOI: 10.3390/cancers10110433] [Citation(s) in RCA: 153] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/03/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022] Open
Abstract
High-grade serous ovarian cancer, also known as high-grade serous carcinoma (HGSC), is the most common and deadliest type of ovarian cancer. HGSC appears to arise from the ovary, fallopian tube, or peritoneum. As most HGSC cases present with widespread peritoneal metastases, it is often not clear where HGSC truly originates. Traditionally, the ovarian surface epithelium (OSE) was long believed to be the origin of HGSC. Since the late 1990s, the fallopian tube epithelium has emerged as a potential primary origin of HGSC. Particularly, serous tubal intraepithelial carcinoma (STIC), a noninvasive tumor lesion formed preferentially in the distal fallopian tube epithelium, was proposed as a precursor for HGSC. It was hypothesized that STIC lesions would progress, over time, to malignant and metastatic HGSC, arising from the fallopian tube or after implanting on the ovary or peritoneum. Many clinical studies and several mouse models support the fallopian tube STIC origin of HGSC. Current evidence indicates that STIC may serve as a precursor for HGSC in high-risk women carrying germline BRCA1 or 2 mutations. Yet not all STIC lesions appear to progress to clinical HGSCs, nor would all HGSCs arise from STIC lesions, even in high-risk women. Moreover, the clinical importance of STIC remains less clear in women in the general population, in which 85–90% of all HGSCs arise. Recently, increasing attention has been brought to the possibility that many potential precursor or premalignant lesions, though composed of microscopically—and genetically—cancerous cells, do not advance to malignant tumors or lethal malignancies. Hence, rigorous causal evidence would be crucial to establish that STIC is a bona fide premalignant lesion for metastatic HGSC. While not all STICs may transform into malignant tumors, these lesions are clearly associated with increased risk for HGSC. Identification of the molecular characteristics of STICs that predict their malignant potential and clinical behavior would bolster the clinical importance of STIC. Also, as STIC lesions alone cannot account for all HGSCs, other potential cellular origins of HGSC need to be investigated. The fallopian tube stroma in mice, for instance, has been shown to be capable of giving rise to metastatic HGSC, which faithfully recapitulates the clinical behavior and molecular aspect of human HGSC. Elucidating the precise cell(s) of origin of HGSC will be critical for improving the early detection and prevention of ovarian cancer, ultimately reducing ovarian cancer mortality.
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Affiliation(s)
- Jaeyeon Kim
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Indiana University Melvin & Bren Simon Cancer Center, Indianapolis, IN 46202, USA.
| | - Eun Young Park
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Olga Kim
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Jeanne M Schilder
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Indiana University Melvin & Bren Simon Cancer Center, Indianapolis, IN 46202, USA.
| | - Donna M Coffey
- Department of Pathology and Genomic Medicine, Houston Methodist and Weill Cornell Medical College, Houston, TX 77030, USA.
| | - Chi-Heum Cho
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, Daegu 41931, Korea.
| | - Robert C Bast
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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80
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Personalised medicine and population health: breast and ovarian cancer. Hum Genet 2018; 137:769-778. [DOI: 10.1007/s00439-018-1944-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
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81
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Doren A, Vecchiola A, Aguirre B, Villaseca P. Gynecological–endocrinological aspects in women carriers of BRCA1/2 gene mutations. Climacteric 2018; 21:529-535. [DOI: 10.1080/13697137.2018.1514006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- A. Doren
- Obstetrics and Gynecology Department, Faculty of Medicine, Universidad Católica del Maule, Talca, Chile
| | - A. Vecchiola
- Endocrinology Department, Faculty of Medicine, Millenium Institute of Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - B. Aguirre
- Breast Imaging, Radiology Service, Clínica Las Condes, Santiago, Chile
| | - P. Villaseca
- Endocrinology Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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82
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Rainey L, van der Waal D, Wengström Y, Jervaeus A, Broeders MJ. Women's perceptions of the adoption of personalised risk-based breast cancer screening and primary prevention: a systematic review. Acta Oncol 2018; 57:1275-1283. [PMID: 29882455 DOI: 10.1080/0284186x.2018.1481291] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Increased knowledge of breast cancer risk factors may enable a paradigm shift from the current age-based mammographic screening programmes to a personalised risk-based approach. This would warrant a significant change in practice, yet the acceptability from a woman's perspective has never been systematically explored. In this systematic review, we inventoried and appraised studies of women's perceptions of risk-based breast cancer screening and prevention to identify factors associated with adopting this new paradigm. METHODS We searched Medline, Embase and PsycInfo to identify original articles in English containing perceptions of risk-based breast cancer screening and/or primary prevention of women with an average to above average risk of developing breast cancer. Qualitative data were systematically extracted and referenced against four theoretical models of preventative health behaviour adoption. RESULTS When considering the adoption of this novel screening and prevention programme, women carefully review their perceived susceptibility to breast cancer. Their decisions are based on a cost-benefit analysis of adopting lifestyle changes, chemoprevention, or prophylactic surgery, taking into account their perceived competence, individual autonomy, relatedness to others, and personal preference. The role of intent is limited when considering behavioural change. CONCLUSIONS Implementing risk-based breast cancer screening and prevention will require a multifactorial approach. The transition from theory to practice can be supported by developing evidence-based shared decision aids and family-oriented (genetic) counselling programmes.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
- Theme Cancer, Karolinska University Hospital, Huddinge, Sweden
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
| | - Mireille J.M. Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Dutch Expert Center for Screening, Nijmegen, The Netherlands
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83
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Dossa F, Cusimano MC, Sutradhar R, Metcalfe K, Little T, Lerner-Ellis J, Eisen A, Meschino WS, Baxter NN. Real-world health services utilisation and outcomes after BRCA1 and BRCA2 testing in Ontario, Canada: the What Comes Next Cohort Study protocol. BMJ Open 2018; 8:e025317. [PMID: 30181190 PMCID: PMC6129086 DOI: 10.1136/bmjopen-2018-025317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Women who have pathogenic mutations in the BRCA1 and BRCA2 genes are at greatly increased risks for breast and ovarian cancers. Although risk-reduction strategies can be undertaken by these women, knowledge regarding the uptake of these strategies is limited. Additionally, the healthcare behaviours of women who receive inconclusive test results are not known. This study protocol describes the creation of a retrospective cohort of women who have undergone genetic testing for BRCA1 and BRCA2, linking genetic test results with administrative data to quantify the uptake of risk-reduction strategies and to assess long-term cancer and non-cancer outcomes after genetic testing. METHODS AND ANALYSIS Approximately two-thirds of BRCA1 and BRCA2 testing in Ontario, Canada is performed at North York General Hospital (NYGH) and Mount Sinai Hospital (MSH), Toronto. We will use registries at these sites to assemble a cohort of approximately 17 000 adult women who underwent BRCA1 and BRCA2 testing from January 2007 to April 2016. Trained chart abstractors will obtain detailed information for all women tested over this period, including demographics, personal and family cancer histories and genetic test results. We will link these data to provincial administrative databases, enabling assessment of healthcare utilisation and long-term outcomes after testing. Study outcomes will include the uptake of breast cancer screening and prophylactic breast and ovarian surgery, cancer incidence and mortality and incidence of non-cancer health outcomes, including cardiovascular, osteoporotic and neurodegenerative disease. ETHICS AND DISSEMINATION This study has been approved by the Research Ethics Boards at NYGH (no 16-0035), MSH (no 13-0124) and Sunnybrook Health Sciences Centre (no 275-2016). We plan to disseminate research findings through peer-reviewed publications and presentations at national and international meetings.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maria C Cusimano
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kelly Metcalfe
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Tari Little
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jordan Lerner-Ellis
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Andrea Eisen
- Sunnybrook Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Wendy S Meschino
- Department of Molecular Genetics, North York General Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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84
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Puski A, Hovick S, Senter L, Toland AE. Involvement and Influence of Healthcare Providers, Family Members, and Other Mutation Carriers in the Cancer Risk Management Decision-Making Process of BRCA1 and BRCA2 Mutation Carriers. J Genet Couns 2018; 27:1291-1301. [PMID: 29594659 PMCID: PMC6612901 DOI: 10.1007/s10897-018-0254-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/19/2018] [Indexed: 01/04/2023]
Abstract
Deciding between increased cancer screening or prophylactic surgery and the timing of such procedures can be a difficult and complex process for women with BRCA mutations. There are gaps in our understanding of involvement of others in the decision-making process for women with BRCA mutations. This study evaluated the management decision-making process of women with BRCA mutations, focusing on the involvement of others. Grounded theory was used to analyze and code risk management decision-making information from interviews with 20 BRCA mutation carriers. Unaffected at-risk participants with a BRCA mutation, those under age 40, and those with no children described having a difficult time making risk management decisions. Physicians were an integral part of the decision-making process by providing decisional support and management recommendations. Family members and other mutation carriers filled similar yet distinct roles by providing experiential information as well as decisional and emotional support for carriers. Participants described genetic counselors as short-term providers of risk information and management recommendations. The study findings suggest that unaffected at-risk women, women under 40, and those who do not have children may benefit from additional support and information during the decision-making process. Genetic counselors are well trained to help women through this process and connect them with resources, and may be under-utilized in long-term follow-up for women with a BRCA mutation.
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Affiliation(s)
- Athena Puski
- Division of Human Genetics, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, 21602 PFP, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Shelly Hovick
- School of Communication, The Ohio State University, Columbus, OH, USA
| | - Leigha Senter
- Division of Human Genetics, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Amanda Ewart Toland
- Division of Human Genetics, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- Department of Cancer Biology and Genetics, The Ohio State University, Columbus, OH, USA
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85
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Carbine NE, Lostumbo L, Wallace J, Ko H. Risk-reducing mastectomy for the prevention of primary breast cancer. Cochrane Database Syst Rev 2018; 4:CD002748. [PMID: 29620792 PMCID: PMC6494635 DOI: 10.1002/14651858.cd002748.pub4] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010. OBJECTIVES (i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH METHODS For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias. MAIN RESULTS All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM. AUTHORS' CONCLUSIONS While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.
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Affiliation(s)
- Nora E Carbine
- Georgetown University Lombardi Cancer CenterTranslational Breast Cancer Research Consortium (TBCRC)WashingtonD.C.USA20007
| | | | | | - Henry Ko
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation Building92‐94 Parramatta Rd.,CamperdownNSWAustralia2050
- Academic Medicine Research Institute, Duke‐NUS Graduate Medical SchoolCentre for Health Services Research, SingHealthSingaporeSingapore169857
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Huesch MD, Schetter S, Segel J, Chetlen A. Evaluation of the "Angelina Jolie Effect" on Screening Mammography Utilization in an Academic Center. J Am Coll Radiol 2018; 14:1020-1026. [PMID: 28601611 DOI: 10.1016/j.jacr.2017.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/28/2017] [Accepted: 03/10/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to understand the impact on screening mammography at our institution, comparing weekly utilization in the 2 years before and the 2 years after Ms Angelina Jolie disclosed in the New York Times on May 13, 2013, that she had had a prophylactic double mastectomy. METHODS All 48,110 consecutive screening mammograms conducted at our institution between May 16, 2011, and May 16, 2015, were selected from our electronic medical record system. We used interrupted time series statistical models and graphical methods on utilization data to understand utilization changes before and after Ms Jolie's news. RESULTS The graphed trend of weekly screening mammogram utilization failed to show changes around the time of interest. Analytical models and statistical tests also failed to show a step change increase or acceleration of utilization around May 2013. However, graphical and time series analyses showed a flattening of utilization in the middle of 2014. CONCLUSIONS In our well-powered analysis in a large regional breast imaging center, we found no support for the hypothesis that this celebrity news drove increased screening.
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Affiliation(s)
- Marco D Huesch
- Department of Radiology, Milton S. Hershey Medical Center, Hershey, Pennsylvania.
| | - Susann Schetter
- Department of Radiology, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Joel Segel
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania
| | - Alison Chetlen
- Department of Radiology, Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Evans DG, Howell SJ, Howell A. Personalized prevention in high risk individuals: Managing hormones and beyond. Breast 2018; 39:139-147. [PMID: 29610032 DOI: 10.1016/j.breast.2018.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/17/2018] [Accepted: 03/24/2018] [Indexed: 12/01/2022] Open
Abstract
Increasing numbers of women are being identified at 'high-risk' of breast cancer, defined by The National Institute of Health and Care Excellence (NICE) as a 10-year risk of ≥8%. Classically women have been so identified through family history based risk algorithms or genetic testing of high-risk genes. Recent research has shown that assessment of mammographic density and single nucleotide polymorphisms (SNPs), when combined with established risk factors, trebles the number of women reaching the high risk threshold. The options for risk reduction in such women include endocrine chemoprevention with the selective estrogen receptor modulators tamoxifen and raloxifene or the aromatase inhibitors anastrozole or exemestane. NICE recommends offering anastrozole to postmenopausal women at high-risk of breast cancer as cost effectiveness analysis showed this to be cost saving to the National Health Service. Overall uptake to chemoprevention has been disappointingly low but this may improve with the improved efficacy of aromatase inhibitors, particularly the lack of toxicity to the endometrium and thrombogenic risks. Novel approaches to chemoprevention under investigation include lower dose and topical tamoxifen, denosumab, anti-progestins and metformin. Although oophorectomy is usually only recommended to women at increased risk of ovarian cancer it has been shown in numerous studies to reduce breast cancer risks in the general population and in those with mutations in BRCA1/2. However, recent evidence from studies that have confined analysis to true prospective follow up have cast doubt on the efficacy of oophorectomy to reduce breast cancer risk in BRCA1 mutation carriers, at least in the short-term.
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Affiliation(s)
- D Gareth Evans
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK.
| | - Sacha J Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - Anthony Howell
- Prevent Breast Cancer and Nightingale Breast Screening Centre, Wythenshawe Hospital Manchester Universities Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK; Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
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88
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Physical activity during adolescence and young adulthood and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers. Breast Cancer Res Treat 2018; 169:561-571. [PMID: 29404807 DOI: 10.1007/s10549-018-4694-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Physical activity is inversely associated with the risk of breast cancer among women in the general population. It is not clear whether or not physical activity is associated with the risk of BRCA-associated breast cancer. METHODS We conducted a case-control study of 443 matched pairs of BRCA mutation carriers to evaluate the association between physical activity and breast cancer risk. Moderate and vigorous physical activities at ages 12-13, ages 14-17, ages 18-22, ages 23-29 and ages 30-34 were determined using the Nurses' Health Study II Physical Activity Questionnaire. We estimated mean metabolic equivalent task hours/week for moderate, vigorous and total physical activities overall (ages 12-34), during adolescence (ages 12-17) and during early adulthood (ages 18-34). Logistic regression analysis was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) for total, moderate and strenuous recreational physical activities and breast cancer risk, by menopausal status. RESULTS Overall, there was no significant association between total physical activity and subsequent breast cancer risk (ORQ4 vs. Q1 = 1.01, 95% CI 0.69-1.47; P-trend = 0.72). Moderate physical activity between ages 12-17 was associated with a 38% decreased risk of premenopausal breast cancer (ORQ4 vs. Q1 = 0.62; 95% CI 0.40-0.96; P-trend = 0.01). We found no association between exercise and breast cancer diagnosed after menopause. CONCLUSIONS These findings suggest that early-life physical activity is associated with a reduced risk of premenopausal breast cancer among BRCA mutation carriers. IMPACT Future prospective analyses, complemented by mechanistic evidence, are warranted in this high-risk population.
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89
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Meadows R, Padamsee TJ, Paskett ED. Distinctive psychological and social experiences of women choosing prophylactic oophorectomy for cancer prevention. Health Care Women Int 2018; 39:595-616. [PMID: 29319429 DOI: 10.1080/07399332.2018.1424855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Women known to have significantly elevated ovarian cancer risk due to genetic mutations or family history can reduce this risk by surgically removing both ovaries and fallopian tubes (RRBSO, risk-reducing bilateral salpingo-oophorectomy). We used interpretive phenomenological analysis (IPA) to explore the psychosocial experiences of women who chose RRBSO for cancer prevention. We extended the traditional use of IPA to compare the experiences of women who chose RRBSO for cancer prevention to those of women who underwent similar gynecologic surgery for benign indications. The analysis resulted in three superordinate themes describing women's psychosocial experiences related to RRBSO: (a) psychological facets of cancer risk (b) social support and (c) shared medical decision making. Findings illustrate that women choosing RRBSO for cancer prevention experience heightened psychosocial challenges before and after surgery compared to women undergoing surgery for benign indication. Furthermore, they may need distinct types of information and support from healthcare providers.
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Affiliation(s)
- Rachel Meadows
- a Division of Epidemiology, College of Public Health, Comprehensive Cancer Center , the Ohio State University , Columbus , Ohio , USA
| | - Tasleem J Padamsee
- b Division of Health Services Management and Policy, College of Public Health, Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
| | - Electra D Paskett
- c Department of Internal Medicine, Division of Epidemiology, College of Medicine, College of Public Health, Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
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Petelin L, Trainer AH, Mitchell G, Liew D, James PA. Cost-effectiveness and comparative effectiveness of cancer risk management strategies in BRCA1/2 mutation carriers: a systematic review. Genet Med 2018; 20:1145-1156. [PMID: 29323669 DOI: 10.1038/gim.2017.255] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/05/2017] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To review the evidence for the effectiveness and cost-effectiveness of cancer risk management interventions for BRCA carriers. METHODS Comparative effectiveness and cost-effectiveness analyses were identified by searching scientific and health economic databases. Eligible studies modeled the impact of a cancer risk management intervention in BRCA carriers on life expectancy (LE), cancer incidence, or quality-adjusted life years (QALYs), with or without costs. RESULTS Twenty-six economic evaluations and eight comparative effectiveness analyses were included. Combined risk-reducing salpingo-oophorectomy and prophylactic mastectomy resulted in the greatest LE and was cost-effective in most analyses. Despite leading to increased LE and QALYs, combined mammography and breast magnetic resonance imaging (MRI) was less likely to be cost-effective than either mammography or MRI alone, particularly for women over 50 and BRCA2 carriers. Variation in patient compliance to risk management interventions was incorporated in 11/34 studies with the remaining analyses assuming 100% adherence. CONCLUSION Prophylactic surgery and intensive breast screening are effective and cost-effective in models of BRCA carrier risk management. Findings were based predominantly on assuming perfect adherence to recommendations without assessment of the health-care resource use and costs related to engaging patients and maximizing compliance, meaning the real-world impact on clinical outcomes and resource use remains unclear.
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Affiliation(s)
- Lara Petelin
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
| | - Alison H Trainer
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Gillian Mitchell
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Paul A James
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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91
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Tuffaha HW, Mitchell A, Ward RL, Connelly L, Butler JRG, Norris S, Scuffham PA. Cost-effectiveness analysis of germ-line BRCA testing in women with breast cancer and cascade testing in family members of mutation carriers. Genet Med 2018; 20:985-994. [DOI: 10.1038/gim.2017.231] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 11/06/2017] [Indexed: 12/13/2022] Open
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92
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Sigl V, Jones LP, Penninger JM. RANKL/RANK: from bone loss to the prevention of breast cancer. Open Biol 2017; 6:rsob.160230. [PMID: 27881737 PMCID: PMC5133443 DOI: 10.1098/rsob.160230] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/21/2016] [Indexed: 12/13/2022] Open
Abstract
RANK and RANKL, a receptor ligand pair belonging to the tumour necrosis factor family, are the critical regulators of osteoclast development and bone metabolism. Besides their essential function in bone, RANK and RANKL have also been identified as the key factors for the formation of a lactating mammary gland in pregnancy. Mechanistically, RANK and RANKL link the sex hormone progesterone with stem cell expansion and proliferation of mammary epithelial cells. Based on their normal physiology, RANKL/RANK control the onset of hormone-induced breast cancer through the expansion of mammary progenitor cells. Recently, we and others were able to show that RANK and RANKL are also critical regulators of BRCA1-mutation-driven breast cancer. Currently, the preventive strategy for BRCA1-mutation carriers includes preventive mastectomy, associated with wide-ranging risks and psychosocial effects. The search for an alternative non-invasive prevention strategy is therefore of paramount importance. As our work strongly implicates RANK and RANKL as key molecules involved in the initiation of BRCA1-associated breast cancer, we propose that anti-RANKL therapy could be a feasible preventive strategy for women carrying BRCA1 mutations, and by extension to other women with high risk of breast cancer.
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Affiliation(s)
- Verena Sigl
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Dr Bohrgasse 3, 1030 Vienna, Austria
| | - Laundette P Jones
- School of Medicine, Department of Pharmacology, University of Maryland, Baltimore, MD 21201, USA
| | - Josef M Penninger
- IMBA, Institute of Molecular Biotechnology of the Austrian Academy of Sciences, Dr Bohrgasse 3, 1030 Vienna, Austria
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93
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Piszczek C, Ma J, Gould CH, Tseng P. Cancer Risk-Reducing Opportunities in Gynecologic Surgery. J Minim Invasive Gynecol 2017; 25:1179-1193. [PMID: 29097232 DOI: 10.1016/j.jmig.2017.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 12/16/2022]
Abstract
This review article discusses cancer risk-reducing opportunities in gynecologic surgery. We cover strategies to reduce ovarian and uterine cancer risk by presenting general practice guidelines and expanding on the literature behind clinical decision points. We address populations of women at increased hereditary risk and those at population risk. We specifically discuss risk-reducing salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, concomitant hysterectomy, opportunistic salpingectomy, bilateral tubal ligation, and hysterectomy. For clinical scenarios in which data are limited or conflicting, we detail the studies on which clinicians' decisions hinge to allow the reader to weigh the available evidence.
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Affiliation(s)
- Carolyn Piszczek
- Division of Women's Services, Legacy Health System, Portland, Oregon.
| | - Jun Ma
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
| | - Claire H Gould
- Advanced Gynecology, Legacy Medical Group, Portland, Oregon
| | - Paul Tseng
- Divisions of Gynecologic Oncology, Legacy Medical Group, Portland, Oregon
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94
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Abstract
Women carrying germline mutations in BRCA1 or BRCA2 have significantly increased lifetime risks of breast and tubo-ovarian cancer. To manage the breast cancer risk women may elect to have breast screening by MRI/mammogram from age 30, to take risk-reducing medication, or to have a prophylactic bilateral mastectomy. To manage the tubo-ovarian cancer risk, the only effective strategy is to have a bilateral salpingo-oophorectomy, recommended by age 40 (BRCA1) or 'around' age 40 (BRCA2). Early studies suggested that uptake of these cancer risk-reducing strategies was low. More recent studies have revealed higher rates of uptake, however it is unclear whether uptake is genuinely improving or whether the higher uptake rates reflect changes in the populations studied. In this study we surveyed 193 BRCA1/2 mutation carriers in the state of Tasmania to determine the uptake of cancer risk-reducing strategies and what factors might influence women's decisions in relation to both gynaecological and breast surgery. We observed that uptake of risk management strategies varied depending on the strength of the recommendation in the national guidelines. Uptake rates were > 90% for strategies which are strongly recommended, such as breast screening by MRI/mammogram and bilateral salpingo-oophorectomy, and were unaffected by demographic factors such as socio-economic disadvantage and educational achievement. Uptake rates were much lower for strategies which are presented in the guidelines as options for consideration and where patient choice and shared decision making are encouraged, such as prophylactic mastectomy (29%) and chemoprevention (1%) and in the case of prophylactic mastectomy, were influenced by both socio-economic advantage and educational achievement.
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95
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Multi-institutional Evaluation of Women at High Risk of Developing Breast Cancer. Clin Breast Cancer 2017; 17:427-432. [DOI: 10.1016/j.clbc.2017.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 02/02/2017] [Accepted: 04/06/2017] [Indexed: 01/10/2023]
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96
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Nurudeen S, Guo H, Chun Y, Coopey S, Barry W, Garber J, Dominici LS. Patient experience with breast reconstruction process following bilateral mastectomy in BRCA mutation carriers. Am J Surg 2017; 214:687-694. [DOI: 10.1016/j.amjsurg.2017.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/30/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
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97
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Abstract
Ovarian cancer remains to be the most lethal of all gynecologic malignancies. There is no effective screening test proven to reduce the mortality associated with this disease. Costs of treating ovarian cancer are substantial and among the highest of all cancer types. Therefore, it is essential to pursue strategies to prevent ovarian cancer that are cost-effective in the context of our health care system. There are 2 subgroups of women for whom ovarian cancer prevention strategies have been evaluated for effectiveness and costs: (1) general population at risk, and (2) BRCA mutation carriers with a high lifetime risk.
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98
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De Felice F, Marchetti C, Boccia SM, Romito A, Sassu CM, Porpora MG, Muzii L, Tombolini V, Benedetti Panici P. Risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutated patients: An evidence-based approach on what women should know. Cancer Treat Rev 2017; 61:1-5. [PMID: 29028552 DOI: 10.1016/j.ctrv.2017.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/12/2022]
Abstract
This review is focused on the ovarian cancer risk reduction management in BRCA mutation carriers and is intended to assist with clinical decision-making. Obviously, treatment decisions must be based on the available evidence. Despite risk-reducing salpingo-oophorectomy is firmly recommended, several separate questions can be raised to address the variety of intense controversy of this approach. A special emphasis lies in the effective preventive surgical measure against ovarian cancer risk, in an attempt to detect the optimal timing and mitigate the impact on patients. The long term implications of risk-reducing salpingo-oophorectomy as well as hormone replacement therapy are also actively debated. This is expected to represent an opportunity for improved management modelling of BRCA mutated patients.
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Affiliation(s)
- F De Felice
- Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - C Marchetti
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - S M Boccia
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - A Romito
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - C M Sassu
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - M G Porpora
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - L Muzii
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
| | - V Tombolini
- Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.
| | - P Benedetti Panici
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy.
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99
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Perspectives of Women Considering Bilateral Prophylactic Mastectomy and their Peers towards a Telephone-Based Peer Support Intervention. J Genet Couns 2017; 27:274-288. [PMID: 28916957 DOI: 10.1007/s10897-017-0148-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/16/2017] [Indexed: 01/26/2023]
Abstract
Prophylactic mastectomy is an effective strategy to reduce the risk of breast cancer for women carrying a BRCA1/2 germline mutation. This decision is complex and may raise various concerns. Women considering this surgery have reported their desire to discuss the implications of this procedure with women who have undergone prophylactic mastectomy. We conducted a qualitative study to describe the topics covered during a telephone-based peer support intervention between women considering prophylactic mastectomy (recipients) and women who had undergone this surgery (peers), and to explore their perspectives regarding the intervention. Thirteen dyads were formed and data from participant logbooks and evaluation questionnaires were analyzed using a thematic content analysis. Three main dimensions emerged: physical, psychological, and social. The most frequent topics discussed were: surgery (92%), recovery (77%), pain and physical comfort (69%), impacts on intimacy and sexuality (54%), cancer-related anxiety (54%), experience related to loss of breasts (46%). Peers and recipients report that sharing experiences and thoughts about prophylactic mastectomy and the sense of mutual support within the dyad contributed significantly to their satisfaction. Special attention should be paid to the similarities between personal and medical profiles in order to create harmonious matches.
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100
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Abstract
Multidisciplinary genetic clinics offer counseling and testing to those who meet criteria for familial breast cancer, and plastic surgeons become integral to this process when risk-reducing surgery and postmastectomy reconstruction are deemed appropriate. As reconstructive surgeons, it is important that plastic surgeons are aware of the risks and issues associated with the genetic variants that cause patients to present for prophylactic or therapeutic surgery.
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