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Jerez J, Santiago M. Unraveling germline predisposition in hematological neoplasms: Navigating complexity in the genomic era. Blood Rev 2024; 64:101143. [PMID: 37989620 DOI: 10.1016/j.blre.2023.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/14/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023]
Abstract
Genomic advancements have yielded pivotal insights into hematological neoplasms, particularly concerning germline predisposition mutations. Following the WHO 2016 revisions, dedicated segments were proposed to address these aspects. Current WHO 2022, ICC 2022, and ELN 2022 classifications recognize their significance, introducing more mutations and prompting integration into clinical practice. Approximately 5-10% of hematological neoplasm patients show germline predisposition gene mutations, rising with risk factors such as personal cancer history and familial antecedents, even in older adults. Nevertheless, technical challenges persist. Optimal DNA samples are skin fibroblast-extracted, although not universally applicable. Alternatives such as hair follicle use are explored. Moreover, the scrutiny of germline genomics mandates judicious test selection to ensure precise and accurate interpretation. Given the significant influence of genetic counseling on patient care and post-assessment procedures, there arises a demand for dedicated centers offering specialized services.
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Affiliation(s)
- Joaquín Jerez
- Hematology Department, Fundación Arturo López Pérez, Chile; Resident of Hematology, Universidad de los Andes, Chile.
| | - Marta Santiago
- Hematology Department, Hospital La Fe, 46026, Valencia, Spain; Hematology Research Group, Instituto de Investigación Sanitaria La Fe, 46026, Valencia, Spain.
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Moretz C, Byfield SD, Hatchell KE, Dalton J, Onglao PN, Hang L, Hansen P, Radford C, Nielsen SM, Heald B, Munro SB, Nussbaum RL, Esplin ED. Comparison of Germline Genetic Testing Before and After a Medical Policy Covering Universal Testing Among Patients With Colorectal Cancer. JAMA Netw Open 2022; 5:e2238167. [PMID: 36279135 PMCID: PMC9593236 DOI: 10.1001/jamanetworkopen.2022.38167] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE In 2020, some health insurance plans updated their medical policy to cover germline genetic testing for all patients diagnosed with colorectal cancer (CRC). Guidelines for universal tumor screening via microsatellite instability and/or immunohistochemistry (MSI/IHC) for mismatch repair protein expression for patients with CRC have been in place since 2009. OBJECTIVES To examine whether uptake of MSI/IHC screening and germline genetic testing in patients with CRC has improved under these policies and to identify actionable findings and management implications for patients referred for germline genetic testing. DESIGN, SETTING, AND PARTICIPANTS The multicenter, retrospective cohort study comprised 2 analyses of patients 18 years or older who were diagnosed with CRC between January 1, 2017, and December 31, 2020. The first analysis used an insurance claims data set to examine use of MSI/IHC screening and germline genetic testing for patients diagnosed with CRC between 2017 and 2020 and treated with systemic therapy. The second comprised patients with CRC who had germline genetic testing performed in 2020 that was billed under a universal testing policy. MAIN OUTCOMES AND MEASURES Patient demographic characteristics, clinical information, and use of MSI/IHC screening and germline genetic testing were analyzed. RESULTS For 9066 patients with newly diagnosed CRC (mean [SD] age, 64.2 [12.7] years; 4964 [54.8%] male), administrative claims data indicated that MSI/IHC was performed in 6645 eligible patients (73.3%) during the study period, with 2288 (25.2%) not receiving MSI/IHC despite being eligible for coverage. Analysis of a second cohort of 55 595 patients with CRC diagnosed in 2020 and covered by insurance found that only 1675 (3.0%) received germline genetic testing. In a subset of patients for whom germline genetic testing results were available, 1 in 6 patients had pathogenic or likely pathogenic variants, with most of these patients having variants with established clinical actionability. CONCLUSIONS AND RELEVANCE This nationwide cohort study found suboptimal rates of MSI/IHC screening and germline genetic testing uptake, resulting in clinically actionable genetic data being unavailable to patients diagnosed with CRC, despite universal eligibility. Effective strategies are required to address barriers to implementation of evidence-based universal testing policies that support precision treatment and optimal care management for patients with CRC.
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Affiliation(s)
| | | | | | - Joline Dalton
- Optum Labs, Minnetonka, Minnesota
- Variantyx Inc, Framingham, Massachusetts
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Whitworth PW, Beitsch PD, Patel R, Rosen B, Compagnoni G, Baron PL, Simmons R, Brown EA, Gold L, Holmes D, Smith LA, Kinney M, Grady I, Clark P, Barbosa K, Lyons S, Riley L, Coomer C, Curcio L, Ruiz A, Khan S, MacDonald H, Hughes K, Hardwick MK, Heald B, Munro SB, Nielsen SM, Esplin ED. Clinical Utility of Universal Germline Genetic Testing for Patients With Breast Cancer. JAMA Netw Open 2022; 5:e2232787. [PMID: 36136330 PMCID: PMC9500554 DOI: 10.1001/jamanetworkopen.2022.32787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE National Comprehensive Cancer Network guidelines currently recommend germline testing for high-risk genes in selected patients with breast cancer. The clinical utility of recommending testing all patients with breast cancer with multigene panels is currently under consideration. OBJECTIVE To examine the implications of universal testing of patients with breast cancer with respect to clinical decision-making. DESIGN, SETTING, AND PARTICIPANTS Patients from a previously reported cohort were assessed as in-criteria or out-of-criteria according to the 2017 guidelines and underwent testing with a multigene germline panel between 2017 to 2018. Patients were women and men aged 18 to 90 years, with a new and/or previous diagnosis of breast cancer who had not undergone either single or multigene testing. Clinicians from 20 community and academic sites documented patient clinical information and changes to clinical recommendations made according to test findings. Association between prevalence of pathogenic or likely pathogenic germline variants and previously unreported clinical features, including scores generated by the BRCAPRO statistical model, was determined. Data were analyzed from April 2020 to May 2022. EXPOSURE New and/or previous diagnosis of breast cancer. MAIN OUTCOMES AND MEASURES Disease management recommendations that were changed as a result of genetic testing results are reported. RESULTS Clinicians were asked to assess changes to clinical management as a result of germline genetic testing for 952 patients. Informative clinician-reported recommendations were provided for 939 (467 in-criteria and 472 out-of-criteria) of the patients with breast cancer (936 [99.7%] female; 702 [74.8%] White; mean [SD] age at initial diagnosis, 57.6 [11.5] years). One or more changes were reported for 31 of 37 (83.8%) in-criteria patients and 23 of 34 (67.6%) out-of-criteria patients with a pathogenic or likely pathogenic variant. Recommendations were changed as a result of testing results for 14 of 22 (63.6%) out-of-criteria patients who had a variant in a breast cancer predisposition gene. Clinicians considered testing beneficial for two-thirds of patients with pathogenic or likely pathogenic variants and for one-third of patients with either negative results or variants of uncertain significance. There was no difference in variant rate between patients meeting the BRCAPRO threshold (≥10%) and those who did not (P = .86, Fisher exact test). No changes to clinical recommendations were made for most patients with negative results (345 of 349 patients [98.9%]) or variants of uncertain significance (492 of 509 patients [96.7%]). CONCLUSIONS AND RELEVANCE In this cohort study, germline genetic testing was used by clinicians to direct treatment for most out-of-criteria patients with breast cancer with pathogenic or likely pathogenic germline variants, including those with moderate-risk variants. Universal germline testing informs clinical decision-making and provides access to targeted treatments and clinical trials for all patients with breast cancer.
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Affiliation(s)
- Pat W. Whitworth
- Nashville Breast Center, Nashville, Tennesee
- TME Breast Care Network, Dallas, Texas
| | - Peter D. Beitsch
- TME Breast Care Network, Dallas, Texas
- Invitae, San Francisco, California
| | - Rakesh Patel
- TME Breast Care Network, Dallas, Texas
- Invitae, San Francisco, California
| | | | | | | | - Rache Simmons
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Eric A. Brown
- Comprehensive Breast Care, A Division of Michigan Healthcare Professionals, Troy
| | - Linsey Gold
- Comprehensive Breast Care, A Division of Michigan Healthcare Professionals, Troy
| | | | | | - Michael Kinney
- Center for Advanced Breast Care, Arlington Heights, Illinois
| | - Ian Grady
- North Valley Breast Clinic, Redding, California
| | - Patricia Clark
- Ironwood Cancer and Research Centers, Scottsdale, Arizona
| | | | | | - Lee Riley
- St Luke’s University Health Network, Easton, Pennsylvania
| | - Cynara Coomer
- Department of Surgery, Northwell Staten Island University Hospital, Staten Island, New York
| | | | - Antonio Ruiz
- Chesapeake Regional Medical Center, Chesapeake, Virginia
| | - Sadia Khan
- Hoag Hospital Newport Beach, Newport Beach, California
| | | | - Kevin Hughes
- Department of Surgery, Medical University of South Carolina, Charleston
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Esplin ED, Nielsen SM, Bristow SL, Garber JE, Hampel H, Rana HQ, Samadder NJ, Shore ND, Nussbaum RL. Universal Germline Genetic Testing for Hereditary Cancer Syndromes in Patients With Solid Tumor Cancer. JCO Precis Oncol 2022; 6:e2100516. [PMID: 36108258 PMCID: PMC9489188 DOI: 10.1200/po.21.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | | | - Heather Hampel
- Division of Clinical Cancer Genomics, Department of Medical Oncology & Therapeutic Research, City of Hope National Cancer Center, Duarte, CA
| | | | - N Jewel Samadder
- Center for Individualized Medicine, Mayo Clinic, Phoenix, AZ.,Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Phoenix, AZ.,Department of Clinical Genomics, Mayo Clinic, Phoenix, AZ
| | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC
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