Recommendations for medical management of hereditary breast and ovarian cancer: the French National Ad Hoc Committee

Mammographic screening in male patients at high risk for breast cancer: is it worth it?

PURPOSE

To investigate the utility of mammography for breast cancer screening in a population of males at increased risk for breast cancer.

METHODS

In this HIPAA-compliant institutional review board-approved single-institution study, mammography records and clinical data of 827 male patients who underwent digital mammography from September 2011-July 2018 were analyzed via the electronic medical record. 664 of these men presented with masses, pain, or nipple discharge and were excluded from this study. The remaining 163 asymptomatic men with familial and/or personal history of breast cancer, or with a known germline mutation in BRCA, underwent screening mammography and were included in this analysis.

RESULTS

163 asymptomatic men (age: mean 63 years, range 24-87 years) underwent 806 screening mammograms. 125/163 (77%) had a personal history of breast cancer and 72/163 (44%) had a family history of breast cancer. 24/163 (15%) were known mutation carriers: 4/24 (17%) BRCA1 and 20/24 (83%) BRCA2. 792/806 (98%) of the screening mammograms were negative (BI-RADS 1 or 2); 10/806 (1.2%) were classified as BI-RADS 3, all of which were eventually downgraded to BI-RADS 2 on follow-up. 4/806 (0.4%) mammograms were abnormal (BI-RADS 4/5): all were malignant. The cancer detection rate in this cohort was 4.9 cancers/1000 examinations.

CONCLUSIONS

In our cohort, screening mammography yielded a cancer detection rate of 4.9 cancers/1000 examinations which is like the detection rate of screening mammography in a population of women at average risk, indicating that screening mammography is of value in male patients at high risk for breast cancer.

Prospective blinded surveillance screening of Swedish women with increased hereditary risk of breast cancer

Purpose

To evaluate the sensitivity and specificity of different screening modalities in women with a family history of breast cancer.

Methods

Our blinded, prospective, comparative cohort analysis included three types of screening, mammography, ultrasound, and clinical breast examination once per year for 6 years. Eligible patients for this study were healthy women with ≥ 17% lifetime risk of breast cancer or with a mutation in BRCA1 or BRCA2.

Results

A total of 632 women were screened between 2002 and 2012 (each for 6 years). During the study, 30 women were diagnosed with breast cancer, with 10 of these diagnoses occurring between screening visits, and six of the 10 diagnosed women were gene carriers. The clinical presentation for the women diagnosed with breast cancer was followed until 2017. No consistent patterns for the diagnostic capacity of the different screening modalities were found, although mammography showed low sensitivity, whereas ultrasound showed better sensitivity in three of the six rounds. The specificity was high in mammography and improved in ultrasound over time. Most importantly, clinical breast examination provided no additional information toward the diagnosis of breast cancer.

Conclusion

Neither mammography nor ultrasound performed yearly were sensitive enough as standalone modalities, although high specificity was confirmed. Our findings indicate that high risk (> 29% life time risk) individuals and gene carriers can be screened biannually, using the same protocol as used in mutation carriers. Our results also suggest that low-risk groups (< 20%) may continue to be referred to population mammography screening program, while clinical breast examination may be omitted in all risk groups, and could be optional in gene carriers.

Electronic supplementary material

The online version of this article (10.1007/s10549-017-4639-0) contains supplementary material, which is available to authorized users.

Performing and Declining PGD: Accounts of Jewish Israeli Women Who Carry a BRCA1/2 Mutation or Partners of Male Mutation Carriers

To describe factors associated with preimplantation genetic diagnosis (PGD) decisions among Jewish Israeli BRCA1/2 carriers or spouses of a male carrier, we contacted all women who initiated PGD consultation for embryonic BRCA1/2 mutation detection at Sheba Medical Center, prior to March 2014. Applying a qualitative approach, we asked women to elaborate on the factors they considered in either opting for PGD or discontinuing the screening procedure. Participants were 18 Jewish Israeli women; 14 were carriers of one of the Ashkenazi founder mutations in BRCA1/2, and four were spouses of male mutation carriers, who underwent at least one cycle of PGD. Prior to seeking PGD, ten of the women had no children. At the time of the interview, all but three had at least one child. Three factors emerged as key motivators for PGD: having witnessed the disease in a close relative (n = 12); prior IVF treatment for infertility (n = 12); and having pre-existing frozen embryos (n = 6). Ten women withdrew from the PGD process due to clinical, logistical, and financial reasons. In conclusion, most women decided to withdraw from PGD instead of continuing until a successful conception was achieved. Those who opted for PGD attributed their discontinuation of further screening to the emotional burden that is greatly intensified by practical difficulties.

Negotiating Present and Future Selves: Managing the Risk of Hereditary Ovarian Cancer by Prophylactic Surgery

Women who are at increased risk of developing ovarian cancer because of their family history are encouraged to make decisions about the medical management of their cancer risk. Using data collected during interviews with 49 high-risk premenopausal women, this article looks at some of the influences on women’s risk-management choices. When describing their attitudes about preventative ovarian surgery, high-risk women draw upon discourses of control. Prophylactic surgery is constructed as both providing women with the means to gain control over their bodies, and as leading to a loss of control. More specifically, women perceive the removal of at-risk organs as both securing and undermining their present and future self-identities. Thus, it is argued that women’s willingness to undergo prophylactic ovarian surgery is dependent upon them negotiating various competing risks to self and body that are associated with this risk-management option.

Effectiveness of Screening With Annual Magnetic Resonance Imaging and Mammography: Results of the Initial Screen From the Ontario High Risk Breast Screening Program

Purpose

The Ontario Breast Screening Program expanded in July 2011 to screen women age 30 to 69 years at high risk for breast cancer with annual magnetic resonance imaging (MRI) and digital mammography. To the best of our knowledge, this is the first organized screening program for women at high risk for breast cancer.

Patients and Methods

Performance measures after assessment were compared with screening results for 2,207 women with initial screening examinations. The following criteria were used to determine eligibility: known mutation in BRCA1, BRCA2, or other gene predisposing to a markedly increased risk of breast cancer, untested first-degree relative of a gene mutation carrier, family history consistent with hereditary breast cancer syndrome and estimated personal lifetime breast cancer risk ≥ 25%, or radiation therapy to the chest (before age 30 years and at least 8 years previously).

Results

The recall rate was significantly higher among women who had abnormal MRI alone (15.1%; 95% CI, 13.8% to 16.4%) compared with mammogram alone (6.4%; 95% CI, 5.5% to 7.3%). Of the 35 breast cancers detected (16.3 per 1,000; 95% CI, 11.2 to 22.2), none were detected by mammogram alone, 23 (65.7%) were detected by MRI alone (10.7 per 1,000; 95% CI, 6.7 to 15.8), and 25 (71%) were detected among women who were known gene mutation carriers (30.8 per 1,000, 95% CI, 19.4 to 43.7). The positive predictive value was highest for detection based on mammogram and MRI (12.4%; 95% CI, 7.3% to 19.3%).

Conclusion

Screening with annual MRI combined with mammography has the potential to be effectively implemented into an organized breast screening program for women at high risk for breast cancer. This could be considered an important management option for known BRCA gene mutation carriers.

Does perceived risk predict breast cancer screening use? Findings from a prospective cohort study of female relatives from the Ontario site of the breast cancer family registry

While the relationship between perceived risk and breast cancer screening use has been studied extensively, most studies are cross-sectional. We prospectively examined this relationship among 913 women, aged 25-72 with varying levels of familial breast cancer risk from the Ontario site of the Breast Cancer Family Registry. Associations between perceived lifetime breast cancer risk and subsequent use of mammography, clinical breast examination (CBE) and genetic testing were assessed using logistic regression. Overall, perceived risk did not predict subsequent use of mammography, CBE or genetic testing. Among women at moderate/high familial risk, those reporting a perceived risk greater than 50% were significantly less likely to have a CBE (odds ratio (OR) = 0.52, 95% confidence interval (CI): 0.30-0.91, p = 0.04), and non-significantly less likely to have a mammogram (OR = 0.70, 95% CI: 0.40-1.20, p = 0.70) or genetic test (OR = 0.61, 95% CI: 0.34-1.10, p = 0.09) compared to women reporting a perceived risk of 50%. In contrast, among women at low familial risk, those reporting a perceived risk greater than 50% were non-significantly more likely to have a mammogram (OR = 1.13, 95% CI: 0.59-2.16, p = 0.78), CBE (OR = 1.11, 95% CI: 0.63-1.95, p = 0.74) or genetic test (OR = 1.29, 95% CI: 0.50-3.33, p = 0.35) compared to women reporting a perceived risk of 50%. Perceived risk did not significantly predict screening use overall, however this relationship may be moderated by level of familial risk. Results may inform risk education and management strategies for women with varying levels of familial breast cancer risk.

Impact of familial risk and mammography screening on prognostic indicators of breast disease among women from the Ontario site of the Breast Cancer Family Registry

Although several studies have found screen-detected cancers in women with familial breast cancer risk have favorable prognostic features compared with symptomatic cancers, the impact of level of familial risk is unknown. A cohort of 899 first-degree female relatives of cases of breast cancer from the Ontario site of the Breast Cancer Family Registry was followed for 2 years. Logistic regression analyses compared diagnoses of breast cancer or benign breast disease (BBD) between women at high (n = 258, 28.7 %) versus low/moderate (n = 641, 71.3 %) familial risk. Similar analyses compared prognostic features of invasive cancers and BBD by level of familial risk and mammography screening status. Among 899 women, 44 (4.9 %) were diagnosed with invasive breast cancer and/or ductal carcinoma in situ, and 56 (6.2 %) with BBD. Women with high familial risk were significantly more likely to be diagnosed with breast cancer [odds ratio (OR) = 2.84, 95 % confidence interval (CI) 1.50-5.38] than low/moderate risk women, particularly if diagnosed at age ≥50 (OR = 2.99, 95 % CI 1.37-6.56) or screened with mammography (OR = 3.33, 95 % CI 1.54-7.18). High risk women were more likely to be diagnosed with BBD (OR = 1.94, 95 % CI 1.03-3.66). Level of familial risk was not associated with prognostic features. Cancers among unscreened women were larger (OR = 9.72, 95 % CI 1.01-93.61) and diagnosed at stage II or above (OR = 7.80, 95 % CI 1.18-51.50) compared with screen-detected cancers. Screening mammography may be effective for women with a first-degree family history of breast cancer, irrespective of level of familial risk.

Accuracy of Self-Reported Screening Mammography Use: Examining Recall among Female Relatives from the Ontario Site of the Breast Cancer Family Registry

Evidence of the accuracy of self-reported mammography use among women with familial breast cancer risk is limited. This study examined the accuracy of self-reported screening mammography dates in a cohort of 1,114 female relatives of breast cancer cases, aged 26 to 73 from the Ontario site of the Breast Cancer Family Registry. Self-reported dates were compared to dates abstracted from imaging reports. Associations between inaccurate recall and subject characteristics were assessed using multinomial regression. Almost all women (95.2% at baseline, 98.5% at year 1, 99.8% at year 2) accurately reported their mammogram use within the previous 12 months. Women at low familial risk (OR = 1.77, 95% CI: 1.00–3.13), who reported 1 or fewer annual visits to a health professional (OR = 1.97, 95% CI: 1.15, 3.39), exhibited a lower perceived breast cancer risk (OR = 1.90, 95% CI: 1.15, 3.15), and reported a mammogram date more than 12 months previous (OR = 5.22, 95% CI: 3.10, 8.80), were significantly more likely to inaccurately recall their mammogram date. Women with varying levels of familial risk are accurate reporters of their mammogram use. These results present the first evidence of self-reported mammography recall accuracy among women with varying levels of familial risk.

International variation in physicians' attitudes towards prophylactic mastectomy - comparison between France, Germany, the Netherlands and the United Kingdom

PURPOSE

Prophylactic mastectomy (PM) has proven to be the most effective method to reduce the risk of breast cancer in high-risk women. The present study aimed to present and compare the attitudes towards PM among physicians in France, Germany, the Netherlands and the United Kingdom (UK).

PATIENTS AND METHODS

An international sample of 1196 general practitioners (GPs) and 927 breast surgeons (BS) were surveyed using a mailed questionnaire.

RESULTS

Only 30% of the French and 27% of the German GPs were of opinion that PM should be an option for an unaffected female BRCA1/2 mutation carrier, as compared to 85% and 92% of the GPs in the Netherlands and UK, respectively. Similarly, 78% of the French and 66% of the German BS reported a positive attitude towards PM, as compared to 100% and 97% of the BS in the Netherlands and UK, respectively. In the whole sample of GPs, a positive attitude towards PM was associated with country of residence, being female, and having more knowledge of breast/ovarian cancer genetics, while among BS there was a positive association with country of residence and having more knowledge of breast/ovarian cancer genetics as well, and, in addition, with a higher number of newly diagnosed breast cancer patients last year.

CONCLUSION

These results demonstrated the international variations in the attitude towards PM among physicians. This might reflect that different policies are adopted to prevent breast cancer in women at-risk.

Perceived risk and adherence to breast cancer screening guidelines among women with a familial history of breast cancer: a review of the literature

OBJECTIVES

A small positive association has been consistently demonstrated between perceived breast cancer risk and mammography use. Evidence specific to women with familial breast cancer risk has not been previously reviewed.

METHODS

A literature search was conducted. 186 studies were identified for abstract/full-text review, of which 10 articles were included. Manual searching identified 10 additional articles. Twenty articles examining the association between perceived breast cancer risk and adherence to mammography, clinical breast examination (CBE) or breast self-examination (BSE) guidelines among women with familial breast cancer risk were reviewed. Studies were classified according to screening modality, categorized by finding and ordered by year of publication. Studies assessing mammography were further classified according to the applied method of measuring perceived risk.

RESULTS

Our review found a weak positive association between higher perceived risk and adherence to mammography guidelines among women with familial breast cancer risk. Consistent associations between perceived risk and adherence to CBE and BSE guidelines were not observed.

CONCLUSIONS

Our ability to understand the relationship between perceived breast cancer risk and adherence to breast screening guidelines is limited, because most previous research is cross-sectional. Future studies with prospective methodologies that use consistent measurement methods and are adequately powered are warranted.

Tissue-based predictors of germ-line BRCA1 mutations: implications for triaging of genetic testing

BRCA testing of patients with breast cancer considered at high risk for having a germ-line BRCA mutation usually consists of comprehensive mutational analysis of both BRCA1 and BRCA2. A more cost-effective strategy of triaging patients for analysis of a single gene could be adopted if tissue-based predictors indicated a high risk specifically for either BRCA1 or BRCA2. To identify potentially useful tissue-based predictors of BRCA mutation status in breast cancer, we evaluated multiple histopathologic features of invasive breast carcinoma on archival tissue sections from 196 high-risk patients who had undergone BRCA testing, and we analyzed which individual or combination of features was most associated with BRCA mutations. Of the 196 patients with invasive breast carcinoma, there were 44 (22%) with a deleterious BRCA1 mutation and 27 (14%) with a deleterious BRCA2 mutation. For patients with available untreated surgical resection specimens for evaluation (n=172), estrogen receptor-positive phenotype was inversely associated with the presence of a BRCA1 mutation (odds ratio, 0.243; 95% confidence interval, 0.070-0.840; P=.025), and high mitotic activity (≥25 mitotic figures per 10 high-power fields) was directly associated with the presence of a BRCA1 mutation (odds ratio, 4.222; 95% confidence interval, 1.353-13.18; P=.013). The combination of estrogen receptor-negative phenotype and high mitotic rate had high specificity (99%; 95% confidence interval, 95%-100%) but low sensitivity (43%; 95% confidence interval, 26%-61%) for identifying a deleterious BRCA1 mutation. In patients with breast cancer at high risk for carrying a BRCA mutation, those with estrogen receptor-negative phenotype and high mitotic rate could be triaged specifically for BRCA1 testing instead of initially performing mutational analysis for both BRCA1 and BRCA2.

The attitudes of women with BRCA1 and BRCA2 mutations toward clinical breast examinations and breast self-examinations

AIMS

In screening studies of women with BRCA mutations, magnetic resonance imaging (MRI) plus mammography has >90% sensitivity for detecting breast cancer, with negligible benefit from the addition of breast self-examination (BSE) or clinical breast examination (CBE). Yet CBE is still frequently recommended, and BSE is encouraged for these women. We sought to determine the attitudes of high-risk women toward CBE and BSE.

METHODS

Between November 2005 and May 2006, 137 women with BRCA mutations participating in a screening study consisting of annual MRI and mammography plus semiannual CBE were asked to complete a mailed Likert-type questionnaire.

RESULTS

Of the 94 (67%) respondents, mean age 47 (range 28-67), 94% strongly agreed or agreed that CBE was an important way to detect breast cancer, and almost all believed it provided an important connection to the healthcare team. Only 10% said it increased anxiety. Of the 71 (77%) who performed BSE at least occasionally, 53 thought that regular BSE gave them a sense of control over their own health. Of the 21(23%) who did not practice BSE at all, only 3 did not believe that BSE was helpful, and it made 9 more worried about breast cancer

CONCLUSIONS

Although CBE adds little to cancer detection rates in women with BRCA mutations screened with MRI, the majority of these women considered CBE to be reassuring and an important means of connecting with the healthcare team. Compliance with BSE was only moderate, but it gave a significant proportion of women a greater sense of control.

Cancer risk management strategies and perceptions of unaffected women 5 years after predictive genetic testing for BRCA1/2 mutations

In a French national cohort of unaffected females carriers/non-carriers of a BRCA1/2 mutation, long-term preventive strategies and breast/ovarian cancer risk perceptions were followed up to 5 years after test result disclosure, using self-administered questionnaires. Response rate was 74%. Carriers (N=101) were younger (average age±SD=37±10) than non-carriers (N=145; 42±12). There were four management strategies that comprised 88% of the decisions made by the unaffected carriers: 50% opted for breast surveillance alone, based on either magnetic resonance imaging (MRI) and other imaging (31%) or mammography alone (19%); 38% opted for either risk reducing salpingo-oophorectomy (RRSO) and breast surveillance, based on MRI and other imaging (28%) or mammography alone (10%). The other three strategies were: risk reducing mastectomy (RRM) and RRSO (5%), RRM alone (2%) and neither RRM/RRSO nor surveillance (6%). The results obtained for various age groups are presented here. Non-carriers often opted for screening despite their low cancer risk. Result disclosure increased carriers' short-term high breast/ovarian cancer risk perceptions (P⩽0.02) and decreased non-carriers' short- and long-term perceptions (P<0.001). During follow-up, high breast cancer risk perceptions increased with time among those who had no RRM and decreased in the opposite case; high ovarian cancer risk perceptions increased further with time among those who had no RRSO and decreased in the opposite case; RRSO did not affect breast cancer risk perceptions. Informed decision-making involves letting women know whether opting for RRSO and breast MRI surveillance is as effective in terms of survival as RRM and RRSO.

CK8/18 expression, the basal phenotype, and family history in identifying BRCA1-associated breast cancer in the Ontario site of the breast cancer family registry

BACKGROUND

BRCA1-associated breast cancer had been shown to be morphologically and genetically distinct from sporadic cancers. The aim of this study was to determine the association of CK8/18 with BRCA1-associated tumors and if, by using CK8/18 and basal biomarkers in conjunction with morphologic features and family history characteristics, the specificity of the BRCA1-associated tumor profile in a pathologically well-characterized cohort would be improved.

METHODS

Fifty-eight patients with known BRCA1 germline mutations and 221 control (familial non-BRCA) patients were selected from the Ontario Familial Breast Cancer Registry. From this database, information on family history and morphologic features was abstracted. Tissue microarrays were constructed and immunohistochemistry to determine expression of several biomarkers was performed. After a logistic regression fit, a best-subsets variable-selection procedure using model performance and predictive ability measures was applied to find a best predictor to distinguish BRCA1-associated tumors from non-BRCA associated tumors.

RESULTS

BRCA1-associated tumors differed significantly from control tumors in terms of morphology, family history, and biomarker profile. CK8/18 was highly significantly associated with BRCA1 tumors. Consistently, BRCA1 cancers showed low levels of CK8/18 compared to non-BRCA tumors, whether they were basal-like or not. A combination of 7 factors, including CK8/18 and family history, best predicted the BRCA1-associated cancers.

CONCLUSIONS

CK8/18 expression was independently associated with BRCA1-associated breast cancers. Reduced CK8/18 expression in conjunction with the basal-like phenotype and family history may have improved the ability to identify which tumors were likely to be associated with a BRCA1 germline mutation and thereby help streamline genetic testing.

Breast cancer: surgery at the South egypt cancer institute

Breast cancer is the most frequent malignant tumor in women worldwide. In Egypt, it is the most common cancer among women, representing 18.9% of total cancer cases (35.1% in women and 2.2% in men) among the Egypt National Cancer Institute's (NCI) series of 10,556 patients during the year 2001, with an age-adjusted rate of 49.6 per 100,000 people. In this study, the data of all breast cancer patients presented to the surgical department of the South Egypt cancer Institute (SECI) hospital during the period from Janurary 2001 to December 2008 were reviewed .We report the progress of the availability of breast cancer management and evaluation of the quality of care delivered to breast cancer patients. The total number of patients with a breast lump presented to the SECI during the study period was 1,463 patients (32 males and 1431 females); 616 patients from the total number were admitted at the surgical department .There was a decline in advanced cases. Since 2001, facilities for all lines of comprehensive management have been made accessible for all patients. We found that better management could lead to earlier presentation, and better overall outcome in breast cancer patients.The incidence is steadily increasing with a tendency for breast cancer to occur in younger age groups and with advanced stages.

Breast cancer: surgery at the South egypt cancer institute

Breast cancer is the most frequent malignant tumor in women worldwide. In Egypt, it is the most common cancer among women, representing 18.9% of total cancer cases (35.1% in women and 2.2% in men) among the Egypt National Cancer Institute's (NCI) series of 10,556 patients during the year 2001, with an age-adjusted rate of 49.6 per 100,000 people. In this study, the data of all breast cancer patients presented to the surgical department of the South Egypt cancer Institute (SECI) hospital during the period from Janurary 2001 to December 2008 were reviewed .We report the progress of the availability of breast cancer management and evaluation of the quality of care delivered to breast cancer patients. The total number of patients with a breast lump presented to the SECI during the study period was 1,463 patients (32 males and 1431 females); 616 patients from the total number were admitted at the surgical department .There was a decline in advanced cases. Since 2001, facilities for all lines of comprehensive management have been made accessible for all patients. We found that better management could lead to earlier presentation, and better overall outcome in breast cancer patients.The incidence is steadily increasing with a tendency for breast cancer to occur in younger age groups and with advanced stages.

Prospective multicenter cohort study to refine management recommendations for women at elevated familial risk of breast cancer: the EVA trial

PURPOSE

We investigated the respective contribution (in terms of cancer yield and stage at diagnosis) of clinical breast examination (CBE), mammography, ultrasound, and quality-assured breast magnetic resonance imaging (MRI), used alone or in different combination, for screening women at elevated risk for breast cancer.

METHODS

Prospective multicenter observational cohort study. Six hundred eighty-seven asymptomatic women at elevated familial risk (> or = 20% lifetime) underwent 1,679 annual screening rounds consisting of CBE, mammography, ultrasound, and MRI, read independently and in different combinations. In a subgroup of 371 women, additional half-yearly ultrasound and CBE was performed more than 869 screening rounds. Mean and median follow-up was 29.18 and 29.09 months.

RESULTS

Twenty-seven women were diagnosed with breast cancer: 11 ductal carcinoma in situ (41%) and 16 invasive cancers (59%). Three (11%) of 27 were node positive. All cancers were detected during annual screening; no interval cancer occurred; no cancer was identified during half-yearly ultrasound. The cancer yield of ultrasound (6.0 of 1,000) and mammography (5.4 of 1,000) was equivalent; it increased nonsignificantly (7.7 of 1,000) if both methods were combined. Cancer yield achieved by MRI alone (14.9 of 1,000) was significantly higher; it was not significantly improved by adding mammography (MRI plus mammography: 16.0 of 1,000) and did not change by adding ultrasound (MRI plus ultrasound: 14.9 of 1,000). Positive predictive value was 39% for mammography, 36% for ultrasound, and 48% for MRI.

CONCLUSION

In women at elevated familial risk, quality-assured MRI screening shifts the distribution of screen-detected breast cancers toward the preinvasive stage. In women undergoing quality-assured MRI annually, neither mammography, nor annual or half-yearly ultrasound or CBE will add to the cancer yield achieved by MRI alone.

PEL: an unbiased method for estimating age-dependent genetic disease risk from pedigree data unselected for family history

Providing valid risk estimates of a genetic disease with variable age of onset is a major challenge for prevention strategies. When data are obtained from pedigrees ascertained through affected individuals, an adjustment for ascertainment bias is necessary. This article focuses on ascertainment through at least one affected and presents an estimation method based on maximum likelihood, called the Proband's phenotype exclusion likelihood or PEL for estimating age-dependent penetrance using disease status and genotypic information of family members in pedigrees unselected for family history. We studied the properties of the PEL and compared with another method, the prospective likelihood, in terms of bias and efficiency in risk estimate. For that purpose, family samples were simulated under various disease risk models and under various ascertainment patterns. We showed that, whatever the genetic model and the ascertainment scheme, the PEL provided unbiased estimates, whereas the prospective likelihood exhibited some bias in a number of situations. As an illustration, we estimated the disease risk for transthyretin amyloid neuropathy from a French sample and a Portuguese sample and for BRCA1/2 associated breast cancer from a sample ascertained on early-onset breast cancer cases.

Histopathological criteria and selection algorithms for BRCA1 genetic testing

To ensure targeted treatment, it would be useful to know at the time of diagnosis whether a BRCA mutation is causally related to an individual breast cancer. The aim of this study was to investigate in an unselected series of breast cancer patients the value of incorporating morphological and immunohistochemical features for the selection of patients who may benefit from BRCA1 genetic testing. In a retrospective approach, histopathological results of tumors from 897 women were reevaluated regarding age at diagnosis, subtype of cancer, tumor grade, and estrogen (ER), progesterone (PR), and Her2/neu receptor status, as well as p53 and Ki67 status. In all, 142 tumors fulfilled morphological criteria indicative of a BRCA1 mutation. Of the 59 women willing to participate, 26 women concomitantly showed a positive family history. Pathogenic BRCA1 germline mutations were detected in 7 of 18 women (39%) (95% confidence interval = 0.17-0.64). All BRCA1-associated tumors were of high grade, invasive-ductal subtype, and PR and Her2/neu negative, and 91% of the tumors were negative for ER; 60% of the tumors showed a high expression of p53 and 60% a high expression of Ki67. There was a significant difference with respect to grading (P = 0.001 for G3), ER negativity (P = 0.0075), Ki67 > or = 65% (P = 0.0039), and triple negativity (i.e., ER(-), PR(-), Her2/neu(-)) (P = 0.0019) between tumors of mutation carriers and noncarriers.

Breast cancer susceptibility: current knowledge and implications for genetic counselling

Breast cancer is the most common malignancy in women in the Western world. Except for the high breast cancer risk in BRCA1 and BRCA2 mutation carriers as well as the risk for breast cancer in certain rare syndromes caused by mutations in TP53, STK11, PTEN, CDH1, NF1 or NBN, familial clustering of breast cancer remains largely unexplained. Despite significant efforts, BRCA3 could not be identified, but several reports have recently been published on genes involved in DNA repair and single nucleotide polymorphisms (SNPs) associated with an increased breast cancer risk. Although candidate gene approaches demonstrated moderately increased breast cancer risks for rare mutations in genes involved in DNA repair (ATM, CHEK2, BRIP1, PALB2 and RAD50), genome-wide association studies identified several SNPs as low-penetrance breast cancer susceptibility polymorphisms within genes as well as in chromosomal loci with no known genes (FGFR2, TOX3, LSP1, MAP3K1, TGFB1, 2q35 and 8q). Some of these low-penetrance breast cancer susceptibility polymorphisms also act as modifier genes in BRCA1/BRCA2 mutation carriers. This review not only outlines the recent key developments and potential clinical benefit for preventive management and therapy but also discusses the current limitations of genetic testing of variants associated with intermediate and low breast cancer risk.

Cancer surveillance based on imaging techniques in carriers of BRCA1/2 gene mutations: a systematic review

We have systematically reviewed the literature focusing on the performance of surveillance programmes and imaging techniques for the early diagnosis of breast and ovarian cancer in women carrying mutations in BRCA1/2 genes. A search for relevant articles published between 1996 and 2005 (inclusive) was run on Medline, Embase and other databases. Of the 749 articles retrieved, only 13 met the inclusion criteria. Of these, 12 provided information on breast cancer surveillance, 1 on ovarian cancer surveillance and a further study addressed both cancer types. A critical appraisal of the studies was performed using a tool for the quality assessment of diagnostic accuracy studies (QUADAS). The synthesis of results is qualitative. All studies on imaging techniques for the diagnosis of breast cancer indicated that screening MRI had the highest sensitivity (between 77% and 100%). Breast cancer surveillance programmes, including MRI, achieved the highest diagnostic performance (between 83% and 95%) for all women. However, it must be taken into account that biases that may affect the validity of the outcomes were seen in the evaluated studies. Also, MRI is an expensive test with a low positive predictive value and, to date, MRI screening has not been proven to reduce mortality rates in women carrying BRCA1/2 gene mutations. As a result of the scant information and low quality of the papers reviewed, no definitive conclusion could be drawn on the performance of ovarian cancer surveillance in women carrying BRCA1/2 mutations.

BRCA1, BRCA2, TP53, and CDKN2A germline mutations in patients with breast cancer and cutaneous melanoma

PURPOSE

From epidemiological studies it appears that breast cancer (BC) and cutaneous melanoma (CMM) in the same individual occur at a higher frequency than expected by chance. Genetic factors common to both cancers can be suspected. Our goal was to estimate the involvement of "high risk" genes in patients presenting these two neoplasia, selected irrespectively from family history and age at diagnosis.

EXPERIMENTAL DESIGN

Eighty two patients with BC and CMM were screened for BRCA1, BRCA2, TP53, CDKN2A and CDK4 (exon 2) germline mutations.

RESULTS

Deleterious mutations were identified in 6 patients: two carriers of a BRCA1 germline mutation, two carriers of TP53 germline mutations (one of which also harbored a BRCA2 deleterious mutation, the other one a BRCA2 unclassified variant), and two carriers of a CDKN2A germline mutation. In addition, 6 variants of unknown signification were identified in BRCA1 or BRCA2 genes. Regarding family history, 3/13 (23%) patients with a positive family history of BC or CMM were carriers of a germline mutation, whereas only 3/69 (4%) patients without family history were carriers of a germline mutation.

CONCLUSION

Our findings show that few patients with BC and CMM who lacked family histories of these cancers are carriers of deleterious germline mutations in four of the five genes we examined. We describe for the first time, two simultaneous BRCA2 and TP53 mutations, suggesting that analysis in more than one gene could be performed if a patient's personal or familial history does not match a single syndrome.

[Hereditary breast and ovarian cancer: primary and secondary prevention for BRCA1 and BRCA2 mutation carriers]

Ten years after the identification of the breast and ovarian cancer predisposition genes, BRCA1 and BRCA2, an emerging literature has explored the efficacy of strategies for primary as well as secondary prevention of breast and ovarian cancer in BRCA1 and BRCA2 mutations carriers. The integration of magnetic resonance imaging for breast cancer screening in BRCA carriers has achieved a higher sensibility of the screening, and an early detection of breast cancer. However, we don't have yet enough level of evidence that magnetic resonance imaging could reduce mortality in BRCA carriers. Because of the limitations of screening for ovarian cancer, bilateral prophylactic salpingo-oophorectomy has been established as one of the most effective strategies to prevent ovarian cancer in BRCA1 and BRCA2 mutation carriers. This strategy also has a favorable effect on the reduction of risk of breast cancer if is performed before the age of 50. The management of this patients must be individualized and multidisciplinary.

Ovarian cancer

Ovarian cancer accounts for 4% of all cancers in women and is the leading cause of death from gynaecologic malignancies. Because early-stage ovarian cancer is generally asymptomatic, approximately 75% of women present with advanced disease at diagnosis. Survival is highly dependent on stage of disease: 5-year survival in patients with early-stage is 80-90% compared to 25% for patients with advanced-stage disease. For all patients, a comprehensive surgical staging should be performed to obtain the histological confirmation of diagnosis and to evaluate the extent of disease. Patients with early-stage should both be optimally staged and be treated with adjuvant platinum-based chemotherapy if they have a medium or high-risk tumour. For advanced disease the currently recommended management is primary cytoreductive surgery followed by platinum-paclitaxel combination chemotherapy. Appropriate salvage therapy is based on the timing and nature of recurrence and the extent of prior chemotherapy. Surgical resection should be considered in patients with long-term remission, especially in those with isolated recurrences and good performance status. Platinum-based combination represents the standard second-line chemotherapy in patients with platinum-sensitive relapsed ovarian cancer. Salvage chemotherapy in platinum-refractory patients usually results in low response rates and short survival.

Screening behavior in women at increased familial risk for breast cancer

This multicenter study examined the adherence of high-risk women to screening recommendations for breast and ovarian cancer following consultation at a familial cancer clinic (FCC). Self-report questionnaires assessing recall of screening advice, tests undertaken, risk perception, anxiety (Impact of Events Scale) and demographics were mailed to 396 consecutive eligible women who had attended one of six FCCs a median of 3.6 years prior. Family history, genetic test results and screening recommendations were abstracted from medical records. 182/266 (68.4%) women responded with 130 lost to follow-up. The proportions of women undertaking at least the recommended frequency of screening tests were: breast self examination (BSE) 50.4%, clinical breast examination (CBE) 66.0%, mammography 82.2%, transvaginal ultrasound (TVUS) 70.0%, CA125 84.0%. Factors associated with adherence to screening were: higher anxiety for BSE and CBE, being BRCA1/2 positive for CBE, older age, method of arrangement and having at least one affected first degree relative for mammography. Factors significantly associated with over-adherence were higher scores for anxiety for BSE and CBE and younger age (< 40 years) for TVUS. Between 41.3% (BSE) and 57.6% (CBE) of women incorrectly recalled their screening recommendations. A substantial minority of high-risk women do not adhere to screening advice. Strategies to improve the accuracy of recall of recommendations and the uptake of recommended screening are required.

Toward cultural competence in cancer genetic counseling and genetics education: lessons learned from Chinese-Australians

PURPOSE

In societies such as Australia with a strong multicultural makeup, culturally determined attitudes to genetics, testing, and counseling may be incompatible with current genetics service provision.

METHODS

An ethnographic investigation using purposive sampling to increase subject diversity was used to explore the range of beliefs about kinship and inheritance using Chinese-Australians as a case. Participants comprised a sample of 15 Chinese-Australians who had been recruited through several community-based organizations.

RESULTS

The level of acculturation does not correlate with holding beliefs about inheritance, kinship, and causes of hereditary cancer that are based on "Western" biomedical or traditional concepts. Mismatch between beliefs may exist within families that can impact participation in cancer genetic testing. Family history taking that underpins the surveillance, management, and referral to genetic counseling where there is a strong family history of breast, ovarian, or colorectal cancer can also be impacted unless recognition is made of the patrilineal concept of kinship prevalent in this Chinese-Australian community.

CONCLUSION

This community-based study confirmed and validated views and beliefs on inheritance and kinship and inherited cancer attributed to senior family members by Chinese-Australians who attended cancer genetic counseling. Barriers to communication can occur where there may be incompatibility within the family between "Western" and traditional beliefs. The findings were used to develop strategies for culturally competent cancer genetic counseling with Australian-Chinese patients. These include nonjudgmental incorporation of their belief systems into the genetic counseling process and avoidance of stereotyping. They have also influenced the development of genetics education materials to optimize family history taking.

Preventive health behaviors and familial breast cancer

AIM

To examine medical and lifestyle preventive behaviors among women with varying levels of familial breast cancer risk.

METHODS

Using cross-sectional data from the Minnesota Breast Cancer Family Study, a historical cohort of 426 families, we compared medical (mammography adherence, antiestrogen use, and prophylactic surgery) and lifestyle (physical activity, smoking, alcohol, and diet) behaviors across three groups of cancer-free women ages 18 to 95 defined by their family history of breast cancer. Family history was classified as high-risk, moderate-risk, or average to low-risk depending on the number and degree of relationship of family members with breast cancer.

RESULTS

After adjusting for age and education, high-risk women were twice as likely to have ever used an antiestrogenic agent (9.0% versus 4.6% among moderate-risk and 4.1% among average to low-risk; P = 0.002). Among women ages <40, the high-risk group were more likely to have ever had a mammogram (82% versus 47% among moderate-risk and 35% among average to low-risk; P < 0.001). Average to low-risk women were the least likely to be current smokers and high-risk women may consume slightly fewer fruits and vegetables compared with the other groups, but there were no other differences in lifestyle behaviors, including physical activity and alcohol use.

CONCLUSIONS

Women with strong family histories of breast cancer are more likely to undertake medical but not lifestyle preventive behaviors.

Knowledge of risk management strategies, and information and risk management preferences of women at increased risk for ovarian cancer

Little research is available on the level of knowledge about ovarian cancer risk management options in women at increased risk for this disease. The study objectives were to evaluate this together with the information and ovarian cancer risk management preferences of high-risk women. One hundred and twenty-nine women were assessed after their attendance at one of six familial cancer clinics in relation to knowledge of surveillance and/or preventative strategies for reduction of ovarian cancer risk, preferences for particular strategies, and information preferences. Screening was selected by 57 (44%) women as the preferred risk management option. One hundred and five women (82%) indicated a wish for as much information as possible about ovarian cancer, including both good and bad outcomes and 114 (89%) reported a preference for sharing treatment decisions with their health professional. Participants' knowledge about ovarian cancer risk management options was significantly associated with educational levels (Z = -3.2, p=0.001) and whether or not ovarian cancer was included in the family history (Z = -2.3, p = 0.018). Findings from this present study indicate that women at increased risk of ovarian cancer who attend familial cancer clinics want as much information as possible about this disease and they want to be involved in the decision-making process. Women who reported a lower level of education (no post-school qualifications) may be most likely to benefit from additional educational strategies designed to supplement genetic counseling to improve their knowledge levels.

Is family history related to preventive health behaviors and medical management in breast cancer patients?

INTRODUCTION

Women diagnosed with breast cancer who also have a family history of the disease are at increased risk of developing additional primary breast or ovarian cancers. We investigated whether a relationship exists between family history and health behaviors in a cross-sectional study of breast cancer survivors.

METHODS

Participants in the Women's Healthy Eating and Living (WHEL) Study (a randomized trial designed to test the effect of a plant-based diet on breast cancer recurrence) completed baseline questionnaires about their family history and health behaviors. Medical records and self-reports provided treatment data. Participants were defined as having a family history (FH+) if they met specific family history criteria (n=195), and were compared with women having no family history (FH-) of breast cancer (n=1736).

RESULTS

The mean age of breast cancer diagnosis was 51.2 years for both groups, but FH+ women were more likely to be diagnosed before age 40. FH+ and FH- women had similar dietary patterns, alcohol intake, exercise patterns, body mass index and smoking histories. However, FH+ women were more likely to have undergone prophylactic contralateral mastectomy (OR=3.6, 95% CI=2.2 - 6.2) and bilateral oophorectomy (OR=1.6; 95% CI=1.0 - 2.3) following diagnosis, adjusted for age and time since diagnosis. The FH+ and FH- groups had similar patterns of use of anti-estrogen medications and frequency of medical follow-up.

CONCLUSIONS

Breast cancer survivors with a strong family history of breast cancer are more likely to undergo surgical preventive measures to reduce their risk of additional cancer, but do not report undertaking more preventive lifestyle behaviors compared to breast cancer survivors without a family history.

Clinical outcome of hereditary breast cancer in the lithuanian population

Breast cancer family history has been known to be one of the main cancer risk factors. Members of high-risk families should be given recommendations which may improve prophylaxis, early diagnosis and treatment. Detection of high-risk families is possible by identification of mutations in cancer susceptibility genes like BRCA1 and BRCA2 as well as by family history showing breast and/or ovary cancer aggregation. In a group of 521 breast cancer patients we identified 26 patients with hereditary breast cancer who fulfilled the following criteria: one more relative with breast cancer, vertical transmission, at least one breast cancer patient affected at the age under 50 years. 8 patients of these developed second primary breast cancer. We also compared the frequency of hereditary cancers in stage I-III with the frequency of respective cancers with negative family history. Hereditary breast cancers were diagnosed less frequently in stage I and more frequently in stage II and III (RR = 0.49, RR = 1.39, RR = 1.62, respectively). Because of importance of family history as well as genetic testing for breast cancer susceptibility genes (BRCA1/2), it is necessary to create a nationwide network of hereditary cancer clinics for proper diagnosis, treatment, and prophylaxis of these patients.

High-risk premenopausal women's experiences of undergoing prophylactic oophorectomy: a descriptive study

Women who are at increased risk of developing ovarian cancer because of their family history may need to make decisions about the medical management of their cancer risk--whether to have ovarian screening or undergo prophylactic surgery. This qualitative study explores the perceived physical and emotional implications of undergoing preventative surgery using data collected during interviews with 23 high-risk premenopausal women who had undergone prophylactic oophorectomy because of their family history of cancer. Despite the fact that all of these women regarded their decision to undergo surgery extremely positively, 20 women also described what they regarded as the costs of undergoing surgery. These included post-operative complications, the onset of menopausal symptoms, side effects of hormone replacement therapy, and negative effects on body image and gender identity. The perceived benefits of surgery were described as risk reduction, enabling one to fulfil family obligations, removing the need for gynecological screening, cessation of menstruation, and positive side effects of hormone replacement therapy. This study suggests there is a need to inform women about potential physical and emotional sequelae of oophorectomy prior to undergoing this procedure.

BRCA patients and clinical collectives: new configurations of action in cancer genetics practices

Since the late 1980s, in France and in a number of other countries, cancer genetics testing has become a clinical reality, particularly for hereditary breast and ovarian cancer. BRCA tests allowing for the assessment of an increased cancer risk among patients and their healthy relatives are now being routinely performed as part of clinical practice. Based on fieldwork on French clinical cancer genetics and on the French Cancer Genetics Collaborative Network, this paper examines the configuration of entities, actors and activities mobilized by the performance of BRAC testing, and argues that the development of clinical molecular genetic practices is predicated upon the development of new forms of collaborative work that lead to a transformation of the content and organization of medical activities and judgements. The paper analyses three major collective configurations - local multidisciplinary collectives, data collectives and new clinical collectives - and argues that they not only provide the material conditions needed to carry out the relevant activities, but also articulate a series of distinctive bio-clinical interventions. These interventions provide an interface with research activities, produce the epidemiological measurements and tools that are a sine qua non for clinical work in this field, and, most importantly, establish the conventions that underlie practices, which define the criteria that turn tools and novel entities into operational components of clinical settings. It thus appears that in the field of clinical cancer genetics, bioclinical collectives, as a locus of expertise, have replaced the individual judgement of the practicing clinician.

Intensive radiologic surveillance: a focus on the psychological issues

Although women who carry BRCA1 or BRCA2 mutations have up to an 85% lifetime risk of breast cancer, the majority choose to forego prophylactic mastectomy, which has been proven to markedly lower breast cancer mortality, and opt for lifelong intensive surveillance. Whether surveillance lowers breast cancer mortality in these women is unknown. However, in a formal survey of 34 of these women, 82% indicated a strong belief in the ability of surveillance to find breast cancer at a stage when it is still curable. Since 1997 we have been conducting a study to compare the sensitivity of breast magnetic resonance imaging (MRI), ultrasound, mammography and clinical breast examination (CBE) in women at high risk for hereditary breast cancer. Breast cancer incidence rates have been even higher than predicted for this population. The addition of MRI and ultrasound to conventional surveillance with mammography and CBE significantly improves sensitivity, but at the expense of decreased specificity. Two years ago we began a formal study of distress and breast cancer anxiety. A sample of 25 new and ongoing participants in the surveillance study have completed the Hospital Anxiety and Depression Scale together with the Breast Cancer Worry Scale, up to six times per year over a 2-year period. To date there has been no evidence of any impact of intensive surveillance, including false-positive studies, on anxiety, depression or breast cancer worry.

An oncologist-based model of cancer genetic counselling for hereditary breast and ovarian cancer

BACKGROUND

We describe a multistep model of cancer genetic counselling designed to promote awareness, and disease surveillance and preventive measures for hereditary and familial breast and ovarian cancer.

PATIENTS AND METHODS

Step T0 of the model entails information giving; this is followed by pedigree analysis and risk estimation (T1), risk communication and genetic testing (T2), and genetic test result communication (T3). User consent was required to proceed from one step to the next. Surveillance and preventive measures are proposed to at-risk users. Of the 311 subjects who requested cancer genetic counselling, consent data to each counselling step were available for 295: 93 were disease-free, 187 had breast cancer, 12 had ovarian cancer and three had breast plus ovarian cancer.

RESULTS

Consent was high at T0 (98.39%), T1 (96.40%) and T2 (99.65%). Consent decreased at the crucial points of counselling: T2 (87.71%) and T3 [genetic test result communication (85.08%), and extension of counselling to and testing of relatives (65.36%)].

CONCLUSIONS

The model fosters the user's knowledge about cancer and favours identification of at-risk subjects. Furthermore, by promoting awareness about genetic testing and surveillance measures, the algorithm enables users to make a fully informed choice of action in case of predisposing or familial cancer risk.

Breast Cancer Surveillance in Women with Hereditary Risk Due to BRCA1 or BRCA2 Mutations

Women with germline mutations in BRCA1 or BRCA2 are known to be at substantially elevated risk for breast cancer. With increasing acceptance of genetic testing, significant numbers of mutation carriers are being identified, but evidence-based guidelines for the management of women at hereditary risk are lacking. This article reviews the most commonly recommended modalities employed in breast cancer surveillance for women at increased risk. It is apparent that the standard techniques of breast self-examination, clinical breast examination, and mammography are suboptimal for the identification of hereditary breast cancer. At least half of the cancers in this population appear to be detected by physical examination in the intervals between routine radiographic surveillance. Host factors (eg, breast density) and tumor features (rapid proliferative rates) likely contribute to the relative insensitivity of mammography. These factors may be mitigated by the deployment of screening techniques for breast cancer such as ultrasound and magnetic resonance imaging. However, the effect of incremental screening on either stage at diagnosis or breast cancer mortality has not been defined. In addition, the impact of the relatively limited specificity of these techniques on the quality of life (QOL) of women at risk has not been studied. Further research is needed to evaluate the effect of incremental radiographic screening on outcomes, to delineate the best way to integrate the different modalities in terms of sequencing and frequency, and to identify interventions that will minimize the impact of intensive surveillance programs on the QOL of the women engaged in them.

Population genetic screening programmes: principles, techniques, practices, and policies

This paper examines the professional and scientific views on the principles, techniques, practices, and policies that impact on the population genetic screening programmes in Europe. This paper focuses on the issues surrounding potential screening programmes, which require further discussion before their introduction. It aims to increase, among the health-care professions and health policy-makers, awareness of the potential screening programmes as an issue of increasing concern to public health. The methods comprised primarily the review of the existing professional guidelines, regulatory frameworks and other documents related to population genetic screening programmes in Europe. Then, the questions that need debate, in regard to different types of genetic screening before and after birth, were examined. Screening for conditions such as cystic fibrosis, Duchenne muscular dystrophy, familial hypercholesterolemia, fragile X syndrome, hemochromatosis, and cancer susceptibility was discussed. Special issues related to genetic screening were also examined, such as informed consent, family aspects, commercialization, the players on the scene and monitoring genetic screening programmes. Afterwards, these questions were debated by 51 experts from 15 European countries during an international workshop organized by the European Society of Human Genetics Public and Professional Policy Committee in Amsterdam, The Netherlands, 19-20, November, 1999. Arguments for and against starting screening programmes have been put forward. It has been questioned whether genetic screening differs from other types of screening and testing in terms of ethical issues. The general impression on the future of genetic screening is that one wants to 'proceed with caution', with more active impetus from the side of patients' organizations and more reluctance from the policy-makers. The latter try to obviate the potential problems about the abortion and eugenics issues that might be perceived as a greater problem than it is in reality. However, it seems important to maintain a balance between a 'professional duty of care' and 'personal autonomy'.

L’offre de tests de prédisposition génétique au cancer du sein ou de l’ovaire en France

One example of the recent advances of scientific research on the human genome is the identification of two susceptibility genes to breast/ovarian cancer, BRCA1 and BRCA2, making possible the introduction in medical practices of genetic testing to detect patients with an increased risk of developing such cancers. In this context of diffusion, two surveys were carried out to appraise the activity profiles in 1998 and in 2001 of all the different participants in those new medical practices in France, physicians in charge of genetic counselling, medical centres where consultations take place and laboratories. Results show that over the period 1998-2001, few changes occurred, mainly the reduction of the average waiting time to get the result of a genetic test, the increase in the annual number of BRCA2 families identified to a level similar to the one of BRCA1 and the automation of the biological analyses without noting a considerable increase in the annual output of laboratories till 2001 however. This surprising moderate evolution must be connected to the existence of some particular external factors making the framework of the development of these new medical and biological practices and their future really uncertain. The diffusion of BRCA1/2 genetic testing has been carried out facing the traditional difficulties of any innovating activities, but also the uncertainties related to intellectual property rights on genes and the reimbursement of genetic counselling and biological testing. These uncertainties have certainly restrained the pace of change as many actors in this field have opted for a wait and see strategy bearing in mind the possible future constraints imposed to their future activity, especially if European patents on the BRCA1/2 genes are finally granted by the European patent office (EPO).

Are medullary breast cancers an indication for BRCA1 mutation screening? A mutation analysis of 42 cases of medullary breast cancer

Recommended guidelines have limited breast cancer gene ( BRCA1 ) mutation testing to individuals with a personal or family history of early onset breast and/or ovarian cancer, and those with multiple affected close relatives. Such large breast cancer families are rare in the general population, limiting the clinical application of the BRCA1 discovery. Previous reports have suggested an association between medullary breast cancer and BRCA1 mutation carriers. To test the feasibility of using these rare histological subtypes as an alternative to epidemiological factors, 42 cases of medullary cancer unselected for family history were screened for BRCA1 point mutations and large exon rearrangements. The large majority (83%) of these patients did not have significant family of breast or ovarian cancer. Two deleterious mutations resulting in a premature stop codon, and one exon 13 duplication were found. All mutations were detected in patients with typical medullary cancer, who had family history of multiple breast and ovarian cancers. Our findings suggest that medullary breast cancers are not an indication for BRCA1 mutation screening in the absence of significant family risk factors.

Prevention and genetic testing for breast cancer: variations in medical decisions

The discovery linking the genes BRCA1&2 to familial breast cancer played an important role in the clinical practice of geneticists and physicians. The availability of genetic tests for BRCA gene mutations prompted cancer geneticists to give information about genetic risk and to assess many women with a personal or family history of breast or ovarian cancer to inform them of preventive measures. These consist mainly of breast self-examination, mammography screening, chemoprevention and prophylactic surgery (mastectomy, oophorectomy). This paper examines clinical practices related to hereditary breast cancer testing and introduces a number of results from a survey carried out, between 1996 and 1998, in three clinics located in Montreal (Quebec, Canada), Marseilles (France) and Manchester (Great Britain). Results show substantial differences in the way cancer geneticists deal with environmental risk factors, breast and ovarian cancer testing, and chemoprevention and prophylactic surgery. Differences across cities persist in the multivariate analysis, suggesting that attitudes towards preventive measures may be partially explained by cultural factors. Different dimensions of culture are discussed including the social representation of health and risk, the interpretation of scientific evidence and the role of innovation leadership.

Analyses of p53 expression pattern and BRCA mutations in patients with double primary breast and ovarian cancer

OBJECTIVE

To analyze the somatic pattern of p53 expression and BRCA germline mutation status in Israeli patients with both ovarian (OvCa) and breast cancer (BrCa).

METHODS

The study group comprised 43 Israeli patients with OvCa, all of whom had previous primary BrCa. p53 immunohistochemistry (IHC) on all available archival tissues and genotyping for the three predominant Jewish germline BRCA1-2 mutations were carried out. Samples from 64 patients with solitary OvCa and 61 with solitary BrCa were similarly analyzed as controls.

RESULTS

p53 expression pattern and the immunopositivity rate were similar in the ovarian and breast tumors within the study group and in the two control groups: positive p53 staining was detected in 68% of ovarian tumors in the study group compared with 71.9% in the controls, and in 19.4% of the BrCa tissues versus 21.3% in the controls. Within the study group, advanced stage OvCa had a higher rate of p53 expression (84%) compared to early stage disease (38.5%) (P = 0.006). This difference was not apparent in the solitary OvCa control group. OvCa in BRCA1-2 mutation carriers from the study group were more likely to display positive p53 staining (79%), especially in tumors diagnosed before the age of 60 (90%) compared with the OvCa of noncarriers (60%), but this difference was statistically insignificant. The p53 expression rate in BrCa samples from the study group was not associated with BRCA1-2 mutation status.

CONCLUSIONS

Positive p53 expression, detected by IHC, in OvCa patients with previous primary BrCa is significantly higher in advanced stage disease in BRCA1-2 mutation carriers. There is a higher positive p53 expression somatically in OvCa in BRCA1-2 carriers in whom OvCa was diagnosed before the age of 60 years, although this trend is not statistically significant. These observations suggest that somatic p53 inactivation may be an important event in ovarian tumorigenesis in this subset of patients.

Comparison of physicians' and cancer prone women's attitudes about breast/ovarian prophylactic surgery. Results from two national surveys

Prophylactic surgery is a major issue for breast/ovarian cancer prone women. Bio-clinical data to help in the decision-making are not sufficient. In this context of uncertainty, physicians' and women's attitudes to prophylactic surgery is information of great value. The physicians' attitudes were assessed by a randomised national sample of practitioners involved in breast and ovarian cancer management. The patients' attitudes were appraised with a pre-consultation self- administered questionnaire presented during a one-year period to all women in five cancer genetic clinics chosen, for their representative geographical locations and their activity level. Consent to prophylactic surgery is higher among physicians than among patients (p < 0.0001). Acceptability of mastectomy is lower than that of oophorectomy in both patients and physicians (p < 0.0001 in both groups). In addition, age at which the intervention is proposed to be performed is a key determinant for both mastectomy and oophorectomy acceptability, in both physicians and patients (p < 0.001 for each comparison). Particularly, the age of 40 years seems to be a critical threshold for the acceptability of prophylactic oophorectomy. In contrast, respondents' age at the time of the survey has no significant effect on the acceptability rate. The higher acceptability rate of prophylactic oophorectomy compared to that of mastectomy observed in the physicians' survey is paradoxical because a more substantial medical impact on life expectancy was expected from the latter. Our results indicate that assumed reduced mortality is not the main criterion steering acceptability. It was anticipated that prophylactic mastectomy should be rarely performed in France.