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Dossa F, Metcalfe K, Sutradhar R, Little T, Eisen A, Chun K, Meschino WS, Velsher L, Ellis JL, Baxter NN. Building the What Comes Next Cohort for BRCA1 and BRCA2 testing: a descriptive analysis. CMAJ Open 2021; 9:E874-E885. [PMID: 34870614 PMCID: PMC8741196 DOI: 10.9778/cmajo.20200228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Our understanding of how testing for and mutations of the BRCA1 and BRCA2 genes affect cancer risk and the use of risk-reduction strategies comes largely from studies of women recruited from specialized genetics clinics. Our aim was to assemble a generalizable cohort of women who underwent BRCA1/BRCA2 testing (the What Comes Next Cohort), irrespective of test result, to enable study of health care utilization and outcomes after testing. METHODS This descriptive study included adult women (≥ 18 yr) who met at least 1 of 13 provincial criteria for BRCA1/BRCA2 testing and who underwent genetic testing at sites in Ontario, Canada, from 2007 to 2016. Most of the women were tested at 1 of 2 main sites, which together capture about 70% of all BRCA1/BRCA2 testing in the province. We collected detailed demographic, genetic testing and family history data through chart review for linkage with data from administrative health databases providing information on cancer history before and after testing. We followed all women to September 2019, evaluating the demographic characteristics of the cohort, indications for testing and test results. RESULTS We identified 15 986 women (mean age 52.5 [standard deviation 13.9] yr) who underwent BRCA1/BRCA2 testing. Of these, 2033 women had positive results, 1175 women had variants of uncertain significance, and 12 778 women had negative results. Positive yields were 41.0% (955/2329) for predictive testing (for familial variants), 10.4% (216/2072) for Ashkenazi Jewish founder testing and 7.4% (862/11 585) for complete gene analysis. Six of the 13 provincial testing criteria had less than 10% positive yield. Among 403 women who tested negative for Ashkenazi Jewish founder mutations and subsequently underwent complete gene analysis, 12 (3.0%) tested positive for alternate pathogenic or likely pathogenic variants in the BRCA1 or BRCA2 gene. INTERPRETATION Several provincial eligibility criteria for BRCA1/BRCA2 testing led to positive results in less than 10% of cases. How testing influences women's health care behaviours, particularly those with negative results and those found to carry variants of uncertain significance, is unknown; the What Comes Next Cohort will be instrumental in the study of long-term implications of BRCA1/BRCA2 testing.
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Affiliation(s)
- Fahima Dossa
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Kelly Metcalfe
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Rinku Sutradhar
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Tari Little
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Andrea Eisen
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Kathy Chun
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Wendy S Meschino
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Lea Velsher
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Jordan Lerner Ellis
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
| | - Nancy N Baxter
- Division of General Surgery, Department of Surgery (Dossa), Institute of Health Policy, Management and Evaluation (Dossa, Sutradhar, Baxter), Lawrence S. Bloomberg Faculty of Nursing ( Metcalfe) Division of Biostatistics, Dalla Lana School of Public Health (Sutradhar), Department of Pediatrics (Meschino) and Department of Laboratory Medicine and Pathobiology (Lerner Ellis), University of Toronto; ICES Central (Sutradhar); Department of Surgery (Little), St. Michael's Hospital; Odette Cancer Centre (Eisen), Sunnybrook Health Sciences Centre; Department of Paediatric Laboratory Medicine (Chun), The Hospital for Sick Children; Genetics Program (Meschino, Velsher), North York General Hospital; Lunenfeld-Tanenbaum Research Institute (Lerner Ellis) and Pathology and Laboratory Medicine (Lerner Ellis), Mount Sinai Hospital, Sinai Health System, Toronto, Ont.; Melbourne School of Population and Global Health (Baxter), University of Melbourne, Melbourne, Victoria, Australia
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Lerner-Ellis J, Mighton C, Lazaro C, Watkins N, Di Gioacchino V, Wong A, Chang MC, Charames GS. Multigene panel testing for hereditary breast and ovarian cancer in the province of Ontario. J Cancer Res Clin Oncol 2021; 147:871-879. [PMID: 32885271 DOI: 10.1007/s00432-020-03377-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/25/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to determine the diagnostic yield of multigene panel testing among patients referred with hereditary breast and ovarian cancer (HBOC). METHODS Patients who met provincial eligibility criteria were tested at the Advanced Molecular Diagnostic Laboratory at Mount Sinai Hospital, Toronto. Gene sequencing and exon-level copy number variant (CNV) analysis was performed. The referring physician had the opportunity to choose between several different gene panels based on patient phenotype. Cases were included in the analysis based on personal and family history of cancer and the type of panel ordered. RESULTS 3251 cases that received panel testing were included in this analysis. Overall, 9.1% (295) had a positive (pathogenic or likely pathogenic) result and 27.1% (882) had an inconclusive result (variant of uncertain significance). The genes with the highest prevalence of positive results were in BRCA2 (2.2%, 71/3235), BRCA1 (1.9%, 62/3235), and CHEK2 (1.4%, 40/2916). Of the positive cases, 9.8% (29) had a pathogenic or likely pathogenic variant in a gene associated with Lynch syndrome (MSH6, MSH2, MLH1, or PMS2). CONCLUSIONS Our overall positive yield is similar to that reported in the literature. The yield of inconclusive results was three times that of positive results. By testing more individuals in families with HBOC and through data-sharing efforts, the clinical significance of most variants may eventually be determined and panel testing for monogenic cancer predisposition syndromes will have greater utility.
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Affiliation(s)
- Jordan Lerner-Ellis
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada.
| | - Chloe Mighton
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Conxi Lazaro
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
- Hereditary Cancer Program, ICO-IDIBELL, Barcelona, Spain
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Nicholas Watkins
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Vanessa Di Gioacchino
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
| | - Andrew Wong
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
| | - Martin C Chang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- University of Vermont Cancer Center, Burlington, VT, USA
| | - George S Charames
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, 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: 8] [Impact Index Per Article: 1.6] [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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