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Daly MB, Pal T, Berry MP, Buys SS, Dickson P, Domchek SM, Elkhanany A, Friedman S, Goggins M, Hutton ML, Karlan BY, Khan S, Klein C, Kohlmann W, Kurian AW, Laronga C, Litton JK, Mak JS, Menendez CS, Merajver SD, Norquist BS, Offit K, Pederson HJ, Reiser G, Senter-Jamieson L, Shannon KM, Shatsky R, Visvanathan K, Weitzel JN, Wick MJ, Wisinski KB, Yurgelun MB, Darlow SD, Dwyer MA. Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:77-102. [DOI: 10.6004/jnccn.2021.0001] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic focus primarily on assessment of pathogenic or likely pathogenic variants associated with increased risk of breast, ovarian, and pancreatic cancer and recommended approaches to genetic testing/counseling and management strategies in individuals with these pathogenic or likely pathogenic variants. This manuscript focuses on cancer risk and risk management for BRCA-related breast/ovarian cancer syndrome and Li-Fraumeni syndrome. Carriers of a BRCA1/2 pathogenic or likely pathogenic variant have an excessive risk for both breast and ovarian cancer that warrants consideration of more intensive screening and preventive strategies. There is also evidence that risks of prostate cancer and pancreatic cancer are elevated in these carriers. Li-Fraumeni syndrome is a highly penetrant cancer syndrome associated with a high lifetime risk for cancer, including soft tissue sarcomas, osteosarcomas, premenopausal breast cancer, colon cancer, gastric cancer, adrenocortical carcinoma, and brain tumors.
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Affiliation(s)
| | - Tuya Pal
- 2Vanderbilt-Ingram Cancer Center
| | - Michael P. Berry
- 3St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center
| | | | - Patricia Dickson
- 5Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Michael Goggins
- 9The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | - Seema Khan
- 12Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | | | | | | | | | | | | | - Holly J. Pederson
- 22Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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2
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Vermeulen RFM, Korse CM, Kenter GG, Brood-van Zanten MMA, Beurden MV. Safety of hormone replacement therapy following risk-reducing salpingo-oophorectomy: systematic review of literature and guidelines. Climacteric 2019; 22:352-360. [PMID: 30905183 DOI: 10.1080/13697137.2019.1582622] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Women at high risk to develop ovarian cancer opt for risk-reducing salpingo-oophorectomy (RRSO) to reduce the risk by 80-96%. RRSO leads to a direct onset of menopause in premenopausal women. Hormone replacement therapy (HRT) can be used to mitigate menopausal symptoms after RRSO. However, it is unclear whether HRT in these women is safe in terms of breast cancer (BC) risk. Methods: We performed a literature search and investigated national guidelines on the use of HRT following RRSO in BRCA1 and BRCA2 mutation carriers. We analyzed differences and similarities between the guidelines and describe what these guidelines were based upon. Results: Seven articles regarding HRT following RRSO in BRCA1 and BRCA2 mutation carriers were identified. None of the included studies yielded any evidence that short-term use of HRT following RRSO increases the risk of developing BC or negates the protective effect of RRSO in BRCA1/2 mutation carriers without a personal history of BC. Eleven national guidelines were found and described. Conclusion: Short-term use of HRT after RRSO seems to be safe. The literature is more favorable toward estrogen alone. The ideal dosage and duration of use are unknown and remain to be investigated in future studies.
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Affiliation(s)
- R F M Vermeulen
- a Department of Gynecology , The Netherlands Cancer Institute , Amsterdam , the Netherlands
| | - C M Korse
- b Department of Laboratory Medicine , The Netherlands Cancer Institute , Amsterdam , the Netherlands
| | - G G Kenter
- a Department of Gynecology , The Netherlands Cancer Institute , Amsterdam , the Netherlands
| | - M M A Brood-van Zanten
- a Department of Gynecology , The Netherlands Cancer Institute , Amsterdam , the Netherlands.,c Amsterdam UMC , Amsterdam , the Netherlands
| | - M van Beurden
- a Department of Gynecology , The Netherlands Cancer Institute , Amsterdam , the Netherlands
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Mæland MK, Eriksen EO, Synnes O. The loss of a mother and dealing with genetic cancer risk: women who have undergone prophylactic removal of the ovaries. Eur J Oncol Nurs 2014; 18:521-6. [PMID: 24880189 DOI: 10.1016/j.ejon.2014.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 04/02/2014] [Accepted: 04/19/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this article is to highlight some new findings from a qualitative study that have not been previously considered. METHOD The research was based on a qualitative phenomenological method. Data were collected by semi-structured individual interviews. A purposeful sample was recruited from West Norway of 14 women with a possible risk of developing breast and ovarian cancer. Data collection took place at least one year after prophylactic removal of the ovaries. Data from the study was analyzed according to the phenomenological method of Amedeo Giorgi. KEY FINDINGS Two themes were revealed as essential factors of the interviewed women's experiences: "the loss of a mother" and "dealing with genetic cancer risk." For the most part, these two themes also appeared to be interrelated. When a mother died of ovarian cancer while her daughter was a child or a young woman, this often led to her daughter's strong desire to find an explanation for her mother's death, as well as to her efforts to undergo genetic testing and surgery to prevent cancer in her family in the future. CONCLUSION The study indicates that women's experiences in families at risk of hereditary cancer are closely related to an understanding of their life stories, particularly their "loss of a mother," and how this influences how they deal with genetic cancer risk. Health care workers can thus help patients identify connections and establish coherence through the act of storytelling, by listening to their illness experiences as part of their life stories.
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Affiliation(s)
- Marie Kvamme Mæland
- Betanien University College, Institute of Nursing and Health, Vestlundveien 19, 5145 Fyllingsdalen, Norway.
| | - Elin Overaa Eriksen
- Betanien University College, Institute of Nursing and Health, Vestlundveien 19, 5145 Fyllingsdalen, Norway.
| | - Oddgeir Synnes
- Betanien University College, Institute of Nursing and Health, Vestlundveien 19, 5145 Fyllingsdalen, Norway.
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Surveillance of survivors: Follow-up after risk-reducing salpingo-oophorectomy in BRCA 1/2 mutation carriers. Gynecol Oncol 2011; 122:339-43. [DOI: 10.1016/j.ygyno.2011.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/31/2011] [Accepted: 04/02/2011] [Indexed: 11/23/2022]
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Keating NL, Stoeckert KA, Regan MM, DiGianni L, Garber JE. Physicians' experiences with BRCA1/2 testing in community settings. J Clin Oncol 2008; 26:5789-96. [PMID: 19001322 PMCID: PMC2645103 DOI: 10.1200/jco.2008.17.8053] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 07/16/2008] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We surveyed a national sample of nonacademic physicians who ordered BRCA1/2 testing to understand their implementation of genetic testing and to assess recommendations for surveillance and cancer risk management of women with positive test results. PATIENTS AND METHODS We surveyed physicians (N = 611 of 1,050; response rate, 58.2%) practicing in nonacademic settings who ordered BRCA1/2 testing during 2004 to 2005. We described physicians' experiences with testing and used multivariable regression models to identify factors associated with more complete counseling and with recommendations for cancer risk management for a BRCA1 mutation carrier. RESULTS Most physicians (68.2%) usually or always discussed six counseling items before testing. In adjusted analyses, physicians who were assisted by genetic counselors, nurse geneticists, or others (v counseling by themselves), those who spent more than 60 minutes in counseling, and medical oncologists (v surgeons or geneticists) were more likely to discuss all six items (all P < .05). A total of 61.4% of physicians would recommend bilateral prophylactic mastectomy to a 38-year-old BRCA1 mutation carrier who had completed childbearing. After adjustment, geneticists and gynecologists were less likely than medical oncologists and surgeons to recommend prophylactic mastectomy (P < .001), as were physicians in the Northeast versus those in other regions of the United States (P = .01). CONCLUSION Community-based physicians seem to be successfully incorporating BRCA1/2 testing into their practices. Physicians' recommendations for surveillance of mutation carriers are generally consistent with practice guidelines, yet recommendations for preference-based procedures such as prophylactic mastectomy vary by physician characteristics such as specialty and geographic region. The providers whom patients see for testing may contribute to variations in prophylactic treatments.
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Affiliation(s)
- Nancy L Keating
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Chlebowski RT, Prentice RL. Menopausal hormone therapy in BRCA1 mutation carriers: uncertainty and caution. J Natl Cancer Inst 2008; 100:1341-3. [PMID: 18812547 DOI: 10.1093/jnci/djn327] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Horsman D, Wilson BJ, Avard D, Meschino WS, Kim Sing C, Plante M, Eisen A, Howley HE, Simard J. Clinical management recommendations for surveillance and risk-reduction strategies for hereditary breast and ovarian cancer among individuals carrying a deleterious BRCA1 or BRCA2 mutation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007; 29:45-60. [PMID: 17346477 DOI: 10.1016/s1701-2163(16)32349-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In Canada, there are wide variations in services for patients at risk for hereditary breast and ovarian cancer (HBOC), and clinical interventions and recommendations differ between regions and/or provinces. National strategies for the clinical management of HBOC exist in the United Kingdom, France, and Australia, and clinical programs in Canada would benefit from similar national recommendations and a consistent approach to clinical management. The National Hereditary Cancer Task Force developed recommendations to address the clinical management of patients at high risk of HBOC and related cancers. These recommendations are based on current practice in high-risk cancer clinics that provide care for individuals with known BRCA1 or BRCA2 mutations. METHODS Canadian consensus recommendations were generated by the National Hereditary Cancer Task Force and compared mainly with two recently published guidance documents on the clinical management of women with increased risk of HBOC, one from the United Kingdom and the other from France. After review of these documents and the associated supporting scientific evidence, the Canadian consensus recommendations were modified and rated using predefined criteria. CONCLUSIONS These recommendations pertain to (1) surveillance options including breast self-examination, clinical breast examination, breast surveillance by imaging, ovarian cancer surveillance, and surveillance for men; (2) risk-reduction strategies including prophylactic mastectomy, prophylactic salpingo-oophorectomy, and pharmacoprevention; and (3) the use of exogenous hormones. Regular updates should occur as new evidence becomes available.
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Affiliation(s)
- Doug Horsman
- British Columbia Cancer Agency, Vancouver, BC, Canada
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Madalinska JB, van Beurden M, Bleiker EMA, Valdimarsdottir HB, Hollenstein J, Massuger LF, Gaarenstroom KN, Mourits MJE, Verheijen RHM, van Dorst EBL, van der Putten H, van der Velden K, Boonstra H, Aaronson NK. The Impact of Hormone Replacement Therapy on Menopausal Symptoms in Younger High-Risk Women After Prophylactic Salpingo-Oophorectomy. J Clin Oncol 2006; 24:3576-82. [PMID: 16877724 DOI: 10.1200/jco.2005.05.1896] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Preventive health strategies for women at increased hereditary risk of ovarian cancer include gynecologic screening (GS) and/or prophylactic oophorectomy (PBSO). Hormone replacement therapy (HRT) is often prescribed to compensate for postsurgical endocrine deficiencies. This study examined the impact of HRT use on levels of endocrine symptoms and sexual functioning among premenopausal women who have undergone PBSO. Comparisons were made with similar women undergoing GS. Patients and Methods Questionnaire data on endocrine symptoms and sexual functioning were obtained from 450 premenopausal, high-risk women who had participated in this nationwide, cross-sectional, observational study. Results Thirty-six percent of women had undergone PBSO and 64% had opted for GS. In the PBSO group, 47% of the women were current HRT users. They reported significantly fewer vasomotor symptoms than nonusers (P < .05). However, compared with premenopausal women undergoing GS, oophorectomized HRT users were more likely to report vasomotor symptoms (P < .01). HRT users and nonusers reported comparable levels of sexual functioning. Compared with women in the GS group, oophorectomized HRT users reported significantly more sexual discomfort due to vaginal dryness and dyspareunia (P < .01). Conclusion Although HRT has a positive impact on surgically induced vasomotor symptoms, it may be less effective than is often assumed. Symptom levels remain well above those of premenopausal women undergoing screening, and sexual discomfort is not alleviated by HRT. Physicians need to provide younger high-risk women considering PBSO with realistic information about both benefits and drawbacks of this preventive strategy, including information about premature menopause and HRT.
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Affiliation(s)
- Joanna B Madalinska
- Division of Psychosocial Research and Epidemiology, and Department of Gynecology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
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Ray JA, Loescher LJ, Brewer M. Risk-Reduction Surgery Decisions in High-Risk Women Seen for Genetic Counseling. J Genet Couns 2005; 14:473-84. [PMID: 16388328 DOI: 10.1007/s10897-005-5833-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Women at greatest risk for hereditary breast and ovarian cancer may consider prophylactic removal of breasts or ovaries as a risk-reduction measure. This report describes uptake of risk-reduction mastectomy (RRM), risk-reduction oophorectomy (RRO), and related factors in 62 high-risk women who received genetic counseling. Seven (11%) participants underwent RRM and 13 (21%) underwent RRO. Of these women, 37% did not have BRCA testing, suggesting other factors influence decisions to undergo surgery. Women who had indicated (pre-genetic counseling) their intent not to have surgery chose not to have surgery. Information received during genetic counseling that women perceived as being most important for influencing risk-reduction surgery decisions was BRCA test result (positive or negative), followed by discussion of family cancer history. Reasons for indecision about risk-reduction surgery included genetic testing results, concerns about surgery, timing in life, and early menopause. The findings enhance our understanding of information that is helpful to women considering this surgery.
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Affiliation(s)
- Jessica A Ray
- Arizona Cancer Center, University of Arizona, Tucson, 85724, USA
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Abstract
Family history is the strongest risk factor for ovarian cancer. Three clinical manifestations of hereditary ovarian cancer have been recognized: (1) "site-specific" ovarian cancer, (2) the breast and ovarian cancer syndrome, and (3) the hereditary nonpolyposis colorectal cancer (HNPCC; Lynch II) syndrome. The first 2 groups are associated with germ line mutations in the BRCA1 and BRCA2 tumor suppressor genes, whereas HNPCC is associated with germ line mutations in the DNA mismatch repair (MMR) genes, primarily hMLH1 and hMSH2. At least 10% of all epithelial ovarian cancers are hereditary, with mutations in the BRCA genes accounting for approximately 90% of cases and most of the remaining 10% attributable to HNPCC. Hereditary ovarian cancers exhibit distinct clinicopathologic features compared with sporadic cancers. The cumulative lifetime risk of ovarian cancer is 40% to 50% for BRCA1 mutation carriers and 20% to 30% for BRCA2 mutation carriers. Both BRCA proteins participate in transcriptional regulation of gene expression as well as the recognition or repair of certain forms of DNA damage, particularly double-strand breaks. Mutations of BRCA1 and BRCA2 are mainly of the frameshift or nonsense variety. Most ovarian cancers associated with germ line BRCA mutations are diagnosed at a younger age and are high-grade and advanced-stage serous carcinomas. BRCA mutations do not seem to play a significant role in the development of mucinous or borderline ovarian tumors. Hereditary ovarian cancers have a distinctly better clinical outcome with longer overall survival and recurrence-free interval after chemotherapy than sporadic cancers. Women with a family history including 2 or more first- or second-degree relatives with either ovarian cancer alone or both breast and ovarian cancers should undertake prophylactic oophorectomy immediately after childbearing has been completed to reduce the risk of ovarian cancer. The cumulative risk of ovarian cancer in HNPCC families is more than 12%. Ovarian cancer in HNPCC syndrome is diagnosed at younger age than in the general population. Most tumors are low-stage well-differentiated or moderately differentiated carcinomas. Annual follow-up is recommended for these patients.
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Affiliation(s)
- Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08025 Barcelona, Spain.
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Affiliation(s)
- Stephen A Cannistra
- Program of Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Agnantis NJ, Paraskevaidis E, Roukos D. Preventing Breast, Ovarian Cancer in BRCA Carriers: Rational of Prophylactic Surgery and Promises of Surveillance. Ann Surg Oncol 2004; 11:1030-4. [PMID: 15545500 DOI: 10.1245/aso.2004.09.910] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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