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Valian H, Hassan Emami M, Heidari A, Amjadi E, Fahim A, Lalezarian A, Ali Ehsan Dehkordi S, Maghool F. Trend of the polyp and adenoma detection rate by sex and age in asymptomatic average-risk and high-risk individuals undergoing screening colonoscopy, 2012-2019. Prev Med Rep 2023; 36:102468. [PMID: 37869540 PMCID: PMC10587514 DOI: 10.1016/j.pmedr.2023.102468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
Adenoma detection rate (ADR) is an imperative quality measure for colorectal cancer (CRC) screening. This retrospective observational study aimed to determine the trend of polyp detection rate (PDR) and ADR in asymptomatic average- and high-risk participants in different age groups who underwent screening colonoscopy over the seven years from April 2012 to March 2019 in a tertiary gastroenterology referral center of Iran. Of 1676 participants, 51.8 % were men (mean age 52.3 years). The overall PDR and ADR were 22.7 %, and 13.5 %, respectively. Both Polyps and adenomas were more common in age groups 51-59 and ≥60 years in high-risk patients than in the corresponding groups of average-risk patients (p < 0.05). Also, both PDR and ADR were more frequent in men than in women among all studied age groups, but it was statistically significant only for the youngest age group (16.8 % versus 10.5 %, p < 0.05) for PDR and the oldest age group (19.7 % versus 13 %, p < 0.05) for ADR, respectively. The trend of total ADR was upward over 7 years in both average-risk (6.7 % to 13.3 %) and high-risk (9.8 % to 27 %) groups and across all age groups in both sexes. Multivariable logistic regression revealed that high-risk individuals had an elevated risk of adenoma compared with average-risk patients (OR: 1.6, p = 0.006). Substantial variation in thresholds of polyp and adenoma detection by age, sex, and risk categories emphasizes the need for a risk-adapted approach to CRC screening and prevention programs.
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Affiliation(s)
- Hengameh Valian
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hassan Emami
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Aida Heidari
- Department of Cell and Molecular Biology and Microbiology, Faculty of Biological Sciences and Technologies, University of Isfahan, Isfahan, Iran
| | - Elham Amjadi
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Fahim
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Anasik Lalezarian
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Fatemeh Maghool
- Poursina Hakim Digestive Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Cell and Molecular Biology and Microbiology, Faculty of Biological Sciences and Technologies, University of Isfahan, Isfahan, Iran
- Department of Family Medicine, University of Debrecen, Debrecen, Hungary
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3
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Seppälä TT, Ahadova A, Dominguez-Valentin M, Macrae F, Evans DG, Therkildsen C, Sampson J, Scott R, Burn J, Möslein G, Bernstein I, Holinski-Feder E, Pylvänäinen K, Renkonen-Sinisalo L, Lepistö A, Lautrup CK, Lindblom A, Plazzer JP, Winship I, Tjandra D, Katz LH, Aretz S, Hüneburg R, Holzapfel S, Heinimann K, Valle AD, Neffa F, Gluck N, de Vos Tot Nederveen Cappel WH, Vasen H, Morak M, Steinke-Lange V, Engel C, Rahner N, Schmiegel W, Vangala D, Thomas H, Green K, Lalloo F, Crosbie EJ, Hill J, Capella G, Pineda M, Navarro M, Blanco I, Ten Broeke S, Nielsen M, Ljungmann K, Nakken S, Lindor N, Frayling I, Hovig E, Sunde L, Kloor M, Mecklin JP, Kalager M, Møller P. Lack of association between screening interval and cancer stage in Lynch syndrome may be accounted for by over-diagnosis; a prospective Lynch syndrome database report. Hered Cancer Clin Pract 2019; 17:8. [PMID: 30858900 PMCID: PMC6394091 DOI: 10.1186/s13053-019-0106-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background Recent epidemiological evidence shows that colorectal cancer (CRC) continues to occur in carriers of pathogenic mismatch repair (path_MMR) variants despite frequent colonoscopy surveillance in expert centres. This observation conflicts with the paradigm that removal of all visible polyps should prevent the vast majority of CRC in path_MMR carriers, provided the screening interval is sufficiently short and colonoscopic practice is optimal. Methods To inform the debate, we examined, in the Prospective Lynch Syndrome Database (PLSD), whether the time since last colonoscopy was associated with the pathological stage at which CRC was diagnosed during prospective surveillance. Path_MMR carriers were recruited for prospective surveillance by colonoscopy. Only variants scored by the InSiGHT Variant Interpretation Committee as class 4 and 5 (clinically actionable) were included. CRCs detected at the first planned colonoscopy, or within one year of this, were excluded as prevalent cancers. Results Stage at diagnosis and interval between last prospective surveillance colonoscopy and diagnosis were available for 209 patients with 218 CRCs, including 162 path_MLH1, 45 path_MSH2, 10 path_MSH6 and 1 path_PMS2 carriers. The numbers of cancers detected within < 1.5, 1.5–2.5, 2.5–3.5 and at > 3.5 years since last colonoscopy were 36, 93, 56 and 33, respectively. Among these, 16.7, 19.4, 9.9 and 15.1% were stage III–IV, respectively (p = 0.34). The cancers detected more than 2.5 years after the last colonoscopy were not more advanced than those diagnosed earlier (p = 0.14). Conclusions The CRC stage and interval since last colonoscopy were not correlated, which is in conflict with the accelerated adenoma-carcinoma paradigm. We have previously reported that more frequent colonoscopy is not associated with lower incidence of CRC in path_MMR carriers as was expected. In contrast, point estimates showed a higher incidence with shorter intervals between examinations, a situation that may parallel to over-diagnosis in breast cancer screening. Our findings raise the possibility that some CRCs in path_MMR carriers may spontaneously disappear: the host immune response may not only remove CRC precursor lesions in path_MMR carriers, but may remove infiltrating cancers as well. If confirmed, our suggested interpretation will have a bearing on surveillance policy for path_MMR carriers.
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Affiliation(s)
- Toni T Seppälä
- 1Department of Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029 HUS Helsinki, Finland.,2University of Helsinki, Helsinki, Finland
| | - Aysel Ahadova
- 3Heidelberg University Hospital and DKFZ, Heidelberg, Germany
| | - Mev Dominguez-Valentin
- 4Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway.,5Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Finlay Macrae
- 6The Royal Melbourne Hospital, Melbourne, Australia.,7University of Melbourne, Melbourne, Australia
| | - D Gareth Evans
- 8University of Manchester & Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Christina Therkildsen
- The Danish HNPCC Register, Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark
| | | | - Rodney Scott
- University of Newcastle and the Hunter Medical Research Institute, Callaghan, Australia
| | - John Burn
- 12University of Newcastle, Newcastle upon Tyne, UK
| | | | - Inge Bernstein
- 14Dept. of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- 15Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Munich, Germany.,16MGZ- Medical Genetics Center, Munich, Germany
| | - Kirsi Pylvänäinen
- 17Central Finland Central Hospital, Education and Research, Jyväskylä, Finland
| | - Laura Renkonen-Sinisalo
- 1Department of Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029 HUS Helsinki, Finland
| | - Anna Lepistö
- 1Department of Surgery, Helsinki University Central Hospital, P.O. Box 340, 00029 HUS Helsinki, Finland
| | | | | | | | - Ingrid Winship
- 6The Royal Melbourne Hospital, Melbourne, Australia.,7University of Melbourne, Melbourne, Australia
| | | | - Lior H Katz
- 20Hadassah Medical Center, Jerusalem, and Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Stefan Aretz
- 21Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - Robert Hüneburg
- 22Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany.,23Center for Hereditary Tumor Syndromes, University Hospital Bonn, Bonn, Germany
| | - Stefanie Holzapfel
- 22Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany.,23Center for Hereditary Tumor Syndromes, University Hospital Bonn, Bonn, Germany
| | - Karl Heinimann
- 24Institute for Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Adriana Della Valle
- Hospital Fuerzas Armadas, Grupo Colaborativo Uruguayo, Investigación de Afecciones Oncológicas Hereditarias (GCU), Montevideo, Uruguay
| | - Florencia Neffa
- Hospital Fuerzas Armadas, Grupo Colaborativo Uruguayo, Investigación de Afecciones Oncológicas Hereditarias (GCU), Montevideo, Uruguay
| | - Nathan Gluck
- Tel-Aviv Soursky Medical Center, Tel-Aviv, Israel
| | | | - Hans Vasen
- 28Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Monika Morak
- 15Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Munich, Germany.,16MGZ- Medical Genetics Center, Munich, Germany
| | - Verena Steinke-Lange
- 15Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Munich, Germany.,16MGZ- Medical Genetics Center, Munich, Germany
| | - Christoph Engel
- 29Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Nils Rahner
- 30Medical School, Institute of Human Genetics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Wolff Schmiegel
- 31Department of Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Deepak Vangala
- 31Department of Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Huw Thomas
- 32St Mark's Hospital, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kate Green
- 8University of Manchester & Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- 8University of Manchester & Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Emma J Crosbie
- 33University of Manchester and St Mary's Hospital, Manchester, UK
| | - James Hill
- 8University of Manchester & Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Gabriel Capella
- Hereditary Cancer Program, Catalan Institute of Oncology, Insititut d'Investigació Biomèdica de Bellvitge (IDIBELL), ONCOBELL Program, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Barcelona, Spain
| | - Marta Pineda
- Hereditary Cancer Program, Catalan Institute of Oncology, Insititut d'Investigació Biomèdica de Bellvitge (IDIBELL), ONCOBELL Program, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program, Catalan Institute of Oncology, Insititut d'Investigació Biomèdica de Bellvitge (IDIBELL), ONCOBELL Program, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Barcelona, Spain
| | - Ignacio Blanco
- Hereditary Cancer Program, Catalan Institute of Oncology, Insititut d'Investigació Biomèdica de Bellvitge (IDIBELL), ONCOBELL Program, L'Hospitalet de Llobregat, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Barcelona, Spain
| | - Sanne Ten Broeke
- 36University Medical Center Groningen, Groningen, the Netherlands
| | | | - Ken Ljungmann
- 38Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Sigve Nakken
- 4Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway
| | - Noralane Lindor
- 39Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ USA
| | - Ian Frayling
- 10Medical Genetics, Cardiff University, Cardiff, UK
| | - Eivind Hovig
- 4Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway.,40Center for Bioinformatics, Department of Informatics, University of Oslo, Oslo, Norway
| | - Lone Sunde
- 41Department of Medical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Matthias Kloor
- 3Heidelberg University Hospital and DKFZ, Heidelberg, Germany
| | - Jukka-Pekka Mecklin
- 42Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland.,43Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Mette Kalager
- 4Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway.,44University of Oslo, Oslo, Norway.,45Harvard School of Public Health, Boston, MA USA
| | - Pål Møller
- 4Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Olso, Norway.,13University Witten-Herdecke, Wuppertal, Germany.,5Department of Medical Genetics, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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Seppälä T, Pylvänäinen K, Evans DG, Järvinen H, Renkonen-Sinisalo L, Bernstein I, Holinski-Feder E, Sala P, Lindblom A, Macrae F, Blanco I, Sijmons R, Jeffries J, Vasen H, Burn J, Nakken S, Hovig E, Rødland EA, Tharmaratnam K, de Vos Tot Nederveen Cappel WH, Hill J, Wijnen J, Jenkins M, Genuardi M, Green K, Lalloo F, Sunde L, Mints M, Bertario L, Pineda M, Navarro M, Morak M, Frayling IM, Plazzer JP, Sampson JR, Capella G, Möslein G, Mecklin JP, Møller P. Colorectal cancer incidence in path_MLH1 carriers subjected to different follow-up protocols: a Prospective Lynch Syndrome Database report. Hered Cancer Clin Pract 2017; 15:18. [PMID: 29046738 PMCID: PMC5635542 DOI: 10.1186/s13053-017-0078-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/02/2017] [Indexed: 12/31/2022] Open
Abstract
Background We have previously reported a high incidence of colorectal cancer (CRC) in carriers of pathogenic MLH1 variants (path_MLH1) despite follow-up with colonoscopy including polypectomy. Methods The cohort included Finnish carriers enrolled in 3-yearly colonoscopy (n = 505; 4625 observation years) and carriers from other countries enrolled in colonoscopy 2-yearly or more frequently (n = 439; 3299 observation years). We examined whether the longer interval between colonoscopies in Finland could explain the high incidence of CRC and whether disease expression correlated with differences in population CRC incidence. Results Cumulative CRC incidences in carriers of path_MLH1 at 70-years of age were 41% for males and 36% for females in the Finnish series and 58% and 55% in the non-Finnish series, respectively (p > 0.05). Mean time from last colonoscopy to CRC was 32.7 months in the Finnish compared to 31.0 months in the non-Finnish (p > 0.05) and was therefore unaffected by the recommended colonoscopy interval. Differences in population incidence of CRC could not explain the lower point estimates for CRC in the Finnish series. Ten-year overall survival after CRC was similar for the Finnish and non-Finnish series (88% and 91%, respectively; p > 0.05). Conclusions The hypothesis that the high incidence of CRC in path_MLH1 carriers was caused by a higher incidence in the Finnish series was not valid. We discuss whether the results were influenced by methodological shortcomings in our study or whether the assumption that a shorter interval between colonoscopies leads to a lower CRC incidence may be wrong. This second possibility is intriguing, because it suggests the dogma that CRC in path_MLH1 carriers develops from polyps that can be detected at colonoscopy and removed to prevent CRC may be erroneous. In view of the excellent 10-year overall survival in the Finnish and non-Finnish series we remain strong advocates of current surveillance practices for those with LS pending studies that will inform new recommendations on the best surveillance interval. Electronic supplementary material The online version of this article (10.1186/s13053-017-0078-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toni Seppälä
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Pylvänäinen
- Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland.,Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland
| | - Dafydd Gareth Evans
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Manchester Centre for Genomic Medicine, Institute of Human Development, MAHSC, University of Manchester, Manchester, UK
| | - Heikki Järvinen
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Finnish Lynch Syndrome registry, Helsinki University Hospital, Helsinki, Finland
| | - Laura Renkonen-Sinisalo
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Post Box 340, 00029 Helsinki, Finland.,Genome-Scale Biology Research Program, University of Helsinki, Helsinki, Finland
| | - Inge Bernstein
- Danish HNPCC Register, Hvidovre University Hospital, Copenhagen, Denmark.,Department Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Elke Holinski-Feder
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, 80336 Munich, Germany.,MGZ - Medizinisch Genetisches Zentrum, Bayerstr. 3-5, 80335 Munich, Germany
| | - Paola Sala
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milan, Italy
| | - Annika Lindblom
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Finlay Macrae
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, Melbourne University, Melbourne, Australia
| | - Ignacio Blanco
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rolf Sijmons
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jacqueline Jeffries
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Hans Vasen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - John Burn
- Institute of Human Genetics, Newcastle upon Tyne, UK
| | - Sigve Nakken
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | - Eivind Hovig
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway.,Institute of Cancer Genetics and Informatics, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway.,Department of Informatics, University of Oslo, Oslo, Norway
| | - Einar Andreas Rødland
- Department of Tumor Biology, Institute of Cancer Research, The Norwegian Radium Hospital, part of Oslo University Hospital, Oslo, Norway
| | | | | | - James Hill
- Department of Surgery, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Juul Wijnen
- Department of Clinical Genetics and Department of Human Genetics Leiden University Medical Centre, Leiden, The Netherlands
| | - Mark Jenkins
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC Australia
| | | | - Kate Green
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lone Sunde
- Danish HNPCC Register, Hvidovre University Hospital, Copenhagen, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Miriam Mints
- Department of Women's and Children's health, Division of Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, Solna S171 76, Stockholm, Sweden
| | - Lucio Bertario
- Unit of Hereditary Digestive Tract Tumors IRCCS Istituto Nazionale Tumori Milan, Milan, Italy
| | - Marta Pineda
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Matilde Navarro
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Monika Morak
- Medizinische Klinik und Poliklinik IV, Campus Innenstadt, Klinikum der Universität München, Ziemssenstr. 1, 80336 Munich, Germany.,MGZ - Medizinisch Genetisches Zentrum, Bayerstr. 3-5, 80335 Munich, Germany
| | - Ian M Frayling
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - John-Paul Plazzer
- Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Melbourne, Australia
| | - Julian R Sampson
- Institute of Medical Genetics, Cardiff University School of Medicine, Heath Park, Cardiff, CF14 4XN UK
| | - Gabriel Capella
- Hereditary Cancer Program. Institut Català d'Oncologia-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gabriela Möslein
- Center for Hereditary Tumors, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Witten, Germany.,Department für Humanmedizin, Universität Witten/Herdecke, Witten, Germany
| | - Jukka-Pekka Mecklin
- Department of Education and Science, Central Finland Health Care District, Jyväskylä, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Pål Møller
- Research Group Inherited Cancer, The Norwegian Radium Hospital, Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
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