Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Prevalence of BRCA1 and BRCA2 mutations in ovarian cancer patients from Yunnan Province in southwest China

Carriers with germline breast cancer 1/2 gene mutations ( BRCA m) are likely to develop ovarian cancer (OC). Therefore, identifying these mutations may enable individualized therapy for OC and preventive measures to reduce OC risk in BRCA m carrier families. Thus, we investigated the prevalence of BRCA m in OC patients from Yunnan Province in Southwest China. In total, 674 unselected OC patients were enrolled and tested for BRCA m via next-generation sequencing. Data on clinicopathological characteristics and personal/family history of cancer were collected. The prevalence rates of pathogenic/likely pathogenic BRCA m were 26.6% overall, 20.8% among BRCA1 m carriers, 5.5% among BRCA2 m carriers, and 0.3% among carriers of both BRCA1 m and BRCA2 m. The most common pathogenic mutation in the BRCA1 gene was c.5114T>C ( n  = 9). The number of BRCA m carriers was significantly greater among patients with serous cancer, a personal tumor history, a family history of hereditary breast and ovarian cancer (HBOC)-related tumors, and bilateral tumors. The most common pathogenic mutation in this cohort was c.5114T>C ( n  = 9) in BRCA1 . The prevalence and spectrum of BRCA m in OC patients from Yunnan Province are different from those in other groups. BRCA status testing is advised for all OC patients, particularly those with a family history of HBOC.

Application of genetic testing criteria for hereditary breast cancer in South Africa

PURPOSE

Breast cancer (BC) is the commonest cancer in South African women. A proportion are associated with a pathogenic or likely pathogenic (P/LP) variant in a BC susceptibility gene. Clinical guidelines for genetic testing are used to optimise variant detection while containing costs. We assessed the detection rate in women of diverse ancestries who met the South African National Department of Health (NDOH) testing guidelines, and analysed relationships between testing criteria, participant characteristics and presence of a BRCA1/2 P/LP variant.

METHODS

Records from 376 women with BC who met NDOH criteria and had genetic testing were included. Demographic, clinical and test result data were collated to describe detection rates according to criteria met, and a multivariate analysis conducted to find variables most frequently associated with a P/LP variant.

RESULTS

P/LP variant prevalence in women meeting NDOH testing criteria was 19.9% (75/376). Women meeting ≥ 2 guideline criteria were over twice as likely to have a P/LP variant (OR 2.27, 95%CI 1.27-4.07, p = 0.006), highlighting the guidelines' capacity to stratify risk. Family history (OR 1.97; 95%CI 1.05-3.70, p = 0.03) and Black African ancestry (OR 2.58; 95%CI 1.28-5.18, p < 0.01) were independently associated with having a BRCA1/2 P/LP variant when controlling for other variables. Notably, although Black African participants were less likely to report a family history, those that did had higher odds of a P/LP variant in BRCA1/2.

CONCLUSION

These results demonstrate the usefulness of the NDOH guidelines in women of diverse ancestries and provide insight into the factors associated with P/LP variants in understudied African populations.

Relating to the Body Under Chronic Cancer Threat: Implications for Psychosocial Health Among Adolescents and Young Adults with Cancer Predisposition Syndromes

Purpose: Adolescents and young adults (AYAs) with cancer predisposition syndromes often experience significant physical and psychosocial burdens. These burdens include cancer worry and potentially distressing bodily changes due to risk-reducing procedures (e.g., mastectomy) or cancer treatments. This qualitative-descriptive study explored how AYAs with Li-Fraumeni syndrome (LFS) relate and adjust to their bodies under the chronic threat of cancer. Methods: Participants were enrolled in the National Cancer Institute's LFS study. This analysis included 42 AYAs with LFS aged 15-39 years at enrollment who completed one or two telephone interviews that explored LFS-related bodily experiences and challenges. Transcripts were thematically analyzed. Results: The majority of participants (n = 26/42, 62%) had ≥1 primary cancer. The mean age at first cancer diagnosis was 21 years (range = 0.5-35 years). Participants described challenges relating to the body due to frequent self-monitoring, whole-body magnetic resonance imaging scans, risk-reducing surgeries, and/or cancer treatments. Heightened body awareness and vigilance not only prompted self-protective behaviors but also triggered worry and distress. AYAs coped with bodily changes and concerns by seeking doctors' reassurance, engaging in health-protective behaviors, and reframing perceptions of their altered bodies. Conclusion: Findings suggest AYAs with cancer predisposition syndromes such as LFS experience difficulties relating and adjusting to the body that may compromise psychosocial health. Our results demonstrate that these difficulties may arise across the time course of genetic disease, including before a cancer diagnosis. Clinicians might support AYAs by conducting routine psychosocial risk assessments, providing anticipatory guidance regarding body-related challenges, sharing peer support resources, and referring to mental health providers, as needed.

Gastric Cancer Screening in the United States: A Review of Current Evidence, Challenges, and Future Perspectives

Gastric cancer remains a leading cause of cancer-related mortality worldwide. In the United States, gastric cancer incidence and mortality are substantially higher among non-White racial and ethnic groups and new immigrants from high-incidence countries. This is in large part related to the higher prevalence of Helicobacter pylori -associated gastric premalignant changes in these populations. Apart from primary prevention, early detection of gastric cancer is the principal strategy to reduce gastric cancer mortality and improve survival. Extensive evidence in Asian countries has demonstrated the benefits of endoscopic screening in detecting early-stage gastric cancer and reducing gastric cancer-related mortality. By contrast, direct, high-quality US-based data, such as from large clinical trials or observational studies, on important outcomes of gastric cancer screening are still lacking. In this review, we evaluate and summarize the latest global evidence on the epidemiology and predisposing factors of gastric cancer as well as the efficacy, benefits vs. risks, and cost-effectiveness of gastric cancer screening. We further discuss the critical knowledge gaps and challenges in promoting gastric cancer screening in the United States. Dedicated research is urgently needed to enrich the US-based data on gastric cancer primary and secondary prevention to inform clinical practice and reduce gastric cancer-related morbidity and mortality in a cost and resource efficient manner.

Development and validation of an ovarian cancer risk assessment tool for first-degree relatives of patients in the Chinese population

OBJECTIVE

To develop and validate an ovarian cancer risk assessment tool for first-degree relatives of patients in the Chinese population.

METHODS

A bidirectional multicenter cohort was established, including 529 probands and 3141 first-degree relatives. Cancer incidence was analyzed using the standardized incidence ratio (SIR). Significant variables were identified through Cox regression analyses and visualized via a nomogram. Model performance was evaluated using the C-index, with first-degree relatives stratified into high- and low-risk groups based on a 10 % cancer risk threshold.

RESULTS

Among 1596 first-degree female relatives, 57 ovarian cancer cases were identified, demonstrating a significant increase in SIR (SIR = 9.19; 95 % CI, 7.03-11.83; p < 0.001). In 980 relatives with germline mutations, elevated SIRs were observed for ovarian cancer (SIR = 23.33; 95 % CI, 16.51-32.09; p < 0.001) and breast cancer (SIR = 3.56; 95 % CI, 2.46-5.00; p < 0.001). Cox regression analyses identified key risk factors, including the proband's age of onset, tumor histology, gene mutation status, family history of breast cancer, and relationship to the proband. The nomogram demonstrated good predictive accuracy, with C-indices of 0.75 (training set), 0.75 (internal validation), and 0.71 (external validation). Calibration plots and Kaplan-Meier curves confirmed strong agreement and significant differences between high- and low-risk groups (cut-off value = 2.1).

CONCLUSIONS

This study develops and preliminarily validates a risk assessment tool for first-degree relatives of ovarian cancer patients in China, utilizing accessible clinical and familial data to enable early identification of high-risk individuals.

Predicting Pathogenic Variants of Breast Cancer Using Ultrasound-Derived Machine Learning Models

Background: Breast cancer (BC) is the most frequently diagnosed cancer in women and the leading cause of cancer-related deaths in women globally. Carriers of P/LP variants in the BRCA1, BRCA2, TP53, PTEN, CDH1, PALB2, and STK11 genes have an increased risk of developing BC, which is why more and more guidelines recommend prophylactic mastectomy in this group of patients. Because traditional genetic testing is expensive and can cause delays in patient management, radiomics based on diagnostic imaging could be an alternative. This study aims to evaluate whether ultrasound-based radiomics features can predict P/LP variant status in BC patients. Methods: This retrospective study included 88 breast tumors in patients tested with multigene panel tests, including all seven above-mentioned genes. Ultrasound images were acquired prior to any treatment, and the tumoral and peritumoral areas were used to extract radiomics data. The study population was divided into P/LP and non-P/LP variant groups. Radiomics features were analyzed using machine learning models, alone or in combination with clinical features, with the aim of predicting the genetic status of BC patients. Results: We observed significant differences in radiomics features between P/LP- and non-P/LP-variant-driven tumors. The developed radiomics model achieved a maximum mean accuracy of 85.7% in identifying P/LP variant carriers. Including features from the peritumoral area yielded the same maximum accuracy. Conclusions: Radiomics models based on ultrasound images of breast tumors may provide a promising alternative for predicting P/LP variant status in BC patients. This approach could reduce dependence on costly genetic testing and expedite the diagnostic process. However, further validation in larger and more diverse populations is needed.

The application of emerging immunotherapy in the treatment of prostate cancer: progress, dilemma and promise

In recent years, there has been a growing trend towards the utilization of immunotherapy techniques for the treatment of cancer. Some malignancies have acquired significant progress with the use of cancer vaccines, immune checkpoint inhibitors, and adoptive cells therapy. Scholars are exploring the aforementioned methods as potential treatments for advanced prostate cancer (PCa) due to the absence of effective adjuvant therapy to improve the prognosis of metastatic castration-resistant prostate cancer (mCRPC). Immunotherapy strategies have yet to achieve significant advancements in the treatment of PCa, largely attributed to the inhibitory tumor microenvironment and low mutation load characteristic of this malignancy. Hence, researchers endeavor to address these challenges by optimizing the design and efficacy of immunotherapy approaches, as well as integrating them with other therapeutic modalities. To date, studies have also shown potential clinical benefits. This comprehensive review analyzed the utilization of immunotherapy techniques in the treatment of PCa, assessing their advantages and obstacles, with the aim of providing healthcare professionals and scholars with a comprehensive understanding of the progress in this field.

Postoperative Outcomes of One-Step Implant-Based Breast and Ovarian Surgery in High-Penetrance Gene Mutation: A Single-Center Experience

Background/Objectives: This study was designed to evaluate skin-sparing mastectomy with implant reconstruction complication rates in patients operated on due to high penetrant gene profile. All patients went to skin-sparing mastectomy with implant reconstruction and risk-reducing salpingo-oophorectomy. The effect of radiotherapy and chemotherapy on wound healing is a frequently discussed topic in the literature. However, studies on the effect of these on patients undergoing implant-based reconstruction are rare. In our clinic, two surgeries are performed under the same anesthesia and it is aimed to investigate the effect of this situation on complications in this rare patient group. In this retrospective study, we report our clinical experience regarding complication rates due to these factors among the high penetrant gene group. Methods: Between June 2022 and June 2024, 61 patients were grouped according to demographic data. Post-operative complications were defined as any of the following: major complications which were active bleeding or wound dehiscence; minor complications which were hematoma, seroma, surgical-site infection, <20% skin or nipple necrosis, and reoperation due to wound dehiscence or any other complication. Patients were compared in terms of complications according to whether they received previous radiotherapy (RT), neoadjuvant chemotherapy (CT), or underwent skin-reducing mammoplasty. Results: Patients receiving neoadjuvant chemotherapy, patients receiving preoperative RT, and patients undergoing skin-reducing mastectomy were compared in terms of major and minor complications. While neoadjuvant CT and preoperative RT only increased the risk of seroma, it was found that skin-reducing mastectomy had no significant effect on complication rates. Conclusions: Skin-sparing mastectomy with implant reconstruction and risk-reducing salphingo-oophorectomy is a comprehensive operation method in this patient group. Complication control can be achieved by performing two surgeries in a single anesthesia period, using the spy immunofluorescence device for vascularization control, and performing all surgeries with the same experienced team.

Extended spectrum of cancers in PTEN hamartoma tumor syndrome

PTEN hamartoma tumor syndrome (PHTS) is associated with increased lifetime risks of breast, thyroid, kidney, endometrial, and colorectal cancers, as well as melanoma (collectively, component cancers). We sought to characterize non-component cancers (NCC) in PHTS. Of 701 research participants with PHTS, 340 (49%) had cancer, with 101 (30%) having at least one NCC. Interestingly, 71 (70%) of those with NCC had at least one other PHTS component malignancy. Patients with pathogenic PTEN variants showed higher risks for prostate cancer and soft tissue sarcomas at younger ages than the general population. A literature survey showed independent cases of NCC in PHTS, with PTEN-related molecular changes including second-hit somatic PTEN alterations in a subset of various specimens. We recommend increased awareness regarding NCC in individuals with PHTS, particularly increased risks for prostate cancer and sarcoma. Further studies are needed to define age-related penetrance and accordingly, the appropriate strategies for cancer risk management.

Understanding the genetic epidemiology of hereditary breast cancer in India using whole genome data from 1029 healthy individuals

Breast cancer is the most highly reported cancer in India. Genetic testing could help tackle the increasing cancer burden by enabling carriers obtain early diagnosis through increased surveillance, and help guide treatment. However, accurate interpretation of variant pathogenicity must be established in a population-specific manner to ensure effective use of genetic testing. Here we query IndiGen data obtained from sequencing 1029 Indian individuals, and perform variant classification of all reported BRCA variants using gold-standard ACMG & AMP guidelines to establish disease epidemiology. To address the high number of VUS variants thus obtained, we further utilize the brca-NOVUS ML tool to obtain pathogenicity predictions in a manner close to ACMG guidelines at scale. Through the manual application of ACMG & AMP guidelines, we determined the genetic prevalence to be the following: 1 in 342 carriers of BRCA1, and 1 in 256 carriers of BRCA2 pathogenic/likely pathogenic variants bear a significant lifetime risk of developing breast / ovarian cancer in India. The high population prevalence and unique variant landscape emphasizes a need for population-scale studies of causative variants to enable effective screening. We advise cautious clinical interpretation, given incomplete penetrance and other complex factors that result in cancer disease. To the best of our knowledge, this is the first and most comprehensive population-scale genetic epidemiological study of BRCA-linked breast cancer variants reported from India.

Germline Genetic Testing in Breast Cancer: Utilization and Disparities in a Middle-Income Country

PURPOSE

Low rates of germline genetic testing (GGT) for breast cancer (BC) have been reported globally, with limited data from low- and middle-income countries (LMICs). In this study, we used real-world data to assess the GGT rate for BC in an LMIC and identified barriers to its use.

METHODS

We analyzed 2,974 newly diagnosed patients with BC from the AMAZONA III study, the largest Brazilian multicenter, prospective BC cohort. GGT rates were determined for the entire cohort and the high-risk hereditary BC group (HR), defined by the National Comprehensive Cancer Network criteria, between 2019 and 2020. Barriers to GGT performance associated with patient characteristics and health care systems were identified using multivariable Poisson regression model. Values of P < .05 were considered significant.

RESULTS

In the AMAZONA III cohort, 1,476 (49%) were classified as HR. Genetic counseling was recommended for 521 patients (35% of HR), and 282 (19%) underwent GGT. Notably, 97% of patients with HR treated within the public health care systems and 56% in the private system did not undergo GGT. Age, education, occupation, monthly income, availability of onsite genetic counseling, and treatment at a teaching center were factors associated with GGT uptake (P < .05). Of those tested, 50 (17%) harbored a germline pathogenic or likely pathogenic variant.

CONCLUSION

Only 9% of this robust Brazilian BC cohort underwent GGT, highlighting a considerable gap from the current recommendation to test all patients with BC under age 65 years. GGT is underused by patients with HR in both public and private health care systems, with those in the public system being more affected. The disparities and barriers identified emphasize the need for educational interventions and enhanced access to GGT. Prioritizing GGT is critical to improving BC outcomes in LMICs.

The pathologic and clinical outcomes of risk-reducing salpingo-oophorectomy in asymptomatic carriers of homologous recombination repair gene mutation

OBJECTIVE

To investigate the prevalence of pathological findings and clinical outcomes of risk-reducing salpingo-oophorectomy (RRSO) in asymptomatic carriers with germline homologous recombination repair (HRR) gene pathogenic/likely pathogenic variants (PV/LPV).

METHODS

This retrospective study enrolled asymptomatic carriers with germline HR gene PV/LPV who underwent RRSO between 2006 and 2022 at the National Cancer Center in Korea. Clinical characteristics, including history of breast cancer, family history of ovarian/breast cancer, parity, and oral contraceptive use, were analyzed.

RESULTS

Of the 255 women who underwent RRSO, 129 (50.6%) had PV/LPV in BRCA1, 121 (47.5%) in BRCA2, and 2 (0.7%) had both BRCA1 and BRCA2 PV/LPV. In addition, 1 carried PV/LPV in RAD51D, and 2 in BRIP1. Among the BRCA1/2 PV/LPV carriers, occult neoplasms were identified in 3.5% of patients: serous tubal intraepithelial carcinoma (1.1%, n=3), fallopian tubal cancers (0.8%, n=2), ovarian cancer (1.2%, n=3), and breast cancer (0.4%, n=1). Of the 9 patients with occult neoplasms, 5 (2.0%) were identified from the 178 breast cancer patients, and 4 (1.6%) were detected in 65 healthy mutation carriers. During the median follow-up period of 36.7 months (interquartile range, 25.9-71.4), 1 (0.4%) BRCA1 PV carrier with no precursor lesions at RRSO developed primary peritoneal carcinomatosis after 30.1 months.

CONCLUSION

Women with HRR gene mutations PV/LPV who undergo RRSO are at a risk of detecting occult neoplasms, with a of 3.5%. Even in the absence of precursor lesions during RRSO, there was a cumulative risk of peritoneal carcinomatosis development, emphasizing the need for continued surveillance.

Genomic Landscapes of Early-Onset Versus Average-Onset Colorectal Cancer Populations

BACKGROUND

Rates of early-onset colorectal cancer (eoCRC), defined as disease diagnosed at <50 years of age, are increasing. The incidence and spectrum of somatic and pathogenic germline variants (PGV) in this population are not well understood.

METHODS

This cross-sectional study leveraged Tempus' clinicogenomic database, including de-identified records of patients diagnosed with CRC between 2000-2022, to analyze and compare eoCRC and average-onset colorectal cancer (aoCRC, disease diagnosed ≥50 years of age) patients. The frequency and spectrum of somatic mutations and PGVs in patients with eoCRC and aoCRC were evaluated and compared.

RESULTS

Among 11,006 participants in this study, 57% were male, 76% were white, and 80% had stage 4 disease. Within the total cohort, 2379 had eoCRC and 8627 had aoCRC. Among patients with eoCRC, 4.2% had a tumor with high microsatellite instability and/or deficient mismatch repair (MSI-H/dMMR) and 6.8% with aoCRC had an MSI-H/dMMR tumor (p < 0.001). The most frequent somatic mutations involved TP53, APC, and KRAS, with the most significant difference in BRAF, which was more frequently mutated in aoCRC (9.8% vs. 4.7%, p < 0.0001). In total, 1413 (59.4%) eoCRC and 4898 (56.8%) aoCRC patients had matched normal specimen (blood or saliva) sequencing and a PGV was identified in 6.9% of eoCRC and 5.0% of aoCRC patients.

CONCLUSIONS

Somatic and germline mutation profiles were similar for eoCRC and aoCRC patients and may not adequately explain differences in tumor behavior and age of disease onset.

De novo familial adenomatous polyposis with germline double heterozygosity of APC/BRCA2: a case report and literature review

BACKGROUND

The widespread application of colonoscopy screening and genetic testing in colorectal cancer (CRC) treatment has led to the identification of a subset of familial adenomatous polyposis (FAP) patients who lack a family history of the disease but harbor germline gene mutations. Moreover, distinct genotypes may be associated with varied clinical presentations and therapeutic options. This case report describes a male patient with de novo FAP who harbored germline double heterozygosity (GDH) for APC and BRCA2 mutations. The patient underwent total colectomy, and genetic testing enabled personalized surveillance and management strategies for his family members.

CASE PRESENTATION

A 43-year-old male with no family history of cancer presented to the outpatient clinic of the Colorectal Surgery Department with complaints of constipation and hematochezia. Colonoscopy revealed hundreds of polyps throughout the colon and a rectal adenocarcinoma located 5 cm from the anal verge. Gastroduodenal endoscopy did not detect any upper gastrointestinal adenomas. The patient underwent laparoscopic total colectomy with abdominoperineal resection of the rectum and end ileostomy. With the consent of the patient and his family, genetic testing was performed. The index patient was found to carry an APC splicing site mutation (exon 15: c.1744-1G > A) and a BRCA2 missense mutation (exon 17: c.7976G > A: p.R2659K). His daughter was found to have inherited the same germline BRCA2 variant. Additionally, the rectal cancer exhibited proficient DNA mismatch repair (pMMR) status, ERBB2 copy number amplification, and a missense mutation, while the KRAS, NRAS, and BRAF genes were wild-type. Based on the genetic testing results and clinical manifestations, the index patient was diagnosed with familial adenomatous polyposis (FAP) and rectal cancer. Personalized surveillance and management strategies were implemented for the patient and his family, focusing on the risks of extra-colonic diseases and potential malignancies in the prostate, pancreas, breast, and ovaries.

CONCLUSION

De novo FAP with double germline mutations in APC and BRCA2, along with somatic ERBB2 mutations, is exceptionally rare among hereditary cancer cases. With the rapid advancements in genomics, the detection of multiple gene variants in individuals or families has become increasingly common. Additionally, the application of artificial intelligence (AI) in medical research may provide powerful tools for genetic analysis and clinical decision-making. Consequently, a comprehensive evaluation of family history, a deep understanding of hereditary cancer syndromes, and precise interpretation of genetic mutations are essential for personalized clinical management in the era of precision medicine. However, these tasks pose significant challenges for clinicians and genetic counselors alike.

Comparative Study of Mastectomy Surgical Techniques Followed by Reconstruction: Hydrodissection and Electrical Plasma Surgery

Background/Objectives: Mastectomy is a surgical option for breast cancer when conservative treatment is unsuitable, and it is also performed prophylactically in high-risk women. Various surgical techniques can be used for mastectomy, including electrosurgery, which can cause thermal damage to tissues, reducing surgical precision and delaying wound healing. This study aims to compare electrical plasma surgery and hydrodissection, which appear to be the least traumatic methods, to determine the better option for performing mastectomy with immediate reconstruction. Methods: Conducted at the "Breast Unit" of AO "OrdineMauriziano Umberto I", this study analyzed 56 patients undergoing 65 mastectomies (9 bilateral, 47 unilateral). A total of 16 were prophylactic, and 49 were oncologic. All patients received immediate subpectoral reconstruction. Data collected included preoperative medical history, pain, drain flow, blood transfusions, hemoglobin levels, and hospital stay duration. Complications were graded using the Clavien-Dindo classification. Results: Both groups were similar in age, body mass index (BMI), smoking habits, and comorbidities. Patients who underwent hydrodissection reported more pain on the first and second postoperative day and had longer hospital stays. The drop in hemoglobin from pre- to postoperative and the volume of surgical drains on the day of surgery and the first and second postoperative days were comparable between groups. Early complications and reintervention rates (Clavien-Dindo grade 3) were similar between techniques. Conclusions: Electrical plasma surgery offers better early postoperative outcomes in terms of pain and hospital stay, although overall complication and reintervention rates are unaffected by the technique used. Larger randomized studies are needed to confirm these findings and optimize patient management.

Sociodemographic characteristics associated with pancreatic cancer incidence and mortality among Blacks in the United States: a SEER-based study

Pancreatic cancer (PC) is the third leading cause of all cancer-related fatalities and accounts for approximately 3% of cancer cases in the United States. PC survival rates are lower in Blacks compared to other races, and this has been attributed to socioeconomic and genetic factors. In this study, we evaluated sociodemographic and genetic characteristics associated with PC incidence and mortality among Blacks. Data from the SEER 22 registries (2000-2020) were used to calculate the incidence rates and relative survival. County mortality rates from 2017 to 2021 were analyzed. Incidence rate ratios based on gender, age, primary disease site, stage, level of education, and poverty were calculated. Survival analysis was conducted using the Kaplan-Meier method. Mutant gene expression was obtained from the MSK-CHORD tumor registry. Overall, 48,606 Black patients were diagnosed with malignant PC between 2000 and 2020: females (53.53%) and males (46.47%). Both males and females experienced a slight increase in Annual Percent Change (APC) of PC incidence (0.24, 95% CI, -0.02-0.53) and (0.22, 95% CI, -0.05-0.51), respectively, from 2000 to 2020. Males aged 55 to 75 years were most frequently affected. Overall incidence risk from 2000-2020 by age was higher in Black males IRR > 1 (1.18, 95% CI, 1.16-1.21). The most common primary PC site for Black males and females was the head of the pancreas, 49.06% and 49.88%, respectively. By staging, distant PC had the highest frequency in Blacks. Poverty level was associated with PC incidence among females and PC mortality among both males and females. Stage was associated with survival among males with localized and regional PC. The 5-year relative survival was less than 11% across combined PC stages for both sexes. Black males had a relatively lower 5-year survival than Black females in localized (31.7 vs. 37.2%) and distant PC (2.6% vs. 2.90%). Mutant KRAS expression was higher in Black males. PC incidence and mortality were significantly higher in Black males. Our analysis points to the importance of poverty alleviation programs that target females are likely to reduce PC incidence. Furthermore, receiving recommended screening for PC and early-stage diagnostics is important to lower PC mortality.

Quality-of-Life Assessment in Patients Undergoing Mastectomy and Breast Reconstruction for Moderate-Penetrance Gene-Related Breast Cancer

Background. Breast cancer remains a leading cause of cancer-related death among women, with genetic mutations playing a key role. While high-penetrance mutations are well-studied, moderate-to-low-penetrance mutations, which present challenges in clinical decision-making and patient outcomes, are less understood. This study explores the quality of life of breast cancer patients with moderate-penetrance mutations, focusing on the psychosocial and physical consequences of mastectomy and reconstruction to improve patient-centered care. Materials and Methods. A cohort of 620 breast cancer patients treated at Regina Maria Private Health Network, Bucharest, between January 2022 and July 2024 was identified. From this group, 61 patients were selected based on the following criteria: (1) meeting NCCN genetic testing guidelines, (2) carrying moderate-to-low-penetrance mutations, (3) undergoing bilateral mastectomy with double reconstruction, and (4) agreeing to complete a modified version of the BREAST-Q questionnaire. Genetic testing was performed using a 125-gene next-generation sequencing panel. Statistical analyses included non-parametric tests to examine group differences and correlations. Results. Significant correlations were found between several factors. Emotional distress was positively correlated with concerns for family, while couple relationships and financial burden showed a strong positive association. Negative correlations were found between couple relationships and self-concept. Distress levels varied, with "Interference with personal relationships" causing more distress than "Impact on employment", and financial burden causing more distressing than impact on sexuality. Conclusions. Prophylactic mastectomy significantly reduces cancer risk for women with moderate-penetrance mutations. This study highlights the relationship between surgical choices and quality-of-life factors, advancing personalized prevention strategies and emphasizing patient-centered care.

Pathogenic Germline Variants in Patients With Metaplastic Breast Cancer

Importance

Metaplastic breast cancer (MpBC) is a rare, heterogeneous disease often associated with inferior outcomes. A growing body of literature describes the clinical and molecular features of MpBC, yet limited data describe the pathogenic germline variants (PGVs) in breast cancer susceptibility genes among affected individuals.

Objective

To examine the frequency and types of PGVs in breast cancer genes among patients with MpBC.

Design, Setting, and Participants

This is a descriptive retrospective cohort study of patients who received a diagnosis of MpBC at the University of Pennsylvania between January 2010 and May 2023. Electronic medical records were reviewed for demographic, clinicopathologic, and germline genetic testing information. Germline variant status was independently confirmed by a licensed genetic counselor and a physician with expertise in genetics. MpBC diagnosis and subtype were confirmed by a breast pathologist. Participants were identified via query of an institutional pathology database for reports signed between January 2010 and May 2023 including the term metaplastic. Among 320 initially obtained reports, 272 individuals had confirmed MpBC and were included in the study.

Exposure

Germline genetic testing to investigate the presence of PGVs in breast cancer susceptibility genes.

Main Outcomes and Measures

The primary outcome measurement was the prevalence of PGVs in breast cancer susceptibility genes among participants. The hypothesis that individuals with MpBC have an enrichment of PGVs in genes associated with inherited breast cancer risk was formulated before data collection.

Results

The total sample size was 272 women, and the median age at diagnosis was 58 years (range, 20-102 years); all were biological female patients; 143 of 272 (52.6%) had documentation of germline genetic testing; and participants with testing were significantly younger than those without (median age, 53 years [range, 20-79 years] vs 63 years [range, 29-102 years]; P < .001). Of the 143 patients, 24 (16.8%) had a PGV in a breast cancer susceptibility gene (BRCA1, n = 17; BRCA2, n = 5; PALB2, n = 1; CHEK2, n = 1). Patients with PGV-associated MpBC received a diagnosis at a younger age than those with sporadic disease, but there were no significant differences in hormone receptor positivity, ERBB2 status, or metaplastic subtype.

Conclusions and Relevance

In this cohort study of patients with MpBC, a substantial proportion of clinically tested patients had a PGV in a breast cancer susceptibility gene, most commonly BRCA1. Germline testing was high yield in patients with MpBC, many of whom would be included in current germline testing eligibility criteria.

Experiences of hereditary cancer care among transgender and gender diverse people: "It's gender. It's cancer risk…it's everything"

Transgender and gender diverse (TGD) individuals are a significant yet underrepresented population within genetic counseling research and broader LGBTQI+ health studies. This underrepresentation perpetuates a cycle of exclusion from the production of medical knowledge, impacting the quality and equity of care received by TGD individuals. This issue is particularly poignant in cancer genetic counseling, where TGD individuals with elevated cancer risk receive risk assessment, counseling, and referral to support based on risk figures and standards of care developed for cisgender individuals. The experiences of TGD individuals navigating inherited cancer syndromes remain largely undocumented in medical literature, posing challenges to the provision of inclusive care by genetics providers. To bridge this knowledge gap, we conducted a cross-sectional qualitative study. Nineteen semi-structured interviews were held with gender diverse adults having hereditary cancer syndromes, family histories of such syndromes, or personal histories of chest cancer. Our study employed thematic analysis using combined inductive and deductive methods to illuminate how hereditary cancer care intersects with participants' gender identities, gender expression, and gender-affirming care experiences. Participants reflected on care experiences that felt affirming or triggered gender dysphoria. Participants also discussed the interplay between risk-reducing mastectomy and top surgery, exploring co-emergent dynamics between cancer risk management and gender expression. Significantly, participants identified actionable strategies for healthcare providers to enhance support for gender diverse patients, including the mindful use of gendered language, collaborative decision-making, and conveying allyship. These findings offer valuable insights into tailoring genetic counseling to meet the unique needs of TGD individuals, advancing the path toward inclusive and appropriate care for LGBTQI+ individuals with hereditary cancer syndromes.

Informatics strategies for early detection and risk mitigation in pancreatic cancer patients

This review provides a comprehensive overview of the current landscape in pancreatic cancer (PC) screening, diagnosis, and early detection. This emphasizes the need for targeted screening in high-risk groups, particularly those with familial predispositions and genetic mutations, such as BRCA1, BRCA2, and PALB2. This review highlights the sporadic nature of most PC cases and significant risk factors, including smoking, alcohol consumption, obesity, and diabetes. Advanced imaging techniques, such as Endoscopic Ultrasound (EUS) and Contrast-Enhanced Harmonic Imaging (CEH-EUS), have been discussed for their superior sensitivity in early detection. This review also explores the potential of novel biomarkers, including those found in body fluids, such as serum, plasma, urine, and bile, as well as the emerging role of liquid biopsy technologies in analyzing circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and exosomes. AI-driven approaches, such as those employed in Project Felix and CancerSEEK, have been highlighted for their potential to enhance early detection through deep learning and biomarker discovery. This review underscores the importance of universal genetic testing and the integration of AI with traditional diagnostic methods to improve outcomes in high-risk individuals. Additionally, this review points to future directions in PC diagnostics, including next-generation imaging, molecular biomarkers, and personalized medicine, aiming to overcome current diagnostic challenges and improve survival rates. Ultimately, the review advocates the adoption of informatics and AI-driven strategies to enhance early detection, reduce morbidity, and save lives in the fight against pancreatic cancer.

What happens after menopause? (WHAM): A prospective controlled study of cognition 24 months after premenopausal risk-reducing salpingo-oophorectomy

OBJECTIVE

Women with BRCA1/2 pathogenic variants considering risk-reducing bilateral oophorectomy (RRSO) may be concerned about potential effects of surgical menopause on cognition. Whether RRSO affects cognition and whether hormone therapy (HT) modifies this effect remains uncertain. This study aimed to prospectively measure the effect of premenopausal RRSO on cognition and the modifying effects of HT up to 24 months.

METHODS

The design was a prospective, multisite (4 sites in Australia), 24-month observational study. Participants were premenopausal BRCA1/2 carriers (n = 83) planning RRSO referred from gynecology-oncology and familial cancer centers and a premenopausal comparison group (n = 98) not planning oophorectomy or pregnancy who self-referred. Baseline data were collected within 8 weeks of eligibility screening, and RRSO was scheduled between baseline and 3 months. Of 687 screened, 181 were analysed. Cognitive performance (verbal learning and memory, psychomotor speed, fluency) was assessed at baseline, 3, 12 and 24 months with the a priori outcomes of verbal learning and memory.

RESULTS

After RRSO, 65 % initiated HT. In multivariable models of group differences in cognitive performance over time, RRSO and comparison groups showed similar performance improvements except for verbal learning. The RRSO group showed a small, statistically significant lower improvement in verbal learning vs comparisons, after adjustment for HT and other factors (p = 0.03). After RRSO, verbal learning was higher in HT users vs non-users (p = 0.04).

CONCLUSIONS AND RELEVANCE

Over 24 months RRSO minimally impacted cognition except for a small adverse effect on verbal learning, partly offset by HT.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (anzctr.org.au); Identifier #: ACTRN12615000082505; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363554&isReview=true.

Characteristics and Survival Outcomes of Male Breast Cancer in Brazil: A Large Population-Based Study

AIMS

This study evaluated the clinicopathological characteristics, treatment trends, and overall survival (OS) in male breast cancer (BC) in Sao Paulo State of Brazil.

MATERIALS AND METHODS

Men diagnosed with invasive breast cancer between January 2000 and June 2020 were identified from Fundação Oncocentro de Sao Paulo database encompasses data pertinent to 46 million residents of the Sao Paulo State of Brazil. Patients were described according to age, education level, clinical stage, treatment modalities, and medical practice. Categorical variables were described as percentages and frequencies. Demographic, treatment factors, and OS were associated using a Cox proportional hazard regression model while accounting for different lengths of participant follow-up. The Kaplan-Meier curves were used to display survival curves.

RESULTS

A total of 907 male BC patients were included. The age distribution at diagnosis was <51 years, 51-70 years, and >70 years in 21.5%, 51.5% and 27.0% of patients, respectively. The proportions of stages I, II, III, and IV were 19.5%, 36.6%, 31.5%, and 12.3%. For each stage I, II, III, and IV, 5- and 10-years OS were 87.9% and 77.8%, 79.9% and 58.9%, 51.6% and 24.5%, 20.0% and 5.6%, respectively. Patients who received postoperative radiotherapy experienced a significant improvement in OS (HR 0.67; 95% CI 0.53-0.84; p < 0.001). In the multivariable analysis adjusted for practice (public or private), education (low or medium/high), age, stage at diagnosis, and treatment modalities, the significant independent predictor for OS was stage at diagnosis.

CONCLUSION

Male BC tends to be diagnosed at a more advanced stage and older age at the time of diagnosis. Age and educational level did not influence survival outcomes. Stage at diagnosis and the use of postoperative radiotherapy were factors associated with improved OS.

A qualitative study of Black breast cancer previvors' and survivors' experiences after positive genetic testing

Black women have a disproportionately high mortality rate from breast cancer, which is likely influenced by an intersection of environmental, cultural, economic, and social factors. Few published studies capture the experiences of Black women after a genetic diagnosis associated with increased risk for breast cancer. This study aims to explore the perspectives and experiences of Black women who carry a pathogenic variant associated with increased breast cancer risk and identify barriers to care for this population. We conducted semi-structured interviews with 16 participants with and without histories of breast cancer. The sample included representation across a range of demographic groups (e.g., income level, employment status, insurance status, and education level). Reflexive thematic analysis was the methodology used to analyze data. Five major themes emerged from participants' descriptions of their experiences during and after genetic testing: (1) searching for representation; (2) information enabling agency; (3) healthcare providers as facilitators or barriers to care; (4) self-identity impacting disclosure; and (5) evolving mental health and coping strategies. Participants identified barriers to care including challenging or misinformed healthcare providers, medical racism, and a lack of Black representation in the cancer community. This work deepens our understanding of the nuanced experiences of Black women across the continuum of cancer care, illustrates unmet needs, and provides a foundation for future research that includes the perspectives of Black women.

Breast Cancer Occurrence After Risk-reducing Mastectomies in 274 Cases: A Single Center With More Than 42 Years of Experience

Introduction

Carriers of genetic mutations with a high risk of developing breast cancer have a lifetime risk of this cancer of up to 70%. To reduce the risk, patients have the option of a risk-reducing mastectomy. There is limited data with only short follow-ups on its safety. The aim of the study was to determine the long-term incidence of breast cancer in healthy patients with no previous surgery, who underwent bilateral risk-reducing mastectomies (BRRMs).

Methods

We retrospectively reviewed 274 patients from our facility with no previous breast surgery, who underwent BRRM from 1981 to 2022, due to genetic mutations, a strong family history, or having very dense mammary glands. We approached these patients during their checkups, by phone call or email, and we asked them if they had developed breast cancer after their procedures. We recorded the patients' demographic factors, their genetic mutation types, and the mastectomy methods carried out.

Results

A total of 274 patients had BRRMs with a mean follow-up after 76 months; 208 patients had undergone nipple-sparing mastectomies, 39 patients had undergone skin-sparing mastectomies, and 27 patients had skin-reducing mastectomies. One BRCA1+ patient developed breast cancer 21 months after undergoing the risk-reducing skin-sparing mastectomy procedure. None of the patients died of breast cancer.

Conclusions

The incidence of breast cancer in the monitored patients is comparable to the results of the other related studies. The study result confirms that risk-reducing mastectomies reduce the risk of breast cancer in high-risk populations, regardless of the type of mastectomy performed.

Impact of barriers and motivators on intention and confidence to undergo hereditary cancer genetic testing

Genetic testing for hereditary cancer syndromes can provide lifesaving information allowing for individualized cancer screening, prevention, and treatment. However, the determinants, both barriers and motivators, of genetic testing intention are not well described. A survey of barriers and motivators to genetic testing was emailed to adult patients eligible for genetic testing based on cancer diagnosis who previously have not had genetic testing (n = 201). Associations between barriers/motivators with testing intention and confidence were examined first by correlation followed by multivariable linear regression model holding constant potential covariates. Seven barrier items from two domains (logistics and genetic testing knowledge) were found to significantly negatively correlate with genetic testing intention. Unexpectedly, three barrier items had significant positive correlation with genetic testing intention; these were related to family worry (passing a condition on to future generations) and testing knowledge (needing more information on the genetic testing process and what it has to offer). Ten barrier items had significant negative correlation with confidence to get a genetic test and encompassed four domains: stigma, insurance/genetic discrimination, knowledge, and cost. All motivator items were associated with intention to get a genetic test, while none were associated with confidence. Multivariable analysis yielded six total barriers (five from the knowledge domain, one from cost domain) and two motivators (relieved to know and treatment impact) that were significantly associated with genetic testing intention or confidence when controlling for demographic characteristics. These findings indicate the need for tailored interventions to amplify motivating factors and counter-message barriers to enhance patient motivation and confidence to undergo testing.

The long road to unbiased estimates of pancreatic cancer incidence in the hereditary breast and ovarian cancer syndrome

The determination of unbiased cancer risk estimates in hereditary breast and ovarian cancer syndrome (HBOC) poses several challenges. The article by Katona and colleagues is the first analysis to provide estimates of pancreatic cancer incidence in HBOC generated from a prospectively followed cohort of BRCA mutation carriers, which addresses several potential biases inherent in retrospective pedigree analyses.

Whole exome sequencing-based homologous recombination deficiency test for epithelial ovarian cancer

BACKGROUND

The homologous recombination deficiency (HRD) test is an important tool for identifying patients with epithelial ovarian cancer (EOC) benefit from the treatment with poly(adenosine diphosphate-ribose) polymerase inhibitor (PARPi). Using whole exome sequencing (WES)-based platform can provide information of gene mutations and HRD score; however, the clinical value of WES-based HRD test was less validated in EOC.

METHODS

We enrolled 40 patients with EOC in the training cohort and 23 in the validation cohort. The WES-based HRD score was calculated using the scarHRD software. We first evaluated the concordance of the HRD status defined by the Myriad MyChoice CDx and then assessed the value of HRD on clinical prognosis in patients with EOC.

RESULTS

The HRD score defined by the WES-based test was positively correlated with that of the Myriad MyChoice® CDx test (r = 0.82, p < 0.01) in the training cohort. In compared to HRD status of Myriad test, the sensitivity, specificity, positive predictive value, and negative predictive value of the WES-based HRD test were 93.5% (29/31), 77.8% (7/9), 93.5% (29/31), and 77.8% (7/9), respectively. Patients with positive HRD status defined by WES-based scarHRD test and Myriad MyChoice® CDx test were both highly associated with platinum sensitive response (both Fisher's exact test, p = 0.002) as well as the superior progression-free survival (both log-rank p = 0.002). The multi-variate Cox regression model incorporated with optimal debulking surgery showed that the recurrence risk was decreased in the patients with positive HRD status, either defined by Myriad MyChoice® CDx test (Hazard ratio (HR) 0.33, 95% confidence interval (CI) 0.14-0.79, p = 0.013) or WES-based test Myriad MyChoice® CDx test (HR 0.34, 95% CI 0.14-0.80, p = 0.014). Nine patients had mutations in the genes involved in HR DNA repair, and all of them were positive for HRD. In the validation group, 23 patients were defined as positive HRD by WES-based testing. Six positive HRD patients and 5 negative HRD patients received maintenance PARPi. The median responsive interval of PARPi was 17 months in positive HRD patients and 3 months in negative HRD patients.

CONCLUSION

The WES-based test is a potential option for determining the HRD status in EOC patients, and desires for further validation in large-scale cohorts.

Validation of the NCCN/Yale criteria for the identification of CDH1 pathogenic variant carriers

BACKGROUND

Diffuse gastric and lobular breast cancer (LBC) syndrome is an autosomal-dominant syndrome characterised by early-onset diffuse gastric cancer and LBC most often caused by germline pathogenic variants (PVs) in CDH1. We previously showed the International Gastric Cancer Linkage Consortium (IGCLC) criteria for genetic testing to have poor sensitivity for CDH1 PV and proposed our own simpler and more sensitive Yale criteria. The European Reference Network on Genetic Tumour Risk Syndromes subsequently proposed expanding the IGCLC criteria and showed its LBC-expanded criteria to be more sensitive than the IGCLC criteria in a European cohort of CDH1 PV carriers.

METHODS

We aggregated demographic and clinical data of all CDH1 PV carriers identified at three US commercial laboratories. These data were used to calculate the sensitivity of the IGCLC, LBC-expanded and National Comprehensive Cancer Network (NCCN)/Yale criteria.

RESULTS

Data on 708 probands and their 4318 family members were included in the analysis. In this cohort, the sensitivities for detecting CDH1 PVs were 23.6% for IGCLC criteria, 35.7% for LBC-expanded criteria and 82.2% for NCCN/Yale criteria.

CONCLUSION

In a large cohort of CDH1 PV carriers to date, the IGCLC and LBC-expanded criteria called for genetic testing in a minority of CDH1 PV carriers while the Yale criteria detected the large majority. Along with their superior sensitivity, the NCCN/Yale criteria address critical practical challenges in cancer genetics by not depending heavily on pathology information from family members which is often lacking and by incorporating recommendations from other cancer genetics guidelines.

Breast cancer surveillance for epithelial ovarian cancer patients with BRCA1 and BRCA2 pathogenic variants: a single-center retrospective study

OBJECTIVES

To identify a method for breast cancer (BC) surveillance in patients with epithelial ovarian cancer (EOC) with germline BRCA1/2 pathogenic variants (gBRCA1/2m) and the incidence of BC after EOC in the era of broad PARP inhibitors use.

METHODS

We retrospectively analyzed the data on EOC patients who had gBRCA1/2m by genetic testing between January 2017 and August 2023 in our single center.

RESULTS

Of 125 patients with EOC, 33 had gBRCA1/2m. Of these, 27 (81.8%) underwent BC surveillance, 20 ultrasound and/or mammography, and seven magnetic resonance imaging (MRI). The median time from EOC diagnosis to the initiation of BC surveillance was 8 months. EOC recurrence was significantly lower in the group with MRI than in the group without MRI (no case vs. 10 cases, P = .0261). The duration from EOC diagnosis to the start of BC surveillance was longer in the group with MRI than in the group without MRI (21 vs. 7 months, P = .1033). Two (6.1%) patients developed BC after EOC. Both cases were early stage, triple-negative BCs that occurred more than 3 years after the diagnosis of stage III EOC.

CONCLUSIONS

With the advent of PARP inhibitors, long-term survival is expected to increase, and a certain number of patients with EOC after initial treatment may benefit from BC surveillance using MRI. In particular, BC surveillance with MRI may be considered for patients who have not experienced EOC recurrence for more than 2 years.

Prostate-specific antigen screening at low thresholds of men with pathogenic BRCA1/2 variants

BACKGROUND

Men with pathogenic BRCA1/2 variants are at higher risk of prostate cancer We included men with likely pathogenic/pathogenic (LP/P) variants in BRCA1/2 in a prostate-specific antigen (PSA) screening program after cascade germline testing since 2014. PSA was tested yearly and an age-specific low PSA threshold for biopsy was used, to determine if a low PSA threshold for biopsy is justified for men with pathogenic BRCA1/2 variants.

METHODS

From 2014 to 2023 a total of 340 men were included in the program. We report demographics, clinical characteristics, and treatment outcomes at 7 years.

RESULTS

The cumulative incidence of a primary biopsy was 37% (95CI: 31‒43) after 7 years. Incidence of prostate cancer diagnosis was 11% (95CI: 7.1‒15). Men referred were 7.8 (95CI: 5.3‒11, p < 0.001) times more likely to be diagnosed with prostate cancer than the general Danish male population. The cumulative incidence of biochemical failure (PSA > = 0.2 ng/ml) 4 years after RP was 22% (95CI: 2.3‒41). The main limitation is that not all men underwent a pre-biopsy MRI.

CONCLUSION

We found a high incidence of prostate cancer in men with LP/P BRCA1/2 variants, but this may be explained by the low PSA threshold for scheduling biopsies. More studies are needed to compare this patient population to men with other germline features. The high risk of recurrence after curative therapy is worrisome and requires further evaluation as to whether this is a biological phenomenon.

The known genetic variants of BRCA1, BRCA2 and NOD2 in pancreatitis and pancreatic cancer risk assessment

The single nucleotide polymorphism in NOD2 (rs2066847) is associated with conditions that may predispose to the development of gastrointestinal disorders, as well as the known BRCA1 and BRCA2 variants classified as risk factors in many cancers. In our study, we analyzed these variants in a group of patients with pancreatitis and pancreatic cancer to clarify their role in pancreatic disease development. The DNA was isolated from whole blood samples of 553 patients with pancreatitis, 83 patients with pancreatic cancer, 44 cases of other pancreatic diseases, and 116 healthy volunteers. The NOD2 (rs2066847), BRCA1 (rs80357914) and BRCA2 (rs276174813) were genotyped. The statistically significant 3-fold increased risk of pancreatic cancer was detected among the patients with rs2066847 polymorphism (OR = 2.77, p-value = 0.019). We did not find the studied polymorphisms in BRCA1 (rs80357914) and BRCA2 (rs276174813). However, the adjacent polymorphisms have been detected only in patients with pancreatic diseases. The studied variant in NOD2 occurs more frequently in pancreatic patients and significantly increases the risk of pancreatic cancer. It can be considered as a genetic risk factor that predisposes to cancer development. The analyzed regions in BRCA1 and BRCA2 may be a potential target in further search for a genetic marker of pancreatic diseases.

Hereditary Pancreatic Cancer: Advances in Genetic Testing, Early Detection Strategies, and Personalized Management

Background: Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal malignancy with a five-year survival rate of approximately 13% for advanced stages. While the majority of PDAC cases are sporadic, a significant subset is attributable to hereditary and familial predispositions, accounting for approximately 25% of cases. This article synthesizes recent advancements in the understanding, detection, and management of hereditary pancreatic cancer (PC). Results: Our review highlights the critical role of genetic testing (GT) in identifying high-risk individuals (HRIs), with germline pathogenic variants (PVs) found in up to 20% of hereditary PDAC cases. Since the implementation of next-generation sequencing (NGS) panels in 2014, detection capabilities have been significantly enhanced. HRIs can be included in screening programs that facilitate the early detection of PDAC. Early detection strategies, including the use of microribonucleic acid (miRNAs) signatures and novel imaging techniques like hyperpolarized 13C-magnetic resonance spectroscopy (MRS) have shown promising results. The identification of germline pathogenic variants (PVs) or mutations in homologous recombination (HR) genes plays a predictive role in the response to various treatments, prolonging patient survival. Discussion: Universal germline testing for PDAC, as recommended by the National Comprehensive Cancer Network (NCCN), is now a standard practice, facilitating the identification of at-risk individuals and enabling targeted surveillance and intervention. Multidisciplinary management, integrating genetic counseling, imaging, and gastrointestinal services, is essential for optimizing outcomes. Conclusions: Advances in genetic testing and biomarker research are transforming the landscape of hereditary PC management. Early detection and personalized treatment strategies are pivotal in improving survival rates. Ongoing multi-institutional research efforts are crucial for validating biomarkers and developing preventive measures, ultimately aiming to reduce the burden of this aggressive cancer.

Bioinformation study of immune microenvironment characteristics of disulfidptosis-related subtypes in ovarian cancer and prognostic model construction

OBJECTIVE

Ovarian cancer significantly impacts women's reproductive health and remains challenging to diagnose and treat. Despite advancements in understanding DNA repair mechanisms and identifying novel therapeutic targets, additional strategies are still needed. Recently, a novel form of cell death called disulfidptosis, which is triggered by glucose deprivation, has been linked to treatment resistance and changes in the tumor microenvironment (TME). However, its role in ovarian cancer is not well understood.

METHODS

Bioinformatics analysis was performed on RNA-seq data from TCGA and GEO databases to identify disulfidptosis-related genes in ovarian cancer. Differential expression analysis and pathway enrichment were conducted, followed by the development of a prognostic model using LASSO Cox regression, validated with GEO datasets (GSE13876, GSE26712). Clinical samples were analyzed using quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) to validate gene expression.

RESULTS

This study identified disulfidptosis-related gene subtypes in ovarian cancer and demonstrated their influence on the tumor microenvironment (TME), immunotherapy responses, and patient prognosis. Six genes (IFNB1, IGF2, CD40LG, IL1B, IL21, CD38) associated with disulfidptosis were identified and incorporated into a prognostic model. This model predicted patient outcomes and was validated externally. Clinical validation showed its accuracy in predicting progression-free survival and resistance to platinum-based chemotherapy.

CONCLUSION

Our findings highlight the significant impact of disulfidptosis-related genes on the ovarian cancer tumor microenvironment, providing insights that could support the development of clinical evaluations and personalized treatment strategies.

Reclassification of VUS in BRCA1 and BRCA2 using the new BRCA1/BRCA2 ENIGMA track set demonstrates the superiority of ClinGen ENIGMA Expert Panel specifications over the standard ACMG/AMP classification system

Purpose

Variants of uncertain significance (VUS) are considered one of the most significant impediments to the translation of genetic test results into precise clinical recommendations. The 2015 American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP) classification guidelines established a general framework for the assessment and classification of genetic variants; yet, gene-specific specifications are needed to enable better variant classification to reduce the number of VUS. The process of gene-specific adaptations of the ACMG/AMP codes is led and accompanied by ClinGen and implemented by Variant Curation Expert Panels (VCEP). The Evidence-based Network for the Interpretation of Germline Mutant Alleles (ENIGMA) VCEP recently published its specifications for the BRCA1 (HGNC:1100) and BRCA2 (HGNC:1101) genes. We investigated the differences in reclassification between the ENIGMA specifications and the standard ACMG/AMP classification system in a clinical setting.

Methods

We reclassified 121 VUS identified in these genes with the latest annotation data using the standard ACMG/AMP classification system and recommendations from the Sequence Variant Interpretation and the ENIGMA specifications. To simplify the reevaluation process, we have created a University of California Santa Cruz Genome Browser track hub that displays the exact data points required for variant classification using the ENIGMA VCEP specifications at the exon and variant level (https://genome.ucsc.edu/s/abenet/BRCA.ENIGMA.hg19).

Results

By comparing the codes used and their different weighting in the 2 approaches, we were able to demonstrate the superiority of the application of ENIGMA VCEP specifications, which resulted in a dramatic reduction of VUS (83.5% ENIGMA VCEP vs 20% ACMG/AMP + Sequence Variant Interpretation).

Conclusion

For the diagnostic analysis of the BRCA1 and BRCA2 genes, the use of the ENIGMA VCEP specifications gives the best possible result in the clinical translation of genetic variants. The University of California Santa Cruz Genome Browser BRCA1/BRCA2 ENIGMA track set significantly simplified the interpretation process.

Occult Breast Cancer in High-Risk Gene-Positive Pakistani Women Undergoing Contralateral Prophylactic Mastectomy/Prophylactic Mastectomy: Implications for Sentinel Lymph Node Biopsy

Introduction

Sentinel lymph node biopsy (SLNB) of the axilla is standard in breast cancer (BC) management; however, its role in prophylactic/contralateral prophylactic mastectomy (CPM) is still questioned. To avoid future consequences on surgical morbidity and socioeconomic aspects in low and middle-income countries (LMICs), we intend to determine the prevalence of occult breast cancer (OBC) among CPM cases.

Objective

To determine the prevalence of OBC in patients undergoing prophylactic mastectomy (PM).

Design

This is a retrospective cohort study.

Materials and methods

This retrospective cohort study is conducted at a tertiary-care hospital from January 2017 to December 2022. All individuals with the positive genetic test for high-risk breast cancer (HRBC) genes who underwent PMs/CPM at our centre were included. We analysed data using SPSS version 23.0.

Results

Twenty-six mutation-positive females underwent PM/CPM (16.1%). Two (7.69%) of 26 had later post-PM recurrence. Only 8 (30.76%) patients had SLNB and all were negative. No OBC was seen in PM/CPM specimens, whereas 3 (11.5%) had atypical ductal hyperplasia (ADH). Two of the ADH had BI-RADS-1, whereas 1 was BI-RADS-4 (33.3%) on the preoperative assessment. Results also showed that with an increase in the tumour grade of the diseased breast, the BI-RADS score of the asymptomatic breast was subsequently increased (P = .029).

Conclusion

Our study shows negative OBCs in PM/CPM cases with persistently negative SLNB results; however, ADH is identified in 11.5% of specimens. Our results suggest that SLNB can be safely omitted in patients undergoing CPM, but, preoperatively, patient and disease factors should be considered.

What happens after menopause? (WHAM): Impact of risk-reducing salpingo-oophorectomy on depressive and anxiety symptoms at 24 months

OBJECTIVE

For women with pathogenic variants in BRCA1 and BRCA2, risk-reducing salpingo-oophorectomy (RRSO) at the recommended age causes surgical menopause. We previously reported elevated depressive symptoms at 6 and 12 months and elevated anxiety symptoms at 6 months after RRSO. We now report these outcomes at 24 months, their baseline and 12-month predictors and the effect of Menopausal Hormone Therapy (MHT).

METHODS

Prospective controlled study of 59 premenopausal women planning RRSO and 91 comparisons who retained their ovaries. Depressive (CESD) and anxiety symptoms (GAD-7) were measured at baseline (before RRSO) and at 12 and 24 months. We used ordinary and logistic multivariable regression to estimate differences between and within groups at 24 months, before and after conditioning on baseline and 12 month measures.

RESULTS

Overall, depressive and anxiety symptoms were not elevated above baseline at 24 months and did not differ between RRSO and comparisons, before or after adjusting for previous measures (P > 0.05). Elevated depressive symptoms at 12 months (OR = 24, P < 0.001), and elevated anxiety symptoms at 12 months (OR = 13, P < 0.001), strongly predicted 24 month measures. Elevated depressive symptoms at baseline no longer predicted 24 month symptoms once 12 month symptoms were considered, but elevated baseline anxiety still predicted anxiety at 24 months, even when 12 month anxiety was considered. No association between MHT use and depressive or anxiety symptoms was observed.

CONCLUSIONS

Depressive and anxiety symptoms are not elevated 24 months after RRSO. However, depressive symptoms at 12 months after RRSO are likely to persist at 24 months.

Patient perspective: Is intensive screening of women at high risk of breast cancer evidence-based medicine or déjà vu?

In 2023, a breast cancer risk assessment and a subsequent positive test for the BRCA-2 genetic mutation brought me to the uncomfortable intersection of a longstanding career as an advocate for high-quality medical evidence to support shared patient-provider decision making and a new role as a high-risk patient. My search for studies of available risk-management options revealed that the most commonly recommended approach for women with a ⩾20% lifetime breast cancer risk, intensive screening including annual mammography and/or magnetic resonance imaging beginning at age 25-40 years, was supported only by cancer-detection statistics, with almost no evidence on patient-centered outcomes-mortality, physical and psychological morbidity, or quality of life-compared with standard screening or a surgical alternative, bilateral risk-reducing mastectomy. In this commentary, I explore parallels between the use of the intensive screening protocol and another longstanding women's health recommendation based on limited evidence, the use of hormone therapy (HT) for postmenopausal chronic disease prevention, which was sharply curtailed after the publication of the groundbreaking Women's Health Initiative trial in 2002. These declines in HT utilization were followed by marked decreases in breast cancer incidence, providing a compelling lesson on the critical importance of a solid evidentiary basis for women's health decisions. Known harms accompanying the benefits of breast screening-overdiagnosis, psychological effects, and mammography-associated radiation-exposure risks-make empirical measurement of patient-centered outcomes essential. Yet, published research on intensive screening of women at high breast cancer risk has largely ignored these outcomes, leaving patients, providers, and guideline developers lacking the evidence needed for best practice. Outcomes research is both feasible and urgently needed to inform care decisions and health policy for this patient population.

Risk-reducing surgeries for breast cancer in Brazilian patients undergoing multigene germline panel: impact of results on decision making

PURPOSE

To assess the behavior change of high-risk breast cancer patients regarding the intention to undergo risk-reducing mastectomies (RRM) before and after genetic testing results and to identify the main influencing factors in decision-making.

METHODS

Prospective cohort study conducted between November 2021 and October 2022 with women under follow-up at the high-risk outpatient clinic of the State University of Campinas (UNICAMP). Patients were referred for genetic testing, followed by counseling according to the test result.

RESULTS

A total of 373 women were included. In the pre-genetic testing analysis, 54.1% of patients intended to undergo RRMs. After testing, 42.2% opted for the procedure. Behavior change occurred in 26.2%, mainly from "yes" to "no/don't know" (72,6%) (p < 0.001). The genetic test result was positive (LPV or PV) in 29.7% of patients. Among the 90 patients with positive results, 62 (68.9%) agreed to RRM, while 22 (24.4%) remained unwilling to accept RRM, regardless of the positive test. Significant influencing factors for behavior change pre- and post-genetic testing (in favor of surgery) in multivariate analysis were: positive genetic test result (OR 2.94, p < 0.001), personal cancer history (OR 2.7, p = 0.008), and ages between 40 and 49 years (OR 2.07, p = 0.008) and ≥ 50 years (OR 3.47, p < 0.001).

CONCLUSION

In a Brazilian population at high-risk for breast cancer and users of the public health system, it was observed that most desired RRM, however, when genetic testing and counseling were performed, behavior change was observed, especially when the result was positive.

Disparities in Hereditary Genetic Testing in Patients with Triple Negative Breast Cancer

Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer that disproportionately affects younger females, non-Hispanic Black women, Hispanic women, and women with the BRCA1 gene mutation. Hereditary genetic testing is particularly important in this population to assess preventative and treatment strategies, however access to genetic testing is variable. A qualitative review was performed to evaluate barriers to genetic testing for patients with TNBC. Mutations common in breast cancer are reviewed along with updated guidelines on management strategies, including the ability to include PARP inhibitors as a treatment strategy. Barriers to genetic testing are multifactorial, with non-Hispanic Black women being tested less often than other groups. The disparity is even further represented by the limited number of non-Hispanic Black patients with TNBC who receive risk-reducing surgery or targeted systemic therapy. Eliminating barriers to genetic testing can allow us to support guideline-directed care for patients with TNBC at higher risk for genetic mutations.

Building a Genomics-Informed Nursing Workforce: Recommendations for Oncology Nursing Practice and Beyond

BACKGROUND

Genomics is a foundational element of precision health and can be used to identify inherited cancers, cancer related risks, therapeutic decisions, and to address health disparities. However, there are structural barriers across the cancer care continuum, including an underprepared nursing workforce, long wait times for service, and inadequate policy infrastructure that limit equitable access to the benefits of genomic discoveries. These barriers have persisted for decades, yet they are modifiable. Two distinct waves of efforts to integrate genomics into nursing practice are analyzed. Drawing on research and observations during these waves, this discussion paper explores additional approaches to accelerate workforce development and health system transformation.

RESULTS

Three recommendations for a third wave of efforts to integrate genomics are explored. (1) Collaborate across the domains of nursing practice, professions, and sectors to reset priorities in response to emerging evidence, (2) Education in leadership, policy and practice for rapid scale-up of workforce and health system transformation, and (3) Create a research framework that generates evidence to guide nursing practice.

CONCLUSIONS

Preparing nurses to lead and practice at the forefront of innovation requires concerted efforts by nurses in all five domains of practice and can optimize health outcomes. Leveraging nursing as a global profession with new strategies can advance genomics-informed nursing.

Combined use of super-resolution ultrasound imaging and shear-wave elastography for differential diagnosis of breast masses

Objectives

Shear-wave elastography (SWE) provides valuable stiffness within breast masses, making it a useful supplement to conventional ultrasound imaging. Super-resolution ultrasound (SRUS) imaging enhances microvascular visualization, aiding in the differential diagnosis of breast masses. Current clinical ultrasound diagnosis of breast cancer primarily relies on gray-scale ultrasound. The combined diagnostic potential of tissue stiffness and microvascular characteristics, two critical tumor biomarkers, remains insufficiently explored. This study aims to evaluate the correlation between the elastic modulus, assessed using SWE, and microvascular characteristics captured through SRUS, in order to evaluate the effectiveness of combining these techniques in distinguishing between benign and malignant breast masses.

Materials and methods

In this single-center prospective study, 97 patients underwent SWE to obtain parameters including maximum elasticity (Emax), minimum elasticity (Emin), mean elasticity (Emean), standard deviation of elasticity (Esd), and elasticity ratio. SRUS was used to calculate the microvascular flow rate and microvessel density (MVD) within the breast masses. Spearman correlation analysis was used to explore correlations between Emax and MVD. Receiver operating characteristic curves and nomogram were employed to assess the diagnostic efficacy of combining SRUS with SWE, using pathological results as the gold standard.

Results

Emax, Emean, Esd, and MVD were significantly higher in malignant breast masses compared to benign ones (p < 0.001), while Emin was significantly lower in malignant masses (p < 0.05). In Spearman correlation analysis, Emax was significantly positively correlated with MVD (p < 0.01). The area under the curve for SRUS combined with SWE (0.924) was significantly higher than that for SWE (0.883) or SRUS (0.830) alone (p < 0.001), thus indicating improved diagnostic accuracy. The decision curve analysis of the nomogram indicated that SWE combined with SRUS model had a higher net benefit in predicting breast cancer.

Conclusions

The MVD of the breast mass shows a significant positive correlation with Emax. By integrating SRUS with SWE, this study proposes a novel diagnostic approach designed to improve specificity and accuracy in breast cancer detection, surpassing the limitations of current ultrasound-based methods. This approach shows promise for early breast cancer detection, with the potential to reduce the need for unnecessary biopsies and improve patient outcomes.

Reduced Breast and Ovarian Cancer Through Targeted Genetic Testing: Estimates Using the NEEMO Microsimulation Model

Background: The effectiveness and cost-effectiveness of genetic testing for hereditary breast and ovarian cancer largely rely on the identification and clinical management of individuals with a pathogenic variant prior to developing cancer. Simulation modelling is commonly utilised to evaluate genetic testing strategies due to its ability to synthesise collections of data and extrapolate over long time periods and large populations. Existing genetic testing simulation models use simplifying assumptions for predictive genetic testing and risk management uptake, which could impact the reliability of their estimates. Our objective was to develop a microsimulation model that accurately reflects current genetic testing and subsequent care in Australia, directly incorporating the dynamic nature of predictive genetic testing within families and adherence to cancer risk management recommendations. Methods: The populatioN gEnEtic testing MOdel (NEEMO) is a population-level microsimulation that incorporates a detailed simulation of individuals linked within five-generation family units. The genetic component includes heritable high- and moderate-risk monogenic gene variants, as well as polygenic risk. Interventions include clinical genetic services, breast screening, and risk-reducing surgery. Model validation is described, and then to illustrate a practical application, NEEMO was used to compare clinical outcomes for four genetic testing scenarios in patients newly diagnosed with breast cancer (BC) and their relatives: (1) no genetic testing, (2) current practice, (3) optimised referral for genetic testing, and (4) genetic testing for all BC. Results: NEEMO accurately estimated genetic testing utilisation according to current practice and associated cancer incidence, pathology, and survival. Predictive testing uptake in first- and second-degree relatives was consistent with known prospective genetic testing data. Optimised genetic referral and expanded testing prevented up to 9.3% of BC and 4.1% of ovarian cancers in relatives of patients with BC. Expanding genetic testing eligibility to all BC patients did not lead to improvement in life-years saved in at-risk relatives compared to optimised referral of patients eligible for testing under current criteria. Conclusions: NEEMO is an adaptable and validated microsimulation model for evaluating genetic testing strategies. It captures the real-world uptake of clinical and predictive genetic testing and recommended cancer risk management, which are important considerations when considering real-world clinical and cost-effectiveness.

A Prospective Monocentric Study of Invasive Breast Carcinoma Diagnosed at 80 Years and Older: Survival Outcomes and Peculiar Challenges

Background: The lengthening of the lifespan led to an increase in breast cancer (BC) diagnosed in very old age, but the treatment recommendations in this patient group usually lack evidence-based practice. We conducted a prospective observational monocentric study specifically targeting patients diagnosed with invasive BC at 80 years of age or older. Methods: We enrolled 88 patients consecutively observed for a new BC diagnosis at 80 years or older. The aim was to investigate progression-free (PFS) and overall survival (OS), with a long follow-up period, along with clinico-pathological characteristics of the population. Results: At the end of the 5-year follow-up, the estimated OS and PFS probabilities were 82.9% (95% CI: 71.3-95.3%) and 64.0% (95% CI: 51.7-79.2%), respectively. After 8.5 years from the BC diagnosis, 48.9% died. The cause of death was BC in 32.6% of patients, different from BC in 13.9%, and unknown in the remaining. Surgery was performed in 69.3% of the cases and was associated with improved 12-month PFS (p < 0.001). Adjuvant systemic therapy and radiotherapy were omitted in 32% and 93% of eligible patients, respectively. A higher rate of metastatic disease at the diagnosis was observed in comparison with data described in younger people, as well as a significantly high rate of drop-out (27.3%). Conclusions: Ultra-old patients have a not negligible life expectancy; therefore, the oncologic treatment should be optimal and should adequately fight BC, always considering the quality of life of these frail patients. Future research should focus on developing personalized treatment protocols that incorporate comprehensive geriatric assessments and quality-of-life metrics. Additionally, larger, multicentric studies are needed to validate our findings and explore the role of emerging therapies in this age group.

Downstream Revenue Generated by Patients With Hereditary Cancer in the Multigene Panel Testing Era

PURPOSE

Patients with hereditary cancer syndromes face increased medical management recommendations to address their cancer risks. As multigene panels are the standard of testing today, more patients needing clinical intervention are being identified. This study calculates the downstream revenue (DSR) generated by patients ascertained by a genetic counselor (GC) with a hereditary cancer likely pathogenic/pathogenic variant (LPV/PV).

METHODS

Retrospective chart review was performed for patients seen in a high-volume cancer genetics clinic between October 1, 2009, and December 31, 2021, with LPV/PVs in hereditary cancer predisposition genes. DSR and work relative value units (wRVUs) were calculated for each patient before and after they met with a GC. Subgroup analyses calculated DSR/wRVUs from patients affected and unaffected with cancer and those whose genetic counseling visit was the first at the institution (naїve).

RESULTS

A total of 978 patients were available for analysis after exclusions were applied. Patients generated $73.06 million (M) in US dollars (USD) in DSR and 54,814 wRVUs after their initial genetic counseling visit. Unaffected patients (n = 370, 37.8%) generated $11.38M (USD) and 13,879 wRVUs; affected patients (n = 608, 62.2%) generated $61.68M (USD) and 40,935 wRVUs. Naïve patients (n = 367, 37.5%) generated $15.39M (USD) and 11,811 wRVUs; established patients (n = 611, 62.5%) generated $57.67M (USD) and 43,003 wRVUs. Unaffected, naïve patients (n = 204, 20.9%) generated $5.48M (USD) and 5,186 wRVUs.

CONCLUSION

By identifying patients with hereditary cancer, GCs can bring in substantial DSR for their institution. Naïve and unaffected patients provide the greatest GC value-add as these patients represent new business and revenue sources to the institution. As multigene panels continue to expand, the number of patients needing downstream services will increase. Recognizing patients at increased cancer risk will improve patient outcomes while simultaneously providing DSR for institutions.

Coronary Artery Calcium Scores After Prophylactic Premenopausal Bilateral Salpingo-Oophorectomy

Background

Premenopausal risk-reducing salpingo-oophorectomy (RRSO) in women at high familial risk of ovarian cancer leads to immediate menopause. Although early natural menopause is associated with increased cardiovascular disease risk, evidence on long-term cardiovascular disease risk after early surgical menopause is scarce.

Objectives

We sought to determine the long-term influence of the timing of RRSO on the development of coronary artery calcium (CAC), an established marker for cardiovascular disease risk.

Methods

We conducted a cross-sectional study (N = 733) nested in a nationwide cohort of women at high familial risk of ovarian cancer. In women aged 60-70 years (n = 328), we compared CAC scores between women with a premenopausal RRSO (age ≤45 years) and women with a postmenopausal RRSO (age ≥54 years), using multivariable Poisson analyses. Within the premenopausal RRSO group (n = 498), we also examined the effect of age at RRSO. In addition, we compared the premenopausal RRSO group with an external reference cohort (n = 5,226).

Results

Multivariable analyses showed that the prevalence rates of any CAC (CAC >0), at least moderate CAC (CAC >100), and severe CAC (CAC >400) were comparable between the premenopausal and postmenopausal RRSO groups (relative risk [RR]: 0.93; 95% CI: 0.75-1.15 for any CAC; RR: 0.71; 95% CI: 0.43-1.17 for at least moderate CAC; RR: 0.81; 95% CI: 0.30-2.13 for severe CAC). There was no difference in CAC between the premenopausal RRSO group and a similar aged reference cohort. Timing of premenopausal RRSO (early premenopausal RRSO [<41 years] vs late premenopausal RRSO [41-45 years]) did not affect the outcomes.

Conclusions

Our results do not show a long-term adverse effect of surgical menopause on the development of CAC.

Clinical experience on the limited role of ultrasound for breast cancer screening in BRCA1 and BRCA2 mutations carriers aged 30-39 years

PURPOSE

In BRCA germline pathogenic sequence variants (PSV) carriers aged 30-39 years imaging is recommended at six-month intervals. The European society for medical oncology recommendation of the use of 6-monthly MRI six-monthly MRI screening is being considered at our institution, particularly for younger carriers under the age of 35, although it is not mandatory. If 6-monthly MRI is unavailable, annual MRI may be supplemented by ultrasound (with or without mammography). The aim of this study was to evaluate the utility of ultrasound screening added to mammography, as a 6-month supplement to annual MRI in BRCA PSV carriers aged 30-39 years.

MATERIALS AND METHODS

This IRB approved retrospective study included BRCA PSV carriers aged 30-39 years, who underwent breast cancer screening at our institution between January 2015 and March 2023. Participants were divided into two groups, those who had supplemental whole-breast US and mammography at six months and underwent screening before March 2019, and those who had only mammography without supplemental US and enrolled in screening after March 2019. Patient characteristics, cancer detection rates and cancer characteristics were compared between the two groups.

RESULTS

Overall, 200 asymptomatic BRCA1/2 PSV carriers undergoing screening in our institution were included in the study. Mean age was 35.7 ± 3.5 years, and mean follow-up time was 37.4 ± 38.0 months. There were 118 (59 %) women screened with supplemental US, and 82 (41 %) women without. Eight cancers were diagnosed during the study period, four in women with supplemental US and four in women without. The sensitivity of whole-breast screening US was 25 % (1/4), specificity 85.7 % (222/259), PPV 2.6 % (1/38), and NPV 98.7 % (222/225). Of the four cancers detected in women screened with supplemental US, one was diagnosed by whole-breast US, two by MRI, and one by mammography. Of eight cancers included in this study, two were not detectable by targeted second-look US. All eight cancers were detectable by MRI.

CONCLUSION

The addition of whole-breast ultrasound to mammography and MRI screening in BRCA PSV carriers aged 30-39 years offered limited incremental benefit. MRI with 6 months supplemental mammography without US detected all cancer cases.

Predicting BRCA mutation and stratifying targeted therapy response using multimodal learning: a multicenter study

BACKGROUND

The status of BRCA1/2 genes plays a crucial role in the treatment decision-making process for multiple cancer types. However, due to high costs and limited resources, a demand for BRCA1/2 genetic testing among patients is currently unmet. Notably, not all patients with BRCA1/2 mutations achieve favorable outcomes with poly (ADP-ribose) polymerase inhibitors (PARPi), indicating the necessity for risk stratification. In this study, we aimed to develop and validate a multimodal model for predicting BRCA1/2 gene status and prognosis with PARPi treatment.

METHODS

We included 1695 slides from 1417 patients with ovarian, breast, prostate, and pancreatic cancers across three independent cohorts. Using a self-attention mechanism, we constructed a multi-instance attention model (MIAM) to detect BRCA1/2 gene status from hematoxylin and eosin (H&E) pathological images. We further combined tissue features from the MIAM model, cell features, and clinical factors (the MIAM-C model) to predict BRCA1/2 mutations and progression-free survival (PFS) with PARPi therapy. Model performance was evaluated using area under the curve (AUC) and Kaplan-Meier analysis. Morphological features contributing to MIAM-C were analyzed for interpretability.

RESULTS

Across the four cancer types, MIAM-C outperformed the deep learning-based MIAM in identifying the BRCA1/2 genotype. Interpretability analysis revealed that high-attention regions included high-grade tumors and lymphocytic infiltration, which correlated with BRCA1/2 mutations. Notably, high lymphocyte ratios appeared characteristic of BRCA1/2 mutations. Furthermore, MIAM-C predicted PARPi therapy response (log-rank p < 0.05) and served as an independent prognostic factor for patients with BRCA1/2-mutant ovarian cancer (p < 0.05, hazard ratio:0.4, 95% confidence interval: 0.16-0.99).

CONCLUSIONS

The MIAM-C model accurately detected BRCA1/2 gene status and effectively stratified prognosis for patients with BRCA1/2 mutations.