1
|
Hanson-Kahn A, Rowe-Teeter C, Siskind C, Dykzeul N. Proposed use of entrustable professional activities (EPAs) in genetic counseling for clinical training and assessment. J Genet Couns 2024; 33:164-167. [PMID: 38356180 DOI: 10.1002/jgc4.1871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/05/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
We introduce Entrustable Professional Activities (EPAs) as a potential framework for clinical training and assessment in genetic counseling. We discuss advantages of this approach, review how EPAs complement Practice-Based Competencies (PBCs), describe our process of generating proposed "core" EPAs, provide examples of specialty-specific EPAs, discuss the concept of entrustment in clinical training, and propose an approach to implementation.
Collapse
|
2
|
Zukin E, Culver JO, Liu Y, Yang Y, Ricker CN, Hodan R, Sturgeon D, Kingham K, Chun NM, Rowe-Teeter C, Singh K, Zell JA, Ladabaum U, McDonnell KJ, Ford JM, Parmigiani G, Braun D, Kurian AW, Gruber SB, Idos GE. Clinical implications of conflicting variant interpretations in the cancer genetics clinic. Genet Med 2023; 25:100837. [PMID: 37057674 PMCID: PMC10416421 DOI: 10.1016/j.gim.2023.100837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023] Open
Abstract
PURPOSE The aim of this study was to describe the clinical impact of commercial laboratories issuing conflicting classifications of genetic variants. METHODS Results from 2000 patients undergoing a multigene hereditary cancer panel by a single laboratory were analyzed. Clinically significant discrepancies between the laboratory-provided test reports and other major commercial laboratories were identified, including differences between pathogenic/likely pathogenic and variant of uncertain significance (VUS) classifications, via review of ClinVar archives. For patients carrying a VUS, clinical documentation was assessed for evidence of provider awareness of the conflict. RESULTS Fifty of 975 (5.1%) patients with non-negative results carried a variant with a clinically significant conflict, 19 with a pathogenic/likely pathogenic variant reported in APC or MUTYH, and 31 with a VUS reported in CDKN2A, CHEK2, MLH1, MSH2, MUTYH, RAD51C, or TP53. Only 10 of 28 (36%) patients with a VUS with a clinically significant conflict had a documented discussion by a provider about the conflict. Discrepant counseling strategies were used for different patients with the same variant. Among patients with a CDKN2A variant or a monoallelic MUTYH variant, providers were significantly more likely to make recommendations based on the laboratory-reported classification. CONCLUSION Our findings highlight the frequency of variant interpretation discrepancies and importance of clinician awareness. Guidance is needed on managing patients with discrepant variants to support accurate risk assessment.
Collapse
Affiliation(s)
- Elyssa Zukin
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA; University of California, Irvine, Irvine, CA
| | - Julie O Culver
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Yuxi Liu
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yunqi Yang
- Dana-Farber Cancer Institute, Boston, MA
| | - Charité N Ricker
- University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Rachel Hodan
- Stanford University School of Medicine, Stanford, CA
| | - Duveen Sturgeon
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - Kerry Kingham
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, CA
| | - Kevin J McDonnell
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - James M Ford
- Stanford University School of Medicine, Stanford, CA
| | - Giovanni Parmigiani
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | - Danielle Braun
- Dana-Farber Cancer Institute, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Stephen B Gruber
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA
| | - Gregory E Idos
- City of Hope National Medical Center, Center for Precision Medicine, Duarte, CA.
| |
Collapse
|
3
|
Idos G, Kurian AW, Ricker C, Sturgeon D, Culver J, Kingham K, Koff R, Chun NM, Rowe-Teeter C, Levonian P, Hong C, Mills M, Ma C, Lancaster JM, Brown K, Kidd J, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Preventive surgery after multiplex genetic panel testing (MGPT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.1525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1525 Background: Guidelines recommend consideration of prophylactic surgery for patients with a germline pathogenic variant in some cancer predisposition genes. We assessed surgery utilization in a prospective, multi-institutional cohort study of MGPT. Methods: 2000 patients had MGPT and completed questionnaires at 3, 6, and 12 months. Patients reported surgical utilization and indication (treatment or prevention). Surgery utilization was assessed according to cancer history and MGPT test results: Positive, pathogenic variant; VUS, variant of uncertain significance; Negative, benign variants. Results: Overall, 12.9% (198/1537) of patients reported surgery after MGPT (median follow-up 13 months). Only 31.3% (62/198) of patients specified that their surgery was preventive. Preventive surgery utilization was significantly higher among patients who tested positive (n=30, 14.9%) compared to those testing negative (n=20, 2.3%, p<0.001) or VUS (n=12, 2.2%, p<0.001). Preventive surgery was very low among patients testing negative or VUS who had no personal history of cancer in the relevant organ (Table). For example, mastectomy was not reported among any patients testing negative or VUS who had no personal history of breast cancer (Table). Conclusions: More than one year after MGPT, prophylactic surgery use was low among patients with VUS or negative results, especially among those with no personal history of cancer at the relevant site. Surgery utilization. [Table: see text]
Collapse
Affiliation(s)
- Gregory Idos
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Charité Ricker
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kerry Kingham
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | | | | | | | | | | | - Cindy Ma
- Stanford Cancer Institute, Stanford University School of Medicine, Palo Alto, CA
| | | | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | - Uri Ladabaum
- Stanford University Cancer Institute, Stanford, CA
| | - James M. Ford
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
4
|
Idos GE, Kurian AW, Ricker C, Sturgeon D, Culver JO, Kingham KE, Koff R, Chun NM, Rowe-Teeter C, Lebensohn AP, Levonian P, Lowstuter K, Partynski K, Hong C, Mills MA, Petrovchich I, Ma CS, Hartman AR, Allen B, Wenstrup RJ, Lancaster JM, Brown K, Kidd J, Evans B, Mukherjee B, McDonnell KJ, Ladabaum U, Ford JM, Gruber SB. Multicenter Prospective Cohort Study of the Diagnostic Yield and Patient Experience of Multiplex Gene Panel Testing For Hereditary Cancer Risk. JCO Precis Oncol 2019; 3:1800217. [PMID: 34322651 PMCID: PMC8260917 DOI: 10.1200/po.18.00217] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2018] [Indexed: 12/05/2022] Open
Abstract
Purpose Multiplex gene panel testing (MGPT) allows for the simultaneous analysis of germline cancer susceptibility genes. This study describes the diagnostic yield and patient experiences of MGPT in diverse populations. Patients and Methods This multicenter, prospective cohort study enrolled participants from three cancer genetics clinics—University of Southern California Norris Comprehensive Cancer Center, Los Angeles County and University of Southern California Medical Center, and Stanford Cancer Institute—who met testing guidelines or had a 2.5% or greater probability of a pathogenic variant (N = 2,000). All patients underwent 25- or 28-gene MGPT and results were compared with differential genetic diagnoses generated by pretest expert clinical assessment. Post-test surveys on distress, uncertainty, and positive experiences were administered at 3 months (69% response rate) and 1 year (57% response rate). Results Of 2,000 participants, 81% were female, 41% were Hispanic, 26% were Spanish speaking only, and 30% completed high school or less education. A total of 242 participants (12%) carried one or more pathogenic variant (positive), 689 (34%) carried one or more variant of uncertain significance (VUS), and 1,069 (53%) carried no pathogenic variants or VUS (negative). More than one third of pathogenic variants (34%) were not included in the differential diagnosis. After testing, few patients (4%) had prophylactic surgery, most (92%) never regretted testing, and most (80%) wanted to know all results, even those of uncertain significance. Positive patients were twice as likely as negative/VUS patients (83% v 41%; P < .001) to encourage their relatives to be tested. Conclusion In a racially/ethnically and socioeconomically diverse cohort, MGPT increased diagnostic yield. More than one third of identified pathogenic variants were not clinically anticipated. Patient regret and prophylactic surgery use were low, and patients appropriately encouraged relatives to be tested for clinically relevant results.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Rachel Koff
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | | | | | | | | | | | - Cindy S Ma
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | | | | | | | | | | | - Uri Ladabaum
- Stanford University School of Medicine, Stanford, CA
| | - James M Ford
- Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
5
|
Ricker CN, Koff RB, Qu C, Culver J, Sturgeon D, Kingham KE, Lowstuter K, Chun NM, Rowe-Teeter C, Lebensohn A, Levonian P, Partynski K, Lara-Otero K, Hong C, Petrovchich IM, Mills MA, Hartman AR, Allen B, Ladabaum U, McDonnell K, Ford JM, Gruber SB, Kurian AW, Idos GE. Patient communication of cancer genetic test results in a diverse population. Transl Behav Med 2018; 8:85-94. [PMID: 29385580 DOI: 10.1093/tbm/ibx010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Research on the communication of genetic test results has focused predominately on non-Hispanic White (NHW) mutation-positive families with high-risk hereditary cancer conditions. Little is known about this process for racially and ethnically diverse individuals or for those with mutations in moderate risk genes. The communication behaviors of study participants who carry a gene mutation were analyzed 3 months after disclosure of genetic test results. Participants were queried about communication of their results, as part of a prospective study of multi-gene panel genetic testing. The responses of particpants who tested positive were analyzed by race/ethnicity and by level of cancer risk (high vs. moderate). Of the 216 mutation-positive study participants, 136 (63%) responded. Self-reported race/ethnicity was 46% NHW, 41% Hispanic, 10% Asian, and 2% Black. The majority (99.0%, n = 135) had shared their results with someone and 96% had told a family member (n = 130). Hispanic respondents were less likely to have told a healthcare provider about their results than NHW (29% vs. 68%, p < .0001). Asian respondents were less likely than NHW to encourage family members to undergo testing (OR = 0.1, p = .03); but Asian family members were more likely to undergo testing (OR = 8.0, p = .03). There were no differences in communication between those with a mutation in a high- or moderate-risk gene. Three months post genetic testing, communication of results was very high; 30% reported a family member underwent genetic testing. Further studies are needed to better understand the communication process in individuals from diverse racial/ethnic backgrounds.
Collapse
Affiliation(s)
| | - Rachel B Koff
- Stanford University Cancer Institute, Stanford, CA, USA
| | - Chenxu Qu
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Duveen Sturgeon
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | - Christine Hong
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | | | | | | | | | - Uri Ladabaum
- Stanford University Cancer Institute, Stanford, CA, USA
| | - Kevin McDonnell
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - James M Ford
- Stanford University Cancer Institute, Stanford, CA, USA
| | | | | | - Gregory E Idos
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| |
Collapse
|
6
|
Idos G, Kurian AW, Ricker C, Sturgeon D, Culver J, Kingham K, Koff R, Chun NM, Rowe-Teeter C, Kidd J, Evans B, Brown K, Mills M, Ma C, Hong C, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Promoting colorectal cancer (CRC) screening after multiplex genetic testing and genetic counseling. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.1582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gregory Idos
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | | | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kerry Kingham
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Rachel Koff
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Nicolette M. Chun
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | | | - Meredith Mills
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Cindy Ma
- Stanford Cancer Institute, Stanford University School of Medicine, Palo Alto, CA
| | | | | | - Uri Ladabaum
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - James M. Ford
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
7
|
Idos G, Kurian AW, Ricker C, Sturgeon D, Culver J, Kingham K, Koff R, Chun NM, Rowe-Teeter C, Kidd J, Evans B, Brown K, Mills M, Ma C, Hong C, McDonnell KJ, Ladabaum U, Ford JM, Gruber SB. Promoting breast cancer screening after multiplex genetic panel testing (MGPT) and genetic counseling. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.1581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gregory Idos
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Charite Ricker
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kerry Kingham
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | | | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | | | | | - Cindy Ma
- Stanford Cancer Institute, Stanford University School of Medicine, Palo Alto, CA
| | | | - Kevin J McDonnell
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Uri Ladabaum
- Stanford University Cancer Institute, Stanford, CA
| | - James M. Ford
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
8
|
Idos G, Roth KG, Naghi L, Ricker CN, Culver J, Sturgeon D, Kingham K, Koff R, Chun NM, Rowe-Teeter C, Hartman AR, Allen B, Evans B, Mills M, Hong C, McDonnell K, Ladabaum U, Ford JM, Gruber SB, Kurian AW. Performance of mutation risk prediction models in a racially diverse multi-gene panel testing cohort. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1523 Background: Mutation carrier prediction models are clinically useful tools for identifying candidates for genetic counseling and testing. Consensus guidelines recommend germline genetic testing for those with a carrier probability (CP) of approximately 5% or higher. However, prediction models may perform less well among racial/ethnic minorities. Our hypothesis is that pathogenic mutations (PM) are identifiable in a clinically meaningful fraction of racially/ethnically diverse patients with a CP of < 5%. Methods: We conducted a multicenter prospective clinical trial of patients undergoing cancer-risk assessment using a 25 gene panel, which include APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, TP53. Patients were recruited from August 2014 to November 2016 at three centers. Patients were enrolled if they met standard clinical criteria for genetic testing or were predicted to have a ≥2.5% probability of inherited cancer susceptibility using validated prediction models. We evaluated the CP of patients with a PM in BRCA1, BRCA2, and/or a mismatch repair (MMR) gene using the following models: (1) BRCApro, (2) MMRpro and (3) PREMM1,2,6. Results: Of 2000 patients enrolled in this cohort, 80.6% are female (n = 1612). Regarding race/ethnicity, the cohort is 40.1% Non-Hispanic White (n = 802), 37.4% Hispanic (n = 748), 11.5% Asian (n = 230), 3.9% Black (n = 78), and 7.1% Other (n = 142). Among 241 (12.1%) patients who tested positive for a pathogenic mutation, 76 (31.5%) patients had a BRCA1 or BRCA2 mutation. Of those, 52 (68.4%) patients had a BRCApro CP of < 5%. Thirty-eight (15.8%) patients had a pathogenic mutation in an MMR gene: 19 (50.0%) had an MMRpro CP of < 5%, while 13 (34.2%) had a PREMM1,2,6 CP of < 5%. The racial/ethnic distribution of BRCA1/2 or MMR mutation carriers is similar to that of the whole cohort. Conclusions: In a diverse cohort of patients undergoing 25-gene multiple-gene panel testing, half or more carriers of BRCA1/2 or MMR mutations had a CP of < 5%, the consensus guideline-recommended cutoff for genetic testing. These results support a lower threshold for genetic testing guidelines. Clinical trial information: NCT02324062.
Collapse
Affiliation(s)
- Gregory Idos
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Katherine G Roth
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Leah Naghi
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Julie Culver
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Duveen Sturgeon
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | | | | | | | | | - Brent Evans
- Myriad Genetic Laboratories, Inc., Salt Lake City, UT
| | | | - Christine Hong
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kevin McDonnell
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - James M. Ford
- Stanford University School of Medicine, Stanford, CA
| | - Stephen B. Gruber
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | |
Collapse
|
9
|
Kurian AW, Idos G, Ricker CN, Culver J, Sturgeon D, Kingham K, Koff R, Lowstuter K, Chun NM, Rowe-Teeter C, Partynski K, Hartman AR, Allen B, Kidd J, Mills M, Hong C, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Safety of multiplex gene testing for inherited cancer risk in a fully accrued prospective trial. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1576 Background: Sequencing more genes increases the chance of finding a pathogenic mutation and/or a variant of uncertain significance (VUS). Little is known about potential harms of multiplex testing for cancer risk, such as unwarranted surgery or adverse psychological effects. Methods: We conducted a prospective trial of sequencing 25 genes : APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, TP53. Patients were eligible if they met standard testing guidelines or predictive models estimated ≥2.5% mutation probability. Participants were surveyed 3 months post-test: the Multidimensional Impact of Cancer Risk Assessment (MICRA) scale measured distress, uncertainty and positive experiences. We report on the fully accrued trial (N = 2000). Results: 1998/2000 (99.9%) participants currently have reported results: 12.1% tested positive for a pathogenic mutation (Pos), 34.5% had VUS only and 53.5% tested negative (Neg). Median age was 51, 81% were female, 40% Hispanic, and 72% had a cancer history. Self-reported preventive surgery rates were low (mastectomy 9.3%, hysterectomy 1.5%, oophorectomy 1.6%), with no difference between VUS and Neg patients (p = 0.346). Most patients never or rarely had thoughts of cancer affecting daily activities (Pos 59.5%, VUS 66.9%, Neg 71.0%), never regretted testing (Pos 84.1%, VUS 90.0%, Neg 93.6%), and wanted to know all results, even those that doctors do not fully understand (Pos 81.7%, VUS 78.8%, Neg 77.1%). Pos patients had higher MICRA distress and uncertainty scores than VUS and Neg patients, whose distress and uncertainty scores did not differ significantly (p = 0.165, p = 0.129). Relatives of Pos patients completed genetic testing (30.4%) more often than VUS (5.8%) or Neg patients (5.1%, p < 0.001). Conclusions: After multiplex testing of 2000 diverse patients, few reported preventive surgery at 3 months; VUS patients had no more distress, regret or uncertainty than Neg patients. Pos patients most often advised relatives to test, suggesting that participants understood the implications of test results. Longer-term follow-up of test-related outcomes is underway. Clinical trial information: NCT02324062.
Collapse
Affiliation(s)
| | - Gregory Idos
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Julie Culver
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Duveen Sturgeon
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | - Katrina Lowstuter
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | | | | | | | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | - Christine Hong
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kevin McDonnell
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - James M. Ford
- Stanford University School of Medicine, Stanford, CA
| | - Stephen B. Gruber
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| |
Collapse
|
10
|
Idos G, Kurian AW, Ricker CN, Sturgeon D, Culver J, Kingham K, Koff R, Chun NM, Rowe-Teeter C, Lowstuter K, Hartman AR, Allen B, Kidd J, Mills M, Ma C, Hong C, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Expanded yield of multiplex panel testing in fully accrued prospective trial. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.1525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1525 Background: Genetic testing is a powerful tool for stratifying cancer risk. Multiplex gene panel (MGP) testing allows simultaneous analysis of multiple high- and moderate- penetrance genes. However, the diagnostic yield and clinical utility of panels remain to be further delineated. Methods: A report of a fully accrued trial (N = 2000) of patients undergoing cancer-risk assessment. Patients were enrolled in a multicenter prospective cohort study where diagnostic yield and off-target mutation detection was evaluated of a 25 gene MGP comprised of APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, TP53. Patients were enrolled if they met standard testing guidelines or were predicted to have a ≥2.5% mutation probability by validated models. Differential diagnoses (DDx) were generated after expert clinical genetics assessment, formulating up to 8 inherited cancer syndromes ranked by estimated likelihood. Results: 1998/2000 patients had reported MGP test results. Women constituted 81% of the sample, and 40% were Hispanic; 241 tested positive for at least 1 pathogenic mutation (12.1%) and 689 (34.5%) patients carried at least 1 variant of uncertain significance. The most frequently identified mutations were in BRCA1 (17%, n = 41), BRCA2 (15%, n = 36), APC (8%, n = 19), CHEK2 (7%, n = 17), ATM (7%, n = 16). 39 patients (16%) had at least 1 pathogenic mutation in a mismatch repair (MMR) gene ( MLH1, n = 10; MSH2, n = 10; MSH6, n = 8; PMS2, n = 11). 43 individuals (18%) had MUTYH mutations – 41 were monoallelic. Among 19 patients who had mutations in APC – 16 were APC I1307K. Only 65% (n = 159) of PV results were included in the DDx, with 35% (n = 86) of mutations not clinically suspected. Conclusions: In a diverse cohort, multiplex panel use increased genetic testing yield substantially: 35% carried pathogenic mutations in unsuspected genes, suggesting a significant contribution of expanded multiplex testing to clinical cancer risk assessment. The identification of off-target mutations broadens our understanding of cancer risk and genotype-phenotype correlations. Follow-up is ongoing to assess the clinical utility of multiplex gene panel testing. Clinical trial information: NCT02324062.
Collapse
Affiliation(s)
- Gregory Idos
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | | | - Duveen Sturgeon
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Julie Culver
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | | | | | - Katrina Lowstuter
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | - Cindy Ma
- Stanford Cancer Institute, Palo Alto, CA
| | - Christine Hong
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Kevin McDonnell
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - James M. Ford
- Stanford University School of Medicine, Stanford, CA
| | - Stephen B. Gruber
- University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| |
Collapse
|
11
|
Kurian AW, Idos G, Culver J, Ricker CN, Koff R, Sturgeon D, Lowstuter K, Hartman AR, Allen B, Kidd J, Rowe-Teeter C, Kingham K, Chun NM, Petrovchich I, Mills M, Hong C, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Safety of multiplex gene testing for inherited cancer risk: Interim analysis of a clinical trial. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.1503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Gregory Idos
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Rachel Koff
- Stanford University Cancer Institute, Stanford, CA
| | | | | | | | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | | | | | | | | | | | | | - Uri Ladabaum
- Stanford University Cancer Institute, Stanford, CA
| | | | | |
Collapse
|
12
|
Idos G, Kurian AW, Ricker CN, Sturgeon D, Culver J, Lowstuter K, Hartman AR, Allen B, Kingham K, Koff R, Rowe-Teeter C, Chun NM, Mills M, Petrovchich I, Hong C, Kidd J, McDonnell K, Ladabaum U, Ford JM, Gruber SB. Yield of multiplex panel testing compared to expert opinion and validated prediction models. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.1509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gregory Idos
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | | | - Julie Culver
- USC Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | | | | | - Kerry Kingham
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Rachel Koff
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | - Nicolette M. Chun
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Meredith Mills
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Iva Petrovchich
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | - John Kidd
- Myriad Genetics, Inc., Salt Lake City, UT
| | | | - Uri Ladabaum
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - James M. Ford
- Stanford University School of Medicine, Stanford, CA
| | | |
Collapse
|
13
|
Kurian AW, Idos G, McDonnell K, Ricker C, Sturgeon D, Culver J, Lowstuter K, Hartman AR, Allen B, Rowe-Teeter C, Kingham KE, Koff RB, Lebensohn A, Chun NM, Petrovchich IM, Mills MA, Hong C, Ladabaum U, Ford JM, Gruber SB. Abstract P2-09-07: The patient experience in a prospective trial of multiplex gene panel testing for cancer risk. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-09-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Multiplex gene sequencing panels (MGP) are increasingly used for assessment of hereditary breast cancer risk. Compared to testing for BRCA1 and BRCA2 (BRCA1/2) only, testing more genes increases the likelihood of identifying a deleterious mutation (DM) and/or a variant of uncertain significance (VUS), which might cause distress, uncertainty or regret about testing. Little is known about the patient experience of MGP testing.
Methods: We conducted a prospective study of MGP testing, using a panel of 25 genes: APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, and TP53. Participants were enrolled at three medical centers and were eligible if they met standard genetic testing guidelines or if they had a ≥2.5% probability of a DM in any gene on the panel, as calculated by predictive models (e.g. IBIS, Penn II, MMRPro). Participants were surveyed about their experiences with MGP testing including distress and uncertainty at baseline (before test results disclosure) and three months later. The 25-item Multidimensional Impact of Cancer Risk Assessment (MICRA) scale measured distress, uncertainty and positive experiences at three months after testing. We present a planned interim analysis after enrolling 500 of 2000 total participants.
Results: Of 500 participants, 332 (66%) were referred for suspicion of hereditary breast/ovarian cancer syndrome. Of these 332, 97% were female, 79% were white, 43% were Hispanic and 33% were Spanish-speaking only; for 25%, high school was their highest level of education. A total of 48% had breast cancer, 5% had ovarian cancer, and 7% had another cancer: 11% had a DM and 35% had VUS in one or more genes. At study entry most participants thought about cancer rarely or not at all (69%, 95% confidence interval (CI) 58%-77%), and few (7%, CI 3%-14%) had thoughts of cancer that affected their daily lives; results were unchanged three months later, after genetic results disclosure (Chi-squared test, p-value >0.1). MICRA scores at three months were low for distress (mean score 2 out of a possible 30) and uncertainty (mean score 7 out of 45), and high for positive testing experiences (mean score 9 out of 15). Most (82%, CI 72%-88%) participants wanted to know all of their MGP results even if the clinical relevance was not fully understood, and most (87%, CI 79%-93%) never regretted learning their MGP results.
Conclusions: Among diverse participants of a prospective, multi-center MGP testing trial, cancer- and genetic testing-related distress were low at entry and remained low three months later. These results provide no evidence for an increase in distress or uncertainty after MGP. Longer-term follow-up in a larger cohort is underway.
Citation Format: Kurian AW, Idos G, McDonnell K, Ricker C, Sturgeon D, Culver J, Lowstuter K, Hartman A-R, Allen B, Rowe-Teeter C, Kingham KE, Koff RB, Lebensohn A, Chun NM, Petrovchich IM, Mills MA, Hong C, Ladabaum U, Ford JM, Gruber SB. The patient experience in a prospective trial of multiplex gene panel testing for cancer risk. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-07.
Collapse
Affiliation(s)
- AW Kurian
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - G Idos
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - K McDonnell
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - C Ricker
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - D Sturgeon
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - J Culver
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - K Lowstuter
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - A-R Hartman
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - B Allen
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - C Rowe-Teeter
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - KE Kingham
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - RB Koff
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - A Lebensohn
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - NM Chun
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - IM Petrovchich
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - MA Mills
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - C Hong
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - U Ladabaum
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - JM Ford
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| | - SB Gruber
- Stanford University School of Medicine, Stanford, CA; University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Myriad Genetics, Salt Lake City, UT
| |
Collapse
|
14
|
Jin P, Walther D, Zhang J, Rowe-Teeter C, Fu GK. Serine 171, a conserved residue in the gamma-aminobutyric acid type A (GABAA) receptor gamma2 subunit, mediates subunit interaction and cell surface localization. J Biol Chem 2004; 279:14179-83. [PMID: 14736867 DOI: 10.1074/jbc.m313411200] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Serine 171 in the GABA(A) receptor gamma2 subunit is highly conserved in the ligand-gated ion channel superfamily. In this paper, we report that mutating serine 171 within gamma2 to glycine or cysteine prevents the interaction of gamma2 with alpha2 and beta1 when these subunits are co-expressed in human embryo kidney 293 cells, resulting in intracellular retention of gamma2. Structure analysis based on a three-dimensional homology model of gamma2 (Ernst, M., Brauchart, D., Boresch, S., and Sieghart, W. (2003) Neuroscience 119, 933-943) reveals that serine 171 may play a critical role in the formation and stabilization of an exposed turn structure that is part of the subunit interaction site. Mutation of serine 171 in the gamma2 subunit could therefore result in alteration of the structure of the subunit interaction site, preventing correct subunit assembly.
Collapse
Affiliation(s)
- Pei Jin
- Incyte Corporation, Palo Alto, California 94304, USA.
| | | | | | | | | |
Collapse
|
15
|
Abstract
We have cloned a novel gamma-aminobutyric acid type A (GABAA) receptor gamma2 subunit variant named gamma2XL. gamma2XL contains an alternatively spliced exon, resulting in the addition of 40 amino acids to the N-terminal extracellular domain between Ser171 and Tyr172. We show that gamma2XL failed to localize to the cell surface when it was coexpressed with the alpha2 and beta1 subunits in human embryonic kidney 293 cells. Expression of gamma2XL in 293 cells suppressed GABAA receptor binding in a dose-dependent manner by preventing GABAA receptor cell-surface localization. We also generated a gamma2 mutant with Ser171 and Tyr172 converted to glycine and threonine, respectively. We demonstrate that this mutant has a significantly lower affinity for the alpha2 and beta1 subunits and failed to reach the cell surface when coexpressed with these subunits. Together, our results indicate that Ser171 and Tyr172 in the gamma2 subunit constitute a critical motif. When this motif is disrupted by insertion of the alternative exon, access of the gamma2 subunit to the cell surface is prevented.
Collapse
Affiliation(s)
- Pei Jin
- Incyte Corporation, Palo Alto, California 94304, USA.
| | | | | | | | | | | |
Collapse
|