Eleven Years of Oncogenetic Consultations in a Swiss Center: Patient and Testing Characteristics

Introduction

Oncogenetic counseling has been provided at the University Hospital of Bern since 2004. Since the public announcement by Ms. Angelina Jolie in 2013 that she had undergone bilateral prophylactic mastectomy, other oncogenetic centers have reported an increase in consultations. We conducted a retrospective review of the oncogenetic consultations at our center to evaluate the presence and the consequences of a potential "Angelina Jolie effect" and to characterize this patient population over a decade.

Methods

All initial oncogenetic consultations between 2005 and 2015 were collected, using electronic records. Demographics, cancer type, testing, and mutation results, as well as consultation rates, were recorded. The yearly trends were analyzed using Joinpoint regression analysis (JPA).

Results

In total, 823 patient cases were included, mostly women (84%), half of them with a positive personal cancer history. A hereditary breast and ovarian cancer (HBOC) risk was the main reason for consultation (72%). Moreover, 22% of patients had a previously detected familial mutation. Two-thirds underwent testing, which yielded a positive test result in 31% of the cases. According to JPA, the consultation rate increased throughout the decade, with a significant upward trend from 2013. Rates of testing and positive results remained stable over time. Most patients (86%) fulfilled the referral criteria of published guidelines.

Discussion

At our center, we found retrospectively a disproportionate growth in the referral rate for HBOC cases compared to other oncological cases after the year 2013, but overall, no change in testing rates was detected.

Long-term yield of pancreatic cancer surveillance in high-risk individuals

OBJECTIVE

We aimed to determine the long-term yield of pancreatic cancer surveillance in hereditary predisposed high-risk individuals.

DESIGN

From 2006 to 2019, we prospectively enrolled asymptomatic individuals with an estimated 10% or greater lifetime risk of pancreatic ductal adenocarcinoma (PDAC) after obligatory evaluation by a clinical geneticist and genetic testing, and subjected them to annual surveillance with both endoscopic ultrasonography (EUS) and MRI/cholangiopancreatography (MRI/MRCP) at each visit.

RESULTS

366 individuals (201 mutation-negative familial pancreatic cancer (FPC) kindreds and 165 PDAC susceptibility gene mutation carriers; mean age 54 years, SD 9.9) were followed for 63 months on average (SD 43.2). Ten individuals developed PDAC, of which four presented with a symptomatic interval carcinoma and six underwent resection. The cumulative PDAC incidence was 9.3% in the mutation carriers and 0% in the FPC kindreds (p<0.001). Median PDAC survival was 18 months (range 1-32). Surgery was performed in 17 individuals (4.6%), whose pathology revealed 6 PDACs (3 T1N0M0), 7 low-grade precursor lesions, 2 neuroendocrine tumours <2 cm, 1 autoimmune pancreatitis and in 1 individual no abnormality. There was no surgery-related mortality. EUS detected more solid lesions than MRI/MRCP (100% vs 22%, p<0.001), but less cystic lesions (42% vs 83%, p<0.001).

CONCLUSION

The diagnostic yield of PDAC was substantial in established high-risk mutation carriers, but non-existent in the mutation-negative proven FPC kindreds. Nevertheless, timely identification of resectable lesions proved challenging despite the concurrent use of two imaging modalities, with EUS outperforming MRI/MRCP. Overall, surveillance by imaging yields suboptimal results with a clear need for more sensitive diagnostic markers, including biomarkers.

Long-term yield of pancreatic cancer surveillance in high-risk individuals

OBJECTIVE

We aimed to determine the long-term yield of pancreatic cancer surveillance in hereditary predisposed high-risk individuals.

DESIGN

From 2006 to 2019, we prospectively enrolled asymptomatic individuals with an estimated 10% or greater lifetime risk of pancreatic ductal adenocarcinoma (PDAC) after obligatory evaluation by a clinical geneticist and genetic testing, and subjected them to annual surveillance with both endoscopic ultrasonography (EUS) and MRI/cholangiopancreatography (MRI/MRCP) at each visit.

RESULTS

366 individuals (201 mutation-negative familial pancreatic cancer (FPC) kindreds and 165 PDAC susceptibility gene mutation carriers; mean age 54 years, SD 9.9) were followed for 63 months on average (SD 43.2). Ten individuals developed PDAC, of which four presented with a symptomatic interval carcinoma and six underwent resection. The cumulative PDAC incidence was 9.3% in the mutation carriers and 0% in the FPC kindreds (p<0.001). Median PDAC survival was 18 months (range 1-32). Surgery was performed in 17 individuals (4.6%), whose pathology revealed 6 PDACs (3 T1N0M0), 7 low-grade precursor lesions, 2 neuroendocrine tumours <2 cm, 1 autoimmune pancreatitis and in 1 individual no abnormality. There was no surgery-related mortality. EUS detected more solid lesions than MRI/MRCP (100% vs 22%, p<0.001), but less cystic lesions (42% vs 83%, p<0.001).

CONCLUSION

The diagnostic yield of PDAC was substantial in established high-risk mutation carriers, but non-existent in the mutation-negative proven FPC kindreds. Nevertheless, timely identification of resectable lesions proved challenging despite the concurrent use of two imaging modalities, with EUS outperforming MRI/MRCP. Overall, surveillance by imaging yields suboptimal results with a clear need for more sensitive diagnostic markers, including biomarkers.

Prospective colonoscopic study to investigate risk of colorectal neoplasms in first-degree relatives of patients with non-advanced adenomas

OBJECTIVE

The risk associated with a family history of non-advanced adenoma (non-AA) is unknown. We determined the prevalence of colorectal neoplasms in subjects who have a first-degree relative (FDR) with non-AA compared with subjects who do not have an FDR with adenomas.

DESIGN

In a blinded, cross-sectional study, consecutive subjects with newly diagnosed non-AA were identified from our colonoscopy database. 414 FDRs of subjects with non-AA (known as exposed FDRs; mean age 55.0±8.1 years) and 414 age and sex-matched FDRs of subjects with normal findings from colonoscopy (known as unexposed FDRs; mean age 55.2±7.8 years) underwent a colonoscopy from November 2015 to June 2018. One FDR per family was recruited. FDRs with a family history of colorectal cancer were excluded. The primary outcome was prevalence of advanced adenoma (AA). Secondary outcomes included prevalence of all adenomas and cancer.

RESULTS

The prevalence of AA was 3.9% in exposed FDRs and 2.4% in unexposed FDRs (matched OR (mOR)=1.67; 95% CI 0.72 to 3.91; p=0.238 adjusted for proband sex and proband age). Exposed FDRs had a higher prevalence of any adenomas (29.2% vs 18.6%; mOR=1.87; 95% CI 1.32 to 2.66; p<0.001) and non-AA (25.4% vs 16.2%; mOR=1.91; 95% CI 1.32 to 2.76; p=0.001). A higher proportion of exposed FDRs than unexposed FDRs (4.3% vs 2.2%; adjusted mOR=2.44; 95% CI 1.01 to 5.86; p=0.047) had multiple adenomas. No cancer was detected in both groups.

CONCLUSION

A positive family history of non-AA does not significantly increase the risk of clinically important colorectal neoplasia. The data support current guidelines which do not advocate earlier screening in individuals with a family history of non-AA.

TRIAL REGISTRATION NUMBER

NCT0252172.

The utility of Leventhal's model in the analysis of the psycho-behavioral implications of familial cancer - a literature review

INTRODUCTION

We aim to highlight the utility of this model in the analysis of the psycho-behavioral implications of family cancer, presenting the scientific literature that used Leventhal's model as the theoretical framework of approach.

MATERIAL AND METHODS

A systematic search was performed in six databases (EBSCO, ScienceDirect, PubMed Central, ProQuest, Scopus, and Web of Science) with empirical studies published between 2006 and 2015 in English with regard to the Common Sense Model of Self-Regulation (CSMR) and familial/hereditary cancer. The key words used were: illness representations, common sense model, self regulatory model, familial/hereditary/genetic cancer, genetic cancer counseling. The selection of studies followed the PRISMA-P guidelines (Moher et al., 2009; Shamseer et al., 2015), which suggest a three-stage procedure.

RESULTS

Individuals create their own cognitive and emotional representation of the disease when their health is threatened, being influenced by the presence of a family history of cancer, causing them to adopt or not a salutogenetic behavior. Disease representations, particularly the cognitive ones, can be predictors of responses to health threats that determine different health behaviors. Age, family history of cancer, and worrying about the disease are factors associated with undergoing screening. No consensus has been reached as to which factors act as predictors of compliance with cancer screening programs.

CONCLUSIONS

This model can generate interventions that are conceptually clear as well as useful in regulating the individuals' behaviors by reducing the risk of developing the disease and by managing as favorably as possible health and/or disease.

Advanced colonic neoplasia in the first degree relatives of colon cancer patients: A colonoscopy-based study

We aimed to determine the risk of advanced neoplasms among a cohort of asymptomatic first degree relatives (FDRs) of patients with sporadic colorectal cancer (CRC) compared with matched controls. Data for patients with a diagnosis of CRC made between September 2013 and August 2014 were obtained from a population-based cancer registry system in Tehran. Screening colonoscopies were done for 342 FDRs and the findings were compared to those from 342 age- and gender-matched healthy controls without a family history of CRC. We reported the association as conditional Odds Ratio (OR) using Mantel Hazel and Logistic regression. The prevalence of advanced neoplasia was 13.2% among FDRs and 3.8% in controls (matched OR [mOR], 4.0, 95% confidence interval [CI], 2.1 - 7.6; p < 0.001). In FDRs aged 40-49 years, the prevalence of advanced neoplasia was significantly higher than in their matched controls (mOR, 6.8, 95% CI, 1.5-31.4; p = 0.01). Family history of CRC in at least one FDR was the strongest predictor of advanced neoplasia (adjusted OR, 4.0, 95% CI: 2.1-7.6; p < 0.001). The age of the index case at diagnosis did not predict the presence of advanced colonic neoplasms in their FDRs. Our study indicates a high risk of advanced neoplasia in FDRs of CRC cases, where only eight colonoscopies are needed to detect one advanced neoplasia. Our data suggest that all FDRs, regardless of the age of CRC diagnosis in their index case, should be considered for a targeted early screening.

International Cancer of the Pancreas Screening (CAPS) Consortium summit on the management of patients with increased risk for familial pancreatic cancer

BACKGROUND

Screening individuals at increased risk for pancreatic cancer (PC) detects early, potentially curable, pancreatic neoplasia.

OBJECTIVE

To develop consortium statements on screening, surveillance and management of high-risk individuals with an inherited predisposition to PC.

METHODS

A 49-expert multidisciplinary international consortium met to discuss pancreatic screening and vote on statements. Consensus was considered reached if ≥ 75% agreed or disagreed.

RESULTS

There was excellent agreement that, to be successful, a screening programme should detect and treat T1N0M0 margin-negative PC and high-grade dysplastic precursor lesions (pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasm). It was agreed that the following were candidates for screening: first-degree relatives (FDRs) of patients with PC from a familial PC kindred with at least two affected FDRs; patients with Peutz-Jeghers syndrome; and p16, BRCA2 and hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥ 1 affected FDR. Consensus was not reached for the age to initiate screening or stop surveillance. It was agreed that initial screening should include endoscopic ultrasonography (EUS) and/or MRI/magnetic resonance cholangiopancreatography not CT or endoscopic retrograde cholangiopancreatography. There was no consensus on the need for EUS fine-needle aspiration to evaluate cysts. There was disagreement on optimal screening modalities and intervals for follow-up imaging. When surgery is recommended it should be performed at a high-volume centre. There was great disagreement as to which screening abnormalities were of sufficient concern to for surgery to be recommended.

CONCLUSIONS

Screening is recommended for high-risk individuals, but more evidence is needed, particularly for how to manage patients with detected lesions. Screening and subsequent management should take place at high-volume centres with multidisciplinary teams, preferably within research protocols.