Pretest Video Education Versus Genetic Counseling for Patients With Prostate Cancer: ProGen, A Multisite Randomized Controlled Trial

PURPOSE

Germline genetic testing (GT) is recommended for men with prostate cancer (PC), but testing through traditional models is limited. The ProGen study examined a novel model aimed at providing access to GT while promoting education and informed consent.

METHODS

Men with potentially lethal PC (metastatic, localized with a Gleason score of ≥8, persistent prostate-specific antigen after local therapy), diagnosis age ≤55 years, previous malignancy, and family history suggestive of a pathogenic variant (PV) and/or at oncologist's discretion were randomly assigned 3:1 to video education (VE) or in-person genetic counseling (GC). Participants had 67 genes analyzed (Ambry), with results disclosed via telephone by a genetic counselor. Outcomes included GT consent, GT completion, PV prevalence, and survey measures of satisfaction, psychological impact, genetics knowledge, and family communication. Two-sided Fisher's exact tests were used for between-arm comparisons.

RESULTS

Over a 2-year period, 662 participants at three sites were randomly assigned and pretest VE (n = 498) or GC (n = 164) was completed by 604 participants (VE, 93.1%; GC, 88.8%), of whom 596 participants (VE, 98.9%; GC, 97.9%) consented to GT and 591 participants completed GT (VE, 99.3%; GC, 98.6%). These differences were not statistically significant although subtle differences in satisfaction and psychological impact were. Notably, 84 PVs were identified in 78 participants (13.2%), with BRCA1/2 PV comprising 32% of participants with a positive result (BRCA2 n = 21, BRCA1 n = 4).

CONCLUSION

Both VE and traditional GC yielded high GT uptake without significant differences in outcome measures of completion, GT uptake, genetics knowledge, and family communication. The increased demand for GT with limited genetics resources supports consideration of pretest VE for patients with PC.

Impact of Genetic Counseling on Patient-Reported Electronic Cancer Family History Collection

BACKGROUND

Cancer family history is a vital part of cancer genetic counseling (GC) and genetic testing (GT), but increasing indications for germline cancer GT necessitate less labor-intensive models of collection. We evaluated the impact of GC on patient pedigrees generated by an electronic cancer family history questionnaire (eCFHQ).

METHODS

An Institutional Review Board-approved review of pedigrees collected through an eCFHQ was conducted. Paired pre-GC and post-GC pedigrees (n=1,113 each group) were analyzed independently by cancer genetic counselors for changes in patient-reported clinical history and to determine whether the pedigrees met NCCN GT criteria. Discrepancy in meeting NCCN GT criteria between pre-GC and post-GC pedigrees was the outcome variable of logistic regressions, with patient and family history characteristics as covariates.

RESULTS

Overall, 780 (70%) patients had cancer (affected), 869 (78%) were female, and the median age was 57 years (interquartile range, 45-66 years; range, 21-91 years). Of the 1,113 pairs of pre-GC and post-GC pedigrees analyzed, 85 (8%) were blank, 933 (84%) were not discrepant, and 95 (9%) were discrepant in meeting any NCCN GT criteria. Of the discrepant pedigrees, n=79 (83%) became eligible for testing by at least one of the NCCN GT criteria after GC. Patients with discrepant pedigrees were more likely to report no or unknown history of GT (odds ratio [OR], 4.54; 95% CI, 1.66-18.70; P=.01, and OR, 18.47; 95% CI, 5.04-88.73; P<.0001, respectively) and belonged to racially and/or ethnically underrepresented groups (OR, 1.91; 95% CI, 1.08-3.25; P=.02).

CONCLUSIONS

For most patients (84%), a standalone eCFHQ was sufficient to determine whether NCCN GT criteria were met. More research is needed on the performance of the eCFHQ in diverse patient populations.

Clinical Impact of Pathogenic Variants in DNA Damage Repair Genes beyond BRCA1 and BRCA2 in Breast and Ovarian Cancer Patients

Simple Summary

The clinical utility of positive findings in DNA damage-repair (DDR) genes BRCA1 and BRCA2 for the treatment of patients with breast or ovarian cancer is well established. However, multigene panel genetic testing for patients with breast and ovarian cancer now commonly includes DDR genes in addition to BRCA1 and BRCA2, a number of which are considered moderate or low-risk genes. This study aimed to describe the clinical utility of positive results from genetic testing when the findings were in one of these other DDR genes. In a group of 101 women with positive findings in a cancer gene other than BRCA1 or BRCA2 (often in a DDR gene), nearly three-fifths (58%) had a clinical recommendation made based on their positive genetic test result and two-thirds (65%) had the clinician make recommendations for family members that may be at risk. This real-world data provides evidence that positive findings from genetic testing for moderate and low-risk genes, including DDR genes, can have clinical utility and can impact a patient’s clinical management.

Abstract

Consensus guidelines for hereditary breast and ovarian cancer include management recommendations for pathogenic/likely pathogenic (P/LP) variants in ATM, CHEK2, PALB2, and other DNA damage repair (DDR) genes beyond BRCA1 or BRCA2. We report on clinical management decisions across three academic medical centers resulting from P/LP findings in DDR genes in breast/ovarian cancer patients. Among 2184 patients, 156 (7.1%) carried a P/LP variant in a DDR gene. Clinical follow-up information was available for 101/156 (64.7%) patients. Genetic test result-based management recommendations were made for 57.8% (n = 59) of patients and for 64.7% (n = 66) of patients’ family members. Most recommendations were made for moderate-to-high risk genes and were consistent with guidelines. Sixty-six percent of patients (n = 39/59) implemented recommendations. This study suggests that P/LP variants in DDR genes beyond BRCA1 and BRCA2 can change clinical management recommendations for patients and their family members, facilitate identification of new at-risk carriers, and impact treatment decisions. Additional efforts are needed to improve the implementation rates of genetic-testing-based management recommendations for patients and their family members.

A Case of Microsatellite Instability-High Colon Cancer in a Young Woman With Familial Adenomatous Polyposis

Two major molecular pathways of colorectal carcinogenesis, chromosomal instability (CIN) and microsatellite instability (MSI), are considered to be mutually exclusive. Distinguishing CIN from MSI-high tumors has considerable therapeutic implications, because patients with MSI-high tumors can derive considerable benefit from immune checkpoint inhibitors, and tumors that evolved through the CIN pathway do not respond to these agents. Familial adenomatous polyposis (FAP) is a genetic syndrome that is defined by a mutation in the APC gene and is thought to lead to carcinogenesis through the CIN pathway. Here, we report a case of a young woman with FAP who was treated for medulloblastoma as a child and developed advanced MSI-high colon cancer as a young adult. Her response to second-line immunotherapy enabled resection of her colon cancer, and she is free of disease >10 months after surgery. This case highlights the potential for overlap between the CIN and MSI carcinogenic pathways and associated therapeutic implications.

Embedding a genetic counselor into oncology clinics improves testing rates and timeliness for women with ovarian cancer

OBJECTIVE

Germline genetic testing is crucial to the care of ovarian cancer patients, and as part of the guideline-based care for ovarian cancer patient's adherence to this recommendation has been low. We sought to determine whether embedding a genetic counselor (GC) within a medical and gynecologic oncology clinic would increase testing rates and improve the timeliness of testing.

METHODS

Prospective cohort study of 358 ovarian cancer patients seen by medical and gynecologic oncologists between 2013 and 2015. Rates of referrals, completion of counseling, and genetic testing and timeliness of counseling were abstracted before and after a GC was embedded in the clinic in 2014. An additional year of data (2015) was collected to evaluate sustainability of the intervention.

RESULTS

Between 2013 and 2015, 88-92% of women were referred for genetic testing, but in 2013 only 66% completed counseling and 61% were tested. After a GC was embedded in the clinic in 2014, more than 80% of referred women completed counseling and germline genetic testing. Time to genetic counseling also decreased from a median of 107 to 40 days, irrespective of age and cancer family history (p < 0.01).

CONCLUSIONS

Embedding a GC into the workflow for ovarian cancer patients is an effective way of improving access to genetic counseling, testing rates, and the timeliness of testing.

A randomized controlled trial of video-education or in-person genetic counseling for men with prostate cancer (ProGen)

1507

Background: Approximately 10% of men with advanced prostate cancer (PC) have pathogenic/likely pathogenic variants (PV) in cancer susceptibility genes and their identification may lead to targeted therapy. Genetic testing (GT) can also guide cancer surveillance and prevention for family members. While GT is recommended for men with potentially lethal PC, traditional testing models are strained, and access limited. The ProGen study examined a novel pretest model aimed at providing access to GT while promoting informed consent. Methods: Inclusion criteria were: potentially lethal PC (metastatic, localized with Gleason score ≥8, rising/persistent PSA after local therapy), diagnosis age ≤ 55 years, prior malignancy, family history suggestive of a PV and/or at oncologist’s discretion. Consented subjects from 3 sites were randomized 3:1 to video education (VE) or in-person genetic counseling (GC). Subjects who consented to GT had 67 genes analyzed (Ambry, USA) with results disclosed by telephone by a genetic counselor. Outcomes included GT uptake, PV prevalence, and survey measures of satisfaction, distress, genetics knowledge, family communication, and impact on cancer care (obtained at the time of intervention, and at 1, 4, and 12 months after result disclosure). Two-sided Fischer exact tests were used for between-arm comparisons. Results: Over a 2-year period: 662 subjects were randomized, VE or GC were completed by 604 subjects (VE: 93.1%, GC: 88.8%) of whom 596 subjects (VE:98.9%, GC:97.9%) consented to GT. To date, 591 subjects have completed GT (VE: 99.3%, GC: 98.6%). At the time of intervention, most subjects agreed or strongly agreed that their assigned arm was useful (VE: 95%, GC: 88%). Differences were not statistically significant. Notably, 84 PV were identified in 78 subjects (13.2%), with BRCA1/2 PV accounting for 32% of subjects with a positive result ( BRCA2:21, BRCA1:4). Conclusions: In this randomized trial, both novel VE and traditional GC yielded high GT uptake without significant differences in outcome measures of acceptability and satisfaction. VE enabled access to critical GT results while maintaining the core tenants of informed consent. PV were found in 13.2% of subjects, 32% of whom had BRCA1/2 PV. Analysis of collected survey data to inform strengths and limitations of VE as compared with pretest GC will be presented. Clinical trial information: NCT03328091.

Genetic counseling processes and outcomes among prostate cancer patients (ProGen)

TPS343

Background: Prostate cancer (PC) is among the leading causes of cancer mortality in males. Recent studies found 8-12% of advanced PC cases may be hereditary. Germline mutations have been reported in BRCA1/2, other DNA repair genes including ATM, CHEK2, PALB2 and DNA mismatch repair genes. Genetic testing can inform treatment decisions including drug targeting, such as PARP inhibitors for men with BRCA mutations, and checkpoint inhibitors for those with pathogenic mutations in mismatch repair genes2. Discovering a pathogenic mutation associated with increased cancer risk also prompts dissemination of this information to family, where subsequent testing can lead to risk stratification and impactful opportunities for cancer screening and prevention. It is critical that men with high risk and potentially lethal prostate cancer routinely be offered genetic testing as a component of their cancer care. Genetic counseling services are limited, and more efficient services are needed. Methods: We are investigating video education prior to genetic testing compared with in-person pretest counseling with a licensed genetic counselor (GC). ProGen is an ongoing randomized trial evaluating two distinct models of cancer genetics service delivery in 450 PC cases over a two-year period. The study is conducted in collaboration with Ambry Genetics utilizing a 67-gene cancer panel. The primary aim is analysis of the proportion and type of germline mutations identified. Secondary aims include testing uptake by arm, evaluation of distress, knowledge, satisfaction with testing services, family communication, and impact on cancer care. Results are communicated by telephone with a GC. Inclusion criteria are: potentially lethal PC (metastatic, localized with Gleason score ≥8, rising/persistent PSA after local therapy), early diagnosis (≤ 55 years), prior malignancy, and/or family history potentially indicating a hereditary cancer risk. Enrollment is 74% completed at a single institution. (NCT03328091). 1 Pritchard CC, et al. Inherited DNA‐repair gene mutations in men with metastatic prostate cancer. NEJM. 2016;375:443 2 Mateo J, et al. DNA-Repair Defects and Olaparib in Metastatic Prostate Cancer. NEJM . 2015;373(18):1697-1708 Clinical trial information: NCT03328091.

Abstract P4-03-02: Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort

Background: MGPT for hereditary cancer syndromes allows for concurrent analysis of genes associated with many different cancer types. This may lead to the identification of unexpected mutations in genes with no BC link. The objective of this study was to examine the landscape of pathogenic mutations in a BC cohort who underwent MGPT, to assess if there was clinical suspicion for identified mutations and if the results would affect subjects' medical management.

Methods: Retrospective review of subjects with BC seen at a single institution who underwent MGPT from 1/1/15- 5/31/18 was conducted. MGPT was defined as testing of more than the 9 genes associated with BC (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, TP53). Deidentified pedigrees were analyzed by genetic counselors to determine whether there was clinical suspicion of the presence of the mutations using national testing guidelines or clinical diagnostic criteria.

Results: Among 3044 subjects, 365 (12%) were found to have one pathogenic mutation in at least one cancer susceptibility gene. Subjects with mutations in APC I307K, moderate-penetrance BC genes (NBN, RAD50, BARD1), and MUTYH were excluded from further analysis. We identified 52 pathogenic mutations in genes not typically associated with risk for BC in 51 (2%) subjects (table 1). There was clinical suspicion for the identified mutation in 17 (33%).

Table 1:Non-BC gene mutation landscape Number of MutationsClinical Suspicion (%)Lynch syndrome117 (64%)MLH110MSH221MSH632PMS254Ovarian181 (6%)BRIP1*111RAD51C40RAD51D30SHDx62 (33%)SDHA*30SDHC*32Other156 (40%)FH10HOXB13*32MITF32NF142VHL40CDKN2A21 (50%)Total5217 (33%)*Contains individuals that also have a mutation in a BC susceptibility gene

Conclusion: Of 3044 BC patients who underwent MGPT, 2% were found to have a pathogenic gene mutation that would have been missed by a smaller BC gene panel. Medical or surgical management would be affected by the MGPT result in 86% of subjects. Only 6% of subjects with genetic risk for ovarian cancer had a family history of this disease. The single FH and 3 of 4 VHL mutations are only associated with disease in the biallelic state; these findings do not affect the subjects' care, but have implications for reproductive risk. The HOXB13 mutations were found in female subjects only, but would have implications for their male relatives. NF1 mutations are associated with BC risk, but were included in this analysis due to a historically distinct clinical phenotype. Only 50% of NF1+ subjects had a clinical diagnosis or family history of NF1. In all cases, cascade testing was offered to at-risk family members, allowing for cancer and reproductive risk stratification and management. This study demonstrates how comprehensive MGPT can provide a more complete and personalized cancer risk assessment for BC patients and their families.

Citation Format: Culver S, Kipnis L, Stokes S, Bychkovsky B, Scheib R, Rana H, Garber J. Casting a wide net: Finding actionable results in non-breast cancer (BC) genes on multi-gene panel testing (MGPT) in a BC cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-03-02.

Abstract P3-03-01: Clinical utility of finding pathogenic mutations beyond BRCA1/2 in breast cancer patients

Background

The clinical utility of germline genetic testing for BRCA1 and BRCA2 has long been established. However, management recommendations for pathogenic variants in other genes, typically included in multigene panels, have only recently been included in consensus guidelines for HBOC. The clinician actions implemented for findings in these genes, and patient follow-up, are not yet well studied. We report interim results from a multi-site study of clinical actions undertaken in patients presenting with HBOC and carrying a pathogenic germline mutation in cancer risk genes other than BRCA1/2.

Methods

We retrospectively examined a cohort of patients with a personal history of HBOC who had been referred for hereditary cancer multigene testing from three major academic medical centers. For patients with pathogenic findings in a non-BRCA1/2 cancer risk gene, ordering clinicians completed a short case report form describing the clinical actions taken in response to the genetic test result, and patient follow-up. Some patients were lost to follow-up and answers of “unknown” were permitted. Genes with positive findings included CHEK2, PALB2, ATM, MUTYH, RAD51C, TP53, MSH6, RAD50, APC, BARD1, BRIP1, MSH2, NF1, NBN, PMS2, and PTEN. Case report forms were available for 77 patients as of our cut off date, and these data were de-identified and summarized for this interim report. Additional cases continue to accrue in this ongoing study.

Results

In 57% (44/77) of cases, clinicians reported that counseling and/or clinical management recommendations were changed in response to the genetic test findings. Management changes included modification of imaging surveillance (38%), considered or recommended surgical prophylaxis (12%), modified surgical plan for an existing malignancy (5%), and for one patient each: inclusion in a research trial for PARP inhibitors, modification of colonoscopy schedule, and screening for cancers other than existing malignancy. Clinicians indicated that genetic test results changed management in 48% of patients, did not change management in 29%, and had unknown impact for 23%.

Clinicians also reported that counseling and/or management for the patients' family members was changed in 67% (52/77) of cases, including family variant testing. 27% (21/77) of the patient families had cascade genetic testing, and one or more new carriers were identified in 47% (10) of the tested families. In 58% of cases, the impact of management recommendations on family members was unknown as of the case report date.

Conclusions

Pathogenic variants in non-BRCA genes are present in about 3-11% of patients with a history of HBOC. This study suggests that genetic test results in cancer genes beyond BRCA1/2 changed clinical management for a majority of patients and their family members, led to identification of new carriers, and directly impacted treatment decisions. In almost half of these patients, genetic test results impacted their health outcome, including those reported to be disease free after undergoing interventional or prophylactic surgery informed by their genetic variant. More research is needed to improve the implementation of genetic testing based management recommendations for patients and their family members.

Citation Format: Esplin ED, Michalski S, Yang S, Hampel H, Jeter J, Sweet K, Pilarski R, Pearlman R, Shane K, Brock P, Westman J, Chittenden A, Stopfer J, Schneider K, Sacca R, Stickevers S, Kipnis L, Koeller D, Gaonkar S, Sotelo J, Vaccari E, Cochrane S, Champine M, Espinel W, Lincoln SE, Nussbaum RL. Clinical utility of finding pathogenic mutations beyond BRCA1/2 in breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-03-01.