2. Update on genetic testing for hereditary breast cancer syndromes Kristin DePrince Mattie, M.S. Licensed / Certified Genetic Counselor William G. Rohrer Cancer Genetics Program

3. Objectives Describe current approaches to genetic testing for hereditary cancer syndromes. Identify potential benefits and limitations of the multi-gene panel testing approach for hereditary cancer syndromes. Focus on breast cancer

4. Breast cancer risk factors Non-modifiable / Intrinsic Female gender Increasing age Personal history of breast cancer Family history of breast cancer Hereditary cancer syndrome Increased breast density Race / ethnicity Breast biopsy pathology http://www.cancer.net/cancer-types/breast-cancer/risk-factors Modifiable / Extrinsic Radiation to the chest Multiple biopsies Estrogen and progesterone exposure Hormone replacement therapy Birth control pill use Lifestyle factors

5. Image from http://publications.nigms.nih.gov/thenewgenetics/chapter1.htmlhttp://publications.nigms.nih.gov/thenewgenetics/chapter1.html All cancers are genetic, but most are NOT hereditary. Sporadic (~70%) –environmental exposures / random chance Familial (~20%) –shared environmental exposures –similar genetic background Hereditary (~10%) –inherited genetic mutation » increased risk

6. BRCA1/BRCA2 mutations increase the risk for multiple cancers: female and male breast, ovary, prostate, pancreas, skin (melanoma), gall bladder, bile duct, stomach, fallopian tube, etc. Causes of breast cancer

7. Hereditary cancer syndrome concepts Inheritance – usually autosomal dominant Penetrance – high / moderate / low Variable expression Age @ cancer dx relatively younger – usually adult onset Gender specific cancer risks Germline genetic testing – not always available – rely on clinical diagnosis as needed – not always informative for a family Image from Genetics Home Reference: https://ghr.nlm.nih.gov/handbook/inheritance?show=all https://ghr.nlm.nih.gov/handbook/inheritance?show=all http://www.cancer.gov/types/breast/hp/breast- ovarian-genetics-pdq

8. Breast @57 Breast @63 Breast @71 80 Breast @37 Bilateral Breast @41 & 52 Breast @43 Sporadic FamilialHereditary

9. NCCN Guidelines Version 2.2016: Guidelines for Detection, Prevention and Risk Reduction: Genetic/Familial High-Risk Assessment: Breast and Ovarian. www.nccn.orgwww.nccn.org

10. Select NCCN evaluation/referral criteria Breast cancer HBC syndrome in family Early age at dx (≤50y) Triple negative dx ≤ 60y ≥2 primary breast cancers Male gender Ashkenazi Jewish ancestry Otherwise depends on strength of family history Ovarian cancer Epithelial v. non-epithelial Fallopian & 1 ˚ peritoneal Family history only 1 st or 2 nd degree relative w/ breast ca. dx ≤ 45y Close (1 st, 2 nd, 3 rd degree) relative meeting certain criteria, such as: – Ovarian cancer – Male breast cancer – HBC syndrome – Breast cancer depending on strength of family history NCCN Guidelines Version 2.2016: Guidelines for Detection, Prevention and Risk Reduction: Genetic/Familial High-Risk Assessment: Breast and Ovarian. www.nccn.orgwww.nccn.org

11. Evolution of hereditary breast cancer (HBC) genetic testing Who performs the testing (commercially)? – Before June 2013 BRCA1/BRCA2 only via Myriad Genetic Laboratories Other HBC genes by other labs as indicated – June 2013 - present Any lab can test BRCA1/BRCA2 or any other HBC gene Which genes are tested? – Before 2012 Usually just BRCA1/BRCA2, Other HBC genes (such as CDH1, PTEN, TP53) as indicated by personal / family history – 2012 – present Next generation sequencing Multi-gene panels vs. single syndrome testing

12. Current genetic testing practices Syndrome- or gene-specific testing Typically single gene or single syndrome testing – i.e. BRCA1 & BRCA2 genes only; PTEN only; CDH1 only; etc. Single-site testing for known familial mutation Multi-gene testing (“panel testing”) Variable number of genes tested Pan-cancer versus single cancer gene panels – Hereditary breast / colon / uterine / ovarian / pancreatic / skin / etc. cancer gene panel – Hereditary breast cancer gene panel Genes can be selected based on level of known cancer risk – High / moderate / “increased” risk levels http://www.cancer.gov/about-cancer/causes-prevention/genetics/risk-assessment-pdq#link/_1320

13. High risk ≥30% Moderate risk <30% “Increased risk” genes still need further study to better define risks Hereditary mutations in other genes may also increase breast cancer risk Mutations in these genes may also increase the risk for other cancer types http://www.cancer.gov/types/breast/ hp/breast-ovarian-genetics-pdq http://www.cancer.gov/types/breast/ hp/breast-ovarian-genetics-pdq Image used with permission from Ambry Genetics http://www.ambrygen.com/sites/default/files/web/cancer/brochures/hereditary _breast_cancer_clinician_brochure.pdf http://www.ambrygen.com/sites/default/files/web/cancer/brochures/hereditary _breast_cancer_clinician_brochure.pdf Use of this image does not imply endorsement.

14. Considerations regarding multi-gene testing Increased mutation detection rate Lower chance of “uninformative” negative results for a family Often more cost- & time- efficient May find a mutation in more than one gene Unexpected results Limited data re: cancer risks for some genes Lack of standard medical guidelines for some genes Variants of unknown significance Insurance companies consider multi-gene panels “investigational” Unexpected results Potential advantagesPotential disadvantages NCCN Guidelines Version 2.2016: Guidelines for Detection, Prevention and Risk Reduction: Genetic/Familial High-Risk Assessment: Breast and Ovarian. www.nccn.orgwww.nccn.org

15. Genetic test result classifications No Mutation (Negative ) VUS- Likely Benign Uncertain Significance (VUS) VUS- Likely Pathogenic Pathogenic (Positive) Medical management based on personal and family history. Uncertain results do not influence recommendations for care. Medical management based on cancer risks linked with gene where mutation found. Slide from COGENT study @ University of Pennsylvania http://rt5.cceb.med.upenn.edu/public/cogent/APPENDIX_F_Modified_VAP_for_all_scenarios_20141210.pdf http://rt5.cceb.med.upenn.edu/public/cogent/APPENDIX_F_Modified_VAP_for_all_scenarios_20141210.pdf

16. NCCN Guidelines Version 2.2016: Guidelines for Detection, Prevention and Risk Reduction: Genetic/Familial High-Risk Assessment: Breast and Ovarian. www.nccn.orgwww.nccn.org

17. Frequency of Mutations in Individuals with Breast Cancer Referred for BRCA1 and BRCA2 Testing Using Next- Generation Sequencing With a 25-Gene Panel (N. Tung et al., Cancer 2015;121:25-33.) Cohort 1: No prior BRCA testing n=1781 1750 women, 22 men, 9 gender unspecified no Ashkenazi Jewish patients 241 (13.5% of total) mutation (+) (includes 7 men) – 162 (67%; 9% of total) BRCA1/BRCA2 (+) – 76 (32%; 4.3% of total) at least 1 mutation in a non- BRCA gene – 3 (1%) with mutations in BRCA2 and another gene (ATM, CHEK2 or NBN) Cohort 2: Prior BRCA negative result n=377 374 women, 3 men 94 reported AJ ancestry 14 (3.7%) mutation (+) – Similar to 4.3% (+) rate in Cohort 1 (76/1781) – None male – None with AJ ancestry – one woman with mutations in both BARD1 and ATM

18. Frequency of Mutations in Individuals with Breast Cancer Referred for BRCA1 and BRCA2 Testing Using Next- Generation Sequencing With a 25-Gene Panel (N. Tung et al., Cancer 2015;121:25-33.) Genes tested: BRCA1, BRCA2, TP53, CDH1, PTEN, ATM, CHEK2, STK11, RAD51C, PALB2, BARD1, BRIP1, NBN, MLH1, MSH2, MSH6, PMS2, EPCAM, RAD51D, APC, MUTYH, CDKN2A, SMAD4, CDK4, BMPR1A Most frequent non- BRCA1/BRCA2 mutations: CHEK2, ATM, PALB2 The frequency of mutations in genes other than BRCA1/BRCA2 was lower in Ashkenazi Jews compared with non-Ashkenazi individuals 41% of individuals (both cohorts) had at least 1 VUS

19. CLINICAL CASES (2)

20. Breast @60 Maternal Ancestry: European, non-Jewish PALB2: breast, pancreas, ?ovarian, ?male breast cancers 70 adopted Breast @36 (triple negative) s/p BL mastectomy Genetic testing 2006 67 43 3 BL Breast @42 & 55 45 Single site testing: PALB2+ 64 died @69 6572 2 2 BRCA1/BRCA2: negative Genetic testing 2015 32 gene panel : PALB2+

21. Ancestry: Maternal Black Paternal Caucasian CDH1: diffuse gastric and lobular breast cancers, colon cancer in some families Prostate @67 Breast @49 (lobular) s/p BL mastectomy Genetic testing 2016 70 52 Died @65 6461 2 9 3 2 5046454449 Lung HBC 14 gene panel : CDH1+

22. Cancer Genetics Program Team Oncologists Generosa Grana, MD Program Director Alexandre Hageboutros, MD Polina Khrizman, MD Marjan Koch, MD Pallav Mehta, MD Jamin Morrison, MD Kanu Sharan, MD Robert Somer, MD Preeti Sudheendra, MD Genetic Counselors Janice Horte, MS Brooke Levenseller Levin, MS Kristin DePrince Mattie, MS Jennifer Stone, MS Program Staff Manager Evelyn Robles-Rodriguez, RN, MSN, APN, AOCN Medical Assistants Brandi Ford, CMA Myra Salcedo, CMA Administrative Coordinator Vicki Kay Atkinson

23. Genetic evaluation practice locations Patients may call 855-MDA-COOPER (855-632-2667) for scheduling 2 Cooper Plaza, 400 Haddon Ave., Camden 900 Centennial Blvd., Voorhees