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Kim M, Hayek J, Acker C, An A, Zhang P, Gorelick C, Kanis MJ. No Racial Disparities Observed Using Point-of-Care Genetic Counseling and Testing for Endometrial and Ovarian Cancer in a Diverse Patient Population: A Retrospective Cohort Study. Cancers (Basel) 2024; 16:1598. [PMID: 38672679 PMCID: PMC11049633 DOI: 10.3390/cancers16081598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/14/2024] [Accepted: 04/20/2024] [Indexed: 04/28/2024] Open
Abstract
We investigated genetic counseling and testing rates for patients with gynecologic malignancy at a tertiary care center with a large minority population. Our retrospective cohort included newly diagnosed epithelial ovarian, fallopian tube, peritoneal, or endometrial cancer patients between January 2014 and June 2022. For endometrial cancer, 373 patients were identified. A total of 207 (55%) patients were screened using mismatch repair immunohistochemistry (MMR IHC). A total of 82 (40%) had MMR deficiencies on IHC. Of these, 63 (77%) received genetic counseling. A total of 62 (98%) underwent genetic testing, and ultimately, 7 (11%) were diagnosed with Lynch syndrome (LS). The overall rate of LS was 1.9%. MMR IHC testing increased steadily, reaching 100% in 2022. For ovarian cancer, 144 patients were identified. A total of 104 (72%) patients received genetic counseling, and 99 (95%) underwent genetic testing. Rates were not influenced by race, ethnicity, insurance type, or family history of cancer. They were significantly different by cancer stage (p < 0.01). The proportion of patients who received genetic counseling increased from 47% in 2015 to 100% in 2022 (p < 0.01). Most counseling was performed by a gynecologic oncologist (93%) as opposed to a genetic counselor (6.7%). Overall, 12 (8.3%) patients were BRCA+. High rates of counseling and testing were observed with few disparities.
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Affiliation(s)
- Michael Kim
- New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
| | - Judy Hayek
- Division of Gynecologic Oncology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | | | - Anjile An
- Weill Cornell Medicine, New York, NY 10065, USA
| | - Peilin Zhang
- New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
| | | | - Margaux J. Kanis
- New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
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Levine R, Kahn RM, Perez L, Brewer J, Ratner S, Li X, Yeoshoua E, Frey MK. Cascade genetic testing for hereditary cancer syndromes: a review of barriers and breakthroughs. Fam Cancer 2024:10.1007/s10689-024-00373-4. [PMID: 38530571 DOI: 10.1007/s10689-024-00373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/09/2024] [Indexed: 03/28/2024]
Abstract
Germline genetic sequencing is now at the forefront of cancer treatment and preventative medicine. Cascade genetic testing, or the testing of at-risk relatives, is extremely promising as it offers genetic testing and potentially life-saving risk-reduction strategies to a population exponentially enriched for the risk of carrying a cancer-associated pathogenic variant. However, many relatives do not complete cascade testing due to barriers that span individual, relationship, healthcare community, and societal/policy domains. We have reviewed the published research on cascade testing. Our aim is to evaluate barriers to cascade genetic testing for hereditary cancer syndromes and explore strategies to mitigate these barriers, with the goal of promoting increased uptake of cascade genetic testing.
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Affiliation(s)
- Rachel Levine
- Department of Obstetrics and Gynecology, HCA Florida Brandon, Brandon, FL, USA.
| | - Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luiza Perez
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Jesse Brewer
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Samantha Ratner
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Xuan Li
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa K Frey
- Division of Gynecologic Oncology, Weill Cornell Medicine, New York, NY, USA
- Genetics and Personalized Cancer Prevention Program, Weill Cornell Medicine, New York, NY, USA
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3
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Gressel GM, Frey MK, Norquist B, Senter L, Blank SV, Urban RR. Germline and somatic testing for ovarian Cancer: An SGO clinical practice statement. Gynecol Oncol 2024; 181:170-178. [PMID: 38215513 DOI: 10.1016/j.ygyno.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/14/2024]
Abstract
Germline and somatic genetic testing have become critical components of care for people with ovarian cancer. The identification of germline and somatic pathogenic variants as well as homologous recombination deficiency can contribute to the prediction of treatment response, prognostic outcome, and suitability for targeted agents (e.g. poly (ADP-ribose) polymerase (PARP) inhibitors). Furthermore, identifying germline pathogenic variants can prompt cascade genetic testing for at-risk relatives. Despite the clinical benefits and consensus recommendations from several organizations calling for universal genetic testing in ovarian cancer, only about one third of patients complete germline or somatic genetic testing. The members of the Society of Gynecologic Oncology (SGO) Clinical Practice Committee have composed this statement to provide an overview of germline and somatic genetic testing for patients with epithelial ovarian cancer, focusing on available testing modalities and options for care delivery.
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Affiliation(s)
- G M Gressel
- Corewell Health Cancer Center, Division of Gynecologic Oncology, Michigan State University- College of Human Medicine, United States.
| | - M K Frey
- Weill Cornell Medicine, Division of Gynecologic Oncology, United States
| | - B Norquist
- University of Washington School of Medicine, Division of Gynecologic Oncology, United States
| | - L Senter
- The Ohio State University, Comprehensive Cancer Center,United States
| | - S V Blank
- Icahn School of Medicine at Mount Sinai, United States
| | - R R Urban
- University of Washington School of Medicine, Division of Gynecologic Oncology, United States
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Ratnaparkhi R, Javellana M, Jewell A, Spoozak L. Evaluation of Homologous Recombination Deficiency in Ovarian Cancer. Curr Treat Options Oncol 2024; 25:237-260. [PMID: 38300479 DOI: 10.1007/s11864-024-01176-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/02/2024]
Abstract
OPINION STATEMENT Homologous recombination deficiency (HRD) is an important biomarker guiding selection of ovarian cancer patients who will derive the most benefit from poly(ADP-ribose) polymerase inhibitors (PARPi). HRD prevents cells from repairing double-stranded DNA damage with high fidelity, PARPis limit single-stranded repair, and together these deficits induce synthetic lethality. Germline or somatic BRCA mutations represent the narrowest definition of HRD, but do not reflect all patients who will have a durable PARPi response. HRD can also be defined by its downstream consequences, which are measured by different metrics depending on the test used. Ideally, all patients will undergo genetic counseling and germline testing shortly after diagnosis and have somatic testing sent once an adequate tumor sample is available. Should barriers to one test be higher, pursuing germline testing with reflex to somatic testing for BRCA wildtype patients or somatic testing first strategies are both evidence-based. Ultimately both tests offer complementary information, germline testing should be pursued for any patient with a history of ovarian cancer, and somatic testing is valuable at recurrence if not performed in the upfront setting. There is a paucity of data to suggest superiority of one germline or somatic assay; therefore, selection should optimize turnaround time, cost to patients, preferred result format, and logistical burden. Each clinic should implement a standard testing strategy for all ovarian cancer patients that ensures HRD status is known at the time of upfront chemotherapy completion to facilitate comprehensive counseling about anticipated maintenance PARPi benefit.
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Affiliation(s)
- Rubina Ratnaparkhi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Melissa Javellana
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrea Jewell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lori Spoozak
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
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Cerbon D, Taylor D, Barreto-Coelho P, Rodriguez E, Schlumbrecht M, Hurley J, George SHL. The Genetic Paradigm of Hereditary Breast and Ovarian Cancer (HBOC) in the Afro-Caribbean Population. Crit Rev Oncog 2024; 29:99-112. [PMID: 38683157 DOI: 10.1615/critrevoncog.2024051599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Differences in tumor biology and genetic predisposition have been suggested as factors influencing overall survival and increased mortality in Black breast and ovarian cancer patients. Therefore, it is key to evaluate genetic susceptibilities in Afro-Caribbean patients because the black population in the US is not homogeneous. Identifying a high incidence of hereditary breast and ovarian cancer (HBOC) in Afro-Caribbean countries can lead to understanding the pattern of inherited traits in US-Caribbean immigrants and their subsequent generations. The paucity of projects studying the genetic landscape in these populations makes it difficult to design studies aimed at optimizing screening and prophylaxis strategies, which in turn, improve survival and mortality rates. This scoping review identifies and categorizes current research on the genetic paradigm of HBOC in the Afro-Caribbean population. We performed an evaluation of the evidence and generated a summary of findings according to preferred reporting items for systematic review and meta-analysis (PRISMA) Extension for Scoping Reviews guidelines. We included articles that assessed the incidence and prevalence of pathologic germline mutations and experience/barriers for genetic testing in Afro-Caribbean Countries and US-Caribbean patients. Our results highlight countries where genetic landscapes remain severely understudied and support recommending multigene testing in Caribbean-born patients. They highlight a need for further research on the genetic paradigm of HBOC in the Afro-Caribbean population to improve genetic testing/counseling and the subsequent adoption of early detection and risk reduction strategies.
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Affiliation(s)
- Danielle Cerbon
- Sylvester Comprehensive Cancer Center, Department of Radiation Oncology. University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Daphanie Taylor
- Christus St. Michael W. Temple Webber Cancer Center, Texarkana, TX
| | - Priscila Barreto-Coelho
- Sylvester Comprehensive Cancer Center, Miami, FL, USA; Division of Medical Oncology, Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Estelamari Rodriguez
- Sylvester Comprehensive Cancer Center, Miami, FL, USA; Division of Medical Oncology, Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Matthew Schlumbrecht
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Judith Hurley
- Division of Medical Oncology, Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Sophia H L George
- Sylvester Comprehensive Cancer Center, Miami, FL, USA; Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Miller School of Medicine, University of Miami, Miami, FL, USA
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Mei S, Chelmow D, Gecsi K, Barkley J, Barrows E, Brooks R, Huber-Keener K, Jeudy M, O'Hara JS, Burke W. Health Disparities in Ovarian Cancer: Report From the Ovarian Cancer Evidence Review Conference. Obstet Gynecol 2023; 142:196-210. [PMID: 37348095 DOI: 10.1097/aog.0000000000005210] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/12/2023] [Indexed: 06/24/2023]
Abstract
Health disparity, defined by the Centers for Disease Control and Prevention (CDC) as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations," is seen across multiple diseases. We conducted an evidence review of health disparities and inequities and their mitigation strategies related to ovarian cancer as part of a CDC-sponsored project to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. Our review found profound disparities in outcomes such as survival, treatment, and stage at diagnosis by factors such as race and ethnicity, insurance, socioeconomic status, and geographic location. We found little direct evidence on mitigation strategies. Studies support equivalent response to equivalent treatment between groups, suggesting that adherence to National Comprehensive Cancer Network guidelines can at least partially mitigate some of the differences.
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Affiliation(s)
- Shirley Mei
- Departments of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York, Virginia Commonwealth University School of Medicine, Richmond, Virginia, the Medical College of Wisconsin, Milwaukee, Wisconsin, Creighton University School of Medicine, Phoenix, Arizona, the University of California, Davis, Davis, California, the University of Iowa Hospitals and Clinics, Ames, Iowa, and Stony Brook University Hospital, New York, New York; and the American College of Obstetricians and Gynecologists, Washington, DC
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Wei CH, Shehayeb S, Santiago NL, Kruper L, Han E, Wang E, Cristea M, Rodriguez-Rodriguez L, Yost SE, Stewart D. BRCA germline mutations in multiethnic gynecologic patients: A 10-year retrospective analysis from a single cancer institute. PLoS One 2023; 18:e0286998. [PMID: 37310942 DOI: 10.1371/journal.pone.0286998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 06/15/2023] Open
Abstract
Histologic and genetic mutation information from racially and ethnically diverse populations is warranted to better inform future cancer predisposition and promote health equity. A single institutional, retrospective capture of patients with gynecologic conditions and genetic susceptibilities to malignant neoplasms of the breast or ovaries was performed. This was achieved with manual curation of the electronic medical record (EMR) from 2010-2020 with the use of ICD-10 code searches. Among 8983 consecutive women identified with gynecologic conditions, 184 were diagnosed with pathogenic/likely pathogenic (P/LP) germline BRCA (gBRCA) mutations. Median age was 54 (22-90). Mutations included insertion/deletion (majority frameshift, 57.4%), substitution (32.4%), large structural rearrangement (5.4%), and alteration in splice site/intronic sequence (4.7%). A total of 48% were non-Hispanic White, 32% Hispanic or Latino, 13% Asian, 2% Black, and 5% Other. The most common pathology was high grade serous carcinoma (HGSC, 63%), followed by unclassified/high grade carcinoma (13%). Additional multigene panels led to the detection of 23 additional BRCA-positive patients with germline co-mutations and/or variants of uncertain significance in genes functionally involved in DNA repair mechanisms. Hispanic or Latino and Asian individuals comprised 45% of patients with concomitant gynecologic condition and gBRCA positivity in our cohort, confirming that germline mutations are represented across racial and ethnic groups. Insertion/deletion mutations, the majority of which led to a frameshift change, occurred in approximately half of our patient cohort, which may have prognostic implication for therapy resistance. Prospective studies are needed to unravel the significance of germline co-mutations in gynecologic patients.
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Affiliation(s)
- Christina H Wei
- Department of Pathology, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Susan Shehayeb
- Department of Population Sciences, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Nicole Lugo Santiago
- Department of Surgery, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Laura Kruper
- Department of Surgery, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Ernest Han
- Department of Surgery, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Edward Wang
- Department or Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Institute, Duarte, CA, United States of America
| | - Mihaela Cristea
- Department or Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Institute, Duarte, CA, United States of America
| | - Lorna Rodriguez-Rodriguez
- Department of Surgery, City of Hope Comprehensive Cancer Institute, Duarte, California, United States of America
| | - Susan E Yost
- Department or Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Institute, Duarte, CA, United States of America
| | - Daphne Stewart
- Department or Medical Oncology & Therapeutics Research, City of Hope Comprehensive Cancer Institute, Duarte, CA, United States of America
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Pitiyarachchi O, Lee YC, Sim HW, Srirangan S, Mapagu C, Kirk J, Harnett PR, Balleine RL, Bowtell DDL, Samimi G, Brand AH, Marsh DJ, Beale P, Anderson L, Bouantoun N, Provan P, Ramus SJ, DeFazio A, Friedlander M. Older age should not be a barrier to testing for somatic variants in homologous recombination DNA repair-related genes in patients with high-grade serous ovarian carcinoma. Transl Oncol 2023; 31:101638. [PMID: 36805919 PMCID: PMC9971549 DOI: 10.1016/j.tranon.2023.101638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND Somatic pathogenic variants (PVs) in homologous recombination DNA repair (HR)-related genes found in high-grade serous ovarian carcinomas (HGSC) are not well-characterised in older patients (≥70 years). This may reflect low testing rates in older patients. METHODS Data from 1210 HGSC patients in AACR Project GENIE and 324 patients in an independent dataset INOVATe were analysed. Cases where somatic variants could be distinguished from germline variants were included, and analysis was restricted to those with a somatic TP53 variant, to ensure cases were HGSC. RESULTS Of 1210 patients in GENIE, 27% (n = 325) were aged ≥70 years at testing. Patients with somatic-only PVs in BRCA2 were older compared with BRCA1 (median 71 vs 60 years, p = 0.002). Median age for 21 patients with somatic-only PVs in 11 other HR-related genes ranged from 40 to 67 years. In older patients, 7% (n = 22) had somatic BRCA1/2 PVs, and 1% (n = 2) had PVs other HR-related genes; this rate was not significantly different to younger patients (<70 years), 7% (n = 62) BRCA1/2 and 2% (n = 19) other HR-related genes (p = 0.36). The overall frequency of somatic BRCA1/2 PVs was similar in INOVATe (n = 25; 7.7%) and somatic-only BRCA2 PVs were again found in older patients compared with BRCA1 (median age: at testing, 70 vs 63 years; at diagnosis, 68 vs 60 years). CONCLUSIONS The overall frequency of somatic-only PVs in HR-related genes was similar in older and younger patients with HGSC, highlighting the importance of somatic testing irrespective of age. Limiting somatic testing by age may exclude patients who could benefit from maintenance poly(ADP-ribose) polymerase (PARP) inhibitors.
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Affiliation(s)
- Omali Pitiyarachchi
- School of Biomedical Sciences, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
| | - Yeh Chen Lee
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Prince of Wales and Royal Hospital for Women, Randwick, NSW, Australia
| | - Hao-Wen Sim
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Camperdown, NSW, Australia; Department of Medical Oncology, The Kinghorn Cancer Centre, Darlinghurst, NSW, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, Australia; Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Sivatharsny Srirangan
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Cristina Mapagu
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Illawarra and Shoalhaven Cancer Care Centres, Wollongong and Nowra, NSW, Australia
| | - Judy Kirk
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
| | - Paul R Harnett
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
| | - Rosemary L Balleine
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - David D L Bowtell
- Research Division, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Cancer Centre Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Goli Samimi
- National Cancer Institute, Bethesda, Maryland, United States of America
| | - Alison H Brand
- Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Deborah J Marsh
- Translational Oncology Group, School of Life Sciences, Faculty of Science, University of Technology Sydney, NSW, Australia; Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Philip Beale
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lyndal Anderson
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; NSW Health Pathology, NSW, Australia; Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Natalie Bouantoun
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Pamela Provan
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Susan J Ramus
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Adult Cancer Program, Lowy Cancer Research Centre, UNSW Sydney, Sydney, NSW, Australia
| | - Anna DeFazio
- Centre for Cancer Research, Westmead Institute for Medical Research, Westmead, NSW, Australia; Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Friedlander
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Prince of Wales and Royal Hospital for Women, Randwick, NSW, Australia
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LILLEY CULLENM, DELILLE MINERVE, MIRZA KAMRANM, PARILLA MEGAN. Toward a More Just System of Care in Molecular Pathology. Milbank Q 2022; 100:1192-1242. [PMID: 36454130 PMCID: PMC9836258 DOI: 10.1111/1468-0009.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 06/23/2022] [Indexed: 12/02/2022] Open
Abstract
Policy Points American health care policy must be critically assessed to establish the role it plays in sustaining and alleviating the health disparities that currently exist in molecular genetic testing. It is critical to understand the economic and sociocultural influences that drive patients to undergo or forgo molecular testing, especially in marginalized patient populations. A multipronged solution with actions necessary from multiple stakeholders is required to reduce the cost of health care, rebalance regional disparities, encourage physician engagement, reduce data bias, and earn patients' trust. CONTEXT The health status of a population is greatly influenced by both biological processes and external factors. For years, minority and low socioeconomic patient populations have faced worse outcomes and poorer health in the United States. Experts have worked extensively to understand the issues and find solutions to alleviate this disproportionate burden of disease. As a result, there have been some improvements and successes, but wide gaps still exist. Diagnostic molecular genetic testing and so-called personalized medicine are just now being integrated into the current American health care system. The way in which these tests are integrated can either exacerbate or reduce health disparities. METHODS We provide case scenarios-loosely based on real-life patients-so that nonexperts can see the impacts of complex policy decisions and unintentional biases in technology without needing to understand all the intricacies. We use data to explain these findings from an extensive literature search examining both peer-reviewed and gray literature. FINDINGS Access to diagnostic molecular genetic testing is not equitable or sufficient, owing to at least five major factors: (1) cost to the patient, (2) location, (3) lack of provider buy-in, (4) data-set bias, and (5) lack of public trust. CONCLUSIONS Molecular genetic pathology can be made more equitable with the concerted efforts of multiple stakeholders. Confronting the five major factors identified here may help us usher in a new era of precision medicine without its discriminatory counterpart.
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Affiliation(s)
| | | | - KAMRAN M. MIRZA
- Loyola University Chicago, Strich School of Medicine
- Loyola Medical Center
| | - MEGAN PARILLA
- Loyola University Chicago, Strich School of Medicine
- Loyola Medical Center
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10
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Huepenbecker SP, Wright JD, Downer MK, Incerti D, Luhn P, Dolado I, Bastiere-Truchot L, Lin YG, Chan JK, Meyer LA. Temporal Patterns and Adoption of Germline and Somatic BRCA Testing in Ovarian Cancer. Obstet Gynecol 2022; 140:758-767. [PMID: 36201776 PMCID: PMC9588544 DOI: 10.1097/aog.0000000000004958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/14/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the testing rate, patient characteristics, temporal trends, timing, and results of germline and somatic BRCA testing in patients with ovarian cancer using real-world data. METHODS We included a cross-sectional subset of adult patients diagnosed with ovarian cancer between January 1, 2011, and November 30, 2018, who received frontline treatment and were followed for at least 1 year in a real-world database. The primary outcome was receipt of BRCA testing, classified by biosample source as germline (blood or saliva) or somatic (tissue). Lines of therapy (frontline, second line, third line) were derived based on dates of surgery and chemotherapy. Descriptive statistics were analyzed. RESULTS Among 2,557 patients, 72.2% (n=1,846) had at least one documented BRCA test. Among tested patients, 62.5% (n=1,154) had only germline testing, 10.6% (n=197) had only somatic testing, and 19.9% (n=368) had both. Most patients had testing before (9.7%, n=276) or during (48.6%, n=1,521) frontline therapy, with 17.6% (n=273) tested during second-line and 12.7% (n=129) tested during third-line therapy. Patients who received BRCA testing, compared with patients without testing, were younger (mean age 63 years vs 66 years, P <.001) and were more likely to be treated at an academic practice (10.4% vs 7.0%, P =.01), with differences by Eastern Cooperative Oncology Group performance score ( P <.001), stage of disease ( P <.001), histology ( P <.001), geography ( P <.001), and type of frontline therapy ( P <.001), but no differences based on race or ethnicity. The proportion of patients who received BRCA testing within 1 year of diagnosis increased from 24.6% of patients in 2011 to 75.6% of patients in 2018. CONCLUSION In a large cohort of patients with ovarian cancer, significant practice disparities existed in testing for actionable BRCA mutations. Despite increased testing over time, many patients did not receive testing, suggesting missed opportunities to identify patients appropriate for targeted therapy and genetic counseling.
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Affiliation(s)
| | - Jason D. Wright
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Mary K. Downer
- Personalized Healthcare Data Science, Genentech, Inc., South San Francisco, CA
| | - Devin Incerti
- Product Development Medical Affairs, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | - Patricia Luhn
- Product Development Oncology, Genentech, Inc., South San Francisco, CA
| | - Ignacio Dolado
- Product Development Medical Affairs, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | | | - Yvonne G. Lin
- Product Development Oncology, Genentech, Inc., South San Francisco, CA
| | - John K. Chan
- California Pacific Medical Center and Palo Alto Medical Foundation, Sutter Health, San Francisco, CA
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11
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Kammula AV, Schäffer AA, Rajagopal PS. Characterization of Oncology Clinical Trials Using Germline Genetic Data. JAMA Netw Open 2022; 5:e2242370. [PMID: 36383380 PMCID: PMC9669814 DOI: 10.1001/jamanetworkopen.2022.42370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE The recent successes of poly-ADP ribose polymerase (PARP) inhibitors and belzutifan support germline genetic data as an exciting, accessible source for biomarkers in cancer treatment. This study hypothesizes, however, that most oncology clinical trials using germline data largely prioritize BRCA1/2 as biomarkers and PARP inhibitors as therapy. OBJECTIVE To characterize past and ongoing oncology trials that use germline data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study of oncology trials used the Informa Trialtrove database to evaluate trial attributes. Trials using germline information (including the terms germline, hereditary, or inherited in the title, treatment plan, interventions, end points, objectives, results, or notes) and conducted globally between December 1, 1990, and April 4, 2022 (data freeze date), were included. MAIN OUTCOMES AND MEASURES Trials by cancer type, phase, participants, sponsor type, end points, outcomes, and locations were described. Associated biomarkers and mechanisms of action for studied therapeutic interventions were counted. How germline data in trial inclusion and exclusion criteria are associated with end points, outcomes, and enrollment were also examined. RESULTS A total of 887 of 84 297 (1.1%) oncology clinical trials in the Trialtrove database that use germline data were identified. Most trials were conducted in cancer types where PARP inhibitors are already approved. A total of 74.8% (672) of trials were performed in the phase 2 setting or above. Trials were primarily sponsored by industry (523 trials [59.0%]), academia (382 trials [43.1%]), and the government (274 trials [30.9%]), where trials may have multiple sponsor types. Among 343 trials using germline data with outcomes in Trialtrove, 180 (52.5%) reported meeting primary end points. Although BRCA1/2 are the most frequent biomarkers seen (BRCA1, 224 trials [25.3%]; BRCA2, 228 trials [25.7%]), trials also examine pharmacogenomic variants and germline mediators of somatic biomarkers. PARP inhibitors or immunotherapy were tested in 69.9% of trials; PARP inhibition was the most frequently studied mechanism (367 trials [41.4%]). An overwhelming number of trials using germline data were conducted in the US, Canada, and Europe vs other countries, mirroring disparities in cancer genetics data. Germline data in inclusion and exclusion criteria are associated with altered end point, outcomes, and enrollment compared with oncology trials with no germline data use. Examples of inclusion and exclusion criteria regarding germline data that may unintentionally exclude patients were identified. CONCLUSIONS AND RELEVANCE These findings suggest that for germline biomarkers to gain clinical relevance, trials must expand biomarkers, therapies, and populations under study.
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Affiliation(s)
- Ashwin V Kammula
- Cancer Data Science Laboratory, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
- University of Maryland, College Park
| | - Alejandro A Schäffer
- Cancer Data Science Laboratory, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Padma Sheila Rajagopal
- Cancer Data Science Laboratory, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
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12
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Omole EB, Aijaz I, Ellegate J, Isenhart E, Desouki MM, Mastri M, Humphrey K, Dougherty EM, Rosario SR, Nastiuk KL, Ohm JE, Eng KH. Combined BRCA2 and MAGEC3 Expression Predict Outcome in Advanced Ovarian Cancers. Cancers (Basel) 2022; 14:cancers14194724. [PMID: 36230652 PMCID: PMC9562635 DOI: 10.3390/cancers14194724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/14/2022] [Accepted: 09/22/2022] [Indexed: 12/02/2022] Open
Abstract
Like BRCA2, MAGEC3 is an ovarian cancer predisposition gene that has been shown to have prognostic significance in ovarian cancer patients. Despite the clinical significance of each gene, no studies have been conducted to assess the clinical significance of their combined expression. We therefore sought to determine the relationship between MAGEC3 and BRCA2 expression in ovarian cancer and their association with patient characteristics and outcomes. Immunohistochemical staining was quantitated on tumor microarrays of human tumor samples obtained from 357 patients with epithelial ovarian cancer to ascertain BRCA2 expression levels. In conjunction with our previously published MAGEC3 expression data, we observed a weak inverse correlation of MAGEC3 with BRCA2 expression (r = −0.15; p < 0.05) in cases with full-length BRCA2. Patients with optimal cytoreduction, loss of MAGEC3, and detectable BRCA2 expression had better overall (median OS: 127.9 vs. 65.3 months, p = 0.035) and progression-free (median PFS: 85.3 vs. 18.8 months, p = 0.002) survival compared to patients that were BRCA2 expressors with MAGEC3 normal levels. Our results suggest that combined expression of MAGEC3 and BRCA2 serves as a better predictor of prognosis than each marker alone.
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Affiliation(s)
- Emmanuel B. Omole
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Iqbal Aijaz
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - James Ellegate
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Emily Isenhart
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Mohamed M. Desouki
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Michalis Mastri
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Kristen Humphrey
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Emily M. Dougherty
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Spencer R. Rosario
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Kent L. Nastiuk
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Joyce E. Ohm
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Correspondence:
| | - Kevin H. Eng
- Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
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13
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Gray SW, Ottesen RA, Currey M, Cristea M, Nikowitz J, Shehayeb S, Lozano V, Hom J, Kilburn J, Lopez LN, Wing S, Sosa E, Shen J, Morris M, Dilsizian B, Joseph T, Shen J, Adeimy C, Phillips T, Bahadini B, Niland JC. Leveraging an Informatics Approach to Identify an Unmet Clinical Need for BRCA1/ 2 Testing Among Patients With Ovarian Cancer. JCO Clin Cancer Inform 2022; 6:e2200034. [PMID: 36049148 PMCID: PMC9470148 DOI: 10.1200/cci.22.00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/31/2022] [Accepted: 07/18/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although BRCA1/2 testing in ovarian cancer improves outcomes, it is vastly underutilized. Scalable approaches are urgently needed to improve genomically guided care. METHODS We developed a Natural Language Processing (NLP) pipeline to extract electronic medical record information to identify recipients of BRCA testing. We applied the NLP pipeline to assess testing status in 308 patients with ovarian cancer receiving care at a National Cancer Institute Comprehensive Cancer Center (main campus [MC] and five affiliated clinical network sites [CNS]) from 2017 to 2019. We compared characteristics between (1) patients who had/had not received testing and (2) testing utilization by site. RESULTS We found high uptake of BRCA testing (approximately 78%) from 2017 to 2019 with no significant differences between the MC and CNS. We observed an increase in testing over time (67%-85%), higher uptake of testing among younger patients (mean age tested = 61 years v untested = 65 years, P = .01), and higher testing among Hispanic (84%) compared with White, Non-Hispanic (78%), and Asian (75%) patients (P = .006). Documentation of referral for an internal genetics consultation for BRCA pathogenic variant carriers was higher at the MC compared with the CNS (94% v 31%). CONCLUSION We were able to successfully use a novel NLP pipeline to assess use of BRCA testing among patients with ovarian cancer. Despite relatively high levels of BRCA testing at our institution, 22% of patients had no documentation of genetic testing and documentation of referral to genetics among BRCA carriers in the CNS was low. Given success of the NLP pipeline, such an informatics-based approach holds promise as a scalable solution to identify gaps in genetic testing to ensure optimal treatment interventions in a timely manner.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Sam Wing
- Health Economics and Outcomes Research, Intuitive Surgical, Sunnyvale, CA
| | | | - Jenny Shen
- The State University of New York at Stony Brook, Stony Brook, NY
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14
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Frey MK, Finch A, Kulkarni A, Akbari MR, Chapman-Davis E. Genetic Testing for All: Overcoming Disparities in Ovarian Cancer Genetic Testing. Am Soc Clin Oncol Educ Book 2022; 42:1-12. [PMID: 35452249 DOI: 10.1200/edbk_350292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Nearly 3% of the population carries genetic variants that lead to conditions that include hereditary breast and ovarian cancer and Lynch syndrome. These pathogenic variants account for approximately 20% of ovarian cancer cases, and those with germline pathogenic variants have an odds ratio between 4 and 40 for developing ovarian cancer compared with noncarriers. Given the high prevalence of genetic variants, multiple organizations, including ASCO, recommend universal genetic counseling and testing for women diagnosed with epithelial ovarian cancer. Unfortunately, most individuals with a hereditary ovarian cancer syndrome are unaware of their underlying mutation, and racial and ethnic minority individuals as well as patients of low socioeconomic status experience disproportionate rates of underrecognition, leading to late and missed diagnoses. In this article, we review the current understanding of disparities in genetic testing for people with ovarian cancer, the role of population-based genetic testing, and innovative strategies to overcome the critical inequities present in current cancer genetic medicine. Underuse and disparities related to accessing recommended genetic services are complex and multifactorial, requiring improvements in processes related to provider identification, genetic counseling and testing referral, and patient uptake/adherence. Through the expansion of remote genetic counseling, offering online strategies for genetic testing, and reaching at-risk relatives through direct relative contact cascade testing and population-based genetic testing, there are a growing number of innovations in the field of genetic medicine, many of which emphasize health equity and offer promising alternatives to the current paradigm of genetic testing.
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Affiliation(s)
- Melissa K Frey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
| | - Amy Finch
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Amita Kulkarni
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
| | - Mohammad R Akbari
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eloise Chapman-Davis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
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15
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Douglas MP, Kumar A. Analyzing Precision Medicine Utilization with Real-World Data: A Scoping Review. J Pers Med 2022; 12:jpm12040557. [PMID: 35455673 PMCID: PMC9025578 DOI: 10.3390/jpm12040557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Precision medicine (PM), specifically genetic-based testing, is currently used in over 140,000 individual tests to inform the clinical management of disease. Though several databases (e.g., the NIH Genetic Testing Registry) demonstrate the availability of these sequencing-based tests, we do not currently understand the extent to which these tests are used. There exists a need to synthesize the body of real-world data (RWD) describing the use of sequencing-based tests to inform their appropriate use. To accomplish this, we performed a scoping review to examine what RWD sources have been used in studies of PM utilization between January 2015 and August 2021 to characterize the use of genome sequencing (GS), exome sequencing (ES), tumor sequencing (TS), next-generation sequencing-based panels (NGS), gene expression profiling (GEP), and pharmacogenomics (PGx) panels. We abstracted variables describing the use of these types of tests and performed a descriptive statistical analysis. We identified 440 articles in our search and included 72 articles in our study. Publications based on registry databases were the most common, followed by studies based on private insurer administrative claims. Slightly more than one-third (38%) used integrated datasets. Two thirds (67%) of the studies focused on the use of tests for oncological clinical applications. We summarize the RWD sources used in peer-reviewed literature on the use of PM. Our findings will help improve future study design by encouraging the use of centralized databases and registries to track the implementation and use of PM.
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Affiliation(s)
- Michael P. Douglas
- Center for Translational and Policy Research on Precision Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA 94143, USA
- Correspondence: ; Tel.: +1-415-502-4025
| | - Anika Kumar
- School of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA;
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16
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Powell CB, Laurent C, Garcia C, Hoodfar E, Karlea A, Kobelka C, Lee J, Roh J, Kushi LH. Factors influencing genetic counseling and testing for hereditary breast and ovarian cancer syndrome in a large US health care system. Clin Genet 2021; 101:324-334. [PMID: 34927729 DOI: 10.1111/cge.14100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 01/26/2023]
Abstract
Investigate whether disparities and other factors influence referral to genetic counseling and testing for hereditary breast and ovarian cancer syndrome (HBOC) in a large health care system. Examination of clinical, demographic, and socioeconomic factors from electronic health records associated with genetic referral and testing within 12 months after a new cancer diagnosed between August 1, 2013 and December 31, 2018. For patients meeting institutional criteria for HBOC testing, 60.6% were referred for genetic counseling, 88% of whom underwent germline testing; at least one pathogenic variant was found in 15.3%. Referral rates for patients with breast (69%) or ovarian cancer (65.7%) were much higher than for metastatic prostate (11.1%, p < 0.0001) or pancreatic cancer (22.3%, p < 0.0001); referral criteria were implemented more recently for the latter two cancers. Younger age, family history, and chemotherapy were associated with referral. Higher Elixhauser comorbidity score and prior cancer were associated with non-referral. No other factors were associated with genetic referral for all eligible cancers combined, although differences were seen in specific cancers. Race was a significant factor only for breast cancer, with fewer Asians than Whites referred. Health disparities in referral to genetics for HBOC cancers are mitigated in a comprehensive integrated health care system.
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Affiliation(s)
- C Bethan Powell
- Kaiser Permanente Northern California, Division of Research, Oakland, California, USA.,Kaiser Permanente Northern California Hereditary Cancer Program San Francisco, Oakland, California, USA
| | - Cecile Laurent
- Kaiser Permanente Northern California, Division of Research, Oakland, California, USA
| | - Christine Garcia
- Kaiser Permanente Northern California Hereditary Cancer Program San Francisco, Oakland, California, USA
| | - Elizabeth Hoodfar
- Kaiser Permanente Northern California Hereditary Cancer Program San Francisco, Oakland, California, USA.,Kaiser Permanente Northern California Genetics Department, Oakland, California, USA
| | - Audrey Karlea
- Kaiser Permanente Northern California Hereditary Cancer Program San Francisco, Oakland, California, USA.,Kaiser Permanente Northern California Genetics Department, Oakland, California, USA
| | - Christine Kobelka
- Kaiser Permanente Northern California Hereditary Cancer Program San Francisco, Oakland, California, USA.,Kaiser Permanente Northern California Genetics Department, Oakland, California, USA
| | - Jaimie Lee
- Kaiser Permanente Oakland Obstetrics and Gynecology Residency Program, Oakland, California, USA
| | - Janise Roh
- Kaiser Permanente Northern California, Division of Research, Oakland, California, USA
| | - Lawrence H Kushi
- Kaiser Permanente Northern California, Division of Research, Oakland, California, USA
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17
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Lin GA, Trosman JR, Douglas MP, Weldon CB, Scheuner MT, Kurian A, Phillips KA. Influence of payer coverage and out-of-pocket costs on ordering of NGS panel tests for hereditary cancer in diverse settings. J Genet Couns 2021; 31:130-139. [PMID: 34231930 DOI: 10.1002/jgc4.1459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/27/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022]
Abstract
The landscape of payment for genetic testing has been changing, with an increase in the number of laboratories offering testing, larger panel offerings, and lower prices. To determine the influence of payer coverage and out-of-pocket costs on the ordering of NGS panel tests for hereditary cancer in diverse settings, we conducted semi-structured interviews with providers who conduct genetic counseling and order next-generation sequencing (NGS) panels purposefully recruited from 11 safety-net clinics and academic medical centers (AMCs) in California and North Carolina, states with diverse populations and divergent Medicaid expansion policies. Thematic analysis was done to identify themes related to the impact of reimbursement and out-of-pocket expenses on test ordering. Specific focus was put on differences between settings. Respondents from both safety-net clinics and AMCs reported that they are increasingly ordering panels instead of single-gene tests, and tests were ordered primarily from a few commercial laboratories. Surprisingly, safety-net clinics reported few barriers to testing related to cost, largely due to laboratory assistance with prior authorization requests and patient payment assistance programs that result in little to no patient out-of-pocket expenses. AMCs reported greater challenges navigating insurance issues, particularly prior authorization. Both groups cited non-coverage of genetic counseling as a major barrier to testing. Difficulty of access to cascade testing, particularly for family members that do not live in the United States, was also of concern. Long-term sustainability of laboratory payment assistance programs was a major concern; safety-net clinics were particularly concerned about access to testing without such programs. There were few differences between states. In conclusion, the use of laboratories with payment assistance programs reduces barriers to NGS panel testing among diverse populations. Such programs represent a major change to the financing and affordability of genetic testing. However, access to genetic counseling is a barrier and must be addressed to ensure equity in testing.
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Affiliation(s)
- Grace A Lin
- Department of Medicine, University of California, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | - Julia R Trosman
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,Center for Business Models in Healthcare, Glencoe, IL, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | | | - Maren T Scheuner
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Allison Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kathryn A Phillips
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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18
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Lin J, Sharaf RN, Saganty R, Ahsan D, Feit J, Khoury A, Bergeron H, Chapman-Davis E, Cantillo E, Holcomb K, Blank SV, Liu Y, Thomas C, Christos PJ, Wright DN, Lipkin S, Offit K, Frey MK. Achieving universal genetic assessment for women with ovarian cancer: Are we there yet? A systematic review and meta-analysis. Gynecol Oncol 2021; 162:506-516. [PMID: 34023131 DOI: 10.1016/j.ygyno.2021.05.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/08/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE Several professional organizations recommend universal genetic assessment for people with ovarian cancer as identifying pathogenic variants can affect treatment, prognosis, and all-cause mortality for patients and relatives. We sought to evaluate the literature on genetic assessment for women with ovarian cancer and determine if any interventions or patient characteristics drive utilization of services. METHODS We searched key electronic databases to identify trials that evaluated genetic assessment for people with ovarian cancer. Trials with the primary aim to evaluate utilization of genetic assessment with or without interventions were included. Eligible trials were subjected to meta-analysis and the moderating influence of health interventions on rates of genetic assessment were examined. RESULTS A total of 35 studies were included (19 report on utilization of genetic services without an intervention, 7 with an intervention, and 9 with both scenarios). Without an intervention, pooled estimates for referral to genetic counseling and completion of genetic testing were 39% [CI 27-53%] and 30% [CI 19-44%]. Clinician-facilitated interventions included: mainstreaming of genetic services (99% [CI 86-100%]), telemedicine (75% [CI 43-93%]), clinic-embedded genetic counselor (76% [CI 32-95%]), reflex tumor somatic genetic assessment (64% [CI 17-94%]), universal testing (57% [28-82%]), and referral forms (26% [CI 10-53%]). Random-effects pooled proportions demonstrated that Black vs. White race was associated with a lower rate of genetic testing (26%[CI 17-38%] vs. 40% [CI 25-57%]) as was being un-insured vs. insured (23% [CI 18-28%] vs. 38% [CI 26-53%]). CONCLUSIONS Reported rates of genetic testing for people with ovarian cancer remain well below the goal of universal testing. Interventions such as mainstreaming can improve testing uptake. Strategies aimed at improving utilization of genetic services should consider existing disparities in race and insurance status.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephanie V Blank
- Icahn School of Medicine at Mount Sinai, Blavatnik Family Women's Health Research Institute, USA
| | - Ying Liu
- Memorial Sloan Kettering Cancer Center, USA
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19
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George SHL, Donenberg T, Alexis C, DeGennaro V, Dyer H, Yin S, Ali J, Butler R, Chin SN, Curling D, Lowe D, Lunn J, Turnquest T, Wharfe G, Cerbon D, Barreto-Coelho P, Schlumbrecht MP, Akbari MR, Narod SA, Hurley JE. Gene Sequencing for Pathogenic Variants Among Adults With Breast and Ovarian Cancer in the Caribbean. JAMA Netw Open 2021; 4:e210307. [PMID: 33646313 PMCID: PMC7921902 DOI: 10.1001/jamanetworkopen.2021.0307] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Rates of breast and ovarian cancer are high in the Caribbean; however, to date, few published data quantify the prevalence of inherited cancer in the Caribbean population. OBJECTIVE To determine whether deleterious variants in genes that characterize the hereditary breast and ovarian cancer syndrome are associated with the development of breast and ovarian cancer in the English- and Creole-speaking Caribbean populations. DESIGN, SETTING, AND PARTICIPANTS This multisite genetic association study used data from germline genetic test results between June 2010 and June 2018 in the Bahamas, Cayman Islands, Barbados, Dominica, Jamaica, Haiti, and Trinidad and Tobago. Next-generation sequencing on a panel of 30 genes and multiplex ligation-dependent probe amplification (BRCA1 and BRCA2) were performed. Medical records were reviewed at time of study enrollment. Women and men diagnosed with breast and ovarian cancer with at least 1 grandparent born in the participating study sites were included; 1018 individuals were eligible and consented to participate in this study. Data were analyzed from November 4, 2019, to May 6, 2020. EXPOSURES Breast and/or ovarian cancer diagnosis. MAIN OUTCOMES AND MEASURES Rate of inherited breast and ovarian cancer syndrome and spectrum and types of variants. RESULTS Of 1018 participants, 999 (98.1%) had breast cancer (mean [SD] age, 46.6 [10.8] years) and 21 (2.1%) had ovarian cancer (mean [SD] age, 47.6 [13.5] years). Three individuals declined to have their results reported. A total of 144 of 1015 (14.2%) had a pathogenic or likely pathogenic (P/LP) variant in a hereditary breast and ovarian cancer syndrome gene. A total of 64% of variant carriers had P/LP variant in BRCA1, 23% in BRCA2, 9% in PALB2 and 4% in RAD51C, CHEK2, ATM, STK11 and NBN. The mean (SD) age of variant carriers was 40.7 (9.2) compared with 47.5 (10.7) years in noncarriers. Individuals in the Bahamas had the highest proportion of hereditary breast and ovarian cancer (23%), followed by Barbados (17.9%), Trinidad (12%), Dominica (8.8%), Haiti (6.7%), Cayman Islands (6.3%), and Jamaica (4.9%). In Caribbean-born women and men with breast cancer, having a first- or second-degree family member with breast cancer was associated with having any BRCA1 or BRCA2 germline variant (odds ratio, 1.58; 95% CI, 1.24-2.01; P < .001). A BRCA1 vs BRCA2 variant was more strongly associated with triple negative breast cancer (odds ratio, 6.33; 95% CI, 2.05-19.54; P = .001). CONCLUSIONS AND RELEVANCE In this study, among Caribbean-born individuals with breast and ovarian cancer, 1 in 7 had hereditary breast and ovarian cancer. The proportion of hereditary breast and ovarian cancer varied by island and ranged from 23% in the Bahamas to 4.9% in Jamaica. Each island had a distinctive set of variants.
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Affiliation(s)
- Sophia H. L. George
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Talia Donenberg
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Genetics, University of Miami, Miami, Florida
| | - Cheryl Alexis
- Faculty of Medical Sciences, University of West Indies-Cave Hill, Barbados
| | | | - Hedda Dyer
- Ross University School of Medicine, Commonwealth of Dominica (now in Barbados)
| | - Sook Yin
- Cayman Islands Cancer Society, Grand Cayman, Cayman Islands
| | - Jameel Ali
- St. James Medical Complex, Northwest Regional Health Authority, Port-of-Spain, Trinidad and Tobago
| | - Raleigh Butler
- Princess Margaret Hospital, University of the West Indies, School of Clinical Medicine and Research, Nassau, Bahamas
| | - Sheray N. Chin
- Department of Pathology, University of West Indies-Mona, Kingston, Jamaica
| | - DuVaughn Curling
- Princess Margaret Hospital, University of the West Indies, School of Clinical Medicine and Research, Nassau, Bahamas
| | - Dwight Lowe
- Department of Pathology, University of West Indies-Mona, Kingston, Jamaica
| | - John Lunn
- Princess Margaret Hospital, University of the West Indies, School of Clinical Medicine and Research, Nassau, Bahamas
| | - Theodore Turnquest
- Princess Margaret Hospital, University of the West Indies, School of Clinical Medicine and Research, Nassau, Bahamas
| | - Gilian Wharfe
- Department of Pathology, University of West Indies-Mona, Kingston, Jamaica
| | - Danielle Cerbon
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Division of Medical Oncology, Department of Medicine, University of Miami, Miami, Florida
| | - Priscila Barreto-Coelho
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Division of Medical Oncology, Department of Medicine, University of Miami, Miami, Florida
| | - Matthew P. Schlumbrecht
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Mohammad R. Akbari
- Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Canada
| | - Steven A. Narod
- Women’s College Research Institute, Women’s College Hospital, University of Toronto, Toronto, Canada
| | - Judith E. Hurley
- Sylvester Comprehensive Cancer Center, Miami, Florida
- Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Division of Medical Oncology, Department of Medicine, University of Miami, Miami, Florida
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20
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Giornelli G, Gallardo D, Hegg R, Abuin GG, La Vega MD, Lim-Law M, Caceres V, Trujillo L, Pilar Estevez-Diz MD, Pacheco C, Sganga L, Goncalves S. FLABRA, frontline approach for BRCA testing in an ovarian cancer population: a Latin America epidemiologic study. Future Oncol 2021; 17:1601-1609. [PMID: 33415992 DOI: 10.2217/fon-2020-1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: FLABRA evaluated the prevalence of BRCA mutations, genetic counseling and management approaches in patients with ovarian cancer in Latin America. Patients & methods: Patients with ovarian cancer from six Latin-American countries were enrolled. Tumor samples were tested for BRCA mutations (BRCAmut). In cases with BRCAmut, blood samples were analyzed to determine germline versus somatic mutations. Medical records were reviewed for counseling approach and treatment plan. Results: From 472 patients enrolled, 406 samples yielded conclusive results: 282 were BRCA wild-type (BRCAwt), 115 were BRCAmut and nine were variants of uncertain significance. In total, 110/115 were tested for germline mutations (77 germline and 33 somatic). Conclusion: Tumor testing to identify mutations in BRCA1/2 in ovarian cancer can help optimize treatment choices, meaning fewer patients require germline testing and genetic counseling, a scant resource in Latin America. Clinical trial registration: NCT02984423 (ClinicalTrials.gov).
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Affiliation(s)
- Gonzalo Giornelli
- Department of Oncology, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Dolores Gallardo
- Department of Medical Oncology, Hospital Nacional de Cancerología, Ciudad de México, México
| | | | | | - Maximo De La Vega
- Department of Internal Medicine, CEMIC (Centro de Educación Médica e Investigaciones Clínicas), Buenos Aires, Argentina
| | - Maria Lim-Law
- Centro Oncológico de Panamá, Hospital Santa Fe, Panamá, República de Panamá
| | - Valeria Caceres
- Department of Clinical Oncology, Instituto de Oncología Ángel H. Roffo, Buenos Aires, Argentina
| | - Lina Trujillo
- Clínica de Ginecología, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Maria Del Pilar Estevez-Diz
- Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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21
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Effects of initiating physician-performed germline testing in safety net clinic patients with epithelial ovarian cancer. Gynecol Oncol Rep 2020; 34:100662. [PMID: 33195785 PMCID: PMC7644881 DOI: 10.1016/j.gore.2020.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/16/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022] Open
Abstract
Expeditious germline testing is a vital component of epithelial ovarian cancer treatment. Uninsured and minority patients are at risk for lower germline testing rates. Physician performed germline testing shortens the interval to results reporting in a safety net clinic population. The majority of patients tested were uninsured or underinsured at the time of testing.
Germline genetic mutations occur in approximately 25% of women with epithelial ovarian cancers (EOC). We sought to determine whether newly initiated in-office oncologist-led germline testing improved time to testing and dissemination of results compared with historical controls. Patients with epithelial ovarian cancer seen between 4/1/2018 and 12/31/2019 were identified. Patients treated before genetic testing kits were made available in the gynecologic oncology clinics were compared to those treated after. Categorical variables were compared using Chi Squared and Fisher’s Exact test. Cox proportional hazards model was used to compare elapsed time from testing to results. 73 patients were identified, and 502 clinic visits were analyzed. 56 (76.7%) patients were White Hispanic, 15 (20.5%) were Black, and 2 (2.7%) were White non-Hispanic. 55 (75.7%) underwent germline testing. Median time to genetic testing in the intervention group was shorter than in the control group (5, vs 24.3 weeks, 95% CI = 0–10.8 vs 14.9–33.7, p < 0.001). Among the 51 patients with genetic tests completed; results were recorded in a clinic note at 14 weeks (95% CI = 0–28.1) from first visit in the intervention group compared with 47 weeks (95% CI = 30.7–63.3) in the control group (p < 0.001). The majority of patients tested had county charity care insurance or were uninsured. Genetic testing in a safety net gynecologic oncology clinic is feasible. By initiating in-office testing, time to testing and receipt of results were meaningfully shortened. This allowed for timely identification of patients who would most benefit from PARP inhibitor maintenance therapy.
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You Y, Li L, Lu J, Wu H, Wang J, Gao J, Wu M, Liang Z. Germline and Somatic BRCA1/2 Mutations in 172 Chinese Women With Epithelial Ovarian Cancer. Front Oncol 2020; 10:295. [PMID: 32211327 PMCID: PMC7077344 DOI: 10.3389/fonc.2020.00295] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022] Open
Abstract
Objective: Despite several nationwide cohort studies of germline BRCA1/2 mutations and several small cohort studies of somatic BRCA1/2 mutations in Chinese epithelial ovarian cancer (EOC) patients, little is known about the impact of these findings on survival outcomes in this population. In this study of 172 retrospectively recruited Chinese EOC patients, germline and somatic BRCA1/2 mutations and their value for predicting survival outcomes were evaluated. Methods: Unselected patients who visited the study center from January 1, 2011, to January 1, 2015, were recruited and asked to provide peripheral blood samples for this study if they were pathologically confirmed to have primary EOC. All patients received staging surgeries or debulking surgeries involving systemic platinum-based chemotherapy, and the patients were then followed up to December 1, 2017. DNA was extracted from formalin-fixed, paraffin-embedded (FFPE) sections and peripheral blood and sequenced for somatic and germline testing, respectively. The demographic and clinicopathological characteristics of the patients were collected to analyze the distribution of BRCA mutations in subgroups. Survival outcomes were compared among various BRCA mutation statuses using univariate and multivariate models. Results: In 58 (33.7%) patients, 63 variants were identified, including variants of unknown significance (VUS) in 18 patients (10.5%) and pathogenic or likely pathogenic variants in a partially overlapping set of 41 patients (23.8%). Germline BRCA mutations, somatic BRCA mutations, BRCA1 mutations in general, and BRCA2 mutations in general were found in 35 (20.3%), 7 (4.1%), 28 (16.3%), and 13 (7.6%) patients, respectively. Five recurrent mutations were identified. Personal and family cancer histories as well as hereditary breast and ovarian cancer (HBOC) criteria were associated with deleterious BRCA mutations both overall and in the germline specifically, whereas only age at diagnosis of EOC was associated with somatic BRCA mutations. In univariate and Cox regression analyses, patients with BRCA1/2 mutations in general had significant improvements in progression-free survival (PFS) and overall survival (OS). Conclusions: In Chinese EOC patients, the distributions and risk factors associated with germline and somatic BRCA1/2 mutations were similar to those previously reported in international studies. Deleterious BRCA mutations in general were associated with improved survival outcomes in this cohort.
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Affiliation(s)
- Yan You
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Lei Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Junliang Lu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Huanwen Wu
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Jing Wang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Jie Gao
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Zhiyong Liang
- Department of Pathology, Molecular Pathology Research Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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Health Disparities in Germline Genetic Testing for Cancer Susceptibility. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00354-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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