1 Kuwait City, Kuwait, February 2017Hereditary Breast and Ovarian Cancer Syndromes: Beyond BRCA 1 and 2: How far can we go? Muhieddine Seoud, MD, FACOG, FACS American University of Beirut Medical Center Kuwait City, Kuwait, February 2017

2

3 Hereditary breast and ovarian cancer (HBOC): ObjectivesReview the rapidly changing landscape of HBOC syndromes Emphasize the importance of history taking in familial cancer syndromes Identify and select appropriate genetic counseling/testing/companion diagnostics to evaluate germline, somatic and epigenetic alterations Present available data on lifetime risk of various mutations in various cancers Summarize the current recommendations for risk reducing interventions Take home message

4 HBOC: Facts The hallmarks of hereditary cancer syndromes:Multiple affected family members Early age of onset Multiple and/or bilateral primary cancers Multiple syndromes associated with increase risks 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

5 Case report: Ms. C.S. : 3 cancers in one, all missed52 years old single female presenting with abdominal carcinomatosis Sister had serous ovarian cancer at age 43: omission # 1 At age 47: Myomectomy for an 18 cm myoma Left 2 cm breast mass: no Work-up and no FU: omission # 2 6 months later, left triple negative breast cancer: Lumpectomy and SLN- chemo/radio/no tamoxifen Right adnexal mass-observed-stable: omission # 3 At age 52: Abdominal carcinomatosis-bilateral ovarian cancers stage IIIC Referred for management – 2 cm thyroid nodule discovered- FNA thyroid papillary cancer: omission # 4

6

7 Case report: Ms. N.S.

8 Hereditary Cancer TestingPatient Cancer Family History No Yes Does the family history raise red flags ? No Yes: Hereditary Cancer Testing Negative or VUS Positive Mutation General Population Familial Risk Hereditary Risk

9 HBOC: Types of genetic eventsGermline mutations in DNA repair pathways Variation in the lineage of germ cells that can be transmitted to offspring ~ 20-30% of patients with BCA may carry it 8-10% have a family history of the ds and may carry mutations in BRCA ½ 8-10% without family history of the ds and may carry mutations in BRCA ½ ~ 22% of patients in a breast surgery practice may be appropriate for BRCA testing Somatic mutations in BRCA: Alterations in DNA after conception in cells except germ cells Can be passed through cell division to progeny of mutated cells but not to offspring Epigenetic factors Heritable changes in gene expression (not involving DNA sequence) Change in phenotype without change in genotype 1. Alsop K et al. J Clin Oncol 2012;30: Liu et al. Clin Cancer 2014; Lodhia K et al. Ann Oncol 2015;26;ii31 Pennongton KP et al. Clin Cancer Res 2014;20:764-75

10 HBOC: Types of genetic eventsBRCAness: Tumors may carry mutations in other proteins associated with DNA repair Caveats: Unknown risk from specific mutations: (Variance of Undermined Significance ) Unknown impact on prognosis & response rates for some of these mutations The science is rapidly progressing 1. Alsop K et al. J Clin Oncol 2012;30: Liu et al. Clin Cancer 2014; Lodhia K et al. Ann Oncol 2015;26;ii31 Pennongton KP et al. Clin Cancer Res 2014;20:764-75

11 Germline mutations and cancer riskSporadic cancer: 2 acquired mutations 2 working copies 1 working copy 1 mutation 2 mutations tumor develops Hereditary cancer: 1 inherited and 1 acquired mutation 1 working copy 1 mutation 2 mutations tumor develops

12 Parent of either sex has a 50-50 chance of passing a mutation to a child of either sexPaternal family history shouldn’t be ignored when we’re discussing BCA or OCA

13 BCA ≤ 50 years with a limited family historycHBOCS: Patients with an increased likelihood of having an inherited predisposition Women AFFECTED with: High grade EOC/TC/PPC BCA ≤ 45 years BCA with: close relativeb with BCA ≤ 50 yrs close relativeb with EOC/TC/PPC BCA ≤ 50 years with a limited family historyc BCA with ≥ 2 close relativesb with BCA at any age BCA with ≥ 2 close relativesb with pancreatic cancer, prostate cancer (GS ≥ 7) 2 breast 1ries, with the 1rst dx < 50 ys Triple negative BCA ≤ 60 years BCA and Ashkenazi Jewish ancestry Pancreatic cancer with ≥ 2 close relativesb with BCA, prostate cancer (GS ≥ 7) Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. b Close relative is defined as a first degree (parent, sibling, offspring), second degree (grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling) or third degree (first cousin, great-grandparent or great-grandchild) relative c Limited family history includes fewer than 2 first- or second-degree female relatives of female relatives surviving beyond 45 years.

14 A close relativeb carrying a known BRCA1 or BRCA2 mutation HBOCS: Patients with an increased likelihood of having an inherited predisposition Women UNAFFECTED with cancer, but with: A 1rst degree or several close relatives that meet one of the above criteria A close relativeb carrying a known BRCA1 or BRCA2 mutation A close relative with male breast cancer Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. b Close relative is defined as a first degree (parent, sibling, offspring), second degree (grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling) or third degree (first cousin, great-grandparent or great-grandchild) relative .

15 NCCN Guidelines For Germline TestingPersonal history of EOC, FTC, or PPC Not dependent on family history Not dependent on ethnicity (i.e. Ashkenazi descent) Not dependent on tumor pathology (i.e. serous histology) Version onward,

16

17 Changing Prevalence-Changing Landscape: 2002Hereditary Susceptibility To Ovarian/Breast Cancer: Changing Prevalence-Changing Landscape: 2002 BRCA2 (30%) BRCA1 (65%) HNPCC (7%) Hereditary (10%) Sporadic (90%) Lifetime risk 15-30% Lifetime risk 30-60% Rebbeck TR, Lynch HT, et al. NEJM 2002

18 Summary of Cancer- Associated Mutations: GOG 218 and 262: Changing Prevalence-Changing Landscape: SGO March 2016 Prevalence increased from 10% to 24% Sporadic BRCA1 (~45%) Hereditary (~24%) BRCA2 (~27%) Lynch (<1%) Other single genes (~27%) wisher Norquist B et al., SGO March 2016

19 Other single genes: (~27%)Summary of Cancer- Associated Mutations: GOG 218 and 262: Changing Prevalence-changing landscape: SGO March 2016 Prevalence increased from 10% to 24% Massively parallel sequencing (NGS) Unselected by age or history 24% of 360 pts had mutation in ≥1 of 21 TS genes >30% had no family history >35% were ≥ 60 yrs at diagnosis Mutations most common in but not limited to grade 3 serous cancer TP53 BRIP1 CHEK2 BARD1 MRE11 MSH6 NBN PALB2 RAD51C RAD50 1 4 5 2 3 Other single genes: (~27%) Norquist B et al., SGO March 2016

20 More Than BRCA1/2? : The Concept Of “Brca-ness” The Cancer Genome Atlas (TCGA) Network: 50% Of 489 Serous OVC Have Germline Or Somatic HR Defects DNA repair by HR: Defects in the FA-BRCA pathway result in HR deficiency (HRD) FANCD2 Ub RAD50 MRE11 BRCA1 BRCA2 NBS1 ATM BRIP1 PALB2 CHEK2 BARD1 RAD51C Fanconi Anemia-BRCA pathway TCGA Netwoek. Nature 2011;474(7353):609-15

21 HGSOC patients can be classified into 3 molecular subgroups: BRCAmut, BRCA-like, Biomarker-negative

22 Overall survival by mutation statusMutations in HR Genes and Response to RX in GOG 218: an NRG Oncology Study Barbara Norquist, MD U.Wash./, Seattle, WA SGO, MARCH 2016 Overall survival by mutation status Median Months OS: BRCA2: BRCA1: Other: No Mutation: 75.2 55.3 56.0 42.1 Proportion surviving BRCA2 vs. no mutation = 33.1 months difference in median OS Months on study Norquist B et al., SGO March 2016

23 Each cancer site is associated with multiple hereditary cancer syndromes:23 Genes panel APC, ATM, BARD1, BMPRIA, BRCA1, BRCA2, BRIP1, CDKN2A, CDK4, CHECK2, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, PTNE, RAD1C, RAD1D, SMAD4, STK11 and TP53

24 Elevated risk Risk Does not meeting HR criteria Single study Contradictory data High Risk 3 x higher > general population Absolute risk ~ > 5% Multiple supporting studies

25 NCCN 21st Annual Conference, Changing Prevalence: April 02, 2016Several new genetic mutations for HBOCs PALB2 mutations are associated with: A 35 to 40% risk of BCA An aggressive form of BCA (# from BRCA 1) RAD51C, RAD51D, and BRIP1 mutations pose an added lifetime risk for OCA NCCN guidelines are not recommending yet BSO when these genetic mutations are present, only that the possibility of the procedure should be discussed List of genetic mutations for which RR mastectomy is recommended: BRCA1, BRCA2, PTEN,  PT53, and PALB2 Pal et al NCCN 21th Annual Confe Apri 2l 2016

26 HBOCS: Facts Women with Lynch HNPCC syndrome:Mutations in DNA mismatch-repair genes: MLH1, MSH2, MSH6, or PMS2 MSI 25–50%-70% lifetime risk of colorectal cancer (lower than male counterparts) Cancer Lifetime Risk MLH1 MSH2 MSH6 PMS2 Endometrial 20–54% 21–49% 16–71% 15% OVC/FT/PC by age 70 4–20% 7.5–24% 0–13.5% small 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

27 HBOCS: Cowden syndromeGermline mutations in the PTEN gene 19–28% risk of endometrial cancer by age 70 True risk higher with an intact uterus 50% risk of breast cancer 3–10% risk of thyroid cancer Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

28 HBOCS: Li Fraumeni syndromeP 53 mutation carriers 60% lifetime risk of breast cancer Sarcomas, brain, and adrenocortical carcinomas , etc.. HBOCS: Other genes Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. DICER1: Sertoli-Leydig tumors SMARCA4: ovarian small cell carcinoma 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

29 HBOCS: Peutz–Jeghers syndromeLess common Mutations in STK11/LKB1 gene 10% risk of cervical (adenoma malignum) 21% risk of ovarian (sex cord stromal tumors) 50% risk of breast cancers Other cancers: colon, pancreas, endometrium, gastric ….. Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

30 Homologous RecombinationExchange of nucleotide between 2 similar or identical DNA strands Conservative mechanism of DNA repair with few errors Critical for repair of double-strand breaks

31 Cell Cycle arrest: ApoptosisBRCA Function Normal DNA BRCA RAD51C Double Strand DNA breaks P 53 Cell Cycle arrest: Apoptosis Loss of BRCA function P 53 Proliferation

32 PARP Inhibition in BRCA-deficient TumorsAccumulation of double strand breaks, in the absence of an alternative DNA repair mechanism, leads to cell death These DSB are usually managed using the homologous recombination pathway in which BRCA1 and BRCA2 play a large role {Point C}. Thus in the presence of a PARP inhibitor and defects in homologous recombination - for example in germline BRCA mutation carriers- {Point D} failure to repair leads to apoptosis in the presence of normal checkpoints Iglehart et al. NEJM 2009, Bryant et al. Nature 2005 , Farmer et al. Nature 2005

33 BRCA 1 and BRCA 2 BRCA1 and BRCA2 mutations:AD, highly penetrant, germline mutations on chromosomes 13, and 17 Lifetime risk varies among different populations: Penetrance Risk-modifiers Different types of cancer and age of onset depending on: gene-gene interactions: Position of the mutation in the BRCA1 or BRCA2 gene Genetic variation in other genes gene-environment interactions: Age/Hormonal or reproductive factors/Lifestyle factors The prevalence in the general population of European ancestry is ~ 0.25 % Higher in Norwegian, Dutch, and Icelandic ancestry Founder effect

34 BRCA 1 and BRCA 2 mutations in ethnic lebanese Arab women with high risk hereditary breast cancer: Saghir N, Zgheib N, Armstrong D, Seoud M et al.. Oncologist 2015 250 Lebanese women with breast cancer ( ) High risk of carrying BRCA1 or BRCA2 mutations young age positive family history of breast or ovarian cancer Despite high percentage of breast cancer in young women of Lebanese and Arab descent Prevalence of deleterious BRCA is lower than expected Doesn’t support the hypothesis that BRCA mutations alone as a cause Oncologist 2015;20:357-64

35 Mutations Dramatically increase the risk of developing cancer Data From Myriad GeneticR

36 HBOCS: Genetic Testing Debate Changing LandscapeSingle gene testing Multigene panel Traditional Sanger Sequencing approach Low throughput High cost for multiple genes Misses structural rearrangements Massive parallel sequencing High throughput Lower cost for multiple genes Better assessment of rearrangements Large number of VUS Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. VUS, variants of uncertain significance

37 HBOCS: Genetic testing Things to considerIncrease in complexity of testing technology Uncertainty in the interpretation of the results Range of potentially identifiable cancer-risk Need for evaluating the likelihood of of a hereditary cancer syndrome Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. Choosing the appropriate test/panel, and interpreting the result, all clearly argue that the first step in patient assessment should be genetic counseling 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

38 Evaluation of available tumor by IHC and MSI (somatic mutations) HBOCS: Genetic counseling Assessment for the presence of an inherited cancer syndrome Education Counseling Evaluation of available tumor by IHC and MSI (somatic mutations) Genetic counselor or others with expertise in cancer genetics Germline genetic testing Five-year survival is over 90 percent for the minority of women with stage I disease. This number drops to about 75 to 80 percent with regional disease, and 25 percent for those with distant metastases. Despite the good prognosis associated with early stage disease, overall five-year survival in women with ovarian cancer is less than 45 percent, in large part because the cancer has spread beyond the ovary at the time of clinical detection in 75 percent of patients. Mortality from ovarian cancer has decreased only slightly in the past 30 years. Little is known about the mechanism or timing of progression from localized to disseminated ovarian cancer. The model of unifocal disease progressing to diffuse disease is plausible; ovarian cancer also may develop from multiple foci within the abdomen since carcinomatosis can develop after the removal of normal ovaries. 1. Ohio Cancer Incidence Surveillance System, Ohio Department of Health, Anderson MR et al. Cancer 2008;113: Myers ER et al. Evidence Report Technology Assessment 2006 full report Cancer Research UK.

39 Risk reducing interventions/proceduresRisk Reduction of ovarian cancer Salpingo-oophorectomy % Tubal ligation 18% Salpingectomy 70% Occult cancers at the time of RRS is 2-18% Cortesi, L., A. Toss, and E. De Matteis. "Preventive Strategies for Ovarian Cancer." (2013), Rice, Megan S. et al, International Journal of Cancer(2013), Aderson et al. Int J Gynecol Cancer 2013

40

41 Take Home Messages Consider taking a comprehensive personal and family history Consider using a risk model to estimate the cancer risk (e.g. Claus model) Consider a medical oncology genetic counseling when it looks too complicated Consider testing when risk estimates are appropriate Discuss risk reducing preventions/surgeries/….. Discuss implications on the patient herself and her family members

42