what oncologists can learn from their genetics...
TRANSCRIPT
City of Hope Comprehensive Cancer Center and Beckman Research Institute
Jeffrey N. Weitzel, M.D.
Professor of Oncology and
Population Sciences
Director, Department of Clinical
Cancer Genetics
What Oncologists Can
Learn from Their
Genetics Colleagues:
Genomics and Cancer
Risk Assessment
Cancer Screening & Prevention Program
• I do not have any financial arrangements or
affiliations with any corporate organization
relating to the topic being presented
• I will not be discussing off label drug use
DISCLOSURES
Advancing
Age Genetics
Alcohol
Lack of
Exercise
Hormone
Replacement
Therapy
Overweight
Gender
???
Passive
SmokeLate
Menopause
Close
Relative
Age at
First Birth
Benign
Breast Disease
Early
Menarche
Risks Related to Cancer
Ionizing
Radiation
Chemicals
-Work
-Home
-Garden
-Recreation
Diet
Education & Income
Genetics
Kesselheim A and Mello M. N Engl J Med 2010;10.1056/NEJMp1004026
Timeline of Important Events in DNA Patenting (Top) and the Discovery and Use
of Genes Conferring Susceptibility to Breast and Ovarian Cancer (Bottom)
June 2013 - U.S. Supreme
Court rules that as nature,
genes cannot be patented
BRCA1- and BRCA2-Associated Cancers: Lifetime Risk
Breast cancer 50%-85% (often early age at onset)
Second primary breast cancer 40%-60%
Ovarian cancer 15%-45%
Absolute risk likely to be higher than 10%
- Prostate cancer
Absolute risk 10% or lower
- Male breast cancer
- Fallopian tube cancer
- Pancreatic cancer
BRCA1 mutations are
prevalent in patients with
triple negative breast
cancer (5-21%) and
medullary breast cancer
Contralateral Breast and Ovarian Cancer Risk in 491 BRCA Carriers
Contralateral breast cancer risk variables:
BRCA2 (v BRCA1): HR 0.73; 95% CI 0.47-1.15
Age 50 at diagnosis: HR 0.63; 95% CI 0.36-1.10
Tamoxifen use: HR 0.59; 95% CI 0.35-1.01
Oophorectomy: HR 0.44; 95% CI 0.21-0.91
10-year risk without Tamoxifen or Oophorectomy:
• 43.4% for BRCA1
• 34.6% for BRCA2
Ovarian cancer risk after breast cancer: 12.7% for BRCA1, 6.8% for BRCA2 (p=0.03)
Ovarian cancer was the cause of death in 25% of the Stage I breast cancer patients
Metcalfe et al. J Clin Oncol 2004, 22:2328-2335; Gyn Onc 2005; 96:222-226
Contralateral Breast and Ovarian Cancer Risk in Absence of Major Predisposition
Contralateral breast cancer risk:
On average for sporadic disease, 0.5% per year
Higher risk if young age (<35)
Modestly higher risk for lobular histology
Moderate risk genes (e.g., CHEK2) Ten year risk ~ 10-20%
Tamoxifen (or other adjuvant hormonal Rx) reduces risk
Ovarian cancer risk after breast cancer not measurably elevated if BRCA neg and no FHx
S. Narod. Bilateral Breast Cancers. Nature Reviews Vol 11:157-166, 2014
BRCA1 and BRCA2
On chromosomes 17 and 13, respectively
Autosomal dominant transmission
Proteins have a role in genomic stability
>2,000 different mutations, polymorphisms, and
variants distributed over both genes
Nonsense Missense Splice-site
BRCA1
Br-47
41
3123 33
Ov-3847
81
Br-45
Br-Pm
43
30
Br-49
28 25
45
21 2524 18261 99 11
Pr-50
71
Br-Pm
HEREDITARY BREAST AND OVARIAN CANCER
+ -+Negative =
Uninformative
Contribution of Known Genes to Explaining
Familial Aggregation of Breast Cancer
Other familial risk factors
(genes, environment)
BRCA1
BRCA2
TP53
PTEN
ATM
CHEK2,BRIP1,PALB2
8 WGA SNPs
CASP8
Results of a
combined analysis
of 154 families:
• good estimate of
BC risk (greater
with + family Hx)
• Inadequate data
to determine
magnitude of
increased OC
risk
Li-Fraumeni Syndrome (LFS)
Bilateral Breast, 40
Leukemia, 33
Brain tumor, 32
Breast, 38Osteosarcoma, 42
Breast, 25
Soft tissue sarcoma, 7
Leukemia, 6
Affected with cancerOften triple positive BC
TP53-mutation carrier
50
LFS Core Cancers:
Brain tumors (choroid plexus)
Sarcoma (rhabdoid, lipo)
Adrenal cortical carcinoma
Breast cancer (young onset)
She has breast cancer – Why the mouth?
Cowden Syndrome Pedigree
Multinodular goiter,
dx 25
Follicular thyroid
cancer, dx 35
Trichilemmomas, dx 21
Breast cancer, dx 35
Macrocephaly
Papillomatous papules
Multinodular goiter, dx 22
Affected
Noncarrier
Eng C. J Med Genet. 2000;37:828-830
Risk for uterine,
but not ovarian
cancer in CS
Major criteria:
• Breast cancer
• Thyroid cancer, usually follicular
• Macrocephaly
• Pathognomonic mucocutaneous lesions: facial trichilemmomas,
papillomas of tongue, oral mucosa
• Lhermitte-Duclos disease (dysplastic cerebellar gangliocytoma)
• Endometrial cancer
Clinical Management of Mutation-Positive Patient
Positive high penetrance
gene test result
Possible testing for
other adult relatives
Increased
surveillance
Prophylactic
surgery
Targeted
Therapy
Chemo-
prevention
“Angelina Jolie’s
double mastectomy
puts genetic testing
in the spotlight”
Study of 483 BRCA
carriers: >90% risk
reductionRebbeck, T.R., et al. JCO
22:1055, 2004
An effective intervention:
Warner et al. JCO 19:3524-3531, 2001
Cumulative incidence of early-stage (stages 0 to I) breast cancer in magnetic resonance imaging
(MRI) –screened cohort and comparison group (competing risk model).
Warner E et al. JCO 2011;29:1664-1669
Diagnosis stage 0-I
Oophorectomy Reduces
Ovarian Cancer, Breast Cancer,
and all cause mortality
Greatest breast cancer risk
reduction among BRCA1
mutation carriers without a prior
dx of breast cancer who had
their oophorectomy < age 50
HR: 0.15 (95% CI 0.04-0.63)
Fanconi Pathway and Contribution of Genomic Stability
Genes to Hereditary Breast and Ovarian Cancer
Synthetic Lethality, BRCA Status and PARP Inhibition
McLornan DP et al. N Engl J Med 2014;371:1725-1735.
Genetic Cancer
Risk Assessment
PreventionTreatment
Oncologic
Consultation
Decisions, decisions…
Somatic/Tumor Genomics – Precision Rx and Germline implications
Homologous Recombination (HR) Gene Mutations in
Ovarian Cancers and Association with Platinum Sensitivity
Pennington K P et al. Clin Cancer Res 2014;20:764-775
• Overall response rate of 33% (16/49)
• Next-generation sequencing identified loss
of function mutations in DNA-repair genes
(n=16); BRCA2 (n=4)
• The response rate was 88% (14/16) among
patients with tumors with defects in DNA
repair genes (P < .001)J. Mateo, et al. NEJM 2015
Schema of Personalized Oncologic Medicine
MacConaill L E , Garraway L A JCO 2010;28:5219-5228
Frequent somatic and
germline gene mutations in:
(A) colorectal,
(B) gastric
(C) pancreatic cancers
Elena M. Stoffel JCO doi:10.1200/JCO.2014.60.6764
MacConaill L E JCO 2013;31:1815-1824
Advances in Massively Parallel Technologies Have
Dramatically Reduced the Cost of Sequencing
How Much Breast and Ovarian Cancer Is Hereditary? It Is a Different Answer with Multiplex Testing
Sporadic
Family clusters
Hereditary
Ovarian CancerBreast Cancer
~5% 15-24%
15% -20%
Proportions Ovarian, Fallopian Tube, or Peritoneal Cancer
Patients with Respective Germ-Line Loss-of-Function Mutations
Walsh T et al. PNAS 2011;108:18032-18037
Cancer Risks in Lynch Syndrome
ASCOAarnio M et al. Int J Cancer 64:430, 1995
% with
cancer
100
80
60
40
20
020 40 60 800
Age (years)
Colorectal 78%
Endometrial 43%
Stomach 19%Biliary tract 18%
Ovarian 9%
Genetic Heterogeneity and Overlapping
Phenotypes = Expanded Differential Diagnoses
Pancreatic
Breast
MelanomaColon
CDKN2A
BRCA2
PALB2
PRSS1
ATM
CHEK2
MMR
Ovarian
Uterine
Breast
BRCA1
BRCA2
PALB2
RAD50
RAD51D
BRIP1
MRE11A
BARD1
RAD51C
PTEN
TP53
STK11
ATM
CHEK2
CDH1MMR
• Could be either
parental lineage
• Magnitude of
ovarian cancer
risk not yet clear
• Need to think
about pancreatic
cancer risk too
Cancer Panel Genes, Stratified by Relative Risk
Cancer
Site
High Relative
Risk (≥5.0)
Moderate
(≥1.5 and <5.0)
Low Relative Risk
(≥1.01 and <1.5)
Breast
TP53, PTEN,
STK11, CDH1,
BRCA1,
BRCA2
CHEK2, ATM,
PALB2, BRIP1
AXIN2, BAP1, BARD1, MRE11A,
NBN, RAD50, RAD51C,
XRCC2, RAD51D
Colon
rectum
APC, MLH1,
MSH2, MSH6,
PMS2
CHEK2
AXIN2, BMPR1A, CDH1, DCC,
EPCAM, EXO1, MUTYH,
PDGFRA, PMS1, PTEN,
SMAD4, STK11, TP53
Ovary
RAD51D,
RAD51C,
BRCA1,
BRCA2
MLH1, MSH2,
MSH6, PALB2
BRIP1
ATM, AXIN2, BARD1, BRIP1,
EPCAM, MRE11A, MUTYH,
NBN, PALB2, PMS2, RAD50, ,
STK11, TP53
Weitzel et al. Genetics, Genomics, and Cancer Risk Assessment: State of the Art and
Future Directions in the Era of Personalized Medicine. CA Cancer J Clin 2011;61:327–359
Suggested Guidance, Pending Real Data
• ASCO affirms that it is sufficient for cancer risk assessment to
evaluate genes of established clinical utility that are suggested by
the patient’s personal and/or family history.
• Because of the current uncertainties and knowledge gaps,
providers with particular expertise in cancer risk assessment should
be involved in the ordering and interpretation of multigene panels
Clinical Management of High-Risk Breast Cancer Susceptibility Gene Mutation-Negative Patients
Negative BRCA and/or multigene panel test
Member of family w/ known high penetrance mutation?
YESNO
Emphasize empirically increased risk of breast and/or ovarian cancer
(moderate risk gene overlap)
Provide individualizedrisk-management plan
Encourage adherence to population screening
guidelines
Emphasize risk of sporadic cancer
• There is clearly a potential to benefit carefully
selected and counseled families, with ever
broader arrays of genetic tools and precision Rx
• PALB2 is among the first rare variant genes to
acquire adequate data for absolute risk estimation
• Genetic technologic advances are changing diagnostic approaches; discerning germline and somatic mutations is an emerging challenge
• Surveillance and prevention can improve survival in at-risk individuals
• Protocols will need to be adapted to lower risk
Cancer Screening & Prevention Program
Hereditary Cancer Risk Assessment and Management
City of Hope Clinical Cancer Genetics Team
Lung Cancer Screening
Dan J. Raz, M.D.Co-Director, Lung Cancer Screening Program
Co-Director, Lung Cancer and Thoracic Oncology ProgramAssistant Professor, Thoracic Surgery
City of Hope
Disclosures
Consultant, Cireca LLC
Outline
–Update on lung cancer screening
–Challenges with lung cancer screening
–Surgery for early stage lung cancer
–High risk patients
Annual U.S. Lung Cancer Deaths
Stage of Lung Cancer at Diagnosis
Stage IV 40%Stage I 20%
Stage II 10%
Stage IIIa 15%Stage IIIb 15%
Lung Cancer Screening
Early Lung Cancer Action Program (ELCAP)
– Low dose CT scan of the chest
– 80% of lung cancers detected stage I
– 85% of stage I patients treated cured
– Decrease lung cancer deaths by about 60%• Save 82,000 lives/year
• 224 lives every day
• Mammography: 15% reduction in breast cancer deaths
Lung Cancer Screening
RCT, n= 53,454 : LD CT vs CXR x 3 years
NLST criteria:Age 55-74>30py smoker or former smokerQuit <15 yrs ago if former smokerNo symptoms of lung cancer
NLST: Lung Cancer CT Screening
– Baseline + 2 yearly screens
– 20% relative reduction in lung cancer mortality
– 7% all cause mortality reduction
– 367/1060 lung cancers detected diagnosed after screening phase
NLST: Lung Cancer CT Screening
Other Benefits of LDCT
• Tobacco cessation
• Coronary calcification
• Emphysema
• Aortic aneurysm
Potential Harms
• Cost
• False positives
– Unnecessary invasive testing
– Anxiety
• Radiation
• ‘Overdiagnosis’
• License to smoke
NLST: Costs
– 24% “positive” (4mm nodule cutoff) 16% with 5mm• 96% false positive
• Definition of positive vs indeterminate
• Invasive testing among positives:– 2% needle biopsy
– 4% bronchoscopy
– 4% surgical procedure
– Adverse events• 16 patients died with 90d of invasive procedure (<0.1%)
• 10 had lung cancer (of 1060 lung cancers)
• Radiation related deaths or morbidity
Henschke, Ann Intern Med 2013
ELCAP:False positives reduced by raising nodule threshold.
No cancers missed by raising from 4mm to 6mm.
ACR Lung RADS
Lung Cancer Screening
IS COST EFFECTIVE
Milliman 2012, Health Affairs:
Cost per year of life saved =$19,000
Cost for mammography=$30-50,000
Cost for screening population=$0.76 per member/month
Cost for mammography=$3.16 per member/month
Cost Analysis: NLST
• Included cost of treating ‘radiation induced lung cancer’
Black et al. NEJM 2014
Effective Radiation Dose
• Chest xray 0.1 mSv
• Mammogram 0.7 mSv
• Low-dose CT 1 mSv
• IV Contrast CT 8 mSv
• CTA (PE) 15 mSv
• PET/CT 25 mSv
3 mSv= background x1yr
FBP VeoASiR
Courtesy of Dr. A. Rotter, COH RadiologyCXR effective dose is about 0.06 mSv.”
Imas courtesy of Pr De Mey,
Universitair Ziekenhuis Brussels, Belgium
Source: Health Physics Society.http://www.hps.org/publicinformation/ate/q2372.html
*Obtained by ICRP using a chest factor of 0.014DLP
100 kVp, 10 mA, 0.4 rotDLP 6.3, 0.09 mSv*
0.625mmRoutine chest CT at nearly chest X-ray dose - 0.09 mSv
False Positives: Anxiety
• NLST: No difference in anxiety/HRQOL at 1 or 6 months in positive vs negative
• NELSON: Anxiety in both groups, higher at 2 months in those with positives
• No information on diverse populations, sex differences, mental illness
COH LCS Video Education Pilot
• Patients randomized in blocks of 5 to video/written education or standard counseling
• What is a nodule?
• What happens if you have a nodule detected?
• What are the odds of needing additional testing?
• Survey tools
Overdiagnosis: Natural History of Stage I NSCLC
Raz DJ, et al. Chest 2008
Lung Cancer Screening
• LDCT SCREENING SAVES LIVES
• CXR screening does not save lives
– Mayo lung, PLCO
• USPSTF draft: Recommended (B)
• CMS approved
• ELCAP, DANTE (Italy), NELSON, Danish
LCS Criteria
LCS criteria for screening USPSTF1 CMS2
NCCN3
Organizations4-6 using NLST
derived criteria
AATS7
Primary Secondary Primary Secondary
Age (years) 55-80 55-77 55-74 ≥50 55-74 55-79 50-79
Smoking History (pack year) ≥30 ≥30 ≥30 ≥20 ≥30 ≥30 ≥20
Quit time (years) 15 15 15 - 15 none none
Other criteria - - - Additional risk factor -
Additional risk factor
or
Lung cancer survivors
USPSTF = US preventative Services Task Force; CMS = Center for Medicare and Medicaid Services; NCCN = National Comprehensive Cancer Network; NLST = National Lung Screening Trial; AATS = American Association for Thoracic Surgery[1] Organizations including the American Cancer Society (ACS), American College of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), American Lung Association (ALA)[1] History of personal cancer, lung disease, family member with lung cancer, radon exposure, occupational exposure, COPD or pulmonary fibrosis. [1] Resulting in cumulative lung cancer risk ≥5% in 5 years (ie. COPD with FEV1<70%, environmental/occupational exposure, prior cancer/radiation therapy, genetic/family history)[1] After 4 yrs negative surveillance
CMS Requirements
• Written order during a “LCS counseling and shared decision meeting.”
– Eligibility
– Shared decision meeting using decision aid to include benefits, harms, follow-up diagnostic testing, overdiagnosis, false positive rate, and radiation exposure
• Tobacco cessation counseling
• Nodule management protocol
• Participated in LCS trial or ACR certified
• Dose <1.5mSv
• Collect and submit data to CMS-approved registry of LCS– ACR
What Makes a Quality LCS Program?
CHEST and ATS (Chest 2015)
• Adhere to USPSTF guidelines
• LDCT based on ACR-STR technical recommendations
What Makes a Quality LCS Program?
CHEST and ATS (Chest 2015)
• Nodule management protocol and structured reporting (LungRADS)
• Expertise in multidisciplinary management of nodules, including non-surgical biopsy and minimally invasive surgery
What Makes a Quality LCS Program?
CHEST and ATS (Chest 2015)
• Nodule management tracking system/database of procedures and outcomes
• Reporting of data annually
What Makes a Quality LCS Program?
CHEST and ATS (Chest 2015)
• Integrated tobacco cessation program with database
• Strategy for educating providers and patients on benefits and harms of LCS
How to Find an LCS Center
ACR Accredited Facility Search
http://www.acr.org/Quality-Safety/Accreditation/Accredited-Facility-Search
Lung Cancer Alliance Screening Centers of Excellence
http://www.lungcanceralliance.org/
LCS Program at COH
•NP run
•Program Coordinator
(Sophia Yeung)
•Multidisciplinary:
•Pulmonology, Thoracic
Surgery, Radiology
•Integrated tobacco
cessation
Barriers to Lung Cancer Screening• Primary Care
– Time
– Incentive
– Understanding of guidelines
– Understanding risk/benefit/cost
• Patient
– Awareness
– Fear
– Availability
• System– Identification of eligible patients
– Availability
Physician Barriers
• COH Primary Care Physician Study
– Lung Cancer Research Foundation
• Surveyed PCPs in LA County on utilization and perception of lung cancer screening
– Analysis beginning
• Goal is to develop educational and system interventions to improve utilization
Patient Barriers
• Plan ‘pilot’ survey of perceptions of LCS among current and former smokers
• Data on lung cancer risk perception
• Integration with tobacco cessation efforts
– California Quit Line
• Tailor educational intervention
– Diverse populations
System Barriers
LCS in Never Smokers
• IELCAP-FAMRI (Flight attendant medical research institute)
• Never smokers exposed to ‘significant’ second-hand smoke
• Age >40
• Target accrual 7000
• Goal: prevalence of nodules, cancer, emphysema, CAC in never smokers
• COH is the Southern California site
Criteria for LCS
Criteria for LCS
What We Find on LCS
Non-solid= Adenocarcinoma
in situ (AIS) or minimally
invasive adenocarcinoma
(MIA)
Part-solid
Solid
Conclusions
• Lung cancer screening saves lives
• All patients with early stage lung cancer should be evaluated for treatment
• Minimally invasive surgery is the standard of care for clinical stage I lung cancer