Download ONTARIO CANCER GENETIC TESTING PROGRAM

ONTARIO CANCER GENETIC TESTING PROGRAM
Requisition for Genetic Screening for Familial Breast and Ovarian Cancer
A pedigree must accompany all requests for testing. Failure to provide all requested information will mean testing is not performed.
Sample Requirements:
Genetics# or ID#___________________________________
Blood
Name______________________________________(M or F)


ACD (yellow top)
_______ ml room temp
EDTA (lavender top) _______ ml room temp
Address__________________________________________
Date of Collection: __________/______/______ (YY/MM/DD)
_________________________________________________
Time of Collection: _______________________
DOB ________/________/________ (YY/MM/DD)
Location: _______________________________
HC#_____________________________Version Code______
Shipping Instructions:
Collect and ship samples at room temperature on the same day.
Samples should be received within 24 to 48 hours.
Name and HC# of consultand if different than above
Name______________________________________(M or F)
HC#_____________________________Version Code______
Has this individual had cancer?
Family Information Known to Consultand
Yes
Have samples from this family been sent to a DNA lab before?
No
Specify Type: _________________________
If No, specify name of index case in the family
Yes
No
If Yes, specify relationship to your patient __________________________
_____________________________________DOB______________
Has a mutation been found in another family member?
Yes
No
Ethnic Background ______________________________________
If Yes, provide specific details (or copy of report) Gene:
_______ Mutation: _______
GENETIC RISK INFORMATION - Use disease specific risk categories described on back of requisition, circle all categories which
apply to your patient. This information must be included.
Risk category:
1
2
3
4
5
6
7
8
9
10
11
12
13
*** For expedited testing, please circle one of the following criteria (see back of requisition): 1 2
TEST REQUESTED:  NGS 16-gene panel  NGS 19-Breast/Ovarian panel  NGS 25-comprehensive cancer panel
 BRCA1/BRCA2  AJ Mutations  Family Specific Mutation (attach copy of relative’s report)  DNA Banking  RNA
Banking  Research
 Expedited Testing (*** must meet one of criteria listed on back)
Contact Person and Phone Number:
Report to (Geneticist, Name and Address):
Other Physician (Name and Address):
Authorized Signature: _____________________________________________(*** For expedited testing, request must be authorized
b
by ordering physician before sample sent ***)
SHIP TO MOLECULAR GENETICS LABORATORY FOR YOUR PROVINCIAL REGION:
 CHEO DNA Diagnostic Laboratory, Rm. W3403, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Ph: (613) 738-3230.
 Credit Valley Hospital, Dept of Laboratory Medicine, Rm. 1858, 2200 Eglinton Ave. W., Mississauga, ON, L5M 2N1, Ph: (905) 813-4104.
 H.H.S C., McMaster Site, Room 3H45, Cancer Genetics, 1200 Main St. W., Hamilton, ON, L8N 3Z5, Ph: (905) 521-2100, X75401.
 KGH DNA Diagnostic Laboratory, Rm. 8-412, 76 Stuart Street, Kingston, ON, K7L 2V7, Ph: (613) 549-6666, X4134.
 LHSC Molecular Genetics Laboratory, Zone, B10-123A, 800 Commissioners Rd. E., London, ON, N6A 5W9, Ph: (519) 685-8122.
 Mount Sinai Hospital, Laboratory Medicine, Rm. 6-306B, 600 University Ave., Toronto, ON, M5G 1X5, Ph: (416) 586-5974.
 NYGH Molecular Genetics Laboratory, 4001 Leslie St., Toronto, ON, M2K 1E1, Ph: (416) 756-6791.
RISK CATEGORIES FOR INDIVIDUALS ELIGIBLE FOR SCREENING FOR A GENETIC
SUSCEPTIBILITY TO BREAST OR OVARIAN CANCERS
Testing for Affected Individuals with Breast or Ovarian Cancer
At least one case of cancer:
1.
2.
3.
4.
Ashkenazi Jewish and breast cancer <50 years, or ovarian cancer at any age.
Note: testing limited to ethnic specific mutations, unless other criteria given in this list are met.
Breast cancer <35 years of age.
Male breast cancer.
Invasive serous ovarian cancer at any age.
At least 2 cases of cancer on the same side of the family:
5.
Breast cancer <60 years, and a first or second-degree relative with ovarian cancer or male breast cancer.
6.
7.
8.
9.
Breast and ovarian cancer in the same individual, or bilateral breast cancer with the first case <50 years.
Two cases of breast cancer, both <50 years, in first or second-degree relatives.
Two cases of ovarian cancer, any age, in first or second-degree relatives.
Ashkenazi Jewish and breast cancer at any age, and any family history of breast or ovarian cancer.
Note: testing limited to ethnic specific mutations, unless other criteria given in this list are met.
At least 3 cases of cancer on the same side of the family:
10.
Three or more cases of breast or ovarian cancer at any age.
Testing for Unaffected Individuals (this should be done only if affected individuals are unavailable e.g.
deceased)
11.
12.
13.
Relative of individual with known BRCA1 or BRCA2 mutation.
Note: specific family mutation only tested.
Ashkenazi Jewish and first or second-degree relative of individual with:
breast cancer <50 years, or-ovarian cancer at any age, or-male breast cancer, or-breast cancer, any age,
with positive family history of breast or ovarian cancer
Note: testing limited to ethnic specific mutations, unless meet other criteria
A pedigree strongly suggestive of hereditary breast/ovarian cancer, i.e. risk of carrying a mutation for the
individual being tested is >10%.
EXPEDITED TEST CRITERIA
1. Patient is currently receiving treatment for breast cancer. Expedited testing would allow the patient and doctor the
option of proceeding with prophylactic mastectomy, instead of radiation therapy is she is found to carrier a
BRCA1 or BRCA2 mutation. If mastectomy is chosen, the patient can avoid unnecessary radiation and have the
full range of options for reconstructive surgery
AND
Patients surgery or radiation therapy is to begin no sooner that 8 weeks form the date of blood draw, and before
the results are expected, based on the current TAT for testing in the province.
Note: this criteria EXCLUDES elective reconstruction and /or prophylactic surgery as a reason for expedited
testing, unless it is being done at the same time as surgery to treat the patients cancer.
2. Patient requires surgery for other urgent medical reasons (eg. Hysterectomy for uterine bleeding causing anemia)
and may use the information to alter surgical decisions (eg. Salphingo-oophorectomy to be done with
hysterectomy)
AND
Patients surgery or radiation therapy is to begin no sooner that 8 weeks form the date of blood draw, and before
the results are expected, based on the current TAT for testing in the province.
Note : this does NOT include unaffected patients who want to make a decisions about prophylactic surgery
June 2008/ LHSC edit Aug 2016