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Pål Møller P-LSD
Project description 2014.06.11
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Prospective Lynch Syndrome Database (P-LSD)
Initiated by a European collaborative group (http://mallorca-group.eu/ ).
Pål Møller (PI)
[email protected]
Summary
Germ-line mutations in one of the four genes MLH1, MSH2, MSH6 and PMS2 are the main cause of
adult onset inherited colorectal cancer (Lynch Syndrome (LS)). LS includes a wide range of cancers:
colorectal, endometrial, urinary tract, ovary, brain, prostate, skin, etc. The early description was
focused on colorectal cancer, and families with nothing but colorectal cancer were selected to testing
to find the genes. Current knowledge of penetrances and expressions of the genes are still mostly
based on such series and include severe ascertainment biases. The collaborative networks of scientists
publishe guidelines for health care followed by most. The networks have data on long-time follow-up
of the mutation carriers, and have decided to compile these series to arrive at empirically observed
age and sex dependent risk for cancer, which cancers they are at risk for, and survival when cancer is
diagnosed. This information will be instrumental to tailor personalized, evidence-based health service
for the mutation carriers.
Goals
1. Determine prospectively observed penetrances and expressions in mutation carriers according
to age, sex, MMR gene mutated, and intervention.
2. Determine prospectively observed survival after cancer diagnoses in MMR mutation carriers.
3. Provide the basis for future in-depth studies in all areas mentioned above.
Introduction
Inherited colorectal cancer is a frequent, serious disorder which may be cured or prevented through
primary and/or secondary prevention strategies. The health service needs validated information on the
inherited colorectal cancer syndromes, tools to identify the high risk groups and means to prevent and
cure the cancers. Four mismatch repair (MMR) genes are demonstrated to cause HNPCC when
mutated: MLH1, MSH2, MSH6 (including EPCAM) and PMS2. These genes cause extra-colonic
cancers as well, and the inherited cancer syndromes they cause are now commonly referred to as
‘Lynch Syndrome’ (LS). LS includes a substantially increased risk of colorectal and endometrial
cancer, along with increased risk of ovarian, gastric, small bowel, urothelial, brain, hepatobiliary,
pancreatic, bladder, kidney, prostate, and breast cancers[1-9, 23].
The four different genes have different penetrances and expressions when mutated.
Over the last years, one has moved from regarding LS primarily as a hereditary colorectal cancer
(CRC) syndrome to considering it a multi organ cancer syndrome. CRC and endometrial cancer are
the predominant cancers observed, but MMR mutations are associated with an increased risk of a
range of other cancers. It has also become clearer that the four MMR genes differ with respect to both
penetrances and expressions. Because both CRC and endometrial cancer seems to be prevented by
today’s means, an increasing number of mutation carriers are expected to become older then before.
In this way the number of persons at risk for extra-colonic cancers in older age is expected to
increase, making (as an example) prostate cancer in males over 50 years a challenge to prevent.
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Estimates of CRC risk in MMR mutation carriers vary from 28-100% in males and 25-83% in
females [10]. It has been reported that MLH1 is associated with a lifetime risk of CRC of 78%
compared to 57% for MSH2 and 54% for MSH6 [10]. Mean age of onset is 3 years younger in MLH1
than MSH2 [11], and 3-10 years lower for MSH2 and MLH1 compared to MSH6 [10,12]. There is
limited information about CRC risk in PMS2, but it may be similar to MSH6 [13]. For endometrial
cancer the situation may be different. Ramsoekh et al found a lifetime risk of endometrial cancer of
61% for MSH6 compared to 25% for MLH1 and 49% for MSH2 [10]. However another study did not
find a difference in endometrial cancer risk [12, 24].
Estimates of lifetime risk of the other LS associated cancers vary from 1.9-8.4% for urinary tract and
upper urinary tract cancer, from 6 -13.5% for ovarian cancer, from 0.6-4.2% for small bowel, from
0.7-9.4% for gastric cancer, from 0.4-3.7% for pancreatic cancer, from 1.9-5.5% for bladder cancer,
from 3.4-3.7% for brain tumours, from 9.1-30% for prostate cancer and from 5.4-14.4% for breast
cancer. Most studies performed on these cancer types report the highest risk for carriers of MSH2
mutations, followed by MLH1. Most studies report a very low frequency of these cancers in carriers
of MSH6 mutations [1]. There is very limited information on cancer risk in carriers of PMS2
mutations, but it has been suggested that its phenotype is similar to MSH6 [13].
When interpreting these numbers, it must be kept in mind that most studies include very few or no
carriers of MSH6 mutations. This may be due both to the fact that testing for MSH2 and MLH1
mutations have been available for the longest time, but also to the fact that most families with
mutations in MSH6 (and possibly PMS2) do not fulfill the clinical criteria used to select families for
genetic testing [14,15,13]. Interestingly, a recent population based study where 1893 women with
epithelial ovarian cancer were tested for mutations in MLH1, MSH2 and MSH6, five had MSH6
mutations, two had MLH1 mutations and two had MSH2 mutations [16]. Similarly, we observed
prostate cancer to occurr with the highest frequency in carriers of MSH6 mutations [8]. In a German
study from 2004, the frequency of prostate, breast, lunch and gastric was increased in carriers of
MSH6 mutations compared to carriers of mutations in MLH1 and MSH2 [12].
In sum, the current knowledge of penetrances and expressions mutations is incomplete but strongly
suggests significant differences between the four genes when mutated. The project will clarify this,
and through that give rationale for tailored/personalized health care to carriers of mutations in the
different genes.
Survival
Some reports on survival of LS cancers detected have been published [17-22], but the full range of
survival based on which cancer, sex and which gene mutated is poorly documented [1] and needs
further clarification.
Prospective studies
is the only method generally approved for oncologic research. The reason why prospective studies are
rare in genetics, is that they are hard to do. No centre or country has large enough series of
prospective data on LS to arrive at conclusions alone. Broad international collaborations are
necessary to compile results from prospective series to reach results within reasonable time. We
started subjecting persons at risk for cancer due to family history to colonoscopy screening more than
two decades ago. Later, the MMR genes were found and the families are now tested – the mutation
carriers have been identified in these old prospective series. In this way we actually have follow-up
data on mutation carriers from prior to identification of the causative genes. The collaborators
together will have more than 50,000 prospective follow-up years of mutation carriers if all with such
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data join, which will be sufficient to reach the goals established. Later, a number of additional
parameters may be added to the current basic structure (number of adenomas removed, months since
last colonoscopy when cancer demonstrated, etc., etc.,) which will result in prospective reports
including such parameters. Most of the collaborating centres have blood samples and/or access to
tumour specimens for additional examinations, which may allow for stratifications with techniques
yet to be invented and for putative modifying genetic factors to be identified.
The topics for the prospective studies will be age, sex and gene dependent penetrances and
expressions of the mutations, and gene and cancer-site specific survival after diagnosed cancer. All
mutation carriers have been subjected to colonoscopic follow-up to detect and remove precancers
(adenomas), meaning that the cumulative risk for colorectal cancer will reflect the effect of
colonoscopy for early detection and treatment. Precancers are rarely seen in other organs. For these
groups, cumulative incidence by age will be measured. Survival may be an effect of early diagnosis
and treatment in these groups as well, but not only because of early diagnosis through follow-up, but
also because of increased cancer awareness in general. Some will have undertaken preventive and
therapeutic surgery (example: hysterectomy, oophorectomy), and the effect of such will be measured.
Some will have been included in chemoprevention trials – these are carried out by a collaborator and
the efforts to analyse the series will be merged [17]. In sum, we will describe the outcome of the
interventions as of today, and identify areas for further research.
The expected outcome will be that each of the four genes when mutated have different penetrances
and expressions, and that health care modalities will be tailored to each carrier with respect to which
gene mutated, age and sex, to which ends the study is translational research and will produce
evidence to arrive at personalized medicine.
Interventions
All results will include effects of interventions as no prospective series without preventive intervention
(colonoscopy) may be available, and all (pre)cancers are assumed subjected to treatment when
demonstrated. All reported patients will have been invited to secondary prevention by colonoscopy
according to standards at the reporting centres. Also, the patients/families have been informed on risk for
extra-colonic cancers and an element of early diagnosis due to cancer-awareness is included.
Compliance with protocol and other details are currently not asked for – they are possible goals for later
studies pending results of this study. The study includes no activity not already undertaken by the
reporting centres.
Methods
1. Prospective open observational trial. Control group for prospective studies are not doable – one
cannot randomize to non-intervention when high risk for cancer is documented nor to nontreatment when (pre)cancer is diagnosed. Retrospective series already published may within the
limitations given by time-trend and selection artifacts be used as contrast groups – these are the
currently used estimates of penetrances and expressions to be replaced with the outcome of our
prospective series.
2. Inclusion criteria:
 Patient included based on any argument to be at risk (initially often family history alone), - and
 Demonstrated mutation in one of the genes MLH1, MSH2, MSH6 or PMS2 at any time before, at
or after inclusion.
 Nationally obtained approvals and consents to the study as needed.
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3. Minimum data asked for- cfr spreadsheet:
– Pseudonym for patient ID – code to remain by each provider (see format below).
– Mutation
– Sex
– Year birth
– Age inclusion
– Age last observation
– Age intervention
– Age organectomy
– Age cancer
– Age death

Patient Id is crucial to the database. Each reporting centre will be given a prefix by
administrator (which will be telephone country code + centre number within country).
The ID is to be one alpha-numeric string starting with the first position given by the
administrator, followed (without space) by the centre-given id which may contain
nothing but letters (A-Z), digits (0-9) and underscore (_). Blanks/spaces are not
allowed. These format specifications are given by the database (Oracle) and are not
negotiable. The above logic will ensure no patient from different centres to have the same
Id and later updates will be possible. This is crucial to the database and is not negotiable.

Mutation is needed for stratifying series on mutated gene.

Sex is needed for stratifying series for sex-limited expressions (ovary, prostate, etc.)

Year birth is needed to consider age-cohorts for time-trends in environmental factors (modifyers
of penetrance and treatment modalities).

Age of inclusion is to be the age at first prospectively planned colonoscopy. Patients identified as
mutation carriers in the process of diagnosing current cancer, should be included. Stratification on
index case due to cancer or prevalent cancer in patient without sign or symptom at inclusion, will
be sorted out later.

Age last observation should be greater than age inclusion (if not, observation time is zero and
patient will anyhow be deleted from analyses – no harm is done if including these patients in
report).

Age cancer is to be age and diagnosis of any cancer diagnosed prior to, at or after inclusion. Age
inclusion compared to age cancer will identify cancers prior to, at or after inclusion. Persons
included with no cancer prior to or at inclusion will be used to estimate cumulative risk for cancer
(subtypes) by age and sex, and comparison with persons having had cancer prior to or at inclusion
will elucidate the prevalence of (para)synchronous cancers. Later identification of ‘true’
prevalence round cancer may be used to assess time in preclinical detectable stages to suggest
intervals between screening examinations, and to be compared with interval cancers reported
pending time since last screening examination.

Age organectomy is needed to not count observation years for endometrial cancer after
hysterectomy, etc.. Organ and age is to be given.
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
Age death is necessary to estimate survival. Cause of death is not asked for initially, but may be
necessary to determine survival if more than one cancer, and should be added in such cases.

Reporting format: Spreadsheet.
Data will be stored in a relational database (Oracle) having the capacity for later addition of any
information of interest, and to examine any combinations of the information stored.
In addition, we will decide methods to analyse pre-infiltrative tumours (colorectal adenomas)
detected and removed – see spreadsheet on full dataset. These data may be contributed at a
later time as an addition to the minimum data set which is necessary to get started.
Collaborative guidelines
1. All contributors may publish own data on their own.
2. Each group may include the authors they feel right to respect those who over years
contributed (cfr international guidelines on authorship)
3. All reports have to be acknowledged by all contributors.
4. Contributors are entitled to withdraw their data set.
5. There may be a group of the major contributors to decide on which reports to produce
when from the data set.
References
1. Vasen, H.F. et al. Revised guidelines for the clinical management of Lynch syndrome (HNPCC):
recommendations by a group of European experts. Gut (2013).
2. Jarvinen, H.J. et al. Ten years after mutation testing for Lynch syndrome: cancer incidence and outcome in
mutation-positive and mutation-negative family members. J Clin Oncol 27, 4793-7 (2009).
3. Umar, A. et al. Revised Bethesda Guidelines for hereditary nonpolyposis colorectal cancer (Lynch syndrome) and
microsatellite instability. J Natl Cancer Inst 96, 261-8 (2004).
4. van Oers, J.M. et al. PMS2 endonuclease activity has distinct biological functions and is essential for genome
maintenance. Proc Natl Acad Sci U S A 107, 13384-9 (2010).
5. Win, A.K. et al. Risks of primary extracolonic cancers following colorectal cancer in lynch syndrome. J Natl
Cancer Inst 104, 1363-72 (2012).
6. Buerki, N. et al. Evidence for breast cancer as an integral part of lynch syndrome. Genes Chromosomes Cancer 51,
83-91 (2012).
7. Scott, R.J. et al. Hereditary nonpolyposis colorectal cancer in 95 families: differences and similarities between
mutation-positive and mutation-negative kindreds. Am J Hum Genet 68, 118-127 (2001).
8. Grindedal, E.M. et al. Germ-line mutations in mismatch repair genes associated with prostate cancer. Cancer
Epidemiol Biomarkers Prev 18, 2460-7 (2009).
9. Win, A.K. et al. Colorectal and other cancer risks for carriers and noncarriers from families with a DNA mismatch
repair gene mutation: a prospective cohort study. J Clin Oncol 30, 958-64 (2012).
10. Ramsoekh, D. et al. Cancer risk in MLH1, MSH2 and MSH6 mutation carriers; different risk profiles may
influence clinical management. Hered Cancer Clin Pract. 23;7(1):17 (2009).
11. Goecke, T. et al. Genotype-phenotype comparison of German MLH1 and MSH2 mutation carriers clinically
affected with Lynch syndrome: a report by the German HNPCC Consortium. J Clin Oncol. 10;24(26):4285-92
(2006).
12. Plaschke, J. et al. Lower incidence of colorectal cancer and later age of disease onset in 27 families with
pathogenic MSH6 germline mutations compared with families with MLH1 or MSH2 mutations: the German
Hereditary Nonpolyposis Colorectal Cancer Consortium. J Clin Oncol. 15;22(22):4486-94 (2004).
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13. Hendriks, YM. et al. Heterozygous mutations in PMS2 cause hereditary nonpolyposis colorectal carcinoma
(Lynch syndrome). Gastroenterology. 130(2):312-22 (2006).
14. Sjursen, W. et al. Current clinical criteria for Lynch syndrome are not sensitive enough to identify MSH6
mutation carriers. J Med Genet. 47(9):579-85 (2010).
15. Ramsoekh, D. et al. A high incidence of MSH6 mutations in Amsterdam criteria II-negative families tested in a
diagnostic setting. Gut. 57(11):1539-44 (2008)
16. Pal, T. et al. Frequency of mutations in mismatch repair genes in a population-based study of women with
ovarian cancer. Br J Cancer. 107(10):1783-90 (2012).
17. Palomaki GE, McClain MR, Melillo S, Hampel HL, Thibodeau SN. EGAPP supplementary evidence review:
DNA testing strategies aimed at reducing morbidity and mortality from Lynch syndrome. Genet Med. 2009
Jan;11(1):42-65. doi: 10.1097GIM.0b013e31818fa2db,
18. Knaebel HP, Benner A, Bläker H, Gebert J, Kienle P, von Knebel Doeberitz M, Kloor M. Microsatellite
instability in colorectal cancer is associated with local lymphocyte infiltration and low frequency of distant
metastases. Br J Cancer. 2005 May 9;92(9):1746-53.
19. Watson P, Lin KM, Rodriguez-Bigas MA, Smyrk T, Lemon S, Shashidharan M, Franklin B, Karr B, Thorson A,
Lynch HT. Colorectal carcinoma survival among hereditary nonpolyposis colorectal carcinoma family members.
Cancer. 1998 Jul 15;83(2):259-66
20. Stigliano V, Assisi D, Cosimelli M, Palmirotta R, Giannarelli D, Mottolese M, Mete LS, Mancini R, Casale V.
Survival of hereditary non-polyposis colorectal cancer patients compared with sporadic colorectal cancer patients. J
Exp Clin Cancer Res. 2008 Sep 19;27:39. doi: 10.1186/1756-9966-27-39
21. Pylvänäinen K, Lehtinen T, Kellokumpu I, Järvinen H, Mecklin JP. Causes of death of mutation carriers in
Finnish Lynch syndrome families. Fam Cancer. 2012 Sep;11(3):467-71. doi: 10.1007/s10689-012-9537-3
22. Grindedal EM, Renkonen-Sinisalo L, Vasen H, Evans G, Sala P, Blanco I, Gronwald J, Apold J, Eccles DM,
Sánchez AA, Sampson J, Järvinen HJ, Bertario L, Crawford GC, Stormorken AT, Maehle L, Moller P. Survival in
women with MMR mutations and ovarian cancer: a multicentre study in Lynch syndrome kindreds. J Med Genet.
2010 Feb;47(2):99-102. doi: 10.1136/jmg.2009.068130. Epub 2009 Jul 26.
23. Grindedal EM, Blanco I, Stormorken A, Maehle L, Clark N, González S, Capella G, Vasen H, Burn J, Møller P.
High risk of endometrial cancer in colorectal cancer kindred is pathognomonic for MMR-mutation carriers. Fam
Cancer. 2009;8(2):145-51. doi: 10.1007/s10689-008-9219-3.Epub 2008 Oct 8.
24. Vasen HF, Stormorken A, Menko FH, Nagengast FM, Kleibeuker JH, Griffioen G, Taal BG, Moller P, Wijnen
JT. MSH2 mutation carriers are at higher risk of cancer than MLH1 mutation carriers: a study of hereditary
nonpolyposis colorectal cancer families. Clin Oncol. 2001 Oct 15;19(20):4074-80
25. Stormorken AT, Clark N, Grindedal E, Maehle L, Møller P. Prevention of colorectal cancer by colonoscopic
surveillance in families with hereditary colorectal cancer. Scand J Gastroenterol. 2007 May;42(5):611-7.
26. Møller P, Clark N, Mæhle L. A SImplified method for Segregation Analysis (SISA) to determine penetrance and
expression of a genetic variant in a family. Hum Mutat. 2011 May;32(5):568-71. doi: 10.1002/humu.21441. Epub
2011 Feb 22.
27. Møller P, Clark N. CGEN--a Clinical GENetics software application. Hum Mutat. 2011 May;32(5):537-42. doi:
10.1002/humu.21452. Epub 2011 Mar 8.
28. Burn J, Mathers JC, Bishop DT. Chemoprevention in Lynch syndrome. Fam Cancer. 2013 Jul 24. [Epub ahead of
print]
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Minimum data structure and reporting format
Tables below may be copied to spreadsheet.
Reporting format Excel 2003 (.xls) or earlier.
For uniform contruction of PtnId as primary and relational key in the database never to have a
duplicate from another contributor, contact PI for instructions.
Minimum data structure for prospective MMR studies
A Parent table One row pr patient (all fields obligatory, age died blank means patient is alive).
PtnID
Contributor
Year Birth
Sex
Gene
Mutation
Age
AgeLastUpdate
inclusion
AgeDied
B Cancers
One row for each cancer for each patient (= none, one or many rows pr
patient)
At least one out of Organ, ICD9 and/or ICD10 must be
completed.
PtnId
Organ
ICD9
ICD10
Age
D Organs completely removed
One row for each organ removed for each patient (= none, one or many rows pr patient)
PtnId
Organ
Age
For full data structure, see attached file DataStructureProspectiveStudies.xls
The collaborative group may decide to ask for all these data later, but completion of the full data
structure is not necessary to join initially. Also, there may be modifications if first results indicate
need for other information.
The principles underlying the study and the database structure, is that we may decide to collect
more data later, insert them into the database to be part of more detailed analyses, and all data
will still be prospective information from inclusion onwards.
For those needing permission to export the anonymized data sets for collaboration, you may
consider to seek permission for the full data structure. The study itself needs no permission, it is
based on the data the collaborative partners already have with the local permissions already
obtained.
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A short-version of ICD9 for cancer diagnoses sufficient for the first analysis will be as follows (but any
extended full ICD9, ICD10 or organ in text will be accepted):
150 ESOPHAGUS
151 GASTRIC
174 BREAST
152 DUODENUM
175 BREAST MALE
153 COLON
180 CERVIX
154 RECTUM/SIG
182 ENDOMETRIE
155 HEPAR
183 OVARY
156 BILIAREY DUCT GALL BLADDER
184 Q GEN
157 PANCREAS
185 PROSTATE
158 PERITONEUM
186 TESTES
159 ABD UNSPEC
188 URINE BLADDER
160 NOSE LARYNX
189 KIDNEY / URETER
161 MOUTH PHARYNX
190 EYE
162 LUNG
191 BRAIN
163 PLEURA
193 THYROID
164 MEDIASTINUM
194 ADRENAL, PARA ETC
SPREAD UNKNOWN
170 OSTEOSARCOM
199
ORIGIN
171 SOFT TISSUE SACRCOMA
202 LYMPHOMA
172 MELANOMA
208 LEUKEMIA
173 SKIN
174 BREAST
175 BREAST MALE
180 CERVIX