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August 2012
Mantra Resort, NSW
PROGRAMME
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand
“Familial Aspects of Cancer 2012 Research and Practice”
Tuesday 21st August
FCC Day –Plantation Room
Sponsored by:
9.00 – 9.10
Welcome: Gillian Mitchell
FCC Session 1.
Chairperson:
9.15 – 10.30
Massively parallel sequencing
Julie McGaughran
Next generation sequencing: the promises and requirements of a
transformative genomic technology.
Tony Roscioli
Massively parallel sequencing: issues for clinical practice.
Graeme Suthers
Followed by panel discussion: Graeme Suthers, Tony Roscioli, Sean
Grimmond, Cliff Meldrum, Andrew Biankin, Alison Trainer, Ian
Campbell
10.30 – 11.00
Morning tea
FCC Session 2
Chairperson
11.00 – 12.30
A smorgasbord for clinical practice
Nicola Poplawski
Risk-reducing behaviour of female BRCA1 and BRCA2 mutation
carriers; long-term follow-up of participants in the Kathleen
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Cuningham Foundation Consortium for Research into Familial
Breast Cancer (kConFab).
Ian Collins
Germline PTEN gene mutations and Cowden Syndrome: a plastic
condition with implications for clinical practice?
Marion Harris
A proposed screening study in Li Fraumeni Syndrome.
Gillian Mitchell
Non-cancer outcomes of risk-reducing bilateral salpingooophorectomy: a proposed clinical trial.
Martha Hickey
12.30 – 1.30
Lunch
12.30 – 12.45
COSA FCC Group - Plantation Room
FCC Session 3
1.30 – 1.50
1.50 - 3.15
eviQ update – current activity and future plans in familial
cancer
Robyn Ward
Counselling adolescents at risk of genetic syndromes
Chairperson: Margaret Gleeson
Developing a youth friendly model of genetic counselling
Mary-Anne Young
Adolescent Clients in the Clinical Genetics Setting: Using predictive
testing for FAP as a case-study for exploring developmentally
appropriate care.
Rony Duncan
Support and counselling of adolescents with cancer, contrasts and
similarities with hereditary cancer syndromes.
Kate Thompson
3.15 – 3.45
FCC Session 4
3.45 – 5.30
Afternoon Tea
Pancreatic/GI cancer
Chairperson: Lara Lipton
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Screening for pancreatic cancer in high risk individuals.
Alina Stoita
A new way to screen for pancreatic cancer?: KRAS serum
screening.
Lara Lipton
A fresh look a SMAD 4.
Noralane Lindor
CAPP3 trial in Lynch syndrome – an update
Finlay Macrae
Follow on meetings in the Plantation room:
IMPACT meeting
5.30 – 6.15 PM
CONFIRM meeting
6.15 – 6.45 PM
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Wednesday 22nd August
ABCFS, ACCFS, kConFab and AOCS –
Plantation Room
8.30 – 8.40
Welcome: Stephen Fox
Session 1 –
Plantation Room
Chairperson: Georgia Trench
8.40 – 9.20
Epigenetic Epidemiology: Exploring the epigenome to find
biomarkers of cancer risk and prognosis.
James Flanagan
9.20 – 9.40
Lobular breast cancer GWAS
Ian Tomlinson
9.40 – 10.00
A GWAS-based cross-disease approach to find genes predisposing to
both endometriosis and endometrial cancer.
Jodie Painter
10.00 – 10.20
Genotypic and phenotypic analysis of familial male breast cancer
shows under representation of the HER2 and basal subtypes in
BRCA-associated carcinomas.
Stephen Fox
10.20 – 10.40
Genome- wide scan of methylation of DNA extracted from archival
blood biospecimens.
Chol-hee Jung
10.40 – 11.10
Morning Tea
11.10 – 11.50
Plantation Room
The Jeremy Jass Memorial Lecture
Introduction & Chair: John Hopper
Presented by:
Looking Forward in Lynch Syndrome
Noralane Lindor
Session 2
Chair: Daniel Buchanan
11.50 - 12.10
Relative risk of colorectal cancer risk in Lynch syndrome is
inversely associated with age: a review.
Mark Jenkins
12.10 – 12.30
Is breast cancer a Lynch syndrome cancer?
Aung Ko Win
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
12.30 – 12.45
Prostate cancers arising in Lynch syndrome mutation carriers
frequently show DNA mismatch repair deficiency
Mike Walsh
12.45 – 1.05
Methylation of DNA Repetitive Elements from Peripheral Blood DNA
is Associated with Early-Onset Colorectal Cancer
Daniel Buchanan
1.05 - 2.00
Lunch
Session 3 –
CONCURRENT SESSION:
Psychosocial and Cohort Research
Moss Room, Peppers
Chair: Rachel Williams
2:00 – 2:20
Disclosure obligations for participants donating a DNA sample for
genetic research to lifepool. What does the woman in the street
need to know and what does she need to tell insurance companies?
Jeff Gleeson
2:20 – 2:40
Evaluation of the efficacy of two models of delivering information
about treatment-focused genetic testing among your women newly
diagnosed with breast cancer
Bettina Meiser
2:40– 3:00
The attitudes of people with sarcoma, their family and health
professionals towards genomics and ancillary information arising
from genetic research.
Mary Anne Young
3:00 – 3:25
What happens when uncertainty remains? A systematic review and
quantitative exploration of distress in unaffected high-risk
individuals who decline, delay or remain ineligible for predictive
genetic testing
Louise Heiniger
3.25 – 3.45
Improving mutation notification when new genetic information is
identified in research: A trial of two strategies in familial breast
cancer employed by kConFab.
Heather Thorne
3.45 – 4.05
What matters to women diagnosed with breast cancer during their
reproductive years? Preliminary results from a qualitative
investigation using a population-based sample.
Maggie Kirkman
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
4.05 – 4.35
Afternoon Tea
Session 4 –
CONCURRENT SESSION
Plantation Room
Chairperson: Melissa Southey
2.55 – 3.15
Population-based estimate of prostate cancer risk for carriers of the
HOXB13 missense mutation G84E
Robert MacInnis
3.15 – 3.35
Colorectal cancer risk for MET T992I missense variant carriers from
the Australasian Colorectal Cancer Family Registry
Daniel D. Buchanan
3.35 – 3.50
Gene regulatory elements as breast cancer susceptibility loci
Melissa Brown
3.50 – 4.10
Gap in the Middle of Familial Colorectal Cancer – Moderately
Penetrant Genetic Variants
Deborah Neklason
5.00 – 7.00
Poster Session + Wine and Cheese in the main foyer
6.00
Plantation Room: The following selected posters will give a 3
minute oral presentation. Chair Judy Kirk.
Order of presentation:
Poster # 5. Kirsty Mann. Interdisciplinary patient file reviews and
follow-up of Peutz-Jeghers syndrome management
Poster # 10. Michelle Bowman. SDHB immunohistochemistry: four
cases from clinical practice.
Poster # 18. Emma Steel. Risk factors for breast cancer: how do
women with a family history obtain and interpret this information?
Posters # 19 & 20. Skye Simpson. Analysis of germline variants in
DNA damage repair genes in pancreatic cancer identified by nextgeneration sequencing, and, The Australian familial pancreatic
cancer cohort: screening for pancreatic cancer in high risk
Australians
Poster # 31. Bryony Thompson. Mismatch Repair Gene Isoforms:
Issues in the Interpretation of Aberrant Splice Transcripts
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Poster #27. Mike Walsh. BRAF V600E immunohistochemistry – A
new approach to screen colorectal cancers for Lynch Syndrome
Poster # 22. Sarah Sawyer. The association of identified breast
cancer common genomic variants and pathological features in
individuals with Hereditary Breast and Ovarian cancer.
Delegates Organise their own Dinner
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Thursday 23rd, August
ABCFS, ACCFS, kConFab and AOCS
- Plantation Room
Session 5 Plantation Room
Chairperson: Gillian Mitchell
9.00 – 9.20
Cancer 2015” (Vic Cancer Genome Cohort): translating discoveries
into cures
John Parisot
9.30 – 9.50
CASCADE: A CAncer tiSsue Collection After DEath programme to
improve our understanding of the progression from primary stage
cancer to metastatic, treatment-resistant disease.
Kathryn Alsop
9.50 – 10.00
Introducing an online bowel cancer risk calculator to promote
colorectal cancer awareness in the community.
Jody Simmons
10.00 – 10.20
A case of two mutations in trans in a women diagnosed with breast
cancer at the age of 30 years.
Margaret Gleeson
10.20 – 10.40
Evaluation of BRCA1/2 variants of uncertain clinical significance
using a combination of multifactorial likelihood analysis,
bioinformatic and in vitro approaches
Phil Whiley
10.40 - 11.10
Morning tea
Session 6 –
Plantation Room
Chairperson: Prue Cowin
11.10 – 11.50
Cloning of the gene for mixed polyposis
Ian Tomlinson
11.50 – 12.10
FAVR (Filtering and Annotation of Variants that are Rare): methods
to facilitate the analysis of rare germline genetic variants from
SOLiD and Illumina datasets
Tú Nguyen-Dumont
12.10 – 12.30
Identification of rare DNA copy number variants overlapping
mismatch repair pathway genes in endometrial cancer patients and
their potential contribution to disease risk
Logan Walker
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
12.30 – 12.50
Scope Vs Hope: when should studies of “missing heritability” go
whole-genome?
Khalid Mahmood
12.50 – 1.10
Mapping the genetic basis of sarcoma in a high risk kindred
David Thomas
1.10 - 2.10
Lunch
Session 7-
Plantation Room
Chairperson: Anna de Fazio
2.10 – 2.30
Invasive epithelial ovarian cancer and BRCA mutations: the South
Australian perspective
Nicola K Poplawski
2.30 – 2.50
LRP1B deletion in high-grade serous ovarian cancers is associated
with acquired chemotherapy resistance to liposomal doxorubicin
Prue Cowin
3.50 – 3.10
Clinically, molecularly and functionally annotated models of HG-SOC
in which to perform pre-clinical analysis of targeted therapies.
Monique Topp
3.10 – 3.30
Molecular profiling of pre-invasive serous ovarian tumours
Sally Hunter
3.30 – 3.50
Genomic profiling of benign, borderline and invasive mucinous
ovarian tumours identifies key and novel genetic events.
Kylie Gorringe
4.00 – 4.30
Afternoon Tea
4.30 – 5.30
Pavillion Room
John Hopper – updates on the Monday and Tuesday meeting
4.30 – 5.00
Plantation Room
FFPE Based Molecular Analysis - The Illumina Story
Brett Kennedy, Product Marketing Manager, Australia and New
Zealand
“Familial Cancer 2012: Research and Practice”
August 2012
6.00 – 8.00
Mantra Resort, NSW
Conference Cocktail drinks pool side @ Peppers.
All delegates welcome.
Delegates organise their own dinner
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Friday, 264h August
ABCFS, ACCFS, kConFab and AOCS
- Plantation Room
Session 8 –
Plantation Room
Chairperson: Michael Bogwitz
8.30-8.50
Improving early diagnosis of MEN2b: raising awareness and
stimulating debate
Hilda High
8.50 – 9.10
Variability of Clinical Features in MEN2
Charlotte Slade
9.10 – 9.30
Review of mutation detection rate for women diagnosed with breast
cancer aged 30 years and younger
Annabelle Ng
9.30 – 9.50
When do we test for Cowden Syndrome?
Leonie Noon
9.50 – 10.10
The Evolution of Li-Fraumeni Syndrome and Challenges for
Counselling
Linda Cicciarelli & Alexandra Lewis
10.10-10.30
Clinical genetic testing for hereditary cancer using next generation
sequencing
Lesley Andrews
10.30 - 11.10
Morning Tea
Session 9 –
Plantation Room
Chairperson: Mandy Spurdle
11.10 – 11.50
Modelling genetic susceptibility to breast and ovarian cancer:
updates to the BOADICEA risk prediction model, and results on
genetic modifiers of cancer risk for BRCA1 and BRCA2 mutation
carriers from the iCOGS custom genotyping array.
Antonis C. Antoniou
11.50 – 12.10
The breast cancer risk prediction model BOADICEA: calibrated for
Australian women and a new easy-to-use batch processor
Robert MacInnis
12.10 – 12.30
Multiple independent TERT variants associated with telomere length
and risks of breast and ovarian cancer
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Georgia Chenevix-Trench
12.30 – 12.50
Risk prediction models for mismatch repair gene mutations: a
systematic review and a meta-analysis.
Aung Ko Win
12.50 – 1.10
Tumour morphology of early-onset breast cancers predicts breast
cancer risk for first-degree relatives
John Hopper
End of Meeting: Lunch will be served
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
PROGRAMME
Tuesday 21st
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
FCC Session 1:
Plantation Room
Chairperson: Julie McGaughran
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
MASSIVELY PARALLEL SEQUENCING: ISSUES FOR CLINICAL PRACTICE
Graeme Suthers, Chair, Genetics Advisory Committee, RCPA; SA Clinical Genetics Service,
SA Pathology, Women’s & Children’s Hospital, North Adelaide SA 5006.
Quality in genetic testing encompasses issues that will be familiar to everyone involved
in the delivery of diagnostic testing: choosing the right test, collecting the right sample,
doing the correct analysis, making the right interpretation, providing a clear and timely
report to the requestor, and trusting that the information will be used appropriately for
decision-making.
However, the scope of genetic testing is huge, both in terms of the variety of tests
available and the potential to impact the health of the patient’s relatives. The
introduction of massively parallel sequencing compounds these challenges. This
introduces some additional challenges for each of these steps:
 Should test selection be restricted to loci known to be associated with disease –
or to potential loci that may be relevant?
 Sampling errors occur and are likely to be missed unless there is corroboration
of key test results.
 The required quality control for a single analyte is stringent. QC for multiple
analytes is challenging. Quality measures in sequencing represent the average
quality over multiple nucleotides – but clinical decision-making is based on the
quality of the specific variants identified.
 The clinical significance of many variants is unknown, and processes to
systematise their consistent interpretation are rudimentary.
 Clinicians already struggle to read reports of older familiar tests accurately. Most
are unskilled in the newer field of genetics.
 A test result may have both immediate and latent significance for the patient or
relatives. How should these be reported?
 The comparative novelty of genetic tests can give them inappropriate influence
in decision-making.
The concept of a genetic test should be re-cast as a consultation with a laboratory
professional if massively parallel sequencing is to be effectively translated into quality
information for patients and their clinicians.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Tuesday 21st
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
FCC Session 2:
Plantation Room
Chairperson: Nicola Poplawski
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
RISK-REDUCING BEHAVIOUR OF FEMALE BRCA1 AND BRCA2 MUTATION
CARRIERS; LONG TERM FOLLOW-UP OF PARTICIPANTS IN THE KATHLEEN
CUNINGHAM FOUNDATION CONSORTIUM FOR RESEARCH INTO FAMILIAL BREAST
CANCER (KCONFAB)
Ian Collins1, Prue Weideman1, John Hopper2, Sue-Anne McLachlan3, Roger Milne4 , Michael
Friedlander5, KConFab Investigators, Kelly-Anne Phillips1,2, Division of Cancer Medicine,
Peter MacCallum Cancer Centre, Melbourne, Melbourne School of Population Health,
University of Melbourne, Oncology Department, St. Vincent's Hospital, Melbourne, Spanish
National Cancer Research Centre, Madrid, Spain, Department of Medical Oncology, Prince
of Wales Hospital, Sydney
Background
Several interventions can prevent breast and ‘ovarian’ cancer in women with a
pathogenic mutation in BRCA1 or BRCA2. Knowledge of the contemporary uptake of
these interventions in Australian women may help guide future policy and clinical
practice.
Methods
Study subjects were female BRCA1 or BRCA2 mutation carriers enrolled in kConFab
between 3/11/1997 and 4/9/2008, unaffected with any cancer at the time of
enrolment, who had completed at least one three-yearly self-reported follow-up
questionnaire (collecting demographic information, cancer events and uptake of risk
reducing measures, including bilateral mastectomy (BRRM) or salpingo-oophorectomy
(RRSO)) since enrolment. Follow-up was censored at a cancer diagnosis, death or date
of last follow-up. Descriptive statistics were calculated using MS Excel.
Results
Of 1317 women from families segregating a mutation in BRCA1 or BRCA2, 447 had a
mutation (237 BRCA1 and 210 BRCA2). Of these, 325(73%) reported knowing their
mutation status (175 BRCA1 and 150 BRCA2), 122(27%) reported being unaware of
their mutation status. During 2447 person-years of follow-up (median 9 years, range 214), 68 incident cancers were reported, including 52 breast cancers, 9 “ovarian”
cancers, 3 melanomas and 1 of each of bowel, gastric, pancreas and unknown primary.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Event
N (%)
Age at event (years)
Median
37
39
45
40
44
n/a
n/a
n/a
36
Range
18-78
18-78
26-80
26-67
30-77
n/a
n/a
n/a
35-56
Cohort entry
325(100)
Disclosure of genetic results
325(100)
Incident cancer diagnosis
68(21)
1
BRRM
69(21)
2
RRSO at any age
110(34)
RRSO by age 40
26(12)3
RRSO by age 50
79(65)4
Both BRRM and RRSO
34(10)
Enrolment in medical prevention
9(3)
trial
Risk reducing tamoxifen
4(1)
37
35-49
Tubal ligation
71(22)
32
20-54
1 7 before cohort entry. 28 Before cohort entry. 3224 women aged 40+ at last followup, 4122 aged 50+ at last follow-up
Of the 71 who reported tubal ligation, 29 subsequently underwent RRSO, including 3
with occult serous cancers. Median time between genetic result disclosure and
subsequent risk reducing behaviour was 1 year [range 0-15].
Conclusion
Most Australian BRCA1 and BRCA2 mutation carriers do not undergo BRRM, few
undergo RRSO before age 40 and 35% had not had RRSO by age 50. Medical prevention
is rarely used. Interestingly 22% undergo tubal ligation (lowering “ovarian” cancer risk)
presumably for contraception. The reasons for the low uptake of risk-reducing
interventions need investigation and intervention is required if genetic knowledge is to
optimally translate into real reductions in cancer incidence in these women.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
COWDEN SYNDROME – THE RELEVANCE OF THE CONDITION FOR FAMILIAL
CANCER PRACTICE IN 2012
Marion Harris, Southern Health Familial Cancer Centre, Victoria
Cowden syndrome ( CS) is a rare tumour- hamartoma syndrome caused by a germline
mutation in the PTEN gene. There is a concern that cases of CS are missed in the BRCA
negative high risk breast cancer population seen by familial cancer services.
The clinical features of the condition will be reviewed and the relevance of the condition
for familial cancer practice in 2012 will be discussed.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
A PROPOSED SCREENING STUDY IN LI FRAUMENI SYNDROME
Gillian Mitchell1, David Thomas1, Mandy Ballinger1, Kate Mahendran2, Nick Ferris3, Martin
Delatycki4, Janet Hiller5, Mary-Anne Young1, Australian Familial Cancer Centres.
1 Peter MacCallum Cancer Centre VIC, 2 Westmead Hospital NSW, 3 Southern Health VIC,
4Austin Hospital VIC, 5 Australian Catholic University VIC.
The Li Fraumeni syndrome is associated with significant risk of cancers arising at
multiple body sites. There is no accepted screening program for adults with this
syndrome other than breast MRI screening for adult women. A recent eviQ guideline
committee meeting reviewed the evidence for screening in this syndrome and only
advised annual breast MRI screening for women with additional annual faecal occult
blood testing and 5-yearly colonoscopy for both men and women.
Whole-body MRI screening is now possible and is attractive for Li Fraumeni families as
it avoids exposure to ionising radiation and can access multiple body sites in a single
screening test. This presentation will outline the proposed whole-body MRI screening
study for Li Fraumeni families in Australia which will form the pilot for a proposed
international screening study in this syndrome.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Tuesday 21st
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
FCC Session 3:
Plantation Room
Chairperson: Margaret Gleeson
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
DEVELOPING A YOUTH FRIENDLY MODEL OF GENETIC COUNSELLING
Mary-Anne Young1, Ann-Maree Duncan1, Lucy Holland2, Kate Thompson2
Familial Cancer Centre, Peter MacCallum Cancer Centre, Victoria, Australia, 2 ONTrac at
Peter Mac, Peter MacCallum Cancer Centre, Victoria, Australia,
1
Evidence suggests that healthcare professionals trained in either adult or paediatric
models of care find it difficult to provide adolescents and young adults (AYAs) services
which meet their developmental and healthcare needs. Genetic counselling is no
exception and anecdotal evidence suggests that it is particularly difficult for these
professionals to provide adolescent care which meets the expectations of both clients
and the counsellor. AYAs present for genetic counselling at a time when they are already
grappling with the developmental challenges of adolescence. Additional anxiety due to
the potential risk of a genetic disease during this lifestage may overwhelm the coping
resources of young people. A lack of specific models of genetic counselling and
counselling strategies for working with young people who are psychosocially
vulnerable compromises the quality of genetic counselling and care received by AYA
clients accessing such services.
To address this problem a reference group was formed to develop a model of AYA
specific genetic counselling. This group comprised experts in adolescent health and
genetic counselling practice and research. A literature review was undertaken following
which a youth friendly model of genetic counselling was developed. This model will be
presented with particular emphasis on genetic counselling practice when working with
AYAs.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
ADOLESCENT CLIENTS IN THE CLINICAL GENETICS SETTING; USING PREDICTIVE
TESTING FOR FAP AS A CASE STUDY FOR EXPLORING DEVELOPMENTALLY
APPROPRIATE CARE
Rony Duncan, PhD, Centre for Adolescent Health
Royal Children’s Hospital, Murdoch Children’s Research Institute
Predictive genetic tests are routinely offered to young people during adolescence as
long as medical benefit is conferred by the test. Nonetheless, it can be highly challenging
to engage, work with and support young people through this process due to (i) their
unique developmental stage of life, (ii) the frequent and simultaneous involvement of
multiple family members, and (iii) the lack of training provided to genetic health
professionals in adolescent health and development. Young people sit between
childhood and adulthood; old enough to have their developing autonomy respected yet
too young to be treated exactly as adults. For these reasons, young people require a
different clinical approach from that provided to adults and this is now gaining strong
recognition internationally.
This presentation will draw on findings from in-depth interviews with young people
who underwent predictive testing for familial adenomatous polyposis (FAP) aged 10-17
years at the time of their test. Using these case-studies and first-hand accounts from
young people, the key challenges associated with seeing adolescent clients, and their
families, in a clinical genetics setting will be highlighted. These findings will then be
placed in the context of existing clinical recommendations for working with adolescents
in the medical setting more broadly. Questions will be raised about what aspects of this
broader guidance are transferable to the clinical genetics setting, with the aim of
working towards a model for best practice with adolescents in clinical genetics
internationally.
Dr Rony Duncan is a Senior Research Fellow at the Centre for Adolescent Health,
Murdoch Childrens Research Institute. She has a background in bioethics, adolescent
health and clinical psychology. Much of Rony’s past research has focused on the
implications of predictive genetic testing in young people. Central to this work were a
series of in-depth interviews with adolescents and young adults who had undergone
genetic tests for Huntington Disease and FAP. Rony’s current program of research
focuses on the ethical issues that arise in adolescent health care, with a particular focus
on confidentiality. In addition to her research, Rony supervises a number of
postgraduate research students, sits on two clinical ethics committees, lectures in ethics
and adolescent health at the University of Melbourne and appears fortnightly on Triple
R Radio as an ethics commentator.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
SUPPORT AND COUNSELLING OF ADOLESCENTS WITH CANCER, CONTRASTS AND
SIMILARITIES WITH HEREDITARY CANCER SYNDROME
Kate Thompson1, Mary-Anne Young2, Lucy Holland1 & Ann-Maree2
1ONTrac at Peter Mac Victorian Adolescent & Young Adult Cancer Service, 2Victorian
Familial Cancer Centre, Peter MacCallum Cancer Centre
Background: A number of developmental changes occur during the adolescent and
young adult (AYA) years that distinguish this life stage from both childhood and
adulthood. Within the healthcare sector, AYA patients present with unique needs
related to biological, psychological and social factors pertinent to this period of
development. Currently these patients receive care within either paediatric or adult
healthcare sectors. However, evidence suggests that healthcare professionals trained in
either model of care find it difficult to provide young people with services which meet
their needs. The specific challenges faced by healthcare professionals include
understanding the AYA life stage and how illness impacts on development, adjustment
and quality of life.
ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service was
developed in 2004 to meet the needs of young people with cancer and their families.
ONTrac at Peter Mac is a Multidisciplinary team which works from the foundational
principles of adolescent development including importance of AYA communication,
promoting autonomy and flexibility working in family models of care. In 2011, in
conjunction with the Familial Cancer Centre at Peter Mac, it was recognised that there
was no specific model of AYA genetic counselling. This was thought to both compromise
the quality of care for young people and present complexities for the professionals
working in this field as work with this patient group is typically accompanied by unique
ethical and practice challenges.
Method: To address this gap, a reference group was formed to develop a model of AYA
specific genetic counselling. This group comprised experts in adolescent health and
genetic counselling practice and research.
Discussion: Principles of practice in work with young people with cancer will be
discussed. The application of these principles to the model of care for working with
young people who present for genetic testing will be delineated. Considerations for the
implementation of this model will be reviewed.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Tuesday 21st
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
FCC Session 4:
Plantation Room
Chairperson: Lara Lipton
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
SCREENING FOR PANCREATIC CANCER IN HIGH RISK INDIVIDUALS
Alina Stoita, St Vincent’s Hospital, Sydney
Ten percent of pancreatic cancers are due to a genetic predisposition (familiar
pancreatic cancer and inherited pancreatic cancer syndromes). The lifetime risk of
pancreatic cancer of an individual with 3 first degree relatives with pancreatic cancer is
40% and with 2 first degrees is 8-12%. Inherited cancer syndromes at high risk of
pancreatic cancer are hereditary pancreatitis, Peutz-Jeghers sydrome, FAMMM, breast
ovarian cancer syndrome and Lynch syndrome. In familial pancreatic cancer, smoking
increases the risk of pancreatic cancer by 2-3 folds and decreased the age of onset by 10
years.
Screening for pancreatic cancer targets individuals with a 5% of greater lifetime risk of
pancreatic cancer. Multiple international screening programs are using endoscopic
ultrasound (EUS) as the main screening modality. Results have shown that EUS can
identify precursor or early lesions and the diagnostic yield is 10% (5-23%). Genetic
counseling in individuals screened was perceived as very useful and these patients
would seek genetic testing if available.
Australian pancreatic cancer screening program, a collaboration of St Vincent’s Hospital
Sydney, NSW Family Cancer Clinics and Garvan Institute targets these high risk groups.
Screening started in 2011 and involves genetic counseling, research blood tests and
EUS.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
A NEW WAY TO SCREEN FOR PANCREATIC CANCER? KRAS SERUM SCREENING
Lara Lipton, Royal Melbourne Hospital, Melbourne
Pancreatic cancer has one of the poorest outcomes of all epithelial cancers. At present
no effective screening tests exist for detecting pancreatic cancer at an early, presymptomatic and potentially curable stage. Although not a common cancer in the
general population, certain individuals and families are at substantial risk due to
inherited causes and chronic pancreatic disease. Over 95% of pancreatic cancers
harbour mutations in KRAS. Current technology is available to detect tiny amounts of
mutant DNA in plasma. This study will collect circulating DNA pre and post-surgery for
operable adenocarcinoma of the pancreas and KRAS mutation testing will be performed
on these samples. If sensitivity appears high, further studies will be performed in
populations of high risk patients.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
A FRESH LOOK AT SMAD 4
Noralane Lindor, Research Program, Mayo Clinic, Arizona, USA
As long ago as 1980, clinicians have described rare families with the combination of
juvenile polyps of the colon associated with digital clubbing and cutaneous and
pulmonary arteriovenous malformations. In 1998, a mutation in SMAD4 was reported
in a large Juvenile Polyposis Syndrome (JPS) family and subsequently it was learned
that SMAD4 mutations cause about 20-25% of autosomal dominant JPS with another
20-25% being explained by mutations in BMPR1A (and the remainder not yet mapped).
On a different front, mutations in ENG and ALK1(ACVRL1) cause about 90% of cases of
Hereditary Hemorrhagic Telangiectasia syndrome (HHT; Osler-Weber-Rendu
syndrome), a vascular malformation disorder. It is notable that all 4 of these genes are
involved with the transforming growth factor-beta signaling pathway. In 2004, 6
families that co-segregated the JPS and HHT phenotypes were all found to have
mutations in SMAD4 and in 2010, 15/19 families with JPS/HHT were confirmed to have
SMAD4 mutations. The phenotypic spectrum of disorders produced by SMAD4 has
expanded now to also include aortopathy, mitral valve dysfunction, and a disorder of
short stature and thick skin known as Myhre syndrome. This talk will review new
information on SMAD4-related disorders with a special emphasis on the JPS/HHT
syndrome that leads easily to the conclusion that any JPS patient with a SMAD4
mutation merits evaluation for HHT and any HHT patient with a SMAD4 mutation
merits evaluation for JPS.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Wednesday 22nd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 1:
Plantation Room
Chairperson: Georgia Chenevix-Trench
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
EPIGENETIC EPIDEMIOLOGY: EXPLORING THE EPIGENOME TO FIND BIOMARKERS
OF CANCER RISK AND PROGNOSIS
James M. Flanagan, Breast Cancer Campaign Fellow, Epigenetics Unit,
Department of Surgery and Cancer, Imperial College London
Epigenetic epidemiology aims to use the natural variation present in the epigenome, in
DNA methylation as well as histone modifications, to look for associations between
particular epigenotypes and disease risk or prognosis. We use a quantitative bisulphite
pyrosequencing as well as methylation microarray based approaches, including custom
tiling microarrays and the Illumina 450K methylation beadchip, to analyse methylation
in peripheral blood DNA. We have analysed blood samples collected from prospective
cohorts including European Prospective Investigation into Cancer (EPIC) and the
Breakthrough Generations Study (BGS) as well as pre-diagnostic blood samples
collected by KConFab. We have recently shown that an intragenic DNA methylation
marker within the ATM gene showed an increased risk of breast cancer limited to
women in the highest quintile (OR=1.89 (1.36-2.64); P = 1.64×10-4) indicating that
blood DNA methylation levels at ATM could be a marker of breast cancer risk. We have
also analysed blood samples from an ovarian cancer clinical trial, SCOTROC1, to identify
prognostic biomarkers of progression free survival, overall survival, response and
toxicity. This study has identified decreased methylation within the SFN gene associated
with better progression free survival as a continuous measure in test (p=0.048, n=430)
and validation sample sets (p=0.026, n=283, Interquartile Hazard Ratio=1.3 (1.1-1.6),
(p=0.033). Finally, in a recent KConFab pilot project we have begun to investigate the
possibility of familial aggregation of tumour methylation profiles from non-BRCA1/2
breast cancer families. From these translational studies, it is now apparent that the
epigenetic variation between individuals is yielding markers of both cancer risk and
prognosis.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
LOBULAR BREAST CANCER GWAS
Ian Tomlinson, The Wellcome Trust, Centre for Human Genetics, Nuffield Department of
Clinical medicine, University of Oxford, UK
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
A GWAS-BASED CROSS-DISEASE APPROACH TO FIND GENES PREDISPOSING TO
BOTH ENDOMETRICAL CANCER
Jodie N Painter1, Stuart Macgregor2, Ian Tomlinson5, Dale R Nyholt3, Krina T Zondervan5,
Deborah Thompson6, Alison Dunning6, Douglas Easton6, Grant W Montgomery4, Amanda B
Spurdle1
Molecular Cancer Epidemiology1, Genetics and Computational Biology2, Neurogenetics3
and Molecular Epidemiology4 Laboratories Queensland Institute of Medical Research,
Brisbane Australia
Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK5
Centre for Cancer Genetic Epidemiology, University of Cambridge, Strangeways Research
Laboratory, Cambridge, UK6
The gynaecological diseases endometriosis and endometrial cancer have serious
consequences on quality of life for affected women and impose significant costs to the
healthcare system in Australia, together accounting for >28,000 hospital bed days in
2009-10. A convincing link between these diseases has been difficult to establish
epidemiologically, although both are hormonally regulated diseases of abnormal
endometrium growth and share a number of risk factors and pathological features.
Utilising previously published and unpublished (I Tomlinson) GWAS data we recently
applied a cross-disease approach to explore the genetic relationship between the two
diseases. Genetic prediction analyses revealed significant (P=7.8x10-10) shared genetic
architecture underlying endometriosis and endometrial cancer, indicating that there are
genetic loci that influence the risk of both diseases. We then performed a cross-disease
meta-analysis which revealed two loci exceeding a genome-wide level of significance
(Chr11 P=2.6x10-8, OR=1.16; Chr17 P=3.6x10-8, OR=1.15) and another two loci just
under this significance threshold (Chr17 P=1.8x10-7, OR=1.16; Chr6 P=2.9x10-7,
OR=1.19).
Three of these regions harbour genes previously linked to other hormonal (breast,
ovarian and prostate) cancers, suggesting that multiple disease susceptibility variants
may be present at these loci. Imputation of the published GWAS datasets to the latest
1000Genomes release has suggested additional SNPs for follow-up in the future, and all
four regions are being investigated for potential functional SNPs/sequences using a
bioinformatics approach. While our results require validation to confirm risk loci, they
indicate that a number of loci contribute to both endometriosis and endometrial cancer
susceptibility, suggest plausible candidate genes, and provide evidence of the value of
cross-disease meta-analyses for finding new genes contributing to complex genetic
diseases.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
GENOTYPID AND PHENOTYPIC ANALYSIS OF FAMILIAL MALE BREAST CANCER
SHOWS UNDER REPRESENTATION OF THE HER2 AND BASAL SUBTYPES IN BRCAASSOCIATED CARCINOMAS
Siddhartha Deb1,2,3, Jia-Min Pang1,3, Hongdo Do4, Elena Takano4, Nicholas Jene1, kConFab
investigators5, Alexander Dobrovic4, Stephen B Fox1,3,4, Department of Anatomical Pathology, Peter
MacCallum Cancer Centre, East Melbourne,, Victorian, Cancer Biobank, Victorian Cancer Council,
Carlton, Department of Pathology, University of Melbourne, Parkville 3052, Molecular Pathology
Research and Development Laboratory, Department of Pathology, Peter MacCallum Cancer Centre,
East Melbourne 3002, Kathleen Cuningham Foundation Consortium for research into Familial
Breast Cancer, Peter MacCallum Cancer Centre, East Melbourne
Background: Male breast cancer (MBC) is an uncommon and relatively uncharacterised
disease accounting for less than 1% of all breast cancers. A significant proportion occurs
in families with history of breast cancer. Here, we characterise clinicopathological and
genomic features of BRCA1 and BRCA2 mutation carriers and males from BRCAX
families. Methods: Cases (n=60) ascertained through kConFab included 3 BRCA1, 25
BRCA2 mutation carries, and 32 non-BRCA1/2(BRCAX) cases with strong family
histories of breast cancer. Clinicopathological factors, mutation status of PIK3CA, AKT,
KRAS and BRAF and methylation of multiple tumour suppressor genes were examined.
Results: Phenotypic correlation: Compared with the general population, MBC
incidence was higher in BRCA1 and BRCA2 carriers and in BRCAX families. There was no
correlation between mutation status and age of onset, disease specific survival or other
clinicopathological factors (all > 0.05). Comparison of our familial cohort with sporadic
MBC studies shows similar clinicopathological features and prognostic variables
including primary tumour size (p=0.003), age (p=0.002), lymphovascular (p=0.019) and
perineural invasion (p=0.027). Fifty-four (90.0%) were ductal carcinoma of no special
type and 2 were lobular (3.3%). Four (6.7%) tumours were invasive papillary
carcinoma and a further 8 (13.3%) had foci of micropapillary differentiation, showing a
trend for occurrence in BRCA2 carriers (p=0.058). Notably, there was no association
between BRCA1 carrier status and basal cell phenotype. Five BRCA2 carriers and 5
BRCAX males but no BRCA1 carries developed a second non-breast primary cancer,
most commonly prostate cancer (n=5). Mutation Analysis: Six of 57 cases (10.5%) of
familial male breast cancers had a PIK3CA mutation. Presence of the mutation was
associated with carrier status, with 5 BRCAX patients and 1 BRCA1 mutation carrier
having a PIK3CA mutation, but no mutations seen in BRCA2 mutation carriers
(p=0.0317). Mutation of AKT, BRAF or KRAS was not observed. Methylation: Of the 5
genes examined (BRCA1, TWIST, RASSF1A, APC and RARB), moderate to high levels of
methylation were most frequently seen in BRCA2 carriers (average of 2.05 genes,
p=0.0070), and least frequently in BRCAX patients (average 1.29 genes, p=0.0081).
RARB methylation was more commonly seen in BRCA2 mutation carriers (47.6% vs
20.0%, p=0.04). Compared to sporadic male breast cancer, less methylation of RASSF1A
was seen in familial male breast cancer (94.1% vs 42%, p=0.0003). BRCA1 methylation
was not seen. Conclusion: MBC in BRCA1/2 carriers and BRCAX families is different to
females. While a clear BRCA1 phenotype is not seen, a possible BRCA2 phenotype with
micropapillary histology. Some genomic differences are also seen between the
subgroups. Comparison with sporadic MBCs and female BRCA-associated cancers shows
some differences making further recruitment and investigation of familial MBCs of value
in further understanding these rare and possibly unique set of tumours.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
GENOME-WIDE SCAN OF METHYLATION OF DNA EXTRACTED FROM ARCHIVAL
BLOOD BIOSPECIMENS
Chol-hee Jung 1, Melissa Southey 2, Dallas English 3,4, Andrew Lonie 1, Alicia Oshlack 5,
Helen Tsimiklis 2, John Hopper 4, Gianluca Severi 3,4, Graham Giles 3,4, Laura Baglietto 3,4
1 Life Sciences Computation Centre, Victorian Life Sciences Computation Initiative, Carlton,
Victoria, 3010, Australia
2 Genetic Epidemiology Laboratory, Department of Pathology, The University of Melbourne
3 Cancer Epidemiology Centre, Cancer Council of Victoria, Melbourne
4 Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of
Population Health, University of Melbourne
5 Murdoch Childrens Research Institute, Royal Children's Hospital, Flemington Road,
Parkville
Within the framework of a large case-control study on methylation and breast cancer
risk in the Melbourne Collaborative Cohort Study, we measured genome-wide
methylation in DNA from 1,311 women. DNA was extracted from biospecimens
collected approximately 20 years ago, including frozen lymphocytes and buffy coats and
dried Guthrie card blood spots. Methylation was measured using the Illumina 450k
Infinium array. Samples were arranged in 15 plates each containing 8 batches of 12
samples. In order to measure the repeatability of the methylation measures, we
included 22 within plate/within batch duplicates and 45 between plates/between
batches duplicates. We evaluated the performance of the 450k Infinium array on our
samples in terms of number of probes detected at a probability lower than 0.01 and in
terms of correlation in methylation between duplicates.
The results of this study provide us with insights into the feasibility of measuring
genome-wide methylation in DNA extracted from different archival samples with
implications in the design of epidemiological studies and future potential relevance in
the clinical context.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
The Jeremy Jass Memorial Lecture
Plantation Room
Introduction & Chair: John Hopper
Presented by: Noralane Lindor
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
THE JEREMY JASS LECTURE
LOOKING FORWARD IN LYNCH SYNDROME
Noralane Lindor, Research Program, Mayo Clinic, Arizona, USA
The basics of Lynch Syndrome were pieced together about 20 years ago now and these
understandings have formed the basis for clinical care. There have, however, been a
number of significant advances in both the laboratory and clinical understanding of
hereditary DNA mismatch repair. Is universal screening for Lynch syndrome coming
and is that a good thing? How often is Lynch syndrome inherited? How much
difference does the underlying gene make in disease penetrance? Do tumors arising in
the context of Lynch syndrome respond to 5-FU-based chemotherapy like other tumors
with microsatellite instability? How much colon should be removed when a Lynchrelated colon tumor is diagnoses? Are breast and prostate cancers part of the Lynch
syndrome spectrum? Are there new serologic methods to diagnose Lynch syndrome or
to track the tumor course? Is aspirin use warranted in Lynch syndrome? An overview
of these and other notable advances in Lynch syndrome will be presented.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
RELATIVE RISK OF COLORECTAL CANCER RISK IN LYNCH SYNDROME IS
INVERSELY ASSOCIATED WITH AGE: A REVIEW
Mark A. Jenkins, Aung Ko Win, James G. Dowty, John L. Hopper, Centre for Molecular,
Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Parkville
Introduction: Carriers of a germline mutation in a mismatch repair gene (MLH1, MSH2,
MSH6, PMS2) are at increased risk of colorectal and other cancers compared with noncarriers (using the population incidences as a comparison). Once ascertainment of
mutation carriers have been adjusted for, the average relative risk of colorectal cancer
is 20-30 fold. However, several studies have assessed the relative risk by age to answer
the question: Does the degree of increased risk vary with age?
Methods: PubMed was used to identify all studies estimating relative risk of colorectal
cancer for carriers of a mismatch repair gene compared to the general population, by
age. We also added unpublished data of our own. Studies were excluded if they did not
adjust for ascertainment of mutation carriers in their analysis. A meta-analysis
(random effects) was conducted for each sex-gene combination available.
Results: Five published studies were identified [1-5] plus one unpublished study of the
Colon Cancer Family Registry (Dowty, personal communication). All of these studies
observed that the relative risk for colorectal cancer was highest at young ages and
decreased with age. This was observed for both sexes and for MLH1, MSH2 and MSH6.
Meta-analysis showed the following approximate increased risks of colorectal cancer
for MMR mutation carriers relative to the general population (relative risks): 85-fold
(30-39 years), 65-fold (40-49 years), 30-fold (50-59 years), 10-fold (60-69 years) and 7fold (70-79 years).
Conclusion: The relative risk of colorectal cancer for carriers of mutations in mismatch
repair genes appears to be inversely related to age. At young ages, the magnitude of the
increased risk compared to the general population is substantially greater than at older
ages. This has also been observed previously for BRCA1 and breast cancer risk [6]. The
reason for this is not known but it adds to the other complexities of MMR gene mutation
penetrance including parent-of-origin effect, polygenic effects, and modifying effects of
gender, personal characteristics, and environmental factors. There is still much to learn
about the effect of MMR gene mutations on colorectal and other cancers that have both
clinical and aetiological research implications.
Baglietto, L., et al., J Natl Cancer Inst, 2010. 102(3): p. 193-201.
Choi, Y.-H., et al., Hereditary Cancer in Clinical Practice, 2009. 7.
Jenkins, M.A., et al., Clin Gastroenterol Hepatol, 2006. 4(4): p. 489-98.
Quehenberger, et al., J Med Genet, 2005. 42(6): p. 491-6.
Stoffel, E., et al., Gastroenterology, 2009. 137(5): p. 1621-7.
Antoniou, A., et al., Am J Hum Genet, 2003. 72(5): p. 1117-30.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
IS BREAST CANCER A LYNCH SYNDROME CANCER?
Aung Ko Win1, Mark A. Jenkins1
1 Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University
of Melbourne, Parkville, Victoria, Australia.
Lynch syndrome is an autosomal dominantly inherited disorder of cancer susceptibility
caused by germline mutations in the DNA mismatch repair genes, MLH1, MSH2, MSH6
and PMS2. It is generally accepted, based on numerous studies, that these mutation
carriers have a substantial burden of increased risks of cancers of the colon, rectum,
endometrium and several other organs which generally occur at younger ages than for
the general population. Initially raised by Henry Lynch and colleagues several decades
ago, the issue of whether breast cancer risk is increased in Lynch syndrome has been
debated with evidence for and against this association. Generally, this research falls into
either molecular/pathological studies of breast tumour in mutation carriers or analysis
of family data to determine whether breast cancer occurs more often than expected in
mutation carrying families.
Molecular/pathological studies have observed genotype-phenotype correlations, i.e.
that breast tumours in women who carry a mutation demonstrate mismatch repair
deficiency. However a limitation of these studies is that they were not able to address
whether the mismatch repair deficiency caused breast cancer or was a phenotype
arising in breast cancer caused by another factor(s).
In previous family studies, the evidence for increased risk of breast cancer has been
inconsistent. Of the studies that investigated breast cancer risk in Lynch syndrome, six
studies did not observe evidence for an association while seven studies found an
increased risk of breast cancer ranging from 2 to 13-fold increase.
I will discuss the current evidence of an elevated risk of breast cancer in Lynch
syndrome including the quality and design of the studies and discuss what further
studies are needed to conclusively answer this question.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
PROSTATE CANCERS ARISING IN LYNCH SYNDROME MUTATION CARRIERS
FREQUENTLY SHOW DNA MISMATCH REPAIR DEFICIENCY
Michael D. Walsh1,2, Christophe Rosty1,3,4, Sally Pearson1, Mark Clendenning1, Rhiannon Walters1,
Belinda Nagler1, David Packenas1, ACCFR Investigators, Joanne P. Young1, John L. Hopper5, Mark A.
Jenkins5, Daniel D. Buchanan1, 1Cancer and Population Studies Group, Queensland Institute of
Medical Research, Bancroft Centre, Herston QLD, 2Department of Histopathology, Sullivan
Nicolaides Pathology, Taringa QLD , 3University of Queensland, School of Medicine, Herston, QLD ,
4Envoi Specialist Pathologists, Herston QLD , 5Centre for Molecular, Environmental, Genetic and
Analytic Epidemiology, School of Population Health, University of Melbourne, Carlton
Background: Lynch syndrome is an inherited predisposition to developing cancers of
the colorectum, endometrium, small intestine and upper urinary tract. Mutations in the
DNA mismatch repair enzymes MLH1, MSH2, MSH6, and PMS2 underpin Lynch
syndrome (LS). While prostate adenocarcinoma is not considered one of the spectrum
tumours for LS, several reports have documented loss of expression of MMR proteins
associated with germline mutations in the corresponding MMR gene, and some studies
have suggested that there is an increased risk of developing prostate cancer in mutation
carriers. We sought to investigate the incidence of MMR loss of expression and to
identify clinicopathological tumour features associated with MMR deficiency in a series
of LS carriers enrolled in the AACFR. Methods: DNA mismatch repair (MMR)
immunohistochemistry was performed on tissue samples of prostate carcinoma.
Germline MMR-gene mutations were identified via sequencing and MLPA. Results:
Prostate cancers (n = 12) were examined from proven or obligate MMR-gene mutation
carriers recruited to the Australasian Colorectal Cancer Family Registry. Participants
ranged in age from 45.5 to 73.7 yr (mean age = 62.8 yr). Pedigrees were available for ten
families (two individuals were from the same family). All families met modified
Amsterdam criteria. Six individuals had been diagnosed with at least one colorectal
carcinoma preceding their diagnosis of prostate carcinoma by 5 to 34 yr. One individual
was diagnosed with pancreatic carcinoma two years following the diagnosis of prostate
carcinoma at the age of 73 yr, and prostate carcinoma was the only malignancy
diagnosed in four individuals. MMR-deficiency was detected in 10/12 (83%) cases: two
tumours showed loss of MLH1 and PMS2 expression, while eight tumours showed loss
of MSH2 and MSH6 proteins. The pattern of loss of MMR expression was consistent with
the individual’s germline mutation in all cases. All twelve cancers were of acinar type.
One tumour had a Gleason score (GS) of 6 (this tumour had normal MMR expression
and arose in an MSH6 mutation carrier), five tumours were GS 7, and six tumours were
poorly differentiated with a GS ≥8. Tumour infiltrating lymphocytes were noted in low
numbers in six of the tumours, and perineural invasion was noted in four of the five
assessable cases. While many of the tumours were typified by high GS, other markers of
aggressive tumour behaviour were commonly absent including p53 expression (1/8
tumours positive) and ERG expression (0/6 tumours positive).Conclusions: These
findings indicate MMR-deficiency is commonly observed in prostate adenocarcinomas
arising in Lynch syndrome mutation carriers. The prostate tumours with MMRdeficiency from these carriers demonstrated features in common with MMR-deficient
cancers from other sites (e.g. poorly differentiated). Prostate carcinoma may thus be
considered a suitable option for tissue testing in the absence of other tumours for
triaging patients suspected of having Lynch syndrome, particularly in the absence of
other cancers.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
METHYLATION OF DNA REPETITIVE ELEMENTS FROM PERIPHERAL BLOOD DNA
IS ASSOCIATED WITH EARLY-ONSET COLORECTAL CANCER
Rhiannon Walters1, Elizabeth Williamson2, Dallas English2, Joanne P Young1, Christophe
Rosty1,3,4, Mark Clendenning1, Michael D. Walsh1, Sally Pearson1, Belinda Nagler1, David
Packenas1, ACCFR Investigators, Susan Parry5,6, Aung Ko Win2, John L. Hopper2, Mark A.
Jenkins2, Daniel D. Buchanan1.
1Cancer
and Population Studies Group, Queensland Institute of Medical Research, Herston,
QLD, Australia,
2Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of
Population Health, University of Melbourne, Carlton VIC 3053, Australia
3University of Queensland, School of Medicine, Herston, QLD 4006, Australia
4Envoi Specialist Pathologists, Herston Q4006
5New Zealand Familial Gastrointestinal Cancer Registry, Auckland City Hospital,
6Department of Gastroenterology and Hepatology, Middlemore Hospital, Auckland, New
Zealand
Background: Methylation levels of DNA from peripheral blood have been shown to be
associated with an elevated risk of cancer. The aim of this study was to investigate the
association between methylation of DNA repetitive elements LINE-1, Alu and Sat2 in
DNA from peripheral blood and: 1) early-onset colorectal cancer (CRC), and 2)
subgroups of CRC including inherited and familial CRC.
Methods: White blood cell (WBC) DNA from 539 probands with CRC diagnosed before
60 years of age and 242 sex and age frequency-matched healthy controls from the
population-based resources of the Australasian Colorectal Cancer Family Registry
(ACCFR) were assessed for methylation levels across three DNA repetitive elements
(Alu, LINE-1 and Sat2) using MethyLight. The percentage of methylation compared to a
reference (PMR) was calculated for each marker. Odds ratios (ORs) and corresponding
95% confidence intervals (CIs) were generated using multivariable logistic regressions.
Results: Probands with early-onset CRC demonstrated significantly higher median
PMRs for LINE-1 (p=<0.001), Sat2 (p=<0.001) and Alu repeats (p=0.02) compared with
controls. Probands with PMR values in the highest quartile were at a significantly
elevated risk of CRC compared with those in the lowest quartile for each of the
repetitive elements (LINE-1 OR= 2.38; 95% CI: 1.50-3.78; p = <0.001, Alu OR= 1.82;
95% CI: 1.16-2.84; p = 0.01, and Sat2 OR= 1.78; 95% CI: 1.13-2.82; p = 0.01), after
adjusting for all measured confounders: age at blood draw, sex, BMI, smoking, drinking,
ethnicity, folate, aspirin and ibuprofen two years ago, and family history (1st or 2nd
degree relative) of CRC or polypectomy. These associations were not significantly
altered by chemotherapy treatment with or without 5FU (LRT LINE-1 p= 0.91, Alu
p=0.06, Sat2 p=0.79). We found no statistical evidence for differential effects when
stratified by family history of CRC or polypectomy, germline MMR or MutYH mutation
status, age at diagnosis (<40, 40-<50, and 50+), or tumour characteristics (MMR
deficiency, BRAF V600E status, site, or T-stage).
Conclusions: We have shown an association between increasing methylation levels of
DNA repetitive elements in WBC DNA and the risk of early-onset CRC. This increased
risk was not related to a family history of CRC or polyps or inherited CRC-predisposing
germline mutations nor was it related to BRAF V600E status, a surrogate marker for a
hypermethylated CRC tumour phenotype.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Wednesday 23rd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 3:
Moss Room, Peppers
Chairperson: Rachel Williams
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
DISCLOSURES OBLIGATIONS FOR PARTICIPANTS DONATING A DNA SAMPLE FOR
GENETIC RESEARCH TO LIFEPOOL. WHAT DOES THE WOMAN IN THE STREET
NEED TO KNOW AND WHAT DOES SHE NEED TO TELL INSURANCE COMPANIES?
Jeff Gleeson1, Gabi Crafti2, Sue Viney3, Sue Timbs4, Ian Campbell5, Stephen Fox5, John Hopper6, Anne
Kavanagh7, Bruce Mann8, Vicki Pridmore3, Lisa Devereux5, Gillian Mitchell5
Affiliations:
Senior Counsel, Isaacs Chambers, Lonsdale Street Melbourne, Barrister at Victorian Bar, Joan
Rosanove Chambers, Lonsdale Street, Melbourne, BreastScreen Victoria, Breast Cancer Network
Australia, Peter MacCallum Cancer Centre, Centre for MEGA Epidemiology, University of
Melbourne, Key Centre for Womens’ Health, Gender and Society, University of Melbourne, The
Royal Melbourne and Royal Women’s Hospital
Background
Lifepool is a prospective cohort of women recruited from the Victorian population.
Funded by the National Breast Cancer Foundation (NBCF), lifepool is a collaboration
between BreastScreen Victoria, Peter MacCallum Cancer Centre, University of
Melbourne and The Royal Melbourne Hospital. Through BreastScreen Victoria, women
are invited to join lifepool at the same time as they are invited to participate in routine
mammographic screening. The vast majority of women have not had breast cancer at
the time they join lifepool.
Consent to participate in lifepool is a two-stage process. The Stage I Consent Form
requests baseline health and lifestyle data via completion of a questionnaire, and
permission for lifepool to access, over time, mammogram data and to track participants’
health via linkage to health databases. Participants are also asked for permission to
access any remnant tumour tissue and associated clinical information, if it becomes
relevant. Participants agree to use of this data in future, although currently unspecified,
research into breast cancer and other important women’s health issues. Access to
lifepool data and biological samples is open to national and international researchers,
subject to stringent scientific and ethical review.
Stage II operates only if the participant has indicated that she would be happy to be
contacted in the future regarding other specific research. Some of those women will be
contacted and asked to donate a blood or saliva sample from which DNA will be
extracted for genetic research. The lifepool project maintains data in a re-identifiable
format to facilitate feedback of significant health information to an individual woman.
The genetic research results may be of relevance to the woman’s blood relatives. Aim
To review the Stage II Participant Information and Consent Form (PICF) in respect of a
woman’s obligation to disclose to her insurers and any future insurers her participation
in long-term cohort studies that include unspecified genetic research.
A key consideration for this review is the recommendation by the Financial Services
Council to its insurer members to include questions in their application forms about
applicants’ participation in genetic research. The challenge, in a setting of population
cohorts, is to provide information that is accurate, clear and succinct whilst not
dissuading participation.
Discussion
We will present a review of the duty of disclosure to insurers in the context of genetic
research and discuss our development of the lifepool Stage II PICF. We will also discuss
the potential for the duty of disclosure to apply in the context of close blood relatives.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
EVALUATION OF THE EFFICACY OF TWO MODELS OF DELIVERING INFORMATION
ABOUT TREATMENT-FOCUSED GENETIC TESTING AMOUNG YOUNG WOMAN
NEWLY DIAGNOSED WITH BREAST CANCER
Meiser B, 1,2, Rahman B,1,2 Watts KJ,1,2 Tucker K,1,2Kirk, 3 Saunders C,4 Barlow-Stewart5
Gleeson M,6 Mitchell G7
1) Department of Medical Oncology, Prince of Wales Hospital, NSW, Australia; 2) Prince of
Wales Clinical School, University of New South Wales, NSW, Australia; 3) Westmead
Institute for Cancer Research, University of Sydney at Westmead Millennium Institute,
NSW, Australia; 4) Department of Surgery, University of Western Australia, WA, Australia;
5) Centre for Genetics Education, NSW, Australia; 6) Hunter Family Cancer Service, NSW,
Australia; 7) Peter MacCallum Cancer Centre, Vic, Australia; WA, Australia;
Background: Increasingly, women newly diagnosed with breast cancer with a relevant
cancer family history or other high risk features, in particular young age and triple
negative pathology, are being offered BRCA genetic testing to guide their treatment
(Treatment-Focused Genetic Testing ‘TFGT’). However, there are concerns that urgently
referring many women newly diagnosed with breast cancer to genetic clinics for
detailed counselling may overwhelm both the women and these services and so a
simpler strategy is needed. In this non-inferiority randomised controlled trial, we
evaluate two ways of offering information about TFGT to young women at diagnosis,
testing the hypothesis that patient outcomes will be no worse if only a simple
information leaflet is given rather than a detailed interview at a family cancer clinic
(FCC).
Methods: A total of 128 women (<50 years) at diagnosis (before definitive breast
cancer surgery) with either a suggestive cancer family history or other high risk
features, are invited to participate by their surgeon in this ongoing study. After
completion of a baseline questionnaire, participants are randomised to receive
information about TFGT either: a) in the form of brief educational materials
(Intervention) or, b) at a FCC (Control). Free BRCA genetic testing is offered; results are
disclosed at a FCC. Self-report questionnaires assess demographic information,
decisional uncertainty about TFGT, and psychosocial and surgical outcomes. The second
questionnaire is administered immediately after the intervention or at an equivalent
time point; the third and fourth questionnaires are completed 2 weeks and 12 months
after results disclosure, respectively.
Results: As of June 2012, results for change in decisional conflict (the primary outcome
variable) are reported for 89 women who completed the first and second
questionnaires, all of whom opted for TFGT. Decisional conflict decreased following
receipt of information about TFGT, with no statistically significant difference in mean
change between the two groups (Intervention M = -13.3, SD = 21.1; Control M = -16.1,
SD = 27.3).
Conclusions: These early data suggest that decisional conflict about genetic testing is
no worse in the intervention group compared to the control group, and that an
abbreviated counselling protocol may be a safe and efficient way of offering TFGT to
women.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
THE ATTITUDES OF PEOPLE WITH SARCOMA, THEIR FAMILY AND HEALH
PROFESSIONALS TOWARDS GENOMICS AND ANCILLARY INFORMATION ARISING
FROM GENETIC RESEARCH
MA Young2, J.L Halliday1, A. Herlihy1, D Thomas2, M.Ballinger2, Gillian Mitchell2
1Murdoch Childrens Research Institute, Parkville, Victoria, Australia
2Peter MacCallum Cancer Centre, Victoria, Australia
The International Sarcoma Kindred Study is a population based study recruiting
individuals with sarcoma (probands), their spouses and genetic relatives. Biospecimens,
clinical and epidemiological data have been collected. Within the study questionnaire is
a section asking about their
1. Beliefs about the genetic component of aspects of health and well-being
2. Feelings towards new genetic discoveries
3. Attitudes towards genetic testing for inherited conditions
4. Attitudes towards predictive testing for sarcoma
5. Attitudes towards the possibility of “incidental findings” as a result of
genomic investigations
Results were available on 524 probands, 514 genetically related family members and
162 spouses. For further comparison, the question related to point 1 above was also
given to 80 health professionals/ researchers in the field of sarcoma.
The beliefs amongst probands, spouses and genetic relatives about the genetic
contribution to a number of conditions and characteristics was similar, although was
markedly different from health professionals.
Older participants, females and those who were more highly educated had higher odds
of feeling more positive about genetic discoveries.
The questionnaire used four hypothetical scenarios to determine what conditions
people would like to be informed about when ancillary information arises as a result of
participating in research. These scenarios were 1) risk for a disease caused by a single
gene for which there is no prevention e.g. inherited blindness, 2) risk for a disease
caused by single gene for which there is screening/treatment which can modify risk e.g.
breast or bowel cancer, 3) risk for a disease caused by many genes which has a major
impact in health for which there is treatment or lifestyle changes which can modify risk
e.g. diet, stopping smoking, exercise 4) risk for a disease caused by many genes which
have a lower impact on health for which there is treatment and lifestyle changes which
can modify risk e.g. asthma.
A higher proportion of spouses as compared to probands and family members thought
research participants would like to be informed about ancillary information indicative
of a single gene disorder for which there is no prevention (p=0.05). For the remaining
three scenarios, almost all participants thought people would like to be given the
ancillary information.
These results add to the body of emerging evidence that show that research participants
wish to be informed about ancillary information that arises as a result of participating in
genomic research for reasons including clinical and personal utility.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
WHAT HAPPENS WHEN UNCERTAINTY REMAINS? A SYSTEMATIC REVIEW AND
QUANTITATIVE EXPLORATION OF DISTRESS IN UNAFFECTED HIGH-RISK
INDIVIDUALS WHO DECLINE, DELAY OR REMAIN INELIGIBLE FOR PREDICTIVE
GENETIC TESTING
Louise E Heiniger1, Phyllis Butow1, Melanie Price1, Margaret Charles1, kConFab Psychosocial Group
on behalf of the kConFab Investigators
1 Centre for Medical Psychology and Evidence-based Decision Making (CeMPED), School of
Psychology, University of Sydney
Background: Research on psychosocial aspects of genetic testing typically focuses on
carriers and non-carriers of genetic mutations. However, the majority of unaffected
high-risk individuals remain untested. Emerging evidence suggests that remaining
ineligible for genetic testing may be more distressing than receiving an unfavourable
genetic result, and that declining or delaying testing, when it is available, is associated
with less distress. The aims of this project were to:
1) review studies of unaffected individuals who decline, delay or remain ineligible for
genetic testing, and
2) compare distress in women who opt for, delay, decline or remain ineligible for
predictive testing for familial breast/ovarian cancer
Systematic Review
Method: Medline, CINAHL, PsychINFO and PubMed were searched, along with
reference lists of eligible articles and relevant reviews to identify articles for review and
quality assessment.
Results and conclusions: Of 1898 potentially eligible articles, 23 (19 different studies)
were included. Findings suggest definitions of delaying and declining are not always
clear cut, there is almost no research on delayers and few studies on those who remain
ineligible for testing. Distress in decliners tended towards lower initial distress with
deterioration over time in some cases. Prospective studies suggest those who remain
ineligible for testing may also be at risk for poorer psychological outcomes. A number of
psychological, personality and family history vulnerability factors were identified for
decliners and individuals who are ineligible for testing. Further research is needed to
improve our understanding of the psychological correlates of being denied the option of
testing, declining and delaying testing.
Quantitative study
Method: This study compared women who opt for (n=120), decline (n=56), delay
(n=90) or remain ineligible (ineligibles; n=865) for predictive testing with regard to
cancer-related distress (CRD; Impact of Events Scale), anxiety and depression (Hospital
Anxiety and Depression Scale) in 1131 unaffected women enrolled in the kConFab
psychosocial study. Controlling for potential confounders (age, education, perceived
risk and cumulative life event stress), statistical and clinical significance of differences
between groups in distress was investigated.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Results: Delayers and testers reported significantly higher CRD than decliners
(ps≤.001) and ineligibles (ps<.05). Moderate-high CRD was observed in 14% of
decliners, 24% of ineligibles, 34% of delayers and 42% of testers (χ2=24.73, p<.001).
Decliners reported lower anxiety than delayers (p=.005) and testers (p=.011), with
possible/definite anxiety disorder in 25% of decliners, 34% of ineligibles, 53% of
delayers and 44% of testers (χ2=19.21, p<.001). Depression was significantly higher in
delayers (p=.036) and testers (p=.009) compared with decliners, and in testers
compared with ineligibles (p=.006). However these differences were not clinically
significant and prevalence of depression did not differ between groups (χ2=3.49,
p=.322).
Conclusion: Decliners and delayers have distinctly different distress profiles and
should be considered as separate groups. Delayers report significantly higher distress,
similar to those who opt for testing, indicating that these two groups have the greatest
need for psychological support and would benefit most from supportive interventions.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
IMPROVING MUTATION NOTIFICATION WHEN NEW GENETIC INFORMATION IS
IDENTIFIED IN RESEARCH: A TRIAL OF TWO STRATEGIES IN FAMILIAL BREAST
CANCER EMPLOYED BY KCONFAB
Claire E. Wakefield1,2, Heather Thorne,3 Judy Kirk,4,5 Eveline Niedermayr,3 Emma L.
Doolan,1,2 the Kathleen Cuningham National Consortium for Research into Familial Breast
Cancer (kConFab) and Kathy Tucker.6,7
1School
of Women’s and Children’s Health, University of New South Wales, Sydney,
NSW, Centre for Children’s Cancer and Blood Disorders, Sydney Children’s Hospital,
Randwick, NSW, 3 Peter MacCallum Cancer Centre, Research Department, Kathleen
Cuningham National Consortium for Research into Familial Breast Cancer (kConFab),
Melbourne, 4 Familial Cancer Service, Westmead Hospital, Westmead, NSW, 5 Faculty of
Medicine, Westmead Clinical School, Westmead Millennium Institute for Medical
Research, University of Sydney, NSW, 6 Hereditary Cancer Clinic, Department of Medical
Oncology, Prince of Wales Hospital, Randwick, NSW, 7 Prince of Wales Clinical School,
University of New South Wales, Sydney, NSW.
2
Aim: The Kathleen Cuningham Foundation Consortium for Research into Familial Aspects
of Breast Cancer (kConFab) is a large-scale research study which notifies participants
when new, personally relevant, information is discovered. In 2009, kConFab instituted
an intensive notification process to ensure at-risk individuals were effectively notified.
This study: i) evaluated the impact of intensive notification on genetic testing uptake; ii)
identified those most likely to undergo testing post-notification, and; iii) identified those
most likely to acknowledge that they had been notified.
Methods: Clinical/demographic data were retrieved from the kConFab database.
Logistic regression analyses were conducted to identify potential predictors of testing
uptake and notification acknowledgment using SPSSTM.
Results: 155/1812 individuals underwent testing after standard notification (8.6%). In
comparison, 23/291 individuals (7.9%) notified using the ‘intensive’ approach
underwent testing (χ2=0.14; p=0.71). After controlling for notification process, females,
and participants with a previous cancer, were most likely to have undergone testing
(p<0.006). Older individuals (50+ years) were most likely to acknowledge they had
been notified (p=.038).
Conclusion: Increasing the intensity of participant follow-up did not increase genetic
testing uptake. The challenge to effectively notify participants, and increase the
proportion whose risk is managed clinically, remains, particularly for males and
individuals unaffected by cancer.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
WHAT MATTERS TO WOMEN DIAGNOSED WITH BREAST CANCER DURING THEIR
REPRODUCTIVE YEARS? PRELIMINARY RESULTS FROM A QUALITATIVE
INVESTIGATION USING A POPULATION-BASED SAMPLE
M Kirkman1,2, C Apicella2, J Graham2, M Hickey3, J Hopper2, L Keogh2, I Winship3, JRW
Fisher1,2
1. The Jean Hailes Research Unit, Monash University, Victoria
2. School of Population Health, The University of Melbourne, Victoria
3. School of Medicine, The University of Melbourne, Victoria
Background: Women diagnosed with breast cancer during their reproductive years
confront a threat not only to their survival but also to their reproductive health and
future motherhood: Breast cancer treatments may result in loss of fertility. Little is
known about the impact on women’s emotional wellbeing of reduced fertility and
impaired reproductive health associated with cancer.
Aim: To investigate psychosocial aspects of sexual and reproductive health and fertility
in women diagnosed with breast cancer when of reproductive age, with the goals of
informing and enhancing patient care and addressing women’s short- and long-term
psychological needs.
Method: Participants were drawn from a population-based sample of women
diagnosed with breast cancer between the ages of 18 and 40, forming part of the
Australian Breast Cancer Family Study. Using the ABCFS protocol, all eligible women
diagnosed either in 1996-2000 or in 2009 were offered the opportunity to be invited to
participate in the research. Participants were interviewed in depth about their fertilityrelated experiences, expectations, and reflections. Written transcripts of interviews
were qualitatively analysed using narrative and thematic techniques.
Results: About 50% of eligible women (51% older, n=27/53; 48% younger, n=23/48)
accepted the invitation and gave informed consent. There are few differences between
participants and non-participants in age at diagnosis, partnership status, and number of
children. Six women in the older group had given birth since diagnosis, in contrast with
non-participants, none of whom had given birth since diagnosis.
The participating women described diverse motherhood desires and experiences
including being pregnant at diagnosis, having completed or not having begun their
childbearing, and hoping for children at the conclusion of treatment, with hopes fulfilled
and unfulfilled. Whilst all emphasised staying alive, often for the sake of existing
children, many women talked of a parallel need to maintain reproductive options but
reported varied consideration of fertility management in their professional care. Some
(mostly older) women did not recall ever having had the topic of fertility raised by their
healthcare team. At the other extreme, some women (most of whom were in the more
recently diagnosed group) assessed their fertility-related care as appropriately suited to
their needs.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Wednesday 22nd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 4:
Plantation Room
Chairperson: Melissa Southey
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
POPULATION-BASED ESTIMATE OF PROSTATE CANCER RISK FOR CARRIERS OF
THE HOXBI3 MISSENSE MUTATION G84E
Robert J. MacInnis1,2, Gianluca Severi1,2, Laura Baglietto1,2, James G. Dowty2, Mark A.
Jenkins2, Melissa C. Southey3, John L. Hopper1, Graham G. Giles1,2
Cancer Epidemiology Centre, Cancer Council Victoria, Victoria, Australia, 2 Centre for
Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population
Health, The University of Melbourne, Victoria, Australia, 3 Genetic Epidemiology
Laboratory, Department of Pathology, The University of Melbourne, Victoria, Australia
1
The HOXB13 missense mutation G84E (rs138213197) has been reported to be
associated with increased risk of prostate cancer, but the current estimate of increased
risk has wide confidence intervals and may be misleading. Using a population-based
series of early-onset prostate cancer cases (probands) and their families, we found that
15 of 1,091 (1.4%) probands carried the missense mutation and of these only three
probands had a family history of prostate cancer.
We estimated the age-specific cumulative risk of prostate cancer (penetrance) for
carriers to be 8% (95% CI 2-31%) at age 60 years, 22% (95% CI 7-53%) at age 70 years
and 47% (95% CI 15-82%) at age 80 years. The age-specific incidence for carriers was
estimated to be, on average, 3.6 (95% CI 1.2-10.3) times that for the Australian
population. Our study has provided a more accurate estimate of the average risk of
prostate cancer for HOXB13 missense mutation G84E carriers, and its precision, that can
be used to guide clinical practice and research.
This study has also shown that the majority of hereditary prostate cancers due to the
HOXB13 missense mutation are ‘sporadic’ in the sense that unselected cases with the
missense mutation do not typically have a family history of prostate cancer.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
COLORECTAL CANCER RISK FOR METT9921 MISSENSE VARIANT CARRIERS FROM
THE AUSTRALASIAN COLORECTAL CANCER FAMILY REGISTRY
Daniel D. Buchanan1, Aung Ko Win2, Mark Clendenning1, Michael D. Walsh1, Rhiannon
Walters1, Sally Pearson1, Belinda Nagler1, David Packenas1, ACCFR Investigators, Joanne P.
Young1, Christophe Rosty1,3,4, John L. Hopper2, Mark A. Jenkins2., 1Cancer and Population
Studies Group, Queensland Institute of Medical Research, Bancroft Centre, Herston QLD,
2Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of
Population Health, University of Melbourne, Carlton VIC 3053, 3University of Queensland,
School of Medicine, Herston,, 4Envoi Specialist Pathologists, Herston
Background: Colorectal cancer (CRC) has a strong familial component with 15-30% of
cases attributed to having a family history of the disease (depending on the age at
diagnosis). Only 2-5% of all CRCs are caused by the known highly penetrant inherited
syndromes, and therefore, additional CRC-predisposing genes remain to be identified.
Recently, the T992I missense variant within the MET oncogene was shown to be
associated with familial CRC. The aim of this study was to estimate the risk of CRC for
MET T992I variant carriers.
Methods: Case-probands were population-based, recent CRC diagnosed before age of
60 years unselected for family history of colorectal cancer (n=600). Control-probands
were identified from electoral rolls and sex and age-frequency matched to caseprobands and had no previous diagnosis of CRC (n=243). All cases and controls were
from the Australasian Colorectal Cancer Family Registry (ACCFR) and were genotyped
for the T992I variant of MET using HRM assay followed by sequencing to confirm
aberrant melting profiles. Relatives of carrier probands with DNA available were also
genotyped. We excluded one family with a co-occurring MLH1 mutation and one family
with de novo MET T992I variant. MET T992I carrier status, sex, age and history of
cancer and polypectomy were sought from 19 probands and 717 relatives (359 females
and 377 males). We estimated the hazard ratios (HR) of CRC incidence for T992I variant
carriers relative to the general population (based on age-, sex- and country-specific
cancer incidences), and hence the age-specific cumulative risks (penetrance) using a
modified segregation analysis that incorporated both genotyped and ungenotyped
relatives and conditioned on ascertainment to produce unbiased estimates.
Results: We identified 21 probands that were heterozygous for the MET T992I variant
(14 case probands and 7 control probands); median age at diagnosis for case-probands
was 54 years (range 31-60) and the CRCs were predominantly in the left colon (64%)
and were of low grade (73%). For the 717 relatives of carriers, 20 were diagnosed with
CRC (median age 73 years (range 34 to 89). The HR for CRC for the MET T992I variant
carriers was 2.56 (95% confidence interval, 1.06-6.19; p=0.04) with no evidence for
difference between males and females (p=0.77). The cumulative risks to age 70 years
were estimated to be 9% (4-20%) for males and 6% (3-14%) for females.
Conclusions: The MET T992I missense variant carriers were at elevated risk of CRC,
consistent with the T992I variant being a low- to moderately-penetrant CRCpredisposing mutation. Further investigation of this variant in larger studies is needed
in order to refine the risk estimates and determine the clinical and biological
significance of the MET T992I variant with CRC.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
GENE REGULATORY ELEMENTS AS BREAST CANCER SUSCEPTIBILITY LOCI
Brooke L Brewster1, Philip Whiley2, Peter Bailey1, Ania Wronski1, Ming Wong3, Juliet D
French1, Stacey L Edwards1, kConFab4, ENIGMA5, Etienne Rouleau6, Melissa C Southey3,
Paolo Peterlongo7, Amanda B Spurdle2, Melissa A Brown1
1School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane,
Australia.
2 Queensland Institute of Medical Research, Brisbane, Australia.
3Department of Pathology, The University of Melbourne
4Kathleen Cuningham Consortium for Research into Familial Breast Cancer.
5Evidence-based Network for the Interpretation of Germline Mutant Alleles.
6Institut Curie, Hoˆpital Rene ́ Huguenin, Saint-Cloud, France.
7Fondazione Istituto FIRC di Oncologia Molecolare and Fondazione IRCCS Istituto
Nazionale Tumori, Milan, Italy.
Many mutations that confer a predisposition to breast cancer have been described;
however these mostly affect protein coding regions and only account for a small
proportion of the genetic risk of this disease. It is becoming increasingly clear that
disease associated variants that affect gene expression also play an important role in
breast cancer susceptibility, however, the precise nature and contribution of such
variants remains to be determined. Variants affecting gene expression have been
identified in transcriptional control elements, including promoters and proximal and
distal enhancers, and in post-transcriptional control elements, including those found in
the 3’UTR. Our group has a long-standing interest in elucidating the transcriptional and
posttranscriptional regulation of breast cancer associated genes, including BRCA1. Our
studies have led to the identification of regulatory sequences mapping to BRCA1
promoter, intronic regions, 3’UTR and extragenic sequences. We have also identified
proteins and miRNAs that target these sequences. We have shown that genetic and
epigenetic changes in these sequences affect gene expression and may be associated
with altered targeting by proteins or miRNAs. For example, BRCA1
c.*1340_1342delTGT, identified in a breast cancer case and located in the 3’UTR,
introduces a functional miR-103 binding site, whilst c.*291C>T disrupts the effect of the
RNA-binding protein, HuR on wild-type BRCA1 3’UTR regulatory activity. Current
studies involve identifying new regulatory variants through the ENIGMA consortium,
elucidating the role of these variants in mammary tumourigenesis, and determining the
clinical utility of these variants as biomarkers of cancer susceptibility. The results of this
project will enable more comprehensive genetic testing and more accurate genetic
counselling, will facilitate the development of accurate risk prediction models for
carriers of all non-coding variants and will potentially form the basis of new RNA-based
therapeutics for minimizing breast cancer risk and improving breast cancer outcomes.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
GAP IN THE MIDDLE OF FAMILIAL COLORECTAL CANCER – MODERATELY
PENETRANT GENETIC VARIANTS
Deborah Neklason1,2, Michelle Done1, Nykole Sargent1, Matthew Bailey3, Craig Teerlink3,
Richard Kerber4, Randall Burt1,3 , 1Huntsman Cancer Institute, 2Department of Oncological
Sciences, 3Department of Medicine, University of Utah, Salt Lake City, UT, USA;
4Department of Epidemiology, University of Louisville, Louisville, KY, USA.
[email protected] (801) 587-9882
Background
The presence of family history is a well-established risk factor for colorectal cancer
(CRC) with 25-35% of CRCs attributable to inherited and/or familial factors. The highly
penetrant inherited colon cancer syndromes account for approximately 5% and genome
wide association studies have identified low penetrance common variants in the
population (relative risk <2) that account for an additional 5% of colorectal cancers.
This leaves greater than 15% of inherited CRCs without clear genetic definition. This
undefined population is composed of both moderately penetrant genetic variants and
rare “private mutations”. Identification of this next tier of unknown genetic risk factors
is important because increased cancer surveillance would be justified in this population.
In addition, by defining the molecular pathways involved we will gain a better
understanding in the development of CRC and thus suggest targets for cancer
prevention in this at-risk population. We report on the successes and the challenges in
identification of the moderate risk inherited factors in cancer, a complex disease
involving interplay of genes and environment.
Methods
Our population consists of CRC affected relative pairs and large multigenerational
families with excess clustering of cancers. The major source of our research population
is an extraordinary resource of over 15 million records that link cancer and medical
records to extensive genealogies dating back to the 1800s and housed in the Utah
Population Database (UPDB). In affected relative pairs and large families, known
syndromes are excluded, phenotypes confirmed with medical records, and genetic
analysis performed by either 1) linkage analysis of whole genome STR or SNP panels or
2) exome sequencing with variant analysis and sharing in affected individuals.
Results
We have recently reported on a germline non-synonymous change in the MET protooncogene (p.T992I also reported as p.T1010I) in ~ 5% of two cohorts of first degree
relative pairs affected with CRC. This mutation is present in ≤ 1% of the general
population. MET T992I was found to segregate with CRC, melanoma, and a large sessile
serrated adenoma in a UPDB CRC family. An additional UPDB cohort of “cancer clusters”
was tested for germline MET T992I and found it in 1.8% of all cases, but a noteworthy
3/44 melanomas (7%). We present a mechanistic hypothesis on how this specific
variant is driving cancer progression. More recently, we have applied exome
sequencing in four CRC cases from three branches in a large UPDB family. We are
working on the model that any one of the cancers could be sporadic and, like MET
T992I, the genetic change may be present in dbSNP and may cause a subtle change to
the protein. Each individual has ~30,000 exon variants, and pairs of individuals share
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
~10,000 coding changes (amino acid change, stop codon, indel). Our current
challenges, approaches, results will be presented.
Conclusions
In the field of familial CRC, an important gap in our knowledge is identification of
moderately penetrant genetic risk factors whose presence in the germline would justify
increased surveillance for cancer. Because they are moderately penetrant and
potentially rare, the classic genetic linkage and the GWAS studies have missed them.
They present challenges in that they may be without a strong phenotype, require
interplay of other risk factors, and may overlap with sporadic cases. MET T992I serves
as a good example of how these moderately penetrant genes could work.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Thursday 23rd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 5:
Plantation Room
Chairperson: Gillian Mitchell
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
“CANCER 2015” (VIC CANCER GENOME COHORT): TRANSLATING DISCOVERIES
INTO CURES
John Parisot1, Heather Thorne1, Neil Watkins8, Paul Waring8, Thomas John10, Melissa
Southey7, John McNeil3, Paula Lorgelly4, Stephen Fox2, Lara Lipton6, David Ashley5, Gary
Richardson11, David Thomas1, Joe Sambrook1. 1Cancer Research Division; 2Molecular
Pathology, Peter MacCallum Cancer Centre, East Melbourne, 3Department of Epidemiology
and Preventative Medicine, Alfred Centre, Monash University, Prahan, 4Centre for Health
Economics, Monash University, Clayton, 5The Andrew Love Cancer Centre, Geelong
Hospital, Barwon Health, , 6The Royal Melbourne Hospital, Melbourne Health, Parkville,
7Cancer Genomics; 8The Department of Pathology, The University of Melbourne, Parkville,
9Monash Medical Centre, Clayton, 10Austin Health, Heidelberg, 11Cabrini Health, Malvern
According to the American Society of Clinical Oncology’s “Blueprint for Transforming
Clinical and Translational Cancer Research”, the goal of improving cancer survival and
outcomes will be achieved by translating advances in molecular genomics into the
effective design, clinical research, and use, of the new wave of molecularly targeted
therapies across the entire health system. It will also necessitate development of
sustainable, economically sound models for future cancer care that will involve the key
partners in health: government, clinicians and researchers, the pharmaceutical industry,
and the community.
The “Cancer 2015” Cohort is an epidemiological study funded by the Victorian Cancer
Agency (VCA) to help ascertain the benefits of such a targeted, “personalised genomic
medicine” approach to cancer care and treatment in Victoria. As one of the world’s
largest prospective, longitudinal population-based molecular studies, it will re-classify
cancers and allow more targeted patient treatments using molecular genomic data to
improve outcomes. It involves a unique collaboration between researchers,
pathologists, treating clinicians and cancer patients using shared molecular information,
validated clinical trial methodology and data input from both clinicians and consumers.
In the UK, Norway, US and elsewhere, large-scale population-based cohorts enrolling
tens of thousands of patients, are being developed to elaborate an evidence base for
affordable health care in the new genomic era.
The study will run over 5 years and include recruitment of 10,000 new cancer patients
independent of cancer histopathology type, representing both metropolitan, regional
and rural health services across Victoria, with the study to be implemented in 2 phases.
The current, phase 1 pilot aims to recruit 1000 patients from 4 hospitals in 2012 and
establish the necessary infrastructure and processes needed for upscaling of the study
for the recruitment of a further 9000 patients over 2013-14 from upto an additional 1012 hospitals.
Cancer 2015 is building on upon existing research and clinical infrastructure and will
ultimately provide a high-resolution map of cancer patterns, survival outcomes and
health economic metrics in Victoria. As one of the world’s largest prospective,
longitudinal population-based molecular studies, Cancer 2015 will make a major
contribution to cancer re-classification using molecular pathology, and link this data to
treatments and outcomes. Data presented herein will demonstrate progress with the
cohort to date and some preliminary results obtained with molecular genotyping and
health economics evaluations as proof-of-principle sub-studies.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
CASCADE: A CANCER TISSUE COLLECTION AFTER DEATH PROGRAMME TO
IMPROVE OUR UNDERSTANDING OF THE PROGRESSION FROM PRIMARY STAGE
CANCER TO METASTATIC, TREATMENT=RESISTANT DISEASE.
Kathryn Alsop, Heather Thorne, Paul Waring, Gillian Mitchell, Robin Anderson, Odette
Spruyt, Anne Hamilton, Mark Shackleton and David Bowtell
The Peter MacCallum Cancer Centre, East Melbourne VIC and the University of Melbourne,
Parkville VIC
With the support of the Victorian Institute of Forensic Medicine (VIFM) and Tobin
Brothers Funerals.
Cancer tissue collected for research purposes is most often obtained from primary
tumours that are deemed resectable - comparatively few samples are collected from
metastatic deposits because patients with disseminated disease usually do not undergo
surgery. However, it is becoming apparent that multiple cancer genomes can exist
within a single patient and even within a single tumour. The relationships between
inter- and intra-tumoural genetic heterogeneity and cancer evolution are presently
unclear but likely profoundly influence patient outcome. For example, although brain
metastases from melanoma are a major cause of morbidity and mortality, it is not
known what evolutionary changes occur in melanoma cells to facilitate cerebral spread.
Similarly, although acquired resistance to cancer therapy is a major event that leads
inexorably to death, in most cases the mechanisms of resistance are obscure.
Fundamentally, the determinants of these outcome-defining events are mostly
unknown because metastatic and/or therapy-resistant tumor tissues are almost never
available for study in research projects. Understanding of these determinants would be
greatly facilitated by collecting multiple, spatially- and temporally-separated tumour
samples from individual patients.
Recent work has highlighted the value of rapid autopsy in pancreatic [1] and prostate
[2] cancer. Autopsies provide an opportunity to obtain a comprehensive survey of
tumour deposits and relatively large amounts of material for multiple assays. We are
piloting a programme, called CASCADE, of rapid autopsy in cancer patients, with an
initial focus on breast, ovarian, prostate cancer, and melanoma. CASCADE leverages
existing Kathleen Cunningham Foundation Consortium (kConFab), Australian Ovarian
Cancer Study (AOCS) and Melbourne Melanoma Project (MMP) studies, and involves
senior pathologists, palliative care specialists, medical oncologists, familial cancer
clinicians, and scientists with extensive experience in biobanking and cancer cohort
studies. The aim of CASCADE is to create a bank of metastatic tumour tissue and clinical
data to investigate mechanisms of resistance, metastasis, and cancer evolution using
genomic and biological tools. Our initial experience of the logistic and scientific
challenges in establishing the CASCADE program will be discussed.
1.
2.
Campbell, P.J., et al., The patterns and dynamics of genomic instability in
metastatic pancreatic cancer. Nature, 2010. 467(7319): p. 1109-13.
Grasso, C.S., et al., The mutational landscape of lethal castration-resistant prostate
cancer. Nature, 2012.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
INTRODUCING AN ONLINE BOWEL CANCER RISK CALCULATOR TO PROMOTE
COLORECTAL CANCER AWARENESS IN THE COMMUNITY
Jody Simmons1, Prof Finlay Macrae2, 3, Dr Elizabeth Chow2, 3, Stuart Wells1, Philippa Davis1,
Chris Enright1
1 Cancer Council Victoria
2 Department of Colorectal Medicine and Genetics, The Royal Melbourne Hospital
3 The Victorian Cooperative Oncology Group
Background
One in twelve males and one in seventeen females in Australia will develop colorectal
cancer in their lifetime, and the number of new cases per year is increasing in Australia.
If detected early it is up to 90% curable, yet it remains the second most common cause
of cancer-related death in Australia. NHMRC Guidelines for colorectal cancer screening
and surveillance in Australia have been in place since 1991. However, there is poor
understanding in the general public of risk factors and the need for
screening/surveillance for colorectal cancer. There needs to be an increased awareness
and education of bowel cancer risk factors, in order to implement appropriate screening
and surveillance for bowel cancer in the community.
Aim
To develop an online interactive risk calculator for colorectal cancer that can be used by
individuals and their doctors to establish the individual’s colorectal cancer risk. The aim
is to accurately define an individual’s risk for bowel cancer and provide advice
regarding screening/surveillance practices based on the individual’s specific risk for
colorectal cancer development (thereby rectifying both over- and under-screening).
Method
The assessment from the online questionnaire captures three aspects of the individual’s
risk for bowel cancer:
1. modifiable lifestyle factors
2. personal history of colonic neoplasia and inflammatory bowel disease
3. family history of colorectal neoplasia
Once the patient’s lifestyle factors have been assessed and specific risk category for
bowel cancer according to NHMRC guidelines has been calculated, educational feedback
in a user friendly format tailored to the subject’s responses will be provided. This will
include general recommendations for screening/surveillance for bowel cancer in
accordance with current NHMRC guidelines, and education on aspects of lifestyle
factors that could be improved upon. A printable synopsis and letter to the patient’s GP
summarising their risk category and screening recommendations will be provided on
completion.
Results
We will introduce this new online tool and discuss the development and implications of
use in aiding understanding of colorectal cancer in the community. We will also discuss
any preliminary statistics and the perception of the general public.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
A CASE OF TWO MUTATIONS IN TRANS IN A WOMEN DIAGNOSED WITH BREAST
CANCER AT THE AGE OF 3+0 YEARS
Margaret Gleeson1, Allan D. Spigelman1,2,3, Cliff J. Meldrum4, Susan Dooley4, Michelle
Wong5, Barbara Young4, Stephen Braye4 and Rodney J. Scott4,5,6
1.
2.
3.
4.
5.
Hunter Family Cancer Service, , HNELHD Cancer Services, Newcastle, NSW
Hereditary Cancer Clinic, Cancer Services, St Vincent’s LHN, Sydney, NSW.
UNSW St Vincents Clinical School, Sydney, NSW
Hunter Area Pathology Service, John Hunter Hospital, Newcastle, NSW
School of Biomedical Sciences and Pharmacy, Faculty of Health, University of
Newcastle, NSW
6. Hunter Medical Research Institute, University of Newcastle, NSW.
Biallelic mutations in BRCA1 are generally considered to be incompatible with neonatal
development as judged by studies in mice. In the presence of an additional TP53
mutation there is partial rescue but the resultant offspring are compromised. In
humans, biallelic mutations are considered to be embryologically lethal, based on the
absence of biallelic mutation carriers. Although a single case has been reported
previously of a woman harbouring a biallelic c.2681_2682delAA mutation in BRCA1,
this report has subsequently been shown to be erroneous.
In this report, we have documented the presence of two BRCA1 mutations
(c.2681_2682delAA and c.594-2A>C) in a woman diagnosed with unilateral breast
cancer at age 30 years. The c.2681_2862delAA results in a frameshift resulting in a
premature termination codon. The c.594-2A>C change is a splice site mutation that has
been reported to result in the skipping of exon 10, resulting in a frameshift and
consequently a premature termination codon.
The breast tumour was a triple negative, node negative, poorly differentiated invasive
carcinoma with squamous metaplasia. The c.2681_2862delAA was maternally inherited
and the splice site change c.594-2A>C was paternally inherited. While the proband’s
mother is currently unaffected at 59 years of age, the probands maternal aunt was
diagnosed with breast cancer at 48 years and subsequently with a parotid gland tumour
at 53 years. The cancer status in the paternal side of the family is sparse. The sibling of
the proband has been tested for the two mutations and thus far, the proband is the only
biallelic case within the family.
This is the first report, to our knowledge, of an unequivocal biallelic mutation carrier. A
possible explanation of this unusual finding is that the splice site mutation may not be
as severe as previously thought. An investigation into the expression of the allele
harbouring the c.594-2A>C slice site change will be reported in the context of this case.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
EVALUATION OF BRCA1/2 VARIANTS OF UNCERTAIN CLINICAL SIGNIFICANCE
USING A COMBINATION OF MULTIFACTORIAL LIKELIHOOD ANALYSIS,
BIOINFORMATICS AND IN VITRO APPROACHES
Whiley, P.J.1, Parsons, M.1, Pettigrew, C.2, Beesley, J.1 , Tavtigian, S.V.3, Vallee, M.3, kConFab4
,Tucker, K.5, Goldgar, D.E.6, Brown, M.A.2, Spurdle, A.B.1
1Genetics and Population Health Division, Queensland Institute of Medical Research,
Brisbane, Queensland
2School of Molecular and Microbial Sciences, University of Queensland, Brisbane,
Queensland
3Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
4Peter MacCallum Cancer Centre, St Andrews Place, East Melbourne, Victoria
5Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, New South Wales
6University of Utah School of Medicine, Salt Lake City, UT, USA
Evaluation of unclassified variants in breast cancer susceptibility genes BRCA1 and
BRCA2 is essential for appropriate genetic counselling of patients and families carrying
these variants. Multifactorial likelihood analysis combines a prior probability of
pathogenicity based on bioinformatic predictions with likelihood ratios based on
clinical data. It is often limited by a paucity of relevant clinical data, and there is need to
improve specificity and sensitivity of bioinformatic predictions. In vitro analysis of the
effect of variants on mRNA/protein structure and function can contribute to assessing
the clinical significance of variants, and is also valuable for testing and refining
bioinformatic prediction tools. We have undertaken multifactorial likelihood analysis,
bioinformatic and in vitro studies of BRCA1/2 variants located in coding, intronic, 5’
untranslated or 3’ untranslated regions. Multifactorial analyses categorised ring domain
BRCA1 His41Arg missense variant as pathogenic, consistent with publications reporting
abrogated BARD1 binding for the 41Arg protein. Transactivation domain (TAD) assays
for three missense variants, Met1775Lys, Val1833Met and Val1838Glu in the BRCA1 cterminus indicate that all three substitutions to result in abrogated BRCA1 TAD
function. Multifactorial analysis indicates that Met1775Lys and Val1838Glu are
pathogenic. mRNA splicing assays undertaken for 19 exonic and intronic variants
identified splicing aberrations for 3 variants, all of which were located in splicing
recognition motifs: BRCA1c.4484G>C , at the last base of exon 14; BRCA2c.67+3G>A,
exon 2 donor motif; BRCA2c.8954-5A>G, exon 23 acceptor motif. The BRCA2 c.67+3
G>A resulted in deletion of exon 2 and thus the ATG translation start site, so GFP
reporter assays were undertaken to test levels of translation initiation at downstream
alternative ATG start sites at codon 107 and 123. Results indicated that the start site at
codon 107 is preferentially used to initiate translation in the absence of exon 2,
resulting in out-of frame translation. In addition, to assess the utility of bioinformatic
predictions for refining prior probability estimates, MaxEntScan-based predictions of de
novo donor/acceptor creation were compared to splicing results, and have been used to
design minigene assays of variants likely to create donors. Lastly, bioinformatic
analysis has prioritised variants in the 5’UTR, 3’UTR and intronic regions for in vitro
investigation of altered gene regulation. A panel of approaches incorporating clinical
and molecular information can facilitate the clinical classification of variants in BRCA1
and BRCA2, and may help refine bioinformatic modelling and estimation of the prior
probability of pathogenicity for future studies of rare variants of uncertain significance.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Thursday 23rd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 6:
Plantation Room
Chairperson: Prue Cowin
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
CLONING OF THE GENE FOR MIXED POLYPOSIS SYNDROME: THE END OF A 50YEAR JOURNEY
Ian Tomlinson, The Wellcome Trust, Centre for Human Genetics, Nuffield Department of
Clinical Medicine, University of Oxford, UK
Hereditary mixed polyposis syndrome (HMPS) was first described in the early 1960s by
clinicians from St Mark's Hospital who were looking after a Jewish family with members
throughout the world, including a branch in London. Affected individuals developed
unusual, large-bowel polyps of several different types and individual polyps could have
more than one morphology. Many individuals had colorectal cancer. The family was
large and the disease had Mendelian dominant inheritance. The family was thought to
be unique. After a few false leads in the 1990s, by the early 2000s, we had mapped the
HMPS gene to the long arm of chromosome 15. We had also identified a few more HMPS
families. However, all affected individuals were of Ashkenazi origin and shared a
chromosome 15 haplotype of about 2Mb on 15q13.3. Conventional sequencing found no
protein-coding mutations to be present in the genes within the region. We then turned
our attention to the possibility of more unusual mutations, consistent with the apparent
monophyletic origin of the disease-causing variant. As part of a copy number screen, we
found a constitutional 40kb copy number gain unique to HMPS patients. This resulted
from a tandem duplication that encompassed part of the gene SCG5 and lay upstream of
the GREM1 (gremlin) gene. We have recently shown that the HMPS duplication affects a
genomic control region, leading to massive over-expression of gremlin and relocation of
its expression from the colorectal mesenchyme to the epithelium. The HMPS mutation
provides a rare example of a Mendelian condition caused by non-coding variation that
has profound effects on gene expression. In the next 50 years, we hope to work out how
the HMPS duplication causes the aberrant gremlin expression and how in turn that
causes colorectal cancer to develop.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
FAVR (FILTERING AND ANNOTATION OF VARIANTS THAT ARE RARE): METHODS
TO FACILITATE THE ANALYSIS OF RARE GERMLINE GENETIC VARIANTS FROM
SOLID AND ILLUMINA DATASETS
Tú Nguyen-Dumont1, Bernard J Pope2, Fabrice Odefrey1, Andrew Lonie2, Melissa C
Southey1, Daniel J Park1*, Genetic Epidemiology Laboratory, Department of Pathology,
Medical Building, The University of Melbourne, Victoria 3010, Australia, Victorian Life
Sciences Computation Initiative, The University of Melbourne, 187 Grattan Street, Carlton,
Melbourne, Victoria 3010
Massively parallel sequencing (MPS) is a powerful tool to facilitate research on the
genetic basis for observed phenotypes, including predisposition to and progression of
human diseases. However, interpretation of MPS data is challenging. A typical single
whole-human exome analysis outputs thousands of genetic variant signals. Only a
fraction of these are real, the remainder being artefacts from the processes of
sequencing and mapping to the reference genome. Many of these are not readily
distinguishable from true variants on the basis of ‘quality metrics’. Of the authentic
variants, only a very small proportion might be relevant to a given phenotype or
disease.
Here, we present FAVR, a suite of new methods designed to assist the shortlisting of
genetic variants under a rare variant-phenotype/disease model. The methods are
designed to work with commonly used MPS analysis pipelines, such as the GATK or
ANNOVAR, and have been made publically available as a suite of software tools
(https://github.com/bjpop/favr). The FAVR methods use signatures in comparator
sequence alignment files to facilitate the filtering of mapping artefacts and common
genetic variants, and annotation of genetic variants based on evidence of co-occurrence
in individuals. As relevant, FAVR methods can also be used to filter out artefacts derived
from imbalanced paired-end sequencing. By applying FAVR methods to whole-exome
sequencing datasets generated on a SOLiD4 platform, we demonstrate a 3-fold reduced
single nucleotide variant shortlist compared to a conventional analysis pipeline with no
detected reduction in sensitivity. This analysis included Sanger sequencing of rare
variant signals not evident in dbSNP131, assessment of known variant signal
preservation, and comparison of observed and expected rare variant numbers across a
range of first cousin pairs. Preliminary analysis of Illumina platform-generated wholeexome sequencing datasets indicates that similar benefits will be realised across MPS
systems.
The principles described herein were applied in our recent work identifying that rare
mutations in XRCC2 are associated with early-onset breast cancer risk.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
IDENTIFICATION OF RARE DNA COPY NUMBER VARIANTS OVERLAPPING
MISMATCH REPAIR PATHWAY GENES IN ENDOMETRIAL CANCER PATIENTS AND
THEIR POTENTIAL CONTRIBUTION TO DISEASE RISK
GL Moir-Meyer1, F Lose2, JF Pearson1, Y Tan2, The Australian National Endometrial Cancer
Study Group2, RJ Scott3,4, The Hunter Community Study5, Studies of Epidemiology and Risk
Factors in Cancer Heredity6, DJ Thompson7, PD Pharoah6,7, AM Dunning4, DF Easton6,7, AB
Spurdle2, LC Walker1
1Department
of Pathology, University of Otago, Christchurch, 2Genetics and Population
Health Division, Queensland Institute of Medical Research, Queensland, Australia, 3John
Hunter Hospital, NSW, Australia, 4Discipline of Medical Genetics, University of Newcastle,
NSW, Australia, 5University of Newcastle, NSW, Australia, 6Department of Oncology,
University of Cambridge, Strangeways Research Laboratory, Cambridge, UK, 7Department
of Public Health and Primary Care, University of Cambridge, Strangeways Research
Laboratory, Cambridge, UK.
Endometrial cancer is the most common gynaecological cancer in New Zealand and the
incidence is increasing as the population ages1. Genetic predictors of endometrial
cancer risk that allow early detection of the disease are important for prevention and
improved management strategies. Mutations in the mismatch repair genes MLH1, MSH2,
MSH6 and PMS2 are known to confer increased risk in a proportion of endometrial
cancer cases, and the mutation spectrum includes copy number variants (CNVs). There
are several other genes encoding proteins that act in the mismatch repair pathway, but
to date the evidence for their involvement in endometrial cancer predisposition is
limited. We have utilised an existing large genetic dataset to screen for CNVs in all genes
for which there is evidence for a role in the mismatch repair pathway. Genome-wide
scanning of CNVs was performed using Illumina610k single nucleotide polymorphism
data from a large cohort of 1336 endometrioid endometrial cancer cases and 619
healthy female controls. Fine-mapping of CNVs was carried out using four CNV calling
algorithms to increase both sensitivity and specificity of predictions and novel CNVs
were validated by quantitative PCR. By interrogating the array data, we identified and
confirmed deletions that disrupted known endometrial cancer susceptibility genes,
MSH2 and MSH6. This genetic information can now be used to facilitate counselling and
clinical management of these families. We also identified novel variants in several other
mismatch repair pathway genes, including duplications overlapping TGFBR3 and
MUTYH, and a deletion in RPA3, that are predicted to disrupt the coding sequence of
TGFBR3 and RPA3. Thus, we have identified novel aberrations in mismatch repair
pathway genes that fall outside the standard testing panel for hereditary endometrial
cancer. Furthermore, pathway analysis of all rare CNVs (CNVs found in cases but not
controls or the Database of Genomic Variants) showed genes predicted to be disrupted
by CNVs belong to several biological networks that may be relevant to endometrial
cancer pathogenesis. These results suggest further investigation is warranted to better
understand rare CNVs as susceptibility factors in endometrial cancer.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
SCOPE VS HOPE: WHEN SHOULD STUDIES OF “MISSING HERITABILITY” GO
WHOLE-GENOME?
Khalid Mahmood1, Chol-Hee Jung1, Joyce Teo2, Tu Nguyen-Dumont2, Fleur Hammet2,
Daniel J. Park2, Miroslaw Kapuscinsji3, David E. Goldgar4,5, Bernard Pope1, Graham G.
Giles6, John L. Hopper3, Andrew Lonie1, Gianluca Severi6, Melissa C. Southey2.
Victorian Life Sciences Computation Initiative (VLSCI), Carlton, Genetic Epidemiology
Laboratory, Department of Pathology, The University of Melbourne, Centre for
Molecular, Environmental, Genetic and Analytical Epidemiology, School of Population
Health, The University of Melbourne, Department of Oncological Sciences, Huntsman
Cancer Institute, University of Utah School of Medicine, Salt Lake City,, Department of
Dermatology, University of Utah School of Medicine, Centre for Cancer Epidemiology,
The Cancer Council Victoria, Carlton
Massively parallel sequencing (MPS) methodologies now offer robust platforms to
support a diverse array of genetic analyses. This technology is supporting a rapid
transition from single gene studies to genome-wide studies of Mendelian
disorders/syndromes to complex diseases, including cancer.
Until very recently there has been compelling justification for undertaking exome
capture followed by MPS (XC-MPS) in studies seeking to identify “missing heritability”.
This justification has centred around the research community’s more advanced ability
to interpret genetic variation in the exome and flanking intronic regions, and
considerably lower cost. Indeed, application of XC-MPS has already identified a number
of genes to be involved in cancer predisposition and progression.
There is now considerably more justification for whole-genome MPS (WG-MPS) in this
setting. The cost differential is now minimal and the bioinformatics tools for exploring
genetic variation in non-coding regions are increasing in number and sophistication.
There is also increasing interest and ability to integrate genome-wide datasets such as
transcriptomes and methylomes with whole-genome sequencing data. Limited use of
this technology has already proven its capacity to characterise genetic syndromes and
challenge the bioinformatician.
We have conducted some pilot work applying WG-MPS (at 30 times average genome
coverage) to a family that had already undergone an array of other genetic analyses
including XC-MPS. As the variations identified by WG-MPS approach are highly
concordant with those identified by XC-MPS or other approach, this has provided us
with more evidence to support the value and potential of a WG-MPS approach. In the
context of our breast cancer research program, we are particularly interested in
applying WG-MPS to examine the genomic regions that have provided signals in other
settings (eg linkage, GWAS) to avoid having to apply repeated upstream targeted
capture methodologies that involve a restricted genetic distance.
We will present our findings and discuss the current and future potential of WG-MPS to
support identification of missing heritability in different contexts.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
MAPPING THE GENETIC BASIS OF SARCOMAS IN HIGH RISK KINDRED
David Thomas1, Mandy Ballinger1, Ian Campbell1, Ella Thompson1, Paul James1, Gillian
Mitchell1, and the International Sarcoma Kindred Study (ISKS) Consortium
1Peter MacCallum Cancer Centre, Melbourne, Australia
Sarcomas have contributed tremendously to understanding the genetic basis of cancers
although only a small fraction of key cancer genes in sarcoma have been mapped
including TP53, RB1 and NF1/2. We aim to identify causal genes in highly penetrant
sarcoma families. ISKS has enrolled families with an unexplained increased risk for
sarcomas.
We have utilized massively parallel sequencing (MPS) to analyze the exomes of first
degree relatives and affected distant relatives to identify shared alleles in those with
cancer. We have refined our candidate list of cancer genes by complementary MPS
analysis of associated tumors, and by medium-throughput screening of additional highrisk sarcoma families using a modified BROCA strategy. Family 1 is comprised of two
unaffected parents and two affected children with four cancers by age 18
(rhabdomyosarcoma, Ewing sarcoma, germ cell tumor and therapy-associated
myelodysplasia). A fifth degree relative developed a high-grade sarcoma at age 19.
Several putative cancer genes were identified in the nuclear family by MPS using whole
exome capture, including Nibrin (NBN) and DNA Ligase 1 (LIG1). Mutations in NBN
cause the Nijmegen Breakage Syndrome, a radiosensitivity-associated cancer predisposition condition, not previously linked to sarcoma. In a medium throughput screen
of 34 other families, a second frameshift mutation (219fsX) in NBN was identified in
another high-risk family. LIG1 germline mutations have been associated with
radiosensitivity and increased cancer risk. Both the NBN and LIG1 mutations in Family 1
were paternally transmitted. The LIG1 mutation was subject to LOH in the
myelodysplastic peripheral blood of one proband, and a complementary somatic
mutation was identified in the tumor of the other affected, consistent with biallelic
inactivation of this gene in two tumors. Several other mutations (homozygous TP53,
BAX & PTEN; heterozygous NRAS & AML1) were also detected in the leukemia of the
first proband that were not shared by the other sibling, consistent with somatic tumor
evolution.
The genetic screening of highly penetrant families will provide insights into the
biological mechanisms of sarcoma leading to better outcomes by guiding early detection
strategies and informing therapeutic approaches.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Thursday 23rd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 7:
Plantation Room
Chairperson: Anna De Fazio
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
INVASIVE EPITHELIAL OVARIAN CANCER AND BRCA MUTATIONS: THE SOUTH
AUSTRALIAN PERSPECTIVE
Nicola K Poplawski1, 2 and Graeme Suthers1,2
1Familial Cancer Unit, SA Pathology (WCH Site), North Adelaide, South Australia;
2University of Adelaide, Adelaide, South Australia
Background: Two recent studies report detecting BRCA1/2 mutations in more than
10% of women with invasive, non-mucinous epithelial ovarian cancer in prospective
unselected series.1, 2 Both studies also reported their mutation detection rate was
influenced by the age at which the ovarian cancer was diagnosed suggesting that the
relative risk of ovarian cancer due to a BRCA mutation declines with age.
Aim: To audit the BRCA1/2 mutation detection rate in women with invasive, nonmucinous epithelial ovarian cancer, who have been referred to the South Australian
Clinical Genetics Service (SACGS) with a personal family history of ovarian cancer with
or without a family history of breast/ovarian cancer.
Method: Audit of the SACGS KinTrak database from 01/01/1995 – 30/06/2012.
Results: A total of 188 women who experienced epithelial ovarian cancer had BRCA1
and BRCA2 testing. The average age at diagnosis of ovarian cancer was 56.3 years
(range 22-83; median 58.5). Genetic testing identified 47 BRCA1 variants (46
pathogenic; 1 variant of uncertain significance or VUS) and 25 BRCA2 variants (16
pathogenic; 9 VUS). Testing was normal in 103 and is not yet completed in 13. Most
women with a pathogenic mutation had a family history of breast and/or ovarian
cancer. The results of testing by age at diagnosis are show in the table.
Zhang
age at
diagnosis
<30 years
30-39
years
40-49
years
50-59
years
60-69
years
70+ years
AOCS
SACGS
numbe BRCA1/2 numbe BRCA1/2 numbe
r tested mutation r tested mutation r tested
9
0
4
0
3
65
9 (13.8%)
28
258
67 (26%)
145
363
50 (13.8)
36
(11.8%)
12 (5.2%)
326
306
229
322
173
5 (17.9%)
36
(24.8%)
56
(17.2%)
33
(10.2%)
11 (6.4%)
11
43
46
56
27
BRCA1
/2
mutati
on
0
1 (9%)
17
(39%)
19
(41%)
21
(37%)
3 (11%)
Conclusion: Despite the difference in ascertainment, our study documents a BRCA
mutation detection rate which is similar to the two recently published larger studies.
The higher detection rate in older women in our study may be explained by a bias
towards referral of women with a family history of breast and/or ovarian cancer.
References
1. Zhang et al. Gynecologic Oncology 2011;121:353-357
2. Alsop et al. J Clin Oncol 2012;30:(10.1200/JCO.2011.39.8545)
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
LRPIB DELETION IN HIGH-GRADE SERIOUS OVARUAN CANCERS IS ASSOCIATED
WITH ACQUIRED CHEMOTHERAPY RESISTANCE TO LIPOSOMAL DOXORUBICIN
Prue A Cowin1,2,3, Joshy George1,4, Sian Fereday1, Elizabeth Loehrer1, Peter Van Loo5,6,
Carleen Cullinane1,3, Dariush Etemadmoghadam1,3, Sarah Ftouni1, Laura Galletta1, Michael
S Anglesio7, Joy Hendley1, Leanne Bowes1, Karen E Sheppard4,8, Elizabeth L Christie1,
Australian Ovarian Cancer Study1,9,10, Richard B Pearson2,4,,8, Paul R Harnett11, Viola
Heinzelmann-Schwarz12, Michael Friedlander13, Orla McNally14, Michael Quinn14, Peter
Campbell4, Anna deFazio9 and David DL Bowtell1,2,3,4
1. Cancer Genomics and Genetics Program, Peter MacCallum Cancer Centre, 2. Sir Peter
MacCallum Department of Oncology, The University of Melbourne, Parkville 3. Department
of Pathology, University of Melbourne, Parkville. 4. Department of Biochemistry and
Molecular Biology, University of Melbourne, Parkville. 5. Cancer Genome Project, Wellcome
Trust Sanger Institute, Cambridge, UK 6. Department of Human Genetics, VIB and
University of Leuven, Leuven, Belgium 7. University of British Columbia, BC Cancer
Research Centre, Vancouver, Canada 8. Oncogenic Signalling and Growth Control
Program, Peter MacCallum Cancer Centre 9. Department of Gynaecological Oncology and
Westmead Institute for Cancer Research, University of Sydney at Westmead Millennium
Institute, Westmead Hospital, New South Wales. 10. Queensland Institute of Medical
Research, Brisbane, Queensland. 11. Crown Princess Mary Cancer Centre Westmead and
Westmead Institute for Cancer Research, University of Sydney at Westmead Millennium
Institute. 12. Ovarian Cancer Group, Lowy Cancer Research Centre, University of New
South Wales, School of Women’s and Children’s Health/ Prince of Wales Clinical School,
Sydney. 13. Prince of Wales Hospital, Randwick, Sydney, NSW. 14. Department of
Obstetrics and Gynaecology, Royal Women’s Hospital, Parkville.
High-grade serous cancer (HGSC), the most common subtype of ovarian cancer, often
becomes resistant to chemotherapy, leading to poor patient outcomes. Intratumoral
heterogeneity occurs in nearly all solid cancers, including ovarian cancer, contributing
to the development of resistance mechanisms. In this study, we examined the spatial
and temporal genomic variation in HGSC using high-resolution SNP arrays. Multiple
metastatic lesions from individual patients were analyzed along with 22 paired pretreatment and post-treatment samples. We documented regions of differential DNA
copy number between multiple tumor biopsies that correlated with altered expression
of genes involved in cell polarity and adhesion. In the paired primary and relapse
cohort, we observed a greater degree of genomic change in tumors from patients that
were initially sensitive to chemotherapy and had longer progression-free interval,
compared to tumors from patients that were resistant to primary chemotherapy.
Notably, deletion or downregulation of the lipid transporter LRP1B emerged as a
significant correlate of acquired resistance in our analysis. Functional studies showed
that reducing LRP1B expression was sufficient to reduce the sensitivity of HGSC cell
lines to liposomal doxorubicin, but not to doxorubicin, whereas LRP1B overexpression
was sufficient to increase sensitivity to liposomal doxorubicin. Together, our findings
underscore the large degree of variation in DNA copy number in spatially and
temporally-separated tumors in HGSC patients, and they define LRP1B as a potential
contributor to the emergence of chemotherapy resistance in these patients.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
CLINICALLY, MOLECULARLY AND FUNCTIONALLY ANNOTATED MODELS OF HGSOC IN WHICH TO PERFORM PRE-CLINICAL ANALYSIS OF TARGETED THERAPIES.
TOPP M*%, Hartley L*, Cook M*, Rutkowski R*, A Dobrovic#, Hutt K%, McNally O^, Pyman J^,
Bowtell D#, Wakefield M, Scott CL* and the Australian Ovarian Cancer Study (AOCS).
Walter and Eliza Hall Institute of Medical Research*, Peter MacCallum Cancer Centre#, The
Royal Women’s Hospital^, Monash University%, Australian Ovarian Cancer Study.
Background: Altered DNA repair capability in epithelial ovarian cancer (EOC) may
underlie response to treatment1,2,3. Molecular sub-classification of serous and
endometrioid EOC, may uncover potential drug targets and possible mechanisms of
drug resistance3,4,5,6. In order to realize the potential of these discoveries, pre-clinical
molecularly-characterized in vivo models of EOC are essential for therapeutic analysis.
Methods: A novel xenograft cohort derived from consecutive cases of human highgrade serous ovarian cancer (HG-SOC) has been generated and characterized according
to histologic, functional and molecular features (at baseline and following
xenotransplantation). Analysis includes documentation of in vitro Homologous
Recombination (HR) DNA repair and drug response capabilities (using novel irradiation and explant drug assays); classification according to molecular subtype
(Tothill classifier4); documentation of NHEJ pathway status7, BRCA1/2 status8 and other
DNA repair gene status9. This in-depth characterization allows meaningful stratification
for in vivo drug treatment studies with the choice of treatment targeted to specific
molecular characteristics.
Each individual chemotherapy naïve HG-SOC is analysed before and after in vivo
treatment with cisplatin and novel therapeutics, an invaluable model for investigating
mechanisms of drug response and resistance. Clonal evolution studies will allow novel
discovery. Resistance to platinum is driven by re-treating relapsed tumours in vivo or
harvesting material for molecular analysis and serial transplantation with re-treatment.
This approach will also be adopted with novel therapies, including PARP inhibitors.
Results: 14 consecutive clinically annotated HG-SOC have been collected. Analyses
carried out to date on the novel xenograft cohort (at baseline and following
xenotransplantation) include histological review; preliminary documentation of in vitro
Homologous Recombination (HR) DNA repair capability including IHC for markers of
DNA damage (H2AX) and DNA repair (RAD51AP1); classification according to
molecular subtype (Tothill classifier) and preliminary RNA sequencing analysis.
Seven of the first 9 HG-SOC transplanted have successfully xenografted, with cryopreservation, serial transplantation and phenotyping of xenograft derivatives
underway. In vivo platinum response data has been obtained for 6 individual HG-SOC.
Five HG-SOC are platinum sensitive, with 2 showing early relapse, and one HG-SOC
appears to be primary treatment refractory. Cohorts of recipient tumor-bearing mice
are being generated for investigation of PARP inhibitor therapy in vivo, based on HR
status as defined by preliminary IHC, germline BRCA1/2 status (where available) and
RNA sequencing analysis.
Conclusions: A novel xenograft cohort of human HG-SOC has been generated, with
characterization of important prognostic features at baseline panel and in subsequent
xenografts.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
This resource will enable us to test molecular hypotheses and provide outstanding
utility for the development of improved therapeutic approaches.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Audeh, Lancet. 2010 Jul 24;376(9737):245-51
Ledermann et al., N Engl J Med. 2012 Apr 12;366(15):1382-92.
Cancer Genome Atlas Research Network Nature. 2011 Jun 29;474(7353):609-15.
Tothill et al, Clinical Cancer Research.2008 (14), 5198-5208
Helland et al, Plos one. 2011 Apr 13;6(4):e18064.
Etemadmoghadam D et al, PLoS One. 2010 Nov 12;5(11):e15498.
Patel A et al, Proc Natl Acad Sci 108(8):3406-11.
Noquist B et al, J Clin Oncol. 2011 Aug 1; 29 (22):3008-15
Walsh T et al, Proc Natl Acad Sci 108(44):18032-7.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
MOLECULAR PROFILING OF PRE-INVASIVE SEROUS OVARIAN TUMOURS
Sally M. Hunter1, Kylie L. Gorringe1,2, Michael S. Anglesio3, David G. Huntsman3,4, C. Blake Gilks3,4,
Raghwa Sharma5, Anna deFazio6,7, Yoke-Eng Chiew6,7, Simone M. Rowley1, Maria Doyle1, Australian
Ovarian Cancer Study1, Ian G. Campbell1,2.
1Centre
for Cancer Genomics and Predictive Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria,
Australia; 2The Department of Pathology, University of Melbourne, Parkville, Australia. 3The Department of
Pathology and Laboratory Medicine, University of British Columbia; 4Genetic Pathology Evaluation Centre of
the Prostate Research Centre and Department of Pathology, Vancouver General Hospital and University of
British Columbia, Vancouver, British Columbia, Canada; 5Anatomical Pathology, University of Sydney and
University of Western Sydney at Westmead Hospital, Australia; 6Department of Gynaecological Oncology,
Westmead Institute for Cancer Research, Westmead Hospital, Sydney, New South Wales, Australia,
7University of Sydney at Westmead Millennium Institute, Westmead Hospital, Sydney, New South Wales,
Australia
Ovarian low grade serous carcinoma (LGSC) are relatively rare compared to their high
grade counterparts, but are nonetheless a clinically relevant subset of epithelial ovarian
carcinoma (EOC). Correct diagnosis of LGSC is integral to maximising patient benefit
from treatment, as LGSC has better outcomes from debulking surgery prior to
chemotherapy and patient surgery can be compromised by use of neo-adjuvant
chemotherapy that is effective for high grade serous carcinomas. Serous borderline
tumours (SBTs), the presumed precursors to LGSC, are relatively common and are
considered to be of low malignant potential, typically following an indolent clinical
course. Long-term clinical follow-up has demonstrated that SBTs can recur, most
frequently as SBTs but also as LGSCs, inspiring a search for factors that may identify
which tumours are likely to recur. Despite significant progress in the past two decades
in differentiating the major histological types of epithelial ovarian carcinoma (EOC),
much remains to be determined and understood regarding the pre-invasive
counterparts to these lesions. Understanding precursor biology contextualises the
molecular pathogenesis of these tumours, informing tumour progression models, and
assisting identification of biomarkers and biologically relevant molecular targets. We
have undertaken molecular characterisation of benign (N=35) and borderline (N=57)
serous ovarian tumours using high-resolution genome-wide copy number analysis,
mutation hotspot screening and exome sequencing. A novel finding of this study was
that only 2.9% serous cystadenomas and cystadenofibromas had detectable copy
number aberrations in the epithelial component of the tumour. In contrast, copy
number aberrations were identified in the stromal component in 34% of cases. In
contrast to the benign serous tumours, 96.5% of SBTs have molecular evidence of
epithelial neoplasia. Consistent with previous reports, 79% of SBTs had oncogenic
mutations in the RAS/RAF/ERBB2 pathway, but appear relatively heterogeneous at the
copy number level. Intriguingly, specific clinical features and copy number events were
found to be significantly associated with either KRAS or BRAF mutation status,
indicating distinct biological consequences arising from these oncogenic events.
Contrary to the hypothesis that low grade serous tumours arise through a cystadenomaborderline tumour-adenocarcinoma sequence, our findings suggest that only a small
subset of serous borderline tumours are likely to be arising from serous cystadenomas
and cystadenofibromas. The vast majority of serous cystadenomas and
cystadenofibromas are not epithelial neoplasms and a significant proportion have
evidence of stromal neoplasia with molecular events consistent with a fibroma. Serous
borderine tumours were found to be a molecularly heterogeneous group that can be
stratified based on clinical features that correlate with oncogenic mutation events,
which may prove informative for identifying tumours that may progress or recur.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
GENOMIC PROFILING OF BENIGN, BORDERLINE AND INVASIVE MUCINOUS
OVARIAN TUMOURS IDENTIFIES KEY AND NOVAL GENETIC EVENTS
Sally M. Hunter*1, Georgina L. Ryland*1,2*, Maria A. Doyle3, Simone M. Rowley1, Michael
Christie5, Prue E. Allan4, Australian Ovarian Cancer Study Group3#, Ian G. Campbell†1,5,6
and Kylie L. Gorringe1,5,6
1. Victorian Breast Cancer Research Consortium (VBCRC) Cancer Genetics Laboratory,
Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia 2. Centre for Cancer
Research, Monash Institute of Medical Research, Monash University, Clayton, Victoria,
Australia 3. Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia 4.
Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, Victoria,
Australia 5. Department of Pathology, University of Melbourne, Parkville, Victoria,
Australia 6. Sir Peter MacCallum Department of Oncology, University of Melbourne,
Parkville, Victoria, Australia. *These authors contributed equally.
Mucinous carcinomas represent a distinct morphological subtype at several organ sites
including the ovary, and their genetic characteristics remain under-described. While
some invasive mucinous carcinomas at the ovary are metastases from distant sites,
primary ovarian mucinous carcinomas may arise through a stepwise progression from
benign cystadenoma to borderline tumour to invasive carcinoma. To explore the
spectrum of genomic alterations common to mucinous tumours we performed high
resolution genome-wide copy number analysis, mutation screening, and
immunohistochemistry on a series of primary ovarian mucinous cystadenomas (n=20),
borderline tumours (n=22) and invasive carcinomas (n=12).
Integration of copy number data, targeted mutation screening of RAS/RAF pathway
members and IHC revealed that p16 loss and RAS/RAF pathway alterations are highly
recurrent events that occur early during mucinous tumour development. The frequency
of concurrence of these events was 40% in benign cystadenomas, 68% in borderline
tumours and 75% in invasive carcinomas. Pilot exome sequencing of 12 tumours to
comprehensively investigate molecular events underlying tumour progression
identified truncating mutations in a novel tumour suppressor gene, which was the
fourth most frequently mutated gene after KRAS, BRAF and TP53. Further screening of
this gene in more cases identified additional deleterious mutations, with a final
frequency of 2/22 (9%) in mucinous ovarian borderline tumours and 6/30 (20%) in
mucinous ovarian carcinomas. The gene was mutated at <1% in TCGA serous
carcinomas, suggesting a mucinous-specific tumour-suppressive role.
This study is the largest and highest resolution analysis of mucinous tumors performed
to date and provides strong support for benign and borderline tumours as precursors of
primary ovarian mucinous adenocarcinoma. The prevalence of the observed genetic
alterations in mucinous tumours from extra-ovarian sites remains to be explored in a
larger data set but is a key step in identifying common pathways that may suggest
targeted treatments specific for this subtype.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Thursday 23rd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Plantation Room
Illumina Presentation.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
FFPE BASED MOLECULAR ANALYSIS - THE ILLUMINA STORY
Brett Kennedy, Product Marketing Manager, Australia and New Zealand
FFPE is a key sample material of interest with a raft of technical
challenges. This talk will outline products and applications from
Illumina with proven performance to anaylse FFPE material.
From genotyping and CNV analysis to methylation and sequencing.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Friday 24th
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 8
Plantation Room
Chairperson: Michael Bogwitz
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
IMPROVING EARLY DIAGNOSIS OF MEN2B: RAIDING AWARENESS AND
STIMULATING DEBATE
Hilda High 1, Kathy Tucker 1, Anne Turner 2, Mary-Louise Freckmann 2
1. Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, Australia
2. Clinical Genetics, Sydney Childrens Hospital, Randwick, Australia
The patient:
As a child, our patient had been reviewed by genetic services for dysmorphic features,
low tone, delayed speech and toe walking. Extensive workup was done to exclude a
connective tissue disorder. Over the 18 months prior to diagnosis he had had severe
diarrhoea, requiring intermittent hospitalisations for rehydration
There was no family history. His uncle has a similar facial appearance
The diagnosis of MEN2B seems obvious now that he has medullary thyroid cancer.
However, due to the missed diagnosis, previous photos were shown to a panel of clinical
geneticists and none considered the diagnosis.
Why is MEN2B hard to pick?
 50% of patients present with de novo mutations
 the typical phenotype becomes more obvious with age
 referrals to genetic centres for investigation for a connective tissue disorder are
common while MEN2B has an estimated prevalence of 1: 600,000.
Should targeted RET testing be performed in children when a diagnosis of Marfan’s
is considered?
 There is high clinical utility in testing. Thyroid cancer presents young, metastasises
early and treatment are limited, prolonged and expensive. Thyroidectomy is
preventive when performed early.
 Often young siblings and other family members are at risk
 >98% of the mutations in MEN2B are RET c.2753T>C, RET c.2647-2648 del ins TT
 Batch testing for these could be performed inexpensively.
We postulate that referrals for connective tissue disease may provide an opportunity to
exclude the diagnosis of MEN2B.
Criteria for proposed RET testing:
 Medullated corneal nerve fibres, detectable as prominent thickened corneal nerves
on slit lamp examination
 mucosal neuromas of the anterior dorsal surface of the tongue, palate, or pharynx.
 enlarged “blubbery” lips
 submucosal nodules of the lips
 ganglioneuromatosis of the gastrointestinal tract, often associated with constipation
in childhood. In one case series, >80% reported gastrointestinal symptoms in
infancy / early childhood.
 asthenic ‘Marfanoid’ body habitus in 75%.
Remembering MEN2B as a differential diagnosis will facilitate detection of the mucosal
and corneal lesions, since investigated for a connective tissue disease includes a full
examination including of the eyes and palate. A question on constipation could easily
be included.
MEN2B is a devastating condition if not diagnosed and treated with early
thyroidectomy. Modelling studies are underway to determine the economic validity of
genetic screening.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
VARIABILITY OF CLINICAL FEATURES IN MEN2
Charlotte Slade, Ingrid Winship
Multiple Endocrine Neoplasia 2 (MEN2) is an autosomal dominant syndrome
characterized by a very high prevalence of medullary thyroid cancer (MTC). It occurs in
approximately 1 in 30,000 individuals, and accounts for approximately 25% of cases of
MTC. The condition is caused by ‘gain of function’ mutations in the RET proto-oncogene,
located on chromosome 10.
MEN2 is characterized by a spectrum of features, and can be categorized as MEN2A,
MEN2B or Familial MTC. MEN2A includes the diagnoses of pheochromocytoma and
hyperparathyroidism. MEN2B features an earlier age of onset of MTC than MEN2A, as
well as marfanoid body habitus, mucosal ganglioneuromatosis and medullated corneal
nerves, but lacks primary hyperparathyroidism. FMTC is defined as 2 or more
generations with a RET mutation and MTC, without other features.
The most common RET mutation is a missense change at codon 634, and is associated
with almost complete penetrance of medullary thyroid cancer. However the discovery
of many other mutations has revealed a spectrum of disease with strong
genotype/phenotype correlation. On the basis of the strength of that association the
specific RET mutation is now used to guide screening and management decisions. The
American Thyroid Association has published guidelines regarding the timing of
prophylactic thyroidectomy based upon genotype.
We describe 2 families, seen at Royal Melbourne Hospital’s Familial Cancer Clinic, in
whom the variable penetrance of clinical features is demonstrated, and is consistent
with the published evidence for geneotype/phenotype correlation.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
REVIEW OF MUTATION DETECTION RATE FOR WOMEN DIAGNOSED WITH
BREAST CANCER AGED 30 YEARS AND YOUNGER
Annabelle Ng1, Camron Ebzery1, Judy Kirk2, Michelle Bowman2, Leonie Noon2, Hilda High2,
Kathy Tucker3, Jessica Duffy3, Sian Greening3, Michael Field4, Joanne Perkins4 and Annabel
Goodwin1, 1Cancer Genetics Clinic, Royal Prince Alfred and Liverpool Hospitals, NSW,
2Familial Cancer Service, Westmead Hospital NSW, 3Hereditary Cancer Centre, Prince of
Wales Hospital, Randwick, NSW, 4Hereditary Cancer Clinic, Royal North Shore Hospital, St
Leonards NSW
Background
Population based data (UK) found less than 10% of women diagnosed with breast
cancer under 30 have an inherited mutation in BRCA1 or BRCA2 unless there is
additional family history or triple negative pathology1,2.
Testing in NSW is usually offered only if there is additional family history.
Aim
To review the mutation detection rate in women diagnosed with breast cancer < 31 who
were tested after attending 4 NSW Family Cancer Clinics. To describe the clinical
characteristics of the BRCA1 & BRCA2 mutation carriers identified.
Methods
Retrospective study involving 4 NSW Family Cancer Clinics (FCC). Women diagnosed
with breast cancer < 31 were identified from each service, databases and files were
searched for additional clinical information.
Results
There were 172 women diagnosed with breast cancer < 31 identified who had a
mutation search of BRCA1 and BRCA2. Eleven women diagnosed with breast cancer <
31 had positive predictive testing for a known family mutation (TP53=1, BRCA1=4,
BRCA2=6). Due to additional family history, 13/172 had testing of TP53 and 4/13
(31%) had a mutation identified. An inherited BRCA mutation was detected in 55/172
women (32%). Of the 38/172 with no additional family history, three had an inherited
BRCA mutation (8%), (BRCA2=2, BRCA1=1) and one a TP53 mutation. Pathology
information was available for 29 (76%) of this group: Eight were known to be triple
negative and two of the eight (25%) had a BRCA mutation. Of those with a family history
of breast cancer only, 29.3% (29/99) had an inherited BRCA mutation (BRCA1=16,
BRCA2=13) and three a TP53 mutation. There was a high mutation detection rate in the
presence of breast/ovarian cancer family history, 66% (23/35). Triple negative
pathology was present for 9/38 BRCA carriers (23.7%) and an additional two had HER2
status unknown (pathology information was available for 38/55). There were more
women with BRCA1 mutations (n=42) diagnosed with breast cancer under age 31 than
BRCA2 (n=23). Risk of contralateral breast cancer for BRCA1 carriers was higher, 50%
(21/42) than for BRCA2 carriers, 22% (5/23).
Conclusion
These results support performing a mutation search of BRCA1 and BRCA2 for young
women diagnosed with triple negative cancers < 31 without any family history (25%),
those with a family history of breast cancer only (29%) or breast/ovarian cancer (66%).
We found a high rate of contralateral breast cancer for BRCA1 mutation carriers.
Evans DG, Moran A, Hartley R, J Dawson et al. Long-term outcomes of breast cancer in women aged 30
years or younger, based on family history, pathology and BRCA1/BRCA2/TP53 status. British Journal of
Cancer (2010) 102, 1091 – 1098.
2 Evans, D. G., A. Howell, D. Ward, et al. "Prevalence of BRCA1 and BRCA2 mutations in triple negative
breast cancer." 2011 J Med Genet 48(8):520-522
1
“Familial Cancer 2012: Research and Practice”
August 2012
THE EVOLUTION
COUNSELLING
Mantra Resort, NSW
OF
LI-FRAUMENI
SYNDROME
AND
CHALLENGES
FOR
Linda Cicciarelli and Alexandra Lewis, Peter MacCallum Familial Cancer Centre
Historically, TP53 mutation searching was offered to families who had a strong family
history, of sarcoma and other Li Fraumeni syndrome (LFS) defining cancers, which met
traditional LFS criteria. These families had often experienced significant trauma as a
result of their experiences of cancer in their family and therefore could be more
vulnerable in the genetic counselling setting. Many patients appeared uncertain about
the benefits of genetic testing for themselves and their families. Clinicians also
demonstrated uncertainty and apprehension when considering genetic testing for TP53
as there were limited evidence-based screening and clinical management options
available; clinicians wished to minimise any additional adverse psychological
consequences in this already vulnerable group. This emphasised the importance of
comprehensive counselling for patients considering a TP53 test. For many clinicians,
LFS is a condition that continues to cause appreciable apprehension when discussing
the possibility of and consequences of a TP53 gene mutation.
More recently, research studies have been identifying germline TP53 mutations in
patients who do not meet traditional LFS criteria, but have been ascertained for other
reasons. This includes patients diagnosed with sarcoma regardless of their family
history (through the International Sarcoma Kindred Study), early-onset HER2 positive
breast cancer, young age of breast cancer onset (<30 years) or multiple tumours
diagnosed in a single individual. Appreciation of these features, and also because we
have new advances in screening and pre-implantation diagnosis (PGD), TP53 testing is
now being considered for a wider group of patients. This position is facilitated by access
to massively parallel sequencing (next generation sequencing) for clinical testing. This
technology will allow testing for several cancer genes in parallel.
As testing for LFS becomes more commonplace, the challenge in genetic counselling will
be using a model that encompasses those families presenting with traditional LFS who
are traumatized as a result of their family history and those who do not have a family
history and view LFS as a less burdensome familial cancer syndrome.
In this presentation we will review the literature about genetic counselling practice in
LFS and provide recommendations to inform future genetic counselling practice in the
increasingly variable clinical landscape of germline TP53 mutations.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
WHEN DO WE TEST FOR COWDEN SYNDROME?
Leonie Noon1, Michelle Bowman1 and Judy Kirk1,2., 1Familial Cancer Service, Westmead
Hospital. 2Sydney Medical School – Westmead, University of Sydney.
Approximately 10% of all breast cancer diagnoses are due to an underlying genetic
predisposition1. Known genes in which a germline mutation causes an increased risk of
breast cancer include BRCA1 and BRCA2 (Hereditary Breast and Ovarian Cancer
Syndrome), TP53 (Li-Fraumeni Syndrome), STK11 (Peutz-Jeghers Syndrome) and PTEN
(Cowden Syndrome).
Cowden syndrome is a part of the PTEN-related hamartoma syndrome spectrum.
Germline mutations in PTEN are inherited in an autosomal dominant manner. PTEN
mutations are rare with a prevalence of at least one in 200,000-250,0002 and
penetrance as high as 80%3. Characteristic phenotypic features of Cowden Syndrome
include benign skin lesions (trichilemmomas, papillomatous papules and acral
keratosis), which are present in up to 99% of individuals by the age of 303. Other clinical
features include multinodular goitre, macrocephaly, gastrointestinal hamartomatous
polyps, benign breast fibrocystic disease and multiple endometrial leiomyomas.
Variable developmental delay has also been reported in some cases.
Cowden Syndrome is also associated with an increased risk of breast cancer (up to 85%
lifetime risk4), thyroid cancer, endometrial cancer and dysplastic gangliocytoma of the
cerebellum. An association between Cowden syndrome and an increased risk of renal
cancer, bowel cancer and melanoma has also been reported4.
JC was referred following a diagnosis of multiple bilateral breast fibroadenomas at 48
years of age. In addition, JC has a strong family history of breast cancer, as well as
numerous additional relatives with benign breast disease and several cases of mild
developmental delay. On clinical examination, JC was found to have a striking number of
pigmented keratoses on her back, as well as sebaceous lesions on her face. She reported
a personal history of a multinodular goitre, uterine fibroids and mild developmental
delay. No macrocephaly or oral lesions were noted.
Clinical BRCA1/2 germline testing had previously been carried out on both JC’s affected
mother and JC’s affected maternal aunt. The family is also a part of the kConFab study.
All BRCA1/2 genetic testing to date was uninformative. Without biopsy confirmation of
her trichilemmomas , JC had an Online Cleveland Clinic PTEN score of 8, corresponding
to a 2% chance of a mutation5. Germline PTEN testing has been initiated in JC and
results are anticipated in late July 2012.
The contribution of PTEN mutations to hereditary breast cancer may have been
underestimated until now, as genetic testing has focussed primarily on BRCA1/2. The
increasing use of next generation sequencing may reveal the role of PTEN in families
such as the one described above.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
CLINICAL GENETIC TESTING FOR HEREDITARY CANCER USING NEXT GENERATION
SEQUENCING
Lesley Andrews1, Bettina Meiser2, Ben Storey3, Belinda Rahman2
1Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick NSW
2Psychosocial Research Department, Prince of Wales Hospital, Randwick NSW
3University of New South Wales, Kensington NSW
Genetic testing is undergoing a major transformation with the introduction of Next
Generation Sequencing (NGS) to laboratories around the world. A number of Australian
laboratories providing mutation searching for hereditary cancer syndromes are
introducing this technology over the next year, however many of the issues associated
with this type of testing are yet to be resolved.
NGS will enable testing of genes which are part of current practice at lower cost and
greater speed. This raises the question as to whether we should change established
criteria for testing. Decisions will need to be made regarding testing of isolated cases of
rarer tumours, and whether testing of unaffected relatives in families with no living
affected members is appropriate.
Secondly, testing for cancer predisposition is likely to involve a large panel of cancer
genes. Some results may be unexpected on the clinical presentation. In addition, data
regarding the risks associated with mutations in some of these genes and their optimal
management may not yet be robust.
Thirdly, it is likely that standard testing may soon involve exome sequencing, where the
outcome may involve
 identification of incidental genetic disorders of clinical and/or personal
significance
 identification of possibly multiple genetic variations of unknown significance in a
single genome
 identification of pathogenic variations in newly identified genes with little
clinical data available to guide management.
The major challenges facing us are the provision of informed consent for these
outcomes, institutional policy regarding the returning of incidental findings and how to
manage the vastly increased the work load for genetic counselling services generated
by the increased complexity of potential results, as well as the capacity for higher
volumes of testing .
In order to determine the attitudes of Australian patients to these challenges, we are
conducting semi-structured telephone interviews with patients of the Prince of Wales
Hereditary Cancer Clinic who have previously undergone mutation searching with an
inconclusive result, as this is a cohort who may be offered NGS in the near future.
This study aims to explore patients’ hypothetical interest and motivations in genomic
testing, perceived advantages and disadvantages, information and communication
preferences regarding incidental findings, and need for assistance regarding decision
making using qualitative research methods. Results of the study will be presented.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Friday 24th
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Session 9:
Plantation Room
Chairperson: Mandy Spurdle
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
MODELLING GENETIC SUSCEPTIBILITY TO BREAST AND OVARIAN CANCER:
UPDATES TO THE BOADICEA RISK PREDICTION MODEL, AND RESULTS ON
GENETIC MODIFIERS OF CANCER RISK FOR BRCA1 AND BRCA2 MUTATION
CARRIERS FROM THE ICOGS CUSTOM GENOTYPING ARRAY
Antonis C. Antoniou, Centre for Cancer Genetic Epidemiology, Department of Public Health
and Primary Care, University of Cambridge, UK
The BOADICEA risk prediction model can be used to compute the probability that an
individual carries a BRCA1 or BRCA2 mutation and estimates their probability of
developing breast or ovarian cancer in the future. A new version of BOADICEA is
expected to be made available in September 2012 which will incorporate a number of
novel features. The presentation will describe the work on extending BOADICEA to
incorporate breast tumour pathology and how this impacts both the predicted mutation
carrier probabilities and cancer risks. The incremental predictive value of incorporating
tumour pathology is currently being evaluated in 7,353 families from the German
Hereditary Breast and Ovarian Cancer Consortium. Additional novel features include
the inclusion of population specific cancer incidences, allowing BOADICEA to be
customised to specific populations, and the inclusion of population cancer incidences
from more recent calendar periods, thus allowing for more accurate future cancer risk
predictions. Ongoing work on incorporating the explicit effects of the common breast
cancer susceptibility alleles identified through genome-wide association studies
(GWAS), and modelling the residual, non-BRCA1/2 familial clustering of ovarian cancer,
will also be described.
Although BOADICEA incorporates a modifying component of breast cancer risk for
BRCA1 and BRCA2 carriers, the explicit effects of the known genetic modifiers are not
currently incorporated. Work by the Consortium of Investigators of Modifiers of
BRCA1/2 (CIMBA) aims to identify and characterise genetic modifiers of cancer risk for
BRCA1 and BRCA2. CIMBA studies have demonstrated that several common alleles
modify the risks of developing breast or ovarian cancer for BRCA1 and BRCA2 mutation
carriers. CIMBA participated in the design of the iCOGS custom array containing
211,155 SNPs selected by several international consortia, primarily on the basis of
evidence from GWAS of breast, ovarian and prostate cancer. Approximately 52,000 of
those SNPs were selected on the basis of the BRCA1 and BRCA2 GWAS. Analysis of the
CIMBA iCOGS SNPs in 11,705 BRCA1 and 8,211 BRCA2 carriers has identified 4 novel
loci that are associated with breast cancer risk of BRCA1 and/or BRCA2 mutation
carriers and 2 novel loci associated with ovarian cancer risk for mutation carriers. Two
of these loci appear to be specifically associated with risk for mutation carriers, the first
of their kind. The presentation will review the latest analyses using the iCOGS array and
the implications for risk prediction in BRCA1 and BRCA2 mutation carriers.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
THE BREAST CANCER RISK PREDICTION MODEL BOADICEA: CALIBRATED FOR
AUSTRALIAN WOMEN AND A NEW EASY-TO-USE BATCH PROCESSOR
Robert MacInnis (1,2), Adrian Bickerstaffe (2), Carmel Apicella (2), Gillian Dite (2), James
Dowty (2), Kelly Aujard (2); Kelly-Anne Phillips (2,3), Prue Weideman (3), Antonis
Antoniou (4), John Hopper (2), Cancer Epidemiology Centre, The Cancer Council, Centre for
MEGA Epidemiology, University of Melbourne, Division of Cancer Medicine, Peter
MacCallum Cancer Centre, 4 CR-UK Genetic Epidemiology Unit, University of Cambridge,
UK
Risk prediction algorithms are an important tool for identifying individuals at increased
risk of developing the disease who can then be offered individually tailored clinical
management. BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier
Estimation Algorithm, Antoniou et al., 2004, 2008) is a risk model for familial breast and
ovarian cancer that can be used to compute BRCA1 and BRCA2 mutation carrier
probabilities and age specific risks for breast and ovarian cancer.
Two criticisms of the model include: Although the carrier prediction algorithm has been
shown to be well calibrated (ref Antoniou 2008), it is still uncertain how well the agespecific risks perform, particularly in an Australian setting and the web based version
can be difficult for users to input data and is currently not set up to batch process
multiple pedigrees. Firstly, to evaluate the age-specific risk estimates of BOADICEA, we
used 1438 families of ABCFS case probands, diagnosed from 1991 to 1998 and aged less
than 80 years. Cumulative breast cancer risks over 10 years of follow-up until 2010
were calculated for 4182 unaffected female relatives. Australian age-specific breast
cancer incidences from 1985 to 2000 were used as the population reference rates. A
total of 136 incident breast cancers were reported. The ratios of expected to observed
number of breast cancers was 0.86 (95% CI 0.73-1.02), while the test for discrimination
(ROC curve) was 0.60 (95% CI 0.55-0.65).
Secondly, a set of new software programs were designed to automate the process of
using BOADICEA in batch mode. These include setting up the pedigree files in the
correct format, validating the pedigrees against the requirements of BOADICEA, data
cleaning and estimation of missing values (using information from relatives), processing
the submission of the data to BOADICEA and collating the results. These programs were
written in Java and can be easily run on a variety of platforms.
We have shown that BOADICEA is easy-to-use, supports batch processing, and is well
calibrated for Australian women. Work is ongoing to add additional factors to
BOADICEA to improve discriminatory accuracy, which will ultimately improve targeting
of clinical interventions. Multiple independent TERT variants associated with telomere
length and risks of breast and ovarian cancer
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
MULTIPLE INDEPENDENT TERT VARIANTS ASSOCIATED WITH TELOMERE
LENGTH AND RISKS OF BREAST AND OVARIAN CANCER.
Georgia Chenevix-Trench1, Stig E Bojesen2, Karen A Pooley3, Sharon E Johnatty1,
Jonathan Beesley1, Stacey L Edwards4, Hilda A Pickett5, Howard C Shen6, Chanel E
Smart7, Simon A Gayther6, Paul D P Pharoah3, Roger R Reddel5, Ellen L Goode8, Mark H
Greene9, Douglas F Easton3, Andrew Berchuck10, Antonis C Antoniou3, and Alison M
Dunning3 on behalf of BCAC, OCAC and CIMBA
(1) Genetics Department, Queensland Institute of Medical Research, Brisbane, Australia. (2)
Copenhagen General Population Study, Herlev Hospital, Copenhagen University Hospital,
University of Copenhagen, Copenhagen, Denmark, (3) Centre for Cancer Genetic Epidemiology,
Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK., (4)
School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia,
(5) Cancer Research Unit, Children’s Medical Research Institute, Westmead, NSW, Australia, (6)
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los
Angeles, CA, USA, (7) The UQ Centre for Clinical Research, The University of Queensland, The Royal
Brisbane and Women's Hospital, Herston, Brisbane, QLD. 4029 Australia, (8) Department of Health
Science Research, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA, (9) Clinical Genetics
Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National
Institutes of Health, Rockville, MD, USA (10) Department of Obstetrics and Gynecology, Duke
University Medical Center, Durham, NC, USA
Common variants around the TERT-CLPTM1L locus and differences in mean telomere
length in blood cells are both reported to be associated with risk of multiple cancer
types. To identify variants associated with telomere length, breast or ovarian cancer
risk, ~480 genotyped and imputed TERT-CLPTM1L locus single nucleotide
polymorphisms (SNPs) were analysed in 103,991 breast cancer cases and controls,
44,308 ovarian cancer cases and controls, and 11,705 BRCA1 mutation carriers as part
of the ‘iCOGS’ chip. Whole blood telomere length was determined in 53,724 individuals
from the UK and Denmark. Associations with all phenotypes fall mainly into three
independent peaks of association: in the TERT promoter (Peak 1), the minor alleles of
SNPs correlated with rs2736108 associate with longer telomeres (P=5.8×10-7), reduced
estrogen receptor negative breast cancer (P=1.2×10-9), reduced breast cancer risk
in BRCA1 mutation carriers (P=1.0×10-5) and altered signal in promoter assays. In Peak
2, the minor allele of SNP rs7705526 associates with longer telomeres (P=2.3×10-14),
increased low malignant potential ovarian cancer risk (P=1.3×10-15) and increased
activity in promoter assays. In Peak 3, minor alleles of highly correlated SNPs,
rs10069690 and rs2242652, increase risk of estrogen receptor negative breast cancer
(P=1.2×10-12), breast cancer risk for BRCA1 mutation carriers (P=1.6×10-14) and serous
invasive ovarian cancer (P=1.3×10-11), but are not associated with telomere length. The
cancer-risk allele of rs2242652 increases the strength of a silencer regulatory element,
while that of rs1006960 generates a novel, truncated TERT splice variant. Both SNPs lie
within an open chromatin site, discovered in stromal and myoepithelial cells from
reduction mammoplasty samples. Only Peak 1, of the three, supports the hypothesis
that increased cancer risk is mediated through shorter telomeres. These strong and
complex associations indicate multiple TERT roles in controlling telomere length and
cancer development.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
RISK PREDICTION MODELS FOR MISMATCH REPAIR GENE MUTATIONS: A
SYSTEMATIC REVIEW AND A META-ANALYSIS
Aung Ko Win1, Mark A. Jenkins1
1 Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University
of Melbourne, Parkville, Victoria, Australia.
One of the strongest predictors of colorectal cancer risk is carrying a germline mutation
in a DNA mismatch repair gene. Identifying people carrying a mismatch repair gene
mutation is important because they are at high risk of colorectal, endometrial and
several other cancers and they can benefit from screening. Conversely, identifying noncarriers of mismatch repair gene mutation who are at the population risk of cancer is
important as they can be relieved of the burden of this intensive screening program.
Prediction models for who is likely or not likely to be a mutation carrier are needed for
cost-effective targeted genetic testing.
Current methods for predicting risk of carrying a mutation in a mismatch gene depend
primarily on whether a person had a colorectal cancer. For those with colorectal cancer,
mutation prediction is currently done by testing the tumour for mismatch repair
protein deficiency and guided by age of diagnosis, other pathology features and/or
family history. For those without a personal history of colorectal cancer, mutation
prediction is currently done using models that incorporate family history.
Several prediction models for mismatch repair gene mutation status have been
developed: Leiden, Amsterdam-plus, MMRpro, PREMM1,2,6, MMRpredict, AIFEG and the
Myriad Genetics Prevalence table. A meta-analysis of the 17 validation studies on the
discrimination performance of these models (area-under curves or c-statistics) revealed
0.84 (95% confidence interval, CI 0.81-0.88) for PREMM, 0.80 (95% CI 0.72-0.88) for
MMRpro, 0.81 (95% CI 0.73-0.88) for MMRpredict, and 0.85 (95% CI 0.78-0.91) for
Leiden model.
I will present an overview of the various published models to predict risk of mismatch
repair gene mutation and their performance.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
TUMOUR MORPHOLOGY OF EARLY-ONSET BREAST CANCERS PREDICTS BREAST
CANCER RISK FOR FIRST DEGREE RELATIVES
Gillian S. Dite1, Enes Makalic1, Daniel F. Schmidt1, Graham G. Giles1, 2, John L. Hopper1,
Melissa C. Southey3
1Centre
for Molecular, Environmental, Genetic and Analytic Epidemiology, The University
of Melbourne, Australia; 2Cancer Epidemiology Centre, Cancer Council Victoria, Australia;
3Department of Pathology, The University of Melbourne, Australia.
Background: We previously found that tumour morphological features predict BRCA1
mutation carriers among women with early-onset breast cancer better than family
history and standard immunohistochemistry. We now hypothesised that risk of breast
cancer could be predicted by tumour morphological features for relatives of women
with early-onset breast cancer, including relatives of women without a detectable
germline mutation in a known breast cancer susceptibility gene.
Methods: We studied mothers and sisters of a population-based sample of 452 index
cases with a first primary invasive breast cancer diagnosed before the age of 40 years
and for whom a standardised tumour morphology review had been conducted.
Standardised incidence ratios (SIR) were calculated by comparing the number of
relatives with breast cancer to the number expected based on Australian incidence
rates. Hazard ratios were calculated using Cox proportional hazards modelling.
Results: Absence of extensive sclerosis, extensive intraductal carcinoma, absence of
acinar and glandular growth patterns, and presence of trabecular and lobular growth
patterns were independent predictors with between 1.8 and 3.1–fold increased risk for
relatives (all p < 0.02). Excluding the 77 (17%) index cases with genetic or epigenetic
causes, independent predictors included minimal sclerosis, circumscribed growth,
extensive intraductal carcinoma and lobular growth pattern, all with between 2.0 and
3.3–fold increased risk for relatives (all p < 0.02). Relatives of the 128 (34%) index
cases with none of these features were at population risk (SIR = 1.03, 95% CI = 0.57–
1.85), while relatives of the 37 (10%) index cases with two or more features were at
high risk (SIR = 5.18, 95% CI = 3.22–8.33).
Conclusion: There is such a wide variation in risks for relatives based on tumour
characteristics that early-onset cases without a known genetic predisposition can be
divided into three groups for whom the breast cancer risks for relatives are the same as
for the three categories in the Guide for Health Professional on Familial Aspects of Breast
and Ovarian Cancer developed by the National Breast and Ovarian Cancer Centre. This
should be important for genetic counselling, prevention and screening. It adds support
to the concept that morphology review of a few key measures could be used to better
inform families of their risks of breast cancer, and therefore be considered as an integral
part of a breast cancer family genetics service. The identification of a group of relatives
at high risk of breast cancer could also help discover new breast cancer susceptibility
genes.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
Programme
Wednesday 22nd
A combined meeting of kConFab, Australian Breast Cancer
Family Study, Australasian Colorectal Cancer Family Study,
Australian Ovarian Cancer Study, Family Cancer Clinics of
Australia and New Zealand.
“Familial Cancer 2012: Research and Practice”
Poster Session
6.00 – 8.00pm
In the main Foyer of Mantra
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#1
THE HETEROGENEITY OF BIRT HOGG DUBE SYNDROME
Authors: Charlotte Slade, Ingrid Winship
Birt Hogg Dubé (BHD) syndrome is a rare, autosomal dominant genodermatosis. It
is characterized by a predisposition to the development of cutaneous hamartomas
(fibrofolliculomas and trichodiscomas), renal tumors, and lung cysts. The lung cysts
may be complicated by spontaneous pneumothorax. Mutations within the folliculin
gene, located on the short arm of chromosome 17, are identified in the majority of
cases. The penetrance of clinical features is highly variable, and the spectrum of features
may be seen within individual families. Management of these patients requires
multidisciplinary care, with the involvement of dermatologists, nephrologists,
respiratory physicians and in some cases thoracic surgeons and urologists.
We describe the clinical features of 32 affected individuals from nine families in whom
we have confirmed the diagnosis of BHD clinically. Seven of those nine families have had
genetic testing which confirms the presence of a folliculin mutation. The variability of
clinical features within families is highlighted, with some individuals developing renal
cancers at a young age, whilst some elderly mutation carriers in the same family are
unaffected.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#2
SURVEILLANCE PROTOCOL SNAPSHOT: VICTORIAN FAMILY CANCER REGISTER,
CANCER COUNCIL VICTORIA
McArdle T1, Black M1, Farrugia H2, Giles GG3, Winship I4
1 Victorian Family Cancer Registry (VFCR), Cancer Council Victoria (CCV)
2 Victorian Cancer Registry, CCV
3 Cancer Epidemiology Centre, CCV
4 VFCR Clinical Consultant
Background
Since 2000 the Cancer Council Victoria has managed an opt-on register for family
members assessed as having a high risk of developing cancer due to a genetic
predisposition (also includes re-consented members from the FAP register established
in 1988). Referrals to the Victorian Family Cancer Register (VFCR) are largely from the
four Victorian Family Cancer centres (FCCs) with a small number referred by doctors
for familial adenomatous polyposis (FAP). The VFCR provides several functions
including two important services; a cancer verification service to help FCCs with cancer
risk assessment and a surveillance appointment reminder service for its members. For
one third of members enrolled in the reminder service, collecting surveillance protocols
from the FCCs is a priority for managing their surveillance appointment reminders.
Surveillance outcomes are sought from hospital, clinics and doctors for FAP members.
For other family cancer syndromes, outcomes are self-reported. Cancer diagnoses are
confirmed by record linkage to the population-based Victorian Cancer Registry. The
benefit of collecting surveillance and cancer outcomes is the ability to measure the
efficacy of surveillance protocols recommended.
Aim: To review surveillance protocols held on the VFCR and evaluate the proportion of
cases that are within recommended clinical guidelines for FAP, Lynch and
Breast/Ovarian cancer syndromes.
Description: The selected sample for review included 715 consented and alive
members up to June 30, 2012. Of these 64% had a surveillance protocol and are
described by procedure, frequency and age group. Surveillance protocols on the VFCR
were compared with EviQ risk management guidelines for FAP, Lynch and
Breast/Ovarian cancer syndromes.
Summary: Results demonstrate the proportion of cases found to have surveillance
protocols within recommended guidelines. Some cases of variance from the
recommended clinical guidelines could be explained by age, medical history or personal
circumstances. In other cases, a complete screening picture was not available to the
VFCR.
The major limitation of the review was that the VFCR holds surveillance protocols for
only 64% of its members. With a comprehensive data set, the VFCR may in the future
have an opportunity to answer complex questions about surveillance, such as,
compliance, efficacy and impact on cancer diagnoses for high cancer risk families.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#3
DILEMMAS WITH IDENTIFICATION OF A CAUSATIVE GENE FOR MULTIPLE SELF
HEALING EPITHELIOMAS
Camron Ebzery1, Annabelle Ng1, Georgina Fenton1, Cliff Meldrum2 and Annabel Goodwin1
1Cancer Genetics Clinic, Royal Prince Alfred and Liverpool Hospital, Sydney.
2 Deputy Director Genetics, Hunter Area Pathology Service
Multiple Self Healing Squamous Epithelioma (MSSE) or Ferguson Smith disease, is a rare
autosomal dominant condition, first identified in patients of Scottish ancestry in 1934.
The condition is characterised by the development of multiple keratoacanthoma (KA)
like lesions which are malignant. The lesions can spontaneously regress without
treatment but may cause scarring resulting in significant disfigurement.
A family with a clinical diagnosis of MSSE was referred to our service for an opinion
regarding management, due to confusion between this condition and Muir Torre
Syndrome by the referring doctor. We reviewed the literature regarding MSSE and a
research group had recently identified a causative gene, TGFBR1 (Gouide et al).
Age of onset and severity of MSSE can vary within families and clinical discrimination of
mutation carriers may be difficult. Additionally, treatment of skin cancers for
individuals diagnosed with MSSE (clinical or genetic diagnosis) may be altered since
there are reports of progression and disfigurement following radiotherapy. Given this
knowledge, we contacted the researchers who offered to test TGFBR1 in this family.
Since this condition may be diagnosed by clinical findings and there is little evidence to
guide management of affected individuals, the benefit of predictive testing for this
condition is not yet established.
Several family members expressed interest in genetic testing to learn whether this was
the cause of MSSE for their family. Research testing of TGFBR1 was then arranged for
an affected family member and a novel truncating mutation was identified in exon 7
(c.1237C>T). We have since approached a clinical laboratory (HAPS), who will perform
predictive genetic testing if it is considered to be of benefit to the family. We will
discuss the clinical dilemmas and potential benefits associated with predictive genetic
testing for this condition.
Goudie DR, D'Alessandro M, Merriman B, Lee H, Szeverenyi I, Avery S, et al. Multiple
self-healing squamous epithelioma is caused by a disease-specific spectrum of
mutations in TGFBR1. Nat Genet 2011;43:365–9.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#4
HEREDITARY LEIOMYOMATOSIS AND RENAL CELL CARCINOMA SYNDROME – THE
ROYAL MELBOURNE HOSPITAL EXPERIENCE
Authors:
Manju Salaria, Alison Trainer, Ingrid Winship.
Affiliations: Department of Genetic Medicine, Royal Melbourne Hospital, Grattan Street,
Parkville, Melbourne
Background:
Hereditary leiomyomatosis and renal cell cancer (HLRCC) characterized by cutaneous
leiomyomas, uterine leiomyomas (fibroids), and/or a renal tumor is a rare autosomal
dominant cancer predisposition syndrome. The most important clinical feature
associated this condition is a predisposition to renal cell carcinoma (RCC), typically
papillary type 2 on histopathology, which occurs at median age of 44 years.
Aim:
The study aimed to characterize the phenotypic features and genotypes of patients with
HLRCC referred to the familial cancer centre at the Royal Melbourne Hospital.
Methods:
The medical records of all the patients assessed with HLRCC from 2007-2012 at the
Royal Melbourne Hospital, Victoria, Australia were scrutinized for inclusion in this
audit.
Results:
A total of five patients were diagnosed with HLRCC during this time period. All of these
patients were females. All of these patients had multiple cutaneous and uterine
leiomyomas. One patient had a renal cancer diagnosed at the age of 32, whilst another
patient had a family history of renal cancer in a sibling. Genetic testing of 4 patients
identified potentially pathogenic mutations in the fumarase hydratase gene (FH gene).
Conclusions:
Skin leiomyomas are an important clue to diagnosis of HLRCC. These skin coloured and
tender lesions usually start during adolescence. Furthermore, in females with multiple
uterine leiomyomas (requiring hysterectomy in 30s or 40s), a skin examination and a
detailed family history may provide important clues towards diagnosis of HLRCC. The
renal tumor in HLRCC is an aggressive tumor, usually requiring nephrectomy. Early
diagnosis of HLRCC is important, and surveillance of at risk family members can be life
saving.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#5
INTERDISCIPLINARY PATIENT FILE REVIEWS AND FOLLOW-UP OF PEUTZIEGHERS SYNDROME MANAGEMENT
Kirsty Mann1, Adrienne Sexton1, Masha Slattery2, Finlay Macrae1,2
1Familial Cancer Centre, Royal Melbourne Hospital
2Bowel Cancer Surveillance Service, Royal Melbourne Hospital
Peutz-Jeghers syndrome (PJS) is caused by mutations STK11 and is characterised by:
hamartomatous polyps in the gastrointestinal system (50% have onset before age 20);
increased risk of cancers of the small bowel, colon, stomach, breast, and pancreas; and
increased risk of adenoma malignum of the cervix, sex cord ovarian tumours with
annular tubules (SCTAT) of the ovaries, and Sertoli cell tumours of the testes.
Surveillance options for PJS have been modified in recent years with the availability of
improved technologies such as capsule endoscopy and breast Magnetic Resonance
Imaging (MRI). A consensus of best practice would aid in improved co-ordination,
rather than a fragmented approach to management distributed across a range of
specialists. In light of these recent developments, we reviewed the current local
management guidelines for PJS. We present a standard letter created to summarise
these recommendations. We jointly undertook an audit of all individuals with PJS that
have attended the Royal Melbourne Hospital (RMH) Familial Cancer Centre (FCC) or
Bowel Cancer Surveillance Service (BCSS). We identified 17 patients seen at the FCC
and/or BCSS since year 2000 and assessed their surveillance records, and compared
this to the newly agreed local guidelines. Where there was discrepancy, the relevant
endoscopic surveillance was arranged. To inform these meetings, we checked genetic
(FCC) files, BCSS files, and private medical records. We reviewed whether or not breast
MRI had been discussed with female patients (and at-risk female relatives of male
probands if applicable), issues related to cascade testing, and any other psychosocial
issues.
These interdisciplinary file reviews found that gastrointestinal surveillance was either
not up to date or records were incomplete for seven patients. There were nine patients
(female or with female at-risk relatives) with no record of breast MRI being discussed.
Twelve individuals had at-risk relatives without record of being seen at a genetics
service. Accordingly, the follow-up involved arranging nine endoscopic procedures,
contacting five patients about cascade testing, contacting six doctors/patients about
breast MRI, and contacting five doctors about general surveillance recommendations.
This process highlighted the complexity of follow-up for PJS patients, and the value of
reviewing files in a systematic way, especially for patients who may have not been in
contact with an FCC in recent years. It may be used as a model for audits of other rare
cancer syndromes, for example Hereditary Diffuse Gastric Cancer and Juvenile
Polyposis.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#6
TWO PATHOGENIC MUTATIONS IN BRCA2 GENE IN THE SAME ALLELE
Aamira Huq1, Megan Cotter1, Serguei Kovalenko2, Agnes Bankier1
1 Department
of Genetic Medicine and Familial Cancer, Austin Health, Melbourne,
Australia.
2 Genetic Technologies Limited, Melbourne, Australia
We present a case with two pathogenic mutations in the same allele of BRCA2 in a
female with breast cancer.
Case: Mrs. LA, a 52 year old lady was referred for BRCA testing, having been diagnosed
with a grade 3 ER/PR/Her2 negative basal type invasive carcinoma with associated
ductal carcinoma in situ at age 51 (in 2011). Family history includes prostate cancer in
her father (aged 75) and her paternal uncle (aged 66) and breast cancer at 36 in his
daughter. Her BRCAPro score was 9% based on her family history and pathology. BRCA
testing was offered on the basis of her pathology and the BRCAPro not being able to
take into account her cousin’s young onset breast cancer diagnosis.
She also developed neuroendocrine tumour of the small bowel with hepatic metastases,
and underwent extensive abdominal surgery at which time she also had bilateral risk
reducing salpingo oophorectomy. Past history includes hepatitis C, treated with
interferon.
Results: Two separate pathogenic mutations in exon 11 and exon 21 of the BRCA2 gene
were identified. The first mutation in exon 11 - c.3405C>A has not previously been
reported in the Breast Cancer Information Core database but it is predicted that this
mutation would result in a truncated BRCA2 protein with impaired function and/or
activity. The second mutation in exon 21 - c.8673_8674delAA causes a frame shift
mutation previously reported in the BIC database as clinically important. This mutation
has also been reported in the dbSNP database, but validation summary is unknown.
Segregation analysis: Further genetic testing in the family identified both mutations in
her father confirming the common allelic nature of both these mutations. Predictive
testing in other family members is still ongoing
Discussion: Compound heterozygosity of the BRCA1 and the BRCA2 genes, as well as
two mutations in an exon and a splicing site of BRCA2 have been previously described.
In our case, the truncating effect of the first mutation would likely dominate over the
effect of the second mutation. However, as there is paucity of such mutations found in
literature, clear genotype phenotype correlations are difficult to obtain.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#7
INDENTIFICATION OF A WHOLE BRCA2 GENE DELETION: NOW WHAT IT SEEMS!
Jan Sullivan, XXXXX
Genetic Health Service NZ – South Island Hub, Christchurch Hospital, Christchurch, NZ
Large genomic rearrangements in the BRCA2 gene are reported as being rare. Routine
BRCA1 and BRCA2 sequencing was performed in 2005 in a 71 year old woman with a
personal history of breast cancer (G1 IDC, node positive, at age 61), and a family history
of breast cancer (two sisters with IDC at ages 45 and 50 respectively, and mother at age
80). No pathogenic mutation was identified. After another at-risk family member
represented in 2011, MLPA was performed on stored DNA from the original patient
sample for completeness. A heterozygous deletion of the entire BRCA2 gene was
detected. This was confirmed by array CGH, which showed two deletions of 53.7Mb and
354 kb on 13q, and encompassing the BRCA2 gene. With a large deletion of almost the
entire 13 q arm, an acquired cause for this karyotypic abnormality was suspected. It
was then confirmed that the patient had been diagnosed with myelofibrosis in 1996,
and had died from AML in 2007. Therefore, this deletion was attributed to her
myeloproliferative disorder and was almost certainly not a germline BRCA2 deletion. It
remains unknown whether there was a germline BRCA2 gene mutation present in the
deleted BRCA2 gene, however. In conclusion, haematological malignancies need to be
considered when whole gene deletions or duplications are identified in BRCA1 and
BRCA2.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#8
HIGH BRCA1/2 MUTATION FREQUENCY IN WOMEN AFFECTED BY YOUNGEST
ONSET BREAST CANCER WHO ATTEND AN AUSTRALIAN FAMILIAL CANCER
CENTRE
Aamira Huq, Michael Bogwitz, Nicholas Pachter, Ingrid Winship, Geoffrey Lindeman,
Alison Trainer
The Royal Melbourne Hospital Familial Cancer Centre, Parkville, VIC 3050, Australia.
Background: Women who develop breast cancer at a young age may carry an
underlying genetic predisposition and have an increased risk of developing another
breast cancer. Population studies of women with young onset breast cancer suggest a
BRCA1and BRCA2 mutation rate of up to 11%, with unclassified variants rate observed
in up to 19%.
Objectives: Our aim was to determine the rate of BRCA1, BRCA2 and TP53 mutations
detected in a cohort of women aged 35 years or under affected by breast cancer who
attended the Royal Melbourne Hospital Familial Cancer Centre and to determine the
associated pathology and family history.
Methods: We reviewed the medical records of 107 women referred to our service
between 2000 and 2012, with breast cancer diagnosed at the age of 35 or less, in whom
BRCA1/2 mutation detection was conducted. Family history and pathology data
including the type and grade of the tumour as well as receptor status were collected
from all cases. We also analyzed any TP53 testing that was performed in this cohort.
Women who underwent predictive testing were excluded from analysis
Results: Of the 107 cases, 19 (18%) were found to carry a pathogenic BRCA1 or 2
mutation, with 7 (6%) cases carrying unclassified variants. TP53 testing was carried out
on 18 (17%) of patients. No TP53 mutations were identified in this subset. Details of
associated pathology information will be provided.
Conclusions: The policy at our Familial Cancer Centre has been to offer BRCA mutation
detection for any woman diagnosed with breast cancer 35 years old or under,
irrespective of family history. Our data suggests an 18% chance of finding a BRCA1 or
BRCA2 mutation in this population. The likelihood increases where there is a family
history of breast cancer. A larger cohort will be required to investigate the merits of
TP53 testing, where tumour grade and HER2 status could be considered.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#9
COMPARISON OF IMMUNOHISTOCHEMISTRY FOR MISMATCH REPAIR PROTEINS
IN PRE AND POST CHEMORADIOTHERAPY TREATED RECTAL CANCER
Names: Cook BC1, Warrier SK2, Yeung J, Norris B, Mitchell C1, Lynch AC1, Heriot AG1,
Trainer A*1, Mitchell G*1.
*Joint senior authors
1 Peter MacCallum Cancer Centre
2 Alfred Hospital
Background
Preoperative adjuvant chemoradiotherapy is commonly used in the treatment of
advanced rectal cancer. Chemoradiotherapy has previously been shown to affect the
reliability
of
microsatellite
instability
testing
for
Lynch
syndrome.
Immunohistochemistry (IHC) staining for mismatch repair (MMR) proteins is now
routinely performed in individuals diagnosed with bowel cancer at a young age as a
preliminary test for Lynch syndrome. Therefore, it is important to determine whether
chemoradiotherapy also affects the reliability of IHC staining for MMR proteins.
Methods
A series of patients (n=24) diagnosed with rectal cancer, where both pre-treatment
biopsies and post-treatment resections were available, was obtained from the Peter
MacCallum Cancer Centre.
Results
All four MMR proteins were present on IHC staining of pre-treatment biopsy in 18 cases.
Four pre-treatment biopsy cases had a loss of staining of MSH2 and MSH6 proteins, and
2 pre-treatment biopsy cases showed a loss of MSH6 protein on IHC staining. There was
100% concordance of IHC staining between each pre-treatment biopsy and the
corresponding post-treatment resection.
Conclusion
In rectal cancer, it appears that the ability of IHC staining to determine the presence of
MMR proteins is not affected by chemoradiotherapy provided there is sufficient tumour
material remaining in the post-chemoradiotherapy surgical resection specimen.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#10
SDHM IMMUNOHISTOCHEMISTRY: FOUR CASES FROM CLINICAL PRACTICE
Michelle Bowman1, Leonie Noon1, Anthony Gill2, Diana E Benn2, 3, Anne Louise Richardson3,
Roderick Clifton-Bligh2, 3, Hilda High1 and Judy Kirk1, 2, 1Familial Cancer Service, Westmead
Hospital, 2University of Sydney, 3Cancer Genetics, Kolling Institute of Medical Research,,
Royal North Shore Hospital
Until recently, a decision to undertake germline genetic testing of the succinate
dehydrogenase subunits (SDHB, SDHC, or SDHD) was made on clinical criteria alone: the
personal and family history of disease which indicated a likely diagnosis of a familial
paraganglioma syndrome. Possible differential diagnoses include Von Hippel-Lindau,
Neurofibromatosis type 1, and other renal cell cancer (RCC) predispositions (Birt-HoggDubé, Hereditary Leiomyomatosis RCC, and Hereditary Papillary RCC).
Tumour immunohistochemistry (IHC) for SDHB protein can be used to triage genetic
testing, as negative staining is good evidence for an underlying mutation in one of the
SDH subunits. This is especially helpful for situations where the differential diagnosis
cannot be clarified on history alone, and/or when there is no family history to suggest
an inherited predisposition.
We present four cases where SDHB IHC has been utilised.
Case 1:
Twenty year old woman, diagnosed with chromophobe renal cancer at the age of 17. No
personal or family history of cancer to suggest any of the possible inherited reasons for
this diagnosis, including no pneumothoraces or the skin lesions seen in Birt-Hogg-Dubé.
Chest CT was normal (no lung cysts). IHC showed positive staining for the SDHB
protein. FLCN testing is pending.
Case 2:
Forty-seven year old woman, with personal history of bilateral multiple clear cell renal
cancers and renal cysts from the age of 45. A sister has a possible retinal haemangioma.
VHL genetic testing did not identify a mutation. IHC showed positive staining for the
SDHB protein.
Case 3:
Twenty-one year old man, diagnosed with a malignant carotid body paraganglioma,
with no definite family history of cancer. IHC showed absent staining for the SDHB
protein. An SDHB mutation has been identified (c.689G>A, p.Arg230His).
Case 4:
Forty-one year old woman, with new diagnosis of breast cancer and a past history of a
paraganglioma in the neck at the age of 29. Family history of paternal grandmother with
breast cancer at an older age, and maternal grandmother dying from cancer in her 30s
(type unknown). IHC on the original paraganglioma showed absent staining for the
SDHB protein and positive staining for the SDHA protein. No point mutations or small
INDELs were identified in SDHB, SDHC or SDHD by Sanger sequencing; large deletion
analysis in these genes is pending.
In each of these cases, SDHB IHC has provided valuable information in the clinic to guide
assessment, genetic testing and management. Our study amplifies the utility of SDHB
IHC for determining the likelihood of germline SDHx mutations in a familial cancer
setting. The immunostain is useful both when negative (when SDHx mutations are
highly likely) and when positive (which effectively excludes SDHx mutations).
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#11
A CLINICAL AUDIT OF INDIVIDUALS WITH HEREDITARY DIFFUSE GASTRIC
CANCER (HDGC) AT THE FAMILIAL CANCER CENTRE AT THE ROYAL MELBOURNE
HOSPITAL
B. Greyling1*, J. Taylor1*, L. Hodgkin1*, M. Slattery2, F. Macrae1, 2
*Joint first authors
1Familial
Cancer Centre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
Cancer Surveillance Service, The Royal Melbourne Hospital, Parkville, Victoria,
Australia
2Bowel
Hereditary Diffuse Gastric Cancer (HDGC) is a rare cancer condition which predisposes
to diffuse gastric cancer and lobular breast cancer. In 25-30% of families, HDGC is
caused by a pathogenic mutation in the CDH1 (E-Cadherin) gene. At the Royal
Melbourne Hospital Familial Cancer Centre, we have several families with HDGC, three
of which have a known mutation in the CDH1 gene.
We carried out a clinical audit on these families, looking at management
recommendations (both surgical and/or surveillance options), screening compliance
and mutation status. We also assessed the level of information disclosure and cascade
testing in each family. In addition, the number, type and histopathology of all cancers
were reviewed.
Of particular interest, we found a high proportion of individuals with either an occult
gastric cancer or pre-invasive lesions following histopathological examination after
prophylactic gastrectomy. Our audit also supported the current literature which
suggests that a mutation is identified in a low number of families. Other findings of
interest will be presented.
Finally, this audit will be used to streamline the future care of these families.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, NSW
#12
CONTINOUS QUALITY IMPROVEMENT PROJECT
RishaZia1 Cancer Care Centre, St George Hospital, Dr Kathy Tucker 2 HCC, Prince of
Wales Hospital, Dr Patricia Bastick3 Cancer Care Centre, St George Hospital
Alison Szwajcer4 Cancer Care Centre, St George Hospital, Rachel Willims5 HCC, Prince of
Wales Hospital
HCC-Hereditary cancer clinic
Aims:
Improve referrals to St George Hospital Hereditary Cancer Clinic through breast
multidisciplinary meetings
Method:
1. Identified problems for low referral rate from breast MDT at St George Hospital.
2. Map the process
3. Implement proposed changes to Breast MDT
4. Evaluate changes to process
Project team: Risha Zia, Dr Kathy Tucker, Alison Szwajcer, Dr Patricia Bastick, Rachel
Williams
Time frame: November 2011 to June 2012
Identified problems:
a. Discordance between number of patients discussed at breast MDT for genetic
counselling referral and the number of referrals received.
b. MDT Consultant focus is treatment focussed-consultants only occasionally present
family history or genetic concerns.
c. Delays in referrals being sent to St George Hospital Hereditary Cancer Clinic, both
from MDT and Prince of Wales Hospital Hereditary Cancer Clinic to where referrals
are initially faxed.
Outcome:
1. Mapped the process.
2. Genetic Counsellor/Cancer Genetics Specialist started to attend every MDT and
obtained number of patients discussed at Br MDT with the coordinator, if unable to
attend.
3. Genetic Counsellor/Cancer Genetics Specialist now enquires about family history of
relevant patients at the meeting
4. Discussed patients with the consultants/coordinator of Breast MDT and organized
referral to genetic counselling. Referral recommendations recorded in MDT
database.
5. New process implemented with POWH HCC-all referrals discussed and received
weekly.
6. 65 patients were discussed at the Br MDT in timeframe, 42 referrals, 21 patients
declined genetic counselling and 2 patients choose a service near their work.
Strategies for maintaining improvement:Attend all Br MDT’s and discuss with the
consultant/coordinator regarding referrals to continue raising awareness of family
history, Discuss with the breast nurse coordinator significance of family history of other
cancers, example, family history of any cancers below 40, family history of thyroid
cancers. Continue weekly discussion with POWH HCC admin regarding all referrals
received in preceding week. These are then sent to STGH HCC.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#13
FIRST IMPRESSIONS COUNT! COMPARISON OF CLIENT SATISFACTION AND DISTRESS
BETWEEN THREE DIFFERENT INTAKE PROCESSES TO A FAMILY CANCER CLINIC.
Silberbauer, L.1, Williams, R.2, Nicholls, R.1, Wakefield, C.3, Barlow-Stewart, K.4
1. Faculty of Medicine, University of Sydney, NSW
2. Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, NSW
3. School of Women’s and Children’s Health, University of New South Wales and Centre for Children's
Cancer and Blood Disorders, Sydney Children's Hospital, NSW
4. Centre for Genetics Education, Royal North Shore Hospital, St Leonards, NSW
Effective genetic counselling requires establishing a good working relationship between clients
and genetic counsellors. Such a relationship usually starts during intake to the clinic. There has
been very little published research looking at intake processes in genetic counselling in Australia,
although some data is available examining the use of family history questionnaires in the UK and
Canada and has specifically examined the use of family history questionnaires. There is a clear
gap in research to address the attributes of the three commonly-used intake procedures from
clients’, genetic counsellors’ and clinicians’ viewpoints: face-to-face intake (interview), telephone
intake, and independent completion of a family history questionnaire. In this study we compare
client satisfaction and distress for cohorts of clients going through each of these intake processes.
Clients referred to the Hereditary Cancer Clinic at the Prince of Wales Hospital, who consent to be
part of the study, were randomly allocated to one of the three intake groups. Following intake,
they were asked to complete three questionnaires - one immediately prior to their first clinic
appointment, one immediately after their first clinic appointment, and one three months after
their first clinic appointment. The questionnaires consisted of a five-point client distress measure
(distress thermometers) and a six-point client satisfaction measure (satisfaction with genetic
counselling). Demographic data were also collected with the first questionnaire. To date 45 of the
planned 90 patients have been recruited to the study. Preliminary results from the first two
questionnaires will be presented.
This study is part of a larger study examining clinician experience and comparing administrative
factors between different intake processes.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#14
THE FAMILY HISTORY QUESTIONNAIRE – WHO IS RESPONDING?
Melanie Boon, Katharine Regnart, Annette Hattam
Genetic Health Queensland, Royal Brisbane and Women’s Hospital
The clinical benefit of family history questionnaires has been previously studied, both in terms of
assisting pre-clinic risk assessment and pedigree construction as well as reducing the amount of
time required for pre-clinic phone intake. However, the response rates of mailed questionnaires
amongst family cancer clinics that utilise them, is consistently reported to be lower than desired.
In order to determine the questionnaire response rate within Genetic Health Queensland, an
internal audit was performed.
Genetic Health Queensland routinely sends out a family history questionnaire to all individuals
referred to our metropolitan service with a personal or family history of cancer. The
accompanying cover letter requests that this questionnaire is returned within 21 days. The
returned questionnaire is then processed by our Cancer Administration Officer who generates a
pedigree and gathers appropriate pathology reports prior to the patient being seen in clinic.
A retrospective analysis was performed on all cancer family history questionnaires sent out
during the six month period between October 2011 and March 2012 to determine the return rate
and response time. Patient demographics were analysed to identify possible future predictors of
responders versus non-responders. Variables assessed included gender, age, referral source,
reason for referral and personal history of cancer.
Subsequent feedback was provided by the genetic counsellors after pre-clinic patient intake on
reasons given for not returning the questionnaire, if volunteered. A qualitative assessment was
also performed on patient questionnaire responses relating to their expectations of the session,
in order to assess themes regarding patient needs.
A detailed analysis of this information will be presented along with possible suggestions for
improvement of our family history questionnaire and departmental processes in order to
facilitate optimal patient care and efficient time management for clinical staff.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#15
‘KNOWLEDGE IS POWER’: COPING WITH THE RISK AND UNCERTAINTY OF FAMILIAL
BREAST CANCER
Louise E Heiniger1, Melanie A Price1, Margaret Charles1, kConFab Psychosocial Group on behalf of
the kConFab Investigators, Phyllis N Butow1
1 Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), School of
Psychology, University of Sydney, NSW, Australia
Background: Studies of how individuals living with increased risk for disease cope with being ‘at
risk’ regard optimal psychosocial functioning as evidence of adaptation, yet the strategies and
processes that precede adaptation have been predominantly unexplored. This study investigated
social, cognitive and behavioural efforts to adapt to familial risk of breast cancer in a sample of
unaffected women.
Method: Adopting a Grounded Theory approach to data collection and analysis, semi-structured
interviews with 27 women enrolled in the Kathleen Cuningham Consortium for Research into
Familial breast cancer (kConFab) psychosocial study explored women’s understanding of their
risk level and their experiences in adapting to the familial risk. Participants were sampled to
include a range of genetic testing statuses (carriers, non-carriers, eligible untested and ineligible
for testing) and patterns of distress (identified from existing quantitative data).
Results: Two themes – risk identity and managing uncertainty and risk – illustrated the
approaches adopted by women in their attempts to cope with being at risk, and a number of
personal, family and healthcare characteristics that facilitated and challenged adaptation were
identified. Knowledge of familial risk was seen as an opportunity to engage proactive strategies,
while subconscious use of social comparisons, intuition and desensitisation facilitated the
integration of ‘being at risk’ into self concept. The impact of, and experiences due to, the family
history of breast cancer shaped the women’s perceptions of risk and their ability to adapt, as did
feelings of security and trust in relation to healthcare. Most regarded personal satisfaction with
risk management efforts, acceptance and a ‘day-by-day’ attitude as crucial to maintaining a
positive outlook. A range of views on the value of genetic testing emerged and adaptation was
facilitated through the preservation of autonomy and provision of information in a manner
appropriate to the individual’s needs.
Conclusion: At-risk women adopt strategies for coping with increased risk to match their
personal and social resources. These findings will be used to guide the development of
interventions for and communication with individuals at increased risk who experience difficulty
adapting to this knowledge.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#16
AN EXPLORATION OF THE LIVED EXPERIENCES OF HAVING BRCA1/2 PREDICTIVE TESTING
TOGETHER WITH A SIBLING
Kitty Cho, Melody Menezes, Maira Kentwell, Yasmin Bylstra, Geoffrey Lindeman
Familial Cancer Centre, Royal Melbourne Hospital, Melbourne, Australia
This study was carried out to explore the lived experiences of individuals who have had pre-test
and post-test genetic counselling for BRCA1/2 predictive testing together with a sibling. The
purpose of this study was to gain a better understanding of the experience of joint genetic
counselling for siblings who had BRCA1/2 predictive testing together and to ascertain whether
being consulted together met their needs and expectations.
The study design utilised a qualitative approach, with a phenomenology theoretical framework.
Data was collected using one-on-one in-depth interviews and analysed using an interpretative
phenomenological approach. Six participants who have had BRCA1/2 predictive testing with their
sibling were recruited from the Royal Melbourne Hospital Familial Cancer Centre, Melbourne.
For this group of participants, the experience of attending together for genetic testing was a
positive and beneficial one. Participants reported that they generally were not influenced by their
sibling in their decision to have testing or to attend together. Their reasons for attending together
were mainly based on practical or logistical considerations. In hindsight, participants identified
numerous types of support that they were able to provide and receive from one another
throughout the duration of the genetic testing process. Participants were highly satisfied with the
joint genetic counselling they received and explained that their needs and expectations were
evenly addressed. They recommended genetic counsellors should provide the option to see
siblings together for BRCA1/2 predictive testing.
This is the first known study specifically seeking to understand the issue of siblings undergoing
predictive genetic testing together. This study presents preliminary evidence that will assist in
informing the genetic counselling practice when siblings request to be seen together for BRCA1/2
predictive testing.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#17
GENETIC PREDISPOSITION TO CANCER: A BARRIER TO ADOPTION?
Gemma Correnti, Genetic Health Queensland, Toowoomba Base Hospital, Toowoomba Qld 4350
Australia
Patients attending clinical genetics services who are considering predictive testing for hereditary
cancer syndromes are routinely informed about the possibility of genetic discrimination. Within
Australia, this discussion has generally been focused on the implications surrounding life and
income protection insurance. Although other types of potential discrimination may exist for
individuals who have an increased risk of developing cancer, they are not well described and
little information is available to guide professionals and their patients. One such area is the
potential barrier to adopting a child. Presented here is a recent case which demonstrates that
individuals with a familial predisposition to cancer could face discrimination from Australian
adoption services.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#18
RISK FACTORS FOR BREAST CANCER: HOW DO WOMEN WITH A FAMILY HISTORY OBTAIN
AND INTERPRET THIS INFORMATION?
Emma J Steel, Belinda J McClaren, Carmel Apicella, John L Hopper, Louise A Keogh for the Australian
Breast Cancer Family Study
Background: For women whose family history suggests an increased risk of breast cancer, but in
which no mutation has been found, little is known about how they obtain, perceive and manage
their risk. This study was concerned with describing how these women perceived their risk of
breast cancer, their theories of the cause of breast cancer in their family, and how they obtained
and interpreted information about breast cancer risk factors. We were particularly interested in
lifestyle adaption.
Methods: Participants were recruited through the Australian Breast Cancer Family Study
(ABCFS), which is a population-based case-control-family study of breast cancer. Data collection
involved a semi-structured interview which was audio recorded and transcribed verbatim.
Women were asked what they thought might increase or decrease their risk of breast cancer.
They were also asked to describe the ways they adapted their lifestyle because of their family
history of breast cancer. Thematic analysis explored women’s sources of knowledge about breast
cancer, beliefs about the cause of breast cancer, and knowledge of and interpretation of the risk
factors for developing breast cancer.
Results: We have previously reported the five risk management styles adopted by this group,
summarising how they interpreted their personal risk. Here we report the analysis of women’s
understanding and interpretation of risk factors. The most common source of information on
breast cancer risk factors was the media (22/24) including newspapers, television programmes
and magazines. Media reports either caused confusion for women or influenced them to make
lifestyle changes. Only two women reported seeing a specialist about their risk, with most were
relying solely on a GP for medical advice about their risk. We summarise the common theories
women used to understand the cause of breast cancer, namely genetics and stress from ‘internal
upsets and worries’. We summarise the various ways women interpreted and responded to what
they identified as the key risk factors. Healthy eating, exercise, and not smoking were viewed as
risk-reducing behaviours by some, but were also mentioned as having no effect on risk by others.
There was also confusion about whether or not being overweight and drinking alcohol has an
effect on risk.
Conclusions: Women need to be provided with consistent and clear messages about breast
cancer risk and risk factors so they can make informed choices around preventative measures.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#19
THE AUSTRALIAN FAMILIAL PANCREATIC CANCER COHORT: SCREENING FOR PANCREATIC
CANCER IN HIGH RISK AUSTRALIANS
S. Simpson1, A. Johns1, A. Spigelman2, D. Williams3, A. Stoita3, K. Tucker4, J. Kirk5, M. Field6, R.
Williams4, A. Goodwin5, S. Grimmond7, J. Humphris1, S. Mead1, D. Chang1, A. Biankin1
1Cancer
Research Program, Kinghorn Cancer Centre/Garvan Institute of Medical Research,
Darlinghurst, NSW, Australia
2Familial Cancer Clinic, Kinghorn Cancer Centre/St Vincent's Hospital, Darlinghurst, NSW, Australia
3Gastroenterology, St Vincent's Hospital, Darlinghurst, NSW, Australia
4Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick, NSW, Australia
5Familial Cancer Service, Westmead Hospital, Westmead, NSW, Australia
6Familial Cancer Service, Royal North Shore Hospital, St Leonards, NSW, Australia
7Queensland Centre for Medical Genomics, Institute for Molecular Bioscience, St Lucia, QLD,
Australia
The majority of pancreatic cancer cases are termed sporadic, although it is estimated that 10%
are familial. Known genetic conditions account for less than 20% of this familial aggregation 1.
The predisposing genetic basis for most families with a clustering of pancreatic cancers is
unspecified, and the predicted risks to unaffected family member can be ambiguous2.
Multiple international familial pancreatic cancer registries are utilising genome sequencing to
collaboratively identify novel pancreatic cancer susceptibility genes, such as PALB23, however
more needs to be known about the predisposing genetic aspects of pancreatic cancer in
Australian families.
The Australian Familial Pancreatic Cancer Cohort (AFPaCC) is a recently established registry
targeting families or individuals with a history of pancreatic cancer. Registration involves
consent, and collation of relevant clinical information. A blood sample is collected to search for
additional pancreatic cancer susceptibility genes. Recruitment will use a multi-centred approach,
with individuals identified through Family Cancer Clinics, treatment centres, cancer registries or
directly by clinicians and our website. AFPaCC will also help to identify high-risk individuals who
may benefit from screening trials.
The overall aims of AFPaCC are to further clarify the risk in families with a history of pancreatic
cancer in Australia and discover genetic and non-genetic causes of pancreatic cancer. Although
AFPaCC is still in it's infancy, this poster aims to raise awareness of the project, provide an initial
overview of the Australian families already involved, and outline some of the challenges already
faced.
[1] Shi C, Hruban RH, Klein AP. Familial pancreatic cancer. Arch Pathol Lab Med 2009 March;
133(3):365-374
[2] Permuth-Wey J, Egan KM. Family history is a significant risk factor for pancreatic cancer:
results from a systematic review and meta-analysis. Familial Cancer 2009;8(2):109-117
[3] Jones S, Hruban RH, Kamiyama M et al. Exomic sequencing Identifies PALB2 as a pancreatic
cancer susceptibility gene. Science 2009;324:217
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#20
ANALYSIS OF GERMLINE VARIANTS IN DNA DAMAGE REPAIR GENES IN PANCREATIC
CANCER IDENTIFIED BY NEXT-GENERATION SEQUENCING
S. Simpson1, A. Johns1, K. Kassahn2, N. Waddell2, J. Humphris1, S. Grimmond2, A. Biankin1
1Cancer Research Program, Kinghorn Cancer Centre/Garvan Institute of Medical Research,
Darlinghurst, NSW, Australia
2Queensland Centre for Medical Genomics, Institute for Molecular Bioscience, St Lucia, QLD,
Australia
For the Australian Pancreatic Cancer Genome Initiative (APGI). For full list of investigators please
see http://www.pancreaticcancer.net.au/apgi/collaborators.
The original localization of the BRCA2 gene was aided by its homozygous deletion in a pancreatic
carcinoma, and BRCA2 is now known to be a high-risk gene that plays a role in a number of
different cancers. It is estimated that BRCA2 accounts for up to 10% of familial pancreatic cancer
(FPC) cases, and the proposed relative risk of pancreatic cancer in BRCA2 carriers ranges from
3.5 to 10 – fold1. In addition, it is proposed that up to 7% of apparently sporadic cases of
pancreatic cancer can harbour pathogenic BRCA2 mutations2. There have also been descriptions
of other DNA damage repair pathway genes, such as BRCA1, ATM and PALB2 playing a role in
pancreatic pathogenicity in a familial setting.
The Australian Pancreatic Cancer Genome Initiative was formed in 2009 to comprehensively
catalogue genomic, transciptomics and epigenomic changes in well characterized, large cohorts
of pancreatic cancers as part of the of the International Cancer Genome Consortium (ICGC,
www.icgc.org). Exome sequencing and copy number analysis in a clinical cohort of 142
prospectively accrued early stage sporadic pancreatic cancers has been performed to date.
Detailed analysis of 70 informative tumour/germline pairs, over 40 germline positions were
detected in the BRCA2 gene, many of which have not been previously demonstrated in this
disease. Smaller but significant numbers of positions were also seen in BRCA1 and PALB2 genes.
Many of these positions were recurrent across numerous patients and ranged from common
previously described variants, to those of unknown clinical significance, to pathogenic variants of
clinical importance.
An overview of the DNA damage repair gene mutation spectrum in a sporadic pancreatic cancer
cohort will be described, with correlation to clinico-pathological data including family history.
We also describe the identification of a pathogenic BRCA2 mutation present in an APGI
participant which was returned via an ethically defensible plan. Processes and outcomes will be
discussed, including predictive and subsequent positive testing of other family members and the
enrollment in a pancreatic cancer screening trial.
[1] Naderi A, Couch FJ. BRCA2 and pancreatic cancer. Int J Gastointest Cancer 2002;31:99-106
[2] Goggins M, Schutte, M, Lu J, et al. Germline BRCA2 gene mutations in patients with apparently
sporadic pancreatic carcinomas. Cancer Research 1996;56:5360-5364
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#21
ASSOCIATION OF EXPRESSION AND GENOTYPE OF THE HUMAN MIR146A AND MIR146B
MICRORNA LOCI WITH SURVIVAL FROM EPITHELIAL OVARIAN CANCER
Cameron N. Johnstone, Sharon E. Johnatty, Jonathan Beesley, Lin Zhang, Georgia Chenevix-Trench
Background:
Hyperactivation of the NF kappa B transcription factor has been implicated in progression of
many human cancers, including ovarian cancer, and drugs that block NF kappa B activation are
being explored in clinical trials as novel anti-cancer agents (1). The MIR146A and MIR146B genes
encode closely related microRNAs that are targets of NF kappa B. They are thought to constitute a
NF kappa B negative feedback loop through targeting of IRAK1 and TRAF6; important signaling
molecules downstream of cytokine and Toll-like receptors (2).
In this study, we explored the association between MIR146A and MIR146B expression level and
survival in advanced epithelial ovarian cancer in a US patient cohort. In addition, we performed a
case:control association study involving assessing a common MIR146A G>C single nucleotide
polymorphism and risk of developing and surviving from sporadic epithelial ovarian cancer.
Results:
MicroRNA microarray data were interrogated for miR146a and miR-146b expression levels in a
pilot cohort of 73 patients with advanced epithelial ovarian cancer and expression levels were
validated by stem-loop qPCR. Univariate Cox proportional hazard regression modeling with
global permutation test indicated that patients with higher miR-146b expression had a
significantly (p < 0.05) worse overall survival (OS) and progression-free survival (PFS) than
those with low expression. Expression of miR-146a was not associated with survival.
In a preliminary case:control association study, case (n=1406) and control (n=1214) genomic
DNAs from the Australian Ovarian Cancer Study (AOCS) dataset (3) were genotyped for MIR146A
SNP rs2910164 using iPLEX technology (Sequenom Inc.). Modification of ovarian cancer risk by
the minor allele of rs2910164 was not found [age-adjusted odds ratio (OR)per-allele 1.01 (95% CI,
0.89–1.15), p = 0.8]. However, when the 611 invasive cancer cases on whom we had clinical
outcome data were analysed, a significant association was observed with PFS, whereby women
with at least one variant ‘C’ allele (that is, G/C + C/C) had longer PFS than those with the G/G
genotype (p = 0.05). This effect was significantly enhanced when only those patients that
received sub-optimal debulking surgery (residual tumour > 1cm) were considered (n = 128, p =
0.004). The follow-up results from a larger cohort will be presented.
The results to date suggest that both MIR146B expression level and MIR146A genotype may
influence the progression of epithelial ovarian cancer and that further investigation is warranted.
References:
1. Baud V, and Karin M. Is NF-kappaB a good target for cancer therapy? Hopes and pitfalls. Nat.
Rev. Drug Discov. (2009) 8:33-40
2. Taganov KD, Boldin MP, Chang KJ, and Baltimore D. NF-kappaB-dependent induction of
microRNA miR-146, an inhibitor targeted to signaling proteins of innate immune responses. Proc
Natl Acad Sci USA. (2006) 103:12481-12486
3. Johnatty SE, Beesley J, Paul J, Fereday S, Spurdle AB, Webb PM, Byth K, Marsh S, McLeod H;
AOCS Study Group, Harnett PR, Brown R, DeFazio A, and Chenevix-Trench G. ABCB1 (MDR 1)
polymorphisms and progression-free survival among women with ovarian cancer following
paclitaxel/carboplatin chemotherapy. Clin. Cancer Res. (2008) 14:5594-5601
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#22
THE ASSOCIATION OF IDENTIFIED BREAST CANCER COMMON GENOMIC VARIANTS AND
PATHOLOGICAL FEATURES IN INDIVIDUALS WITH HEREDITARY BREAST AND OVARIAN
CANCER
Sawyer S1, Chenevix-Trench G2, Harris M3, Lindeman G4, Mitchell G1 and James P1,5.
1Peter MacCallum Cancer Institute, 2Queensland Institute of Medical Research, 3Monash Medical
Centre, 4Royal Melbourne Hospital, 5Victorian Clinical Genetics Service
Background: Genome-wide association studies have identified numerous common genomic
variants that are significantly associated with breast cancer risk. In recent times, investigators
have begun to examine the association between breast cancer common genomic variants and
pathological features such as histopath subtype, hormonal status and grade of tumour
differentiation. Results from studies utilising breast cancer affected individuals from the general
population have found several common genomic variants are associated with ER-positive
(FGFR2, TOX3, 8q24, MAP3K1, 5p12 and 12q24) and ER-negative breast cancers (CASP8, RAD51L,
ESR1). Here we assess the association of pathological features and with an extended panel of
common genomic variants in index cases from high-risk Victorian Breast and Ovarian cancer
families.
Aim: To examine the association of recently described common genomic variants and pathology
features of breast cancer in the context of a family history.
Methods and Results:
Detailed information of breast cancer pathology was reviewed for 200 of the index cases from the
Victorian Familial Cancer Centre (FCC) Translational Breast Cancer Cohort. Genotyping was
performed for 22 common genomic variants (SNPs) previously identified in breast cancer GWAS.
Control genotype data was obtained from the Australian population (n=895, recruited from the
electoral role for the AOCS). The association of common genomic variants with specific
pathological features was examined by logistic regression and proportions compared for
hormones status, HER2 expression and grade.
Conclusions: We will present data on the association of common genomic variants and breast
cancer pathological features. Our study highlights the need for further research to determine if
these associations can help us understand tumour heterogeneity and lead to improved treatment
and prevention for high-risk breast and ovarian cancer families.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#23
HIGH GRADE PIN DOES NOT DISPLAY LOSS OF HETEROZTGOSITY AT THE MUTATION
LOCUS IN BRCA2 MUTATION CARRIES WITH AGGRESSIVE PROSTATE CANCER
Liam Kavanagh1,2,4, Amber Willems-Jones1,2, David Clouston3, Damien Bolton4, kConFab
Investigators1,2, Stephen Fox2,5 and Heather Thorne1,2
1Kathleen Cuningham Consortium for Research into Familial Breast Cancer (kConFab), Research
Department, Peter MacCallum Cancer Centre, East Melbourne, 3002, Australia;
2Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, 3010,
Australia;
3Focus Pathology, South Yarra, 3141, Australia;
4Department of Urology, Austin Hospital, Heidelberg, 3084, Australia;
5Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, 3002, Australia.
Introduction & objectives:
The risk of developing prostate cancer is increased for men carrying a pathogenic germline
mutation in BRCA2. High-grade prostatic intraepithelial neoplasia (HG PIN) has been considered
a precursor to prostate adenocarcinoma. This study aims to determine genetic hallmarks within
normal tissue, HG PIN or invasive tissue identifying it as a precursor of tumour development and
progression in this group of men.
Methods:
From the kConFab biobank of high-risk breast cancer families, twenty participants were
identified with a diagnosis of aggressive prostate cancer and presence of HG PIN, confirmed
carriers of a family specific BRCA2 mutation, and where there was access to archival radical
prostatectomy specimens. Using laser capture microscopy, we were able to micro-dissect
prostate adenocarcinoma tissue, as well as HG PIN tissue and normal prostate tissue, and extract
DNA from these samples. We examined for loss of heterozygosity (LOH) at the site of their family
specific BRCA2 gene mutation from HG PIN using mutation specific PCR and sequencing of DNA.
Prostate adenocarcinoma tissue DNA, plus normal prostate and HG PIN DNA, was sent for whole
exome analysis of copy number changes across the genome.
Results:
We were able to retrieve sufficient DNA from the HG PIN tissue of ten pathogenic BRCA2 carriers.
No participant displayed LOH at the mutation locus within HG PIN, irrespective of whether or not
the invasive tumour DNA displayed LOH. Further analysis will follow from whole exome analysis
of prostate adenocarcinoma tissue from BRCA2 mutation carriers.
Conclusions:
HG PIN does not appear to be a genetic precursor to the development of prostate cancer in
patients who carry a family specific pathogenic BRCA2 mutation.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#24
HOXB13 G84E MUTATION IN COLORECTAL CANCER CASES FROM THE AUSTRALASIAN
COLORECTAL CANCER FAMILY REGISTRY
Daniel D. Buchanan1, Mark Clendenning1, Michael D. Walsh1, Christophe Rosty1,3,4,Joanne P Young1,
Rhiannon Walters1, Sally Pearson1, Belinda Nagler1, David Packenas1, Aung Ko Win2, ACCFR
Investigators, Sean Cleary5, Steve Gallinger5, John L. Hopper2, Mark A. Jenkins2.
1Cancer and Population Studies Group, Queensland Institute of Medical Research, Bancroft Centre,
Herston QLD 4006, Australia,
2Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population
Health, University of Melbourne, Carlton VIC 3053, Australia
3University of Queensland, School of Medicine, Herston, QLD 4006, Australia
4Envoi Specialist Pathologists, Herston Q4006
5 Cancer Care Ontario, Toronto, Ontario, Canada
Background: Recently, the G84E missense mutation within the HOXB13 gene has been shown to
be associated with a significantly increased risk of hereditary prostate cancer. The HOXB13 gene
encodes a homeobox transcription factor that is important in prostate development and is
reportedly expressed in the distal colon. The aim of this study was to investigate the association
between the HOXB13 G84E mutation and colorectal cancer (CRC).
Methods: A total of 600 CRC cases diagnosed before 60 years of age and 243 sex- and agefrequency matched controls from the population-based resources of the Australasian Colorectal
Cancer Family Registry (ACCFR) were genotyped for the HOXB13 G84E missense mutation
(rs138213197) using a Taqman allelic discrimination assay.
Results: Two CRC cases were identified as carriers of the G84E mutation (0.33%), with no
carriers identified in the controls.
The first carrier developed a high grade adenocarcinoma in the sigmoid colon at 42 years of age.
This carrier inherited the mutation from his father who was diagnosed with prostate cancer at 65
years of age. No other family history of cancer was reported nor was there DNA available from
other relatives for testing.
The second carrier was diagnosed with a high grade adenocarcinoma in the caecum at 22 years of
age. This CRC also demonstrated loss of expression of MSH6 and high levels of microsatellite
instability (MSI-H) and was shown to carry a MSH6 c.3311_3312delTT p.Phe1104TrpfsX3
deleterious mutation. No DNA was available from relatives for further genotyping.
Conclusions: The HOXB13 G84E mutation does not account for a significant proportion of CRC
suggesting the tumorigenic effects of this mutation may not play a significant role in CRC
development.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#25
TESTING FOR GERMLINE MUTATIONS IN POLYPOSIS – ASSOCIATED GENES BMPRIA,
SMAD4, PTEN AND MUTYH IN PATIENTS WITH SERRATED POLYPOSIS
Joanne P. Young1, Mark Clendenning1, Kevin Sweet2, Michael D. Walsh1, Rhiannon Walters1, Sally
Pearson1, Belinda Nagler1, David Packenas1, Genetics of Serrated Neoplasia Study Investigators,
Christophe Rosty1,3,4, Susan Parry5,6, Daniel D. Buchanan1.
1Cancer and Population Studies Group, Queensland Institute of Medical Research, Bancroft Centre,
Herston QLD 4006, Australia
2Division of Human Genetics, The Ohio State University Medical Center, USA
3University of Queensland, School of Medicine, Herston, QLD 4006, Australia
4Envoi Specialist Pathologists, Herston QLD 4006, Australia
5New Zealand Familial Gastrointestinal Cancer Registry, Auckland City Hospital, Auckland, New
Zealand
6Department of Gastroenterology and Hepatology, Middlemore Hospital, Auckland, New Zealand
Background: Recent reports have made the observation that patients with serrated polyps,
some of whom meet the clinical criteria for serrated polyposis, are among those who carry
germline mutations in genes associated with polyposis syndromes including; (1) genes known to
underlie hamartomatous polyposes (SMAD4, BMPR1A; and PTEN), (2) MutYH-associated
polyposis and (3) GREM1 in Hereditary mixed polyposis syndrome (HMPS). Therefore, the aim of
this study was to screen patients fulfilling the current WHO criteria for serrated polyposis
syndrome for germline mutations in these polyposis-associated genes.
Methods: Seventy-eight patients with serrated polyposis from the Genetics of Serrated Neoplasia
(GSN) study, none of whom were of Ashkenazi descent, were screened for coding mutations in
the MutYH, PTEN, SMAD4 and BMPR1A genes as follows. Standard PCR was performed to amplify
DNA across exons 1-9 of PTEN (NM_000314.4), exons 2-12 of SMAD4 (NM_005359.5) and exons
3-13 of BMPR1A (NM_004329.2), and the common European variants of MutYH in exons 7 and
13. Only coding regions and directly flanking introns were sequenced. PCR products underwent
clean-up using Millipore Multi-screen HTS PCR plates. Sequencing reactions were run on an ABI
3100 genetic analyser, and annotated using DNA Star Lasergene 8 software. Large deletions in
PTEN, SMAD4 and BMPR1A were sought using the JPS MLPA kit from MRC Holland.
Results: We found no deleterious germline mutations in any patient who filled the current
clinical criteria for serrated polyposis, and identified only a single patient with a novel variant in
intron 2 (c.164+223T>C) of PTEN, predicted by in silico analysis to have no functional
consequences. Testing for the recently reported duplication within GREM1 is currently being
completed.
Conclusions: Genes involved in gastrointestinal hamartomatous polyposes and in hereditary
mixed polyposis syndrome are not altered in individuals with serrated polyposis.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#26
DETECTION OF LARGE SCALE 3’ DELETIONS IN THE PMS2 GENE AMONGST COLON-CFR
PARTICIPANTS – HAVE WE BEEN MISSING ANYTHING?
Mark Clendenning1*, Michael D Walsh1, Judith Balmana Gelpi2, Stephen N. Thibodeau3, Noralane
Lindor4, John D. Potter5,6, Polly Newcomb5, Loic LeMarchand7, Robert Haile8, Steve Gallinger9,
Colorectal Cancer Family Registry, John L. Hopper10, Mark A. Jenkins10, Christophe Rosty1,11, Joanne
P. Young1, Daniel D. Buchanan1
1Cancer and Population Studies, Queensland Institute of Medical Research, Herston, QLD, Australia
2Cancer Prevention Unit, Medical Oncology Department, Hospital Vall d’Hebron, Barcelona, Spain
3Department of Lab Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
4Department of Health Science Research, Mayo Clinic Arizona. Scottsdale, AZ, USA
5Cancer Prevention Program, Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
6Centre for Public Health Research, Massey University, Wellington, New Zealand
7Cancer Research Centre of Hawaii, University of Hawaii at Manoa, Honolulu, HI, USA
8Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
9Cancer Care Ontario, Toronto, Ontario, Canada
10Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of
Population Health, The University of Melbourne, Parkville, VIC, Australia
11University of Queensland, School of Medicine, Herston, QLD, Australia
Mutations in the mismatch repair (MMR) genes MLH1, MSH2, MSH6 or PMS2 result in increased
risk of colorectal, endometrial and other cancers, as part of Lynch Syndrome. Identification of
MMR gene mutation carriers is of critical importance to ensure that appropriate genetic
counselling, screening and prophylactic treatment options are offered to suspected Lynch
patients. Immunohistochemical (IHC) analysis of an individual’s tumour is generally used to
direct mutation detection in Lynch syndrome, with loss of expression of PMS2 only indicative of a
mutation in the PMS2 gene. However, in a proportion of tumours that are deficient in PMS2, a
mutation in PMS2 cannot be identified after exonic sequencing and MLPA. Until recently, the
detection of large-scale deletions from the 3′ end of the PMS2 gene has not been possible due to
technical difficulties associated with pseudogene sequences. The aim of this study was to
determine the frequency of germline deletions in the 3’ end of the PMS2 gene in CRC-affected
individuals whose tumours show solitary loss of PMS2 expression, but in whom no other
germline aberrations of PMS2 have been observed.
The study set consisted of 76 CRC-affected probands from the Colorectal Cancer Family Registry
(Colon CFR) who were identified as being candidates for a PMS2 mutation based on the solitary
loss of expression of PMS2 and an MSI-H phenotype following immunohistochemical (IHC) for
the four MMR proteins and microsatellite instability (MSI) analyses (from a total of 4402
probands’ tumors had undergone IHC analysis of all four proteins). Standard mutation detection
via long-range PCR and large deletion detection for the 5′ end of the gene identified pathogenic
mutations in 59/76 (78%) cases. Of the remaining 17 cases whose tumors showed solitary loss of
PMS2 expression but did not have a pathogenic mutation detected in PMS2, sufficient DNA was
available to perform this new MLPA/long-range analysis for all but one of these unresolved cases.
These remaining 16 probands suspected of harbouring mutations in the 3′ end of the PMS2 gene
were screened using a new MLPA/long-range PCR-based approach (MRC-Holland MLPA kit
P008-B1). Testing revealed no deletions in the 3’ end of PMS2 within these 16 cases. Therefore,
we conclude that 3′ deletions in PMS2 are not a frequent occurrence in such families.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#27
BRAF V600E IMMUNOHISTOCHEMISTRY – A NEW APPROACH TO SCREEN COLORECTAL
CANCERS FOR LYNCH SYNDROMEMichael D Walsh*1,2, Chris Toon*3,4, Angela Chou5, Adele Clarkson3, Keith Byron6, Scott Mead5,
Loretta Sioson1, Stephen Clarke4,7 Capper D8,9, von Deimling A8,9, Rhiannon J. Walters1, Mark
Clendenning1, Christophe Rosty1,10,11, Joanne P. Young1,11, Aung Ko Win12, John L. Hopper12, Mark A.
Jenkins12, Anthony J Gill#3,4,13, Daniel D. Buchanan PhD#1
* and # These two authors contributed equally, 1 Cancer and Population Studies Group, Queensland
Institute of Medical Research Brisbane , Department of Histopathology, Sullivan Nicolaides
Pathology, Taringa QLD, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney,
NSW, Northern Cancer Translational Research Unit, Royal North Shore Hospital, Sydney,
Department of Anatomical Pathology, SYDPATH, St Vincents Hospital Darlinghurst, University of
Sydney, University of Sydney, Sydney, Department of Neuropathology, Institute of Pathology,
Ruprecht-Karls University; Heidelberg, Germany, Clinical Cooperation Unit Neuropathology,
German Cancer Research Center (DKFZ), Heidelberg, Germany, Envoi Specialist Pathologists,
Herston, University of Queensland, School of Medicine, Herston, QLD, Centre for Molecular,
Environmental, Genetic and Analytic Epidemiology, School of Population Health, University of
Melbourne, Carlton, University of Sydney, Sydney, NSW Australia 2006
Background: The presence of a somatic BRAFV600E mutation in a colorectal cancer (CRC) is an
effective marker for excluding Lynch syndrome in a tumour that shows loss of expression of the
MLH1 and PMS2 mismatch repair (MMR) proteins. The aim of this study was to; 1) compare a
new immunohistochemistry (IHC) test for the BRAFV600E mutation to currently used PCR-based
tests, 2) determine its utility in the identification of MLH1 mutation carriers and 3) assess the
value of a novel approach that includes IHC testing for BRAFV600E and the DNA mismatch repair
(MMR) proteins on a series of CRCs.
Methods: We compared BRAFV600E (clone VE1) IHC to BRAF determined by multiplex
polymerase chain reaction (PCR) and MALDI-TOF spectrometry in 216 consecutive CRCs.
Discordant cases were resolved by realtime PCR (rt-PCR). An additional 51 CRCs from the
Australasian Colorectal Cancer Family Registry (ACCFR) that were characterized for MMR status
(MMR IHC and MSI), MLH1 promoter methylation, germline MLH1 mutations and the BRAF
V600E mutation using an allele-specific PCR (AS-PCR) assay were also tested to determine the
utility of BRAFV600E IHC (sensitivity, specificity and concordance) for the identification of MLH1
mutation carriers. We then applied this new BRAFV600E IHC method to tissue microarrays
comprising 1403 consecutive CRCs.
Results: Comparison of the results for both BRAF IHC (45/216 positive 20%) and BRAFV600E by
MALDI-TOF spectrometry results (38/201 positive 19%) demonstrated a high sensitivity or
positive percent agreement (PPA=97.4%, 95%CI=86.5-99.5%), specificity or negative percent
agreement (NPA=96.3%, 95%CI=92.2-98.3%) and accuracy or overall percent agreement
(OPA=96.5%, 95%CI=93.0-98.3%) between tests. Of the 7 initial discordant cases, rt-PCR was
concordant with the BRAFV600E IHC result in 6. In the 51 CRCs from the ACCFR, IHC was
concordant with allele-specific PCR in 50 cases, also demonstrating high sensitivity (PPA=100%,
95%CI=87.7-100%), specificity (NPA=96.4%, 95%CI=86.3-96.4%) and accuracy (OPA=98%,
95%CI=86.9-98%). Furthermore, we estimated the utility of a negative result for BRAF IHC
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
(BRAF-wildtype) in the identification of MLH1 mutation carriers, demonstrating a sensitivity of
(PPA=90%, 95%CI=76.6-98.1%), and specificity of (NPA=41.7%, 95%CI=19.4-55.2%). We then
performed BRAFV600E IHC and MMR IHC on 1403 CRCs arranged on TMAs, demonstrating the
following phenotypes: BRAF+ve/MSS (97 cases, 7%), BRAF-ve/MSS (1030,73%), BRAF+ve/MSI
(178,13%), and BRAF-ve/MSI (98,7%). BRAF+ve/MSS CRC presented with higher stage disease.
Conclusion: BRAFV600E IHC demonstrated a high level of concordance with two currently used
PCR-based BRAF V600E assays and therefore, performs equally well as in the identification of
MLH1 mutation carriers and Lynch syndrome. BRAF IHC however, has the advantage of being a
cost-effective and easily deployable alternative to PCR-based BRAF V600E testing in a routine
clinical diagnostic setting. It is for this reason that we propose an alternative approach to
screening for Lynch syndrome encompassing reflex MMR and BRAFV600E IHC.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#28
INCREASING FAECAL BUTYRATE CONCENTRATION BY INDESTION OF BUTYRYLATED
STARCH IN PARTICIPANTS WITH FAMILIAL ADENOMATOUS POLYPOSIS
JM Clarke1, A Boussioutas2, T Lockett1, FA Macrae2
1CSIRO Preventative Health National Research Flagship; 2Department of Gastroenterology, Royal
Melbourne Hospital
Introduction: Experimental evidence suggests dietary butyrylated high amylose maize starch
(HAMSB) may reduce the risk of colorectal cancer (CRC) in rats (1;2). HAMSB can deliver butyrate
to the colon of humans (3) and ingestion of 40 g/day increased faecal butyrate concentration in
healthy adults (4). A Cancer Council Multi-State Research Grant was awarded to investigate the
effect of HAMSB, a novel dietary chemopreventative agent, on polyposis in familial adenomatous
polyposis (FAP) participants. The aim of this pilot study was to identify the optimal daily intake of
HAMSB by FAP who have reduced large bowel microflora as a result of undergoing colectomy
with ileo-rectal anastomosis (IRA), or total proctocolectomy with ileal pouch (IP).
Methods: Five participants with IRA and three with IP were recruited and randomly assigned to
one of six treatment sequences consuming 2.5, 10 or 20 g HAMSB twice daily for 14 days. There
was a seven day washout between each dose period. Faeces were collected (24 hours) at baseline
and day 13 to enable measurement of faecal output, pH, moisture and free and esterified butyrate
concentrations. Participants completed questionnaires assessing the effects of the starches on
their gastrointestinal function and quality of life at baseline and end of each period, and 3 day
weighed food diaries during baseline and each washout period.
Results: The starches were well tolerated. The change in free faecal butyrate concentrations
between baseline and d13 increased with the dose of HAMSB ingested. Faecal output, moisture
and pH were not affected by amount of butyrylated starch consumed.
Conclusions: This study confirms that a significant proportion of ingested esterified butyrate is
released by the large bowel microflora in FAP with IRA and IP and supports the selection of this
well recognised model of sporadic CRC for testing the efficacy of HAMSB and other potential CRC
chemo-preventative agents that require an active microbiota to promote their bioavailability.
Key words: butyrate, colorectal cancer, familial adenomatous polyposis
References:
1. Clarke JM et al. Carcinogenesis 2008;29:2190-4.
2. Bajka BH, et al. Carcinogenesis 2008;29:2169-74.
3. Clarke JM, Bird AR, Topping DL, et al. Am J Clin Nutr 2007;86:1146-51.
4. Clarke JM, Topping DL, Christophersen CT et al. Am J Clin Nutr 2011;94:1276-83.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#29
ANALYSIS OF THE START CODON VARIANT MLH1 C.1A>G P.(MET1?)
Michael Parsons1, Bryony Thompson1, Phillip Whiley1, Jonathan Beesley1, Adrian Weigmans1, John
Hopper2, Mark Jenkins2, Colon Cancer Family Registry, Daniel Buchanan1, Amanda Spurdle1
Queensland Institute of Medical Research, Brisbane, Australia 1; Centre for Genetic Epidemiology,
University of Melbourne, Melbourne, Australia2
Mutations in the mismatch repair (MMR) genes MLH1, MSH2, MSH6 or PMS2 result in increased
risk of colorectal, endometrial and other cancers, as part of Lynch Syndrome. Identification of
MMR gene mutation carriers is of critical importance to ensure that appropriate genetic
counselling, presymptomatic screening and prophylactic treatment options are offered to
suspected Lynch patients. However, guiding appropriate patient care becomes difficult for
clinical geneticists when gene sequencing identifies variations of unknown clinical significance,
such as missense, small in-frame insertions/deletions and intronic variants. Variants that alter
the translation initiation site are a specific class of unclassified variant that might be amenable to
investigation using bioinformatic predictions with supporting functional data, in addition to
empirical risk data.
We are investigating the clinical significance of the start codon variation MLH1 c.1A>G p.(Met1?).
The family identified with this variant was participating in the Australian Colorectal Cancer
Family Registry. There was limited clinical information available to assist with interpretation of
pathogenicity, with no tumour MSI and MMR IHC data, and few family DNAs to genotype for
segregation analysis. To further investigate this variant, we designed an in vitro Green
Fluorescence Protein (GFP) reporter assay to assess whether the next three downstream ATG
trinucleotide sequences are possible translation initiation sites. These alternative start sites at
c.89A and c.122A are predicted to result in out of frame transcripts/truncated proteins while the
start site at c.103A is in-frame and if translated would result in a 722aa protein lacking two of
four ATP-binding domains.
Current results indicate that the G variant within the start codon reduces the level of reporter
protein translation initiation by ~90% relative to the wildtype A variant. There was no evidence
for translation initiation at the next downstream ATG at c.89A. The second downstream ATG at
c.103A appears to be recognised as the predominant alternative start site in the presence of the
c.1A>G variant, resulting in 70-100% levels of reporter protein expression relative to that for the
wildtype construct with start site c.1A. There was also evidence for limited translation initiation
for the ATG at c.122A. We are currently assessing which transcripts are likely to be translated
into protein in vivo, by conducting an in vitro transcription/translation assay with LCL-derived
RNA from the c.1A>G proband.
Our experimental study indicates that the molecular consequences of the MLH1 c.1A>G variant
are complex, and that further data from carrier families will be necessary to determine its clinical
significance. Our study importantly highlights the need for molecular investigation of start codon
variants to determine the effect on protein translation, and to guide development of
bioinformatic prediction models.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#30
DNA MISMATCH REPAIR DEFICIENCE IN SEBACEOUS SKIN LESIONS: A LARGE CASE SERIES
FROM SULLIVAN NICOLAIDES PATHOLOGY
Michael D Walsh1,2, Rhonda J Edwards1, Kevin J Whitehead1, Michael R Gattas3, and Daniel D
Buchanan2
[1] Department of Histopathology, Sullivan Nicolaides Pathology, Taringa QLD 4068
[2] Cancer and Population Studies Group, Queensland Institute of Medical Research, Herston QLD
4006
[3] Clinical Genetics, Sullivan Nicolaides Pathology, Taringa QLD 4068
Muir Torre syndrome is characterized by the presence of sebaceous skin tumours (sebaceous
adenomas, carcinomas, sebaceomas, and hyperplasia,) and/or multiple keratoacanthomas, as
well as a personal or family history of internal malignancies. It is now recognized that many of
these families are a phenotypic variant of Lynch syndrome in which there is an inherited genetic
defect in one of the DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6 or PMS2), and that
mutation carriers may be identified through testing sebaceous skin tumours for loss of
expression of these proteins. In many cases, however, loss of MMR expression in skin tumours
may be sporadic in nature, and further study is required to determine whether
clinicopathological features or other tumour molecular changes can refine the process of triaging
patients for expensive genetic testing for Lynch syndrome. The aim of this retrospective study
was to assess the results from screening sebaceous tumours for MMR protein expression in order
to identify associations between clinicopathologic features of these skin tumours including
subtypes and locations and loss of MMR expression (MMR deficiency).
An audit of sebaceous tumours tested by Immunohistochemistry (IHC) for MMR expression
identified 428 individuals (149 females, 279 males) with one or more lesions tested between
January 2009 and April 2012, at Sullivan Nicolaides Pathology. Patients’ ages ranged from 17 to
100 years. A total of 450 skin lesions were examined: 232 sebaceous adenomas, 66 sebaceous
carcinomas, 82 sebaceomas, 27 sebaceous hyperplasias, 12 sebaceous tumours NOS, as well as 14
squamous cell and 13 basal cell carcinomas with sebaceous differentiation, and 4
keratoacanthomas. Excluding unclassified sebaceous tumours, MMR deficiency was detected in a
total of 129/438 (29%) lesions. Of the MMR deficient tumours 97 showed loss of MSH2 and
MSH6 (75%), with MLH1/PMS2 loss observed in 21 (16%) cases, solitary MSH6 loss in 10 (8%),
and PMS2 loss alone in one (1%). No statistical association was found between MMR deficiency
and gender (81/279 (29%) males; 37/149 (25%) females), or patient age (68 yr MMR deficient
vs. 65 yr MMR normal). The majority of tumours were located on the head and neck (366/447:
82%), while 52 (12%) were on the trunk and 19 (4%) on the limbs. While most MMR deficient
tumours were located on the head and neck (84/366; 23%), MMR loss of expression was more
commonly observed in lesions on the trunk (36/62; 58%) and limbs (9/19; 47%), and
MLH1/PMS2 and MSH6 only losses were proportionally more common in non-head and neck
sites. MMR loss was most commonly observed in sebaceous adenomas (84/232: 36%) and
sebaceomas (22/82: 27%), and less frequently in other sebaceous lesions. We have identified
MMR deficiency in a significant number of sebaceous skin lesions, yet it remains unclear from the
current data what proportion of these patients have a germline mutation in an MMR gene and
thus have Muir Torre (Lynch) syndrome.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#31
MISMATCH REPAIR GENE ISOFORMS: ISSUES IN THE INTERPRETATION OF ABERRANT
SPLICE TRANSCRIPTS
Bryony A Thompson1,2, Amanda B Spurdle1
Genetics and Computational Biology Division, Queensland Institute of Medical Research, Brisbane,
QLD1; School of Medicine, University of Queensland, Brisbane, QLD2
Germline mutations in the DNA mismatch repair (MMR) genes MLH1, MSH2, MSH6 and PMS2
cause the hereditary colorectal and endometrial cancer predisposition disorder known as Lynch
syndrome. A significant number of MMR gene mutations result in aberrant mRNA splicing,
including exon skipping, intron retention, and cryptic splice site usage. However, the clinical
interpretation of splicing assays for MMR gene variants is complicated by the existence of
multiple naturally occurring alternative mRNA transcripts. These isoforms can mask the
detection of truly aberrant transcripts in RT-PCR assays, or may be mistaken as patient-specific
splicing aberrations. In addition, some gene variants are reported to be associated with
upregulation of naturally occurring isoforms, but the relationship between isoform expression
level and cancer risk is unknown.
We conducted a comprehensive search to identify all reported naturally occurring isoforms in
MLH1, MSH2, MSH6 and PMS2 to provide a catalogue for design and interpretation of splicing
assays. A literature review was performed using PubMed
(http://www.ncbi.nlm.nih.gov/pubmed/). Additional searches of mRNA expression data were
also done using the Ensembl (http://asia.ensembl.org/) and UCSC (http://genome.ucsc.edu/)
genome browsers. The InSiGHT database (http://insight-group.org) and PubMed were used to
identify MMR gene variants reported to be associated with altered mRNA splicing. Searches
identified 37 MLH1, 32 MSH2, 16 MSH6 and 5 PMS2 naturally occurring isoforms (51 from public
databases only, including all MSH6 and PMS2 isoforms). Many isoforms are predicted to produce
truncated protein. Level of isoform upregulation has been quantified in vitro for only the MLH1 ∆
exon 15, ∆ exon 16, and ∆ exon 17, with relative expression between 20-60% of the full-length
transcript. Furthermore, 60 variants in MLH1 and 21 variants in MSH2 are reported to affect the
expression of isoforms, none of which have been studied using truly quantitative assays.
This is the first systematic review conducted of alternate splicing isoforms in the MMR genes. It
demonstrates that there are a large number of naturally occurring isoforms for the MMR genes,
which may complicate interpretation of splicing assays. It also highlights the importance of
quantifying isoform expression level in controls to interpret relevance of isoform upregulation in
carriers of MMR gene variants.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#32
DICHLOROACETATE REVERSES THE WARBURG EFFECT AND SENSITIZES BREAST CANCER
CELLS TOWARDS APOPTOSIS
B.P. Gang1, P. Dilda2, P. Hogg2, A.C. Blackburn1
1Cancer Metabolism and Genetics Group, The John Curtin School of Medical Research, The
Australian National University, Canberra, ACT, Australia
2Lowy Cancer Research Centre, University of New South Wales, Sydney, NSW, Australia
The Warburg effect occurs in 90% of tumours and causes a high rate of glycolysis even in the
presence of oxygen, resulting in increased lactate production and reduced mitochondrial
oxidation of pyruvate. Glucose metabolites are diverted to anabolic processes as a consequence,
reducing pyruvate oxidation, hyperpolarizing the mitochondrial membrane potential, causing
apoptotic resistance. Dichloroacetate (DCA) is a drug that can reverse the Warburg effect by
inhibiting the pyruvate dehydrogenase kinases (PDKs), promoting oxidative metabolism of
pyruvate. We are investigating in breast cancer cells (a) the effects of DCA on cell growth, (b)
factors governing DCA sensitivity and (c) if DCA can enhance apoptosis induced by 4-(N-(Spenicillaminylacetyl)amino) phenylarsonous acid (PENAO), a novel anti-mitochondrial agent.
At 5 mM DCA (48 hr treatment) there were 3-40% less viable cells present in MDA-MB-231,
MCF7, MDA-MB-468, MCF10AT1, and T-47D breast cancer cell cultures. Growth of MCF10A noncancerous cells was not affected, showing DCA selectively targets cancer cells. The PDKs have
different sensitivities towards DCA inhibition (PDK2>PDK4>PDK1>PDK3). To determine if PDKs
governed DCA sensitivity, PDK expression was examined by western blotting. In T-47D cells the
expression of PDK2 (Ki 0.2 mM) and low levels of PDK1 (Ki 1 mM) and 3 (Ki 8 mM) correlated
with their high sensitivity to DCA treatment. In MCF7 and MDA-MB-468 cells, high expression of
PDK3 (Ki 8 mM) may explain their relative insensitivity to DCA. Extracellular lactate was also
reduced by 50% at 1 mM and 5 mM DCA in T-47D and MCF7 cells respectively after 24 hr,
indicating reversal of the Warburg effect, correlating with the PDK profiles. Induction of PDK1 in
MCF7 cells under hypoxia increased sensitivity to DCA, showing the PDK profile still correlated
with DCA sensitivity.
The ability of DCA to enhance apoptosis induced by PENAO was also examined. The IC 50 for
PENAO (48 hr) was 3-13 µM for MDA-MB-468, MDA-MB-231, T-47D, MCF7 and MCF10AT1 cells,
whereas 12 µM reduced cell viability by only 7% in the non-cancerous MCF10A cells. When
combined with 5 mM DCA, the IC50 of PENAO for all cancer cell lines decreased by 15-70%, while
toxicity to MCF10A cells was not increased. To measure apoptosis, cells were stained with
annexin V and sorted by FACS. Treatment for 48 hr with 5 mM DCA and 5 µM PENAO doubled the
proportion of apoptotic cells compared to PENAO alone on T-47D and MDA-MB-231 cells. DCA
alone did not inhibit growth or induce apoptosis of MDA-MB-231 cells, thus showing potentiation
of apoptosis.
We have shown that DCA reverses the Warburg effect, inhibiting growth and enhancing
apoptosis. PDKs may be a useful biomarker in determining whether DCA alone will be effective
against different tumour types.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#33
VITAMIN D, CYP2RL AND BREAST CANCER SUSCEPTIBILITY IN MICE
Madara Ratnadiwakara1, Rohan Williams2, Anneke C. Blackburn1
1Cancer Metabolism and Genetics Group, John Curtin School of Medical Research, Australian
National University, Canberra ACT 0200. 2Molecular System Biology Group, John Curtin School of
Medical Research, Australian National University, Canberra ACT 0200.
Vitamin D is a group of fat-soluble secosteroids. Apart from its main physiological role in calcium
homeostasis, several studies have demonstrated a wide range of functions of vitamin D which can
be associated with cancer. Even though the exact mechanism underlying the protective action of
vitamin D against cancer is not clearly understood, there is strong experimental evidence showing
that vitamin D participates in cell growth regulation, apoptosis and proliferation in normal and
malignant breast cells. This evidence has lead to the hypothesis that high levels of vitamin D might
reduce the risk of breast cancer.
In order to be biologically active, vitamin D must be converted to its active form 1,25(OH) 2D3.
CYP2R1 is a major vitamin D hydroxylase that catalyzes the first step of this activation producing
25(OH)D3. Cyp2r1 is located within the SuprMam1 locus, a mammary tumour susceptibility locus
identified in the BALB/c-Trp53+/- mouse model of spontaneous breast cancer (1). Affymetrix data
comparing T cell gene expression have identified Cyp2r1 to be differentially expressed between
BALB/c and C57BL/6 mouse strains (0.68 fold reduction in BALB/c, the mammary tumour
susceptible strain). As lower CYP2R1 levels should result in lower vitamin D levels and may
contribute to the higher cancer susceptibility of BALB/c mice, we studied the Cyp2r1 gene
expression and plasma 25(OH)D3 levels in SM09 congenic-mice (BALB/c SuprMam loci in C57BL/6
background) in comparison to C57BL/6-controls.
A real-time quantitative PCR of Cyp2r1 in different tissues from SM09 and control mice revealed
that there is a significant difference in Cyp2r1 expression in mammary glands of the two strains
(2.76 fold reduction in SM09, p=0.04). But this difference was not observed in liver or lymph node
tissues of the same mice. An affymetrix exon array on hormone stimulated mammary glands from
SM09 and control mice confirmed the q-rtPCR result, where SM09 mice had a 2.04 fold reduction in
Cyp2r1 expression compared to control mice (p=0.0003). Measurement of 25(OH)D3 levels in
plasma collected from SM09 and control mice were performed (RDDT, Melbourne) to identify the
biological effects of differential expression of Cyp2r1. Surprisingly, the plasma levels of 25(OH)D3
were significantly higher in SM09 mice, the opposite of what was expected (59.03 vs 46.67 nM/L in
SM09 vs control males, p=0.02, and 59.85 vs 52.75 nM/L in SM09 vs control females, p=0.018).
Further investigation of the major regulators of vitamin D pathway (serum levels of calcium,
phosphate and parathyroid hormone) and 25(OH)D3 levels within the mammary gland is required
to determine if vitamin D metabolism is contributing to BALB/c mammary tumour susceptibility .
1. Blackburn AC, Hill LZ, Roberts AL, et al. Genetic mapping in mice identifies DMBT1 as a
candidate modifier of mammary tumors and breast cancer risk. Am J Pathol. 2007;
170:2030–41.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#34
EGFR MUTATIONS, TRIPLE NEGATIVE BREAST TUMOURS AND BRAIN METASTASES
Tatjana Seidens, Erik Tilch, Sibylle Cocciardi, Fares Al-Ejeh and Georgia Chenevix-Trench
Queensland Institute of Medical Research, Brisbane
Triple-negative and basal-like breast cancers share many properties, including the upregulation
of EGFR (epithelial growth factor receptor) expression. Teng et al., (2011) analysed 70 triple
negative Asian breast cancers and reported EGFR mutations in 11% tumours , while we reported
an EGFR mutation in 1/14 breast tumours that had metastasized to the brain (daSilva et al.,
2010), as well as in 3/9 brain metastases from other primary tumours (lung and kidney). We
have used the near-normal mammary epithelial cell line, MCF10A, to generate clones that overexpress wildtype or mutatnt EGFR (EGFR_G719S and EGFR_E746-A750 del). We then assayed
the clones in proliferation and morphological assays (2D and 3D cultures), as well as for their
sensitivity to the tyrosine kinase inhibitor, gefitinib. Both EGFR mutations rendered the cell lines
independent of EGF supplement, and also conferred resistance to gefitinib inhibition. In contrast,
the parental and the wildtype over-expressing cell lines were hardly affected. We observed
morphological features in 3D cultures, such as the filling of luminal spaces, that are characteristic
of tumour cells for all three transfected cell lines but these were most distinctive for the
EGFR_G719S mutant cell line. This cell line also developed filopodia-like structures. However, we
have not yet observed tumours in mice injected with these cell lines. Given our identification of
somatic mutations in tumours that have metastasized to the brain, it is possible that activation of
EGFR may promote metastasis in mice and so we are now using the whole MCF10 series to
investigate the metastatic potential in pre-malignant and tumorigenic cell lines.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#35
EXPLORATORY TARGETED RESEQUENCING OF BRCA1 AND BRCA2 IN INHERITED BREAST
CANCER
Michelle W. Wong, 2Simone Li, 2Marc Wilkins, 1 Kelly A. Avery-Kiejda, 1 Nikola A. Bowden,
Rodney J. Scott
1 Discipline of Medical Genetics and Centre for Information-Based Medicine (CIBM), The University
of
Newcastle and Hunter Medical Research Institute (HMRI), Newcastle, Australia
2 Department of
3 Division of Genetics, Hunter Area Pathology Service (HAPS), Newcastle, Australia
1
1,3
Breast cancer is the leading cause of cancer-related deaths in women worldwide, affecting about
13,000 women every year in Australia. Inherited loss-of-function mutations in BRCA1 and BRCA2
predispose to high risk of breast and/or ovarian cancer. Since the discovery of breast cancer
susceptibility genes BRCA1 and BRCA2 two decades ago, there have not been any other genes
identified that play a significant role in predisposition to inherited breast cancer. A large
proportion of individuals with inherited breast cancer are negative for BRCA mutations and
despite numerous research efforts, further breast cancer susceptibility genes still remain elusive.
We hypothesize that genetic anomalies are present in the BRCA1 and BRCA2 genes in a subset of
individuals with inherited breast cancer where no genetic anomalies where identified using
traditional Sanger sequencing. This study aims were to identify genetic anomalies in BRCA1 and
BRCA2 by completely re-sequencing 200 kilobases surrounding BRCA1 and BRCA2 using targeted
massively parallel sequencing, or next-generation sequencing.
For this study, DNA was used from 10 individuals referred for genetic testing after meeting the
criteria for inherited breast cancer, and had been screened for BRCA1 and BRCA2 mutations by
the Hunter Area Pathology Service (Newcastle, NSW, Australia). All individuals used for this
study did not harbour causative genetic changes in the coding regions of BRCA1 or BRCA2.
Targeted next-generation paired-end sequencing of regions containing BRCA1 and BRCA2 was
performed using Agilent SureSelect and an Illumina GAIIx (The Ramaciotti Centre for Gene
Function Analysis). An average of 50x coverage was achieved across the targeted genomic region
for all samples. The sequence data was aligned to the Human Reference Sequence 37.2. Single
nucleotide polymorphisms present in dbSNP or the 1000 Genomes Project were removed from
further analyses. Genetic differences in the form of single nucleotide variants (SNVs) and
insertions/deletions (indels) were identified in most individuals tested in regions that had
previously remained unexplored, such as the non-coding regions of BRCA1 and BRCA2, the 5’UTR
and promoter sites.
This study has comprehensively investigated BRCA1 and BRCA2 and surrounding genomic
regions in a mutation-negative inherited breast cancer population. The issue of accuracy of
mutation detection by traditional methods, such as Sanger sequencing alone, has also been
addressed by this study. The outcome of this study is the increase in current knowledge of the
genetic variations that results in the development and/or progression of inherited breast cancer,
aid in the management of individuals with breast cancers by providing a more specific diagnosis
of disease risk and provide information required for the development of personalized treatment.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#36
CLINICAL GENETIC TESTING FOR HEREDITARY CANCER USING NEXT GENERATION
SEQUENCING
Lesley Andrews1, Bettina Meiser2, Ben Storey3, Belinda Rahman2
1Hereditary Cancer Clinic, Prince of Wales Hospital, Randwick NSW
2Psychosocial Research Department, Prince of Wales Hospital, Randwick NSW
3University of New South Wales, Kensington NSW
Genetic testing is undergoing a major transformation with the introduction of Next Generation
Sequencing (NGS) to laboratories around the world. A number of Australian laboratories
providing mutation searching for hereditary cancer syndromes are introducing this technology
over the next year, however many of the issues associated with this type of testing are yet to be
resolved.
NGS will enable testing of genes which are part of current practice at lower cost and greater
speed. This raises the question as to whether we should change established criteria for testing.
Decisions will need to be made regarding testing of isolated cases of rarer tumours, and whether
testing of unaffected relatives in families with no living affected members is appropriate.
Secondly, testing for cancer predisposition is likely to involve a large panel of cancer genes. Some
results may be unexpected on the clinical presentation. In addition, data regarding the risks
associated with mutations in some of these genes and their optimal management may not yet be
robust.
Thirdly, it is likely that standard testing may soon involve exome sequencing, where the outcome
may involve
 identification of incidental genetic disorders of clinical and/or personal significance
 identification of possibly multiple genetic variations of unknown significance in a single
genome
 identification of pathogenic variations in newly identified genes with little clinical data
available to guide management.
The major challenges facing us are the provision of informed consent for these outcomes,
institutional policy regarding the returning of incidental findings and how to manage the vastly
increased the work load for genetic counselling services generated by the increased complexity
of potential results, as well as the capacity for higher volumes of testing .
In order to determine the attitudes of Australian patients to these challenges, we are conducting
semi-structured telephone interviews with patients of the Prince of Wales Hereditary Cancer
Clinic who have previously undergone mutation searching with an inconclusive result, as this is a
cohort who may be offered NGS in the near future.
This study aims to explore patients’ hypothetical interest and motivations in genomic testing,
perceived advantages and disadvantages, information and communication preferences regarding
incidental findings, and need for assistance regarding decision making using qualitative research
methods. Results of the study will be presented.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#37
THE 10-YEAR FOLLOW-UP OF THE AUSTRALIAN BREAST CANCER FAMILY REGISTRY
Carmel Apicella1, Kelly Aujard1, Gerda Evans2, Gillian Dite1, Roger Milne1, Graham Giles3, Melissa
Southey4, John Hopper, The Centre for Molecular, Environmental, Genetic and Analytic
Epidemiology, The University of Melbourne, Australia. 2 Breast Cancer Network Australia (BCNA)
Community Representative 3Cancer Epidemiology Centre, Cancer Council Victoria, 4Department of
Pathology, The University of Melbourne
Background: The Australian Breast Cancer Family Registry (ABCFR) is a resource of families,
data, bio-specimens, researchers and community representatives established to conduct of
collaborative research on breast and associated cancers. It is enriched for women above average
risk for breast cancer, and includes 13,363 participants from 3,313 Australian families mostly
recruited between 1992 and 2000. Ten years after recruitment, we conducted a follow-up of the
cohort.
Aims: To systematically update family history; to expand the pedigree to include first- and
second-degree relatives of the participants other than the proband; to update the epidemiological
data provided by participants; to collect more blood samples including renewal of exhausted
samples; and to recruit more participants within these families.
Eligibility: The 9,773 participants from 2,272 families who were informed at baseline interview
that we might wish to contact them in the future.
Methods: An invitation letter with information sheet and consent form and a short questionnaire
was mailed. This was followed up with a phone call to expand on responses to the questionnaire
and obtain a family history from the participant. Reponses to some questions triggered other
activities, such as: retrieval of genetic testing results from clinics; obtaining pathology reports
and tumour material for new breast cancer cases; and request for a blood sample.
All participants were asked about their family history, sometimes resulting in multiple reports on
the same individuals in the family. Interviewers reconciled discrepant information to obtain the
best estimate of the family history. Pedigrees were expanded to include first- and second-degree
relatives of the participants. Verification of cancers and deaths through linkage with the Victorian
Cancer Registry, Australian Institute of Health and Welfare and pathology reports was conducted
and is ongoing.
Results: We were able to update the family history for 1982 (87%) families, and epidemiology
data for 6651 (79%) participants. We recruited an additional 694 participants, obtained an
additional 1,759 blood samples, and learnt about new clinical genetic testing for BRCA1 and
BRCA2 mutations for 196 participants.
Conclusions: We have demonstrated how high participation at follow-up after 10 years without
contact can be achieved with a family design. The 10-year follow-up has added value to the
cohort and the new dataset is being used in analyses and as a basis for successful NHMRC and
NIH grant applications.
Acknowledgements: We thank the ABCFR participants who continue to generously give their
time, information and samples for this research. Funding has been received from the NIH (USA),
NHMRC, Cancer Australia, NBCF and VBCRC.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#38
THE AUSTRALASIAN COLORECTAL CANCER FAMILY REGISTRY 5-AND 10-YEAR FOLLOW UP
Mark A. Jenkins, Judi Maskiell, Aung Ko Win, Ingrid Winship, John L. Hopper for the ACCFR
investigators.
Centre for MEGA Epidemiology, The University of Melbourne
Introduction: The Australasian Colorectal Cancer Family Registry (ACCFR) is a resource of
families, data, biospecimens, researchers and community representatives established for
collaborative research on colorectal and associated cancers.
The ACCFR was established in 1996. It comprises 11,500 participants from 1,800 families either
recruited via a population-based incident colorectal cancer (960 families from Melbourne), via a
population-based control (270 families from Melbourne) or via a family cancer clinic (580
families from Brisbane, Sydney, Melbourne, Adelaide, Perth, or Auckland). 7920 participants
have completed a detailed risk factor questionnaire at recruitment and donated a blood sample.
These participants have been genetically characterised and comprise 972 carriers of a mutation
in a mismatch repair gene (350 MLH1, 453 MSH2, 94 MSH6, 57 PMS2, 18 EPCAM) (308 families)
and 88 carriers of a MutYH mutation (76 monoallelic and 12 biallelic) (48 families). In addition
to participants, we have cancer status and demographic data for 64,500 relatives of participants.
Methods: We have attempted follow-up of participants every five years, by questionnaire, to
update vital status, surgery, cancer screening, polypectomy, and personal and family history of
cancer history. This has been done for all participants from population-based case families and
clinic-based families. We have also linked all participants and non-participant relatives to the
National Death Index and the National Cancer Clearing House to identify any additional cancers
and deaths and to verify personal reports.
Results: We have 5-year follow-up on 1299 participants who had colorectal cancer at baseline
(CRC cohort) and 6169 participants who did not have colorectal cancer at baseline (non-CRC
cohort). We have 10-year follow-up on 628 of the CRC-cohort and 3059 of the non-CRC cohort.
Total person years = 9635 for the CRC cohort and 46,140 years for the non-CRC cohort.
Response for the 5- and 10-year follow-ups was 90% for individuals and 95% for families.
For the CRC cohort, since baseline, 103 have been diagnosed with a new primary CRC (11 per
1,000 person years), 184 with a new primary extracolonic cancer (19 per 1,000 person-years)
and 422 have died (44 per 1,000 person years). For the non-CRC cohort, since baseline, 125 have
been diagnosed with a CRC (3 per 1,000 person years), 455 with an extracolonic cancer (10 per
1,000 person-years) and 436 have died (9 per 1,000 person years).
Conclusion: The ACCFR is a part of the international Colon Cancer Family Registry of 35,000
participants and ~400,000 non-participating relatives from 17,000 families available to address
clinical, genetic and public health research.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#39
AN UPDATE ON THE IMPACT STUDY: IDENTIFICATION OF MEN WITH A GENETIC
PREDISPOSITION TO PROSATE CANCER: TARGETED SCREENING IN BRCA1/2 MUTATION
CARRIERS AND CONTROLS
Drew K1, Amor D4, Frydenberg M5, Harris M6, Kirk J7, Lam J8, Lindeman G9,10, McKinley J1, Murphy D3, Pachter
N11, Petelin L1, Shackleton K9, Spigelman A12,13,14, Susman R15, Suthers G16,19, Taylor L8, Townshend S11, Tucker
K17, Ward R18, IMPACT collaborators and Mitchell G1,2.
Familial Cancer Centre, Peter MacCallum Cancer Centre, VIC 2. Sir Peter MacCallum Department of
Oncology, The University of Melbourne, VIC 3. Division of Cancer Surgery, Peter MacCallum Cancer Centre,
VIC 4. Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, VIC 5. Dept of Urology,
Monash Medical Centre, VIC 6. Southern Health Familial Cancer Centre, Southern Health / Monash
Medical Centre, VIC 7. Familial Cancer Service, Westmead Hospital, NSW 8. Dept of Urology, Repatriation
General Hospital, SA 9. Familial Cancer Service, Royal Melbourne Hospital, VIC 10. The Victorian Breast
Cancer Research Consortium Laboratory, WEHI, VIC 11. Genetic Services of WA, King Edward Memorial
Hospital, WA 12. Hunter Family Cancer Service, Hunter New England Health, NSW 13. St Vincent's
Clinical School, Faculty of Medicine, University of NSW 14. St Vincent’s Hospital, NSW 15. Genetic Health
QLD, Royal Brisbane & Women’s Hospital, QLD 16. Department of Genetic Medicine, Women’s &
Children’s Hospital, SA 17. Hereditary Cancer Clinic, Prince of Wales Hospital, NSW 18. Dept of Medical
Oncology, Prince of Wales Hospital, NSW 19. University of Adelaide, SA
IMPACT is a worldwide prostate cancer screening study of men with germline BRCA mutations
and the Australian arm has now been underway for over 5 years. It comprises 5 years of annual
serum PSA screening with prostate biopsy triggered at a PSA >3ng/ml. At April 2012, 1457 men
from 45 centres across 15 countries had been recruited (BRCA1=488, 33%; BRCA2=500, 34%;
Controls=462, 32%), with the overall aim to enrol 1000 carriers and 850 controls. Australia’s
contribution makes up ~20% of the cohort, having recruited 299 of these men from 10 centres
across VIC, NSW, SA, QLD, TAS and WA. Of the 171 men within the worldwide cohort who have
had an elevated PSA, 129 underwent a prostate biopsy. Pathology for 25 biopsies is pending, but
prostate cancer was diagnosed in 42/114 giving a positive predictive value (PPV) of PSA
screening in this cohort of 36.7% (39.5% for mutation carriers only; 45.5% for BRCA2 mutation
carriers only). Ten of the cancers have been from the Australian cohort. Of these, 7 were in
mutation carriers (1 BRCA1; 6 BRCA2), 3 in controls; 6 were clinically significant enough to treat
with a prostatectomy, 1 had radiotherapy and 1 had Brachytherapy. This initial data shows that
the PPV of PSA screening in BRCA mutation carriers is relatively high and supports the
hypothesis that men with BRCA mutations are at increased risk of prostate cancer and that PSA
screening can detect clinically significant prostate cancer in this group. These results support the
rationale for prostate cancer screening in such men and the importance of the IMPACT study in
developing an effective method of screening for this group. A recent addition to the study design
is a voluntary end of study (EoS) biopsy after 5 years of annual PSA screening if the participant
has not already required a biopsy as a result of a raised PSA. Of the 3 Australian EoS biopsies (all
mutation carriers), 2 returned a cancer diagnosis and 1 showed atypical cells suspicious of (but
not definitive for) cancer. No cancers have been detected in 23 other EoS biopsies performed in
the overseas cohort. These biopsies will enable an evaluation of the prevalence of prostate cancer
in men with lower PSA levels, determine the most appropriate PSA thresholds for biopsy and
help refine prostate cancer risk estimates for this population – essential for accurate genetic
counselling and risk management for this population.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#40
THE KCONFAB EXPERIENCE – 15 YEARS OF BIOBANKING
Heather Thorne, Eveline Niedermayr, Lynda Williams, Lana Djandjgava, Kylie Ioculano, Carla
Osinski, Genna Glavich, Sarah MacRaild, and the kConFab research nurses on behalf of the Kathleen
Cuningham Consortium for Research into Familial Breast Cancer (kConFab).
kConFab, Research Department, Peter MacCallum Cancer Centre, St. Andrew’s Place, East
Melbourne, VIC, 3002.
kConFab, the Australian/New Zealand consortium for research into families at high risk of breast
and ovarian cancer, has completed collection & recruitment of 1,487 families during the past 15
years. Biological material, genetic, epidemiological, and psychosocial data are collected from
affected and unaffected, female and male participants over the age of 18. This material is
available to peer reviewed, ethically approved and funded research projects. kConFab has
previously and currently supplied biospecimens and/or data to 121 research projects worldwide.
The kConFab biological repository contains blood specimens from a total of 12, 642 participants
and 234 best friend controls. The standardized blood processing protocol produces plasma, non
lymph, blood pellet and white blood cell fractions. White blood cells undergo EBV transformation
which can be used by in functional assays or as a replacement source of DNA/RNA. To date, 1560
unique EBV cell line transformations are available.
As of Jun 2012, 97% of completed kConFab families have had genetic testing; identifying 40% of
families with a pathogenic, large genomic rearrangement (LGR) or splice site mutation in either
BRCA1 or BRCA2. An additional 5% of completed families carry unclassified variants in BRCA1 or
BRCA2; with a further 0.9 % with mutations in the ATM, CHEK2 or TP53 genes. Of the 1702 female
participants who harbour a germline mutation, 56% are affected with breast or ovarian cancer.
kConFab has collected a total of 923 fresh tissue collections, including prophylactic mastectomy
and oophorectomy specimens; and has a large collection of archival specimens. The tissue bank
consists primarily of breast, ovarian and prostate tissue (tumour and normal), with a small
proportion of other tissues. Following collection, a full research pathology review is conducted,
wherein features such percentage tumour, normal epithelial, lymph and necrotic components are
scored.
kConFab has constructed a total of 29 tissue microarrays (TMAs) (both sporadic and familial
tumours) from our tissue bio bank. Where possible, tumour is matched to normal from the same
archival block.
kConFab are currently working to supplement our glass slide archive with a digital slide
repository. This will provide researchers with high resolution, high quality whole slide digital
images for ease of transport, storage, review and analysis. Currently we have >2000 slides
scanned for more than 1200 participants.
The kConFab resource enables researchers to answer important questions relating to familial
aspects of breast cancer. Information about the kConFab resource and the application process is
available on the web site (http://www.kconfab.org).
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#41
IMMUNOHISTOCHEMISTRY FOR 616 AND THE IDENTIFICATION OF MLH1 MUTATION
CARRIERS IN COLORECTAL CANCER DEMONSTRATING LOSS OF MLH1 AND PMS2
EXPRESSION
Sally Pearson1, Michael D. Walsh1, Mark Clendenning1, Rhiannon Walters1, Belinda Nagler1, David
Packenas1, ACCFR Investigators, John L. Hopper2, Mark A. Jenkins2, Joanne P. Young1, Christophe
Rosty1,3,4, Daniel D. Buchanan1, 1Cancer and Population Studies Group, Queensland Institute of
Medical Research, Bancroft Centre, Herston QLD , 2Centre for Molecular, Environmental, Genetic and
Analytic Epidemiology, School of Population Health, University of Melbourne, Carlton , 3University of
Queensland, School of Medicine, Herston, QLD , 4Envoi Specialist Pathologists, Herston
Background: Diagnostically, the presence of MLH1 methylation and/or the somatic BRAFV600E
mutation in colorectal cancers (CRC) that demonstrate loss of expression of the MLH1 and PMS2
mismatch repair (MMR) proteins largely excludes the presence of a MLH1 gene mutation and the
diagnosis of Lynch syndrome. Recently, an immunohistochemistry (IHC) test for p16 expression
was reported to improve the effectiveness of tumour screening for Lynch syndrome. We assessed
the utility of p16 IHC as a screening tool for the identification of MLH1 mutation carriers.
Methods: Individuals with CRC (n=42) recruited from both population- and clinic-based
resources from the Australasian Colorectal Cancer Family Registry (ACCFR) were characterized
for MMR status (MMR IHC and MSI), MLH1 promoter methylation, the BRAFV600E mutation and
for germline MLH1 mutations. IHC for p16 expression was conducted on whole tissue sections.
Staining results were dichotomised to represent loss of expression versus other p16 expression
patterns.
Results: CRCs (n=42) were grouped into the following categories based on molecular and genetic
testing: 1) MLH1/PMS2 deficient CRCs that were from MLH1 germline mutation carriers (n=18,
42.9%), 2) MLH1/PMS2 deficient CRCs with MLH1 methylation (n=13, 31%) with (9/13) and
without (4/13) the BRAFV600E mutation and 3) MMR-proficient/MSS CRCs with BRAFV600E
mutation (n=11, 26.1%). Loss of p16 expression was identified in 23.8% of the CRCs (10/42) and
was associated with a significantly older mean age at CRC diagnosis (p<0.001, 63.1 ± 8.9 (SD)
years versus 48.1 ± 11 years). CRCs from all 3 categories demonstrated loss of p16 expression:
MLH1 mutation carriers (4/18, 22.2%), MLH1 methylated, MSI-H CRCs (5/13, 38.5%) and BRAFmutated, MSS CRCs (1/11, 9.1%). We found no significant association between loss of p16
expression and MLH1 methylation (p=0.14, OR=3.0, 95%CI=0.55-16.9), BRAF V600E-mutated
CRC (p=0.37, OR=1.9, 95%CI=0.37-10.4) or right-sided tumour site (p=0.31, OR=2.4,
95%CI=0.37-10.4). Comparing all MLH1/PMS2 deficient CRCs (n=31), the positive predictive
value (PPV) of loss of p16 expression for identifying MLH1 methylated, MSI-H CRC was 55.6%
(95%CI=25.2-82.7%) with a negative predictive value (NPV) of 63.6% (95%CI=51.2-74.7%). In
comparison, BRAFV600E mutation testing demonstrated a PPV=100% (95%CI=51.2-74.7%) for
MLH1 methylated CRC, and NPV =81.8% (95%CI=51.2-74.7%).
Conclusions: In this study, IHC for p16 was not associated with features of sporadic MSI-H CRC
including, MLH1 methylation and the BRAFV600E mutation. BRAFV600E mutation was more
effective than IHC for p16 expression in distinguishing MLH1/PMS2 deficient CRCs resulting
from MLH1 methylation from those resulting from MLH1 mutation carriers.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#42
TUMOUR MORPHOLOGY OF EARLY-ONSET BREAST CANCER CANCERS PREDICTS BREAST
CANCER RISK FOR FIRST-DEGREE RELATIVES
Gillian S. Dite1, Enes Makalic1, Daniel F. Schmidt1, Graham G. Giles1, 2, John L. Hopper1, Melissa C.
Southey3
1Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of
Melbourne, Australia; 2Cancer Epidemiology Centre, Cancer Council Victoria, Australia;
3Department of Pathology, The University of Melbourne, Australia.
Background: We previously found that tumour morphological features predict BRCA1 mutation
carriers among women with early-onset breast cancer better than family history and standard
immunohistochemistry. We now hypothesised that risk of breast cancer could be predicted by
tumour morphological features for relatives of women with early-onset breast cancer, including
relatives of women without a detectable germline mutation in a known breast cancer
susceptibility gene.
Methods: We studied mothers and sisters of a population-based sample of 452 index cases with
a first primary invasive breast cancer diagnosed before the age of 40 years and for whom a
standardised tumour morphology review had been conducted. Standardised incidence ratios
(SIR) were calculated by comparing the number of relatives with breast cancer to the number
expected based on Australian incidence rates. Hazard ratios were calculated using Cox
proportional hazards modelling.
Results: Absence of extensive sclerosis, extensive intraductal carcinoma, absence of acinar and
glandular growth patterns, and presence of trabecular and lobular growth patterns were
independent predictors with between 1.8 and 3.1–fold increased risk for relatives (all p < 0.02).
Excluding the 77 (17%) index cases with genetic or epigenetic causes, independent predictors
included minimal sclerosis, circumscribed growth, extensive intraductal carcinoma and lobular
growth pattern, all with between 2.0 and 3.3–fold increased risk for relatives (all p < 0.02).
Relatives of the 128 (34%) index cases with none of these features were at population risk
(SIR = 1.03, 95% CI = 0.57–1.85), while relatives of the 37 (10%) index cases with two or more
features were at high risk (SIR = 5.18, 95% CI = 3.22–8.33).
Conclusion: There is such a wide variation in risks for relatives based on tumour characteristics
that early-onset cases without a known genetic predisposition can be divided into three groups
for whom the breast cancer risks for relatives are the same as for the three categories in the
Guide for Health Professional on Familial Aspects of Breast and Ovarian Cancer developed by the
National Breast and Ovarian Cancer Centre. This should be important for genetic counselling,
prevention and screening. It adds support to the concept that morphology review of a few key
measures could be used to better inform families of their risks of breast cancer, and therefore be
considered as an integral part of a breast cancer family genetics service. The identification of a
group of relatives at high risk of breast cancer could also help discover new breast cancer
susceptibility genes.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#43
DOES RNA ANALYSIS MAKE A DIFFERENCE?
Christopher Manning1, Graeme Suthers1, 2, Lesley Rawlings3, ScottGrist4 and Nicola Poplawski1, 2
1. SA Clinical Genetics Service, SA Pathology (WCH site), North Adelaide, SA 5006 Australia
2. University of Adelaide, Adelaide, SA 5008 Australia
3. Molecular Pathology, SA Pathology, Frome Road, Adelaide SA 5000 Australia
4. Molecular Pathology, SA Pathology, Flinders Medical Centre SA 5042 Australia
BACKGROUND: Variants of unknown significance (VUS) are identified in many genes responsible
for familial cancer syndromes. Most VUS have only been studied at the genomic level. Analysis of
RNA size, sequence, and abundance can elucidate the effect of VUS on mRNA expression and
hence their likely pathogenicity1–3. Since 1998 the Familial Cancer Unit has performed RNA
analyses on selected cases involving splice sites, exon deletions and exon duplication events of
uncertain significance.
AIMS: 1. To audit the RNA studies performed in clients of the SA Clinical Genetics Service who
have a VUS in BRCA1, BRCA2, or the DNA mismatch repair (MMR) genes, MLH1, MSH2, MSH6 or
PMS2. 2. To identify the proportion of RNA studies which altered the clinical management of the
family in which the VUS was identified.
METHOD: A clinical audit of the clinical database from 1 January 1998 to 31 December 2011.
RESULTS:
Study population: In the study period 398 probands were screened for MMR mutations and 38
VUS were identified. In the same period 1540 probands were screened for BRCA1/2 mutations
and 163 VUS were identified.
Results: 9 (24%) of the patients with an MMR VUS had RNA studies. Studies of RNA size and
abundance were normal in 4 (45%) and equivocal in 2 (22%); the classification of these variants
was not altered by this analysis. However, the remaining 3 variants (33%) exhibited unequivocal
abnormalities of RNA size or abundance such that the VUS was reclassified as pathogenic.
20 (12%) of the patients with a BRCA1/2 VUS had RNA studies. Studies of RNA size and
abundance were normal in 8 (40%) and equivocal in 6 (30%); the classification of these variants
as VUS was not altered by this analysis. However, the remaining 6 variants (30%) exhibited
unequivocal abnormalities of RNA such that the VUS was reclassified as pathogenic
Overall a VUS was reclassified as pathogenic in 1/3 of cases in which RNA analysis was
performed. These involved 3 splice sites, 5 deletions, and 1 duplication event.
CONCLUSION: In one third of those tested, RNA analysis clarified the interpretation of the VUS.
This allowed predictive genetic testing in close relatives, confirming that there is utility
associated with RNA studies. The outcome of such RNA studies should be added to the available
mutation databases.
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#44
A RESOURCE FOR BREAST CANCER RESEARCH
Lisa Devereux1, Gillian Mitchell1, Anne Kavanagh2, Bruce Mann3, Stephen Fox1, Vicki Pridmore4,
Rhonda Mawal1, Jaymes Charlesworth5, Kelly Aujard5, John Hopper5, Ian Campbell1
Affiliations:
1. Peter MacCallum Cancer Centre
2. Key Centre for Women’s Health, Gender & Society, University of Melbourne
3. The Royal Melbourne and Royal Women’s Hospital
4. BreastScreen Victoria
5. Centre for MEGA Epidemiology, University of Melbourne
Background
Lifepool is a prospective cohort of Victorian women. The project is funded by the National Breast
Cancer Foundation and is an open resource. Lifepool aims to recruit 100,000 women by the end
of 2014.
The Resource
Lifepool participants provide health and lifestyle information through completion of a baseline
questionnaire. Data is collected on factors contributing to breast cancer risk across the following
headings: Personal medical history, family history of cancer, reproductive history, menopause,
surgery, use of hormone replacement therapy and other medication use, smoking habits, alcohol
consumption and ionising radiation exposure.
Mammographic density calculations will be available on all participants as the women give
consent for lifepool to access their mammograms from BreastScreen Victoria and other
providers.
Cancer incidence is tracked through linkage with the Victorian Cancer Registry and participants
also give written consent for linkage with the Medicare and Pharmaceutical Benefits databases to
track cancer assessments and diagnoses and consequent health service utilisation.
As 1 August 2012, the resource has 21,011 participants. The average age of lifepool participants
is 60 years. The vast majority of participants do not have breast cancer at the time of entry into
lifepool.
Participants indicate consent for future contact to allow completion of further questionnaires and
also to consider donating DNA for research. To date, the lifepool resource holds 967 peripheral
blood and 129 saliva samples from women on whom cancer diagnosis can be ascertained with
certainty through linkage and from whom health and lifestyle information is provided.
The lifepool resource is open to application from national and international researchers. Data
and biospecimens are available to support research into breast cancer and other women’s health
issues, subject to review by the NBCF Access Committee and appropriate Human Research Ethics
Committee approvals.
For further information please contact [email protected] or visit the website
www.lifepool.org
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
#45
CONTRALATERAL PROPHYLACTIC MASTECTOMY – WHAT MAKES A SURGEON
RECOMMEND REMOVING A NORMAL BREAST?
Christobel Saunders and Toni Musiello, School of Surgery, University of Western Australia
[email protected]
Background: Contralateral prophylactic mastectomy (CPM) is the removal of the opposite,
unaffected breast in patients with unilateral breast cancer (BC). This may be logical in women
carrying a BRCA mutation who have up to a 75% lifetime risk of a second cancer on the opposite
side (1) but there is no known survival benefit in normal risk women (2) with an annual risk of
contralateral BC in older women around 0.25% (3). Yet the rates of CPM are increasing
significantly (4). Whilst increasing awareness of high risk genes and enhanced availability of
genetic testing may partially explain this increase, the vast majority of CPMs are performed on
women with sporadic BC without susceptibility genes (3).
Patients report “doctor’s advice” as the main reason for deciding on a CPM (5). Few studies have
examined surgeon characteristics influencing recommendations for CPM. We investigated breast
surgeons’ perceptions, knowledge and attitudes towards CPM, and reasons for recommending it.
Methods: A cross sectional study of 220 surgeons in BreastSurgANZ using a self-report on-line
questionnaire
Results: Response rate was 37% (a third female). 44% of surgeons perceived that the rates of
CPMs they performed had increased over the last year, with half performing over 5 CPMs per
year. CPM rates were found to be unrelated to surgeons’ age (P=0.773) or gender (P=0.941). The
majority reported they discussed CPM with 5-20% of their patients and a third of discussions are
with women with no risk factors for contra-lateral cancer. Interestingly 57% of surgeons felt the
side effects of a second mastectomy in these low risk women outweighed any benefit, yet most
surgeons felt these discussions were increasing in number. The top three reasons a surgeon
recommended CPM included 2 objective risk factors: BRCA mutation and family history of breast
cancer, and 2 subjective patient factors: fear/anxiety of a new breast cancer and desire for
symmetry.
Conclusions: Most surgeons use BRCA status and family history as the main reason for
recommending CPM but the third most common reason is patients’ fear and anxiety. This raises
the question of whether it is advisable for surgeons to recommend an irreversible, surgical
procedure to relieve fear and anxiety, rather than using alternative management options,
including treatment with preventative agents such as Tamoxifen, accurate communication of risk,
or psychological interventions to reduce anxiety. Breast cancer specific survival appears to have
little impact on either surgeons’ or patients’ decision making regarding CPM, in line with
evidence.We intend to develop decision algorithms to assist both the patient and her surgeon in
making an informed decision regarding CPM.
References:
1. Blackwood M et al. JCO 1998;16(5):1969-77
2. Peralta EA et al Am J Surg 2000; 180(6):439-45
3. King TA et al JCO 2011; 29(16):2158-64
4. Yao K et al. Ann Surg Onc 2010;17(10):2554-62
Arrington AK et al. Ann Surg Onc 2009; (10):2697-704
“Familial Cancer 2012: Research and Practice”
August 2012
Mantra Resort, Queensland
Delegates List 2012
Aamira Huq
Adrienne Sexton
Agnes Bankier
Alex Metcalf
Alexandra Lewis
Alison Trainer
Amanda Spurdle
Amber Johns
Amy Pearn
Alina Stoita
Anna DeFazio
Anna Nash
Annabel Goodwin
Annabelle Ng
Anneke Blackburn
Annette Hattam
Antonis Antoniou
Ashley Crook
Aung Ko Win
Belinda Creighton
Belinda Nagler
Bettina Meiser
Brenda Greyling
Briony Patterson
Brett Kennedy
Bronwyn Cook
Brooke Brewster
Bruce Hopper
Bryony Thompson
Carla Osinski
Camron Ebzery
Charlotte Slade
Chol-Hee Jung
Christobel Saunders
Clare Scott
Cliff Meldrum
Daniel Buchanan
Daniel Park
David Packenas
David Thomas
Deborah Weston
Deborah Neklason
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“Familial Cancer 2012: Research and Practice”
August 2012
Dragana Prodanovic
Diana Moynihan
Christopher Manning
Driss Ait Ouakrim
Ella Thompson
Eveline Niedermayr
Finlay Macrae
Fiona McKenzie
Gemma Correnti
Georgia ChenevixTrench
Geoffrey Lindeman
Gillian Mitchell
Graeme Suthers
Heather Thorne
Helen Mar Fan
Hilda High
Ian Campbell
Ian Collins
Ian Tomlinson
James Flanagan
Jacquie Armstrong
Jan Sullivan
Jan Wakeling
Jane Garrad
Jasmin Mar
Jessica Taylor
Jeff Gleeson
Jillian Hung
Joanne Young
Jodie Painter
John Heath
John Hopper
John Parisot
Jonathan Beesley
Judy Kirk
Julie McGaughran
Jun Li
Karen Crowe
Kate Crough
Kate Mahendran
Kate Drew
Kate Riley
Kate Thompson
Kathy Tucker
Kathryn Alsop
Mantra Resort, Queensland
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“Familial Cancer 2012: Research and Practice”
August 2012
Khalid Mahmood
Kim Riddell
Kimberley Gamet
Kirsty Mann
Kitty Cho
Kristy Barnes-Cullen
Kylie Gorringe
Kylie Shackleton
Laney Lindor
Lara Lipton
Lara Petelin
Leonie Noon
Lesley Andrews
Linda Cicciarelli
Lindsay Fowles
Lisa Devereux
Lisa Huang
Logan Walker
Louise Heiniger
Lucy Holland
Lynda Williams
Lyn Schofield
Lynne Purser
Madara Ratnadiwakara
Maira Kentwell
Mandy Ballinger
Manju Salaria
Margaret Tassell
Margaret Gleeson
Marion Harris
Mark Clendenning
Mantra Resort, Queensland
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Mark Jenkins
Marni Giles
Martin Delatycki
Mary McPhillips
Mary Shanahan
Mary-Anne Young
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Megan Cotter
Melanie Boon
Melissa Brown
Melissa Southey
Michael Bogwitz
Michael Field
Michael Parsons
Michael Walsh
Michelle Bowman
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“Familial Cancer 2012: Research and Practice”
August 2012
Michelle Wong
Monique Topp
Ngaire Knight
Nicola Poplawski
Paul James
Phillip Whiley
Prue Cowin
Prue Weideman
Robyn Ward
Rachel Susman
Rachel Waller
Rachel Williams
Rebecca Driessen
Rhiannon Walters
Risha Zia
Robert MacInnis
Robyn Sayer
Rony Duncan
Sally Hunter
Sally Jackson
Sally Pearson
Sarah Jordan
Sarah Sawyer
Serguei Kovalenko
Sharon Johnatty
Shona O'Connell
Sian Fereday
Sian Greening
Simone McInerny
Skye Simpson
Sophie Walker
Sue Healey
Stephen Fox
Tatjana Seidens
Tish Silberbauer
Tony Proietto
Tony Roscioli
Toula McArdle
Tu Nguyen
Vicki Fennelly
Vivianne Geldard
Xiaoqing Chen
Yoke-Eng Chiew
Mantra Resort, Queensland
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“Familial Cancer 2012: Research and Practice”