Christa Slaught1, Elizabeth G Berry2, Lindsay Bacik3, Alison H Skalet1,4,5,6, George Anadiotis7, Therese Tuohy7, Sancy A Leachman1,5. 1. Department of Dermatology, Oregon Health & Science University, 3303 SW Bond Ave, Suite 16D, Portland, OR, 97239, USA. 2. Department of Dermatology, Oregon Health & Science University, 3303 SW Bond Ave, Suite 16D, Portland, OR, 97239, USA. berryel@ohsu.edu. 3. Department of Dermatology, Penn State Health, Hershey, USA. 4. Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, USA. 5. Knight Cancer Institute, Oregon Health & Science University, Portland, USA. 6. Department of Radiation Medicine, Oregon Health & Science University, Portland, USA. 7. Legacy Cancer Institute, Cancer Genetics Services, Legacy Health Systems, Portland, USA.
Abstract
BACKGROUND: In the past two decades, genetic testing for cancer risk assessment has entered mainstream clinical practice due to the availability of low-cost panels of multiple cancer-associated genes. However, the clinical value of multiple-gene panels for cancer susceptibility is not well established, especially in cases where panel testing identifies more than one pathogenic variant. The risk for specific malignancies as a result of a mutated gene is complex and likely influenced by superimposed modifier variants and/or environmental effects. Recent data suggests that the combination of multiple pathogenic variants may be fewer than reported by chance, suggesting that some mutation combinations may be detrimental. Management of patients with "incidentally" discovered mutations can be particularly challenging, especially when established guidelines call for radical procedures (e.g. total gastrectomy in CDH1) in patients and families without a classic clinical history concerning for that cancer predisposition syndrome. CASE PRESENTATION: We present two cases, one of an individual and one of a family, with multiple pathogenic mutations detected by multi-gene panel testing to highlight challenges practitioners face in counseling patients about pathogenic variants and determining preventive and therapeutic interventions. CONCLUSIONS: Ongoing investigation is needed to improve our understanding of inherited susceptibility to disease in general and cancer predisposition syndromes, as this information has the potential to lead to the development of more precise and patient-specific counseling and surveillance strategies. The real-world adoption of new or improved technologies into clinical practice frequently requires medical decision-making in the absence of established understanding of gene-gene interactions. In the meantime, practitioners must be prepared to apply a rationale based on currently available knowledge to clinical decision-making. Current practice is evolving to rely heavily on clinical concordance with personal and family history in making specific therapeutic decisions.
BACKGROUND: In the past two decades, genetic testing for cancer risk assessment has entered mainstream clinical practice due to the availability of low-cost panels of multiple cancer-associated genes. However, the clinical value of multiple-gene panels for cancer susceptibility is not well established, especially in cases where panel testing identifies more than one pathogenic variant. The risk for specific malignancies as a result of a mutated gene is complex and likely influenced by superimposed modifier variants and/or environmental effects. Recent data suggests that the combination of multiple pathogenic variants may be fewer than reported by chance, suggesting that some mutation combinations may be detrimental. Management of patients with "incidentally" discovered mutations can be particularly challenging, especially when established guidelines call for radical procedures (e.g. total gastrectomy in CDH1) in patients and families without a classic clinical history concerning for that cancer predisposition syndrome. CASE PRESENTATION: We present two cases, one of an individual and one of a family, with multiple pathogenic mutations detected by multi-gene panel testing to highlight challenges practitioners face in counseling patients about pathogenic variants and determining preventive and therapeutic interventions. CONCLUSIONS: Ongoing investigation is needed to improve our understanding of inherited susceptibility to disease in general and cancer predisposition syndromes, as this information has the potential to lead to the development of more precise and patient-specific counseling and surveillance strategies. The real-world adoption of new or improved technologies into clinical practice frequently requires medical decision-making in the absence of established understanding of gene-gene interactions. In the meantime, practitioners must be prepared to apply a rationale based on currently available knowledge to clinical decision-making. Current practice is evolving to rely heavily on clinical concordance with personal and family history in making specific therapeutic decisions.
Authors: Kim E Nichols; Chimene A Kesserwan; Jamie L Maciaszek; Ninad Oak; Wenan Chen; Kayla V Hamilton; Rose B McGee; Regina Nuccio; Roya Mostafavi; Stacy Hines-Dowell; Lynn Harrison; Leslie Taylor; Elsie L Gerhardt; Annastasia Ouma; Michael N Edmonson; Aman Patel; Joy Nakitandwe; Alberto S Pappo; Elizabeth M Azzato; Sheila A Shurtleff; David W Ellison; James R Downing; Melissa M Hudson; Leslie L Robison; Victor Santana; Scott Newman; Jinghui Zhang; Zhaoming Wang; Gang Wu Journal: Cold Spring Harb Mol Case Stud Date: 2019-10-23