EGAPP Recommendations for
Lynch Syndrome Genetic Testing:
Impact on Colorectal Cancer Care
Heather Hampel, MS, CGC
Professor, Division of Human Genetics
The Ohio State University
Department of Internal Medicine
Columbus, OH
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Outline
• Why determine which cases of CRC have
defective mismatch repair?
• Screening for Lynch syndrome among newly
diagnosed CRC patients
• EGAPP recommendations
• OSU clinical experience doing IHC on all
newly diagnosed CRC patients
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Colorectal Cancer
15%
85%
CIN
(Chromosome Instability)
MIN (MSI+)
(Microsatellite Instability)
2-3%
Lynch Syn
Germline Mutation
MMR genes
MLH1, MSH2,
MSH6 & PMS2
13%
Sporadic MSI(+)
•Epigenetic silencing of
MLH1 by hypermethylation
of its promoter region
<1%
FAP
Germline
Mutation
APC
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
85%
Sporadic
Acquired
APC, p53,
DCC, kras,
LOH,...
Why Determine which CRC Cases are
MSI+ and which have LS?
• All MSI+ CRC patients have a better
prognosis
• MSI+ CRC patients MAY need different
treatment in future
• LS patients at high risk for second primary
cancers (CRC and others)
• LS patients have at-risk relatives who
could benefit from genetic testing
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Prognostic Implications
• Pooled data analysis of 32 studies with 7,642
cases found:
– HR for Overall Survival with MSI = 0.65
– Restricting analysis to clinical trial patients
(HR=0.69) did not alter benefit
– Restricting to those with locally advanced
disease (HR=0.67) did not alter benefit
Popat S, et al. JCO. 2005;23:609-618.
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Treatment Implications
• MSI-H stage II and III patients did not have a
significant difference in RFS whether or not
they received 5-FU (HR, 0.96; 95% CI, 0.62
to 1.49; P=.86)
• MSI-H patients did not have a significant
difference in OS whether or not they were
treated with 5-FU (HR, 0.70; 95% CI, 0.44 to
1.09; P=.12)
• MSS patients do benefit from 5-FU (HR, 0.77;
95% CI 0.68 to 0.87; P<.001)
Des Guetz G, et al. Euro J Cancer 45:1890-6,2009.
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Patient & Family Implications: Lynch Syndrome
MSH2
MSH6
MLH1
PMS2
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Autosomal Dominant Inheritance
Carrier Parent
Non-carrier Parent
Aa
aa
Aa
Aa
Carrier
Carrier
1/2
aa
aa
Non-carrier
Non-carrier
1/2
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Lynch Syndrome: Lifetime Risks for Cancer
Cancer
Colon cancer
Lynch
General
syndrome
Public
56%
22%
Endometrial cancer 35%
26%
Gastric cancer
13%
1%
Ovarian cancer
12%
1.5%
Small bowel,
bladder, ureter,
renal pelvis, brain
<4% each
<1% each
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Lynch Syndrome Surveillance Options
Intervention
Colonoscopy
Endometrial
sampling
Transvaginal U/S
Recommendation
Every 1-2 y beginning at age 20
(MLH1), 25 (MSH2), or 30 (MSH6 &
PMS2)
Every 1 y beginning at age 30-35
Every 1 y beginning at age 30-35
Urinalysis with
Every 1-2 y beginning at age 25-35
cytology
History & Exam w/ Every 1 y beginning at age 21
review of systems
© CoC 2011—Content
cannot be reproduced or
without
writtenet
permission
the CoC. Genet 2007;44:353-62.
Lindor N et al. JAMA
2006;296:1507-17.
&repurposed
Vasen
HFA
al. JofMed
15-year prophylactic
colonoscopic screening
Screened
Not screened
n=133
n=119
Colorectal cancer
8
19
n=0.014
Death from colorectal
cancer
0
9
p<0.001
Overall deaths
10
26
p<0.001
Järvinen et al. 1995 and 2000
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Lynch Syndrome Prophylactic Surgery Options
• Options include subtotal colectomy,
hysterectomy, and oophorectomy
• Subtotal colectomy does not eliminate
cancer risk
• Hysterectomy eliminates risk of endometrial
and ovarian cancer
• Expert panels made no recommendation for
or against surgery due to unproven efficacy
Schmeler et al. NEJM 2006;354:261-9.
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Lynch Syndrome Implications for Patient
• 16-30% chance of second primary CRC in the 10
years after their first diagnosis
• NCCN guidelines differ for CRC patients with LS
and without LS
– With LS, colonoscopy every 1-2 years for life
– Without LS, colonoscopy 1 yr after dx, repeat
in 2-3 yrs, then every 3-5 years based on
findings
• Management also changes due to the risk for
other cancers
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Lynch Syndrome Implications for Family
• 6 relatives tested on average per proband
identified with LS
• 50% with LS need increased cancer surveillance
– High Compliance (96% CRC & 97% Gyn)
– Cancer risk ratio of relatives with LS compared
to relatives without LS is 5.8
– No significant difference in cancer mortality
(RR, 2.28) or overall death rates (RR, 1.26)
• 50% without LS follow the ACS guidelines
Jarvinen HJ et al. J Clin Oncol 2009;27:4793-7.
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Tumor Tests to Screen for Lynch Syndrome
• Microsatellite Instability (MSI) testing
– Performed on DNA extracted from tumor and
normal tissue – requires laboratory
– Test is positive in 15% of CRC cases
– Test is positive in 77-89% of LS cases
• Immunohistochemistry staining
– Performed on thin slide of tumor – can be
done in pathology department
– 1-2 proteins are absent in 20% of CRC cases
– 1-2 proteins are absent in 83% of LS cases
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MSI testing on Genotyper
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Five Possible IHC Results:
1. Normal – All 4 Stains Present
•
•
•
•
80% of the time you will get this result
CRC is probably not MSI+
Prognosis worse than if MSI+
Refer to Genetics ONLY if you suspect
polyposis, patient dx <45, patient has had
multiple CRC primaries, or the patient has an
first degree relative (FDR) with CRC at any
age
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2. Abnormal – MLH1 & PMS2 Absent
•
•
•
•
15% of the time
CRC is MSI+
Better prognosis
80% acquired
methylation of
MLH1
• 20% will be LS
MLH1
MSH6
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MSH2
PMS2
2. Abnormal – MLH1 & PMS2 Absent
• Either refer all cases to Genetics
OR
• Refer those diagnosed under age 60, those
with multiple primary LS cancers, and those
with an first or second degree relative (SDR)
with a LS cancer at any age
OR
• Reflex to BRAF or MLH1 methylation testing
& refer those without BRAF mutation or
without methylation
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BRAF and CRC
• V600E (1799T>A) mutation strongly
associated with MSI+ and CpG island
methylator phenotype (CIMP)
• Not yet reported in a patient with a germline
MLH1 gene mutation
• MLH1 promoter methylation
– MLH1 absent on IHC, no MMR gene
mutation; 68% with V600E in BRAF
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3. Abnormal – MSH2 & MSH6 Absent
•
•
•
•
3% of the time
CRC is MSI+
Better prognosis
Most likely LS due
to either MSH2 or
MSH6 gene
mutation
• Always refer to
Genetics
MLH1
MSH2
MSH6
PMS2
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4. Abnormal – MSH6 Absent
•
•
•
•
1% of the time
CRC is MSI+
Better prognosis
Most likely LS due
to an MSH6 gene
mutation
• Always refer to
Genetics
MLH-1
MSH-6
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MSH-2
PMS-2
5. Abnormal – PMS2 Absent
•
•
•
•
1% of the time
CRC is MSI+
Better prognosis
Most likely LS due
to an PMS2 gene
mutation
• Always refer to
Genetics
MLH1
MSH6
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MSH2
PMS2
The Family History Is Key to Diagnosing LS – or
is it?
CRC
dx 50s
CRC
dx 45
CRC
dx 61
CRC
dx 48
CRC
dx 52
Endometrial 45
Ca, dx 59
CRC
dx 75
CRC
dx 42
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Ovarian
Ca, dx
64
Amsterdam II criteria
• 3 or more relatives with verified Lynchassociated cancer in family
• Two or more generations
• One case a first-degree relative of the
other two
Does not include
• One CRC dx <50
ovarian, gastric, brain,
• FAP excluded
biliary tract or
pancreatic cancer
Vasen HFA et al. Gastroenterology. 116:1453, 1999
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Bethesda Guidelines
• Individual with CRC dx <50
• Individual with synchronous or metachronous
CRC, or other Lynch-associated tumors
regardless of age
• Individual with CRC with MSI-H histology dx <60
• Individual with CRC with >1 FDR with an Lynchassociated tumor, with one cancer dx <50
• Individual with CRC with >2 FDRs or SDRs with
an Lynch-associated tumor, regardless of age
Umar A, et al. JNCI. 2004;96(4):261-268.
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Warning: Family Histories
can be Deceiving
• Family size is getting smaller
• Wider use of colonoscopy likely to prevent
many colon cancers
• MSH6 & PMS2 may have lower cancer
risks
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Identification of Lynch syndrome in
the Genetics Clinic
• Can predict who is more likely to have LS using family history
criteria (Amsterdam & Bethesda)
• Can predict the likelihood of a MMR gene mutation using three
new programs
– PREMM1,2,6
http://www.dana-farber.org/pat/cancer/gastrointestinal/crccalculator/
– MMRpro
http://www4.utsouthwestern.edu/breasthealth/cagene/
– MMRpredict
http://www1.hgu.mrc.ac.uk/Softdata/MMRpredict.php
• Can order MSI and/or IHC on tumor to screen for LS
• Can diagnose Lynch syndrome with genetic testing
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Identification of Lynch syndrome among
all Newly Diagnosed CRC Patients
• Unlikely to have good family history
• High volume
• Must rely on screening tests for LS
(MSI/IHC)
• Pathologists will know age at dx,
synchronous primaries, but not likely to
know all metachronous primary or family
history of patients
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Columbus-area HNPCC study (1999-2005)
Colorectal cancer
Total accrued (n=1600)
Testing completed (n=1566)
MSI positive (high & low)
MSI negative
n=307 (19.6%)
n=1259 (80.4%)
Sequence
Immunohistochemistry
Methylation of MLH1 promoter
Deleterious mutation
Variant of uncertain
significance
Polymorphism
or no mutation
n=44* (2.8%)
*2 had MSI- tumors
n=55 (3.5%)
n=209 (13.4%)
Hampel et al. New Engl J Med 2005; 352:1851-60
Hampel
et al.
Oncol
2008;
26:5783-88
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cannotJ
be Clin
reproduced
or repurposed
without written
permission of the CoC.
CRC probands with deleterious mutations (n=44)
• Age at diagnosis – 51.4 (range 23-87)
• 50% diagnosed over age 50
• 25% did not meet either Amsterdam or
Bethesda criteria
• Mutations
– 20.5% MLH1
– 52.3% MSH2
– 13.6% MSH6
– 13.6% PMS2
Hampel et al. New Engl J Med 2005; 352:1851-60
Hampel
et al.
J beClin
Oncol
2008;
26:5783-88
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cannot
reproduced
or repurposed
without written
permission of the CoC.
Family Studies of 35/44 CRC Probands
35 CRC probands have had genetic counseling
Degree of
Kinship
First
Second
> Second
Total
Tested
99
64
86
249
Positive
52
28
29
109
Hampel et al. NEJM 2005;352:1851-60.; Hampel et al. JCO 2008.
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1-2
Col on Cancer
2-3
Col on Cancer
+64
Col on Cancer
+89
Prostate Cancer
+64
Col on Cancer 45
Prostate Cancer 61
Amsterdam: Yes
Lynch: Yes
942+3 a>t MSH2
mutation
+54
Stomach Cancer
Liver
86
59
M el anoma 53
Prostate Cancer 55
Ski n Cancer, NOS 56
SCC on back and nose
Col on Cancer 57
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14
Amsterdam: No
Lynch: Yes
3155delAG MSH6
mutation
+40's
+el derly
+birth
67
+85
Col on Cancer 82
Pros tate Cancer 82
65
+82
+54
Uterine Canc er 51
85
58
Endometri al Cancer 50
+20's
+50's
CaSU
85
Uterine Canc er 52
56
55
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
57
52
62
+60s
82
57
+60's
62
37
Col on Cancer 37
+60's
+57
Col on Cancer 57
+35
+40's
Brain Cancer 40's
60
+30
Col on Cancer 29
Amsterdam: Yes
Lynch: No
Tumors MSI- with
intact IHC
14
21 months
© CoC
cannot be reproduced
11 2011—Content10
4 or repurposed without written permission of the CoC.
EGAPP Recommendations
• Evaluation of Genomic Applications in
Practice and Prevention
• Established in 2005 to assess evidence
regarding the validity & utility of rapidly
emerging genetic tests for clinical practice
• Independent, multidisciplinary panel prioritizes
and selects tests, reviews CDCcommissioned evidence reports, finds gaps,
and provides guidance
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Steps in the EGAPP Working Group
Review Process
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Seven Evidence Reports Available to Date
1.
2.
3.
4.
5.
6.
7.
October 2006 - Genomic Tests for Ovarian Cancer
Detection and Management
January 2007 – Testing for CYP450 Polymorphisms in
adults with depression before trtmnt with SSRIs
May 2007 – Lynch diagnostic strategies
January 2008 – Gene Expression Profiling and Breast
Cancer Outcomes
January 2009 – DNA strategies aimed at reducing morbidity
and mortality from Lynch syndrome
January 2009 – Can UGT1A1 genotyping reduce M&M in
pts with metastatic CRC treated w/Irinotecan
June 2009 – Outcomes of genetic testing in adults with a
history of venous thromboembolism
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Four EGAPP Working Group Recommendations
Insufficient Evidence to recommend for or against
1. Tumor profiling to improve outcomes in patients with
breast cancer
2. UGT1A1 genotyping to reduce morbidity and
mortality in patients with metastatic CRC treated
with Irinotecan
3. Use of CYP450 testing to predict response to SSRis
in adults with depression
Sufficient Evidence to recommend for
4. Screening newly diagnosed CRC patients for LS with
either MSI or IHC
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EGAPP Recommendations
• Moderate certainty that testing patients with CRC for LS and then
testing their relatives would provide moderate population benefit.
• Adequate evidence to conclude that the analytic sensitivity and
specificity of the preliminary and diagnostic tests were high.
• Adequate evidence to describe the clinical sensitivity and
specificity of three preliminary tests and four testing strategies.
• Adequate evidence for testing uptake, compliance with
surveillance, relatives approachable, harms associated with f/u
and effectiveness of routine c-scope supporting the use of
genetic testing strategies to reduce morbidity and mortality in
relatives with LS.
• No one test strategy was clearly superior.
• Inadequate evidence that screening for LS will reduce EC
morbidity or mortality
EGAPP Genet Med 2009;11:35-41; Palomaki G, Genet Med 2010;11:42-65.
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Potential Impact
• 146,970 new cases of CRC in the US in 2009
• 4,115 have Lynch syndrome (2.8%)
• 12,345 of their relatives have LS (~3 per
proband)
• Total of 16,460 individuals who could be
diagnosed with LS this year with universal
screening
American Cancer Society Facts & Figures
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Choosing the Screening Test: MSI vs. IHC
• IHC is available in virtually all hospitals
• MSI requires molecular diagnostics and
normal for comparison
• IHC with 4 antibodies is similar in cost to MSI
with 5 markers
• IHC directs gene testing saving money
• Ethical issues surrounding IHC
• IHC and MSI have limitations
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Cost-effectiveness Study
• Follow-up to EGAPP evidence review
• Modeling used the statistics from the EGAPP
review
• My role on the project was to:
– Explain the various strategies one might use
to screen for LS
– Provide Medicare reimbursement rates & list
prices for various tests
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Strategies Compared
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Cost-effectiveness Results
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Incremental Cost-Effectiveness Ratios
per LYS compared to no testing at all
Strategy
Medicare
rates
List prices 12
from labs relatives
IHC, BRAF testing &
sequencing
$22,552
$30,331
$12,332
IHC testing &
sequencing
$23,321
$30,740
$12,663
MSI testing &
sequencing
$41,511
$49,272
$20,470
Genetic sequencing
for 4 genes
$142,289 $200,037
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
$63,773
Cost-Effectiveness Evaluation
• Universal screening detects nearly twice as
many cases of LS as targeting younger patients
• Strategy 1 is the most cost effective strategy
• Cost-effectiveness ratio of universal screening is
< $25,000 per life-year saved relative to no
testing
• ICER comparable with other preventive services
(colonoscopy every 10 years has ICER of
$25,000)
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Universal IHC screening for CRC: OSU experience
• Genetics notified by pathology of all abnormal CRC
results
• Permission from ordering physician to contact patient
• Patient contacted
– Take limited family history
– Make recommendation for genetic consultation
• Letter sent
• If contact cannot be made, letter is sent explaining
results with our contact information
• Gyn/Onc’s notify their own patients regarding their
IHC results
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Universal IHC screening for CRC: OSU experience
• Began March 1, 2006
• 270 cases of CRC in first 2 years
– 57 (21.1%) absent for one or two MMR proteins
– 54 contacted by genetics with physician consent
• 5 deceased, reported to next of kin
• 7 prisoners
– 34 appropriate for consultation
– 18 scheduled appointment
– 9 completed appointment
– 7 tested
– 2 confirmed Lynch, 3 with MLH1 methylation
South et al, Genet Med 2009; 11:812-817
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© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
How to Follow-up on IHC Results
All proteins present
(80%)
MLH1 and PMS2
absent
(15%)
BRAF mutation
analysis
BRAF mutation
present (10-12%)
BRAF mutation
absent (3-5%)
MSH2 and/or
MSH6 absent;
PMS2 only absent
(5%)
Sequence and
large
rearrangements
for absent one(s)
Sequence and
large
rearrangements
for MLH1
STOP
No germline mutation in MLH1, MSH2, MSH6, PMS2
Consider family history, MSI analysis
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Universal IHC - Challenges
• These patients are not as motivated to seek
genetic counseling and testing
– Many who likely have Lynch syndrome
declined further counseling/testing
– Prisoners??
• Many do NOT have Lynch syndrome but we
cannot rule these out without further testing not easy to order and cost
– BRAF testing has helped with this
tremendously
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OSU Successes and Pitfalls
• Successes
– Proven need for tumor testing rather than family history
reliance
– Proven equivalence of MSI vs IHC
– Institutional buy-in for universal screening
– IHC plus BRAF to optimize efforts
• Pitfalls
– Need for multi-provider communication of tumor results to
increase patient follow through
– IHC only routine on primary CRC resections
• Uninformative on many polyps
• IHC should be done on initial biopsy for rectal cancers since
neoadjuvant radiation reduces available cancer cells
• Can be ordered on any specimen
– Each institution requires adherence to pathology standards to
assure equivalence of results
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Conclusions
• 1 out of every 35 CRC patients has LS
• Family history criteria will miss 25% of CRC
patients with LS
• Lives can be saved by diagnosing LS early
• Universal Screening for LS among all newly
diagnosed CRC patients
– Is feasible
– Is recommended
– Is cost-effective
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.
Acknowledgements
Albert de la Chapelle
Jenny Panescu
Judith Westman
Jan Lockman
Ilene Comeras
Jennifer LaJeunesse
Wendy Frankel
Dan Fix
Julie Stephens
Leigha Senter
Thomas Prior
Mark Clendenning
Jeffrey Fowler
Kaisa Sotamaa
David Cohn
Yange Zhang
Edward Martin
Hidewaki Nakagawa
Mark Arnold
Martha Yearsley
© CoC 2011—Content cannot be reproduced or repurposed without written permission of the CoC.