33
Il test BRCA dal laboratorio alla clinica Valentina Guarneri DiSCOG, Università di Padova Istituto Oncologico Veneto IRCCS
Il test BRCA dal laboratorio alla clinica Valentina Guarneri
DiSCOG, Università di Padova
Istituto Oncologico Veneto IRCCS
• Prognostic importance/prediction of tumor behaviour
• Impact on patient treatment - Platinum sensitivity
- Sensitivity to intraperitoneal chemotherapy
- Sensitivity to other chemotherapy
- Pegylated liposomal doxorubicin
- Trabectedin
- PARP inhibition
Why perform BRCA1/2 test in ovarian cancer
patients?
• Identification of unaffected mutation carriers
• Identification of unaffected mutation carriers
Bolton, JAMA 2012
Impact of BRCA1/2 germline mutations on survival
Kaye SB, et al. J Clin Oncol 2012
BRCA status and response to chemotherapy
• 42% platinum resistant; 58% partially platinum
sensitive
Monk , et al. Ann Oncol 2015
• OVA-301 phase III study in recurrent ovarian cancer
• PLD +/- trabectedin
Olaparib 400mg bid
Placebo bid
1:1
Platinum-sensitive high-grade serous ovarian cancer (>6m response to prior platinum) >2 previous platinum-containing regimens
Relapse Platinum-based Chemotherapy
> 6 months Platinum-based Chemotherapy
<8 weeks
Primary endopoint: PFS
Secondary endpoints: TTP (recist+CA125)
OS
ORR
Safety, QoL Ledermann J et al. N Engl J Med 2012;366:1382–92
Ledermann J et al. Lancet Oncol 2014
Ledermann J et al. Lancet Oncol 2014
Progression-free Survival in BRCAm
Study 19: Overall survival<br />BRCAm patients*
Presented By Jonathan Ledermann at 2016 ASCO Annual Meeting
Cancers associated with BRCA genes
mutations
• Today the focus of BRCA testing is generally on risk assessment and the potential for preventive interventions
• Ovarian cancer patients have different priorities from genetic testing
• A formal pre-test genetic counselling is maybe not necessary providing:
• Expert genetic for result interpretation
• Genetic counselling availability (post-test or pre-test if patients require additional discussion)
• Specific genetic counselling for family members
Adapting genetic counselling to the new paradigm
For medical, non promotional use only
Sanger Sequencing Next Generation Sequencing
Gold standard, high accuracy
BRCA1/2: 80 sequencing reactions for one patient
Involved procedure, limited capacity, high costs
Invented already in 1992
Affordable NGS benchtop devices since 2009
BRCA1/2 only or gene panel analysis
e.g. 48 genes, 16 patients in parallel*
* Illumina MiSeq sequencing device, 44 gene panel, Agilent
SureSelect XT protocol, mean exon coverage: 431 (range: 210-
623)
demand for low cost,
high throughput
sequencing
For medical, non promotional use only
Next generation sequencing – bioinformatics pipelines gene coverage
visualise reads
data export
X
For medical, non promotional use only
Class Description Probability of
being
pathogenic
Clinical
predictive
testing of at
risk relatives
Management
recommendations if
at-risk relative has the
variant
Research testing
of family members
5 Definitely
pathogenic
>0.99 Yes Full high-risk guidelines Not indicated
4 Likely pathogenic 0.95-0.99 Yes Full high-risk guidelines May be helpful to
further classify
variant
3 Uncertain 0.05-0.949 No Presence of variant is
irrelevant to risk
assessment, manage
risk based on family
history only
May be helpful to
further classify
variant
2 Likely not
pathogenic or of no
clinical significance
0.001-0.049 No Manage risk based on
family history only
May be helpful to
further classify
variant
1 Not pathogenic or
of no clinical
significance
<0.001 No Manage risk based on
family history only
Not indicated
IARC 5-tier classification of BRCA1/2 VUS
Modified from Plon et al, Hum Mutat.2008
For medical, non promotional use only
BRCA wild type
BRCA-mutant
BRCA-VUS
If genetic variants were Gremlins:
A story about: “The Good, the Bad and the VUS”
Types of BRCA genetic variants
For medical, non promotional use only
BRCA-mutant or
pathogenic variant
Disrupt normal protein
function
Include:
- Nonsense
- Frameshift
- Large gene rearrangements
- Splice variants canonical sites
- Some missense changes
Types of BRCA genetic variants
BRCA-VUS
Differ from published reference
DNA-sequence but effect is
unknown
Include:
- Missense changes (vast majority)
- Small in-frame insertions or deletions
- Potential splice-site alterations
- Possible regulatory sequence
alterations
BRCA-wild type or
neutral variant or of no
clinical significance
Reference DNA sequence
or
Changes that do not disrupt
Protein function
For medical, non promotional use only
Family A
26 yrs 35 yrs 33 yrs
54 yrs 49 yrs
28 yrs
BRCA mutation positive
Male
Female
Index BRCA test (positive)
Dead
For medical, non promotional use only
APC
ATM
ATR
BAP1
BARD1
BMPR1A
BRCA1
BRCA2
BRIP1
CDH1
CDK4
CDKN2A
CHEK1
CHEK2
EPCAM
FAM175A
GALNT12
GEN1
GREM1
HOXB13
MLH1
MRE11A
MSH2
MSH6
MUTYH
NBN
PALB2
PMS2
PRSS1
PTEN
RAD50
RAD51
RAD51C
RAD51D
RET
SMAD4
STK11
TP53
TP53BP1
VHL
XRCC2
BR
OC
A 4
0 g
en
e p
an
el
(cro
ss-c
ancer,
htt
p:/
/web.la
bm
ed.w
ashin
gto
n.e
du/t
ests
/genetics/B
RO
CA
ATM
BARD1
BRCA1
BRCA2
BRIP1
CDH1
CHEK2
MRE11A
MUTYH
NBN
PALB2
PTEN
RAD50
RAD51C
STK11
TP53
AM
BR
Y G
en
eti
cs
Bre
as
tNe
xt
(16
gen
es
) htt
p:/
/ww
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mbry
gen.c
om
/tests
/bre
astn
ext
MY
RIA
D m
yR
ISK
Pa
ne
l (2
5 g
en
es
)
APC
ATM
BARD1
BMPR1A
BRCA1
BRCA2
BRIP1
CDH1
CDK4
CDKN2A
CHEK2
EPCAM
MLH1
MSH2
MSH6
MUTYH
NBN
PALB2
PMS2
PTEN
RAD51C
RAD51D
SMAD4
STK11
TP53
ATM
BARD1
BRCA1
BRCA2
BRIP1
CDH1
CHEK2
MRE11A
MSH6
NBN
PALB2
PTEN
RAD51
RAD51C
STK11
TP53
CE
NT
OG
EN
E B
C/O
C p
an
el (1
6 g
en
es
) htt
ps:/
/ww
w.c
ento
gene.c
om
/cento
gene
25
Gene-panel analyses (BC, OC, cross-cancer)
16 16
40
AIP
ALK
APC
ATM
BAP1
BLM
BMPR1A
BRCA1
BRCA2
BRIP1
BUB1B
CDC73
CDH1
CDK4
CDKN1C
CDKN2A
CEBPA
CEP57
CHEK2
CYLD
DDB2
DICER1
DIS3L2
EGFR
EPCAM
ERCC2
ERCC3
ERCC4
ERCC5
EXT1
EXT2
EZH2
FANCA
FANCB
FANCC
FANCD2
FANCE
FANCF
FANCG
FANCI
FANCL
FANCM
FH
FLCN
GATA2
GPC3
HNF1A
HRAS
KIT
MAX
MEN1
MET
MLH1
MSH2
MSH6
MUTYH
NBN
NF1
NF2
NSD1
PALB2
PHOX2B
PMS1
PMS2
T
ruS
igh
t™ C
an
ce
r (I
llu
min
a)
htt
p:/
/res.illu
min
a.c
om
/docum
ents
/pro
ducts
%5C
data
sheets
%5C
data
sheet_
trusig
ht_
cancer.
PRF1
PRKAR1A
PTCH1
PTEN
RAD51C
RAD51D
RB1
RECQL4
RET
RHBDF2
RUNX1
SBDS
SDHAF2
SDHB
SDHC
SDHD
SLX4
SMAD4
SMARCB1
STK11
SUFU
TMEM127
TP53
TSC1
TSC2
VHL
WRN
WT1
XPA
XPC
94
ATM
BARD1
BLM
BRIP1
MEN1
MUTYH
RAD50
XRCC2
CDH1
MLH1
NBN
RAD51C
BRCA1
CHEK2
MRE11A
PALB2
RAD51D
BRCA2
EPCAM
MSH2
PMS2
STK11
FAM175A
MSH6
PTEN
TP53
Mu
ltip
lic
om
Here
dit
ary
Can
ce
r M
AS
TR
Plu
s
htt
p:/
/ww
w.m
ultip
licom
.com
/pro
ducts
/brc
a-h
ere
ditary
-cancer-
mastr
-plu
26
Genetic Basis of Breast
Cancer
Tutt A, SABCS 2014
TNT: Carboplatin vs Docetaxel as 1st line for TNBC
Tutt A, SABCS 2014
Phase III trials examining PARP inhibitors
in HER2-neg BRCA1/2 carriers with Breast
Cancer
R
Potent PARP
inhibitor at MTD as
continuous
exposure
Physician Choice
within SOC options
Capecitabine
or
Vinorelbine
or
Eribulin
or
Gemcitabine
gBRCA1 / BRCA2
Carriers
Advanced
anthracycline taxane
resistant breast cancer
Primary
endpoint
PFS
Olaparib – OLYMPIAD - NCT02000622
Talazoparib (BMN 673)
– EMBRACA - NCT01945775
Niraparib – EORTC / BIG BRAVO Trial
Adjuvant olaparib in breast cancer patients with gBRCA
mutations at high risk of recurrence
N=1,320
• Study to start recruiting patients with TNBC; plan to add ER/PR+ patients once data available from PK/PD interactions (expected Mid 2014)
• Primary endpoint: IDFS (invasive disease-free survival; STEEP approach) • HR=0.7 (CV=0.81), 90% power, 5% significance level, approx 330 events required
• Assumes consistent treatment effect (HR=0.7) across patient groups • N=1320 (25% maturity), assuming 4 years recruitment, IDFS analysis estimated approx. 5.5–
6 years from FSI
Post-neoadjuvant gBRCA TNBC Non pCR patients Assumptions: - Control arm 3-year EFS ~ 60%C
Post-adjuvant gBRCA TNBC Node positive or N0 with T>2 cm Assumptions: - Control arm 3-year EFS ~ 77%C
12 mos Olaparib
300mg bd DDF
S,
OS
12 mos Placebo
IDFS 1:1 R
OlympiA
pCR Rates by Treatment and According to <br />HR Deficiency Status (ypT0 ypN0)
Presented By Gunter Von Minckwitz at 2015 ASCO Annual Meeting
Conclusions
• Therapeutic decisions are impacted by BRCA mutation status
• Some women will be adversely affected discussing the implication
of BRCA testing at the time of cancer diagnosis, but not having
BRCA status takes away choice
• It’s our role to identify those people who are struggling, and
providing them with additional support
• Strict cooperation between lab and clinic is crucial
