From Paths of Progress Spring/Summer 2015
by Christine Hensel Triantos
On a cold winter day in 2002, Sharon Goyette stepped into Dana-Farber's
Center for Cancer Genetics and Prevention. She was a 21-year-old college student, and this was the last place she wanted to be. But her mother had insisted.
colon cancer, Goyette's mother had been diagnosed with
Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer),
an inherited condition that increases the risk of many types of cancer, including colorectal, uterine, stomach, brain, and skin.
Her colon cancer was now advanced, and she had pleaded with Goyette to undergo
genetic testing to find out if she, too, carried the genetic mutation that would increase her own
cancer risk — and, more importantly, take the necessary steps to avoid the same path.
So Goyette met with a genetic counselor and
Sapna Syngal, MD, MPH, a gastroenterologist at Dana-Farber/Brigham and Women's Cancer Center who leads the
Gastrointestinal Cancer Genetics and Prevention program.
They explained the goal of the test was to keep Goyette healthy. If she didn't have the mutation, her risk was not elevated. If she did have the mutation, Syngal and her team would create a screening and prevention plan to reduce her risk of disease.
The results came back positive: Goyette had Lynch syndrome. "I was finishing school, trying to figure out what to do with my life, and on top of that I was losing my mom," she said. It was emotionally overwhelming, but she was reassured by the promise
of continuing care provided by Syngal and her team.
Goyette is now 35, and has not been diagnosed with any cancer. Syngal continues to take an active role in Goyette's overall medical management, which includes a specially designed regimen of screenings and exams.
Who Should Consider Genetic Testing?
Genetic testing is on the rise. Amplified awareness, lower costs, and wider accessibility have prompted many people to wonder: Should I be tested?
Genetic testing isn't for everyone — at least not yet. Testing is recommended for people with personal or family histories that suggest an
inherited genetic component. That could be a family pattern of cancer, or a close relative with
a known gene mutation. It could also be someone diagnosed with cancer at an early age or with multiple cancer types.
Experts also recommend genetic testing for all women diagnosed with
ovarian cancer, primary peritoneal cancer, or fallopian tube cancer, and for people who are diagnosed with rare tumors.
The reality is that more people should be tested than actually are, said Syngal.
"There's much more awareness now, but probably less than half of the people who should undergo testing are getting referred by their physicians," she said.
"Fear plays a role, and possibly misunderstanding of the implications," said
Huma Q. Rana, MD, a geneticist and clinical director of the Center for Cancer Genetics and Prevention.
"People should not be afraid to discuss genetic testing with their doctors," said
Judy Garber, MD, MPH, a medical oncologist and the longtime director of the center. "If their doctors have questions, we are here to help patients and their doctors figure it out."
In recent years, researchers have made significant strides in understanding cancer-related genetics. All cancers — including the hereditary forms — have accumulated mutations in their DNA that are responsible for their abnormal behaviors.
However, five to 10 percent of all cancers are now attributed to inherited gene mutations. When these are identified, patients can use the information to guide screening and preventive behaviors that can help them to avoid the cancers that have occurred
in their family members.
Researchers fully expect to discover more gene mutations that increase the risk of various cancers. Currently, about 200 of those are recognized — including the two most commonly known,
"The field of genetics is changing very rapidly; there are almost daily advances," said Garber.
Established in 1990, at what Garber noted was the "very beginning of hereditary cancer genetics," the Center for Cancer Genetics and Prevention offers genetic testing and counseling for all of the syndromes known to be related to cancer risk. The center
is staffed by medical oncologists, gastroenterologists, surgeons, genetic counselors, nurses, psychologists, a medical geneticist, and researchers.
"Other genetics centers have a 'diagnose and discharge' model," explained Rana. "Our center is unique because we continue to follow patients and their family members with these syndromes."
To assess genetic risk, it's important for people to understand and document their
family health histories. "Patients really need to be proactive," said Syngal,
who recommends appointing a family record keeper. "Families need to talk about their cancers and the particulars of their cancers as well as premalignant conditions." There are many types of premalignant conditions; examples include adenomatous polyps
(colon), thyroid nodules, and sebaceous adenomas (skin).
The age at which people should be tested varies, said Rana. "In the case of a hereditary cancer syndrome that carries pediatric risk, we would recommend testing children." For breast syndromes and other syndromes that don't carry pediatric risk, testing
typically starts at age 25, although testing for certain colon syndromes could start at 18.
Discovering you harbor an inherited mutation can carry an emotional burden, along with additional medical appointments and oversight, more frequent screenings, possible medications and prophylactic surgery, uncomfortable family discussions, and even potential
challenges with life and disability insurance.
It's important, said Syngal, for patients to have guidance through this process. Before testing is done, genetic counselors meet with patients to discuss family histories as well as the risks and benefits of testing. They point out, for example, that
patients might want to secure life and/or disability insurance before testing, since – unlike health insurance – there is no protection for people with pre-existing conditions or genetic risk. They discuss whether genetic testing makes sense, and
outline the medical implications of a positive result.
Costs for genetic testing range considerably. For patients who are the first in their families to be tested, the average cost ranges from $1,500 to $3,500. If the testing is narrowed because a family genetic mutation has already been identified, the cost
averages $300 to $400. Many private insurance plans will cover the cost, but Medicare will cover costs for genetic testing only if the patient has already been diagnosed with cancer.
The test itself is swift and easy: a quick blood draw. (For people averse to needles, there's also a saliva-swab option.) Results are delivered in about a month.
If a patient is found to have an inherited mutation that increases cancer risk, physicians will develop a long-term management plan. Sharon Goyette's plan, for example, includes annual colonoscopies and dermatological exams as well as biennial upper endoscopies
and uterine ultrasounds. At age 40, she will consider a prophylactic hysterectomy.
Genetic testing results often have a ripple effect, spurring family interaction that can be both unifying and anxiety-producing.
"The minute there's a mutation identified in the family, we go through the family tree and identify anybody else who's at risk," explained Syngal. Often the patient will speak directly with those family members, but to allay any discomfort, the center
can provide a letter with testing and screening recommendations that the patient can present to family members.
"We help people share the information," said Garber. "It's hard for people to make phone calls and say, 'I know we haven't talked in 30 years, but I must tell you we have a BRCA mutation in the family.' Sometimes patients ask us to talk with
relatives directly to help educate them about the issues."
As someone with an inherited mutation, Goyette understands complicated family perspectives. "It's tricky," she said. "If you're related to someone with this diagnosis, it can be very sensitive to talk about it."
But she has never regretted her decision to be tested. "I'm glad I have this information and know how to be proactive," she said. "It's very empowering to know what you can do to keep yourself healthier."
Paths of Progress Spring/Summer 2015 Table of Contents