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 OCA 4 0 gene pane l
(cross-cancer, http://web.labmed.washington.edu/tests/genetics/BROCA ATMBARD1 BRCA1 BRCA2 BRIP1 CDH1 CHEK2 MRE11A MUTYH NBN PALB2 PTEN RAD50 RAD51C STK11 TP53
A M BR Y Ge netic s Brea s tN e x t (16 gene s )
http://www.ambrygen.com/tests/breastnextM Y R IA D my R IS K Pa nel (25 genes )
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
CENT OG E NE BC /O C pa nel (16 gene s )
https://www.centogene.com/centogene25
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 ruSi ght ™ Canc e r (Illum ina )
http://res.illumina.com/documents/products%5Cdatasheets%5Cdatasheet_trusight_cancer.pdfPRF1 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
M ultipli c om Here ditar y Canc e r M A S TR P lus
http://www.multiplicom.com/products/brca-hereditary-cancer-mastr-plu26
Genetic Basis of Breast
Cancer
Tutt A, SABCS 2014
TNT: Carboplatin vs Docetaxel as 1 st 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)
