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GENETIC TESTINGVolume 2, Number 4, 1998Mary Ann Liebert, Inc.

Genetic Testing for Breast-Ovarian Cancer Susceptibility:A Regional Trial

STARLENE LOADER,1 JEFFREY C. LEVENKRON,2 and PETER T. ROWLEY1

ABSTRACT

To evaluate receptivity to testing for a genetic susceptibility to breast-ovarian cancer, information is neededon the response when the offer is open to all qualifying women in a given region. To qualify in this trial, awoman who had not had breast or ovarian cancer had to have at least two first-degree relatives or one first-and one second-degree relative with breast and/or ovarian cancer, whereas a woman who had had breast orovarian cancer had to have at least one first-degree relative with breast or ovarian cancer and a first- or sec-

ond-degree relative without cancer willing to be tested. Of 140 women qualifying and interested enough to re-turn questionnaires requesting baseline information, 111 were referred by their physician and 29 were iden-tified from a regional tumor registry. Of these 140, 112 came for pretest education and 98 of these chose tobe tested. Thus, the acceptance rate was 70% for all those returning baseline questionnaires, but 88% forthose interested enough to come for pretest education. The most common reasons for accepting testing wereto take extra precautions if a mutation were found (42.9%) and to determine if offspring were at risk (24.5%).The most common reasons for declining were anxiety and absence of specific interventions. Factors predict-ing who chose testing were years of education (p < 0.005) and family closeness (p < 0.02). Fourteen deleteri-ous BRCA1 or BRCA2 mutations were found in 13 of the 87 families actually tested. If the criteria for test-ing had been three or more affected family members rather than two or more, the number of families testedwould have been reduced by 46%, but the number of families found to have a deleterious mutation wouldhave been reduced by only 9%.

INTRODUCTION

The isolation of the breast-ovarian cancer susceptibil-ity genes BRCA1 (Miki et al., 1994) and BRCA2 (Wooster

et al, 1995) and the characterization of mutations in these genesin affected families have made it possible to identify women athigh risk for these types of cancers. Widespread public concern

about these types of cancers, especially about breast cancer,means that large numbers of women may seek testing from theirphysicians even though the impact of such testing has yet to befully evaluated.

For BRCA1, located on chromosome 17q21 (Hall et al.,1990), over 500 different mutations have been reported (BreastCancer Information Core Steering Committee, 1998). Reportsbased on families with large numbers of affected individualssuggest that a woman with a BRCA1 mutation has an 87%chance (confidence interval 72-95%) of developing breast can-

cer and a 44% chance (confidence interval 28-56%) of devel-oping ovarian cancer by age 70 (Ford et al., 1994). However,penetrance may be lower in families with fewer affected mem-

bers or in certain subpopulations (Easton, 1997), e.g., a reported56% risk of breast cancer and 16% risk of ovarian cancer byage 70 in persons of Ashkenazi Jewish descent (Struewing etal, 1997). BRCA2 is located on chromosome 13ql2-13(Wooster et al, 1994). Over 280 different BRCA2 mutationshave been reported (Breast Cancer Information Core SteeringCommittee, 1998). A BRCA2 mutation confers a high risk ofbreast cancer, similar to a BRCA1 mutation, but a lower riskof ovarian cancer than a BRCA1 mutation (Wooster et al,1995). About 2.5% of Ashkenazi Jews have a BRCA1 or

BRCA2 mutation (Easton, 1997). This increase is due chieflyto three specific mutations, two in BRCA1 (185delAG and5382insC) and one in BRCA2 (6174delT).

Interest in mutation detection is high among affected fami-

1 Department of Medicine, Division of Genetics, and the 2Department of Psychiatry, University of Rochester School of Medicine, Rochester,NY 14642.

305

306 LOADER ET AL.

lies (Lerman et al, 1994, 1995) and even in the general public(Andrykowski et al, 1997). Previously, we have assessed in-terest in testing for genetic susceptibility to breast and ovariancancer in Rochester among 498 women visiting their privateobstetrician-gynecologist for any reason and 484 women hav-ing routine mammography in a busy radiologie practice (Cha-liki et al, 1995). These women were unselected for a personalor family history of breast or ovarian cancer. Yet over 90% ineach group said they would want such testing, if free, and 56%provided their name, address, and telephone number for notifi-cation when testing became available.

The existing information about test receptivity is limited byreliance chiefly on members of single families or small num-

bers of families previously recruited for cancer genetic researchwho therefore may not be representative of at-risk families inthe general population (see Discussion). Our study was de-signed to provide more generalizable information and differsfrom previous studies in several ways. First, individuals offeredtesting were not part of families previously identified to havea mutation. Rather, genetic counseling and testing were opento everyone in the county who met the cancer family historycriteria. Second, most individuals coming to inquire about test-

ing first learned about it from their own physician, not from a

research team. Third, to be tested, an individual had to recruita relative willing to be tested. Fourth, all participants expectedto learn their results. Fifth, women who presented themselveswere asked to decide whether or not to be tested on the basisof whether, following detailed pretest education, they expectedthat benefits would outweigh burdens in their own case, andnot in order to help research.

PATIENTS AND METHODS

Population studiedTwo populations were studied. One consisted of patients re-

ferred by their physician because of a family history of breastcancer. Because most of these patients had not had breast can-

cer themselves, a second population, women with a family his-tory of breast cancer who had had breast cancer themselves,was obtained from our regional tumor registry.

To identify the first population, we informed area providersabout the clinical trial at a regular conference of the obstetrics-gynecology staff of each of the five hospitals having such a ser-

vice in Monroe County (containing Rochester). Physicianknowledge and attitudes about testing for a genetic suscepti-bility to breast and ovarian cancer as assessed on those occa-

sions have been previously reported (Rowley and Loader,1996). All other physicians in the county were invited to par-ticipate via an article in the county medical society newsletter.To be eligible for testing, a woman who had not had breast or

ovarian cancer, an "at-risk" woman, had to have at least tworelatives with breast or ovarian cancer on the same side of herfamily; one of these had to be a first-degree and the other a

first- or second-degree relative, one of whom had to be living.The second population was drawn from all women diagnosed

in 1994 with breast cancer at or below age 50 in Monroe County(n = 213) using the Rochester Regional Tumor Registry. Physi-cians of record reported that six had died and did not give us

permission to contact 37 others. We wrote to the remaining 170

women to inform them of the offer of genetic testing and to in-vite them to contact us if they had a qualifying family history.To qualify, we required a first-degree relative with breast or

ovarian cancer and an at risk first or second-degree relative so

that these families would be similar to the two-affected-mem-ber families ascertained through physician referral.

Pretest educationWhen a woman from an affected family telephoned us to in-

quire about testing, it was determined whether her family metthe criteria stated above. If it did, the woman was sent a set ofquestionnaires, including a cancer family history questionnaire,the Breast Cancer Worry Scale (Lerman et al, 1994), the MillerBehavioral Style Scale (Miller, 1987), the Brief Cope (Carveretal, 1989), the Beck Depression Inventory (Beck et al, 1979),the Life Orientation Test (Scheier et al, 1994), and the Rand36-Item Health Survey 1.0 (SF-36) (Hays etal, 1993). The pur-pose of the Beck Depression Inventory was to exclude from of-fering DNA testing any seriously depressed person, but none

were detected. Also included was a questionnaire assessingbreast cancer knowledge, attitudes, and surveillance practices.The attitude questions included perceptions about seriousness,susceptibility, curability, and surveillance effectiveness andwere similar in design to those used in previous genetic screen-

ing studies of ours (Rowley et al, 1991), and involved ratingusing a Likert scale. As soon as the completed questionnaireswere returned and reviewed, an appointment was made.

At the first visit, a detailed family history of all types of can-

cer was obtained to detect any variant cancer syndrome (e.g.,Li-Fraumeni); none were detected. The patient was given an

explanation of genetic susceptibility for breast and ovarian can-

cer and of the significance of mutation detection. Both poten-tial benefits and potential risks and limitations of testing (listedin the Discussion) were enumerated so that she could make a

decision for herself; in other words, we merely offered testing,rather than recommending it. It was explained that a negativeresult in an at-risk person had limited value unless an affectedrelative had been shown to have a mutation, because the mu-

tation responsible for multiple cases in the family might be one

not detected by current methods or might be in a gene not an-

alyzed. For this reason an affected family member had to beshown to have a mutation before an at-risk member was tested.The first visit usually required about 90 min.

The patient was not asked to make a decision about testingon this first visit, but rather was given an explanatory brochureand a detailed consent/decline form to take home. She was toldthat, if she decided to be tested, she should return with the ap-propriate relative. The appropriate relative for an at-risk woman

was a relative who had had breast or ovarian cancer. If the in-dex patient had had breast or ovarian cancer, we requested thatshe return with a relative who had not had cancer, not becauseit was medically necessary, but because we wished to compareat-risk women who learned about testing from their physicianwith at-risk women who learned about testing from a relativewith breast or ovarian cancer.

BRCA1 and BRCA2 testingWhen the index patient returned with the appropriate rela-

tive, any additional questions were answered, informed consentdocumented, and blood drawn on both persons. Mutation de-

BREAST-OVARIAN CANCER SUSCEPTIBILITY TESTING 307

tection for the affected patients was performed by Myriad Ge-netic Laboratories, Inc. (Salt Lake City, UT) by sequencing theentire coding region of BRCA1 and adjacent intronic regionsas previously described (Shattuck-Eidens et al., 1997). Samplesfrom most patients were analyzed independently by OncorMed(Gaithersburg, MD) employing initial screening by antisenseoligonucleotide hybridization for common mutations and byprotein truncation assays for mutations in exon 11 ; these were

followed by sequence analysis only if an abnormality was de-tected by one of the two screening tests.

Before results from all the BRCA1 tests had been reported,Myriad Genetics permitted us to offer BRCA2 testing to a

member of the 26 families who had submitted samples most re-

cently, and whose affected member had tested negative for a

BRCA1 mutation. Of these 26 offers, 21 families accepted. Oneindividual each from three other families, who tested negativefor a BRCA1 mutation but were not offered free BRCA2 test-

ing, paid for such testing. Thus, of 87 families tested for a

BRCA1 mutation, some member of 24 families was also testedfor a BRCA2 mutation. Myriad used the same method to de-tect BRCA2 mutations as for BRCA1 mutations.

Communication of resultsBefore blood was drawn, it was explained that results were com-

municated only in person to the index patient and relative together,thus necessitating a third visit. For women found to have a muta-tion, the recommendations for management made by the CancerStudies Consortium (Burke et al, 1997) were communicated.

Human subjectsThis project was approved by the Research Subjects Review

Board of the University of Rochester. No charge was made forpretest education, DNA testing, or post-test counseling.

RESULTS

Characteristics of index patientsAmong the women who contacted us to inquire about test-

ing, 140 women ("index patients") met the family history cri-teria and returned questionnaires providing baseline informa-tion. Of these 140 women, 41 women had a personal history ofbreast or ovarian cancer ("affected") and 99 had not ("at risk").These 41 women with a personal history of breast or ovariancancer included 29 patients identified from the Tumor Registry.Of the 140, 111 had families with breast cancer without ovar-

ian cancer and 29 had a family history of both breast and ovar-

ian cancer. The number of persons with breast or ovarian can-

cer per family ranged from two to eleven, but most families(89%) had only two to four such persons. The mean age was

44.3 years. The mean number of years of education was 14.9.The proportion married was 74.3%. The proportion employedwas 61.4%. Racial composition was three African-Americans,one Hispanic, and 136 non-Hispanic Caucasians. Nine persons(6.4%) were of Ashkenazi Jewish descent.

Decision about testingOf these 140 index patients qualifying for testing, 112 came

for the first visit to receive pretest education, but 28 did not.

After these 112 index patients had received pretest education,98 chose testing and 14 chose no testing. The acceptance ratewas thus 70% (98/140) for the whole group qualifying for test-ing, but 88% (98/112) for those interested enough to come forpretest education.

The most common reasons given for choosing testing were

to take extra precautions if a mutation were found (42.9%) andto determine if their offspring were at risk (24.5%). Reasonsfor testing less commonly given were to obtain reassurance or

to comply with the recommendation of physician or a relative.To those 28 who had qualified for testing, but had never re-

turned the set of questionnaires mailed to them, we sent a sec-

ond set including a question about their reason for decliningtesting and offered a small payment for completion. Of the 42who did not desire testing (including both the 28 who did notcome for pretest education and 14 who chose no testing aftereducation), 17 provided a reason. Seven were concerned abouttheir emotional reaction to a positive result, five would not

change their surveillance even if their result were positive, threefound that the intended relative was unwilling or had died inthe interim, and two were worried about the effect of a posi-tive result on their insurability.

Comparison of index subjects accepting or

declining testingThe 98 "acceptors" and the 42 "decliners" (see Fig. 1) among

the index patients are compared in Table 1. The two groupswere significantly different in two characteristics. First, themean number of years of education was greater for acceptors(15.3 years) than for decliners (14.0 years, p < 0.005). Second,acceptors rated their families as closer than did decliners (p <

0.02). (Family closeness was assessed by the question, "Howclose is your relationship with your family?", using a scale withfour choices ranging from 1 = not at all close to 4 = veryclose.) There were no significant differences in age, race, mar-

ital status, number of children, perceived seriousness of breastcancer, perceived susceptibility to breast cancer, adherence tobreast cancer surveillance, family history of ovarian cancer as

well as breast cancer, affected versus at-risk status, breast can-

cer worry, depression, optimism, or self-perceived generalhealth, energy, emotional well-being, or social functioning.

Results desired by individuals when testedAfter the program had started, we began asking participants

at the time blood was drawn, "What do you hope will be theoutcome of your testing?" Of 65 at-risk patients, 27 said theyhoped that their affected relative would be shown to have a mu-

tation and that they had not inherited it, 27 said that they hopedthat their affected relative was not found to have a mutationand understood that this result would mean that they would notbe tested, and only three said that they hoped that both they andtheir relative would be shown to have a mutation. In addition,four wanted a negative test result on both themselves and theiraffected relative (although such a result was not a possible out-come according to our protocol), three simply replied that theywanted to help research, and one said she was resigned to anyresult.

Of the affected patients responding, 27 said that they hopedthat they would be shown to have a mutation and that their at-risk relative had not inherited it, but 32 hoped not to be shown

308 LOADER ET AL.

41

personal historyand family history

ofbreast or ovarian cancer

("affected")

99

family historybut no personal history

ofbreast or ovarian cancer

("at risk")

Table 1. Comparison of Index Patients Accepting orDeclining the Offer of DNA Testing

-1-140

index patientsfrom familieswith 2 or more

breast or ovariancancers

_I_,

112

received

pretest education

28

declined

pretest education

98 14

scheduled phlebotomy did not continue

98

ACCEPTORS42

DECLINERS

87

tested_I_

not tested*

61 at-riskindex patients

I61 affected

relatives

26 affected

index patientsI

26 at-risk

relatives

FIG. 1. Choices of 140 index women offered BRCA1 testingon basis of positive family history. *Eleven women who hadaccepted testing were not tested because, partway through thestudy, Myriad changed the criteria for free testing by creditingbreast cancer only if diagnosed before age 50.

to have a mutation, and only one hoped that a mutation wouldbe detected in both herself and her at-risk relative. In addition,two wanted a negative result on both themselves and their at-risk relative, one was conflicted about the desired result, one

was confused about the implication of having a mutation, andone merely wanted to help research.

Sequence alterations detectedOf the 98 choosing testing, 11 were later disqualified by Myr-

iad who imposed the additional requirement (after the patienthad chosen testing) that a family member with breast cancer becounted only if the diagnosis had been made before the age of50. Of the 87 families tested for BRCA1 mutations and the 24of these tested for BRCA2 mutations, 20 families (23%) were

found to have sequence alterations. These 20 families had 27alterations. Table 2 classifies these alterations as either delete-rious mutations or alterations of uncertain significance, as re-

VariableAcceptors(n = 98)

Decliners(n = 42)

Years of education"Family closenessbAgeCaucasian, non-HispanicMarriedNumber of childrenPerceived seriousness

of breast cancerPerceived susceptibility

to breast cancerAdherence to breast cancer

surveillanceType of family

Breast, no ovarian cancerBreast and ovarian cancer

Personal cancer statusAffectedAt risk

Breast cancer worry

15.33.65

44.699%78%2.3

7.42

12.57

5.73

7721

28707.73

14.03.21

43.798%79%2.0

7.00

12.30

5.61

348

1230

8.17

Tests of significance used were chi-square or r-tests.ap < 0.005.bp < 0.02.

ported by Myriad Genetics. Frameshift and nonsense mutationsare classified as deleterious because no full-length protein isproduced. Most missense mutations are classified as of uncer-

tain significance because the amino acid replacement in thegene product may or may not have a deleterious effect, de-pending on its location in the protein and on the nature of thesubstitution.

Twelve families were found to have one deleterious muta-tion and one family was found to have two deleterious muta-tions. Of these 14 mutations, 10 involved BRCA1 and four in-volved BRCA2. An individual in one family (no. 123247), an

unaffected 34-year-old woman whose mother had ovarian can-

cer, was found to have a deleterious mutation in both BRCA1(E1694X) and BRCA2 (6633del5) (Loader and Rowley, 1998).In addition, 10 families had alterations reported as of uncertainsignificance, five in BRCA1 and five in BRCA2. A woman

from one family (no. 170244), who had been diagnosed withbreast cancer at age 49, was found to have four different BRCA2mutations of unknown significance.

The presence of ovarian cancer in a first- or second-degreerelative significantly increased the likelihood of finding a dele-terious mutation. In the 65 families with breast but not ovariancancer, six (or 9.4%) had a deleterious mutation. However, inthe 22 families with both breast and ovarian cancer, seven (or31.8%) had a deleterious mutation, a significantly higher pro-portion (p < 0.02, Fisher's exact test).

In the 87 families with two or more members with breast or

ovarian cancer, 13 (or 14.9%) had a deleterious mutation. How-ever, in the 47 families with three or more members with breastor ovarian cancer, 12 (or 25.5%) had a deleterious mutation.

When notified that their results were available, most testedpersons returned to learn their results. However a few subjects


Table 2. BRCA Mutations Among 87 Families with Two or More Breast and/or Ovarian Cancers

Familynumber

Familyhistory

Number ofbreast and

ovariancancers

Averageage at

diagnosis

Testée 'sage at

diagnosis Exon Mutation

Othermalignancies

in familyBRCA1 deleterious

206232 Breast/ovarianBreast/ovarianBreastBreast

174233

110134172137

103268a

213239

123247b

106239e

Breast/ovarianBreast/ovarianBreast/ovarianBreast

212147 Breast134232 Breast/

ovarianBRCA1 uncertain significance

103268a

124123189234

176133202137

Breast/ovarianBreastBreast/ovarianBreastBreast

BRCA2 deleterious199249 Breast/

ovarian142132 Breast

2B, lO

6B, 40

3B3B

3B, 30

2B, 20

4B, 20

2B

4B3B, lO

3B, 30

4BIB, 20

2B3B

2B, lO, 1BO

200133123247b

BreastOvarian

3B

3B10

BRCA2 uncertain significance146124204233

170244

123247b

106239e

BreastBreast/ovarianBreast/ovarianBreast/ovarianBreast

3B2B, 1BO

3B, lO

4B, 20

2B

43

51

3737

47

41

47

36

5046

47

7047

5151

39

41

5348

4955

37

47

36

49 B

58 B

44B48B

37, 53 B

29 B

49, 60 O

31 B

33, 39 B29 B

37, 53 B

62 B39 B

59 B46 B

33 B 35 O

35 B

38, 44 B34 unaffected

42 unaffected46 B

47 B

49, 60 O

33 unaffected

2 187delAG(185delAG)

7 525insA

11 Q563X11 2080delA

(2073delA)16 Y1563X

18 E1694X

18 E1694X

20 5382insC(5385insC)

24 R1835XIVS 8+2 T-h>A

IVS 7-3delT

11 R841W11 R1347G

11 P1238L16 M1652I

10 204 linsA

10 R2034C

11 R3128X11 6633del5

(6635del5)

4 P655R11 A2717S

11 K2339N, H2440R,A2466V, V3244I

11 S1172L

11 I3412V

LymphomaCervix, tongue

ProstateMyelomaBladder

LungColon, prostate

Colon, uterus,leukemia

Stomach, lungPancreas, colon,

leukemia

Bladder

BladderBrain, pharynx

Uterus, brain

Leukemia

Uterus, cervix,melanoma

ColonLymphoma,

pancreas,prostate

MelanomaLymphoma, brain

Colon, prostate

Colon, uterus

B, Unilateral or bilateral breast cancer;"Same person.'This family number has two different

tion and a BRCA2 mutation of uncertaincSame family.

O, ovarian cancer; BO, breast and ovarian cancer.

family histories listed because one member has inherited a BRCA1 deleterious muta-significance from her mother and a BRCA2 deleterious mutation from her father.

apparently changed their mind. Both tested members of two DISCUSSIONfamilies declined to receive them; one family cited the fear ofinsurance discrimination and the other did not give a reason. In Potentiai consequences of mutation detectiona third family, although the at-risk index patient came, the af-fected relative did not come because of anxiety about the re- Mutation detection may confer both benefits and burdens,suit. Potential benefits include the opportunity to protect oneself, ei-

310 LOADER ET AL.

ther by adopting preventive measures (e.g., prophylacticsurgery) or by enhancing surveillance, and to alert relatives totheir risk (Kaback et al, in press). However, potential burdensinclude anxiety, depression, a compromised self-image, frus-tration with the limited effectiveness of available prophylacticmeasures, the risks and costs of additional surveillance or pro-phylaxis, guilt about possible transmission to children, stigma-tization, and discrimination by insurers or employers (Kabacket al, in press). Clearly, before undergoing testing, the indi-vidual patient contemplating mutation detection needs to be in-formed of its potential burdens, as well as of its potential ben-efits.

Because of the paucity of information on the impact of test-

ing, many organizations have urged caution in offering testingand called for more research, including the National AdvisoryCouncil for Human Genome Research (National AdvisoryCouncil or Human Genome Research, 1994), the American So-ciety of Human Genetics (American Society of Human Genet-ics, 1994), the American Society of Clinical Oncology (Amer-ican Society of Clinical Oncology, 1996), the Committee on

Genetics of the American College of Obstetricians and Gyne-cologists (American College of Obstetrics and Gynecology,1996), and the Advisory Committee of the National Institutesof Health Office of Research on Women's Health (Pinn andJackson, 1996).

Experience of othersIs such genetic susceptibility testing beneficial or harmful?

Although there are many reports of anticipated responses to thehypothetical offer of testing, there are few published accountsof patient receptivity or test result impact when testing is actu-

ally offered (Lynch et al, 1993; Dudok et al, 1994; Watson etal, 1995; Lerman et al, 1996; Croyle et al, 1997; Lerman etal, 1997a; Lynch et al, 1997). Several reports are based on

one or two families. Lynch et al (1993) offered test results toaffected and at-risk members of a single, large breast-ovariancancer family previously shown to be BRCA1-linked. Of 176eligible individuals, only 32% requested their result. Womenwho were told they were carriers expressed an increased moti-vation for surveillance and prophylactic surgery, whereas mostwomen who were told they were not carriers indicated that theywould not proceed with prophylactic surgery, but would con-

tinue careful surveillance. Dudok de Wit et al. (1994) offeredgenotyping to 10 members of a BRCA1-linked family. Onlyseven were tested. Deterioration of the index patient promptedincreased anxiety and a greater interest in prophylactic surgeryamong identified carriers. Watson et al. (1995) offered geno-typing to 32 unaffected members of two breast-ovarian cancer

families. Only 13 accepted. Croyle et al. (1997) offered testingto members of a single, large family already known to have a

BRCA1 mutation. Of 213 women responding to a written in-vitation, 28% had been tested at last report. Upon receiving theirresults, women found to be carriers experienced more generalanxiety and more test-related distress than women found to benoncarriers. Women who had not had cancer were more dis-tressed by learning of their carrier status than were those whohad already had cancer.

Lerman et al. (1996) offered test results to affected and at-risk members of 13 breast cancer families who were selected

for study because a BRCA1 mutation had been previously iden-tified in the family. As in the Lynch study, family members hadalready provided blood samples for testing, but had made no

commitment to receive the results. When later offered the re-

sults, only 43% requested them. Requests for results were more

frequent from persons having health insurance, with more first-degree relatives affected with breast cancer, and with more

knowledge of BRCA1 testing. Subsequently, Lerman et al.(1997a) reported that, in a study of 11 families known to havea BRCA1 mutation, requests for results were more frequentfrom women than from men and from individuals with a higherobjective risk. More recently, Lynch et al. found that in 14 fam-ilies 80% of those testing negative reported emotional relief,whereas over one-third of those testing positive reported sad-ness, anger, or guilt.

Richards et al (1997) found that, when the availability of185delAG testing was publicized by Jewish organizations, thoseattending group education sessions tended to be those with a

personal or family history of breast or ovarian cancer. The ma-

jor reasons for requesting testing included concern for their own

risk or their children's risk and a desire to learn about surveil-lance options. The most common reason given for decliningwas concern about discrimination by health insurers.

Who decides to be tested?

The mean age of women who contacted us to inquire abouttesting was 44.3 years. This is older than is optimal for gain-ing maximal benefit from mutation detection. For example, a

woman who would choose prophylactic mastectomy andoophorectomy if a deleterious mutation were detected may for-feit a significant fraction of her expected gain of life years iftesting is delayed from 30 to 44.3 years of age, viz. 37-44% ofthe gain depending on her a priori risk, as calculated from datarecently reported by Schräg et al. (1997).

The majority of women who came for pretest education de-cided to be tested notwithstanding our explanation orally andin writing of the various risks and limitations of testing. Thisfinding confirms the high interest in mutation detection amongwomen with a family history of breast-ovarian cancer noted byothers (Lerman et al, 1995; Struewing et al, 1995), even whenthe candidates for testing are documented to have understoodthe risks and limitations of testing (Lerman et al, 1997b).

The most frequent reason for choosing testing was to takeextra precautions if the result were positive. However, most ofthose inquiring about testing were already having an annualmammogram and an annual physician examination, althoughmany did not perform regular self-examinations. Additionalpreventive measures for breast cancer have been limited, e.g.,prophylactic surgery and avoidance of estrogens. However, re-

cent reports that certain drugs can prevent breast cancer mayprompt more women to request testing. The second most com-

mon reason was to determine if children were at risk, a reason

found in other studies (Lerman et al, 1996; Richards et al,1997). We explained before testing that we did not offer test-ing to those under 18, but many had older children.

Nevertheless some declined testing. Some cited a fear abouttheir own emotional reaction to a positive result, suggestingthat, although they knew their risk was high, the finding of a

mutation might confer an unwelcome (and unwarranted) sense


of inevitability. Although the risk of discrimination was ex-

plained in detail to those who came for pretest education, a fearof discrimination, prominent in other trials (Lerman et al., 1996;Richards et al, 1997) was not prominent among the reasons

given for declining testing in this trial.Acceptors differed from decliners in rating their family as

closer (Table 1). This finding has not been reported previously.To be tested, a woman had to recruit a family member willingto be tested. This recruitment involved raising a potentiallythreatening topic with the relative and persuading her to riskreceiving unwelcome news. A person at risk for family cancer

syndromes not involving breast cancer is likely to be asked torecruit an affected relative to be tested first. Therefore, familycloseness may be a factor in genetic testing for other cancer

syndromes also. Previous studies may not have been in a posi-tion to detect this predictor because many studies have dealtwith subjects previously recruited as families for linkage stud-ies and families that were not close may have declined to par-ticipate from the outset.

We confirmed that those desiring testing generally have more

education (Table 1 ), as reported by Lerman et al. (1994) althoughthe group as a whole was well-educated (a mean of 14.9 yearsof education). We did not find as many predictors of test accep-tance as some other studies. For example, although several stud-ies have found that acceptors perceive their risk of developingbreast cancer as higher than decliners (Lerman et al., 1994;Struewing et al., 1995), we did not find this to be true in our

study. A possible reason is the greater diversity of patients in thisstudy, intended to more closely resemble clinical practice.

Who should be offered BRCA1 or BRCA2 testing?The presence of ovarian cancer was confirmed to increase

the likelihood of a mutation. Among families without ovariancancer, only 15% had a deleterious mutation, whereas, amongfamilies with ovarian cancer, 58% had a deleterious mutation(p < 0.05).

When two or more affected relatives among first- and sec-

ond-degree relatives were required for the offer of testing, mu-

tations were found in 13 of 87 families. However, if three or

more affected relatives had been required among first- or sec-

ond-degree relatives, only 47 of these families would have qual-ified for testing, but 12 of these 13 mutations would still havebeen detected. In other words, raising the required number ofaffected first- and second-degree family members from two tothree would have reduced the number of families to be testedby 46%, but decreased the number of families found to have a

deleterious mutation by only 9%. However, if four or more af-fected persons had been required, only six of the 13 familieswe found to have deleterious mutations would have been de-tected (Fig. 2).

Eleven alterations of uncertain significance were also found.At the time these alterations were reported to the patient, therewas no information about whether or not they increased cancer

risk. Although the physician may be confident that this infor-mation will be available eventually, this fact is scant comfortto patients who find unsettling the discovery of an abnormalityof unknown significance and anxiously await more definitiveinformation. Thus, it is important that the possibility of such a

test result be communicated before testing.

87 No. of families that would qualify

for testing using different criteria

No. of families found'- to have a mutation

47

13 12 13

I>2 >3 >4

FIG. 2. Relationship between the number of breast and ovar-ian cancers in a family that might be required for testing andthe number of families that would have been found to have a

deleterious mutation in this study. For this purpose, the indexsubject is assumed unaffected. An affected first-degree relativeis required in each of the illustrated cases. Using two or morefirst- and second-degree affected relatives as the criterion foroffering testing, 13 families were detected to have mutationsamong 87 tested families. However, if three or more first- or

second-degree relatives had been required, 12 families wouldhave been detected to have mutations among 47 families qual-ifying from the same set of families. Thus, the more stringentcriterion would have reduced the number of families tested by46%, while reducing the number of families found to have a

mutation by only 9%. If four or more affected relatives hadbeen required, only six of the families detected to have a mu-

tation would have been identified.

Our study used a simple criterion for the offer of testing (i.e.,number of affected relatives). A more accurate estimate of thelikelihood of detecting a mutation can be obtained by consid-ering a large number of risk factors. Mathematical functions forestimating the likelihood of a BRCA1 or BRCA2 mutation havebeen proposed that take into account multiple factors affectingthe risk of having a mutation, including not only the number ofaffected relatives, but also age at diagnosis, bilaterality of breastcancer, occurrence of ovarian cancer, and Ashkenazi descent(Shattuck-Eidens et al., 1997; Frank et al., 1998). Perhaps as

important a consideration as the likelihood of detecting a mu-

tation is the practical significance of mutation detection. Con-sider two women with an identical a priori risk for having a

mutation based on the above risk factors. One is an elderlywoman who has no living relative, while the other is a youngwoman who has a large number of female relatives. With lim-ited resources, the latter woman may deserve a higher priorityfor testing.

312 LOADER ET AL.

Study limitations

This study attempted to assess the characteristics of candi-dates for testing in the setting resembling clinical service ratherthan research. However, certain limitations of the study in thisregard are here acknowledged. First, we do not know how manywomen who qualified for testing by family history were notidentified by their physician, were identified but not referred,or were referred but did not contact us. These uncertainties con-

cerning physician-referred patients was one of our reasons foralso utilizing the tumor registry. In choosing to study patientsreferred by their own physicians, we incurred the liability ofhaving no denominator to use to calculate an acceptance rate,except for those who came for pretest education. Second, we

took the initiative of contacting some patients who had alreadyhad breast cancer because commercial laboratories are market-ing testing to oncologists and thus affected women are the in-dex patients in some families being tested on a service basiselsewhere. Our contacting and informing patients who have hadbreast cancer, although done with permission of the patient'sphysician, may have evoked a different response than a spon-taneous offer by the woman's own physician. Third, we re-

quired that the first person in a family whose sample was ana-

lyzed be an affected person. However this is not a requirementof all laboratories offering testing and, to this extent, our sam-

ple may not be representative of candidates for testing wherethis requirement is not made. Fourth, since our sample size was

small, some factors analyzed and found not to predict test ac-

ceptance should be reassessed when a larger sample of similarsubjects is available. Fifth, we required completion of ques-tionnaires that would not be required in a service setting andthat may have discouraged some patients who would have oth-erwise participated. Finally, we offered testing and counselingservices free of charge because our intent was to evaluate whatinformation women want. For the present, the cost of testing islikely to limit testing severely, whether the payer is the patientor a third party. However, recent advances in technology are

likely to greatly reduce the cost of testing in the future.We are following these patients found to have a deleterious

mutation or an alteration of uncertain significance and will laterreport on their understanding of their result, attitudes, and be-havior, including whether or not they told others their result,changed their surveillance, or chose prophylactic surgery.

ACKNOWLEDGMENTS

We wish to thank participating families and providers, andespecially Myriad Genetics and OncorMed, for generously pro-viding mutation detection for this study without charge.

REFERENCES

AMERICAN COLLEGE OF OBSTETRICS AND GYNECOLOGY(1996). Breast-ovarian cancer screening. Committee opinion no. 176.Washington, D.C.

AMERICAN SOCIETY OF CLINICAL ONCOLOGY (1996). State-ment on genetic testing for cancer susceptibility. J. Clin. Oncol. 14,1730-1736.

AMERICAN SOCIETY OF HUMAN GENETICS (1994). Statement

on genetic testing for breast and ovarian cancer predisposition. Am.J. Hum. Genet. 55, i-iv.

ANDRYKOWSKI, M.A., LIGHTNER, R., STUDTS, J.L., MUNN,R.K. (1997). Hereditary cancer risk notification and testing: how in-terested is the general population? J. Clin. Oncol. 15, 2139-2148.

BECK, AT., RUSH, A.J., SHAW, B.F., EMERY, G. (1979). Cogni-tive Therapy of Depression. (Guildford, New York).

BREAST CANCER INFORMATION CORE STEERING COMMIT-TEE (1998). The breast cancer information core: An online database.Available from URL: Http://www.nhgri.nih.gov/Intramural_re-search/Lab_transfer/Bic/.

BURKE, W., DALY, M„ GARBER, J., BOTKIN, J., KAHN, M.J.,LYNCH, P., McTIERNAN, A., OFFIT, K, PERLMAN, J., PE-TERSEN, G, THOMSON, E., and VARRICCHIO, C. (1997). Rec-ommendations for follow-up care of individuals with an inheritedpredisposition to cancer. II. BRCA1 and BRCA2. J. Am. Med. Assn.277, 997-1003.

CARVER, C.S., SCHEIER, M.F., and WEINTRAUB, J.K. (1989). As-sessing coping strategies: a theoretically based approach. J. Personal.Soc. Psychol. 56, 267-283.

CHALIKI, H., LOADER, S., LEVENKRON, J.C., LOGAN-YOUNG,W., HALL, W.J., and ROWLEY, P.T. (1995). Women's receptivityto testing for a genetic susceptibility to breast cancer. Am. J. Publ.Health 85, 1133-1135.

CROYLE, R.T., SMITH, K.R., BOTKIN, J.R., BATY, B., and NASH,J. (1997). Psychological responses to BRCA1 mutation testing: pre-liminary findings. Health Psychol. 16, 63-72.

DUDOK DE WIT, A.C., MEIJERS-HEIJBOER, E.J., TD3BEN, A.,FRETS, P.G., KLIJN, J.G., DEVILEE, P., and NIERMEIJER, M.F.( 1994). Effect on a Dutch family of predictive DNA-testing for hered-itary breast and ovarian cancer. Lancet 344, 197.

EASTON, D. (1997). Breast cancer genes—what are the real risks? Na-ture Genet. 16,210-211.

FORD, D., EASTON, D.F., BISHOP, D.T., NAROD, S.A.,GOLDGAR, D.E., and THE BREAST CANCER LINKAGE CON-SORTIUM (1994). Risks of cancer in BRCA1 mutation carriers.Lancet 343, 692-695.

FRANK, T.S., MANLEY, S.A., OLOPADE, O.I., CUMMINGS, S.,GARBER, J.E., BERNHARDT, B., ANTMAN, K, RUSSO, D.,WOOD, M.E., MULLINEAU, L., ISAACS, C, PESHKIN, B.,BUYS, S., VENNE, V., ROWLEY, P.T., LOADER, S., OFFIT, K,HAMPEL, H., BRENER, D., WINER, E.P., CLARK, S., WEBER,B„ STRONG, L.C., RIEGER, P., McCLURE, M., WARD, B.E.,SHATTUCK-EIDENS, D., OLIPHANT, A., SKOLNICK, M.H., andTHOMAS, A. (1998). Sequence analysis of BRCA1 and BRCA2:Correlation of mutations with family history and ovarian cancer risk.J. Clin. Oncol. 16, 2417-2425.

HALL, J.M., LEE, M.K., NEWMAN, B., MORROW, J.E., ANDER-SON, L.A., HUEY, B., and KING, M.C. (1990). Linkage of early-onset familial breast cancer to chromosome 17q21. Science 250,1684-1689.

HAYS, R.D., SHERBOURNE, CD., and MAZEL, R.M. (1993). TheRand 36-Item Health Survey 1.0. Health Economics 2, 217-227.

KABACK, M.M., GREENDALE, K, FONSECA, L., ROWLEY, P.T.,ROSENTHAL, G, BARBASCH, A., EDGE, S.B., FARRELL, CD.,FINE, B.A., GOODMAN, T.L., OFFIT, K, ROSENBLATT, R., andRUNOWICZ, CD. (in press). Genetic susceptibility to breast andovarian cancer: counseling and testing guidelines. New York StateDepartment of Health.

LERMAN, C, DALY, M., MASNY, A., BALSHEM, A. (1994). Atti-tudes about genetic testing for breast-ovarian cancer susceptibility.J. Clin. Oncol. 12, 843-850.

LERMAN, C, SEAY, J., BALSHEM, A., and AUDRAIN, J. (1995).Interest in genetic testing among first-degree relatives of breast can-

cer patients. Am. J. Med. Genet. 57, 385-392.LERMAN, C, NAROD, S., SCHULMAN, K, HUGHES, C, GOMEZ-


CAMINERO, A., BONNEY, G„ GOLD, K., TROCK, B., MAIN,D., LYNCH, J., FULMORE, C, SNYDER, C, LEMON, S.J., CON-WAY, T., TONIN, P., LENOIR, G, and LYNCH, H. (1996). BRCA1testing in families with hereditary breast-ovarian cancer. A prospec-tive study of patient decision making and outcomes. J. Am. Med.Assn. 275, 1885-1892.

LERMAN, C, SCHWARTZ, M.D., LIN, T.H., HUGHES, C,NAROD, S„ and LYNCH, H.T. (1997a). The influence of psycho-logical distress on use of genetic testing for cancer risk. J. Consult.Clin. Psychol. 65, 414-420.

LERMAN, C, BIESECKER, B., BENKENDORF, J.L., KERNER, J.,GOMEZ-CAMINERO, A., HUGHES, C, and REED, M.M. (1997b).Controlled trial of pretest education approaches to enhance informeddecision-making for BRCA1 genetic testing. J. Nati. Cancer Inst. 89,148-157.

LOADER, S., and ROWLEY, P.T. (1998). Deleterious mutations of bothBRCA1 and BRCA2 in three siblings. Genet. Testing 2(1), 75-77.

LYNCH, H.T., WATSON, P., CONWAY, T.A., LYNCH, J.F.,SLOMINSKI-CASTER, S.M., NAROD, S.A., FEUNTEUN, J., andLENOIR, G. (1993). DNA screening for breast/ovarian cancer sus-

ceptibility based on linked markers. Arch. Intern. Med. 153,1979-1987.

LYNCH, H.T., LEMON, S.J., DURHAM, C, TINLEY, S.T., CON-NOLLY, C, LYNCH, J.F., SURDAM, J., ORINION, E., SLOMIN-SKI-CASTER, S., WATSON, P., LERMAN, C, TONIN, P.,LENOIR, G, SEROVA, O., and NAROD, S. (1997). A descriptivestudy of BRCA1 testing and reactions to disclosure of test results.Cancer 79, 2219-2228.

MIKI, Y., SWENSEN, J., SHATTUCK-EIDENS, D., FUTREAL, P.A.,HARSHMAN, K., TAVTIGIAN, S., LIU, Q., COCHRAN, C, BEN-NETT, L.M., DING, W., BELL, R., ROSENTHAL, J., HUSSEY,C, TRAN, T., McCLURE, M., FRYE, C, HATTfER, T., PHELPS,R., HAUGEN-STRANO, A., KATCHER, H, YAKUMO, K, GHO-LAMI, Z„ SHAFFER, D., STONE, S., BAYER, S., WRAY, C,BOGDEN, R., DAYANANTH, P., WARD, J., TONIN, P., NAROD,S., CANNON-ALBRIGHT, L., GOLDGAR, D., WISEMAN, R.,KAMB, A., and SKOLNICK, M.H. (1994). A strong candidate forthe breast and ovarian cancer susceptibility gene BRCA1. Science266, 66-71.

MILLER, S.M. (1987). Monitoring and blunting: Validation of a ques-tionnaire to assess styles of information seeking under threat. J. Per-sonal Soc. Psychol. 52, 345-353.

NATIONAL ADVISORY COUNCIL ON HUMAN GENOME RE-SEARCH. (1994). Statement on use of DNA testing for presympto-matic identification of cancer risk. J. Am. Med. Assn. 271, 785.

PINN, V.W., and JACKSON, D.M. (1996). ORWH update: Advisorycommittee to NIH office passes resolutions. J. Women's Health. 5,549-553.

RICHARDS, C.S., WARD, P.A., ROA, B.B., FRIEDMAN, L.C.,BOYD, A.A., KUENZLI, G., DUNN, J.K., and PLON, S.E. (1997).Screening for 185delAG in the Ashkenazim. Am. J. Hum. Genet. 60,1085-1098.

ROWLEY, P.T., and LOADER, S. (1996). Attitudes of obstetrician-gynecologists toward DNA testing for a genetic susceptibility to

breast cancer. Obstet. Gynecol. 88, 611-615.ROWLEY, P.T., LOADER, S., SUTERA, C.J., WALDEN, M., and

KOZYRA, A. (1991). Prenatal screening for hemoglobinopathies.III. Applicability of the health belief model. Am. J. Hum. Genet. 48,452-459.

SCHEIER, M.F., CARVER, C.S., and BRIDGES, M.W. (1994). Dis-tinguishing optimism from neuroticism (and trait anxiety, self-mas-tery, and self-esteem): A réévaluation of the life orientation test. J.Personal Soc. Psychol. 67, 1063-1078.

SCHRÄG, D., KUNTZ, K.M., GARBER, J.E., and WEEKS, J.C.(1997). Decision analysis—Effects of prophylactic mastectomy and

oophorectomy on life expectancy among women with BRCA1 or

BRCA2 mutations. New Engl. J. Med. 336, 1465-1471.SHATTUCK-EIDENS, D., OLIPHANT, A., McCLURE, M.,

McBRIDE, C, GUPTE, J., RUBANO, T., PRUSS, D., TAVTI-GIAN, S.V., STAEBELL, M., GUMPPER, K, LINGENFELTER,B., MANLEY, S., LUCE, M., WARD, B., CANNON-ALBRIGHT,L., OFFIT, K., FRANK, T., BUYS, S., GELEWSKI, T., NORTON,L., GIULOTTO, E., ZOLI, W., RAVAIOLI, A„ NEVANLINNA,H, THOMAS, A., ROWLEY, P., PILARSKI, R., LOADER, S., OS-BORNE, M.P., DALY, M., TEPLER, I., MICHAELSON, R.,SCOTT, R.J., RADICE, P., PDEROTTI, M., GARBER, J.E.,ISAACS, C, LIPPMAN, M.E., DOSIK, M.H., CALIGO, M.A.,GREENSTEIN, R.M., WEBER, B., BURGMEISTER, R.S., andSKOLNICK, M., (1997). Complete DNA sequence analysis ofBRCA1 in 798 women at high risk for susceptibility mutations. J.Am. Med. Assn. 278, 1242-1250.

STRUEWING, J.P., LERMAN, C, KASE, R.G., GIAMBARRESI,T.R., and TUCKER, M.A. (1995). Anticipated uptake and impact ofgenetic testing in hereditary breast and ovarian cancer families. Can-cer Epidem. Biomarkers Prev. 4, 169-173.

STRUEWING, J.P., HARTGE, P., WACHOLDER, S., BAKER, S.M.,BERLIN, M., McADAMS, M., TDMMERMAN, M.M., BRODY,L.C., and TUCKER, M.A. (1997). The risk of cancer associated withspecific mutations of BRCA1 and BRCA2 among Ashkenazi Jews.N. Engl. J. Med. 336, 1401-1408.

WATSON, M„ MURDAY, V., LLOYD, S., PONDER, B., AVERILL,D., and EELES, R. (1995). Genetic testing in breast/ovarian cancer

(BRCA1) families. Lancet 346, 583.WOOSTER, R., NEUHAUSEN, S.L., MANGION, J., QUIRK, Y.,

FORD, D., COLLINS, N, NGUYEN, K., SEAL, S., TRAN, T.,AVERILL, D„ FIELDS, P., MARSHALL, G, NAROD, S.,LENOIR, G.M., LYNCH, H, FEUNTEUN, J., DEVILEE, P., COR-NELISSE, C.J., MENKO, F.H., DALY, P.A., ORMISTON, W., Mc-MANUS, R., PYE, C, LEWIS, CM., CANNON-ALBRIGHT, L.A.,PETO, J., PONDER, B.A.J., SKOLNICK, M.H., EASTON, D.F.,GOLDGAR, D.E., and STRATTON, M.R. (1994). Localization of a

breast cancer susceptibility gene, BRCA2, to chromosome 13ql2—13.Science 265, 2088-2090.

WOOSTER, R., BIGNELL, G, LANCASTER, J., SWIFT, S., SEAL,S., MANGION, J., COLLINS, N, GREGORY, S., GUMBS, C,MICKLEM, G, BARFOOT, R, HAMOUDL, R„ PATEL, S., RICE,C, BIGGS, P., HASHIM, Y., SMITH, A., CONNOR, F., ARASON,A., GUDMUNDSSON, J., FICENEC, D., KELSELL, D., FORD,D., TONIN, P., BISHOP, D.T., SPURR, N.K., PONDER, B.A.J.,EELES, R., PETO, J., DEVILEE, P., CORNELISSE, C, LYNCH,H, NAROD, S., LENOIR, G, EGLISSON, V., BARKADOTTTR, R.B.,EASTON, D.F., BENTLEY, D.R., FUTREAL, P.A., ASHWORTH, A.,and STRATTON, M.R. (1995). Identification of the breast cancer

susceptibility gene BRCA2. Nature 378, 789-792.

Address reprint requests to:Dr. Peter T. Rowley

Division of Genetics, Box 641University of Rochester School of Medicine

601 Elmwood Avenue Room 5-6926Rochester, NY 14642

E-mail: peter_rowley@ URMC.Rochester.edu

Received for publication July 26, 1998; accepted November 9,1998.