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Influence of germline test results on surgical decision making in women with invasive breast cancer

  • Ashlee B. Vargason
    Affiliations
    Breast Care Clinic, Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
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  • Clesson E. Turner
    Affiliations
    National Human Genome Research Institute, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA
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  • Craig D. Shriver
    Affiliations
    Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA

    Department of Surgery, Uniformed Services University of the Health Sciences, 8901 Rockville Pike, Bethesda, MD 20889, USA
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  • Rachel E. Ellsworth
    Correspondence
    Corresponding author at: 620 Seventh Street, Windber PA 15963.
    Affiliations
    Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA

    Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Dr., Bethesda, MD 20817, USA
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      Highlights

      • 17% and 20% of women had mutations and VUS in cancer predisposition genes.
      • Surgeries did not differ between women with VUS and benign findings.
      • 78% of women with mutations in moderate risk genes underwent prophylactic surgery.

      Abstract

      Background

      While therapeutic mastectomy with contralateral prophylactic mastectomy (TM+CPM) and/or bilateral salpingo-oophorectomy (BSO) are recommended for women with pathogenic variants (PV) in some cancer predisposition genes, evidence for the utility of these surgeries for women with PV in other genes currently is insufficient. In conjunction, current guidelines recommend that clinical management should not be influenced by a return of a variant of uncertain significance (VUS). Return of germline test results may, however, influence surgical decision making regardless of current guidelines. We thus evaluated surgical choices amongst a cohort of women with invasive breast cancer who underwent clinical genetic testing.

      Methods

      Germline test results and all surgical procedures were extracted for women who had unilateral invasive breast cancer and had clinical testing before definitive surgery (n = 591). Results were classified as pathogenic/likely pathogenic (PV, 17.1%), VUS (19.5%) or benign/likely benign (63.4%). Data were analyzed using chi-square tests with p<0.05 defining significance.

      Results

      Rates of TM+CPM and BSO were not significantly different for women with VUS compared to those with benign findings. Rates of TM+CPM were significantly higher for women with PV in BRCA1 and BRCA2, PALB2, PTEN and TP53, as well in genes with insufficient data to recommend risk-reducing mastectomy. Rates of BSO were significantly higher in women with PV in BRCA1 and BRCA2, PALB2, PTEN and TP53 and BRIP1, RAD51C and RAD51D compared to those with benign findings.

      Conclusion

      Overall, surgical choices for women with a VUS were more similar to those from women with benign variants than to those with PV, however, in the group with PV in genes for which insufficient evidence exists for the benefit of risk-reducing mastectomy, rates of TM+CPM were high. Thus, while the management of women with VUS is in agreement with ACMG guidelines, patients with mutations in other cancer genes demonstrate a preference for more aggressive breast surgeries.

      Keywords

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