Study: Genetic testing for inherited mutations may be helpful for all people with advanced or metastatic cancer
Contents
At a glance | Clinical trials |
Study findings | Guidelines |
Strengths and Limitations | Questions for your doctor |
What does this mean for me? | Resources |
In-depth |
STUDY AT A GLANCE
What is this study about?
This study looked at how many cancer patients had inherited mutations and whether that changed their cancer treatment.
Why is this study important?
A growing number of treatments for advanced or cancer may benefit individuals with inherited mutations in genes that affect cancer risk. Genetic test results might guide these patients’ treatment decisions and improve their care. Despite this, cancer patients are not always offered genetic testing for inherited mutations. This study looked at people with cancer across different cancer types and measured the following:
- how common inherited mutations are in this group of people.
- how often that knowledge was “actionable” (might be used to guide treatment).
Study findings
How frequent are inherited mutations?
Researchers enrolled 11,947 patients from across the United States, including 9,079 participants (76 percent) who had or recurrent cancer. from each participant was tested for inherited mutations in 76 to 88 genes that are associated with cancer risk.
- 17% of participants tested positive for an in a gene linked to cancer.
Which inherited mutations may guide treatment?
Researchers listed all of the harmful (pathogenic or likely pathogenic) mutations found in participants and categorized them according to knowledge base. is a large database, which lists mutations that could potentially be used to guide treatment.
- Level 1 were mutations in genes with an FDA-approved drug treatment for the person's cancer type.
- Level 3B were mutations in genes with an FDA-approved or investigational treatment for a different type of cancer than the participant's cancer.
- Level 4 were mutations linked to response in a drug that was still being tested in clinical trials.
A potential treatment based on genetic test results existed for 10% of patients in this study.
- 2,037 harmful inherited mutations were found among the participants.
- 10% of patients had a harmful mutation with an actionable treatment:
- 4% were Level 1 (linked to an approved-FDA drug treatment for their cancer).
- 4% were Level 3B (linked to an approved-FDA drug treatment for a different tumor type).
- 1% were level 4 (linked to evidence for a response to drug treatment in a clinical trial).
71% of participants did not know they had an inherited mutation; this knowledge might have guided their treatment.
- Awareness of status differed by a gene mutation.
- Of those who knew that they had an , most had a or gene mutation.
- 20% of people with an mutation knew of their mutation.
- 19% of people with a mutation knew of their mutation.
- 4% of people with a RAC51C/D mutation knew of their mutation.
- 4% of people with a mutation knew of their mutation.
How often do or recurrent cancer patients with an actionable have a gene-directed treatment that may be effective for someone with their mutation?
Researchers looked at medical records for all patients with or recurrent cancer who had Level 1 or 3B mutations to see if they had treatment based on their status.
- 41% of patients with or recurrent cancer who had actionable received the corresponding gene-directed treatment.
- 227 of 371 (61%) of patients with Level 1 mutations received a drug that was FDA-approved for their type of cancer.
- 62 of 339 (18%) of patients with Level 3B mutations received a drug that was FDA-approved for a different type of cancer.
Strengths and limitations
Strengths
- This was a large study that looked at multiple types of cancer.
- All participants had testing for known cancer genes regardless of the type of cancer they had.
- The researchers determined whether the identified mutation had an approved treatment for that cancer or a different cancer and whether the participant received that treatment. This provided insight into gaps in gene-directed treatment.
Limitations
- For some of the genes included on the actionable list, data supporting effectiveness for people with different cancer types is limited. The authors note this as a limitation and suggest that more research is needed to understand which treatments are most appropriate based on mutation and tumor type.
- Many more patients had cancer than cancer. The selection and enrollment criteria were not entirely described. Because the participants did not represent a random sampling of cancer patients, it is unclear whether these findings will hold up for the general population.
- The study looked at the medical records of patients who received care at the researchers’ institution. Care received by patients at other hospitals was not included in the study.
- Nearly 20% of the participants were non-white; however, no information was given about whether the findings were the same or different for white and non-white participants. Sixteen percent of the participants were of heritage; no additional racial or ethnic information was provided.
What does this mean for me?
If you have any type of or recurrent cancer, you may want to have genetic testing for inherited mutations. Test results may change your treatment plan or make you eligible for a clinical trial. For this reason, NCCN guidelines recommend that all patients with pancreatic, breast, ovarian or cancer have genetic testing because this information may change their treatment plan. Genetic counseling is recommended before and after genetic testing to ensure that you have information about the risks and benefits and that you understand what that information means for your situation.
If you know you have an in a cancer gene, consider discussing with your doctor how that information affects your treatment options.
Share your thoughts on this XRAY review by taking our brief survey.
posted 9/30/21
Reference
Stadler ZK, Maio A, Chakaravarty D, et al. Therapeutic Implications of Germline Testing in Patients With Advanced Cancers. Journal of Clinical Oncology. 2021; 39(24): 2698-2709. Published online June 16, 2021.
Disclosure
FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.
This article is relevant for:
people with metastatic or recurrent cancer
This article is also relevant for:
people with metastatic or advanced cancer
people with breast cancer
men with breast cancer
people with prostate cancer
people with endometrial cancer
people with ovarian cancer
people with pancreatic cancer
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IN-DEPTH REVIEW OF RESEARCH
Study background
Genetic testing for inherited mutations has been used to identify high-risk people before they have cancer (previvors) or those with cancer to help guide risk-reducing treatment decisions. Historically, genetic testing for inherited mutations in cancer patients was uncommon. As new cancer treatments have been developed for people with inherited mutations, the need to understand when this information is most useful has grown. Over the last several years, research has shown that a substantial number of patients with ovarian, or pancreatic cancer have inherited mutations and may benefit from targeted treatments. The National Comprehensive Cancer Network (NCCN) recommends genetic testing for inherited mutations for all of these patients.
While testing of tumors for mutations is common, cancer patients do not always have genetic testing for inherited mutations. Knowing about an might guide treatment decisions and improve care in cancer patients. This study focused on understanding the frequency of inherited mutations among patients regardless of cancer type and how often that knowledge was used to provide targeted cancer treatment.
Researchers of this study wanted to know
Researchers wanted to know the frequency of cancer patients who have inherited mutations and what portion of those had treatment tailored to their mutation status.
Populations looked at in this study
Researchers enrolled 11,947 patients from across the United States from January 2015 to May 2019. Among participants, 53.2 percent were female. While 60 percent were non-Ashkenazi Jewish, white patients, 16.3 percent were and 19.5 percent were non-white, non-Ashkenazi Jewish. Race and ethnicity were unknown for the remaining 4.3 percent of participants. No additional information regarding race was given. The average age at cancer diagnosis was 55. The majority of participants (9,079 or 76 percent) had or recurrent cancer.
Participants had many different cancers:
Cancer type |
Percent of participants |
Percent with cancer |
Breast |
14% |
73% |
14% |
77% |
|
Pancreatic |
12% |
88% |
Colorectal |
10% |
72% |
Uterine |
7% |
60% |
Ovarian |
6% |
95% |
Kidney |
4% |
70% |
Bladder |
3% |
68% |
Brain or CNS |
3% |
29% |
Sarcoma |
3% |
74% |
Other |
22% |
81% |
Study design
from tumor samples and normal blood samples of each participant was tested for inherited mutations in any of 76 to 88 genes that are associated with elevated cancer risk (4,593 patient samples were tested with a 76-gene panel; 7,354 were tested using an updated 88-gene panel).
Researchers listed all harmful (pathogenic or likely pathogenic) mutations. Variants of uncertain significance were not included.
Mutations were then categorized according to their actionability in the Knowledge base as of Sept 17, 2020:
- Level 1: Mutations in genes with an FDA-approved drug treatment for that tumor type.
- Level 1-MSI-H: Indicated mutations in genes (, , or ) from patients whose tumors were also classified as having (MSI-H) or mismatch repair deficiency (). This category was independent of tumor type and was included with other Level 1 mutations.
- Level 3B: Mutations in genes with an FDA-approved or investigational treatment in a different type of cancer.
- Level 4: Evidence that the mutation is linked to drug response in an investigational drug
If a patient had multiple mutations, the highest level of those mutations was used.
Researchers looked at medical records for all patients with or recurrent cancer who had Level 1 or 3B mutations to determine whether they had a treatment based on their status.
Study findings
A substantial portion of participants had an in a gene that is linked to cancer risk.
- 17% of participants (77% with or recurrent cancer and 23% with cancer) had an .
- 10% of all participants (with any cancer) had a harmful (pathogenic or likely pathogenic) in a gene with a high or moderate risk of cancer.
- 4% of participants had an in or .
- 1% of participants had an in a gene.
An actionable gene-directed treatment exists for 10% of patients.
- 2,037 harmful inherited mutations were found among the participants.
- 10% of patients had a harmful mutation with an actionable treatment:
- 4% were Level 1 mutations that are linked to an FDA-approved drug treatment for that person's cancer.
- Level 1 mutations occurred most commonly among those with nerve sheath tumors, , ovarian, pancreatic or small bowel cancer.
- 4% were Level 3B mutations that are linked to an approved-FDA drug treatment for a different type of cancer than the participant had.
- 1% were level 4 mutations that are linked to evidence for a response to a drug treatment being tested in a clinical trial.
- 4% were Level 1 mutations that are linked to an FDA-approved drug treatment for that person's cancer.
Most participants did not know they had an actionable .
- 1,042 participants had an actionable . In other words, they were eligible for a cancer treatment that is designed to specifically target their cancer but would not have known that they were eligible for that treatment.
- 71% of participants with an did not know they had an .
- 29% of participants knew they had a harmful as a result of prior personal or family genetic testing.
- Most people who knew their status had or mutations.
- Among those with a or mutation, awareness of status differed by cancer type:
- 75% of people with ovarian cancer knew their mutational status.
- 69% of people with breast cancer knew their mutational status.
- 40% of people with pancreatic cancer knew their mutational status.
- 18% of people with cancer knew their mutational status.
- Awareness of status differed by gene mutation:
- 20% of people with an mutation knew their mutational status.
- 19% of people with a mutation knew their mutational status.
- 4% of people with a RAC51C/D mutation knew their mutational status.
- 4% of people with a mutation knew their mutational status.
Only half of the patients with or recurrent cancer who had an actionable received the corresponding gene-directed treatment.
Researchers asked how many of the 9,079 participants with or recurrent cancer received gene-directed cancer treatment. Participants with 3C ovarian cancer and inoperable nerve sheath tumors were included in this group.
- 710 participants (8%) with or recurrent cancer had a level 1 or 3B .
- 289 participants received treatment that was gene-directed.
- 3.2% of the patients with metastatic/recurrent cancer (289 of 9,079 patients) received gene-directed treatment.
- Only 41% of eligible patients (289 of 710 patients) received gene-directed cancer treatment:
- 227 of 371 (61%) of patients with Level 1 mutations received gene-directed treatment.
- 62 of 339 (18%) of patients with Level 3B mutations received gene-directed treatment.
- 244 participants had cancer of an unknown primary, meaning that the location of the original tumor was undetermined. Of these, 22 (nearly 10%) people had an inherited mutation:
- 11 had a mutation in or
- 2 had a mutation in a gene
- 3 had a mutation in
- 3 had a mutation in
- 2 had a mutation in CHEK1
- 1 had a mutation in
Strengths and Limitations
Strengths
- This was a large study that looked at multiple types of cancer. The size of the participant group means that observations are more likely to reflect the general population and less likely to occur by chance.
- All participants had testing for known cancer genes regardless of the type of cancer they had. This differs from panel testing that may have otherwise been specific to genes that are linked to their type of cancer.
- The researchers associated whether the mutation identified had an approved treatment (for that cancer or a different cancer) with whether the participant received that treatment. This provided insight into gaps in gene-directed treatment.
Limitations
- For some of the genes included on the actionable list, data supporting effectiveness for people with different cancer types is limited. The authors note this as a limitation and suggest that more research is needed to understand which treatments are most appropriate based on mutation and tumor type.
- Many more patients had cancer than cancer. Because participants did not represent a random sampling of cancer patients—the selection and enrollment criteria were not entirely described—it is unclear whether these findings will hold up for the general population.
- Nearly 20% of the participants were non-white people; however, no information was given about whether the findings were the same or different for white and non-white participants. No additional racial or ethnic information was provided other than that 16% of participants were of heritage.
Context
Genetic testing for inherited mutations has become more available in recent years. Its use to help inform risk-reducing decisions for cancer patients has become more common. In contrast, people with cancer may not have had genetic testing for inherited mutations, despite the growing number of gene-directed treatment options that are now available. Prior studies of particular types of cancer (e.g., pancreatic or ) have shown that a substantial number of those with cancer have inherited mutations. This is the first study that looked at cancer patients with any type of cancer. These findings suggest that a portion of patients with unrecognized inherited mutations would be eligible for actionable treatments. Identifying these patients may allow them to take advantage of treatments that are otherwise unavailable to them.
Conclusions
A substantial portion of people with cancer in this study had inherited mutations with actionable gene-directed treatment options. Most people with cancer did not know that they had an inherited mutation; only 40% percent received gene-directed treatment for which they were eligible. The authors suggest that genetic testing for inherited mutations should be considered in addition to standard tumor testing for all patients with advanced or cancer.
Share your thoughts on this XRAY review by taking our brief survey.
Posted 9/30/21
- With my personal and family cancer history, should I consider genetic testing?
- What are the risks and benefits of genetic testing?
- How do I receive genetic counseling?
- I have been newly diagnosed with an in a cancer gene. What options or changes would you suggest for my cancer treatment?
- I have an in a cancer gene. What are my risks of different types of cancer given my mutation status?
The following studies involve genetic testing in people with advanced cancers:
- NCT01775072: Genomic Profiling in Cancer Patients. This is the ongoing study referenced in this review. This study aims to better understand how genetic changes affect cancer outcomes. Researchers are looking at inherited and tumor mutations .
- NCT03503097: Genetic testing for men with prostate cancer (GENTleMEN). The goal of this research study is to determine if online genetic education and testing with online genetic counseling is an acceptable method of providing genetic testing to men with prostate cancer.
- NCT03665295: PROMPT. The goal of the PROMPT Registry is to follow people with mutations or variants in genes found on genetic testing panels so that patients physicians and researchers can more clearly understand other lesser-known risks.
- NCT04353973: A Study of an eHealth Delivery Alternative for Cancer Genetic Testing for Hereditary Predisposition in Breast, Ovarian, and Pancreatic Cancer Patients (E-Reach). This study is looking at using web options to increase access to testing AND patients in this study can get genetic counseling and testing in their home.
Updated: 05/27/2023
The following studies are looking at treatment for people with advanced .
- NCT05252390: NUV-868 Alone and in Combination With PARP Inhibitors in Patients With Advanced .This study will test the safety and effectiveness of the experimental drug NUV-868 alone and combined with a in people with advanced . This study is open to people whose cancer stopped responding or progressed on PARP inhibitors.
- NCT02264678: Ascending Doses of Ceralasertib in Combination With Chemotherapy and/or Novel Anti Cancer Agents. This is a study of ceralasertib administered orally in combination with chemotherapy regimens and/or novel anticancer agents to patients with advanced cancer. The study is enrolling people with inherited mutations, including , , , , , and people with tumors that are HRD-positive.
- NCT04644068: Study of AZD5305 as Monotherapy and in Combination With Anti-cancer Agents in Patients With Advanced Solid Malignancies (PETRA). This research is designed to learn whether treatment with a new , AZD5305, used alone or in combination with anti-cancer agents is safe, tolerable and has anti-cancer activity in patients with advanced . The study is open to people who have previously been treated with PARP inhibitors.
- NCT04267939: ATR Inhibitor Plus Study in Advanced and Ovarian Cancer. This study will look at how well people with advanced respond to treatment with the BAY1895344 in combination with the . This study is open to people with inherited mutations in , , and other genes. Contact the study coordinator for information about eligibility for people with mutations in other genes.
- NCT04657068: Treatment with ATR Inhibitor for Advanced or Solid Tumors. This study will look at how well a new oral known as an ATR inhibitor works on advanced or with mutations in genes that are linked to damage repair. This study is open to people who have an inherited or acquired or mutation or whose tumors are HRD-positive. This study is open to people whose cancer stopped responding or progressed on PARP inhibitors.
Updated: 02/01/2024
The following resources can help you locate a genetics expert near you or via telehealth.
Finding genetics experts
- The National Society of Genetic Counselors website has a search tool for finding a genetic counselor by specialty and location or via telehealth.
- InformedDNA is a network of board-certified genetic counselors providing this service by telephone. They can also help you find a qualified expert in your area for face-to-face genetic counseling if that is your preference.
- Gene-Screen is a third-party genetic counseling group that can help educate, support and order testing for patients and their families.
- JScreen is a national program from Emory University that provides low-cost at-home genetic counseling and testing with financial assistance available.
- Grey Genetics provides access to genetic counselors who offer genetic counseling by telephone.
- The Genetic Support Foundation offers genetic counseling with board-certified genetic counselors.
Related experts
Genetics clinics
- The American College of Medical Genetics website has a tool to find genetics clinics by location and specialty.
Other ways to find experts
- Register for the FORCE Message Boards and post on the Find a Specialist board to connect with other people who share your situation.
- The National Cancer Institute (NCI)-designated comprehensive cancer centers have genetic counselors who specialize in cancer.
- FORCE's toll-free helpline (866-288-RISK, ext. 704) will connect you with a volunteer board-certified genetic counselor who can help you find a genetics expert near you.
Updated: 07/21/2023
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