Risk management for people with inherited MLH1 mutations

The National Comprehensive Cancer Network (NCCN) provides risk management guidelines for people with MLH1 mutations.  We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and can help you determine the best risk management plan. You can learn more about risk management options in our section on Screening and Risk Reduction by Cancer Type. 

NCCN risk management guidelines for people with MLH1 mutations include information on the following cancers:

• colorectal cancer 
• endometrial cancer
• ovarian cancer
• pancreatic cancer
• urinary tract cancer
• brain cancer
• prostate cancer
• skin cancer
• stomach cancer

People with an MLH1 mutation may also qualify for clinical trials looking for more effective screening or prevention for cancer.

Colorectal Cancer 

• Begin colonoscopy between ages 20-25 (or 2-5 years before the earliest age of colon cancer in the family, if diagnosed before age 25).
• Repeat coloscopy every 1-2 years. Speak with your doctor about whether your screenings should be yearly or every two years. Men, people over age 40, and people with a personal history of colon cancer or colon polyps may benefit most from yearly screenings. 
• Daily aspirin can decrease the risk for colorectal cancer. The best dose and timing for aspirin is not known. Speak with your doctor about the benefits and risks, best timing and dose.

Endometrial cancer 

• Symptom awareness and biopsy: Endometrial cancer can often be caught early based on symptom awareness followed by a biopsy. Be aware of endometrial cancer symptoms and immediately report any of the following to your doctor: 
  • unusual vaginal bleeding
  • pelvic or abdominal pain
  • bloating or distended belly
  • difficulty eating
  • increased urination or pressure to urinate 
• Screening: For people with no symptoms of endometrial cancer, regular endometrial cancer screening through transvaginal ultrasound and/or endometrial biopsies does not appear to improve outcomes. Despite this, some people prefer to undergo regular screening through transvaginal ultrasound and endometrial biopsies.
  • Speak with your doctor about the benefits, risks, costs and timing of transvaginal ultrasound and endometrial biopsies in order to make a decision about screening.
  • For those who choose screening, endometrial biopsy every 1-2 years may begin at age 30-35.
  • Annual transvaginal ultrasound to detect endometrial cancer is not recommended for screening until after menopause. 
• Surgery: Removal of the uterus (hysterectomy) lowers the risk for endometrial cancer. However, more research is needed to show that hysterectomy lowers the risk for death from endometrial cancer. Speak with your doctor about the benefits and risks of hysterectomy and the best timing for surgery after you have completed childbearing. 
• Medication: Oral contraceptive pills (birth control) may lower the risk for endometrial cancer associated with Lynch syndrome. Speak with your doctor about the benefits, risks and timing of oral contraceptives. 

Ovarian cancer

• Surgery: Removal of the ovaries and fallopian tubes (also called risk-reducing salpingo-oophorectomy or RRSO) can lower the risk for ovarian cancer. Speak with your doctor about the benefits and risks of RRSO and the best timing for surgery after you have completed childbearing.
  • After RRSO, a very small risk remains (about 1-2 percent) for a related cancer known as primary peritoneal cancer (PPC). Given how rare this cancer is, experts do not recommend screening for PPC after RRSO. Be aware of symptoms of primary peritoneal cancer and report any symptoms to your doctor.
• Symptom awareness: Experts recommend that people become aware of ovarian cancer symptoms. Report to any of the following symptoms that persist for several weeks and are a change from normal to your doctor:
  • pelvic or abdominal pain
  • bloating or distended belly
  • difficulty eating
  • feeling full sooner than normal
  • increased urination or pressure to urinate 
• Screening: In the absence of symptoms, some people undergo regular screening through transvaginal ultrasound and CA125 blood tests. However, ovarian cancer screening does not detect ovarian cancer early. If you are not planning surgery, speak with your doctor about the benefits, risks, costs and timing of transvaginal ultrasound and CA125.  
• Medication: Oral contraceptive pills (birth control) may lower the risk for ovarian cancer in people with Lynch syndrome. Speak with your doctor about the benefits, risks and timing of oral contraceptives. 

Pancreatic cancer screening for people with a family history

There are two tests that are used to look for pancreatic cancer. 

• Contrast-enhanced magnetic resonance cholangiopancreatography (MRCP) is a special type of MRI imaging that looks closely at the pancreas, liver, gallbladder, bile duct and pancreatic duct to find abnormalities such as cancer.
• Endoscopic ultrasound (EUS) involves passing a tiny scope with an attached ultrasound probe down the esophagus to the stomach. This allows doctors to look closely at the pancreas.  

Pancreatic cancer screening for people with a MLH1 mutation is only recommended for people with a family history of pancreatic cancer.

• People with an MLH1 mutation who have a first- or second-degree relative with pancreatic cancer, should consider screening beginning at age 50 or 10 years younger than the age of diagnosis of that relative. 
• Before undergoing screening, you should have a conversation with your doctor about the benefits, risks, costs and limitations of screening.
• Screening includes annual contrast-enhanced MRI/MRCP (magnetic resonance cholangiopancreatography) and/or EUS (endoscopic ultrasound). 
• Screening should be done at a facility with experience in screening high-risk patients for pancreatic cancer.

Bladder, kidney and ureteral cancer

• Consider annual urinalysis beginning between ages 30-35, especially for people from families with a history of urinary tract cancer.

Prostate cancer

• By age 40, you should have a conversation with your doctor about the potential benefits, risks, costs and limitations of screening for prostate cancer.
• If you choose to have screening, the guidelines recommend an annual digital rectal exam and Prostate Specific Antigen (PSA) test. 

Brain cancer

• Learn the signs of brain cancer and report any symptoms to your doctor. 

Skin cancer

• Talk with your doctor about the benefits of having a skin exam every 1-2 years with an expert trained in finding skin changes related to Lynch syndrome. 

Stomach cancer

• Begin stomach cancer screening at age 30-40 using a procedure known as EGD (esophagogastroduodenocopy) and repeat every 2-4 years. 
  • Earlier onset screening may be recommended based on family history.
  • More frequent screening may be recommended based on prior screening findings. 
• If gastric screening is performed, considered random biopsy to test for H. pylori. If gastric biopsy is not performed, consider non-invasive testing for H. pylori.
  • People who test positive should receive treatment for H. pylori. 

Other cancer screening and prevention

Guidelines do not address screening or prevention of other cancers for people with MLH1 mutations. However, clinical trials may be available.