Uptake, Results, and Outcomes of Germline Multiple-Gene Sequencing After Diagnosis of Breast Cancer

Abstract

<div class="section"> <a class="named-anchor" id="ab-coi180019-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e414">Importance</h5> <p id="d3637947e416">Low-cost sequencing of multiple genes is increasingly available for cancer risk assessment. Little is known about uptake or outcomes of multiple-gene sequencing after breast cancer diagnosis in community practice. </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e419">Objective</h5> <p id="d3637947e421">To examine the effect of multiple-gene sequencing on the experience and treatment outcomes for patients with breast cancer. </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e424">Design, Setting, and Participants</h5> <p id="d3637947e426">For this population-based retrospective cohort study, patients with breast cancer diagnosed from January 2013 to December 2015 and accrued from SEER registries across Georgia and in Los Angeles, California, were surveyed (n = 5080, response rate = 70%). Responses were merged with SEER data and results of clinical genetic tests, either <i>BRCA1</i> and <i>BRCA2</i> ( <i>BRCA1/2</i>) sequencing only or including additional other genes (multiple-gene sequencing), provided by 4 laboratories. </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e438">Main Outcomes and Measures</h5> <p id="d3637947e440">Type of testing (multiple-gene sequencing vs <i>BRCA1/2</i>-only sequencing), test results (negative, variant of unknown significance, or pathogenic variant), patient experiences with testing (timing of testing, who discussed results), and treatment (strength of patient consideration of, and surgeon recommendation for, prophylactic mastectomy), and prophylactic mastectomy receipt. We defined a patient subgroup with higher pretest risk of carrying a pathogenic variant according to practice guidelines. </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e446">Results</h5> <p id="d3637947e448">Among 5026 patients (mean [SD] age, 59.9 [10.7] years), 1316 (26.2%) were linked to genetic results from any laboratory. Multiple-gene sequencing increasingly replaced <i>BRCA1/2</i>-only testing over time: in 2013, the rate of multiple-gene sequencing was 25.6% and <i>BRCA1/2-</i>only testing, 74.4%; in 2015 the rate of multiple-gene sequencing was 66.5% and <i>BRCA1/2-</i>only testing, 33.5%. Multiple-gene sequencing was more often ordered by genetic counselors (multiple-gene sequencing, 25.5% and <i>BRCA1/2-</i>only testing, 15.3%) and delayed until after surgery (multiple-gene sequencing, 32.5% and <i>BRCA1/2-</i>only testing, 19.9%). Multiple-gene sequencing substantially increased rate of detection of any pathogenic variant (multiple-gene sequencing: higher-risk patients, 12%; average-risk patients, 4.2% and <i>BRCA1/2</i>-only testing: higher-risk patients, 7.8%; average-risk patients, 2.2%) and variants of uncertain significance, especially in minorities (multiple-gene sequencing: white patients, 23.7%; black patients, 44.5%; and Asian patients, 50.9% and <i>BRCA1/2</i>-only testing: white patients, 2.2%; black patients, 5.6%; and Asian patients, 0%). Multiple-gene sequencing was not associated with an increase in the rate of prophylactic mastectomy use, which was highest with pathogenic variants in <i>BRCA1/2</i> ( <i>BRCA1/2</i>, 79.0%; other pathogenic variant, 37.6%; variant of uncertain significance, 30.2%; negative, 35.3%). </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e479">Conclusions and Relevance</h5> <p id="d3637947e481">Multiple-gene sequencing rapidly replaced <i>BRCA1/2</i>-only testing for patients with breast cancer in the community and enabled 2-fold higher detection of clinically relevant pathogenic variants without an associated increase in prophylactic mastectomy. However, important targets for improvement in the clinical utility of multiple-gene sequencing include postsurgical delay and racial/ethnic disparity in variants of uncertain significance. </p> </div><p class="first" id="d3637947e487">This population-based cohort study examines the effect of multiple-gene sequencing on the experiences and treatment outcomes of patients with breast cancer. </p><div class="section"> <a class="named-anchor" id="ab-coi180019-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e493">Question</h5> <p id="d3637947e495">What are the results and outcomes of more comprehensive genetic sequencing after diagnosis of breast cancer? </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e498">Findings</h5> <p id="d3637947e500">In this population-based study, multiple-gene sequencing markedly replaced <i>BRCA1-</i> and <i>BRCA2</i>-only tests and enabled 2-fold higher detection of clinically relevant pathogenic variants without an associated increase in prophylactic mastectomy. Multiple-gene sequencing was more often delayed postsurgery and yielded much higher rates of variants of uncertain significance, particularly in racial/ethnic minorities. </p> </div><div class="section"> <a class="named-anchor" id="ab-coi180019-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d3637947e509">Meaning</h5> <p id="d3637947e511">Multiple-gene sequencing rapidly replaced more limited testing and enabled 2-fold higher detection of clinically relevant findings, but important targets for improvement include postsurgical delay and racial/ethnic disparity in variants of uncertain significance. </p> </div>