First prospective analysis links breast and pancreatic cancer risk with lynch syndrome
Andrey Nailor, M.D.·Published 15 February 2012·9 min read
Key points
A new prospective study of patients with Lynch syndrome – an inherited disorder of cancer susceptibility caused by mutations in specific DNA repair genes – provides the first strong evidence that people with Lynch syndrome face significantly increased risks of breast and pancreatic cancers.
Hereditary non-polyposis colorectal cancer syndrome (HNPCC) or Lynch Syndrome is characterized by early age onset colorectal cancer and endometrial (uterine) cancer as well as other extracolonic tumors.
The most common type of inherited breast cancer is hereditary breast and ovarian cancer syndrome (HBOC).
The debate on whether or not breast cancer is in the tumor spectrum for Lynch syndrome produces a conundrum for healthcare providers.
A new prospective study of patients with Lynch syndrome – an inherited disorder of cancer susceptibility caused by mutations in specific DNA repair genes – provides the first strong evidence that people with Lynch syndrome face significantly increased risks of breast and pancreatic cancers. The study also provided new, clearer estimates of the risks of cancers already recognized to be associated with Lynch syndrome, including those of the colon, uterus, ovary, kidney, stomach and bladder. The findings – published February 13 in the Journal of Clinical Oncology – may have implications for screening and early detection of cancers in patients with the condition. Additionally, the study showed that relatives of individuals with Lynch syndrome who do not carry a genetic mutation associated with the condition have no increased risk of developing cancer, compared to the general population.
While the risk of pancreatic cancer had been suggested in prior research on Lynch syndrome, the elevated risk of breast cancer was an unexpected finding in this study. "Our study is the first prospective analysis to find a strong association between breast cancer and Lynch syndrome," explained Mark A. Jenkins, PhD, senior author and Associate Professor at The University of Melbourne in Australia. "Further clarification of the risk of breast cancer for women at various ages is needed to determine the recommended age for mammography for each patient, and to determine whether additional tests such as MRI are warranted for women with Lynch syndrome."
DNA errors are a common occurrence within cells. Under normal circumstances, cells are able to correct these errors – for example, by using a set of genes called "mismatch repair genes," which correct a specific type of DNA errors called mismatches. When these errors are not repaired, due to the failure of the mismatch repair genes, additional gene mutations can occur, which can lead to cancer development.
Lynch syndrome is an inherited condition characterized by a mutation in one of the four key mismatch repair genes, and carriers are known to be at high risk for developing cancer, particularly colon cancer. In fact, researchers estimate that three to five of every 100 colon cancers are caused by Lynch syndrome. Individuals with Lynch syndrome are also at greater risk of developing multiple cancers during their lifetime, and tend to be diagnosed with cancer at a younger age than people in the general population. According to the National Cancer Institute, one to three percent of the population may have Lynch syndrome.
In this study, researchers followed a group of 446 carriers of one of four mismatch repair mutations related to Lynch Syndrome, as well as 1,029 of their relatives who did not carry these mutations ("non-carriers"). Participants were evaluated every five years at recruitment centers affiliated with the Colon Cancer Family Registry in Australia, New Zealand, Canada and the United States. The analysis was conducted by Aung Win, MPH, MBBS, Research Fellow at The University of Melbourne.
Written and revised by
Andrey Nailor, M.D.
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In this News Digest: Summary of the first prospective study – published online February 13, 2012 in the Journal of Clinical Oncology – to provide strong evidence of increased breast and pancreatic cancer risk in individuals with Lynch syndrome, who carry certain inherited genetic mutations in DNA repair genes. The study is also the first to show that relatives of people with Lynch syndrome who do not carry these mutations have no increased risk of cancer.
After a median follow-up of five years, the researchers found that, compared to the general population, carriers had a 20-fold greater risk of colorectal cancer; a 30-fold greater risk of endometrial (uterine) cancer; a 19-fold higher risk of ovarian cancer; an 11-fold greater risk of renal (kidney) cancer; a 10-fold greater risk of pancreatic, stomach, and bladder cancers; and a four-fold greater risk of breast cancer. They confirmed that carriers who developed cancer also tended to be diagnosed at an earlier age than the general population. The researchers did not find evidence that family members who were non-carriers had any increased risk of cancer, suggesting that they do not need more intense cancer screening than the general population.
Lynch syndrome is an autosomal dominant cancer predisposition syndrome characterized by an increased risk for colon cancer and cancer of the stomach, small intestine, upper urinary tract, liver, brain and skin. Women with this condition also have an increased risk for cancer of the lining of uterus (endometrium) and ovaries.
Hereditary Non-polyposis Colorectal Cancer Syndrome (Lynch Syndrome)
Hereditary non-polyposis colorectal cancer syndrome (HNPCC) or Lynch Syndrome is characterized by early age onset colorectal cancer and endometrial (uterine) cancer as well as other extracolonic tumors. Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch Syndrome is caused by mutations in DNA mismatch repair genes (MLH1, MSH2, MSH6 or PMS2). A variant of HNPCC-Lynch Syndrome called Muir Torre Syndrome is associated with increased risk for certain skin tumors. A second variant, called Turcot Syndrome, is associated with certain brain tumors (different than in FAP).
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Hereditary Breast & Ovarian Cancer Syndrome
The most common type of inherited breast cancer is hereditary breast and ovarian cancer syndrome (HBOC). HBOC is caused by mutations in the BRCA1 and BRCA2 genes. A woman with an inherited mutation in the BRCA genes has a higher chance of developing breast and ovarian cancer in her lifetime than a woman who does not carry a mutation. A man with an inherited mutation in the BRCA genes has a higher chance to develop breast and prostate cancer in his lifetime. Additionally, some families have higher incidence of pancreatic cancer, melanoma and other cancers.
"Eventually, we expect that the management of cancer risk, including the choice and timing of screening, will be able to be tailored to the specific underlying gene mutation in a person with Lynch syndrome," said Jenkins.
"Currently, individuals with the syndrome are typically advised to undergo colonoscopy at an earlier age and more frequently than the general population. However, there is no data demonstrating that screening for these other cancers is beneficial, in part due to the absence of effective screening tests."
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The researchers are continuing to follow this cohort. Since much larger numbers of carriers are needed to determine cancer risks specific to each of the four genes for Lynch syndrome, they are establishing the International Mismatch Repair Consortium to pool data from 51 clinical research centers in Africa, Asia, Australia, Europe, and North and South America. Collectively, these centers treat more than 7,500 families with Lynch syndrome and over 13,000 mismatch mutation carriers.
Lynch Syndrome - is breast cancer a feature?
The debate on whether or not breast cancer is in the tumor spectrum for Lynch syndrome produces a conundrum for healthcare providers. The classic tumor spectrum for Lynch Syndrome (LS) includes colon, endometrial, ovarian, stomach, small intestine, hepatobiliary, urinary tract and brain/central nervous system cancers. Muir-Torre Syndrome (MTS) is a variant of LS that is associated with additional skin lesions including sebaceous gland tumors and keratoacanthomas. MTS was observed in 28% of LS families when assessing for MTS skin lesions [1]. It has also been reported that 10-14% of individuals with MTS present initially with breast cancer [2,3]. An extensive study published in 2002 excluded breast cancer as part of the tumor spectrum associated with LS [4]. However, more recently it was reported that DNA mismatch repair (MMR) gene deficiencies were identified in 51% of breast cancers arising in MMR mutation carriers [5]. Another study reported a male with an MLH1 mutation who had both colon and breast cancer. The breast cancer exhibited somatic reduction to homozygosity for the MLH1 mutation [6]. Here we report two unrelated families in which the proband has a germline MMR gene mutation and bilateral breast cancer, and one family in which the proband had ovarian and renal cancer and her daughter, maternal aunt and cousin had breast cancer at age 47, 59, and 48 respectively. This raises the question are these breast cancers associated with the MMR mutations or a breast cancer susceptibility gene and what testing should be offered?
References
South C, Hampel H, Comeras I, Westman J, Frankel W, Chapelle A: The Frequency of Muir-Torre Syndrome Among Lynch Syndrome Families. Journal National Cancer Institute 2008, 100:277-281. Cohen P, Kohn S, Kurzrock R: Association of Sebaceous Gland Tumors and Internal Malignancy: The Muir Torre Syndrome. The American Journal of Medicine 1991, 90:606-613. Cohen P, Kohn S, Davis D, Kurzrock R: The Muir Torre Syndrome. Dermatologic Clinics 1995, 13:79-89. Muller A, Edmonston TB, Corao DA, et al.: Exclusion of breast cancer as an integral tumor of hereditary nonpolyposis colorectal cancer. Cancer Research 2002, 62:1014-1019. Walsh M, Buchman D, Cummings M, Pearson S, Arnold S, Clendenning M, Wlaters R, McKeone D, Spurdle A, Hopper J, Jenkins M, Phillips K, Suthers G, George J, Goldblatt J, Muir A, Tucker K, Pelzer E, Gattas M, Woodall S, Parry S, Macrae F, Haile R, Baron J, Potter J, Marchand L, Bapat B, Thibodeau S, Lindor N, McGucklin M, Young J: Lynch Syndrome- Associated breast cancer: Clinicopathologic Characteristics of a Case Series from the Colon Cancer Family Registry. Clinical Cancer Research 2010, 16(7):2214-2224. Boyd J, Rhei E, Federici M, Borgen P, Watson P, Franklin B, Karr B, Lynch J, Lemon S, Lynch H: Male breast cancer in hereditary nonpolyposis colorectal cancer syndrome. Breast cancer research and treatment 1999, 53:87-91
### Zohra AK Catts, Carrie Barnum, Marcie Parker, Chandra Somerman, Becky Grey and Bruce Boman
Robert Sticca, MD, ASCO Cancer Communications Committee member, executive editor of CancerProgress.Net and surgical oncologist
"This study adds to growing evidence linking specific inherited genetic mutations to certain cancers. Additional follow-up will lead to even more accurate estimates of cancer risk for individuals with Lynch syndrome. Such data may help us refine screening guidelines and could ultimately lead to early detection of the cancers these patients are at risk for, preventing the long-term consequences of cancer development. In addition, these data may indicate that some patients with Lynch syndrome are eligible for prophylactic treatments to prevent the development of these cancers."
Lynch Syndrome Linked to Breast, Pancreatic Cancers A prospective study has confirmed that Lynch syndrome, an inherited disorder that predisposes to many types of cancer, significantly raises the risk of both breast cancer and pancreatic cancer.
The trial is the first to "find a strong association between breast cancer and Lynch syndrome," said senior author and genetic epidemiologist Mark A. Jenkins, Ph.D., of the centre for molecular, environmental, genetic, and analytic epidemiology at the University of Melbourne.
Risk of breast cancer was fourfold higher for the Lynch syndrome patients, compared with the general population. The syndrome is known to increase the risk for a wide variety of other cancers, including colon cancer. Patients are typically advised to begin colonoscopies at an earlier age and repeat them more often than does the general population.
The new findings suggest that women with the syndrome might also benefit from enhanced breast cancer screening, but "further clarification of the risk of breast cancer for women at various ages is needed to determine the recommended age for mammography ... and to determine whether additional tests such as MRI are warranted," Dr. Jenkins said.
The researchers also found an 11-fold increase in pancreatic cancers among the Lynch syndrome patients. Although elevated risk of this cancer has long been suspected, the evidence from previous studies has been inconsistent. The results were published online Feb. 13 in the Journal of Clinical Oncology.
### By: M. ALEXANDER OTTO, Oncology Report Digital Network
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The Journal of Clinical Oncology is the tri-monthly peer-reviewed journal of the American Society of Clinical Oncology (ASCO), the world's leading professional society representing physicians who treat people with cancer.
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Nicole Fernandes [email protected] 571-483-1354 American Society of Clinical Oncology
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