title: Statewide Retrospective Review of Familial Pancreatic Cancer in Delaware, and Frequency of Genetic Mutations in Pancreatic Cancer Kindreds.
abstract: BACKGROUND
  Considering the typical rapid progression and high mortality of pancreatic cancer (PC), early detection may lead to an improved outcome. To date, there is no safe, sensitive, and cost-effective screening strategy to detect PC. Currently, screening is focused on individuals at the highest risk of developing PC based on family history. A high-risk individual is defined as having two or more first-degree relatives with PC, or one first- or second-degree relative with PC with a confirmed mutation in a gene associated with PC. The BRCA2 gene is one of the most common genes linked to pancreatic-only cancer families; however, other hereditary cancer syndromes have also been associated with an increased risk for PC.
  
  
  METHODS
  We conducted a retrospective review of pedigrees of families with a pancreatic adenocarcinoma cancer diagnosis held in the statewide Ruth Ann Minner High Risk Family Cancer Registry at the Helen F. Graham Cancer Center and Research Institute, Christiana Care Health System, Newark, DE, USA, from 2002 to 2013. The registry was queried based on how many first-, second-, or third-degree relatives of the proband were affected with PC, genetic testing status, and (if applicable) the results. These data were then categorized into families that meet familial PC (FPC) criteria, defined as two first-degree relatives with PC (FPC families), families that did not meet the FPC definition but had one first-degree relative affected with PC (first-degree families), and probands with PC (probands). Each family was counted only once in the analysis, even if multiple family members were tested.
  
  
  RESULTS
  Our analysis revealed that 175 of 597 families fitting any of the above criteria completed genetic testing. Of this cohort, 52 had pathogenic alterations with nine different genes implicated. Overall, 164 of the 175 families that fitted into any of the three categories previously identified had BRCA1 or BRCA2 testing, either by DNA sequencing or next-generation sequencing via a panel test that included BRCA1/2. BRCA1 pathogenic alterations were noted in 17/164 (10.4 %) and BRCA2 pathogenic alterations were noted in 23/164 (14.0 %). FPC families (n = 46) 42/46 of the FPC families underwent BRCA1/2 testing, and 11/42 (26 % [95 % CI 12.89-39.49]) had pathogenic alterations. Specifically, 4/42 = BRCA1 (9.5 %) and 7/42 = BRCA2 (16.7 %). Additionally, 16/46 of the FPC families underwent exclusively Lynch syndrome (LS) testing, and pathogenic mutations in a mismatch repair protein were identified in 2/16. Specifically, 1/16 = MLH1 (6.3 %) and 1/16 = MSH2 (3.6 %). Overall, a genetic mutation within any gene associated with an increased PC risk was found in 28 % of FPC families. First-degree families (n = 106) 99/106 of the families with one first-degree relative underwent BRCA1/2 testing, and 21/99 (21.2 % [95 % CI 13.16-29.27]) had pathogenic alterations. Specifically, 11/99 = BRCA1 (11.1 %) and 10/99 = BRCA2 (10.1 %). 32/99 first-degree families underwent exclusively LS testing, and pathogenic mutations were identified in 4/32. Specifically, 3/32 = MLH1 (9 %) and 1/32 = MSH6 (3 %). 25/99 of the families pursued panel testing, and pathogenic alterations in any gene were identified in 3/25. Specifically, the mutations were found in 1/25 = ATM (4 %), 1/25 = CHEK2 (4 %), and 1/25 = RAD51D (4 %). Affected probands (n = 23) Lastly, all 23 probands affected with PC pursued genetic testing. Of these, 11/23 were found to have pathogenic alterations. All 23 underwent BRCA1/2 testing, and pathogenic alterations were identified in 8/23 (35 % [95 % CI 15.32-54.25]), specifically 2/23 = BRCA1 (9 %), and 6/23 = BRCA2 (26 %). 10/23 patients underwent panel testing and pathogenic alterations were found in 3/10 (30 %) patients, of whom 1/10 = MSH6 (10 %), 1/10 = ATM (10 %), and 1/10 = TP53 (10 %).
  
  
  CONCLUSIONS
  This study demonstrates that a statewide high-risk family cancer registry is an important instrument in studying the risk of PC in families. Our analysis revealed 14 mutations associated with FPC, among which hereditary breast and ovarian cancer and LS were most prevalent. BRCA1 was found to have the same association with PC as BRCA2, which appears unique to our population. We plan to use our knowledge of these mutations in developing a PC screening program.
authors.affiliation: Department of Cancer Genetics, Cancer Genetics Program, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA.
authors.forename: Zohra Ali-Khan
authors.initials: ZA
authors.lastname: Catts
authors.affiliation: Department of Internal Medicine, Christiana Care Health System, Newark, DE, USA.
authors.forename: Muhammad Khurram
authors.initials: MK
authors.lastname: Baig
authors.affiliation: Department of Cancer Genetics, Cancer Genetics Program, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA.
authors.forename: Becky
authors.initials: B
authors.lastname: Milewski
authors.affiliation: Department of Cancer Genetics, Cancer Genetics Program, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA.|Department of Biological Sciences, University of Delaware, Newark, DE, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Keywan
authors.affiliation: Department of Cancer Genetics, Cancer Genetics Program, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA.|Department of Internal Medicine, Christiana Care Health System, Newark, DE, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Guarino
authors.affiliation: Department of Cancer Genetics, Cancer Genetics Program, Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE, USA. npetrelli@christianacare.org.|Department of Internal Medicine, Christiana Care Health System, Newark, DE, USA. npetrelli@christianacare.org.|Department of Biological Sciences, University of Delaware, Newark, DE, USA. npetrelli@christianacare.org.|Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA. npetrelli@christianacare.org.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Petrelli
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019313:BRCA1 Protein / Q000235:genetics*; D024682:BRCA2 Protein / Q000235:genetics*; D014408:Biomarkers, Tumor / Q000235:genetics*; D002277:Carcinoma / Q000453:epidemiology / Q000235:genetics*; D003691:Delaware / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D020022:Genetic Predisposition to Disease; D005820:Genetic Testing; D018095:Germ-Line Mutation / Q000235:genetics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009154:Mutation / Q000235:genetics*; D009367:Neoplasm Staging; D010190:Pancreatic Neoplasms / Q000453:epidemiology / Q000235:genetics*; D010375:Pedigree; D011379:Prognosis; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D019313:BRCA1 Protein; C492913:BRCA1 protein, human; D024682:BRCA2 Protein; C551750:BRCA2 protein, human; D014408:Biomarkers, Tumor