Genetic cancers are relatively uncommon but not rare. Although there has not been a comprehen- sive study of the incidence of cancers that are
caused by an identifiable single gene mutation, it is estimated that they account for approximately 5% to 10%
of all cancers, or 50,000 to 100,000 patients annually in
the U.S.1 The hallmarks of a genetic cancer syndrome are
early onset, multiple family members in multiple generations with cancer, bilateral cancer, and multiple cancers
in the same person.
Until recently, the VA has not had a significant interest in genetic cancer risk assessment (GCRA). This is
changing, however, because veterans with identified genetic risks for cancer can benefit from targeted screening
and intervention strategies to lower their risk of dying of
cancer. The value of GCRA was also recognized in the
2015 standards for accreditation of the American College
of Surgeons, which include a requirement for programs
to include a provision for GCRA.2
The 2 most common familial cancer syndromes are hereditary breast and ovarian cancer (HBOC) syndrome,
which occurs in about 5% of all patients with breast cancer, and Lynch syndrome (LS), or hereditary nonpolyposis
colorectal cancer (CRC) syndrome, which occurs in about
3% of all patients with CRC.3,4 Other familial cancer syndromes are rare: For example, familial adenomatous polyposis (FAP) accounts for 0.2% to 0.5% of all CRC cases.5
The Raymond G. Murphy VAMC in Albuquerque is
the sole VA hospital in New Mexico. Its catchment area
extends into southern Colorado, eastern Arizona, and
western Texas. About 40 CRCs and 8 breast cancers are
diagnosed at this facility yearly. Given the incidence of
these familial cancer syndromes, one might expect to see
1 LS case/year, 1 HBOC case every 2 years, and 1 FAP or
attenuated FAP case every 5 to 10 years.
In 2010, a GCRA clinic was set up to evaluate and manage treatment of veterans who might have inherited a
genetic cancer syndrome. Prior to that, veterans with suspected genetic cancer family syndromes were referred to
the University of New Mexico for evaluation and testing.
Initially, the pathology department (PD) paid for genetic
testing. However, due to the cost of testing, a formal budget for genetic testing was approved. Contracts were set
up by the PD with outside laboratories for genetic testing
services. For quality control, all veterans who were referred for genetic evaluation were seen by Dr. Lin.
The initial consultation consisted of construction
of a family pedigree and evaluation, using available
models or tables, such as the Myriad tables (BRCA),
Penn II BRCA, or PREMM1,2,6 (LS), to estimate likelihood of finding a mutation. Veterans who had a ≥ 10%
likelihood of finding a gene mutation were counseled,
following the American Society of Clinical Oncology
guidelines (Table 1). Those who consented to genetic
testing signed a consent form and were given a copy of
that form and a copy of their family pedigree. Because
the VA covers the cost of counseling and testing, cost
was not discussed.
Veterans had a follow-up visit to review the test results. Patients were counseled on treatment recommendations, including a copy of current consensus
recommendations, and disclosure to the family. The
recommendations were then included in the patient’s
Establishing a Genetic Cancer
Risk Assessment Clinic
James Lin, MD
A VA medical center is evaluating and managing the treatment of veterans who might have
familial risk of developing 3 types of cancer.
Dr. Lin is a staff physician in the Division of Hematology/Oncology at the
Raymond G. Murphy VAMC in Albuquerque, New Mexico.