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Hereditary nonpolyposis colorectal cancer

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We support Lynch syndrome testing and bowel cancer in people under 50


https://i1.wp.com/www.bowelcanceruk.org.uk/media/414473/lynch_syndrome_and_bowel_cancer_november_2014.jpgBowel Cancer UK and clinical experts are urging all hospitals across the UK to implement Lynch syndrome testing at diagnosis for everyone with bowel cancer under the age of 50. Lynch syndrome is an inherited condition which causes over 1,000 cases of bowel cancer in the UK every year, many of them in people under the age of 50. However, fewer than 5% of people with Lynch syndrome in the UK have been diagnosed.

Testing everyone with bowel cancer under the age of 50 at diagnosis for Lynch syndrome will help identify family members who may carry Lynch syndrome and be at risk of bowel cancer. It has been shown to be cost effective for the NHS, and is recommended by the Royal College of Pathologists and British Society of Gastroenterologists. It is also a key recommendation in our Never Too Young campaign.

People with Lynch syndrome should then access regular surveillance screening, which can detect bowel cancer in the early stages and has been shown to reduce mortaility from bowel cancer by 72%.

Despite this, testing and surveillance screening are patchy across the UK. A letter in the Daily Telegraph (13 November 2014) from eight leading clinical experts supports our call for all hospitals to implement Lynch syndrome testing at diagnosis for people with bowel cancer under the age of 50.

The letter and signatories are as follows:

Dear Editor

There are more than 1,000 cases of bowel cancer a year that are attributable to Lynch syndrome (LS), many under the age of 50. LS is an inherited condition that predisposes individuals to bowel and other cancers, with a lifetime risk of around 70 per cent. Yet in the UK we have identified fewer than 5 per cent of families with LS. The family of Stephen Sutton, who was diagnosed with bowel cancer and whose father has LS, was one of them. It is a consistently under-recognised, under-diagnosed and inadequately treated condition.

Both the Royal College of Pathologists and the British Society of Gastroenterology recommend testing everyone with bowel cancer under the age of 50 at diagnosis to help us to identify family members who may carry LS and be at risk of bowel cancer. Yet testing is patchy. We urge all hospitals across the UK to implement this guidance.

This testing would mean people at risk could access surveillance programmes for regular colonoscopies, helping detecting bowel cancer early but also preventing it.

Patient groups such as Bowel Cancer UK are in support. A recent NHS study found that LS testing at diagnosis for everyone under 50 with bowel cancer would be cost effective enough to have been approved by NICE. The evidence is overwhelming. We must end this postcode lottery.

Dr Kevin Monahan, Consultant Gastroenterologist and General Physician at Family History of Bowel Cancer Clinic, West Middlesex University Hospital (WMUH), London

Professor Sue Clark, Chair of the Colorectal Section of the British Society of Gastroenterology, Consultant Colorectal Surgeon, St Mark’s Hospital

Professor John Schofield, Consultant Pathologist, Cellular Pathology Department, Maidstone Hospital and Kent Cancer Centre

Dr Suzy Lishman, President, The Royal College of Pathologists

Professor Ian Tomlinson, Professor of Molecular and Population Genetics, Group Head / PI and Consultant Physician, Wellcome Trust Centre for Human Genetics

Professor Huw JW Thomas, Consultant Gastroenterologist, Family Cancer Clinic, St Mark’s Hospital, London

Professor Malcolm Dunlop MD FRCS FMedSci FRSE, Colon Cancer Genetics Group and Academic Coloproctology, Head of Colon Cancer Genetics, Institute of Genetics & Molecular Medicine

Professor D Gareth Evans MD FRCP, Professor of Clinical Genetics and Cancer Epidemiology and Consultant Geneticist, University of Manchester

Commenting on the letter from clinical experts, Deborah Alsina, CEO of Bowel Cancer UK, said:

“The Royal College of Pathologists recently produced best practice guidelines recommending everyone with bowel cancer under the age of 50 should be tested for Lynch syndrome at diagnosis. Speedy implementation is vital as testing is currently patchy at best and if people are tested at all, it is often after treatment ends.  Yet a diagnosis of Lynch syndrome can affect treatment decisions. We are therefore calling for all UK hospitals to implement this guidance swiftly.”

“This will also help to identify the risk to other family members who may also carry Lynch syndrome and who may be at higher risk of developing bowel cancer. Once identified, people at risk, including those diagnosed who have a greater chance of recurring or developing another linked cancer, should have access to surveillance programmes including regular colonoscopies. This will help to ensure bowel cancer is either prevented or detected early.”

Bowel Cancer UK will be writing to all Clinical Commissioning Groups and Health Trusts in the UK asking them if they have implemented systematic Lynch syndrome testing, and we will report back on the responses. In the meantime, please share our infographic on the subject on social media to help raise awareness of the issue.

Inherited Colorectal Cancer Course for the Multidisciplinary Team, London 15th January 2015


 

Date: January 15th, 2015

Venue: St Mark’s Hospital, London

Click here for more information

Target Audience:  All members of the Colorectal Cancer MDT (nurse specialists, oncologists, gastroenterologists, colorectal surgeons, pathologists), Geneticists, genetics counsellors

Learning Style: Lectures and case discussions

Learning Outcomes: On completion of this course, attendees will:

  • Appreciate the contribution of inheritance to colorectal cancer
  • Be able to assess family history and associated risk
  • Understand how to manage individuals at moderate risk of colorectal cancer
  • Understand the basic features and management of polyposis syndromes
  • Understand the diagnosis and management of Lynch syndrome

Course Fees:

£150.00 – Consultants
£75.00 – Nurses, Trainees and other Healthcare Professionals

To apply, complete the application form and send to nwlh-tr.StMarksAcademicInstitute@nhs.net.

For further information, view the programme and brochure for the course. If you have any questions, please feel free to contact the Academic Institute.

Why do GPs fail to spot bowel cancer in young people like Stephen – until too late? (From the Daily Mail)


   Why do GPs fail to spot bowel cancer in young people like Stephen – until too late? (From the Daily Mail)

  • Stephen Sutton died after a four-year battle with bowel cancer
  • 19-year-old raised millions for the Teenage Cancer Trust before his death
  • Number of under-50s diagnosed is gradually rising to around 2,100 a year

By Judith Keeling

Hayley was 'too young' for bowel cancer to be considered

Hayley was ‘too young’ for bowel cancer to be considered

Hayley Hovey was 23 weeks’ pregnant with her first baby when she suddenly woke in the middle of the night with a sharp, shooting pain in her side.

She visited her GP’s out-of-hours service but was reassured to hear her baby’s heartbeat and be told all was well. The pain was probably ‘ligament strain’ caused by the weight of the growing baby. ‘I was ecstatic to be having a baby – I’ve always wanted to be a mum,’ says Hayley, 34. ‘All my scans showed my baby was healthy, so I didn’t think anything more about that pain.’

She now knows it was the first sign there was a grave threat to her baby’s life, and her own. Four weeks later her daughter, Autumn, was born prematurely and later died. Then Hayley was found to have bowel cancer.

Doctors now think Autumn’s death was linked to her mother’s cancer, with a blood clot breaking away from the tumour, damaging Hayley’s placenta and cutting off the food supply to her unborn baby.

However, it took four months after Autumn’s death for Hayley to be diagnosed. The problem was her age – she was ‘too young’ for bowel cancer to be considered.

Hayley, who lives in Fareham, Hants, with her husband Paul, a 35-year-old IT consultant, says: ‘Looking back, I had textbook symptoms – exhaustion, intermittent stomach pains, increasingly bad diarrhoea, blood in my stools and bleeding.

The disease is Britain’s second-biggest cancer killer, claiming 16,000 lives a year. The number of under-50s diagnosed has been gradually rising – to around 2,100 a year.

But a recent survey by the charity Bowel Cancer UK of patients under 50 found that 42 per cent of the women had visited their GP at least five times before being referred for tests.

Indeed, Hayley, a supply planner for an IT firm, was examined five times by different doctors and midwives, who all missed her symptoms, despite a golf ball-sized lump appearing on her stomach after her pregnancy. By the time she was diagnosed, Hayley had stage three to four cancer, meaning the tumour had broken through her bowel wall.

She had to undergo a seven-hour operation to remove the 6cm growth, followed by six months of chemo and radiotherapy.

 

But her experience is not uncommon, says Deborah Alsina, chief executive of Bowel Cancer UK: ‘We hear from many younger people who express frustration at not getting a diagnosis and support.’

‘Bowel cancer is often associated with older patients over 50 – but younger people can, and do, regularly get it, as the tragic story of Stephen Sutton recently highlighted,’ adds Kevin Monahan,  consultant gastroenterologist at West Middlesex University Hospital, London.

Stephen Sutton, 19, raised more than £3million during his three-year battle against multiple tumours

Stephen Sutton, 19, raised more than £3million during his three-year battle against multiple tumours

 

Stephen Sutton, the 19-year-old fundraiser who died last week from the disease, told the Mail earlier this month of his anger that he was not diagnosed for six months after his symptoms started. This was despite his family history of Lynch syndrome, a genetic condition that raises the risk of bowel cancer.

‘If it had been caught earlier, it could have led to a better prognosis,’ he said. Hayley, too, eventually discovered she had Lynch syndrome.

Bowel cancer is very treatable if detected early – 93 per cent of patients who are found to have a small tumour on the bowel wall  live for five years or more. Yet only 9 per cent of cases are diagnosed at this stage – most are diagnosed at stage three. So, the overall five-year survival rate for bowel-cancer patients is just 54 per cent.

Because patients and many doctors assume that young people won’t get bowel cancer, they are particularly likely to have advanced-stage tumours at the time of diagnosis.

What to watch for

Bleeding or blood in faeces

A change in bowel habits lasting more than three weeks

Exhaustion

Unexplained weight loss

Abdominal pain

See bowelcanceruk.org.uk; beatingbowelcancer.org (phone 08450 719 301); and familyhistorybowelcancer.wordpress.com/

Cancer charities are campaigning to improve diagnosis for all ages – they want new diagnostic guidelines for GPs and earlier screening procedures.

Sean Duffy, NHS England’s national clinical director for cancer, says: ‘The UK lags behind much of Europe in terms of survival from bowel cancer. We need to change this, and this includes identifying it better in patients under 50.’

National GP guidelines state only patients aged 60 and over should be automatically referred to hospital for tests if they have one symptom. Patients aged 40 to 60 must exhibit two or more symptoms.

For under 40s, there is often an assumption the symptoms must be something else, says Mark Flannagan, chief executive of the charity Beating Bowel Cancer. ‘We’ve had patients with red-flag symptoms – such as blood in their stools – being told “you’ve got IBS” or “you’re too young to have cancer” by their GPs.’

Four weeks after Hayley’s initial scare, she was unable to feel her baby moving. Tests revealed Autumn had stopped growing, and she had to be delivered by emergency caesarean. After her birth, in July 2011, she was taken to a specialist neo-natal unit at Southampton General Hospital but died in hospital a few weeks later.

Two weeks afterwards, Hayley experienced more shooting pains. With her pregnancy bump gone, there was also a noticeable lump on the side of her waist. Her midwife said it was probably an infection, and Hayley was given antibiotics.

But her health deteriorated rapidly and she had to take six weeks off work with exhaustion, which her GP put down to depression.

Within three months of Autumn’s death, Hayley was suffering from nausea and abdominal pain.

Unable to get a GP’s appointment, she went to A&E but was told the lump was possibly an infection related to her caesarean. Doctors performed a cervical smear test (which was subsequently lost) and sent her home with paracetamol.

Stephen Sutton with his mother Jane whilst Prime Minister David Cameron visited him

Stephen Sutton with his mother Jane whilst Prime Minister David Cameron visited him

‘I got the impression they didn’t take me very seriously,’ she recalls.

Soon after, she was vomiting up to ten times a day, feeling dizzy and weak, passing blood and experiencing chronic diarrhoea. At an emergency GP appointment, she was examined by a different doctor who immediately referred her to hospital; after several days of tests, she was diagnosed with cancer.

Four days before Christmas, Hayley underwent surgery. ‘We thought we’d be enjoying our first Christmas as a family, but instead I was in hospital, grieving for the loss of our little girl and terrified about the future,’ she recalls. ‘My treatment might have been less of an ordeal if my cancer had been picked up sooner. It makes me quite angry to think if I’d been 60, it would have been picked up more quickly.’

But even obvious symptoms are often missed by doctors, says Mr Flannagan. ‘I am not blaming GPs, but we need to not be shy of pointing out where things are going wrong. The default position should be for a GP to rule out cancer, just to be safe.’

‘It can also be problematic if patients don’t have obvious symptoms such as bleeding’, says Dr Monahan. ‘They may instead have vaguer symptoms such as tiredness, unexplained weight loss or abdominal pain, which could be attributed to being symptoms of other conditions such as irritable bowel syndrome or Crohn’s disease.’

Public awareness is also an issue. A survey in March by health insurer AXA PPP found nearly half of men couldn’t name one symptom of bowel cancer.

Indeed, Martin Vickers, 49, had never heard of it before his diagnosis in 2008. ‘I was totally shocked,’ says the father of four, who lives in Burton-on-Trent with wife Andrea, 48. ‘I didn’t know bowel cancer existed. It was hugely traumatic.’

Martin visited his GP five times in nine months with extreme tiredness and loose stools. His symptoms were attributed to stress – his mother had recently died and he has a high-pressure job as head of capital investment for Cambridge and South Staffordshire Water – and then IBS.

Joining friends and family to complete a Guinness Book of Records challenge creating hearts with hands

Joining friends and family to complete a Guinness Book of Records challenge creating hearts with hands

 

‘But I knew something wasn’t right,’ says Martin. ‘It was instinctive.’ He was finally diagnosed with stage three bowel cancer in November 2008, after his GP did an internal examination and felt a lump.

Martin underwent three months of chemotherapy and radiotherapy, followed by surgery, another six months of chemotherapy and a second operation. He now has to use a colostomy bag but has been in remission for five years.

Currently, screening is only available to people aged 60-plus. They are sent home tests, which involve sending a stool sample to a lab. But the Department of Health is now looking at a new procedure, bowel scope screening, which involves a partial colonoscopy -examining only the lower bowel.

A major UK trial of 55 to 64 year olds showed that people screened this way were 43 per cent less likely to die from bowel cancer, and 33 per cent less likely to develop it.

 

Beating bowel cancer – The bottom line

This is because the procedure is usually successful at detecting small growths known as polyps, which can become cancerous.

The screening – which would be offered to everyone aged 55 and over – is now being piloted. Campaigners hope it will be made available nationally by 2016.

‘This is a really important development and should make a big difference to bowel cancer outcomes,’ says Dr Monahan, who runs the Family History of Bowel Cancer clinic at West Middlesex University Hospital, specialising in hereditary components of the disease.

It won’t, however, help younger patients such as Hayley. Before her chemotherapy, she and Paul had nine embryos frozen via IVF. However she is worried she may pass on Lynch syndrome, so the couple are considering what to do.

But she says: ‘I am still here, I have a life ahead of me – and I hope my story will help others to be diagnosed in time.’

Read more: http://www.dailymail.co.uk/health/article-2633287/Why-GPs-fail-spot-bowel-cancer-young-people-like-Stephen-late.html#ixzz32TNCY2Lm

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Bowel Cancer UK Campaign: People at high risk of bowel cancer


Bowel Cancer UKFrom Bowel Cancer UK: Read more here

Our briefing highlights the lack of surveillance screening for younger people at higher risk of bowel cancer.

Genetic factors contribute up to 30% of bowel cancer cases, an estimated 8,000-12,000 cases each year.

Genetic factors mean a strong family history of bowel cancer, or genetic conditions such as familial adenomatous polyposis (FAP) or Lynch syndrome. People with long-term inflammatory bowel disease are also at higher risk.

Research findings

People in higher risk groups are likely to develop bowel cancer much younger than the general population. Clinical guidance recommends that people in high-risk groups should be in a surveillance screening programme, which is proven to reduce deaths in these groups.

Recent evidence shows that:

  • People diagnosed are not routinely tested for genetic conditions, and only a third of centres identify and manage high-risk patients through a registry.
  • Even when they are in a surveillance programme, patients may have to wait a long time for their screening colonoscopy. Thirty-five hospitals offering a surveillance programme have a waiting time of over 26 weeks (6 months) for people at higher risk.
  • More than half of centres do not have a programme for managing high-risk groups.
  • 64% of clinicians believed that someone else should be carrying out the surveillance work.

Recommendations

Our briefing, “Never too young: Supporting people at higher risk of bowel cancer”, has five recommendations to improve services for people in high risk groups:

  1. Better surveillance screening for those at high risk of developing bowel cancer.
  2. Clear information should be made available for GPs and the public on who may be at higher risk of bowel cancer.
  3. As people with a genetic condition such as Lynch syndrome typically develop bowel cancer at a young age, anyone diagnosed with bowel cancer under the age of 50 should have a genetic test for these conditions, so they and their families can be included in a surveillance programme.
  4. Adequate endoscopy service capacity to ensure that people at high risk do not have a long wait for their colonoscopy.
  5. Designation of a single named lead person in each hospital trust with responsibility for a registry of people at higher risk.

Full details of our findings and recommendations are in our full report available here.

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Lynch Syndrome Awareness Day: March 22, 2014


Imageby Georgia Hurst, MA (Founder of Ihavelynchsyndrome.com)

Does your family have a history of early onset colon cancer? If so, your family may have Lynch syndrome.  Lynch syndrome may also increase one’s chances of developing cancers of the stomach, small intestine, liver, gallbladder ducts, upper urinary tract, kidneys, bladder, pancreas, brain, skin, and if you are a male, the prostate. Women with this syndrome also are at higher risk for developing cancer of the endometrium, ovaries, and breasts. Approximately up to 1,000,000 people in the U.S. have Lynch syndrome and yet only 5% know it. Genetic testing, along with preventative measures, and annual medical screening may help one take steps to minimize risk of illness and death.

Please visit ihavelynchsyndrome.com or Lynchcancers.com for more information.

 

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American College of Medical Genetics and Genomics (ACMG) technical standards and guidelines for genetic testing for inherited colorectal cancer


Read the original article in Genetics in Medicine (2013) Hegde et al

Lynch syndrome, familial adenomatous polyposis, and Mut Y homolog (MYH)-associated polyposis are three major known types of inherited colorectal cancer, which accounts for up to 5% of all colon cancer cases. Lynch syndrome is most frequently caused by mutations in the mismatch repair genes MLH1, MSH2, MSH6, and PMS2 and is inherited in an autosomal dominant manner. Familial adenomatous polyposis is manifested as colonic polyposis caused by mutations in the APC gene and is also inherited in an autosomal dominant manner. Finally, MYH-associated polyposis is caused by mutations in the MUTYH gene and is inherited in an autosomal recessive manner but may or may not be associated with polyps. There are variants of both familial adenomatous polyposis (Gardner syndrome—with extracolonic features—and Turcot syndrome, which features medulloblastoma) and Lynch syndrome (Muir–Torre syndrome features sebaceous skin carcinomas, and Turcot syndrome features glioblastomas). Although a clinical diagnosis of familial adenomatous polyposis can be made using colonoscopy, genetic testing is needed to inform at-risk relatives. Because of the overlapping phenotypes between attenuated familial adenomatous polyposis, MYH-associated polyposis, and Lynch syndrome, genetic testing is needed to distinguish among these conditions. This distinction is important, especially for women with Lynch syndrome, who are at increased risk for gynecological cancers. Clinical testing for these genes has progressed rapidly in the past few years with advances in technologies and the lower cost of reagents, especially for sequencing. To assist clinical laboratories in developing and validating testing for this group of inherited colorectal cancers, the American College of Medical Genetics and Genomics has developed the following technical standards and guidelines. An algorithm for testing is also proposed.

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Guest Blog: Wellcome Witnesses to Contemporary Medicine series, ‘Clinical Cancer Genetics: Polyposis and Familial Colorectal Cancer c.1975–c.2010’.


Polyposis (carpeting a rectum after a previous ileocolonic anastamosis)

Polyposis (carpeting a rectum after a previous ileocolonic anastamosis)

A history of polyposis and familial colorectal cancer

(Link to full article can be found here)

On the 25 September 2012 a meeting was held in Central London, convened by the History of Modern Biomedicine Research Group of Queen Mary, University of London, and funded by the Wellcome Trust.   Assembled were many of the men and women whose research was at the forefront of the breakthroughs that led to the identification of genes for familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC) (Lynch Syndrome) in the 1990s.

One of the most significant locations for early research into hereditary bowel cancer was St Mark’s Hospital in London, where surgeon John Percy Lockhart-Mummery (1875–1957) and pathologist Dr Cuthbert Dukes (1890–1977) were based. As Ms Kay Neale explained: ‘St Mark’s Polyposis Registry started in 1924 as a result of John Percy Lockhart-Mummery having an interest in family diseases and Dr Dukes having an interest in polyps turning into cancer.’ The Registry’s success was helped enormously by the work of Dick (later Dr) Bussey, who, aged just 17, started a meticulous system for recording patients with  FAP, a condition that had first been noted in the medical literature as early as 1882. Neale elaborated on the spread of the Registry’s impact beyond the UK: ‘Dukes, of course, would lecture and publish in the journals of the day and so people would send pathological slides or descriptions of cases of polyposis from all over the world, and Dr Bussey would record them all and catalogue them.’ Fast forward to the 1980s when Sir Walter Bodmer became Director of Research at the Imperial Cancer Research Fund (ICRF) and, during the meeting, he recalled how in 1984 he established a St Mark’s Unit at the ICRF for all aspects of colorectal cancer, as research in familial cancer began to take more shape.  The context for this growth in familial cancer research during the 1980s is discussed by Professor Tim Bishop in his introduction to the publication, along with several seminar participants who reflect on the work of the UK’s Cancer Family Study Group.

Representing a transatlantic viewpoint, Professor Jane Green from Canada moved the story into the 1990s and to HNPCC. A world away from the research lab, she tried to find familial links amongst cancer patients: ‘I spent many hours on roads in Newfoundland going to different small communities and talking to people in their homes. Every time somebody said, I’ll speak to my grandmother because she knows more of the history,’ or ‘You need to know about that other part of the family’ and they would contact them … As I put the pedigrees together they were very, very interesting.’  Her informal conversations revealed linkages, the understanding of which would be critical to the international effort that identified the MSH2 and MLH1 HNPCC-related genes in 1993. Like Jane Green’s families, patients from St Mark’s Polyposis Register were critical in providing DNA samples that helped identify APC, the gene for polyposis in 1991.

These and many other stories from the scientists, clinicians and others  involved in this significant research can be read in more depth in the published, annotated transcript of this Witness Seminar.  This volume is free to download from the Group’s website as a PDF document.

http://www.history.qmul.ac.uk/research/modbiomed/wellcome_witnesses/vol46/

Emma M Jones, Alan Yabsley

History of Modern Biomedicine Research Group
Queen Mary, University of London
Mile End Road
London E1 4NS
United Kindom

Diet & bowel cancer risk in Lynch syndrome


coverAnalysis from a recent study has found that loading up on snack foods may increase cancer risk in individuals with an inborn susceptibility to colorectal and other cancers. Published early online in Cancer, a peer-reviewed journal of the American Cancer Society, the study suggests that an eating pattern low in snack foods could help these individuals — who have a condition called Lynch syndrome — lower their risk.

Lynch syndrome is an inherited condition characterized by a high risk of developing colorectal cancer, endometrial cancer, and other cancers at an early age. The syndrome is caused by mutations in genes involved with repairing DNA within cells.

Numerous studies have investigated associations between certain foods and colorectal cancer, and now there is general agreement that red and processed meats and alcohol consumption can increase individuals’ risk. Only a few studies have evaluated lifestyle factors and colorectal cancer in patients with Lynch syndrome, though. To investigate, Akke Botma, PhD, MSc, of the Wageningen University in the Netherlands, and her colleagues collected dietary information from 486 individuals with Lynch syndrome. During an average follow-up of 20 months, colorectal polyps (precancerous lesions) were detected in 58 people in the study.

“We saw that Lynch syndrome patients who had an eating pattern with higher intakes of snack foods — like fast food snacks, chips, or fried snacks — were twice as likely to develop these polyps as Lynch syndrome patients having a pattern with lower intakes of snack foods,” said Dr. Botma.

The findings suggest that certain dietary patterns have an influence on the development of polyps in individuals with Lynch syndrome. “Unfortunately, this does not mean that eating a diet low in snack foods will prevent any polyps from developing, but it might mean that those Lynch syndrome patients who eat a lot of snack foods might have more polyps than if they ate less snack foods,” said Dr. Botma. Because the study is observational, other studies are needed to confirm the results.

Previous work from the group revealed that smoking and obesity may also increase the risk of developing colorectal polyps among individuals with Lynch Syndrome. Thus, even though they may have inherited a very high risk of developing cancer, it may be possible to affect this risk by adopting a healthy lifestyle, including a healthy diet.

Akke Botma, Hans F. A. Vasen, Fränzel J. B. van Duijnhoven, Jan H. Kleibeuker, Fokko M. Nagengast and Ellen Kampman. Dietary patterns and colorectal adenomas in Lynch syndrome : The GEOLynch Cohort Study. Cancer, 2012; DOI: 10.1002/cncr.27726

Related Articles

Lifestyle and bowel cancer risk

Lynch Syndrome in Ireland: An opportunity for cancer prevention?


English: The island of Ireland, showing intern...Lynch Syndrome is an inherited cancer syndrome which causes up to 1 in 20 cases of bowel cancer in Ireland, that is equivalent to over 100 cases annually in the Republic of Ireland alone.  It is also an important cause of multiple cancers outside the bowel including endometrial, ovarian, and urinary tract cancers.

Prevention of cancer in people at high risk depends on the accurate identification of families with this condition. However it is estimated that over 90% of families remain unidentified. Currently there are two clinical genetics centres in Ireland, in Dublin and Belfast. Unfortunately there is only limited access to genetic testing particularly in the Republic of Ireland where testing for Lynch Syndrome may only be requested from within the genetics department in Dublin.  Thus it may be argued that much more could be done to improve the management of this condition in Ireland.

Some published data indicates that Lynch Syndrome may account for up to 5% of colorectal cancer in Ireland, thus this has a highly clinically significant impact.

Resources

1. Irish Cancer Society Factsheet

2. National Centre for Medical Genetics Information

A series of published abstracts from international medical conferences have been reproduced below which summarise the available academic work on Lynch Syndrome in Ireland.

Screening an Irish cohort with colorectal cancer for Lynch Syndrome using immunohistochemistry for mismatch repair proteins

Journal of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings (Post-Meeting Edition). Vol 25, No 18S (June 20 Supplement), 2007: 10547 © 2007 American Society of Clinical Oncology. D. G. Power, M. P. Farrell, C. B. Muldoon, E. Fitzpatrick, C. Stuart, D. Flannery, M. J. Kennedy, R. B. Stephens and P. A. Daly St James’s Hospital, Dublin, Ireland Background: Large-scale screening for germ-line mutations that lead to the onset of disease in adulthood is possible owing to recent technical advances. The care of those with inherited predisposition to breast and ovarian cancer is now becoming a mainstream component of medical care. It is more difficult to identify those with Lynch Syndrome (LS) as various criteria (Amsterdam and Bethesda) have not proved definitive. An important development is the examination of tumor tissue to detect mismatch repair (MMR) protein loss using immunohistochemical (IHC) techniques. When coupled with family history those at risk of harbouring a mutation for LS can be identified. Once a mutation is identified predictive testing can be offered to family members, risk-reduction measures applied and mortality from colorectal cancer reduced. Methods: Screening for MMR protein expression (MLH1, MSH2, MSH6, PMS2) was planned on all colorectal cancer (CRC) cases using IHC on formalin-fixed tumor tissue from January 1st 2002. Local ethics committee approval was obtained and then written informed-consent from patients. Family history data was gathered from the index case or an appropriate relative. An aliquot of blood was stored from index cases for subsequent genetic screening if indicated by IHC analysis and genetic counseling. Results: 108 cases with CRC (62 male, 46 female, median age 59 years) from a potential total of 612 have been screened for MMR protein expression by a gastrointestinal pathologist and independently validated. Turn-around time for IHC analysis was 9 weeks. 5 patients (4.6%) had loss of MMR proteins, MSH2/MSH6- 2 cases, MSH6 alone- 1 case and MLH1/PMS2- 2 cases. All 5 have opted for genetic counselling and sequencing of relevant genes. Conclusion: These early results in an Irish cohort with CRC showing MMR loss in 4–5% of cases is consistent with other population findings. Microsatellite instability analysis is difficult, expensive and relatively unavailable. IHC, however, is an established technique in pathology departments and can be the cheapest and most reproducible approach to identify LS cases. IHC results along with robust family data can guide the genetic counseling process towards preventing deaths from CRC and other LS-associated cancers. Published on Meeting Library (http://meetinglibrary.asco.org)

Investigating parent of origin effects (POE) and anticipation in Irish Lynch syndrome kindreds. 

J Clin Oncol 30: 2012 (suppl 34; abstr 431) Author(s): Michael P. Farrell, David J. Hughes, Jasmin Schmid, Philip S. Boonstra, Bhramar Mukherjee, Margaret B. Walshe, Padraic M. Mac Mathuna, David J. Gallagher; Mater Private and Mater Misericordiae University Hospital, Dublin, Ireland; Centre for Systems Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Biostatistics, University of Michigan, Ann Arbor, MI; High Risk Colorectal Family Clinic, Mater Misericordiae University Hospital, Dublin, Ireland; Mater Private Hospital and Mater Misericordiae University Hospital, Dublin, Ireland

Background: Genetic diseases associated with dynamic mutations often display parent-of-origin effects (POEs) in which the risk of disease depends on the sex of the parent from whom the disease allele was inherited. Genetic anticipation describes the progressively earlier onset and increased severity of disease in successive generations of a family. Previous studies have provided limited evidence for and against both POE effect and anticipation in Lynch syndrome. We sought evidence for a specific POE effect and anticipation in Irish Lynch syndrome families. Methods: Affected parent-child pairs (APCPs) (N = 53) were evaluated from kindreds (N = 20) from two hospital-based registries of MMR mutation carriers. POE were investigated by studying the ages at diagnosis in the offspring of affected parent-child pairs. Anticipation was assessed using the bivariate Huang and Vieland model. Results: Paired t-test revealed anticipation with children developing cancer mean 11.8 years earlier than parents, and 12.7 years using the Veiland and Huang bivariate model (p < 0.001). Conclusions: These data demonstrate a similar age at diagnosis among all offspring of affected mothers that was indistinguishable from affected fathers. Affected sons of affected mothers were diagnosed with cancer almost 3 years younger than female offspring; however, this finding failed to reach statistical significance. Genetic anticipation was present in this cohort of LS families, emphasizing the importance of early-onset screening. An additional 60 LS kindreds are under review and updated data will be presented at the meeting. POE effect: comparison in age at diagnosis in 53 affected parent-child pairs with Lynch syndrome associated malignancies. Affected mothers Affected fathers P value Unique parent N = 14 N = 13 0.28 Mean = 48.8 Mean = 53.6 Range = 27-73 Range = 36-85 All offspring N = 24 N = 30 0.67 Mean = 40.4 Mean = 41.6 Range = 23-72 Range = 23-60 Female offspring N = 6 N = 15 0.75 Mean = 42.5 Mean = 41.06 Range = 31-64 Range = 27-58 Male offspring N = 18 N = 15 0.94 Mean = 39.77 Mean = 40.07 Range 23-72 Range = 20-60 P value female vs male offspring 0.604 0.95 ________________________________________ Source URL: http://meetinglibrary.asco.org/content/106059-133 Published on Meeting Library (http://meetinglibrary.asco.org) Home > 88749-115 ________________________________________ 88749-115

Breast cancer in Irish families with Lynch syndrome.

J Clin Oncol 30, 2012 (suppl 4; abstr 413) Author(s): E. J. Jordan, M. P. Farrell, R. M. Clarke, M. R. Kell, J. A. McCaffrey, E. M. Connolly, T. Boyle, M. J. Kennedy, P. J. Morrison, D. J. Gallagher; Mater University Hospital, Dublin, Ireland; St. James Hospital, Dublin, Ireland; Mater University Hospital , Dublin , Ireland; Belfast City Hospital HSCTrust, Belfast, Northern Ireland Background: Breast cancer is not a recognised malignant manifestation of Lynch Syndrome which includes colorectal, endometrial, gastric, ovarian and upper urinary tract tumours. In this study we report the prevalence of breast cancer in Irish Lynch Syndrome families and determine immunohistochemical expression of mismatch repair proteins (MMR) in available breast cancer tissue. Methods: Breast cancer prevalence was determined among Lynch Syndrome kindreds from two institutions in Ireland, and a genotype phenotype correlation was investigated. One kindred was omitted due to the presence of a biallelic MMR and BRCA1 mutation. The clinicopathological data that was collected on breast cancer cases included age of onset, morphology, and hormone receptor status. Immunohistochemical staining was performed for MLH1, MSH2, MSH6, and PMS2 on all available breast cancer tissue from affected individuals. Results: The distribution of MMR mutations seen in 16 pedigrees was as follows; MLH1 (n=5), MSH2 (7), MSH6 (3), PMS2 (1). Sixty cases of colorectal cancer and 14 cases of endometrial cancer were seen. Seven breast cancers (5 invasive ductal and 2 invasive lobular cancers) and 1 case of ductal carcinoma in situ were reported in 7 pedigrees. This compared with 4 cases of prostate cancer. Six MSH2 mutations and 1 MSH6 mutation were identified in the 7 Lynch syndrome kindreds. Median age of breast cancer diagnosis was 49 years (range 38-57). Hormone receptor status is available on 3 breast cancer cases at time of abstract submission; all were ER positive and HER 2 negative. All cases had grade 2 or 3 tumours. Final results of immunohistochemistry for mismatch repair protein expression on breast cancer samples are pending and will be reported at the meeting. One breast cancer has been tested to date and demonstrated loss of MSH2 protein expression in an individual carrying an MSH2 mutation. Conclusions: Breast cancer occurred at an early age and was more common than prostate cancer in Irish Lynch Syndrome pedigrees. All reported breast cancer cases were in kindreds with MSH2 or MSH6 mutations. Enhanced breast cancer screening may be warranted in certain Lynch Syndrome kindreds. ________________________________________ Source URL: http://meetinglibrary.asco.org/content/88749-115

Clinical correlation and molecular evaluation confirm that the MLH1 p.Arg182Gly (c.544A>G) mutation is pathogenic and causes Lynch syndrome.

Fam Cancer. 2012 Sep;11(3):509-18. doi: 10.1007/s10689-012-9544-4.Farrell MP, Hughes DJ, Berry IR, Gallagher DJ, Glogowski EA, Payne SJ, Kennedy MJ, Clarke RM, White SA, Muldoon CB, Macdonald F, Rehal P, Crompton D, Roring S, Duke ST, McDevitt T, Barton DE, Hodgson SV, Green AJ, Daly PA. Source Department of Cancer Genetics, Mater Private Hospital, Dublin 7, Ireland. farrelm7@tcd.ie

Approximately 25 % of mismatch repair (MMR) variants are exonic nucleotide substitutions. Some result in the substitution of one amino acid for another in the protein sequence, so-called missense variants, while others are silent. The interpretation of the effect of missense and silent variants as deleterious or neutral is challenging. Pre-symptomatic testing for clinical use is not recommended for relatives of individuals with variants classified as ‘of uncertain significance’. These relatives, including non-carriers, are considered at high-risk as long as the contribution of the variant to disease causation cannot be determined. This results in continuing anxiety, and the application of potentially unnecessary screening and prophylactic interventions. We encountered a large Irish Lynch syndrome kindred that carries the c.544A>G (p.Arg182Gly) alteration in the MLH1 gene and we undertook to study the variant. The clinical significance of the variant remains unresolved in the literature. Data are presented on cancer incidence within five kindreds with the same germline missense variant in the MLH1 MMR gene. Extensive testing of relevant family members in one kindred, a review of the literature, review of online MMR mutation databases and use of in silico phenotype prediction tools were undertaken to study the significance of this variant. Clinical, histological, immunohistochemical and molecular evidence from these families and other independent clinical and scientific evidence indicates that the MLH1 p.Arg182Gly (c.544A>G) change causes Lynch syndrome and supports reclassification of the variant as pathogenic. PMID: 22773173 [PubMed – indexed for MEDLINE]

Germline MSH6 mutations are more prevalent in endometrial cancer patient cohorts than Hereditary Non Polyposis Colorectal Cancer cohorts

Ulster Med J. 2008 January; 77(1): 25–30. PMCID: PMC2397009 Lisa A Devlin,1 Colin A Graham,1 John H Price,2 and Patrick J Morrison1

Objective To determine and compare the prevalence of MSH6 (a mismatch repair gene) mutations in a cohort of families with Hereditary Non-Polyposis Colorectal Cancer (HNPCC), and in an unselected cohort of endometrial cancer patients (EC). Design Two patient cohorts participated in the study. A cohort of HNPCC families who were known to the Regional Medical Genetics department, and an unselected cohort of patients with a history of EC. All participants received genetic counselling on the implications of molecular testing, and blood was taken for DNA extraction with consent. All samples underwent sequencing and Multiple Ligation probe analysis (MLPA) for mutations in MSH6. Populations DNA from one hundred and forty-three probands from HNPCC families and 125 patients with EC were included in the study. Methods Molecular analysis of DNA in all participants from both cohorts for mutations in MSH6. Outcome measures Prevalence of pathogenic mutations in MSH6. Results A truncating mutation in MSH6 was identified in 3.8% (95% CI 1.0–9.5%) of patients in the endometrial cancer cohort, and 2.6% (95% CI 0.5–7.4%) of patients in the HNPCC cohort. A missense mutation was identified in 2.9% and 4.4% of the same cohorts respectively. No genomic rearrangements in MSH6 were identified. Conclusion MSH6 mutations are more common in EC patients than HNPCC families. Genomic rearrangements do not contribute to a significant proportion of mutations in MSH6, but missense variants are relatively common and their pathogenicity can be uncertain. HNPCC families may be ascertained through an individual presenting with EC, and recognition of these families is important so that appropriate cancer surveillance can be put in place. Keywords: Endometrial, Cancer, MSH6, HNPCC

Guest blog from Georgia Hurst, Lynch Syndrome ‘previvor’: “I will not get sick”


A guest blog from Georgia Hurst, as she worries about the impact of her diagnosis of Lynch Syndrome on her son.  Read more at ihavelynchsyndrome.com

“I will not get sick, but if I do…

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…I will have the strength to endure it.”

This is my new mantra. The above photo is the view from my zafu when I go to Buddhist Temple for meditation; the solace this gives me is immeasurable. I have been finding myself at Temple a lot lately, meditating and reaching for my internal strength to deal with the unbearable anxiety and stress which currently confront me. I’m trying not to discuss it with people; it’s too much for me to process, let alone them. Besides, I feel as though I put them into a precarious position if I do bring it up because there are no words available to them which can possibly comfort me at this time. I am going to Mayo Clinic in 11 days and the anxiety is increasing by the minute. I am expecting the worst, whilst hoping for the best. I’m sure I am not the only one with Lynch syndrome that feels this way when it’s close to testing time. The plethora of emotions are running rampant in me little head. I feel guilt. My oldest brother did not have a chance, my second brother does not have a colon – and then I think of all of the people I’ve met through my blog and Facebook and other forms of social media who are fighting for their lives because they, too, have been blindsided by this genetic curse. Damn you, Lynch syndrome. I feel anger because I may have given this to my beautiful little boy. If I knew for sure that this monster ended with me with 100% certainty, I would at least not have to fret about my child. I also feel anger for all the children who are watching their parents suffer and die, leaving them with a life of endless uncertainties and insecurities. I feel sad, not for myself, but for my family, my dog, and my friends; because I know that part of you dies when someone you love dies. I feel lucky; I’m fortunate to know I have this genetic mutation, have insurance, and have the ability to exhibit some control of it; I get to go Mayo and get see the Rock Star Doctors of Lynch syndrome. I feel confident; I keep reminding myself that I eat well, exercise, surround myself with loving, nourishing people, animals, books, etc., and have eliminated every imaginable toxin in my life. I feel fearless and empowered in many ways; yet, helpless in so many others. I vacillate between optimism and negativity; perhaps I should simply stop it and end up somewhere in the middle. I am exhausted, whilst I exhibit every possible emotion known to humanity. I long for the days when I didn’t know of my charming genetic nemesis and wasn’t emotionally imprisoned by Lynch syndrome. I would give everything I have to simply appreciate a few minutes of life sans Lynch. Two weeks from today, I will know if everything I talk about truly matters or if my genetics will trump everything I think and do. I just want spend the next several days being fearless. Fearless. Fearless. Fearless. In the eloquent words of Tagore: Let me not pray to be sheltered from dangers but to be fearless in facing them. Let me not beg for the stilling of my pain but for the heart to conquer it. Let me not look for allies in life’s battlefield but to my own strength. Let me not cave in… Yours, Georgia Hurst, MA ihavelynchsyndrome.com This post was written in late April before I went to the Mayo Clinic in early May for my annual testing; I received a clean bill of health and not even one little polyp was found in my colon.

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