Cancer Genetics Overview (PDQ®)

As a National Cancer Institute (NCI)-designated Comprehensive Cancer Center, a core part of our mission is to educate patients and the community about cancer. The following summary is trusted information from the NCI.

Introduction

Many of the medical and scientific terms used in this summary are found in the NCI Dictionary of Genetics Terms. When a linked term is clicked, the definition will appear in a separate window.

The etiology of cancer is multifactorial, with genetic, environmental, medical, and lifestyle factors interacting to produce a given malignancy. Knowledge of cancer genetics is rapidly improving our understanding of cancer biology, helping to identify at-risk individuals, furthering the ability to characterize malignancies, establishing treatment tailored to the molecular fingerprint of the disease, and leading to the development of new therapeutic modalities. As a consequence, this expanding knowledge base has implications for all aspects of cancer management, including prevention, screening, and treatment.

Genetic information provides a means of identifying people who have an increased risk of cancer. Sources of genetic information include biologic samples of DNA, information derived from a person's family history of disease, findings from physical examinations, and medical records. DNA-based information can be gathered, stored, and analyzed at any time during an individual's life span, from before conception to after death. Family history may identify people with a modest to moderately increased risk of cancer or may serve as the first step in the identification of an inherited cancer predisposition that confers a very high lifetime risk of cancer. For an increasing number of diseases, DNA-based testing can be used to identify a specific mutation as the cause of inherited risk and to determine whether family members have inherited the disease-related mutation.

The proportion of individuals carrying a mutation who will manifest the disease is referred to as penetrance. In general, common genetic variants that are associated with cancer susceptibility have a lower penetrance than rare genetic variants. This is depicted in Figure 1. For adult-onset diseases, penetrance is usually described by the individual carrier's age and sex. For example, the penetrance for breast cancer in female BRCA1/BRCA2 mutation carriers is often quoted by age 50 years and by age 70 years. Of the numerous methods for estimating penetrance, none are without potential biases, and determining an individual mutation carrier's risk of cancer involves some level of imprecision. Figure 1. Genetic architecture of cancer risk. This graph depicts the general finding of a low relative risk associated with common, low-penetrance genetic variants, such as single-nucleotide polymorphisms identified in genome-wide association studies, and a higher relative risk associated with rare, high-penetrance genetic variants, such as mutations in the BRCA1/ BRCA2 genes associated with hereditary breast and ovarian cancer and the mismatch repair genes associated with Lynch syndrome.

Throughout this summary, the term "mutation" will be used to refer to a change in the usual DNA sequence of a particular gene. Mutations can have harmful, beneficial, neutral, or uncertain effects on health and may be inherited as autosomal dominant, autosomal recessive, or X-linked traits. Mutations that cause serious disability early in life are usually rare because of their adverse effect on life expectancy and reproduction. However, if the mutation is autosomal recessive—that is, if the health effect of the mutation is caused only when two copies (one from each parent) of the mutated gene are inherited—mutation carriers (healthy people carrying one copy of the altered gene) may be relatively common in the general population. "Common" in this context refers, by convention, to a prevalence of 1% or more. Mutations that cause health effects in middle and older age, including several mutations known to cause a predisposition to cancer, may also be relatively common. Many cancer-predisposing traits are inherited in an autosomal dominant fashion, that is, the cancer susceptibility occurs when only one copy of the altered gene is inherited. For autosomal dominant conditions, the term "carrier" is often used in a less formal manner to denote people who have inherited the genetic predisposition conferred by the mutation. Refer to individual PDQ summaries focused on the genetics of specific cancers for detailed information on known cancer-susceptibility syndromes.

Increasingly, the public is turning to the Internet for information related both to familial and genetic susceptibility to cancer and to genetic risk assessment and testing. Direct-to-consumer marketing of genetic testing for hereditary breast and colon cancer is also taking place in some communities. This wider availability of information related to inherited cancer risk may raise concerns among persons previously unaware of the implications inherent in their family histories and may lead some of these individuals to consult their primary care physicians for management advice and recommendations. In many instances, the evaluation and advice will be relatively straightforward for physicians with a basic knowledge of familial cancer. In a subset of patients, the evaluation may be more complex, calling for referral to genetics professionals for further evaluation and counseling.

Correctly recognizing and identifying individuals and families at increased risk of developing cancer is one of countless important roles for primary care and other health care providers. Once identified, these individuals can then be appropriately referred for genetic counseling, risk assessment, consideration of genetic testing, and development of a management plan. When medical and family histories reveal cardinal clues to the presence of an underlying familial or genetic cancer susceptibility disorder (see list below), further evaluation may be warranted. (Refer to the PDQ summary on Cancer Genetics Risk Assessment and Counseling for more information about the components of a genetics cancer risk assessment.)

Features of hereditary cancer include the following:

  • In the individual patient:
    • Multiple primary tumors in the same organ.
    • Multiple primary tumors in different organs.
    • Bilateral primary tumors in paired organs.
    • Multifocality within a single organ (e.g., multiple tumors in the same breast, all of which have risen from one original tumor).
    • Younger-than-usual age at tumor diagnosis.
    • Tumors with rare histology.
    • Tumors occurring in the sex not usually affected (e.g., breast cancer in men).
    • Tumors associated with other genetic traits.
    • Tumors associated with congenital defects.
    • Tumors associated with an inherited precursor lesion.
    • Tumors associated with another rare disease.
    • Tumors associated with cutaneous lesions known to be related to cancer susceptibility disorders (e.g., the genodermatoses).
  • In the patient's family:
    • One first-degree relative with the same or a related tumor and one of the individual features listed.
    • Two or more first-degree relatives with tumors of the same site.
    • Two or more first-degree relatives with tumor types belonging to a known familial cancer syndrome.
    • Two or more first-degree relatives with rare tumors.
    • Three or more relatives in two generations with tumors of the same site or etiologically related sites.

Concluding that an individual is at increased risk of developing cancer may have important, potentially life-saving management implications and may lead to specific interventions aimed at reducing risk (e.g., tamoxifen for breast cancer, colonoscopy for colon cancer, or risk-reducing salpingo-oophorectomy for ovarian cancer). Information about familial cancer risk may also inform a person's ability to plan for the future (lifestyle and health care decisions, family planning, or other decisions). Genetic information may also provide a direct health benefit by demonstrating the lack of an inherited cancer susceptibility. For example, if a family is known to carry a cancer-predisposing mutation in a particular gene, a family member may experience reduced worry and lower health care costs if his or her genetic test indicates that he or she does not carry the family's disease-related mutation. Conversely, information about familial cancer risk may have psychological effects or social costs (e.g., worry, guilt, or increased health care costs). Family dynamics also may be affected. For instance, the involvement of one or more family members may be required for genetic testing to be informative, and parents may feel guilt about passing inherited risk on to their children.

Knowledge about a cancer-predisposing mutation can be informative not only for the individual tested but also for other family members. Family members who previously had not considered the implications of their family history for their own health may be led to do so, and some will undergo genetic testing, resulting in more definitive information on whether they are at increased genetic risk. Some relatives may learn their mutation status without being directly tested, for example, when a biological parent of a child who is a known mutation carrier is identified as an obligate carrier. Founder effects may result in the recognition that specific ethnic groups have a higher prevalence of certain mutations, knowledge that can be either clinically useful (permitting more rational genetic testing strategies) or potentially stigmatizing. Testing may reveal the presence of nonpaternity in a family. There is the theoretical possibility that genetic information may be misused, and concerns about the potential for insurance and/or employment discrimination may arise. Genetic information may also affect medical and lifestyle decisions.

Refer to individual PDQ summaries for available evidence addressing all ancillary issues.

References:
  • Lindor NM, McMaster ML, Lindor CJ, et al.: Concise handbook of familial cancer susceptibility syndromes - second edition. J Natl Cancer Inst Monogr (38): 1-93, 2008.

Genetic Counseling

Genetic counseling is a process of communication between genetics professionals and patients with the goal of providing individuals and families with information on the relevant aspects of their genetic health, available testing and management options, and support as they move toward understanding and incorporating this information into their daily lives. Genetic counseling generally involves the following six steps:

  1. Family and medical history assessment.
  2. Analysis of genetic information.
  3. Communication of genetic information.
  4. Education about inheritance, genetic testing, management, risk reduction, resources, and research opportunities.
  5. Supportive counseling to facilitate informed choices and adaptation to the risk or condition.
  6. Follow-up.

Genetic evaluation involves an interaction with a medical geneticist or other genetics professional and may include a physical examination and diagnostic testing, in addition to genetic counseling. The principles of voluntary and informed decision making, nondirective and noncoercive counseling, and protection of client confidentiality and privacy are central to the philosophy of genetic counseling. (Refer to the PDQ summary on Cancer Genetics Risk Assessment and Counseling for more information on the nature and history of genetic counseling.)

From the mid-1990s to the mid-2000s, genetic counseling expanded to include discussion of genetic testing for cancer risk, as more genes associated with inherited cancer risk were discovered. Cancer genetic counseling often involves a multidisciplinary team of health professionals that may include a genetic counselor, an advanced practice genetics nurse, or a medical geneticist; a mental health professional; and various medical experts such as an oncologist, surgeon, or internist. The process of counseling may require a number of visits to address medical, genetic testing, and psychosocial issues. Even when cancer risk counseling is initiated by an individual, inherited cancer risk has implications for the entire family. Because genetic risk affects an unknown number of biological relatives, contact with these relatives is often essential to collect accurate family and medical histories. Cancer genetic counseling may involve several family members, some of whom will have had cancer and others who have not.

The impact of risk assessment and predisposition genetic testing is improved health outcomes. The information derived from risk assessment and/or genetic testing allows the health care provider to tailor an individual approach to health promotion and optimize long-term health outcomes through the identification of at-risk individuals before cancer develops. The health care provider can thus intervene earlier either to reduce the risk or diagnose a cancer at an earlier stage, when the chances for effective treatment are greatest. The information may be used to modify the management approach to an initial cancer, clarify the risks of other cancers, or predict the response of an existing cancer to specific forms of treatment, all of which may alter treatment recommendations and long-term follow-up.

References:
  • Resta R, Biesecker BB, Bennett RL, et al.: A new definition of Genetic Counseling: National Society of Genetic Counselors' Task Force report. J Genet Couns 15 (2): 77-83, 2006.
  • Baker DL, Schuette JL, Uhlmann WR, eds.: A Guide to Genetic Counseling. New York, NY: Wiley-Liss, 1998.
  • Bartels DM, LeRoy BS, Caplan AL, eds.: Prescribing Our Future: Ethical Challenges in Genetic Counseling. New York, NY: Aldine de Gruyter, 1993.
  • Kenen RH: Genetic counseling: the development of a new interdisciplinary occupational field. Soc Sci Med 18 (7): 541-9, 1984.
  • Kenen RH, Smith AC: Genetic counseling for the next 25 years: models for the future. J Genet Couns 4 (2): 115-24, 1995.

Familial Cancer Susceptibility Syndromes

Individual PDQ summaries focused on the genetics of specific cancers contain detailed information about many known cancer susceptibility syndromes. Although this is not a complete list, the following cancer susceptibility syndromes are discussed in the PDQ cancer genetics summaries (listed in parentheses following the syndromes):

Methods of Genetic Analysis and Gene Discovery

Linkage Analyses

The recognition that cancer clusters within families has led many investigators to collect data on multiple-case families with the goal of localizing cancer susceptibility genes through linkage studies.

Linkage studies are typically performed on high-risk kindreds, in whom multiple cases of a particular disease have occurred, in an effort to identify disease susceptibility genes. Linkage analysis statistically compares the genotypes between affected and unaffected individuals and looks for evidence that known genetic markers are inherited along with the disease trait. If such evidence is found (linkage), it provides statistical data that the chromosomal region near the marker also harbors a disease susceptibility gene. Once a genomic region of interest has been identified through linkage analysis, additional studies are required to prove that there truly is a susceptibility gene at that position. Linkage analysis is affected by the following:

  • Family size and having a sufficient number of family members who volunteer to contribute DNA.
  • The number of disease cases in each family.
  • Factors related to age at disease onset (e.g., utilization of screening).
  • Gender differences in disease risk (not relevant in gender-specific cancers).
  • Heterogeneity of disease in cases (e.g., aggressive vs. nonaggressive phenotype).
  • The accuracy of family history information.
  • Prevalence of phenocopies.

An additional issue in linkage studies is the background rate of sporadic cancer in the context of family studies. For example, because a man's lifetime risk of prostate cancer is one in seven, it is possible that families under study have both inherited and sporadic prostate cancer cases. Thus, men who do not inherit the prostate cancer susceptibility gene that is segregating in their family may still develop prostate cancer.

One way to address inconsistencies between linkage studies is to require inclusion criteria that defines clinically significant disease. This approach attempts to define a homogeneous set of cases/families to increase the likelihood of identifying a linkage signal. It also prevents the inclusion of cases that may be considered clinically insignificant that were identified by screening in families.

Investigators have also incorporated clinical parameters into linkage analyses with the goal of identifying genes that may influence disease severity. This type of approach, however, has not yet led to the identification of consistent linkage signals across datasets.

Genome-wide Association Studies (GWAS)

GWAS are showing great promise in identifying common, low-penetrance susceptibility alleles for many complex diseases, including cancer. This approach can be contrasted with linkage analysis, which searches for genetic-risk variants cosegregating within families that have a high prevalence of disease. While linkage analyses are designed to uncover rare, highly penetrant variants that segregate in predictable heritance patterns (e.g., autosomal dominant, autosomal recessive, X-linked, and mitochondrial), GWAS are best suited to identify multiple, common, low-penetrance genetic polymorphisms. GWAS are conducted under the assumption that the genetic underpinnings of complex phenotypes, such as prostate cancer, are governed by many alleles, each conferring modest risk. Most genetic polymorphisms genotyped in GWAS are common, with minor allele frequencies greater than 1% to 5% within a given population (e.g., men of European ancestry). GWAS capture a large portion of common variation across the genome. The strong correlation between many alleles located close to one another on a given chromosome (called linkage disequilibrium) allows one to "scan" the genome without having to test all 10 million known single nucleotide polymorphisms (SNPs). With GWAS, researchers can test 500,000 to 1 million SNPs per study and ascertain almost all common inherited variants in the genome.

In a GWAS, allele frequency for each SNP is compared between cases and controls. Promising signals—in which allele frequencies deviate significantly in case and control populations—are validated in replication cohorts. To have adequate statistical power to identify variants associated with a phenotype, large numbers of cases and controls, typically thousands of each, are studied. Because up to 1 million SNPs are evaluated in a GWAS, false-positive findings are expected to occur frequently when using standard statistical thresholds. Therefore, stringent statistical rules are used to declare a positive finding, usually using a threshold of P < 1 × 10-7.

To date, well over 100 cancer-risk variants have been identified by well-powered GWAS and validated in independent cohorts. These studies have revealed convincing associations between specific inherited variants and cancer risk. However, the findings should be qualified with a few important considerations:

  1. GWAS reported thus far have been designed to identify relatively common genetic polymorphisms. It is very unlikely that an allele with high frequency in the population by itself contributes substantially to cancer risk. This, coupled with the polygenic nature of tumorigenesis, means that the contribution by any single variant identified by GWAS to date is quite small, generally with an odds ratio for disease risk of less than 1.5. In addition, despite extensive genome-wide interrogation of common polymorphisms in tens of thousands of cases and controls, GWAS findings to date do not account for even half of the genetic component of cancer risk.
  2. Variants uncovered by GWAS are not likely to directly contribute to disease risk. As mentioned above, SNPs exist in linkage disequilibrium blocks and are merely proxies for a set of variants—both known and previously undiscovered—within a given block. The causal allele is located somewhere within that linkage disequilibrium block.
  3. Admixture by groups of different ancestry can confound GWAS findings (i.e., a statistically significant finding could reflect a disproportionate number of subjects in the cases versus controls, rather than a true association with disease). Therefore, GWAS are typically powered to analyze a single predominant ancestral group. As a result, many populations remain underrepresented in genome-wide analyses.

The implications of these points are discussed in greater detail in the PDQ summaries on Genetics of Breast and Ovarian Cancer; Genetics of Colorectal Cancer; and Genetics of Prostate Cancer. Additional details can be found elsewhere.

References:
  • American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014. Available online. Last accessed May 21, 2014.
  • Stanford JL, McDonnell SK, Friedrichsen DM, et al.: Prostate cancer and genetic susceptibility: a genome scan incorporating disease aggressiveness. Prostate 66 (3): 317-25, 2006.
  • Chang BL, Isaacs SD, Wiley KE, et al.: Genome-wide screen for prostate cancer susceptibility genes in men with clinically significant disease. Prostate 64 (4): 356-61, 2005.
  • Lange EM, Ho LA, Beebe-Dimmer JL, et al.: Genome-wide linkage scan for prostate cancer susceptibility genes in men with aggressive disease: significant evidence for linkage at chromosome 15q12. Hum Genet 119 (4): 400-7, 2006.
  • Witte JS, Goddard KA, Conti DV, et al.: Genomewide scan for prostate cancer-aggressiveness loci. Am J Hum Genet 67 (1): 92-9, 2000.
  • Witte JS, Suarez BK, Thiel B, et al.: Genome-wide scan of brothers: replication and fine mapping of prostate cancer susceptibility and aggressiveness loci. Prostate 57 (4): 298-308, 2003.
  • Slager SL, Zarfas KE, Brown WM, et al.: Genome-wide linkage scan for prostate cancer aggressiveness loci using families from the University of Michigan Prostate Cancer Genetics Project. Prostate 66 (2): 173-9, 2006.
  • Slager SL, Schaid DJ, Cunningham JM, et al.: Confirmation of linkage of prostate cancer aggressiveness with chromosome 19q. Am J Hum Genet 72 (3): 759-62, 2003.
  • Wellcome Trust Case Control Consortium: Genome-wide association study of 14,000 cases of seven common diseases and 3,000 shared controls. Nature 447 (7145): 661-78, 2007.
  • The International HapMap Consortium: The International HapMap Project. Nature 426 (6968): 789-96, 2003.
  • Thorisson GA, Smith AV, Krishnan L, et al.: The International HapMap Project Web site. Genome Res 15 (11): 1592-3, 2005.
  • Evans DM, Cardon LR: Genome-wide association: a promising start to a long race. Trends Genet 22 (7): 350-4, 2006.
  • Cardon LR: Genetics. Delivering new disease genes. Science 314 (5804): 1403-5, 2006.
  • Chanock SJ, Manolio T, Boehnke M, et al.: Replicating genotype-phenotype associations. Nature 447 (7145): 655-60, 2007.
  • Ioannidis JP, Castaldi P, Evangelou E: A compendium of genome-wide associations for cancer: critical synopsis and reappraisal. J Natl Cancer Inst 102 (12): 846-58, 2010.
  • Jorgenson E, Witte JS: Genome-wide association studies of cancer. Future Oncol 3 (4): 419-27, 2007.

Clinical Sequencing

Introduction

Broad-scale genome sequencing approaches, including multigene panel testing, whole-exome sequencing (WES), and whole-genome sequencing (WGS), are rapidly being developed and incorporated into a spectrum of clinical oncologic settings, including cancer therapeutics and cancer risk assessment. Several institutions and companies offer tumor sequencing, and institutions are developing "precision medicine" programs that sequence tumor genomes to identify driver genetic alterations that are targetable for therapeutic benefit to patients. Many of these tumor-based approaches use reference germline DNA sequences to identify pathogenic alterations, which can also provide information on inherited risk of cancers in families. In the genetic counseling and cancer risk assessment–setting, the use of gene panel testing to evaluate inherited cancer risk is becoming more common and may become routine in the near future, with institutions and companies offering gene panel testing to detect alterations in a host of cancer risk–associated genes.

These advances in gene sequencing technologies also identify alterations in genes related to the primary indication for ordering genetic sequence testing, along with findings not related to the disorder being tested. The latter genetic findings, termed incidental or secondary findings, are currently a source of significant clinical, ethical, legal, and counseling debate. This section was created to provide information about genomic sequencing technologies in the context of clinical sequencing and highlights additional areas of clinical uncertainty for which further research and approaches are needed.

Background

DNA sequencing technologies have undergone rapid evolution, particularly since 2005 when massively parallel sequencing, or next-generation sequencing (NGS), was introduced.

Automated Sanger sequencing is considered the first generation of sequencing technology. Sanger cancer gene sequencing uses polymerase chain reaction (PCR) amplification of genetic regions of interest followed by sequencing of PCR products using fluorescently labeled terminators, capillary electrophoresis separation of products, and laser signal detection of nucleotide sequence. While this is an accurate sequencing technology, the main limitations of Sanger sequencing include low throughput, a limited ability to sequence more than a few genes at a time, and the inability to detect structural rearrangements.

NGS refers to high throughput DNA sequencing technologies that are capable of processing multiple DNA sequences in parallel. Although platforms differ in template generation and sequence interrogation, the overall approach to NGS technologies involves shearing and immobilizing DNA template molecules onto a solid surface, which allows separation of molecules for simultaneous sequencing reactions (millions to billions) to be performed in a parallel fashion. Thus, the major advantages of NGS technologies include the ability to sequence thousands of genes at one time, a lower cost, and the ability to detect multiple types of genomic alterations such as insertions, deletions, copy number alterations, and rearrangements. Limitations include the possibility that specific gene regions may be missed, turnaround time can be lengthy (although it is decreasing), and informatics support to handle massive amounts of genetic data has lagged behind the sequencing capability. A well-recognized bottleneck to utilizing NGS data is the need for advanced computational infrastructure to preserve, process, and analyze the vast amount of genetic data. The magnitude of the variants obtained from NGS is exponential; bioinformatics approaches need to evaluate genetic variants for predicted functional consequence in disease biology. There is also a need for user-friendly bioinformatics pipelines to analyze and integrate genetic data to influence the scientific and medical community.

The following terms need to be defined to understand the clinical application of NGS testing and implications of results reported.

  • Germline alteration: A gene change in a reproductive cell (egg or sperm) that becomes incorporated into the DNA of every cell in the body of the offspring. A germline mutation is passed on from parent to offspring. Also called hereditary mutation. (NCI Dictionary of Cancer Terms)
  • Somatic alteration: An alteration in DNA that occurs after conception. Somatic mutations can occur in any of the cells of the body except the germ cells (sperm and egg) and therefore are not passed on to children. These alterations can (but do not always) cause cancer or other diseases. (NCI Dictionary of Cancer Terms)
  • Incidental findings: Genetic test results that are not related to the indication for ordering the sequencing but that may be of medical value or utility to the ordering physician, the patient, or his or her family. (Adapted from )
  • Actionable genetic alteration: The presence or absence of a genetic mutation in a tumor or the germline that can be used to inform clinical management. (Adapted from ).

Emerging Clinical Application

NGS has multiple potential clinical applications. In oncology, the two dominant applications are: 1) the assessment of somatic alterations in tumors to inform prognosis and/or targeted therapeutics; and 2) the assessment of the germline to identify cancer risk alleles.

Somatic testing

There are multiple approaches to tumor testing for somatic alterations. With targeted gene panel testing, a number of different genes can be assessed simultaneously. These targeted panels can differ substantially in the genes that are included, and they can be tailored to individual tumor types. Targeted gene panels limit the data to be analyzed and include only known genes, which makes the interpretation more straightforward than in whole exome or whole genome techniques. In addition, greater depth of coverage is possible with targeted panels, compared with WES or WGS. Depth of coverage refers to the number of times a nucleotide has been sequenced; a greater depth of coverage has fewer sequencing errors. Deep coverage also aids in differentiating sequencing errors from single nucleotide polymorphisms.

WES and WGS are far more extensive techniques and aim to uncover mutations in known genes and in genes not suspected a priori. The discovery of a mutation that is unexpected for a particular tumor type can lead to the use of a directed therapeutic, which could improve patient outcomes. WES generates sequence data of the coding regions of the genome (representing approximately 1% of the human genome), rather than the entire genome (WGS). Consequently, WES is less expensive than WGS.

Noncoding variants can be identified using WGS but cannot be identified using WES. The use of WGS is limited by cost and the vast bioinformatics needed for interpretation. Although the costs of sequencing have dropped precipitously, the analysis remains formidable.

Although the goal of WES and WGS is to improve patient care by detecting actionable genetic mutations (mutations that can be targeted therapeutically), a number of issues warrant consideration. This testing may detect deleterious mutations, variants of uncertain significance, or no detectable abnormalities. In addition, deleterious mutations can be found in genes that are thought to be clearly related to tumorigenesis but can also be detected in genes with unclear relevance (particularly with WES and WGS approaches). Variants of uncertain significance have unclear implications as they may, or may not, disrupt the function of the protein. The definition of actionable can vary, but often this term is used when an aberration, if found, would lead to recommendations against certain treatments (such as mutations in ras) for which a clinical trial is available, or for which there is a known targeted drug. Although there are case reports of success with this approach, it is unlikely to be straightforward. Studies are ongoing.

Some commercial and single-institution assays test only the tumor. Clearly deleterious mutations found in important genes in the tumor can be somatic but could also be from the germline. In situations in which somatic analysis is paired with a germline analysis, it is known whether the alteration is inherited; when somatic analysis only is performed, it is not known. Reported allelic frequencies of the mutation in the somatic analysis can provide clues, but they are not always reported by laboratories and do not give a definitive answer. As many medical professionals do not have a deep understanding of genetics, guidance as to when to proceed to germline testing would be valuable.

Germline testing

The goal of germline testing is to identify mutations associated with an inherited risk of cancer and to guide cancer risk–management decisions. Also, germline testing can aid in some management decisions at the time of diagnosis (e.g., decisions about colectomy in Lynch syndrome–related colon cancer and contralateral mastectomy in BRCA1/2 mutation carriers). In addition, there are emerging data that germline status may help determine systemic therapy (e.g., the use of cisplatin or PARP inhibitors in BRCA1/2-related cancer).

To date, most germline genetic testing has been performed in a targeted manner, looking for the gene(s) associated with a clinical picture (e.g., BRCA1 and BRCA2 in hereditary breast and ovarian cancer; or the mismatch repair [MMR] genes in Lynch syndrome). However, multiple targeted gene panels now available commercially or within an institution contain different sets of genes. Some are targeted to all cancers, others to specific cancers (e.g., breast, colon, or prostate cancers). The genes on the panels include high penetrance genes related to the specific tumor (such as BRCA1/2 on a breast cancer panel); high penetrance genes related to a different type of cancer but with a more moderate risk for the tumor of reference (such as CDH1 or MSH6 on a breast cancer panel); and moderate penetrance genes for which clinical utility is uncertain (such as NBN on a breast cancer panel). Because multiple genes are included on these panels, it is anticipated that many, and perhaps most, individuals undergoing testing on using these panels will be found to have at least one variant of unknown significance. As it is not possible to do standard pretest counseling models for a panel of 20 genes, new counseling models are needed. Ethical issues of whether patients can opt out of specific results (such as TP53 or CDH1 in breast cancer) and how this would be done in clinical practice are unresolved.

WES for inherited cancer susceptibility is also commercially available. Incidental findings are likely and management of such findings is evolving.

Governance, interpretation, and institutional oversight of NGS

Several layers of complexity exist in managing NGS in the clinical setting. At the purely technical level, improvements in the sequencing technique have allowed for sequencing across the entire genome, not merely the exome. As the costs decrease, exomic and genomic sequencing of tumor and of normal tissue can be expected to become more routine.

With routine use of WGS, major challenges in interpretation emerge. Foremost is the matter of determining which sequence variations in known cancer predisposition genes are pathologic, which are harmless, and which variations require further evaluation as to their significance. This is not a new challenge. Various groups are developing processes for the interpretation and curation of a growing database of variants and their significance. For example, the International Society for Gastrointestinal Hereditary Tumors has developed such a process for the MMR genes in concert with the Human Variome Project and International Mismatch Repair Consortium.

This process, which has been put in place for the known MMR genes, may serve as a framework for the emerging challenge of interpreting the significance of sequence variations in genes of uncertain or unknown function in regulation of neoplastic progression or other diseases. Larger cancer predisposition panels have been developed by commercial laboratories, with their own process for interpretation. To the extent that increasingly larger panels include genes of unknown significance, governance of the interpretation process requires that academic institutions offering their own panels or using external proprietary panels develop a deliberative process for managing the quality assurance for test performance (including Clinical Laboratory Improvement Amendments [CLIA], where appropriate) and interpretation.

The American College of Medical Genetics (ACMG) has issued the following guidelines for achieving accountability in interpreting and reporting incidental variants:(Adapted from )

  • Constitutional mutations should be reported by the laboratory to the ordering clinician, regardless of the indication for which the clinical sequencing was ordered and regardless of patient age. This includes the normal sample of a tumor-normal sequenced dyad.
  • Only variants previously reported and a recognized cause of the disorder, or variants previously unreported but of the type expected to cause the disorder, should be reported.
  • It is the responsibility of the ordering clinician to provide comprehensive pretest and posttest counseling and alert patients to the possibility that clinical sequencing may generate incidental findings requiring further evaluation.
  • Clinicians should be familiar with basic attributes and limitations of clinical sequencing.
  • Given the complexity of genomic information, the clinical geneticist should be consulted at the appropriate time, which may include ordering, interpreting, and communicating about genomic testing.
  • ACMG, together with content experts and other professional organizations, should continue to refine and update such guidelines annually.

It is still very early in the development processes for oversight at the institutional level. At the University of Texas M.D. Anderson Cancer Center, the following process has been used:

  1. When considering evaluation of tumor tissue for research purposes, patients are asked to consent to undergo tests of very large panels of somatic tissue that are paired with corresponding panels for constitutional tissue. The key research undertakings involve evaluating for differences in prognosis and treatment response according to mutation patterns in tumors.
  2. The consent process outlines the possibility that mutations suggesting underlying tumor susceptibility may be identified. Patients are asked whether they want to receive this information, should an actionable mutation be identified. Patients also receive expedited genetic counseling process (via counselors associated with research protocol). If a patient has chosen not to receive such actionable mutation information, findings will nevertheless be reported to the patient's institutional primary care physician (PCP). Unresolved to date are the circumstances in which a patient may be approached again by his or her PCP regarding pertinent findings, notwithstanding a previous decline to receive such information.
  3. When potentially significant results are found, the specific test may be repeated in a CLIA lab.
  4. A committee was formed to review variants to determine whether they are considered pathogenic or otherwise actionable.
  5. A second committee was formed to provide oversight for the conduct of such protocols, in the interest of deliberately evolving the processes above in a manner consistent with the anticipated routine performance of such panels in cancer patients, balanced against the need for patient autonomy and appropriately detailed informed consent.

Informed consent issues arising from the application of NGS

Informed consent for the sequencing of highly penetrant disease genes has been conducted since the mid 1990s in the contexts of known or suspected inherited diseases within selected families. However, the best methods and approaches for educating and counseling individuals about the potential benefits, limitations, and harms of genetic testing to facilitate informed decisions have not been fully elucidated or adequately tested. New informed consent challenges arise as NGS technologies are applied in clinical and research settings. Challenges to facilitating informed consent include the following:

  • Providing a person-centered appreciation for the breadth and diversity of medical risks potentially identified through genomic sequencing. Establishing informed consent may be particularly challenging in medically underserved populations with less familiarity with the concept of disease risk and in individuals with no previous knowledge, experience, or context of the disease(s) for which they are identified to be at increased risk.
  • Sequencing for diseases without clear management algorithms or identified best practices.
  • Interpretation of variants of possible but unclear pathogenicity.
  • Communicating genetic information that may be of relevance for other family members.
  • Additional challenges are anticipated as health care providers not trained in genetic/genomic medicine order and receive results on behalf of their patients with the expectation to return and manage medically actionable results.

Conclusion

Advances in genetic sequencing technologies have dramatically reduced the cost of sequencing an individual's full genome or exome. WGS and WES are increasingly being employed in the clinical setting in testing for both somatic and germline mutations. In addition, multiple-gene panel tests are now available commercially or within an institution. Considerable debate surrounds the clinical, ethical, legal, and counseling aspects associated with NGS and gene panels. Future research is warranted to address these issues.

References:
  • Dancey JE, Bedard PL, Onetto N, et al.: The genetic basis for cancer treatment decisions. Cell 148 (3): 409-20, 2012.
  • Meric-Bernstam F, Farhangfar C, Mendelsohn J, et al.: Building a personalized medicine infrastructure at a major cancer center. J Clin Oncol 31 (15): 1849-57, 2013.
  • Sleijfer S, Bogaerts J, Siu LL: Designing transformative clinical trials in the cancer genome era. J Clin Oncol 31 (15): 1834-41, 2013.
  • National Human Genome Research Institute: DNA Sequencing Costs: Data from the NHGRI Genome Sequencing Program (GSP). 2014. Available online. Last accessed April 10, 2014.
  • Sanger F, Nicklen S, Coulson AR: DNA sequencing with chain-terminating inhibitors. Proc Natl Acad Sci U S A 74 (12): 5463-7, 1977.
  • MacConaill LE: Existing and emerging technologies for tumor genomic profiling. J Clin Oncol 31 (15): 1815-24, 2013.
  • Rizzo JM, Buck MJ: Key principles and clinical applications of "next-generation" DNA sequencing. Cancer Prev Res (Phila) 5 (7): 887-900, 2012.
  • Linnarsson S: Recent advances in DNA sequencing methods - general principles of sample preparation. Exp Cell Res 316 (8): 1339-43, 2010.
  • Fernald GH, Capriotti E, Daneshjou R, et al.: Bioinformatics challenges for personalized medicine. Bioinformatics 27 (13): 1741-8, 2011.
  • Green RC, Berg JS, Grody WW, et al.: ACMG recommendations for reporting of incidental findings in clinical exome and genome sequencing. Genet Med 15 (7): 565-74, 2013.
  • Mardis ER: The $1,000 genome, the $100,000 analysis? Genome Med 2 (11): 84, 2010.

Structure and Content of PDQ Summaries

PDQ cancer genetics summaries focus on the genetics of specific cancers, inherited cancer syndromes, and the ethical, social, and psychological implications of cancer genetics knowledge. Sections on the genetics of specific cancers include syndrome-specific information on the risk implications of a family history of cancer, the prevalence and characteristics of cancer-predisposing mutations, known modifiers of genetic risk, opportunities for genetic testing, outcomes of genetic counseling and testing, and interventions available for people with increased cancer risk resulting from an inherited predisposition.

The source of medical literature cited in PDQ cancer genetics summaries is peer-reviewed scientific publications, the quality and reliability of which is evaluated in terms of levels of evidence. Where relevant, the level of evidence is cited, or particular strengths of a study or limitations of the evidence are described.

Refer to the Levels of Evidence for Cancer Genetics Studies summary for more information on the levels of evidence utilized in the PDQ cancer genetics summaries.

Genetic Resources

Health care providers who deliver genetic services, including genetic counseling, can be located through local, regional, and national professional genetics organizations and through NCI's Cancer Genetics Services Directory Web site. Providers of cancer genetic services are not limited to one specialty and include medical geneticists, genetic counselors, advanced practice genetics nurses, oncologists (medical, radiation, or surgical), other surgeons, internists, pediatricians, family practitioners, and mental health professionals. A cancer genetics health care provider will assist in constructing and evaluating a pedigree, eliciting and evaluating personal and family medical histories, and calculating and providing information about cancer risk and/or probability of a mutation being associated with cancer in the family. In addition, if a genetic test is available, these providers can assist in pretest counseling, laboratory selection, informed consent, test interpretation, posttest counseling, and follow-up.

Table 1. Clinical Genetics Information ResourceDescriptionHuman Genome Epidemiology Network (HuGENet)Network for sharing population-based human genome epidemiologic information.National Institutes of Health Genetic Testing Registry (GTR)Central location for voluntary submission of genetic test information by providers. The scope includes the test's purpose, methodology, validity, evidence of the test's usefulness, and laboratory contacts and credentials.Online Mendelian Inheritance in Man (OMIM)Catalog of human genes and genetic disorders.Table 2. Clinical Management InformationResourceDescriptionClinical Practice Guidelines from the American College of Medical Genetics (ACMG)Clinical practice guidelines developed by expert panels for risk assessment, testing, and counseling of individuals with various inherited conditions, including some cancers, or individuals with a high risk of developing these conditions.Clinical Practice Guidelines from the American Society of Clinical Oncology (ASCO)Clinical practice guidelines developed by expert panels for specific clinical situations (disease-oriented) or use of approved medical products, procedures, or tests (modality-oriented).National Comprehensive Cancer Network (NCCN) GuidelinesClinical practice guidelines developed by expert panels that detail the sequential management decisions and interventions for the malignant cancers that affect 97% of all patients with cancer. In addition, separate guidelines relate to major prevention and screening topics, and another set of pathways focuses on the major supportive care areas.National Guideline Clearinghouse from the Agency for Healthcare Research and Quality (AHRQ)A public resource for evidence-based clinical practice guidelines.Table 3. Consumer/Client: General InformationResourceDescription Cancer Genetics Services Directory (National Cancer Institute [NCI])Directory lists professionals who provide cancer genetics services (cancer risk assessment, genetic counseling, genetic susceptibility testing, and others). Dictionary of Genetics Terms (NCI)Definitions of more than 150 terms related to genetics. The DNA FilesSeries of 14 one-hour public radio documentaries and related information.Dolan DNA Learning Center Variety of educational resources, including an interactive DNA timeline.Facing Our Risk of Cancer Empowered (FORCE)Support and information to individuals and families affected by hereditary breast and ovarian cancer through a toll-free help line, message boards, chat rooms, and support groups. Genetic and Rare Diseases Information Center (National Human Genome Research Institute [NHGRI]):Information service for the general public, including patients and their families, and for health care professionals and biomedical researchers.Genetic Science Learning Center (The University of Utah)Information about basic genetics, genetic disorders, genetics in society, and several thematic units.Genetic Testing for Hereditary Cancer Syndromes (NCI)A fact sheet about genetic testing for inherited cancer risk, including types of tests, who should consider testing, how to understand test results, and who has access to a person's test results. Also contains information about at-home or direct-to-consumer genetic tests.Genetics Education CenterMaterial for educators.Genetics Home Reference (National Library of Medicine)Consumer information about genetic conditions and the genes or chromosomes responsible for those conditions.Talking Glossary of Genetics Terms (NHGRI)Contains definitions of more than 200 terms related to genetics and a quiz to test your knowledge of genetic terminology. Many terms also have images, animations, and descriptions by specialists in the field of genetics. Understanding the Human Genome Project (NHGRI)An education kit that includes a dynamic timeline, a 3-D computer-animated video on basic molecular biology, and other classroom activities.Table 4. Ethical, Legal, and Social Implications; Policy; and Legislation InformationResourceDescriptionbioethics.netLinks to articles on genetics and bioethics.Bioethics Resources on the WebLinks to bioethics resources.DNA Patent DatabaseSearchable database of U.S. DNA-based patents and patent applications issued by the U.S. Patent and Patent Applications Trademark Office.Ethical, Legal, and Social Issues (U.S. Department of Energy) Information, articles, and links on a wide range of genetics issues.Genethics.caInformation on the social, ethical, and policy issues associated with genetic and genomic knowledge and technology.Genetic Information Nondiscrimination Act (GINA) of 2008 (National Human Genome Research Institute [NHGRI])Fact sheet that describes genetic discrimination and GINA for the public.GINA: An Overview (Coalition for Genetic Fairness)Describes GINA's protections, including a history of the legislation, key examples, and definitions.GINA of 2008 Information for Researchers and Health Care Professionals (NHGRI)Fact sheet that describes GINA for researchers and health professionals.Genetics and Public Policy CenterInformation on public policy related to human genetic technologies for the public, media, and policy makers.Genome Technology and Reproduction: Values and Public Policy and Communities of Color and Genetics Policy ProjectTwo subprojects combined to form a 5-year project designed to provide policy recommendations based on public perceptions and responses to the explosion of genetic information and technology. HumGen InternationalComprehensive international database on the legal, social, and ethical aspects of human genetics.National Conference of State Legislatures Genetic Technologies ProjectResources on a variety of genetics public policy and related issues for state legislators, legislative staff, and other policy makers.National Information Resource on Ethics and Human Genetics (Georgetown University)Search engine for literature on specific issues related to ethics and human genetics.National Society of Genetic Counselors Code of Ethics A statement to clarify and guide the ethical conduct of genetic counselors.Policy and Legislation Database (NHGRI)Searchable database of federal and state laws/statutes, federal legislative materials, and federal administrative and executive materials about privacy of genetic information/confidentiality; informed consent; insurance and employment discrimination; genetic testing and counseling; and commercialization and patenting.THOMAS Legislative Information (The Library of Congress)Searchable database of U.S. legislation (current and previous Congresses).Your Genes, Your Choices: Exploring the Issues Raised by Genetic ResearchDescription of the Human Genome Project, the science behind it, and the ethical, legal, and social issues raised by the project.Table 5. Family History ToolsResourceDescriptionFamily Health History (Genetic Alliance)Tips for collecting family history information and links to resources.Family History Public Health Initiative (Centers for Disease Control and Prevention)Web site devoted to using family history to promote health.Family Medical History (American Medical Association)Tools for gathering family history and links to resources.My Family Health Portrait (U.S. Surgeon General)Web-based family history tool.Understanding and Collecting Your Family History (National Society of Genetic Counselors)Information on collecting a family health history.Table 6. Genome Research InformationResourceDescriptionBLAST = Basic Local Alignment Search Tool; COSMIC = Catalogue Of Somatic Mutations In Cancer; iHOP = information hyperlinked over proteins; SARS = severe acute respiratory syndrome; SNPs = single nucleotide polymorphisms; UCSC = University of California, Santa Cruz.BLAST Search (part of the Ensembl Project; see below)Search protein or DNA sequence against metazoan genomes.The Cancer Genome Anatomy Project (CGAP)Access to all CGAP data and biological resources.Cancer Genome Workbench (CGWB)Integrates clinical tumor mutation profiles with the reference human genome to improve the accuracy of mutation identification.Chromosomal Variation in ManSearchable database of literature citations on chromosomal variants and anomalies.Ensembl (Joint software project between the European Bioinformatics Institute and the Wellcome Trust Sanger Institute)Data sets resulting from an automated genome analysis and annotation process.Genome ChannelJava viewers for human genome data.Genome Sequencing Center: Homo sapiens MapsLinks to clone and accession maps of the human genome.International Cancer Genome Consortium Data PortalA collection of genome data from more than 25 cancer projects consisting of over 3,500 tumor genomes from 13 cancer types and subtypes. Most data are available with open access.International HapMap ProjectA variety of ways to query for SNPs in the human genome.Leiden Open Variation DatabaseA flexible, free tool for gene-centered collection, curation, and display of DNA variation.KMcancerDBHuman gene mutation database with graphical display of molecular information for cancer-related genes. National Center for Biotechnology Information: Genomic BiologyViews of chromosomes, maps, and loci; links to other NCBI resources.Online Mendelian Inheritance in Man (OMIM)Catalog of human genes and genetic disorders.UCSC Genome BioinformaticsReference sequence for the human and C. elegans genomes and working drafts for the mouse, rat, Fugu, Drosophila, C. briggsae, yeast, and SARS genomes. Table 7. Health Professional Practice and Genetic Education InformationResourceDescriptionCentre for Genetics EducationEducation and service resources for patients and professionals.Dolan DNA Learning CenterInteractive multimedia genetics education resources.Essentials of Genetic and Genomic Nursing: Competencies, Curricula Guidelines, and Outcome Indicators, 2nd editionEstablishes minimum basis to prepare the nursing workforce to deliver competent genetic and genomic-focused nursing care.Evaluation of Genomic Applications in Practice and Prevention (EGAPP)Provides an evidence-based review of genetic tests and other genomic applications that are in transition from research to clinical and public health practice in the United States.Genetics and Social Science: Expanding Translational ResearchA free, online education program designed to provide social and behavioral scientists with sufficient genetics background to support the integration of genetics concepts in their own research and allow for collaborative studies with geneticists.Genetics Education CenterOnline center for educators interested in human genetics and the Human Genome Project.Genetics Education Program for Nurses (GEPN)Sample genetics nursing course syllabi and other genetics educational opportunities and resources for nurses.Genetics/Genomics Competency Center for Education (G2C2)A repository of genetics/genomics education resources for nursing and physician assistant educators.Genetics in Clinical Practice: A Team Approach Interactive virtual genetics clinic with case scenarios and case discussions. Target audience is primary care professionals.Genetics in Primary CareTraining program curriculum materials.Genomic Applications in Practice and Prevention Network (GAPPNet)A collaborative initiative that aims to bring together stakeholders in order to accelerate and streamline effective and responsible use of validated and useful genomic knowledge and applications, such as genetic tests, technologies, and family history, into clinical and public health practice.Medical School Core Curriculum in GeneticsMedical school course competencies, skills, knowledge, and behaviors that should be covered in a genetics curriculum developed by the Association of Professors of Human and Medical Genetics and the American Society of Human Genetics.National Coalition for Health Professional Education in Genetics (NCHPEG)Core competencies in genetics and reviews of education programs. Descriptions of available instructional resources, courses, and institutes.National Genetics and Genomics Education CentreDevelops, provides, and evaluates genetics education opportunities and resources.Six Weeks to Genomic AwarenessWebcast of six lessons in genomics for public health professionals.Table 8. Institutional Review Boards (IRBs)ResourceDescriptionGenetic Testing and Screening in the Age of Genomic Medicine. New York State Task Force on Life and the Law.Includes general and state-specific information in a bulleted report.Pharmacogenetics: Ethical Issues. Nuffield Council on Bioethics.Includes a section discussing the use of pharmacogenetics in clinical trials.Protecting Human Research Subjects Institutional Review Board Guidebook, Chapter V, Section H: Human Genetic Research. Office for Human Research Protections.Discusses many issues that continue to challenge IRBs, investigators, and policy makers today.Table 9. Professional Organizations: GeneticsResourceDescriptionAmerican Board of Genetic Counseling (ABGC)Information about certification of genetic counselors.American Board of Medical Genetics (ABMG)Information about medical genetic training programs and certification of geneticists.American College of Medical Genetics (ACMG)Resources, policy statements, and practice guidelines about medical genetics.American Society for Human Genetics (ASHG)Resources, projects, and policies concerning human genetics.Genetics Nursing Credentialing Commission (GNCC)Information about credentialing of genetics nurses.Genetics Society of America (GSA)Links to teaching Web sites, general educational courses, and journals and publications about genetics.International Society of Nurses in Genetics (ISONG)Resources to help nurses incorporate new knowledge about human genetics into practice, education, and research.National Society of Genetic Counselors (NSGC)Information about genetic counseling: practice guidelines, links to genetic counselors, and genetic discrimination resources.Table 10. Risk Assessment InformationResourceDescriptionBreast Cancer Risk Assessment Tool (National Cancer Institute [NCI])Interactive tool for estimating a woman's risk of developing invasive breast cancer.Colorectal Cancer Risk Assessment Tool (NCI)Interactive tool for estimating the risk of developing colorectal cancer in a non-Hispanic white man or woman aged 50 to 85 years.Disease Risk Index (Harvard School of Public Health)Personalized estimation of cancer risk and tips for prevention.Family HealthLink (The Ohio State University Medical Center) Interactive tool that estimates cancer risk by reviewing patterns of cancer in a family.Melanoma Risk Assessment Tool (NCI)Interactive tool for estimating an individual's absolute risk of developing melanoma.MyGenerationsInteractive tool that estimates cancer risk by reviewing patterns of cancer in a family. Table 11. Online Gene Mutation Prediction ProgramsResourceDescriptionHuGE = Human Genome Epidemiology; MMR = mismatch repair; MRC = Medical Research Council.HuGE Risk TranslatorCalculates the predictive value of genetic markers.MRC Human Genetics Unit, EdinburghPredicts the likelihood of mutations in one of the MMR genes in persons with colon cancer.The Penn II Risk ModelEstimates the probability that an individual has a BRCA1 or BRCA2 mutation.PREMM1,2,6 Model: Prediction Model for MLH1, MSH2, and MSH6 Gene MutationsEstimates the probability that an individual carries a mutation in one of the MMR genes.Table 12. Search Engines Specializing in Genetics and GenomicsResourceDescriptionGAMAdb = Genome-wide Association and Meta Analyses Database; GWAS = genome-wide association studies; HuGE = Human Genome Epidemiology; SNP = single nucleotide polymorphism.Cancer GAMAdbAn online database of published GWAS and meta-analyses for genetic polymorphisms and cancer risk.Catalog of Published Genome-Wide Association StudiesAn online catalog of SNP-trait associations from published GWAS for use in investigating genomic characteristics of trait/disease-associated SNPs.HuGE NavigatorAn integrated, searchable knowledge base of genetic associations and human genome epidemiology.National Information Resource on Ethics and Human Genetics (Georgetown University) Search engine for literature on specific issues related to ethics and human genetics.Table 13. United States Government AgenciesResourceDescriptionHRSA = Health Resources and Services Administration; NIH = National Institutes of Health.Centers for Disease Control and Prevention Office of Public Health GenomicsInformation on how human genomic discoveries can be used to improve health and prevent disease, including links to many resources.Genetic Modification Clinical Research Information System (GeMCRIS) Information about human gene transfer trials registered with NIH.National Cancer InstituteSummaries of cancer genetics–related information.National Human Genome Research InstituteResearch, policy, ethics, education, and training information and resources about genetic and rare diseases.U.S. Department of Energy Office of ScienceGenomics educational resources.U.S. Department of Health and Human ServicesLinks to publications and materials available for purchase or download from the HRSA Information Center. References:
  • Schully SD, Yu W, McCallum V, et al.: Cancer GAMAdb: database of cancer genetic associations from meta-analyses and genome-wide association studies. Eur J Hum Genet 19 (8): 928-30, 2011.


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