Accurate and Timely BRCA Mutation Testing Can Help Ensure Patients Receive Appropriate Treatments1

Biomarker testing is a multistep process. Proper testing and quick return of results can help ensure patients receive the most appropriate treatments based on BRCA mutation status.1

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CHOOSE a sample type

Tumor tissue or blood samples can be used to detect BRCA mutations and inform treatment decisions2; however, advantages and considerations differ for each sample type.3-5

Tumor samples

  • Detect germline and somatic BRCA mutations3 but cannot distinguish between them and, therefore, may identify an additional 50% of patients with BRCA mutations6
  • Must be followed with blood sample testing to determine familial risk4,5
  • Can inform treatment decisions2

Blood samples

  • Detect germline BRCA mutations only4
  • Inform familial risk5
  • Can inform treatment decisions2

To maximize the number of patients identified through testing4-7:

  • Test for BRCA mutations using tumor tissue first
  • If the patient is BRCA mutation–positive, assess germline mutation status using blood samples
If the patient is BRCA mutation–positive, assess germline mutation status using blood samples
If the patient is BRCA mutation–positive, assess germline mutation status using blood samples

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) recommend BRCA1/2 mutation testing in patients with histologically confirmed OC. If not previously done, tumor molecular testing for BRCA1/2 mutations is recommended in patients with recurrent OC.10

Collect the sample icon ovarian cancer
COLLECT the sample

The quantity of DNA analyzed can affect the accuracy of the results; therefore, sufficient sample must be collected.1

Tumor samples

  • Collect tumor tissue through a biopsy or during debulking surgery3,11
  • Ensure tumor cell content is sufficient by confirming sample content via pathology or cytology1
  • For example: FoundationOne® CDx recommends 30% tumor cell content as optimum, and 20% tumor cell content as the minimum12

Blood samples

  • Draw sufficient whole blood sample to allow for testing13
  • For example: BRACAnalysis CDx® requires collection of ≈7 mL of whole blood in a tube containing EDTA (provided in the sample collection kit)13
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PROCESS the sample

Samples should be processed quickly and according to specific test instructions to preserve DNA quality.1,14

Tumor samples

  • Preserve promptly after collection in 10% NBF for 8 to 48 hours1
  • Other fixatives are not recommended (eg, alcohol-based, acidic, or heavy metal fixatives, or decalcifying agents)1
  • For example: FoundationOne® CDx recommends fixation in 10% NBF for 6 to 72 hours12

Blood samples

  • Refer to test instructions; processing is typically not required13
  • For example: BRACAnalysis CDx® requests shipping the whole blood sample to the testing lab at ambient temperatures13

Within your multidisciplinary team, discuss how to reduce the wait time before processing and minimize sample degradation.14

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CHOOSE a diagnostic test

Diagnostic tests may use different technologies, such as Sanger sequencing or next-generation sequencing (NGS).

Sanger sequencing

Advantages

  • Gold standard15
  • Highly accurate15

Considerations

  • Tests a limited amount of DNA at one time15
  • Should be supplemented with PCR to detect all types of BRCA mutations7

NGS

Advantages

  • Used in panel testing to sequence large amounts of DNA in parallel15
  • More likely to identify a positive result16

Considerations

  • More likely to identify unknown variants that are not actionable and, therefore, require more extensive pre-test counseling17
  • Must be chosen carefully, because panels may test different genes and have a different way of classifying variants18

To optimize turnaround time and cost efficiency, some laboratories offer testing for BRCA mutations first, then automatically reflex to a larger multigene panel if the BRCA mutation test returns negative results.17

FDA-approved tests are available to detect BRCA mutations in OC2

FDA-approved tests are available to detect BRCA mutations in OC2

 
  BRACAnalysis CDx®19
FoundationOne® CDx20
  • Testing technology
  • PCR and Sanger Sequencing
  • NGS
  • Sample type
  • Whole blood
  • FFPE tissue
  • Mutation type
  • Germline
  • Somatic and germline (but does not distinguish between them)

BRACAnalysis CDx®19

Testing technology

PCR and Sanger sequencing

Sample type

Whole blood

Mutation type

Germline

FoundationOne®CDx20

Testing technology

NGS

Sample type

FFPE tissue

Mutation type

Somatic and germline (but does not distinguish between them)

NCCN Guidelines recommend NGS testing for somatic BRCA1/2 mutations in patients with histologically confirmed OC.10

 

CLIA-certified LDTs are available to detect BRCA mutations

Ambry Genetics®24-26

Testing technology

NGS

Sample type

Blood, saliva, buccal swab, or tissue

Mutation type

Germline or somatic (tissue testing cannot distinguish between germline and somatic)

ARUP® Laboratories27,28

Testing technology

PCR and Sanger Sequencing

Sample type

Whole blood

Mutation type

Germline

GeneDx29

Testing technology

NGS

Sample type

Blood or buccal swab

Mutation type

Germline

Invitae30

Testing technology

NGS

Sample type

Whole blood or saliva

Mutation type

Germline

Labcorp31,32

Testing technology

NGS

Sample type

Whole blood or saliva

Mutation type

Germline

Quest DiagnosticsTM33,34

Testing technology

NGS

Sample type

Whole blood

Mutation type

Germline

Kew, Inc.35-38,†

Testing technology

NGS

Sample type

FFPE tissue

Mutation type

Somatic and germline (but does not distinguish between them)

 
  Ambry Genetics®24-26 
ARUP® Laboratories@27,28 
GeneDx29 
Invitae30
Labcorp31,32 Quest DiagnosticsTM33,34 Kew, Inc.35-38,†
  • Testing technology
  • NGS
  • PCR and Sanger Sequencing
  • NGS
  • NGS
  • NGS
  • NGS
  • NGS
  • Sample type
  • Blood, Saliva, buccal swab, or tissue
  • Whole blood
  • Blood or buccal swab
  • Whole blood or saliva
  • Whole blood or saliva
  • Whole blood
  • FFPE tissue
  • Mutation type
  • Germline or somatic (tissue testing cannot distinguish between germline and somatic)
  • Germline
  • Germline
  • Germline
  • Germline
  • Germline
  • Somatic and germline (but does not distinguish between them)

Laboratory-developed tests (LDTs) are diagnostic tests that are developed and used within a single laboratory. Although not FDA-approved, they meet specific requirements of and are regulated by the Clinical Laboratory Improvement Amendments (CLIA) of 1988.21,22*

These tests are performed in laboratories that adhere to performance specifications established by the Clinical Laboratory Improvement Amendments (CLIA) of 1988 under the regulation of the Centers for Medicare & Medicaid Services. They are not FDA approved.21,23

Kew, Inc. is CLIA-certified in all states except New York.

LDTs are not the same as direct-to-consumer commercial tests39

Direct-to-consumer tests have varying levels of evidence to support their claims, and few have been reviewed by the FDA.39 Therefore, care must be taken when interpreting results from direct-to-consumer tests.39

Appropriate sample collection, processing, and testing are key in determining BRCA mutation status and making informed treatment decisions.1,14

BC, breast cancer; BRCA, breast cancer susceptibility gene; CLIA, Clinical Laboratory Improvement Amendments; EDTA, ethylenediaminetetraacetic acid; FDA, Food and Drug Administration; FFPE, formalin-fixed paraffin-embedded; LDT, laboratory-developed test; NBF, neutral buffered formalin; NCCN, National Comprehensive Cancer Network; NGS, next-generation sequencing; OC, ovarian cancer; PCR, polymerase chain reaction.

 

References: 1. Capoluongo E et al. Semin Oncol. 2017;44(3):187-197. 2. FDA. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm. Updated March 11, 2019. Accessed April 16, 2019. 3. Robson ME et al. J Clin Oncol. 2015;33(31):3660-3667. 4. Robson ME et al; American Society of Clinical Oncology. J Clin Oncol. 2010;28(5):893-901. 5. George A et al. Nat Rev Clin Oncol. 2017;14(5):284-296. 6. Vergote I et al. Eur J Cancer. 2016;69:127-134. 7. Wallace AJ. Eur J Hum Genet. 2016;24(suppl 1):S10-S18. 8. Pal T et al. Cancer. 2005;104(12):2807-2816. 9. Pennington KP et al. Clin Cancer Res. 2014;20(3):764-775. 10. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer V1.2020. © National Comprehensive Cancer Network, Inc. 2020. All rights reserved. Accessed March 16, 2020. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 11. National Collaborating Centre for Cancer. Ovarian Cancer: The Recognition and Initial Management of Ovarian Cancer. Cardiff, UK: National Collaborating Centre for Cancer; 2011. 12. FoundationOne®CDx [specimen instructions]. Cambridge, MA: Foundation Medicine, Inc.; 2018. 13. Center for Drug Evaluation and Research; Food and Drug Administration (FDA). https://www.accessdata.fda.gov/drugsatfda_docs/nda/2014/206162Orig1s000ClinPharmR.pdf. Accessed October 26, 2018. 14. Leyland-Jones BR et al. J Clin Oncol. 2008;26(34):5638-5644. 15. Rizzo JM, Buck MJ. Cancer Prev Res (Phila). 2012;5(7):887-900. 16. O’Leary E et al. Ann Surg Oncol. 2017;24(10):3060-3066. 17. Stanislaw C et al. Cancer Biol Med. 2016;13(1):55-67. 18. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic V1.2020. © National Comprehensive Cancer Network, Inc. 2019. All rights reserved. Accessed March 3, 2020. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 19. BRACAnalysis CDx® [technical information]. Salt Lake City, UT: Myriad Genetics Laboratories, Inc.; 2017. 20. FoundationOne®CDx [technical information]. Cambridge, MA: Foundation Medicine, Inc.; 2017. 21. Fitzgibbons PL et al; College of American Pathologists Pathology and Laboratory Quality Center. Arch Pathol Lab Med. 2014;138(11):1432-1443. 22. FDA. https://www.fda.gov/medicaldevices/productsandmedicalprocedures/invitrodiagnostics/laboratorydevelopedtests/default.htm. Updated October 12, 2018. Accessed October 26, 2018. 23. CMS. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html?redirect=/clia. Updated September 19, 2018. Accessed October 26, 2018. 24. Centers for Medicare & Medicaid Services (CMS). https://www.ambrygen.com/file/material/view/759/CLIA_EXP_5.29.20.pdf. Effective May 30, 2018. Accessed October 26, 2018. 25. Ambry Genetics®. https://www.ambrygen.com/clinician/genetic-testing/23/oncology/brca1-and-brca2. Accessed October 26, 2018. 26. Ambry Genetics®. https://www.ambrygen.com/clinician/specimen-requirements. Accessed October 26, 2018. 27. ARUP® Laboratories. https://www.aruplab.com/testing/licensure-accreditations. Accessed May 23, 2019. 28. ARUP® Laboratories. http://ltd.aruplab.com/tests/pub/2011954. Accessed May 23, 2019. 29. GeneDx. https://www.genedx.com/test-catalog/specialty/oncology. Accessed May 23, 2019. 30. Invitae. https://www.invitae.com/en/physician/tests/50002/#info-panel-assay_information. Accessed May 23, 2019. 31. Labcorp. https://www.labcorp.com/sites/default/files/LabCorp_Phoenix%2C%20AZ_CLIA_03D0528350_Expires20210208.pdf. Accessed May 23, 2019. 32. Labcorp. https://www.labcorp.com/test-menu/21366/brca12-comprehensive-analysis-brcassure%C2%AE. Accessed May 23, 2019. 33. Quest DiagnosticsTM. http://www.questvantage.com/wp-content/uploads/2014/06/25654_SB3428_BRCAvantage_Oncologist_Brochure_V2_MT_060914.pdf. Accessed May 23, 2019. 34. Quest DiagnosticsTM. https://www.questdiagnostics.com/home/about/locations/licenses-accreditations. Accessed May 23, 2019. 35. Kew, Inc. https://kewinc.com/kew-inc/. Accessed May 23, 2019. 36. Kew, Inc. https://kewinc.com/wp-content/uploads/2017/07/Full-gene-list.pdf. Accessed May 23, 2019. 37. Kew, Inc. https://kewinc.com/wp-content/uploads/2017/07/Specimen-Handling-Instructions.pdf. Accessed May 23, 2019. 38. Kew, Inc. https://kewinc.com/kews-cancerplex-molecular-diagnostic-test-made-available-cancer-patients-eu-mytomorrows-platform/. Accessed May 23, 2019. 39. FDA. https://www.fda.gov/medical-devices/vitro-diagnostics/direct-consumer-tests. Updated November 1, 2018. Accessed May 23, 2019.