Family issues in a psychoeducation group for women with a BRCA mutation.

Few services exist for women who test positive for BRCA1 and BRCA2 mutations despite the distress that they and their families may experience. We present one model of a time-limited family-oriented psychoeducation group to provide information and support for nine women who received positive test results. We report on five family-oriented themes that arose from the discussions: distress about possible transmission to children; family conflict about testing; concerns about disclosure; different coping styles and decision making; and underlying family conflict and unresolved grief. We also include recommendations from these women to enhance the services available to families by expanding assessment, and providing written literature and contact information. In addition, referrals for a psychoeducation group, community support group, or psychotherapy may be useful for individuals, couples and families who are considering genetic testing for BRCA mutations.

Points to consider in designing a clinical trial to ascertain the utility of a genetic screening test.

In designing a clinical trial to ascertain the utility of a genetic screening test, the follow recommendations should be considered: (1) imbed the genetic test in a genetic service; (2) choose a specific outcome to monitor; (3) compare two strategies for achieving the desired outcome; (4) assemble a multidisciplinary team; (5) attempt to reach all potential subjects in a defined region; (6) derive an outcome for each subject; (7) assess each expected benefit and burden.

Telomerase inhibitors.

Telomerase is attracting great interest as a target for anticancer research because telomerase activity is present in most malignant cells, but undetectable in most normal somatic cells. The antisense approach has been widely exploited and directed to telomerase RNA, chiefly the template region. Ribozymes have been less investigated. Agents that stabilize folded G-quadruplex structures also inhibit telomerase. Inhibitory agents from many chemical classes have been identified, many through screening, but their specificity of action is in doubt. A specific inhibitor is expected to immediately inhibit activity but not cell division, produce telomerase shortening over multiple generations, and ultimately produce end-to-end chromosomal fusion and growth arrest.

Telomere-related components are coordinately synthesized during human T-lymphocyte activation.

Since telomerase activity is present in most malignant cells, but absent in most normal cells, its induction in normal cells warrants scrutiny. Therefore we have analyzed the inducibility of telomere-related components in normal lymphocytes during their activation. Telomerase activity increased over 400-fold, telomerase reverse transcriptase (hTERT) mRNA 52 x , telomerase RNA 32 x , TTAGGG repeat binding factor 1 mRNA 19 x , TTAGGG repeat binding factor 2 mRNA 20 x , and telomerase-associated protein mRNA 17 x . The peak value for each was reached at about 72 h. However hTERT rose fastest and synchronously with telomerase activity. Thus in normal human lymphocytes (1) the syntheses of all cloned telomerase-related components are coordinately regulated and (2) hTERT may have a priming role.

Circular antisense oligonucleotides inhibit growth of chronic myeloid leukemia cells.

BACKGROUND: Antisense represents a conceptually powerful method for regulating gene expression. However, antisense oligonucleotides developed to date manifest two serious limitations-nuclease susceptibility and nonspecific hybridization. Circular oligonucleotides may be superior to conventional linear oligonucleotides in both respects. First, circular agents, having no ends, are exonuclease-resistant. Second, they bind to complementary strands of RNA and DNA with a higher affinity than corresponding linear agents. METHODS AND RESULTS: We assessed the activity of circular phosphodiester deoxynucleotides using chronic myeloid cell lines by targeting polypurine sequences. To represent cells having a bcr3/abl2-type junction, we used K562 cells. A circle targeting a bcr polypurine sequence 385 nucleotides 5' to the junction decreased the cell number by day 5 with an IC(50) of 9 microM. To represent cells having a bcr2/abl2-type junction, we used BV173 cells. A circle targeting the bcr-abl junction itself decreased the cell number by day 7 with an IC(50) of 8 microM. Control oligonucleotides, whether the same sequence uncircularized or circles with the same nucleotide composition but in scrambled sequence, had little effect. Unlike linear agents, circles were stable when incubated in 10% serum. The amount of bcr-abl protein detected by Western blotting using a specific anti-bcr-abl antibody at 24 hr in antisense-treated BV173 cells was only 10% of that of cells treated with control circles, which demonstrates an antisense mechanism of action. CONCLUSIONS: Circular oligodeoxyribonucleotides (1) inhibit the accumulation of CML cells, (2) decrease the amount of bcr-abl protein per cell, (3) have sequence-selective activity, and (4) are more active than linear oligonucleotides containing only the base-pairing region.

Issues in implementing prenatal screening for cystic fibrosis: results of a working conference.

PURPOSE: To summarize a conference convened to examine how cystic fibrosis screening might appropriately be introduced into routine prenatal practice. METHODS: Participants included experts from various relevant disciplines. Systematic reviews and data from individual trials were presented; issues were identified and discussed. RESULTS: Judged by published criteria, prenatal cystic fibrosis screening is suitable for introduction. Screening can be performed cost-effectively by identifying racial/ethnic groups at sufficient risk and then using either of two models for delivering laboratory services. Validated educational materials exist. Ethical issues are not unique. CONCLUSIONS: Once adequate facilities for patient and provider education, testing, counseling, quality control, and monitoring are in place, individual programs can begin prenatal screening for cystic fibrosis.

Prenatal screening for cystic fibrosis carriers: an economic evaluation.

The cloning of the CFTR gene has made it technically possible to avert the unwanted birth of a child with cystic fibrosis (CF). Several large trials offering prenatal CF carrier screening suggest that such screening is practical and that identified carriers generally use the information obtained. Therefore, a critical question is whether the cost of such screening is justified. Decision analysis was performed that used information about choices that pregnant women were observed to make at each stage in the Rochester prenatal carrier-screening trial. The cost of screening per CF birth voluntarily averted was estimated to be $1,320,000-$1,400,000. However, the lifetime medical cost of the care of a CF child in today's dollars was estimated to be slightly>$1,000,000. Therefore, despite both the high cost of carrier testing and the relative infrequency of CF conceptions in the general population, the averted medical-care cost resulting from choices freely made are estimated to offset approximately 74%-78% of the costs of a screening program. At present, if it is assumed that a pregnancy terminated because of CF is replaced, the marginal cost for prenatal CF carrier screening is estimated to be $8,290 per quality-adjusted life-year. This value compares favorably with that of many accepted medical services. The cost of prenatal CF carrier screening could fall to equal the averted costs of CF patient care if the cost of carrier testing were to fall to $100.

Sequence analysis of BRCA1 and BRCA2: correlation of mutations with family history and ovarian cancer risk.

PURPOSE: Previous studies of mutations in BRCA1 or BRCA2 have used detection methods that may underestimate the actual frequency of mutations and have analyzed women using heterogeneous criteria for risk of hereditary cancer. PATIENTS AND METHODS: A total of 238 women with breast cancer before age 50 or ovarian cancer at any age and at least one first- or second-degree relative with either diagnosis underwent sequence analysis of BRCA1 followed by analysis of BRCA2 (except for 27 women who declined analysis of BRCA2 after a deleterious mutation was discovered in BRCA1). Results were correlated with personal and family history of malignancy. RESULTS: Deleterious mutations were identified in 94 (39%) women, including 59 of 117 (50%) from families with ovarian cancer and 35 of 121 (29%) from families without ovarian cancer. Mutations were identified in 14 of 70 (20%) women with just one other relative who developed breast cancer before age 50. In women with breast cancer, mutations in BRCA1 and BRCA2 were associated with a 10-fold increased risk of subsequent ovarian carcinoma (P = .005). CONCLUSION: Because mutations in BRCA1 and BRCA2 in women with breast cancer are associated with an increased risk of ovarian cancer, analysis of these genes should be considered for women diagnosed with breast cancer who have a high probability of carrying a mutation according to the statistical model developed with these data.

Human lymphocyte telomerase is genetically regulated.

Research on both cancer and aging has focused attention on the regulation of telomerase, the enzyme that synthesizes the ends of chromosomal DNA. To analyze the relative importance of genetic vs. environmental factors in determining telomerase inducibility, we have compared telomerase activity in phytohemagglutinin-stimulated peripheral blood lymphocytes from monozygotic and dizygotic twin pairs. The heritability calculated was 0.814, indicating that lymphocyte inducible telomerase activity is determined principally by genetic rather than by environmental factors.

Genetic testing for breast-ovarian cancer susceptibility: a regional trial.

To evaluate receptivity to testing for a genetic susceptibility to breast-ovarian cancer, information is needed on the response when the offer is open to all qualifying women in a given region. To qualify in this trial, a woman who had not had breast or ovarian cancer had to have at least two first-degree relatives or one first- and one second-degree relative with breast and/or ovarian cancer, whereas a woman who had had breast or ovarian cancer had to have at least one first-degree relative with breast or ovarian cancer and a first- or second-degree relative without cancer willing to be tested. Of 140 women qualifying and interested enough to return questionnaires requesting baseline information, 111 were referred by their physician and 29 were identified from a regional tumor registry. Of these 140, 112 came for pretest education and 98 of these chose to be tested. Thus, the acceptance rate was 70% for all those returning baseline questionnaires, but 88% for those interested enough to come for pretest education. The most common reasons for accepting testing were to take extra precautions if a mutation were found (42.9%) and to determine if offspring were at risk (24.5%). The most common reasons for declining were anxiety and absence of specific interventions. Factors predicting who chose testing were years of education (p < 0.005) and family closeness (p < 0.02). Fourteen deleterious BRCA1 or BRCA2 mutations were found in 13 of the 87 families actually tested. If the criteria for testing had been three or more affected family members rather than two or more, the number of families tested would have been reduced by 46%, but the number of families found to have a deleterious mutation would have been reduced by only 9%.

Cystic fibrosis carrier population screening: a review.

Population screening for cystic fibrosis (CF) carriers, now possible because of the cloning of the CFTR gene, merits evaluation because CF is common, serious, and without satisfactory treatment, and because prenatal diagnosis is available. Clinical trials of CF population carrier screening are reviewed. These trials have involved pregnant women, adults of both sexes of reproductive age, or adolescents. Schools, the usual setting for screening programs for adolescents, provide an excellent opportunity for a formal educational component and for comprehensive coverage of the population, but compared to a health-care setting, may entail subtle coercion and may compromise confidentiality. In the case of adults, many say they prefer screening before conception but do not see a physician for evaluation before conception and providers find screening more readily accomplished in the setting of a prenatal visit. Two large U.S. studies of prenatal screening with quite different subject populations and health-care settings encountered few of the adverse outcomes originally predicted for CF carrier population screening.

Carrier screening for cystic fibrosis: test acceptance and one year follow-up.

We identified 124 carriers among 4,879 patients of prenatal care providers in the Rochester region. Six factors were identified that together permitted a correct classification regarding test acceptance for 77.5% of all subjects. For those pregnant, the most influential of these factors was a more accepting attitude toward abortion. As an indication for abortion, cystic fibrosis (CF) ranked between mild and moderate mental retardation. Of the 124 carrier women identified, we obtained 1-year follow-up information on 100. Mean score for CF knowledge at 1 year (77.4 +/- 13.2%), although significantly lower than immediately after counseling (84 +/- 12.4%), was still significantly higher than after detection but before counseling (51.1% +/- 20.7%). Anxiety about having a child with CF significantly declined from 25.8 +/- 8.0 SD immediately after counseling to 18.9 +/- 7.8 at 1 year (Spielberger State Anxiety Scale). Although 15 carriers regretted having been tested, 83% believed that they benefited from testing, 83% would make the same decision to be tested over again, and 79% would recommend testing to a friend. We conclude that, for most women, CF carrier screening accomplished its purpose: most carriers detected came for counseling, had their partners tested, and, if their partners were also carriers, had prenatal diagnosis. The major undesirable outcomes were that many women testing negative did not understand that a negative result did not exclude being a carrier and that three women found to be carriers did not have their partners tested because of anxiety or the unacceptability of pregnancy termination and therefore may not have carefully considered their decision to be tested. Both of these undesirable outcomes could have been avoided by greater attention to pretest patient education by the primary care provider.

Attitudes of obstetrician-gynecologists toward DNA testing for a genetic susceptibility to breast cancer.

OBJECTIVE: To assess knowledge and attitudes of area obstetrician-gynecologists toward DNA testing for genetic susceptibility to breast cancer. METHODS: At a staff meeting of each of the Rochester area's hospitals that had an obstetric service, we assessed knowledge of inherited predisposition to breast cancer, presented the current status of testing for genetic susceptibility, and assessed attitudes toward such testing. RESULTS: The majority of the physicians surveyed believed that current BRCA1 testing can detect a genetic predisposition to breast cancer accurately enough to be clinically useful (81%) and that a young woman with a family history of breast cancer not currently having regular mammography is likely to benefit from DNA testing because a positive result may motivate her to start mammography earlier (88%). However, most respondents thought that women who test positive are likely to be excessively anxious (87%) and may be discriminated against for insurance purposes (75%). In response to an invitation to participate in a clinical trial of free BRCA1 screening, 74 (70%) desired to participate. CONCLUSION: Obstetrician-gynecologists expect women detected to have a BRCA1 mutation to be motivated to conduct surveillance, but also to experience anxiety and possible discrimination.

Cystic fibrosis carrier population screening in the primary care setting.

To determine the receptivity of prenatal care providers and their patients to carrier testing for cystic fibrosis (CF), we offered free carrier screening, followed by genetic counseling of carriers, to all prenatal care providers in Rochester, NY, for all their female patients of reproductive age, pregnant or not. Of 124 prenatal care providers, only 37 elected to participate, but many of these offered screening only to pregnant women. The acceptance rate among pregnant women was approximately 57%. The most common reasons for accepting screening were to obtain reassurance (50.7%) and to avoid having a child with CF (27.8 %). The most common reasons for declining screening were not intending to terminate a pregnancy for CF (32.4%) and believing that the chance of having a CF child was very low (32.2%). Compared with decliners, acceptors were more likely to have no children, regarded having a child with CF as more serious, believed themselves more susceptible to having such a child, knew more about CF, would be more likely to terminate a pregnancy if the fetus were shown to have CF, and more strongly supported offering CF screening to women of reproductive age. Of 4,879 women on whom results were obtained, 124 were found to be carriers. Of these 124 carriers, the partners of 106 were tested. Of the five at-risk couples, four requested prenatal diagnosis and one requested neonatal diagnosis. No woman found to be a carrier whose partner tested negative requested prenatal diagnosis. Except for the imperfect knowledge of those testing negative, none of the adverse outcomes predicted for CF carrier testing in the general population were observed in this study.

The effect of bcr-abl antisense oligonucleotide on DNA synthesis and apoptosis in K562 chronic myeloid leukemia cells.

Mutations in oncogenes have traditionally been viewed as inducing malignancy by causing excessive cell division. However, an additional possible tumorigenic mechanism is inhibition of normally occurring apoptosis. We have studied the mechanism of action of bcr-abl in chronic myeloid leukemia (CML) by inhibiting its expression using antisense oligonucleotides. K562 cells, derived initially from a patient with CML, were incubated with 16 microM 3',5'-capped bcr-abl antisense phosphodiester 18mer targeting the bcr-abl junctional sequence. Antisense reduced cell number by day 5 by 44% +/- 2.5% S.E. compared to nonsense or no-oligomer controls. Compared to nonsense oligomer, antisense oligomer reduced [3H]thymidine incorporation by only 13% +/- 1%. By the more reliable bromodeoxyuridine incorporation method, antisense had no inhibiting effect on DNA synthesis. In contrast to its minimal effect on DNA synthesis, antisense had a large effect on apoptosis. At day 4, after 3 days of oligomer treatment, antisense increased the proportion of cells with less than 2 N DNA 2.5 +/- 0.3-fold compared to nonsense, as revealed by analysis of DNA distribution following propidium iodide-staining. After 3 days of oligomer treatment and 24 h of serum deprivation, antisense increased the proportion of cells with less than 2 N DNA even more, over 3.1 +/- 1.1-fold compared to nonsense. Because CML cells are resistant to the induction of apoptosis (as judged by DNA laddering on electrophoresis, which requires double-stranded breaks), we also assayed the binding of terminal deoxynucleotidyl transferase (TdT), which requires only single-stranded DNA breaks. Antisense treatment for 3 days increased TdT binding at day 4 by 16.4 +/- 8.7-fold. We conclude that, in CML, bcr-abl may lead to the accumulation of myeloid cells to a greater extent by inhibiting apoptosis than by increasing cell division. This bcr-abl induced inhibition of apoptosis may thwart chemotherapy and foster the accumulation of further mutations leading to the development of the blastic phase of the disease.

Women's receptivity to testing for a genetic susceptibility to breast cancer.

Four hundred eighty-four patients undergoing mammography and 498 patients visiting their obstetrician-gynecologist were asked whether they would take a breast cancer 1 (BRCA1) test to detect a genetic susceptibility to breast cancer. More than 90% in both groups said they would take the test. Women were more likely to accept if they were regularly having breast examinations by a physician, believed that mammography effectively detects early breast cancer, and believed that early breast cancer is curable. If shown to have inherited a susceptibility, many reported that they would be very anxious, would want the test repeated, would examine their breasts more often than monthly, and would want mammography more often than yearly. Many also reported that they would recommend testing to relatives.