UCSF center adds to revolution of care for BRCA carriers

A new center at University of California, San Francisco, is designed to provide comprehensive and integrated care for patients with cancer who carry BRCA and other mutations.

The Center for BRCA Research at UCSF Helen Diller Family Comprehensive Cancer Center joins Basser Center for BRCA in Philadelphia as the only facilities solely devoted to BRCA–related cancers.

HemOnc Today spoke with Pamela N. Munster, MD, leader of the developmental therapeutics program and co-director of the Center for BRCA Research, about how the center came about, how she became involved, and what she hopes the center will do for BRCA mutation carriers and their families.

Pamela N. Munster

Question: What led you to become involved in the creation of this center?

Answer: BRCA research has evolved rapidly over the last several years. Until recently, genetic testing had been limited to individuals who presented with cancer at a young age or to families in which multiple young members were affected. Germline testing has become increasingly more acceptable. Many more tumors are now linked to germline mutations, and the testing for family members has become more affordable. Having the BRCA2 mutation myself, I recognized that being diagnosed with a BRCA mutation leaves many with a sense of overwhelm. Most commonly, an unaffected individual is tested because a relative has been diagnosed with a BRCA–related tumor. After receiving a positive test result, carriers without cancer typically are seen by genetic counselors who outline the risks and present recommendations for screening and multiple risk-reducing surgeries. There is, however, very limited guidance on who will coordinate the recommended screening strategies. Recommendations are mostly population-based and not tailored for individual family members or personal needs. For other BRCA–related cancers — such as pancreatic cancer, melanoma and prostate cancer — there is much uncertainty about when to begin and how to screen. Putting all these recommendations in perspective and finding the appropriate experts feels very confusing.

Q: What is the center’s mission ?

A: The overall mission of the center is to provide coordinated and comprehensive care from experts who specialize in hereditary cancer to the patient rather than a patient having to seek out individual experts from many disciplines. The treatment of BRCA–related tumors has emerged rapidly, and the treatment choices often differ from how we treat sporadic tumors. Patients with BRCA–mutated cancers should have an opportunity to receive therapy focused on their mutation, not necessarily based on their tumor type. Second, we want to provide a clinic for unaffected mutation carriers. Mutation carriers should be able to seek out experts to tailor the appropriate screening while reflecting risks, personal choices and other confounding factors. Decision-making on the timing and extent of risk-reducing surgeries may require multiple clinic visits. Many young carriers may seek guidance with family planning and support with the considerable distress and fears this mutation may cause. This requires experts from different fields, including medical oncologists, surgeons, internists, gynecologists, reproductive endocrinologists, psychologists and anthropologists.

Q: How will the center be staffed?

A: We brought together experts in many cancer disciplines to find consensus on current screening and risk-reduction strategies for select cancers associated with a hereditary mutation. We created a clinic where mutation carriers or patients with a prior cancer are seen and counseled on current recommendations according to their age, family history and lifestyle. Our next step is to provide outreach and education to the broader community of physicians and health care providers.

Q: What are the short-term goals of the center?

A: We will bring together researchers and clinicians with a focus on BRCA research to guide treatment and develop novel approaches in the risk assessment, prevention and treatment of tumors associated with BRCA mutations. Our research activities will include bench research, translational studies and clinical trials focused on patients with BRCA and other related mutations. The prevention of cancers in mutation carriers often includes risk-reducing surgery and intense screening spanning many tumor types. Consistent follow-up in a clinic with experts stemming from multiple disciplines is crucial, and real-time adaptation of screening procedures is needed to facilitate adherence and acceptance of such guidelines. We hope a center devoted to the care for mutation carriers will increase the ability to prevent tumors. In addition to treating patients with mutations, a major goal in the first few years will be to raise awareness of the presence of hereditary cancer in populations not currently thought to be at risk, and to define better criteria for broader germline testing.

Q: What are the long-term goals?

A: The long-term goal is to better define who is at risk for cancer. We hope to avoid risk-reducing surgeries in those mutation carriers who would develop cancer, and to study contributing endogenous and environmental factors that promote cancers. The center’s in-depth research focus and its community of experts will provide an opportunity to define more effective treatments for those with cancer and, most importantly, to develop prevention strategies that do not entail removal of vital and gender-defining organs. Of course, we hope to create an opportunity to eliminate such cancer-associated mutations from our next generations.

Q: Do you expect to collaborate with Basser Center for BRCA ?

A: Cancer treatment and our mission toward the eradication of BRCA–related cancers is a team effort. Our mission is very much aligned with that of the Basser Center in Philadelphia. The launch of our center allows us to formally bring together experts from many complementary disciplines focusing on BRCA research at UCSF, as well as in collaboration with the Basser Center and many other institutions worldwide. A common focus will consolidate and cross-pollinate efforts. Yet, most importantly, it will create a center to allow patients to benefit from recent advances in a timelier manner. There have been considerable advances in research associated with BRCA mutations, and we hope its translation into patient care will broaden rapidly. By integrating research and patient care specific to a mutation, we anticipate we will be able to raise even greater awareness.

Q: What is your ultimate hope for the center?

A: I want for my children to have a place, when they come of age and decide to test themselves, where their prevention and treatment is based upon prospective studies integrating the latest research advances in clinical care, using noninvasive prevention strategies rather than treating tumors that should have been prevented — or at least diagnosed — at an early stage. My hope, of course, is to eradicate BRCA–related tumors within our children’s generation. In the past, we have had very few opportunities to intervene and prevent tumors targeting a specific mutation. In the future, I hope that risk-reducing surgery is needed only for very few individuals. Broader screening in the population should identify mutation carriers at risk rather than upon diagnosis of cancer. Additionally, we believe that prevention strategies can be tailored commensurate to a patient’s risk, that pre-implantation diagnostics can be used to eliminate the mutation from the population and that large-scale studies can be conducted to determine environmental factors that contribute to cancer. – by Jennifer Southall

For more information:

Pamela N. Munster, MD, can be reached at UCSF Helen Diller Family Comprehensive Cancer Center, Box 1711, San Francisco, CA 94143-1711; email: pmunster@medicine.ucsf.edu.

Disclosure: Munster reports no relevant financial disclosures.