There are a variety of tests that you may face during the process of your diagnosis which will likely affect your treatment decision making. Join this informative webinar where Scott Weissman, MS, CGC, will explain the difference between tumor and germline testing so that you can better understand the tests you receive and what they mean for you.

1. ‘Tumor vs. Germline Testing:
What’s the Difference?’

2. TODAY’S WEBINAR
 SPEAKER(S)
 Scott M. Weissman, MS, CGC
 QUESTIONS
 Ask a question in the panel on the RIGHT SIDE of your
screen
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3. RESOURCES
TABOO-TY PODCAST MINI MAGAZINES YOUR GUIDE IN THE FIGHT

4. FIGHTCOLORECTALCANCERDISCLAIMER
The information and services provided
by Fight Colorectal Cancer are for
general informational purposes only.
The information and services are not
intended to be substitutes for
professional medical advice,
diagnoses or treatment.
If you are ill, or suspect that you are ill,
see a doctor immediately. In an
emergency, call 911 or go to the
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Fight Colorectal Cancer never
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any condition.

5. ScottM.Weissman,MS,CGC Scott M. Weissman is the founder of Chicago Genetic Consultants, LLC, a private
genetic counseling practice. He received his Bachelor of Science degree in Biology from
the University of Illinois at Urbana-Champaign in 1998. In 2002, he graduated from
Northwestern University in Chicago with his Masters of Science in Genetic
Counseling. Scott practiced clinically at NorthShore University HealthSystem for 12
years and was the Program Manager at the Center for Medical Genetics. His primary
focus was hereditary cancer syndromes but also worked with individuals who had
hereditary cardiac disease, neurologic conditions as well as a multitude of other adult
onset genetic conditions and the burgeoning area of pharmacogenomics. He also has
experience with new genetic testing technologies and Next Generation Sequencing
from his time with GeneDx, a clinical genetic testing company.
Scott is currently a Clinical Faculty member at the Northwestern University Graduate
Program in Genetic Counseling. He has been an active member of the National Society
of Genetic Counselors (NSGC) where he has worked on a variety of committees and
held positions as the Co-Chair of the Familial Cancer Risk Special Interest Group and
Liaison to both the Commission on Cancer and the National Accreditation Program of
Breast Centers, two programs housed in the American College of Surgeons. Scott is
well known among his peers for his extensive work in the field and has authored
numerous scholarly articles that have appeared in several prestigious publications such
as Genetics in Medicine, Cancer, The Journal of the American Medical Association, and
Journal of Genetic Counseling, to name a few.

6. Tumor vs. Germline Testing: What’s the
Difference
SCOTT M. WEISSMAN, MS, CGC
December 11, 2018

7. Conflict of Interest
• Employee and Stock Holder – Genome Medical
• Owner – Chicago Genetic Consultants, LLC
• Advisory Board and Stock Holder – Kolgene
• Paid Speaker – NSGC, Ambry Genetics (2018)

8. • I am not a medical oncologist
• Nothing in this talk is promoting specific tests,
companies or treatment recommendations.
• Many nuances that help determine which tests and
treatments are best
Disclosure

9. Points of Discussion
• Genetics Primer
• Tumor Genetic Testing
• Germline Genetic Testing

10. Cell

11. Nucleus

12. Chromosomes

13. DNA

14. What is a Gene?
• Made of 4 chemicals (base pairs) – Adenine, Guanine, Cytosine, Thymine
• Carries the chemical instructions to make all of the proteins in the body
• One gene has the instruction or “code” for one or more proteins
• Two copies of most genes; one copy from mother and one copy from father

15. What is a Genetic Test?
• DNA extracted from blood, tissue, tumor or saliva
• DNA shredded into small fragments
• DNA amplified over and over again with different chemicals to be able
to generate enough DNA to read the genetic code
• ‘Like spell check’
• Pathogenic variant (mutation) is a change to the genetic code causing
the gene not to work correctly
• Polymerase Chain Reaction (PCR) or Next Generation Sequencing
(NGS)

16. T
G

17. All Cancer Arises From Gene Mutations
Germline mutations Somatic mutations
Somatic mutation
(e.g., colon)
Mutation
in egg or
sperm
All cells
affected in
offspring
Parent Child
 Present in egg or sperm
 Are heritable
 Cause cancer family syndromes
 ~10% of cancer
 Occur in nongermline tissues
 Are nonheritable
 Sporadic cancer
 90-95% of cancer

18. How does colorectal cancer arise?
N Engl J Med 2009; 361:2449-2460

19. Why Somatic (Tumor) Testing?
• Prognostic Information
• tells healthcare providers about aggressiveness of tumor
• higher or lower risk for developing metastatic disease
• Treatment Decisions
• helps healthcare providers in making chemotherapy (or other) decisions
• whether to give chemotherapy or immunotherapy
• type of chemotherapy or immunotherapy
• in people with advanced or refractory disease – new treatment options
Some somatic tests can identify people with hereditary forms of cancer

20. Somatic Testing in Colorectal Cancer
• Recommended
• American Society for Clinical Oncology (ASCO)
• National Comprehensive Cancer Network (NCCN)
• Optional Tests

21. Somatic Testing in Colorectal Cancer
• Recommended
• American Society for Clinical Oncology (ASCO)
• National Comprehensive Cancer Network (NCCN)
• Optional Tests

22. Somatic Testing in Colorectal Cancer
• Mismatch Repair (MMR) System
• genes involved in correcting single
base pair mistakes that can occur
during DNA replication
• If not working, MMR deficiency or
dMMR
• Common genes include MLH1,
MSH2, MSH6 and PMS2

23. How to test for dMMR?
• Immunohistochemistry (IHC)
• the staining of a tumor sample to
visualize a protein of interest
• loss of staining for a MMR protein in a
tumor points to an underlying genetic
event in the corresponding gene
• Adjacent normal tissue and other
non-cancer cells will still exhibit
normal staining
• Gene is working - protein present
(normal) – Brown
• Gene is mutated and not working -
protein absent (abnormal) – Blue
MLH1
MSH6
MSH2
PMS2

24. Somatic Testing in Colorectal Cancer
• Microsatellite Instability Analysis
• Microsatellites are short segments of DNA that have a repeated sequence
such as CACACACA
• Repeats can be 1 or more base pairs (CA), and can be various sizes
• Occur in regions of DNA that are non-coding
• Inherited from parents
• Genetic test to measure the sizes of the microsatellite repeat size
• Microsatellite instability (MSI) is the somatic (tumor/tissue specific) expansion
or contraction of microsatellites, and is a downstream effect of loss of
function of the mismatch repair system

25. MSI Testing
STABLE - MSS
Instable –
MSI-high

26. Why is dMMR or MSI relevant?
• 10-15% of colon cancers will have dMMR or MSI
• Less common in rectal cancer
• Most common in stage II cancers
• Prognostic
• Tumors less likely to become metastatic
• More favorable outcomes (i.e., patients do better)
• Treatment
• Do not respond to 5-FU (Fluorouracil) - Chemotherapy
• No treatment for low risk stage II cancers
• Keytruda (pembrolizumab) - Immunotherapy
• Given in metastatic disease when tumor is dMMR or MSI-high (any cancer, not just colon)

27. Why is dMMR or MSI relevant?
• Hereditary
• 90-95% of individuals with Lynch syndrome have dMMR or MSI-high colon
cancers
• If identified, indicates a referral should be made to a genetics professional for an
evaluation for Lynch syndrome
• Due to germline mutations in MLH1, MSH2, MSH6 and PMS2 genes (also EPCAM)
Due to prognostic, treatment and hereditary implications, anyone who has a
colorectal cancer should have IHC for MMR or MSI analysis performed at the
time of diagnosis

28. Somatic Testing in Colorectal Cancer
• Epithelial Growth Factor Receptor (EGFR) Pathway
• Important in cell
• Growth
• Survival
• Proliferation
• Differentiation
• In cancer – if overactive, can lead to
progression of cancer
• Two drugs specific for individuals with active
EGFR (anti-EGFR) – monoclonal antibodies
• Drugs that recruitment the immune system to fight
the cancer
• Erbitux (cetuximab)
• Vectibix (panitumumab)

29. EGFR Pathway Genes
• RAS - KRAS/NRAS
• Genes that involved with cell signaling pathways that control cell growth, cell
maturation, and cell death
• When the gene is in the normal state, it is called wild-type
• At least 40% of colorectal cancers have mutations in KRAS gene, NRAS less common
• Any individual with metastatic colorectal cancer should be tested for mutations in
these genes
Prognostic
• May lead to shorter disease free intervals
Treatment
• When in the wild-type state, individuals with metastatic colon cancer can be treated with
cetuximab or panitumumab
• If genes are mutated in tumor, cannot receive treatment with these drugs – will not
work!

30. EGFR Pathway Genes
• RAF – BRAF
• Genes that involved with cell signaling pathways that control cell growth, cell maturation, and cell
death
• When the gene is in the normal state, it is called wild-type
• Primarily one mutation occurs in cancers, V600E
• 5-9% of colorectal cancers have the BRAF V600E mutation
Prognostic
• Poor prognostic indicator when BRAF V600E is present, tumors more aggressive
• Less responsive to certain therapies
Treatment
• When in the wild-type state, individuals with metastatic colon cancer can be treated with (Erbitux)
cetuximab or (Vectibix) panitumumab
• If V600E is present, treatment with anti-EGFR drugs generally not recommended

31. EGFR Pathway Genes
• RAF – BRAF
Hereditary
• Often seen in tumors that have dMMR or MSI
• When present, unlikely individual has Lynch syndrome
• Due to prognostic and treatment implications, anyone who has stage IV colorectal
cancer should be tested for BRAF V600E mutation.
• If tumor is dMMR or MSI, testing for BRAF V600E should be considered to evaluate
for the possibility of Lynch syndrome

32. Somatic Testing in Colorectal Cancer
• Recommended
• American Society for Clinical Oncology (ASCO)
• National Comprehensive Cancer Network (NCCN)
• Optional Tests

33. EGFR Pathway Genes
• PIK3CA and PTEN
• Genes that can have an impact on the
development and prognosis of
colorectal cancer
• Found in about 10-18% and 5-14%
of colorectal cancers, respectively
• Data is controversial and no data to
conclusively show impacts treatment
choices
• Not recommended to be tested for
outside of a clinical trial

34. MultiGene Tests
• Tests that evaluate multiple genes at once
• Some are proprietary in terms of the genes evaluated
• Several on the market
• May be run depending on the stage of the colorectal cancer
• All using some form of NGS and other genetic test technologies
• Many covered by insurance

35. MultiGene Tests – Stage II or III Disease
• OncotypeDx (Genomic Health)
• Looks at expression of 12 genes and provides a recurrence score (low, intermediate
or high) to guide treatment
• Prognostic for recurrence, disease free survival and overall survival
• Not predictive for benefit of therapy
• ColoPrint (Agendia)
• Looks at expression of 18 genes and provides a recurrence score (low or high)
• “Improves the identification of patients who benefit from therapy”
• ColDx (Almac)
• 482 genes and another >100 genetic markers to develop a recurrence score (low or
high)
• Same idea as ColoPrintThese tests do not identify people with hereditary forms of
cancer

36. MultiGene Tests – Stage II or III Disease
• Tests are designed to help with making treatment decisions
• To treat or not to treat…that is the question!
• Low risk – no treatment, High risk – treatment, Intermediate – other risk factors
• Typically not for treatment choice

37. MultiGene Tests – Advanced Disease
• FoundationOne CDx (Foundation Medicine)
• detection of substitutions, insertion and deletion alterations, and copy
number alterations in 324 genes and select gene rearrangements, as well as
genomic signatures including MSI and tumor mutational burden
• Colorectal cancers with high tumor mutational burden more likely to benefit from immunotherapy
• Molecular Intelligence Comprehensive Tumor Profiling (Caris Life Sciences)
• Looks at DNA, RNA and proteins in tumors to help with treatment decisions
• Tempus xO
• Evaluates 1711 genes in the DNA and RNA
• Many academic institutions offer their own testing
• All of these tests can identify people with hereditary forms of cancer

38. MultiGene Tests – Advanced Disease
• Tests are looking for genetic mutations or tumor mutation burden (TMD) in the
tumors to see if a novel or off label therapy can be tried
• Like EGFR pathway, many other pathways that lead to cancer develop and many drugs on
the market that can be used based on molecular markers
• e.g, drug that is typically used and approved for pancreatic cancer could it be used
for colorectal cancer
Can also be used for clinical trial eligibility

39. Somatic Tumor Testing Summary
• Genetic testing done on tumor tissue to help determine prognosis of a colorectal
cancer diagnosis and in some situations, guide treatment decisions
• Usually used in individuals with stage II or higher disease
• Testing done using a combination of different genetic tests
• Some can identify individuals with a hereditary form of cancer
• Often covered by insurance (but not always)

40. All Cancer Arises From Gene Mutations
Germline mutations Somatic mutations
Somatic mutation
(e.g., colon)
Mutation
in egg or
sperm
All cells
affected in
offspring
Parent Child
 Present in egg or sperm
 Are heritable
 Cause cancer family syndromes
 ~10% of cancer
 Occur in nongermline tissues
 Are nonheritable
 Sporadic cancer
 90-95% of cancer

41. Causes of Hereditary Susceptibility to
Colorectal Cancer

42. When to Suspect Hereditary Cancer
Syndrome
• Cancer in 2 or more close relatives
(on same side of family)
• Early age at diagnosis (<50 years)
• Multiple primary tumors
• Bilateral or multiple rare cancers
• Constellation of tumors consistent with specific cancer syndrome (e.g., colon and
uterine; colon and multiple colon polyps)
• Evidence of autosomal dominant transmission (sometimes recessive)

43. • Penetrance is often incomplete
• May appear to “skip” generations
• Individuals inherit altered cancer susceptibility gene,
not cancer
Normal
Susceptible Carrier
Carrier, affected
with cancer
Sporadic cancer
Most Cancer Susceptibility Genes are Dominant with
Incomplete Penetrance

44. 3 ‘Categories’ of Hereditary Colorectal Cancer
Genes
• Baseline Colorectal Cancer Risk – 5% (1 in 20)
• High Risk (30-100% lifetime risk)
• Increased screening
• Cancer prevention
• Moderate Risk (<30% lifetime risk)
• Increased Screening
• New/Low Risk (Unknown/<20% lifetime risk)
• Management not known

45. High Risk Genes
• Lynch syndrome
• MLH1, MSH2, MSH6, PMS2, EPCAM
• Familial Adenomatous Polyposis
(FAP)/Attenuated FAP
• APC
• MUTYH-associated Polyposis (MAP)
• MUTYH
• Peutz-Jeghers syndrome
• STK11
• Juvenile Polyposis syndrome
• BMPR1A, SMAD4
• Polymerase Proofreading-associated
Polyposis (PPAPP)
• POLD1, POLE

46. Moderate Risk Genes
• ATM
• Primarily breast cancer
• BRCA1/BRCA2
• Primarily breast/ovarian cancer
• CHEK2
• Primarily breast cancer
• GALNT12
• MUTYH – 1 mutation
• PTEN
• Primarily breast cancer

47. Newer Genes
• AXIN2 (presumed high)
• Missing multiple teeth, polyposis
• GREM1 (presumed high)
• Mixed polyposis syndrome
• MSH3 (presumed high)
• Polyposis
• NTHL1 (presumed high)
• Polyposis

48. Genetic Testing
• Historically (1995 – present) – Single conditions
mostly
• Could test for high risk genes individually
• 2013 – panel tests became available
• Can test for multiple genes in one test for the same
cost (or less than single genes)
• High risk, High and moderate risk or all 3 categories

49. Genetic Testing - Who to Test
• Guidelines exist for when to offer genetic testing
• Diagnosed <50
• >10 adenomas (or mix of polyps)
• >2-3 juvenile or Peutz-Jeghers polyps
• >5 serrated polyps
• Tumor is dMMR or MSI-high
• Multiple family members with colorectal cancer or combination of other
cancers +/- polyps
• Most insurance companies cover some if not all of the cost
• Same type of testing in terms of next generation sequencing

50. Genetic Testing - Management
• High/Moderate Risk Genes
• Clinically actionable
• Can offer some combination of
increased screening and/or
prevention via surgeries
• Can clearly identify who in the
family is at risk with additional
genetic testing

51. Genetic Testing - Management
• High/Moderate Risk Genes
• Clinically actionable
• Can offer some combination of
increased screening and/or
prevention via medications or
surgeries
• Can clearly identify who in the
family is at risk with additional
genetic testing
• New/Low Risk Genes
• Don’t know full risk, so do not
have lots of evidence level of
screening need
• Would not recommend
prevention w/o knowing high
risk or symptoms (polyps)

52. Genetic Testing – Possible Results
Positive
• Pathogenic or Likely Pathogenic Variant
• Increased risk for colorectal (and/or polyps or other cancers)
• Testing can be done for other relatives
Negative
• No variants identified
• Not likely hereditary BUT no genetic testing is 100% sensitive
• Testing generally not recommended for other relatives
Variant of Uncertain Significance (VUS)
• Variation in genetic code found – significance in terms of cancer risk not known
• Do not change medical management
• Do not recommend testing other family members

53. Genetic Testing
• Who to start with?
• Ideally, start with an
individual who has had
cancer
• Not always available so
can test unaffected
individuals
• Challenge – If results are
negative,
‘uninformative’

54. Genetic Testing
• Who to start with
• Ideally, start with an
individual who has had
cancer
• Not always available so
can test unaffected
individuals
• Challenge – If results are
negative,
‘uninformative’
• Why Uninformative?
• 1) No mutation in family
• 2) False negative
• Missed path variant
• Gene not on test
• 3) True negative

55. Genetic Testing – What If I Was Tested?
If tested before 2013 – follow-up with healthcare provider that tested you to see
if additional genetic testing is needed or should be considered
If tested after 2013 – check back with healthcare provider every 1-2 years to see
if additional genetic testing should be considered
Genes change
Technology changes

56. Germline Genetic Testing Summary
• Genetic testing done on blood or saliva to help determine a cause to the cancer
to identify future cancer risk for individual and family
• Can be done on anyone and certain criteria to determine best candidates
• Testing done doing single genes or panels of genes
• Often covered by insurance (but not always)
• Testing may be done a second time in the future when more is known

57. Thank You for Your Attention!
• QUESTIONS?
• Email: scott@chicagogenetics.com
• Website: www.chicagogenetics.com
• Twitter: @chicagogenetics
• LinkedIn: linkedin.com/in/scott-weissman-9963a3114

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