- Were you diagnosed with colon or rectal cancer before the age of 50? - Was anyone in your family diagnosed with colon cancer before the age of 50? - Was anyone in your family diagnosed with uterine (endometrial) cancer before the age of 50? - Are there cancers across several generations on one side of your family? If you answered YES to just one of these questions, it's time to talk turkey about Lynch syndrome. Lynch syndrome is an inherited genetic mutation, and having it increases your chance of getting colorectal cancer to 80%. Unfortunately, nearly every person living with Lynch syndrome is completely unaware of it. Lynch syndrome also puts you at higher risk for brain, breast, kidney, melanoma, ovarian, pancreas, small bowel, stomach, or uterine/endometrial cancers. Knowledge is power and will help your medical team act more aggressively with their screening measures. Brian Mansfield, a music critic for USA Today, didn't know he had Lynch syndrome until he was diagnosed with colorectal cancer earlier this year at the age of 48. After his diagnosis, he began talking with his family about their health history, "then the family tree lit up like a Christmas tree." Brian is chronicling his journey through a weekly USA Today online column, "My Semicolon Life." Join national patient advocacy group Fight Colorectal Cancer as we host Brian and his doctor, Dr. Bill Harb, a colorectal surgeon at Cumberland Surgical Associates, along with Associate Director of Human Genetics at Ohio State University Heather Hampel as they tell you more about Lynch syndrome and how to dig into the medical mystery that may be lurking within your family tree. With the holidays coming up, never has there been a more appropriate time to talk turkey...and Lynch syndrome. **Fight Colorectal Cancer thanks Can't Stomach Cancer, the Colon Club, Kidney Cancer Association, Myriad Genetics, and Ovarian Cancer National Alliance for their assistance with this webinar.**

1. Welcome!
Talking Turkey
About Lynch Syndrome
Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series
Our webinar will begin shortly
www.FightColorectalCancer.org
877-427-2111

2. Fight Colorectal Cancer
1. Tonight’s speaker’s: Brian Mansfield, Dr. William Harb, and
Heather Hampel
2. Archived webinars: Link.FightCRC.org/Webinars
3. Follow up survey to come via email. Get a free Blue Star of
Hope pin when you tell us how we did tonight.
4. Ask a question in the panel on the right side of your screen
5. Or call the Fight Colorectal Cancer Answer Line at 877-427-2111
www.FightColorectalCancer.org
877-427-2111

3. Fight Colorectal Cancer
Upcoming 2013 Webinar’s
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4. Fight Colorectal Cancer
Funding Research Directly
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http://fightcolorectalcancer.org/research/lisa-fund

5. Fight Colorectal Cancer
Disclaimer
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, diagnosis, 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 nearest
emergency room.
Fight Colorectal Cancer never recommends or endorses any
specific physicians, products or treatments for any condition.
www.FightColorectalCancer.org
877-427-2111

6. Fight Colorectal Cancer
Resources
To learn more about Lynch Syndrome
http://fightcolorectalcancer.org/awareness/lynch_syndrome
5 Questions to Ask your Family at Thanksgiving
http://fightcolorectalcancer.org/images/posts/2012/10/5-
Questions.pdf
Is Lynch Syndrome Lurking in your family worksheet
http://fightcolorectalcancer.org/images/posts/2012/10/Lynch-
lurking.pdf

7. Fight Colorectal Cancer
Patient
Lynch
Syndrome
Genetics
Physician
Counselor

8. Fight Colorectal Cancer
Brian Mansfield

9. Fight Colorectal Cancer
To learn more about Brian’s Story:
Downloadable PDF -
http://fightcolorectalcancer.org/images/posts/
2012/10/Lynch-article-FINAL.pdf
www.FightColorectalCancer.org
877-427-2111

10. Fight Colorectal Cancer
Dr. William Harb

11. Talking Turkey about
Lynch Syndrome
Dr. William J. Harb, M.D., FASCRS
Colorectal Surgeon
Nashville, TN

12.  48 year old male presents with a change in his bowel
habits
 Referred by his internist to a gastroenterologist
 Undergoes colonoscopy
 Family history?
 Maternal great-grandfather had colon cancer
 Maternal uncle with colon cancer
 Questionable ovarian cancer in paternal grandmother and
aunt

14. What next?

15.  A visit to the colorectal surgeon
 What do we talk about?
 Review of colonoscopy
 Review of CT scan
 Discussion of colon anatomy
 Discussion of family history

17.  Genetic testing
 Why?
 Age under 50
 Family history
 Often unreliable as in Brian’s case – many physicians would
think that maternal great-grandfather and uncle not related
closely enough
 Ovarian cancer often neglected in family history

18.  Brian had genetic testing prior to surgery
 It actually changed what operation he had!

21.  He needs colonoscopy every year
 Not every 5 years or 3 years
 Need to check his stomach
 Family members need genetic testing
 Referral to genetic counselor

22. Summary
 Lynch syndrome is not rare
 But if you don’t look for it then it won’t be found
 We need the help of patients to discuss this with their
family and their doctors
 We can prevent colon cancer with genetic testing
 And we can prevent people like Brian from having to go thru
this ordeal
 Please talk to your doctors and your family – the holidays
are a great time of year to talk about medical history

23. Fight Colorectal Cancer
Heather Hampel

24. Talking Turkey about
Lynch syndrome
Heather Hampel, MS, CGC

25. Causes of Hereditary Susceptibility to
CRC
Sporadic
(65%–85%)
Familial
(10%–30%)
Rare CRC
syndromes Lynch syndrome (3%)
(<0.1%)
Familial adenomatous
polyposis (FAP) (1%)
Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 25

26. Lynch Syndrome
MSH2
MSH6
MLH1
PMS2
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 26

27. Sporadic Inherited
Normal gene Germline
mutation
Somatic
mutation
Somatic
mutation
Somatic
mutation
• Later age at onset (60s or 70s) •Early age at onset (<50)
• Little or no family history of cancer •Multiple generations with
cancer
• Single or unilateral tumors
•Clustering of certain cancers
(i.e. breast/ovarian)
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 27

28. Autosomal Dominant Inheritance
Carrier Parent Non-carrier Parent
Aa aa
Aa Aa aa aa
Carrier Carrier Non-carrier Non-carrier
1/2 1/2
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 28

29. Clinical Features of Lynch syndrome
 Early but variable age at CRC
diagnosis (~45 years)
 Tumor site in proximal colon
predominates
 Extracolonic cancers:
endometrium, ovary, stomach,
urinary tract, small bowel, bile
ducts, sebaceous skin tumors
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 29

30. Lynch Syndrome Cancer Risks (to 70)
Cancer MLH1& MSH2 MSH6 PMS2
♂ Colon cancer 56% - 85% 22% 20%
♀ Colon cancer 48% - 85% 10% 15%
Endometrial cancer 35% - 64% 26% 15%
♂ Other LS cancers 19.3% 3% 6%
♀ Other LS cancers 5% 11% 6%
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 30

31. Surveillance Options for Patients with
Lynch syndrome
Malignancy Intervention Recommendation
Colorectal cancer Colonoscopy Begin at age 20–25,
repeat every 1–2
years
Endometrial  Transvaginal Annually, starting at
cancer ultrasound age 25–35
 Endometrial
aspirate
Lindor NM, et al. JAMA 2006;296(12):1507-1517.
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 31

32. Surveillance Reduces Risk of Colorectal
Cancer in Lynch syndrome Families
30
No surveillance
% of Surveillance
subjects 20
with CRC
11.9%
10
4.5%
0
0 3 6 9
Years of follow-up
Jarvinen HJ et al. Gastro 108:1405, 1995
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 32

33. Prophylactic Surgery Options for
Patients with Lynch syndrome
 Options include subtotal colectomy,
hysterectomy, and oophorectomy
 Surgery does not eliminate cancer risk
 Recent data that hysterectomy with BSO
eliminates the risk of endometrial and ovarian
cancer in LS patients
Schmeler KM, et al. NEJM 2006;354:261-269.
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 33

34. The Family History is Key to Diagnosing
Lynch syndrome
CRC
dx 50s
CRC CRC
CRC dx 61 dx 75 Ovarian
dx 45 Ca, dx 64
CRC CRC Endometrial 45 CRC
dx 48 dx 52 Ca, dx 59 dx 42
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 34

35. Amsterdam Criteria II
 3 or more relatives with verified HNPCC-
associated cancers* in family
 One case a first-degree relative of the other two
 Two or more generations
 One CRC by age 50
 FAP excluded
*HNPCC associated cancers: CRC, endometrial, small bowel,
ureter, renal pelvis
Vasen HFA et al. Gastroenterology 116:1453, 1999
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 35

36. Genetic Features of Lynch Syndrome
 Genes belong to DNA mismatch repair
(MMR) family
 Mutations in MMR genes lead to
microsatellite instability
 MMR proteins are missing in the tumor
tissue making immunohistochemical staining
useful
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 36

37. Microsatellite Instability (MSI)
 Repetitive DNA sequences 1- 4 nucleotides
(microsatellites) normally found genome
 Mono: TCGAGG AAAAAAAA GGAGCT
 Di: TCGAGG CACACACACACA GGAG
 With MMR failure, variability in repeats
 90% of HNPCC tumors are MSI+
 10%–15% of sporadic CRCs are MSI+
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 37

38. MSI testing on Genotyper
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 38

39. Immunohistochemistry
 Identify MMR
proteins
 Normally present
 If protein is absent,
gene is not being
expressed (mutation
MLH1 MSH2
or methylation)
 Helps direct gene
testing by predicting
likely involved gene
 If abnormal IHC
(absent), MSI+
PMS2
The Ohio State University Comprehensive Cancer Center –
MSH6
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 39

40. When to Suspect Hereditary Cancer
Syndrome
Cancer in 2 or more close relatives
(on same side of family)
Early age at diagnosis
Multiple primary tumors
Bilateral or multiple rare cancers
Constellation of tumors consistent with specific
cancer syndrome (eg, breast and ovary)
Evidence of autosomal dominant transmission
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 40

41. When Should Genetic Testing Be
Considered?
 Significant family cancer history
 Reasonable likelihood of carrying an altered
cancer susceptibility gene
 Ideally, test affected person first
 Results will influence medical management
 Patient wants information (empowerment)
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 41

42. GINA
 Prevents health insurers from denying coverage,
adjusting premiums, or otherwise discriminating on the
basis of genetic information.
 Group and self-insured policies
 Insurers may not request that an individual undergo a
genetic test.
 Employers cannot use genetic information to make
hiring, firing, compensation, or promotion decisions.
 Sharply limits a health insurer's or employer's right to
request, require, or purchase someone's genetic
information.
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 42

43. Resources
 Heather Hampel
 614-293-7240
 Heather.Hampel@osumc.edu
 Family HealthLink
 https://familyhealthlink.osumc.edu
 Free, on-line tool that assesses
family history of cancer and
cardiovascular disease
 Find a Genetic Counselor
 www.nsgc.org
 www.cancer.gov/cancertopics/gen
etics/directory/results
The Ohio State University Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 43

44. Fight Colorectal Cancer
Patient
Lynch
Syndrome
Genetics
Physician
Counselor

45. Fight Colorectal Cancer
www.FightColorectalCancer.org
877-427-2111

46. Fight Colorectal Cancer
Resources
To learn more about Lynch Syndrome
http://fightcolorectalcancer.org/awareness/lynch_syndrome
5 Questions to Ask your Family at Thanksgiving
http://fightcolorectalcancer.org/images/posts/2012/10/5-
Questions.pdf
Is Lynch Syndrome Lurking in your family worksheet
http://fightcolorectalcancer.org/images/posts/2012/10/Lynch-
lurking.pdf

47. Fight Colorectal Cancer
CONTACT US
Fight Colorectal Cancer
1414 Prince Street, Suite 204
Alexandria, VA 22314
(703) 548-1225
Toll-Free Answer Line: 1-877-427-2111
www.FightColorectalCancer.org
Email us: Info@FightColorectalCancer.org