Dissertations / Theses on the topic 'Hereditary breast cancer patient'

Background: Women with breast or ovarian cancer (patients) are increasingly offered genetic testing shortly after diagnosis to guide management and identify future cancer risks. As a result, new approaches to communication about hereditary cancer are needed to inform decision-making amongst patients and their relatives. Aims: This thesis aimed to investigate expert opinion and guideline recommendations about the communication needs of patients undergoing genetic testing, the information communicated by genetics health professionals and recalled by patients and their relatives and the experience of patients with newly diagnosed breast cancer who undergo genetic testing. Methods: A scoping review and five studies were conducted using UK data from patients and health professionals: an observational study, a Delphi survey, a content analysis, a document analysis and mixed methods matrix and a qualitative study. Results: Accuracy of information recall was low amongst patients and relatives following genetic counselling, especially about hereditary cancer management. Expert health professionals and service users agreed on the key messages required by patients to inform decision-making for themselves and their relatives. However, during genetic counselling, half of the key messages were communicated to patients and fewer key messages were communicated about hereditary cancer management than genetic testing. Recommended information to communicate to patients was identified from international genetics guidelines. Recommendations about hereditary cancer management were infrequently reflected in expert opinion, communicated by genetics health professionals or recalled by patients. Newly diagnosed patients experienced growing uncertainty and concern about inheritance and surgical decision-making, especially when their genetic test result was unexpected. Conclusions: Patients received insufficient information to understand their future cancer risks and make informed decisions about managing hereditary cancer. Steps are needed to improve information provision, especially when results are unexpected. These findings can help guide refinements to communication as genetic testing is integrated into mainstream oncology.

Breast cancer is the most common cancer in women in most part of the world. Although there are multiple risk factors which have been reported to be related to breast factors, by far one of the highest risk of breast cancer is the inheritance of the BRCA1 and BRCA2 cancer susceptibility genes. The lifetime risk of breast cancer can be as high as 60-80% for BRCA mutation carriers. As the breast cancer epidemiology and genetic predisposition is increasingly understood, it transpires that ethnic differences exist. Although variations of genetic factors may play a role, the reasons for these differences remain unclear. Most published data are Caucasian based and there are limited publications on hereditary breast cancer in Asians available to date. This thesis hypothesizes that due to the known differences in genetic predisposition in different ethnic groups, it is likely that the mutation spectrum of BRCA mutations and breast cancer characteristics of Hong Kong Chinese, a relatively unexplored cohort, will differ to that of Caucasians. Moreover, the ancestors of local Hong Kong population migrated from Mainland China of which majority were from Southern China. They then remained in Hong Kong and populated and hence similar to smaller countries such as Iceland and Poland where founder mutations are identified, it is likely that a founder mutation will be present. Lastly due to different cultural differences and availability of screening facilities, management options of those found to carry the BRCA mutation may differ to that of other countries. The aims of this study are as follows 1) Perform a comprehensive genetic and phenotypic analysis using Full Gene Sequencing and Multiplex ligation-dependent probe amplification (MLPA) testing of Hong Kong Chinese cohort or breast cancer patients/families who are clinically high risk and to develop a registry to collect data related to this study. 2) To identify the spectrum of BRCA mutation in Hong Kong. 3) To report, any novel mutations, founder mutations, large rearrangements and deletions (using MLPA) if any are found. 4) If founder mutations are present, to develop a fasting and cheaper technique so that rapid screening can be offered. 5) To identify the choice of management in this high risk cohort. A total of 451 clinically high-risk breast and /or ovarian cancer patients from 1 March 2007 to 28 February 2011 were recruited. Based on sequencing results, 59 (13.1%) deleterious BRCA gene mutations were identified: 24 (41%) were in BRCA1 and 35 (59%) in BRCA2. Of the 59 deleterious mutations, 22 (37%) were novel mutations, 8 were BRCA1 and 14 were BRCA2 mutations. Eight recurrent mutations were identified of which four were proven to be founder mutations. These results showed that both BRCA1 and BRCA2 mutations account for a substantial proportion of hereditary breast/ovarian cancer in Sothern Chinese population. By using MLPA, four patients with large genomic rearrangement were identified and one of whom has a de novo BRCA1 mutation encompassing exons 1 to 12 deletion. Such mutations are rare and this de novo mutation has not been previously reported. Moreover another novel BRCA2 variant of unknown significance (c.7806-9T>G), a splice-site intronic mutation, was recharacterized to be pathogenic due to clinical suspicion based on its co-segregation. High Resolution Melting Technique in performing rapid screening for the founder mutations was developed and tested on a further cohort confirming the possibility of the use of founder mutations screening technique in future. Finally, concerning the management choice of BRCA mutation carriers undertaken in Chinese, BRCA mutation carriers in our cohort are more likely to choose intensive surveillance as an option of risk management rather than prophylactic interventions. In summary, this study provides valuable information on mutation spectrum of BRCA1 and BRCA2 in Southern Chinese population. Identifications founder mutations and knowledge of its prevalence in this Chinese population provides important information both to genetic counselling and risk assessment as well as to development of a cost-effective screening strategy. Furthermore, our study on the choice of management of mutation carriers allows us to have a baseline for development of future studies of psychological impact of genetic testing and management related to genetic testing, so that these high risk families can be better supported.
published_or_final_version
Surgery
Doctoral
Doctor of Philosophy

Background: Although the large number of studies investigating BRCA mutations and their clinical role in different populations and ethnicities, there is a lack of a systematic analysis on these alterations in Italian cohorts, including the analysis of Variants of Unknown biological and clinical Significance (VUS). Moreover, correct management of breast cancer patients tested positive for alterations in BRCA1 or BRCA2 genes is still controversial. We aimed to assess the biological and clinical relevance of BRCA alterations in a consecutive cohort of hereditary breast cancer patients, with particular attention to VUS. Methods: Genetic and clinical data from 366 patients with familial history of breast cancer were reviewed. The association between clinical-pathological, molecular data, and breast cancer patient subgroups was assessed. BRCA1/2 and γ-H2AX expression levels were assessed by qRT-PCR and IHC for all tumors. In silico protein prediction models were computed for VUS with potential clinical significance. Cell proliferation and apoptosis assays for CRISPR/Ca9s-generated mutant MDA-MB-231 cell line were performed to evaluate the sensitivity of specific VUS to DNA damage agents. Results: Overall, 73 breast cancer patients (20%) tested positive for BRCA1/2 alterations. BRCA1 and BRCA2 mutations were reported in 34 (46.5%) and 15 (20.5%) patients, respectively. Two patients (3%) showed two concurrent mutations in both genes. Twenty-two patients (30%) tested positive for VUS. Breast cancer family history and early onset of disease were significantly associated with BRCA1 (p < 0.001) and BRCA2 (p = 0.045 and p = 0.005) mutations. Triple-negative histotype, grading 3, and high Ki-67 levels were significantly associated with BRCA1 mutations (p < 0.001). Molecular, in silico and in vitro experiments confirmed the deleterious effect of BRCA1 c.5509T>C VUS, which was associated with significant high levels of DNA damage and greater sensitivity to Olaparib compared to Cisplatin treatment. Conclusions: Our study supports the deleterious effect of the BRCA1 c.5509T>C VUS in hereditary breast cancer patients, and suggests that breast cancer patient carriers of this variant could benefit from an intense surveillance and from a single agent treatment with Olaparib avoiding various side effects of chemotherapy treatment.

Abstract In the present study, mutations in BRCA1 and BRCA2, the two major genes predisposing individuals to hereditary breast and ovarian cancer, were screened in Finnish and Turkish cancer families. Germline BRCA1 mutations were found in 7% (6/88) and BRCA2 mutations in 6% (5/88) of the Finnish families studied in Oulu. Two distinct BRCA1 (3745delT, 4216nt-2A→G) and three BRCA2 (999delTCAAA, 6503delTT, 9346nt-2A→G) mutations were identified, all of which are recurrently found in Finland. In the 15 Turkish cancer families studied, 5382insC and 5622C→T were detected in BRCA1, and 3414delTCAG in BRCA2. The novel 3414del4 mutation was found in a family with a case of male breast cancer. In order to determine their ages and origin, 9 recurrent Finnish BRCA1 and BRCA2 mutations were studied further as regards haplotype conservation. Common origins approximately 18–80 generations (400–1600 years) ago were demonstrated for all studied mutations by partial haplotype sharing. The majority of the mutations showed geographical clustering, supporting the theory of regional founder effects. Four of the nine mutations are unique for Finland, whereas five have also been seen elsewhere. Mutations in the 5' end of BRCA1 tend to predispose individuals to ovarian cancer and those found in the 3' end to breast cancer. The age of ovarian cancer onset was significantly lower for BRCA1 (51 years) than for BRCA2 mutation carriers (61 years). Germline TP53 mutations were sought in the Finnish breast cancer families found to be negative after BRCA1 and BRCA2 screening but who exhibited some phenotypic features of the Li-Fraumeni syndrome. The Asn235Ser was found in a family displaying Li-Fraumeni syndrome phenotype and the Tyr220Cys in a family with a milder Li-Fraumeni-like phenotype. The nature of both mutations as cancer-predisposing alterations was supported by means of loss of heterozygosity (LOH) and p53 immunohistochemistry studies. Regional clustering of BRCA1 and BRCA2 founder mutations enables targeted genetic tests including especially those mutations characteristic of the birthplace of each patient. Additional genes are likely to explain a large proportion of the inherited susceptibility to breast cancer in particular. Germline TP53 mutations are expected to be found in the breast cancer families with other clinical features seen in the Li-Fraumeni syndrome.

Abstract In Western countries, breast and ovarian cancer are among the most frequent malignancies affecting women. Approximately 5–10% of the cases in the general population have been suggested to be attributed to inherited disease susceptibility. BRCA1 and BRCA2 are the main genes associated with predisposition to breast and ovarian cancer. Mutations in these two genes explain a major part of the families displaying a large number of early-onset breast and/or ovarian cancers, but at least one third of the cases appear to be influenced by other, as yet unidentified genes. Therefore, it is likely that defects in other cancer predisposing genes, perhaps associated with lower disease penetrance and action in a polygenic context, will also be discovered. In the present study, the contribution of germline mutations in putative breast and/or ovarian cancer susceptibility genes, based on their biological function, has been investigated in Finnish breast cancer families. The role of large genomic deletions or other rearrangements in the BRCA1 and BRCA2 genes was evaluated by Southern blot analysis, and mutation analysis of TP53, RAD51, the BRC repeats of BRCA2, and 53BP1 was performed by conformation sensitive gel electrophoresis and DNA sequencing. Germline TP53 mutations were searched for in 108 Finnish breast cancer families without BRCA1 or BRCA2 alterations. In this study, the pathogenic TP53 germline mutation, Arg248Gln, was identified in only one family. This family showed a strong family history of breast cancer and other cancers also fulfilling the criteria for Li-Fraumeni-like syndrome. Germline TP53 mutations are expected to be found in cancer families with clinical features seen in Li-Fraumeni or Li-Fraumeni-like syndromes. In this study, large deletions in BRCA1 and BRCA2 were not observed in 82 breast and/or ovarian cancer families. Likewise, no disease-related aberrations were detected in RAD51, the BRC repeats of BRCA2 or 53BP1 in the 126 breast and/or ovarian cancer families studied. The obtained results were validated by comparing to the occurrence in 288–300 female cancer-free control individuals. These results do not support the hypothesis that alterations in these particular genomic regions play a significant role in breast cancer predisposition in Finland. Thus, there are still genes to be discovered to explain the molecular background of breast cancer.

Individuals with a BRCA1 or BRCA2 pathogenic variant have an increased risk of developing breast, ovarian and prostate cancer. Offspring have a 50% chance of inheriting the pathogenic variant. At-risk young adults informed of their risk are often contemplating family planning and risk management choices. Few studies have explored communication processes regarding disclosure of genetic status from parents to young adults from the perspectives of all family members. This thesis includes: 1) a systematic review of young adults’ family communication experiences, risk perception, and cancer knowledge; 2) semi-structured interviews with young adults’ about their need for genetic information; 3) family interviews exploring the collective family experience with communicating genetic risk; and 4) focus groups and semi-structured interviews with genetic health professionals (GHPs) about the perceived needs of at-risk young adults, the challenges the GHPs experienced in supporting families during disclosure of genetic results, including strategies and training needed to support this process. In brief, young adults were not satisfied with the resources offered and although genetic information was accessible, the collective family’s experience with cancer influenced perceptions towards hereditary cancer information. Six key themes were identified exploring responsibility, gender, family culture, adversarial growth, key events, and GHPs role in supporting families. A lack of understanding of the importance to inform others and wider family systemic issues were challenging for GHPs. Strategies to address challenges include the management of appointments to accommodate family dynamics, family letters, and follow-up appointments. Clinical practices across Australia vary due to legislation. This thesis is the initial stage of exploration required to understand the perspective of young adults, relatives, and GHPs, before the development of an intervention to improve disclosure rates.

Abstract Two major genes are involved in hereditary predisposition to breast and ovarian cancer – BRCA1 and BRCA2. However, germline mutations in these tumor suppressors account for a maximum 20% of the familial breast cancer cases. A significant portion of the genes predisposing to this disease is unknown and therefore needs to be discovered. The aim of this study was to identify novel breast cancer susceptibility genes from the interweaving BRCA/Fanconi anemia (FA) pathway. Five candidate genes – MERIT40, ABRAXAS, BRIP1, CHK1, and FANCA – were screened for mutations by utilizing conformation-sensitive gel electrophoresis and sequencing, or with multiplex ligation-dependent probe amplification in blood DNA samples of Finnish familial breast cancer patients. Investigation of the MERIT40 gene revealed novel nucleotide changes, being the first report on mutation screening of this gene. None of the observed alterations, however, appeared to be disease related, suggesting that germline mutations in MERIT40 are rare or absent in breast cancer patients. A missense alteration (c.1082G>A, leading to Arg361Gln) was identified in ABRAXAS in 3 out of 125 Northern Finnish breast cancer families (2.4%), but not in any of the 867 healthy controls. The prevalence of the mutation between familial and control cases was statistically significantly different (p=0.002). ABRAXAS c.1082G>A appears to have pathological significance based on its exclusive occurrence in cancer cases, evolutionary conservation, disruption of a putative nuclear localization signal, reduced nuclear localization of the protein, and defective accumulation at DNA damage sites. The BRIP1 (FANCJ) and CHK1 genes were screened for large genomic rearrangements, but no abnormalities were detected, ruling out a significant contribution to breast cancer susceptibility in the Northern Finnish population. A novel large heterozygous deletion was identified in the FANCA gene in one out of 100 breast cancer families, removing the promoter and the first 12 exons. The deletion allele was not present in the tested controls, suggesting that it might contribute to breast cancer susceptibility. This is the first report on the association of a large-size germline deletion in a gene acting in the upstream part of the FA signaling pathway with familial breast cancer
Tiivistelmä BRCA1 ja BRCA2 ovat kaksi tärkeintä perinnöllisen rinta- ja munasarjasyövän alttiusgeeniä. Niissä esiintyvät ituradan muutokset selittävät kuitenkin vain noin 20 % familiaalisista rintasyöpätapauksista. Suurin osa alttiusgeeneistä on edelleen tunnistamatta ja näitä tekijöitä etsitään aktiivisesti. Tämän tutkimuksen tarkoituksena on ollut tunnistaa uusia alttiustekijöitä toisiinsa läheisesti liittyviltä BRCA/Fanconin anemia (FA) signaalinsiirtoreiteiltä. Viisi kandidaattigeeniä - MERIT40, ABRAXAS, BRIP1, CHK1 ja FANCA – kartoitettiin mutaatioiden suhteen suomalaisissa rintasyöpäperheissä käyttämällä konformaatiosensitiivistä geelielektroforeesia ja sekvensointia, tai multiplex ligation-dependent probe amplification- menetelmää. MERIT40-geenissä havaittiin useita aikaisemmin raportoimattomia nukleotidimuutoksia, mutta yhdenkään niistä ei havaittu liittyvän rintasyöpäalttiuteen. MERIT40-geenimuutosten mahdollista yhteyttä rintasyöpäalttiuteen ei ole tutkittu aikaisemmin. ABRAXAS-geenissä havaittiin missense-mutaatio (c.1082G>A, joka johtaa Arg361Gln aminohappokorvautumiseen) kolmessa pohjoissuomalaisessa rintasyöpäperheessä (3/125, 2.4 %). Muutosta ei havaittu terveissä kontrolleissa (N=867), ja ero mutaation esiintyvyydessä familiaalisten rintasyöpätapausten ja terveiden kontrollien välillä oli tilastollisesti merkitsevä (p=0.002). ABRAXAS c.1082G>A-muutos on todennäköisesti patogeeninen, sillä kyseinen aminohappopaikka on evolutiivisesti konservoitunut ja sijaitsee todennäköisellä tumaanohjaussignaalialueella. Funktionaaliset kokeet osoittivat, että mutatoitunut proteiinituote lokalisoitui villityypin proteiinia heikommin tumaan ja sen ohjautuminen DNA-vaurioalueille oli puutteellista. BRIP1- (FANCJ) ja CHK1-geeneistä etsittiin laajoja genomisia uudelleenjärjestelyjä, mutta niitä ei havaittu. Näin ollen kyseisillä muutoksilla ei ole merkittävää roolia perinnöllisessä rintasyöpäalttiudessa suomalaisessa väestössä. FANCA-geenissä havaittiin laaja heterotsygoottinen deleetio yhdessä tutkitusta 100 rintasyöpäperheestä. Deleetio poistaa geenin promoottorialueen lisäksi sen 12 ensimmäistä eksonia. Deleetioalleelia ei havaittu terveissä kontrolleissa, joten se mahdollisesti liittyy perinnölliseen rintasyöpäalttiuteen. Tutkimus on ensimmäinen, jossa raportoidaan laaja genominen deleetio FA-signaalinsiirtoreitin ylävirran geenissä familiaalisessa rintasyövässä

Breast cancer is the most common malignancy affecting women in the Western world. At present, several risk factors have been identified and, among them, the most significant is a positive family history for the disease due to the presence of inherited predisposing germline alterations. Despite the discovery of many susceptibility genes, among which the highly penetrant BRCA1 and BRCA2 are the most relevant, more than 70% of the genetic predisposition to breast cancer remains unexplained. During my three-years Ph.D., I used different analytical approaches to investigate DNA alterations and loci that could be relevantly implicated in the aetiology and progression of hereditary breast cancers. As first project on non informative BRCA1/2 families, I was involved in the assessment of the pathogenetic role of the BRCA1 p.Val1688del allele, which recurs in the Northeast Italy. Unclassified variants (UVs) provide a considerable challenge in the clinical management of high-risk families. Indeed, the absence of conclusive data on UVs pathogenicity, due to the lack of an evident deleterious effect on protein function, prevents their use in the identification of individuals predisposed to breast cancer development. To assess the pathogenetic role of BRCA1 p.Val1688del, we used the integrated multifactorial likelihood model described by Goldgar et al. (2004). Several independent evidences were derived from epidemiologic and linkage studies as well as histopathology, LOH and evolutionary conservation analyses, in 12 families carrying the p.Val1688del allele. All the evidences were than properly evaluated to obtain, from each, the probability of the observed data given that the variant is a deleterious mutation, against the probability of the observed data under the hypothesis that the variant is neutral. The likelihood ratios were integrated to obtain a combined odd of variant causality, resulting in a clear assessment of the BRCA1 p.Val1688del pathogenicity. Indeed, the final integrated odd of 349,000:1 in favor of disease causality largely exceeds the established cut off 1,000:1 needed to state the deleterious effect of the variant. The second project, described herein, focused on the identification of molecular alterations involved in non-BRCA1/BRCA2 breast cancers. To this purpose, I performed a comprehensive genomic profile of the breast cancer cell line HCC1500, which was established from a patient who probably harboured a predisposing germline mutation affecting genes other than BRCA1 and BRCA2. Indeed, despite the early age of disease development and a positive family history for breast and colon cancer, we did not detect any deleterious BRCA1, BRCA2 or TP53 alteration. The HCC1500 cell line was analysed by two complementary approaches: i) a novel combined strategy named GINI (Gene Identification by NMD Inhibition; Noesie and Dietz, 2001) for the identification of nonsense mutations at the transcriptome level, and ii) a copy number alteration (CNA) analysis that was achieved by array-based high-density SNP genotyping. This approach led to the identification of genes specifically mutated by either point mutations or major genomic rearrangements. In particular, we identified an intronic substitution in the PNLIPRP3 gene, which is predicted to create a PTC by altering pre-mRNA splicing. Moreover, high-resolution CNA analysis allowed the detection of small homozygously deleted regions as well as focal amplifications, involving single or few genes. A gene selection based on the specific biological function and/or type of mutation and/or previously reported involvement in cancer pathways, allowed the definition of a relatively small number of candidate breast cancer genes that will deserve further and more specific investigation. Finally, among the minor research projects that I will not discuss in my thesis, I was also directly involved in studies carried out by our research group as part of an international consortium, named CIMBA (Consortium of Investigators of Modifiers of BRCA1/2), whose aim is the identification of genetic factors implicated in the modification of BRCA1 and BRCA2 penetrance (Chenevix-Trench et al., 2007). Candidate single nucleotide polymorphisms (SNPs), most of which derived from genome-wide association studies, were genotyped in 213 BRCA1/2 mutation carriers from our cohort by the taqman allele discrimination technique, and subsequently statistically analyzed together with the data obtained from more than 30 study groups world-wide. The genotyping of SNP alleles in thousands of BRCA1/BRCA2 mutation carriers provide the necessary statistical power for the identification of significant association between common SNPs with typical low effects and specific subclasses of individuals at higher risk. These studies were carried out on more than 9400 BRCA1 and 5600 BRCA2 mutation carriers and allowed the identification of a significant association between rs3817198 in LPS1 and rs13387042 at 2q35 (already found to be associated with increased breast cancer risks in the general population) and increased breast cancer risk in BRCA2 and both BRCA1 and BRCA2 mutation carriers, respectively. The identification of genetic modifiers of breast cancer risk not only will favor a better understanding of breast cancer predisposition and pathogenesis but will also allow more precise cancer risk estimates and will represent a useful tool for the design of new therapeutic approaches.
Il tumore della mammella e’ la neoplasia più frequente nelle donne dell’Occidente. Ad oggi sono stati identificati alcuni fattori di rischio per lo sviluppo della neoplasia mammaria, ma il maggiormente significativo è la presenza di storia familiare, che è associata alla presenza nei membri della famiglia di alterazioni germinali predisponenti. Fino ad oggi sono stati identificati alcuni geni responsabili dell’aumento di rischio per lo sviluppo del tumore della mammella, tra cui i più rilevanti sono i geni ad alta penetranza BRCA1 e BRCA2. Tuttavia più del 70% dell’eccesso di rischio che si riscontra in casi familiari di tumore della mammella rispetto la popolazione generale non trova ad oggi un riscontro in alterazioni genetiche predisponenti. Durante il mio dottorato mi sono occupata dell’identificazione di alterazioni genetiche coinvolte nella predisposizione e progressione del tumore eredo-familiare della mammella in cui sono state escluse mutazioni chiaramente patogenetiche dei geni BRCA1/BRCA2. In un primo progetto ho partecipato alla caratterizzazione del ruolo patogenetico della variante BRCA1 p.Val1688del, identificata come variante di incerto significato clinico (Unclassified Variant, UV) e riscontrata frequentemente in pazienti provenienti dalla regione Veneto. In assenza di un chiaro effetto deleterio sulla funzionalità della proteina, le UV non possono essere utilizzate per l’identificazione e la sorveglianza degli individui ad alto rischio per lo sviluppo della neoplasia mammaria. Allo scopo di chiarire il ruolo patogenetico della delezione p.Val1688del, abbiamo utilizzato un approccio multi fattoriale, descritto da Golgar et al. (2004), attraverso il quale evidenze di diversa natura vengono integrate per derivare un rapporto di probabilità in favore della patogenicità o neutralità della variante. A questo scopo, i membri di 12 famiglie portatrici della variante sono stati analizzati per ottenere dati quali la co-segregazione della variante con il fenotipo tumorale, la co-presenza di mutazioni patogenetiche nel gene BRCA1, l’istopatologia del tumore, la perdita di eterozigosi (LOH) e la conservazione filogenetica del residuo aminoacidico alterato. Assunta l’indipendenza delle evidenze raccolte, i rapporti di probabilità associati a ciascuna evidenza sperimentale e clinica sono stati combinati, ottenendo un valore di 349000:1 in favore del ruolo patogenetico della variante, che supera di molto il cut off di 1000:1 stabilito per poter classificare la variante come alterazione predisponente. Il secondo progetto di cui mi sono occupata riguarda la definizione del profilo genetico della linea cellulare di carcinoma mammario HCC1500, derivata da una paziente con probabile tumore eredo-familiare della mammella. Nonostante l’età precoce di insorgenza e la storia familiare di tumore della mammella e del colon, il coinvolgimento dei geni BRCA1, BRCA2 e TP53 è stato escluso mediante screening mutazionale. La linea HCC1500 è stata quindi analizzata mediante due approcci complementari: i) l’identificazione di mutazioni nonsenso mediante l’utilizzo di un’approccio di analisi recentemente descritto chiamato GINI (Gene Identification by NMD Inhibition; Noesie and Dietz, 2001), e ii) l’identificazione di alterazioni numeriche mediante l’utilizzo di array per la genotipizzazione di un elevato numero di SNP, una recente tecnologia che permette un’elevata risoluzione di analisi. Mediante questo approccio è stato possibile identificare singoli geni mutati con specifiche alterazioni puntiformi o a causa di più estesi riarrangiamenti genomici. In particolare, nel gene PNLIPRP3 abbiamo identificato una sostituzione intronica che, modificando lo splicing del pre-mRNA, potrebbe dare origine ad un trascritto con mutazione troncante. Inoltre, l’elevata risoluzione dell’analisi per lo studio delle alterazioni cromosomiche numeriche, ci ha permesso di identificare singoli o pochi geni coinvolti in delezioni in omozigosi, amplificazioni di piccole regioni e riarrangiamenti intragenici derivanti da eventi di amplificazione o delezione. Sulla base di criteri quali la funzione biologica e mutazioni ritenute rilevanti per la selettività con cui alterano specifiche regioni codificanti, abbiamo selezionato alcuni geni che, prioritariamente ad altri, andrebbero confermati e analizzati in maggior dettaglio con ulteriori studi.. Un terzo progetto che ho seguito direttamente, ma che comunque non tratterò nella mia tesi, riguarda l’identificazione di fattori genetici coinvolti nella modificazione del rischio per i soggetti portatori di mutazione BRCA1 e BRCA2. Tale progetto si inserisce nell'ambito di un consorzio internazionale, denominato CIMBA (Consortium of Investigators of Modifiers of BRCA1/2; (Chenevix-Trench et al., 2007). SNP identificati prevalentemente attraverso studi di associazione genome-wide sono stati genotipizzati in 213 carriers di mutazione BRCA1/2 della nostra casistica mediante discriminazione allelica con sonde TaqMan. L’analisi statistica è stata effettuata sui dati genotipici provenienti da più di 30 gruppi di lavoro, permettendo la raccolta di dati derivanti da migliaia di individui. In questo modo è possibile ottenere la potenza statistica necessaria per l’identificazione dell’associazione tra polimorfismi con debole effetto e un aumentato rischio di sviluppo del tumore della mammella in specifiche sottoclassi di soggetti già portatori di mutazione nei geni ad alta penetranza BRCA1/2. Effettuati su più di 9400 e 5600 carriers di mutazione rispettivamente di BRCA1 e BRCA2, tali studi hanno permesso di identificare un’associazione significativa tra gli SNP rs3817198 (LPS1) e rs13387042 (2q35) ed un aumentato rischio in soggetti portatori di mutazioni BRCA2, e, nel secondo caso BRCA1 o BRCA2. L’identificazione e studio di fattori genetici modificatori permetterà di acquisire una più approfondita conoscenza della predisposizione e patogenesi del tumore della ereditario mammella, ma anche di stimare con migliore precisione il rischio di sviluppo della neoplasia così come di fornire utili informazioni per l'identificazione di nuovi approcci terapeutici.

This thesis concentrates on the treatment of women with breast cancer in the 19th and 20th century. It analyses written published patient narratives linking them with clinical developments. Medical history holds a rich source of information providing the view of the clinician. This includes case reports and case series from one surgeon or one hospital for the earlier period of the study and has progressed to the double blind randomised controlled trial that dominates comparative research today. There is an imbalance in the material available for the analysis of patients’ perceptions of their treatment. The patient view is not represented well in the history of medicine. This thesis attempts to provide a more complete assessment of the developments in breast cancer treatment by including the patient’s view. Three narratives provide an insight into the perception of women who were treated with breast cancer prior to the introduction of anaesthesia and infection control. The novelist, Fanny Burney (1752-1840), underwent a mastectomy in 1811. In a letter to her sister she wrote about her experience providing details of her diagnosis and treatment. In comparison, Emily Gosse (1806-1857) refused a mastectomy for her breast cancer and sought alternative treatment with caustics. Her husband, Phillip Gosse and friend, Anna Shipton, wrote narratives about Emily’s suffering. A third narrative provides the view of a woman with breast cancer who received no treatment and died of metastatic breast cancer; Zelie Martin died in 1877. These narratives were linked to a case report by Lorenz Heister (1683-1758). Heister described the procedure for amputation of the breast in detail. His method prevailed until new scientific developments in surgery such as anaesthesia and infection control improved the short-term survival of patients and enabled surgeons to operate sooner with a greater attention to detail.

Women found to carry mutations in the BRCA1 or BRCA2 genes have up to an 88% lifetime risk of breast cancer and up to a 65% lifetime risk of ovarian cancer. Strategies to address these heightened risks include breast cancer screening, and risk-reducing (RR) surgeries (i.e., mastectomy and salpingo-oophorectomy). Some women might change their lifestyle or use complementary and alternative medicine to prevent hereditary breast and ovarian cancer (HBOC). The objectives of this research were to describe: a) the HBOC RR strategies used by women prior to receiving their genetic test results, the influence of individual and psychological factors on the uptake of these strategies, and their risk management information needs, b) how women construct the ‘right time’ to consider RR surgery decisions, and c) the process of making decisions regarding HBOC RR strategies. A survey of 143 women was conducted to address the first objective and in-depth interviews with 22 BRCA1/2 carriers were conducted to address the remaining two objectives. Survey respondents engaged in breast cancer screening at the time of genetic testing and a sub-group modified their lifestyle to reduce their cancer risk. Qualitative analyses revealed women’s constructions of the ‘right time’ to consider RR surgery decisions to be when: (1) decisions fit into their lives, (2) they had enough time to think about decisions, (3) they were ready emotionally, (4) all the issues and conflicts were sorted out, (5) there were better options available, and (6) the health care system was ready for them. Grounded theory analyses suggested that the overarching process of making decisions about HBOC RR strategies was one of ‘preserving the self.’ This process was shaped by the characteristics of health services, the nature of HBOC RR decisions, gendered roles, and the women’s perceived proximity to cancer. The women engaged in five decision-making styles, which were characterized by combinations of seven decision-making approaches. Findings from these three studies capture the diverse trajectories of decision making about HBOC risk management and highlight the role of personal and social context in shaping these decisions.

About one in eight women in the United States will develop breast cancer over the course of her lifetime. Moreover, patient-to-patient variability in disease progression continues to complicate clinical decisions in diagnosis and treatment for breast cancer patients. Early detection of tumors is a key factor influencing patient survival, and advancements in diagnostic and imaging techniques has allowed clinicians to spot smaller sized lesions. There has also been an increase in premature treatments of non-malignant lesions because there is no clear way to predict whether these lesions will become invasive over time. Patient variability due to genetic polymorphisms has been investigated, but studies on variability at the level of cellular activity have been extremely limited. An individual’s biochemical milieu of cytokines, growth factors, and other stimuli contain a myriad of cues that pre-condition cells and induce patient variability in response to tumor progression or treatment. Circulating white blood cells called monocytes respond to these cues and enter tissues to differentiate into monocyte-derived macrophages (MDMs) and osteoclasts that produce cysteine cathepsins, powerful extracellular matrix proteases. Cathepsins have been mechanistically linked to accelerated tumor growth and metastasis. This study aims to elucidate the variability in disease progression among patients by examining the variability of protease production from tissue-remodeling macrophages and osteoclasts. Since most extracellular cues initiate multiple signaling cascades that are interconnected and dynamic, this current study uses a systems biology approach known as cue-signal-response (CSR) paradigm to capture this complexity comprehensively. The novel and significant finding of this study is that we have identified and predicted donor-to-donor variability in disease modifying cysteine cathepsin activities in macrophages and osteoclasts. This study applied this novel finding to the context of tumor invasion and showed that variability in tumor associated macrophage cathepsin activity and their inhibitor cystatin C level mediates variability in cancer cell invasion. These findings help to provide a minimally invasive way to identify individuals with particularly high remodeling capabilities. This could be used to give insight into the risk for tumor invasion and develop a personalized therapeutic regime to maximize efficacy and chance of disease free survival.

Abstract Around 5–10% of all breast cancers stem from a strong hereditary predisposition to the disease. Mutations in currently known breast cancer predisposing genes, however, account for only 25–30% of all hereditary breast cancer cases, BRCA1 and BRCA2 being the two major ones. Since BRCA1 and BRCA2 participate in the DNA damage response, mutations in other genes, such as PALB2 and RAP80, which are involved in these pathways, may also predispose to breast tumours. Therefore, the aim of this study was to evaluate variations of the human PALB2 and RAP80 genes as novel potential candidates for breast cancer susceptibility and to further characterize the role of PALB2-deficiency in cancer development. A mutation, c.1592delT, was identified in PALB2 at an elevated frequency among breast cancer patients (0.9%) compared to controls (0.2%) (P =  0.003, OR 3.94, 95% CI 1.5–12.1). Among familial cases the frequency was even higher (2.7%). This mutation represents a genuine loss-of-function mutation since its protein product showed significantly decreased BRCA2-binding affinity and could neither support homologous recombination nor restore crosslink repair in PALB2-deficient cells. Heterozygous PALB2 c.1592delT carriers displayed haploinsufficiency of PALB2 marked by aberrant DNA replication and DNA damage response that led to a significant increase in genomic instability. As the tumours were negative for loss of heterozygosity at this chromosomal locus, these findings provide a mechanism for the early stages of breast cancer development in PALB2 c.1592delT carriers. Palb2 was also found to play a critical role in early mouse development. As in Brca1/2-deficient embryos, homozygous inactivation of Palb2 resulted in embryonic lethality due to mesoderm differentiation and cell proliferation defects. The phenotypic similarity of Palb2 and Brca1/2-deficient mice further supports the close functional relationship shown in vitro for these proteins. A novel mutation, delE81, was identified in RAP80 in one out of 112 breast cancer families, and in one patient diagnosed with bilateral breast cancer out of 503 unselected breast cancers. The resultant delE81 protein displayed significantly reduced ubiquitin binding and double-strand break (DSB) localization. Furthermore, it impaired the recruitment of the whole BRCA1-A complex to the site of DSBs, thus compromising BRCA1-mediated DNA damage response signalling. Although the mutation is quite rare, the current results indicate that the RAP80 delE81 defect is biologically relevant and is likely associated with a hereditary predisposition to breast cancer
Tiivistelmä Arviolta 5–10 % rintasyöpätapauksista aiheutuuu merkittävästä perinnöllisestä alttiudesta sairauteen. Mutaatiot tähän mennessä tunnistetuissa rintasyövän alttiusgeeneissä, joista BRCA1 ja BRCA2 ovat tärkeimmät, selittävät kuitenkin vain 25–30 % kaikista perinnöllisistä rintasyöpätapauksista. Tämän tutkimuksen tarkoituksena on arvioida PALB2- ja RAP80-geenien mahdolliset vaikutukset rintasyöpäalttiuteen, sekä määrittää tarkemmin PALB2:n vaikutus syövän kehitykseen. PALB2:sta löydettiin mutaatio, c.1592delT, jota esiintyi merkittävästi enemmän rintasyöpäpotilailla (0,9 %) kuin kontrollihenkilöillä (0,2 %) [P =  0.003, OR 3.94, 95 % CI 1.5–12.1]. Kaikista yleisimmin geenimuutos esiintyi perinnöllisten ritasyöpätapausten joukossa (2,7 %). Mutaatio aiheuttaa toiminnallisesti viallisen proteiinin, joka sitoutuu BRCA2:n kanssa normaalia heikommin, eikä se pysty kunnolla toimimaan homologisessa rekombinaatiossa tai ristikkäiden DNA-virheiden korjauksessa. Heterotsygoottisen PALB2 c.1592delT-mutaation aiheuttaa PALB2-geenin haploinsuffisienssi joka ilmentyy kantajien soluissa epänormaalina DNA:n kahdentumisena ja DNA-vauriovasteena, jotka johtavat merkittävästi kohonneeseen genomin epävakaisuuteen. Jo kyseiset toiminnalliset puutteet näyttävät tarjoavan pätevän selityksen PALB2 c.1592delT kantajien merkittävästi suurentuneelle rintasyöpäriskille ja lienee myös syy siihen, ettei potilaiden kasvaimissa havaittu normaalin vastinaleelin menetystä. Palb2:lla on keskeinen rooli hiiren alkiokehityksessä. Kuten Brca1/2-puutteellisissa alkioissa, myös homotsygoottinen Palb2-inaktivaatio aiheuttaa alkioiden enneaikaisen kuoleman, joka aiheutuu puutteista mesodermin erilaistumisessa ja hidastuneesta solujen kasvussa. Palb2- ja Brca1/2-puuttellisten hiirien samankaltaisuus vahvistaa ennestään näiden proteiinien toiminnallista yhteyttä, joka on osoitettu jo aikaisemmin laboratorio-oloissa. RAP80-geenistä löydettiin uusi mutaatio, delE81, yhdestä 112 tutkitusta rintasyöpäperheestä. Kyseinen muutos nähtiin myös yhdessä molemminpuoliseen rintasyöpään sairastaneessa potilaassa valikoimattomassa 503 tapauksen kattavasta aineistosta. Mutatoitunut proteiinituote vähensi huomattavasti DNA-vauriovastekompleksin kykyä sitoutua ubikitiiniin ja paikallistua DNA-kaksoisjuostekatkoksille. Ennen kaikkea mutaatio heikensi BRCA1-A kompleksin kuljetuksen DNA-vauriopaikalle, vaarantaen BRCA1-välitteisen DNA-vauriovasteen. Harvinaisuudesta huolimatta nämä tutkimustulokset osoittavat RAP80 delE81 vaikutuksen olevan biologisesti merkittävä. Kyseinen synnynnäinen RAP80-geenimuutos altistaa mitä todennäköisimmin kantajansa rintasyövälle

Inheritance of a protein truncating mutation of the tumour suppressor gene BRCA1 causes approximately 5% of breast tumours. Over 450 distinct BRCA1 missense mutations have also been found in patients with a family history of breast cancer and the functional significance of most of these is unclear. Increasing evidence suggests that DNA missense mutations can affect RNA stability or sequence by disrupting splicing regulators. I have used a variety of techniques to investigate the effect of genomic BRCA1 missense mutations on transcript expression. BRCA1 monoallelic expression has previously been reported in association with missense mutations. I therefore initially used the technique of Pyrosequencing™ to identify imbalances in BRCA1 cDNA allele expression. Analysis of patients with known BRCA1 truncating mutations, missense mutations and controls identified no examples of monoallelic expression and indicated that a previous report of monoallelic BRCA1 expression was erroneous. I subsequently developed a series of multiplex RT-PCR reactions using overlapping primer pairs to identify alternative BRCA1 transcripts in the same groups of subjects. This technique effectively demonstrated the common BRCA1 isoforms and confirmed that the c4185A>G silent mutation is associated with deletion of exon 12. To provide a systematic analysis of the effect of BRCA1 mutations on splicing regulation I designed minigenes centred on 4 different BRCA1 exons; 5,6,10 and 18. All mutations within these exons reported to the Breast Cancer Information Core database were introduced into the appropriate minigenes, and wildtype and mu'tant miriigel1es were transfected into HEK 293 cells. The resulting transcripts were examined to identify aberrant splicing. Only one of twenty-one missense mutations investigated resulted in alternative transcripts, suggesting that only a small proportion of BRCA1 missense mutations do affect splicing. Additional work was also performed to investigate whether the MDM2 SNP 309 acts as a disease modifying gene in BRCA1 associated hereditary cancer.

Problem statement: Mutations in the genetic material BRCA I/II are linked to increased incidence of cancer among the women who carry these alterations, raising lifetime risk of breast cancer to as high as 87%. Genetic testing exists to identify these alterations, empowering women to obtain advanced screening for breast and ovarian cancer, as well as incorporate prophylactic medications and surgeries for prevention of disease. Research has shown that appropriate risk assessment methods are not being utilized among primary care providers to identify those patients who would benefit from genetic counseling and testing. Purpose: To determine if a knowledge deficit about U.S. Preventative Services Task Force BRCA risk assessment recommendations exists among the rural Arizona nurse practitioner population, and to determine the level of confidence Arizona NPs have regarding the topic. Methods: A needs assessment completed via an 18-question online survey distributed through two provider organizations in Arizona. Inclusion criteria included NP must hold an active license in Arizona, NP must practice in primary healthcare, and practice site must serve patients who reside in a rural area of Arizona. Data collection remained open for three weeks. Analysis: Descriptive statistics using quantitative analysis evaluated provider demographics, responses to basic knowledge questions and clinical scenarios, and provider self-confidence analyses. Results: Participants were able to identify inheritance patterns of BRCA mutations, but incorrectly answered the majority of knowledge questions. Regarding self-reported confidence with awareness and use of the USPSTF guideline, nearly half of participants felt that they had at least average confidence. However, only one participant was able to answer every question correctly. Most agreed that the guidelines were relevant to their current practice. These results indicate a knowledge gap among NPs who care for patients living in rural Arizona. These results may inform future research aimed at educational interventions and practice improvement initiatives that will improve understanding and use of guidelines for screening, counseling, and testing patients at high-risk of carrying a harmful BRCA-mutation. Ultimately, these results will impact outcomes of patients living in rural Arizona.

This thesis questions whether the experiences of women at-risk of hereditary breast and ovarian cancer (HBOC) might be genetically exceptional. Using a combination of retrospective in-depth interviews with women at-risk and observations of consultations carried out at a regional specialist centre, this research questions the genetic exceptionalism thesis and the argument that the experiences and decisions that women at-risk of HBOC make, are unique and thus different compared to those of women diagnosed with non-genetic, sporadically developing breast or ovarian cancer. In examining the arguments for and against genetic exceptionalism, this thesis revisits the medical sociological literature on the doctor-patient relationship and discusses the difficulty in establishing who should be recognised to be the patient within the genetic consultation, the decision to undergo genetic testing and the decision to have risk-reducing, prophylactic surgery. The resulting analysis recognises the data to be moral accounts, constructed by research participants so that their utterances would be perceived in a particular manner. For example, while justifying their reported actions, participants were attempting to portray themselves as moral, responsible citizens, mothers, patients and women. In addressing these four aspects of women’s HBOC experiences, this thesis concludes that there is little unfamiliar to medical sociologists about the experiences described and the rationales given by the participants. Such data lends itself to the position where the notion of genetic exceptionalism cannot be supported. Consequently, the thesis concludes that the experiences of women at-risk of HBOC seem to be little different from other, non-genetic health experiences.

Abstract Hereditary mutations in DNA damage response (DDR) genes often lead to genomic instability and ultimately tumor development. However, the molecular mechanism of how these DDR deficiencies promote genomic instability and malignancy is not well understood. Thus, the specific aim of this thesis is to identify the functional and molecular framework behind the elevated breast cancer risk observed in heterozygous PALB2 and ABRAXAS mutation carriers. The heterozygous germline alteration in PALB2 (c.1592delT) causes a haploinsufficiency phenotype in the mutation carrier cells. Due to PALB2 haploinsufficiency, elevated Cdk activity and consequently aberrant DNA replication/damage response was observed in the PALB2 mutation carrier cells. Excessive origin firing that is indicative of replication stress was also seen in the PALB2 mutation carrier cells. In addition to replication stress, PALB2 mutation carrier cells also experience G2/M checkpoint maintenance defects. The increased malignancy risk in females associated with heterozygosity for the Finnish PALB2 founder mutation is likely to be due to aberrant DNA replication, elevated genomic instability and multiple different cell cycle checkpoint defects. The heterozygous germline alteration in ABRAXAS (c.1082G>A) causes a dominant-negative phenotype in the mutation carrier cells. Decreased BRCA1 protein levels as well as reduced nuclear localization and foci formation of BRCA1 and CtIP was observed in the ABRAXAS mutation carrier cells. This causes disturbances in basal BRCA1-A complex localization, which is reflected by a restraint in error-prone DNA double-strand break (DSB) repair pathway usage, attenuated DNA damage response, deregulated G2/M checkpoint control and apoptosis. Most importantly, mutation carrier cells display a change in their transcriptional profile, which we attribute to the reduced nuclear levels of BRCA1. Thus, the Finnish ABRAXAS founder mutation acts in a dominant-negative manner on BRCA1 to promote genome destabilization in the heterozygous carrier cells
Tiivistelmä Perinnölliset muutokset DNA-vauriovasteen geeneissä johtavat usein genomin epävakauteen ja lopulta syövän kehittymiseen. Molekyylitason mekanismeja, joilla vauriovasteen vajaatoiminta ajaa genomin epävakautta ja syöpää, ei kuitenkaan ymmärretä kunnolla. Tämän väitöskirjan tavoitteena on tunnistaa solutoiminnan ja molekyylitason vaikuttajat heterotsygoottisten PALB2- ja ABRAXAS-geenimuutosten kantajien kohonneen rintasyöpäriskin taustalla. Heterotsygoottinen ituradan suomalainen perustajamuutos PALB2-geenissä (c.1592delT) aiheuttaa haploinsuffisienssin kantajahenkilöiden soluissa. PALB2:n haploinsuffisienssin seurauksena kantajasoluissa havaittiin kohonnutta Cdk-proteiinin aktiivisuutta ja siitä johtuvaa kiihtynyttä DNA:n kahdentumista. PALB2-mutaatiota kantavissa soluissa nähtiin myös liiallista replikaation aloituskohtien käyttöä, mikä viittaa replikaatiostressiin. Replikaatiostressin lisäksi PALB2-mutaation kantajasoluilla havaittiin vaikeuksia ylläpitää solusyklin G2/M-tarkastuspisteen toimintaa. Näiden solutoiminnan poikkeavuuksien takia heterotsygoottisen PALB2 c.1592delT -mutaation kantajilla todettiin genomin epävakautta ja kohonnut syöpäriski. Heterotsygoottinen ituradan mutaatio ABRAXAS-geenissä (c.1082G>A) aiheuttaa dominantti-negatiivisen fenotyypin mutaation kantajasoluissa. ABRAXAS-mutaatiota kantavissa soluissa havaittiin BRCA1-proteiinitasojen laskua sekä BRCA1- ja CtIP-proteiinien vähentynyttä lokalisaatiota tumaan ja DNA-vauriopaikoille. Tämä aiheuttaa häiriöitä BRCA1-A-kompleksin paikallistumisessa, mikä johtaa häiriöihin virhealttiiden DNA-kaksoisjuoste¬katkoksien korjausmekanismien käytössä, DNA-vauriovasteessa, G2/M-tarkastus-pisteen säätelyssä ja ohjelmoidussa solukuolemassa. Tärkeimpänä löydöksenä havaittiin mutaation kantajasoluissa muuttunut transkriptioprofiili, joka johtunee BRCA1-proteiinitasojen laskusta tumassa. Näin ollen suomalainen ABRAXAS-perustajamutaatio toimii dominantti-negatiivisena BRCA1:n suhteen, aiheuttaen genomin epävakautta heterotsygoottisissa kantajasoluissa

Background Mastectomy is the mainstay of surgical treatment for women with breast cancer in South Africa. The increase in breast reconstruction after a mastectomy has prompted the need to evaluate patient reported outcome measures (PROMs) for this set of operative intervention. This study aimed to assess clinical and patient reported outcome measures in immediate breast reconstruction patients using the BREAST-Q and compare these with international cohorts. Methods A cross-sectional study was performed on all patients who underwent immediate breast reconstruction between January 2011 and December 2016. This consisted of a retrospective clinical record review of perioperative outcomes, and a quality of life analysis using the BREAST-Q Post-Reconstruction questionnaire. Outcome predictors were identified using Chi-square, Fisher exact, One-way ANOVA, Student t-tests and Kruskal Wallis analysis of variance. A random-effect single arm meta-analysis was performed to compare the BREASTQ scores with international cohorts. Results A total of 52 patients were included with a mean age of 43.2 (+/-9.5) years. Eighteen patients (34.6%) developed early complications; of these 8 (44.4%) were major. Thirty-one patients (59.6%) developed late complications; of these 18 (58.1%) were major. Fifteen patients (28.8%) had failed reconstruction. There was a significantly higher risk of failure following a total mastectomy (TM) (p=0.02), tissue expander reconstruction (TE) (p< 0.01) and stage 2 breast cancer (p=0.01). Patients who underwent nipple reconstruction and immediate-delayed reconstruction before 12 months, reported higher well-being and satisfaction scores. Compared to international cohorts our BREAST-Q scores were lower but fall within the 95% confidence interval for Sexual Well-Being and Satisfaction with Nipples and Care. Conclusion Immediate breast reconstruction poses a high risk of complications and reconstructive failure especially, with TM and TE. Our BREAST-Q scores are comparable to international studies and may be useful in guiding patient consent.

Abstract Mutations in BRCA1 and BRCA2 explain only about 20% of familial aggregation of breast cancer, suggesting involvement of additional susceptibility genes. In this study five DNA damage response genes, ATM, ATR, MRE11, NBS1 and RAD50, were considered as putative candidates to explain some of the remaining familial breast cancer risk, and were screened for germline mutations in families displaying genetic predisposition. Analysis of ATM indicated that clearly pathogenic mutations seem to be restricted to those reported in ataxia-telangiectasia (A-T). However, a cancer risk modifying effect was suggested for a combination of two ATM polymorphisms, 5557G>A and IVS38-8T>C, as this allele seemed to associate with bilateral breast cancer (OR 10.2, 95% CI 3.1–33.8, p = 0.001). The relevance of ATM mutations, originally identified in Finnish A-T patients, in breast cancer susceptibility was evaluated by a large case-control study. Two such alleles, 6903insA and 7570G>C, in addition to 8734A>G previously associated with breast cancer susceptibility, were observed. The overall mutation frequency in unselected cases (7/1124) was higher than in controls (1/1107), but a significantly elevated frequency was observed only in familial cases (6/541, p = 0.006, OR 12.4, 95% CI 1.5–103.3). These three mutations showed founder effects in their geographical occurrence, and had different functional consequences at protein level. In ATR no disease-related mutations were observed, suggesting that it is not a breast cancer susceptibility gene. The mutation screening of the Mre11 complex genes, MRE11, NBS1 and RAD50, revealed two novel potentially breast cancer associated alleles: NBS1 Leu150Phe and RAD50 687delT were observed in 2.0% (3/151) of the studied families. The subsequent study of newly diagnosed, unselected breast cancer cases indicated that RAD50 687delT is a relatively common low-penetrance susceptibility allele in Northern Finland (cases 8/317 vs. controls 6/1000, OR 4.3, 95% CI 1.5–12.5, p = 0.008). NBS1 Leu150Phe (2/317) together with a novel RAD50 IVS3-1G>A mutation (1/317) was also observed, both being absent from controls. Loss of the wild-type allele was not observed in the tumors of the studied mutation carriers, but they all showed an increase in chromosomal instability of peripheral T-lymphocytes. This suggests an effect for RAD50 and NBS1 haploinsufficiency on genomic integrity and susceptibility to cancer.

This thesis is the culmination of five years of communication design research (2006 – 2010) on a specific area of healthcare—breast cancer detection and screening. It is a project-­‐based doctoral work, underpinned by a practice-­‐led research journey of a graphic designer. The result is this written thesis with an accompanying set of uniquely designed objects: • a series of posters on breast cancer detection • an educational leaflet and risk assessment form • a series of working website prototypes (see worldwidebreastcancer.com) This thesis offers an in-­‐depth case study that demonstrates and contextualises the need for using communication design in patient engagement and education efforts in order to create a more patient-­‐centred experience in breast cancer detection. The significant contributions of this thesis are: • the development of a human-­‐centred design thinking methodology, known as the ‘USER’ model, which helps a designer develop a product for use within a system in an iterative, intuitive and analytical way. This is the first design thinking model of its kind to embed a framework for analysing objects within a systems framework; • the production and testing of visual metaphor, which was found to improve patient literacy and confidence. The significance of this has been to increase the potential for symptoms to be reported early and decrease mortality rates; • a map illustrating the patient journey of breast cancer screening that illustrates roles, communications and detection activities. This has been developed for general practices and imaging centres in a visually clear and distinct way; • a risk assessment tool that encourages doctors and patients to engage in collaborative decision-­‐making in the planning of breast cancer screening activities. Finally, the work presented here has profound implications for future studies of patient engagement and health literacy in breast cancer detection. The research journey, findings and objects in this thesis may lead to improved patient communication experiences and decreased mortality in breast cancer. This thesis also acts as a model for exploring and developing design solutions for other health causes.

This study's purpose was to describe, from their own perspective, the experience of individuals coping with metastatic breast cancer-related pain at home. Understanding how individuals cope on a day-to-day basis, in their natural setting, is essential in order to facilitate effective management of cancer pain in the home setting. Using a qualitative approach and multiple case study design, data was collected by means of unstructured, in-depth interviews with six female co-researchers. All interviews were audiotaped and transcribed verbatim. Transcripts and field notes were analyzed for common themes, which were then reconstructed into a case study format and validated by the co-researchers. Finally, co-researcher accounts were integrated into one coherent description. This study adds an extensive description to existing literature, providing an explicit portrayal of the experiences lived by these women. There were many commonalities in their stories, yet each person's story was unique, with each woman managing cancer pain in their own way. This study suggests that women did not commonly achieve adequate pain relief through the use of medications. A multitude of factors, including the severity of medication side effects, influenced their decisions not to take increased doses of pain medications. However, women acted from a position of choice by electing to tolerate pain in order to maintain control of the life they valued. This study leaves little doubt that the impact of pain related to breast cancer is potentially devastating to a life. The challenge of describing and managing cancer pain effectively continues to be a serious problem for both professionals and individuals coping with breast cancer-related pain.
Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
Graduate

Breast cancer is the most widely diagnosed cancer among women and the second leading cause of death after lung cancer. \"Many women with cancer describe the moment they found out about their diagnosis as truly devastating\" (National Breast Cancer Organization [NBCO], 2000, p.1). There are numerous ways in which women cope during this upsetting time. Two ways to help women cope is to encourage them to understand their new diagnosis through education and exploring all available treatment options. There is a shortage of documentation on breast cancer education and few studies have examined patients\' perception of breast cancer education. The target population for this study was adult women with a diagnosis of breast cancer who received treatment from a medium sized northwestern cancer clinic. The population and the sample consisted of residents from urban and rural regions of central Montana. A convenience sample of persons eighteen years and older consisting of the 168 women who are on the breast cancer survivors\' monthly mailing at the cancer clinic were invited to participate in the study; the actual sample consisted of 59 women. The sample was self-selecting and participation was voluntary. A descriptive, retrospective, cross-sectional design was used as the framework for this study. The questionnaire that was developed for this study was used to collect data that explored participants\' perceptions of the education received. Participants were asked where they received their education about breast cancer and 71.2% said that they received their educational materials from the cancer treatment facility. A large majority (79.7%) indicated that immediately after breast cancer diagnosis they felt ready to learn. Almost half (42.4%) felt acceptance of their breast cancer diagnosis. A total of 63% felt that their educational materials were either very helpful or helpful.

Hereditary breast and/or ovarian cancer (HBOC) accounts for 5-10% of all breast and ovarian cancer diagnoses, with a significant proportion of these being connected to a BRCA 1 or BRCA2 mutation. Mutation carriers are at high risk (50%-85%) of developing breast cancer and (20%-40%) risk of ovarian cancer and often face life changing decisions. Most research in this population has been undertaken with women who carry a BRCA1/2 mutation, but have not yet experienced cancer and it is uncertain whether findings reflect the experience of women whose cancer diagnosis is compounded by a positive genetic test. Aim and Methods:' This study aims to understand the impact of a positive genetic test on affected women after they leave the genetic clinic. Grounded theory methodology was selected as most appropriate. A two stage approach incorporating a retrospective group (n=11) and a longitudinal group (n=15) was used. Theoretical sampling of twenty-six women, three relatives and four health professionals (n=33) generated the total number of interviews (n=49). Patients completed reflective diaries. Findings: A substantive theory of maximising survival was generated that explains and predicts the behaviour and psychosocial processes women experience. Maximising survival is a basic social psychological process with four stages: behaving altruistically, verifying genetic status, striving to contain cancer and reconstituting identity. Conclusions: Initially women's main concern is passing on an abnormal gene that could compromise their children's survival, but the positive test result heightened concerns for their own survival and prioritised their own health needs. Absence of a clear care pathway for these women as they moved through testing, genetic diagnosis, surgery and beyond coupled with a lack of information and support contributed to their anxiety. Closer multidisciplinary working and further engagement with service users is required to develop more appropriate and responsive care for this population.

The development of whole exome sequencing has transformed the study of disease predisposition. The sequencing of both large disease sets and smaller rare disease families enables the identification of new predisposition variants and potentially provide clinical insight into disease management. There is no standard protocol for analysing exome sequencing data. Outside of extremely large sequencing studies including thousands of individuals, statistical approaches are often underpowered to detect rare disease associated variants. Aggregation of variants into functionally related regions, including genes, gene clusters, and pathways, allows for the detection of biological processes that, when interrupted, may impact disease risk. In silico functional studies can also be utilised to further understand how variants disrupt biological processes and identify genotype-phenotype relationships. This study describes the exploration of sequencing datasets from cancers and benign tumour diseases including: i) hereditary diffuse gastric cancer, ii) sweat duct proliferation tumours, iii) adrenocortical carcinoma, and iv) breast cancer. Each set underwent germline whole exome sequencing followed by additional tumour or targeted sequencing to identify associated predisposition genes. Variants within a cluster of risk genes that are involved in double strand break repair were identified as associated with hereditary diffuse gastric cancer risk via gene ontology enrichment analysis. This cluster included PALB2 within which, using externally collated data, loss of function variants were identified as significantly associated with hereditary diffuse gastric cancer risk. Germline protein-affecting variants in the myosin gene MYH9 were identified in all individuals with a rare sweat duct proliferative syndrome, suggesting a role for MYH9 in skin development, regulation and tumorigenesis. These MYH9 variants were analysed in silico to identify a genotype-phenotype relationship between the clinical presentation and variants in the ATP binding pocket of the protein. Tumour matched normal sequence data from adrenocortical carcinoma cases was used to elucidate the role of Lynch syndrome genes in disease pathogenesis. Within the breast cancer set, candidate genes were selected to undergo targeted sequencing in a larger set of cases to further explore their role in breast cancer risk. Risk associated genes identified within this study may ultimately aid in diagnosis and management of disease. This thesis has also generated multiple novel tools and sequencing analysis techniques that may be of use for further studies by aiding in the prioritisation of candidate variants. The described techniques will provide support to researchers working on rare, statistically underpowered datasets and to provide standard analysis pipelines for a range of dataset sizes and types, including familial data and unrelated individuals.

5-10% of hereditary breast cancer cases are caused by germline mutations in well-defined, dominantly acting susceptibility genes such as BRCA1 and BRCA2. However, more than 50% of the genetic predisposition to hereditary breast cancer remains unexplained. In the following thesis, we present a multifaceted approach aimed at further elucidating hereditary breast cancer associated with BRCA1 and BRCA2 interacting genes; specifically, by analyzing the potential contribution from of two previously unscreened BRCA1-associating genes, RAP80 and Abraxas, assessing the presence and risk associated with CHEK2 susceptibility alleles in the previously uninvestigated French Canadian population and by investigating molecular and cellular mechanisms underlying the increased risk associated with PALB2 susceptibility alleles.
A combination of genotyping 96 BRCA1/2 negative, high risk breast cancer patients and segregation analysis was utilized in the determination of whether or not RAP80 and Abraxas are breast cancer susceptibility genes. The contribution of CHEK2 associated breast cancer amongst the French Canadian population was determined through the genotyping 25 BRCA1/2 negative, high risk breast cancer and a cohort of 25 controls. Finally, the biological significance of four PALB2 susceptibility alleles was investigated through the use of the cellular cytotoxicity assay WST-1, telomere specific Q-FISH, centromere specific FISH and spectral karyotyping.
The results presented herein suggest that both RAP80 and Abraxas are not high to moderately penetrant breast cancer susceptibility genes. Further, our results suggest that alleles other than the CHEK2 1100delC are unlikely to significantly contribute to the hereditary breast cancer risk in the French Canadian population. Lastly, the results obtained throughout our analysis of PALB2 heterozygous cell lines may be suggestive of a possible chromosomal instability phenotype predisposing carriers to additional tumourgenic mechanisms.
5-10% des cas de cancer héréditaire du sein sont causés par des mutations germinales dans des gènes des susceptibilité bien caractérisés et à l'effet dominant tel les gènes BRCA1 et BRCA2. Cependant, plus de 50% de la prédisposition génétique au cancer du sein héréditaire demeure inexpliquée. Dans cette thèse, nous présentons une approche à trois volets ayant pour but d'étudier les cas de cancer héréditaire du sein associés avec des gènes interagissant avec BRCA1 et BRCA2. D'abord, nous analysons la contribution potentielle de deux gènes peu caractérisés qui sont partenaires de BRCA1 : RAP80 et Abraxas. Nous étudions ensuite le risque associé avec la présence d'allèles nouveaux ou connus du gène CHEK2 jamais encore caractérisés dans la population canadienne française. Enfin, nous examinons les mécanismes cellulaires et moléculaires responsables de l'augmentation du risque de cancer du sein conférée par des allèles à risque du gène PALB2.
Nous avons utilisé une combinaison de génotypage chez 96 patients souffrant du cancer du sein mais étant non porteurs de mutations dans BRCA1/2 et d'analyse de ségrégation des mutations et des phénotypes dans leurs familles afin de déterminer si RAP80 et Abraxas sont ou non des gènes de prédisposition au cancer héréditaire du sein. La contribution au risque de cancer du sein du gène CHEK2 fût déterminée grâce au génotypage de 25 cas à haut risque, non porteurs de mutations chez BRCA1/2, et de 25 contrôles sans cancer. Finalement, nous avons étudié 4 allèles nonsense du gène PALB2 à l'aide du test de toxicité cellulaire WST-1 ainsi qu'en utilisant l'analyse Q-FISH spécifique aux télomères, l'analyse FISH spécifique aux centromères et finalement par caryotype spectral (SKY).
Les résultats présentés dans cet ouvrage suggèrent que RAP80 et Abraxas ne sont pas des gènes de susceptibilité au cancer du sein à pénétrance moyenne ou élevée. De plus, il est peu probable que des allèles du gène CHEK2 autres que l'allèle connu 1100delC contribuent de façon significative au risque de cancer du sein héréditaire dans la population canadienne française. Par contre, les résultats de notre analyse du gène PALB2 dans les lignées cellulaires hétérozygotes pour un allèle nonsense suggèrent la possibilité que la présence de ces allèles crée de l'instabilité chromosomique chez les porteurs de mutations qui puissent prédisposer à la progression tumorale.

Objetivo: Até 10% dos casos de câncer de mama estão associados com uma síndrome genética de predisposição ao câncer. A identificação de possíveis portadores dessas síndromes e o consequente encaminhamento para aconselhamento genético permitem a adoção de estratégias direcionadas de prevenção e rastreamento capazes de diminuir morbidade e mortalidade. O objetivo do presente estudo foi avaliar a proporção de pacientes com câncer de mama atendidos no Hospital Universitário de Santa Maria (HUSM) que necessitariam ser encaminhados para avaliação genética. Métodos: Pacientes com câncer de mama que iniciaram tratamento oncológico no HUSM durante o ano de 2014 foram considerados elegíveis. Uma entrevista foi conduzida com cada paciente para coleta de dados e exame físico dirigido. O questionário FSH-7 (Family Story Screening 7) e os critérios do NCCN (National Comprehensive Cancer Network) foram utilizados para identificar os pacientes que deveriam ser encaminhados para avaliação genética. Estes pacientes foram então avaliados quanto à indicação de teste genético - de acordo com as recomendações do NCCN para teste genético – e à probabilidade de mutações nos genes BRCA1 e BRCA2 através de modelos de predição de risco (BOADICEA, Penn II, sistema de escore de Manchester e tabelas da Myriad). Resultados: Dentre os 114 participantes do estudo, 65 (57%) preenchiam critérios de encaminhamento para avaliação genética de acordo com as diretrizes do NCCN. O questionário FHS-7 apresentou uma sensibilidade de 90% para identificar estes pacientes, com uma especificidade de 85%. A presença de história pessoal ou familiar de câncer de mama antes dos 50 anos foi o critério mais comum para indicar avaliação genética. Em relação aos testes genéticos, 52 pacientes (45%) deveriam ser testados para mutações nos genes BRCA1 e BRCA2 e 4 pacientes (3,5%) possuíam indicação de teste para mutações em TP53, de acordo com as recomendações do NCCN. Utilizando os modelos de predição de risco, 10,2% a 57,1% dos pacientes apresentavam uma probabilidade ≥ 10% de mutações em BRCA1 ou BRCA2. Conclusão: Este estudo revelou que a maioria dos pacientes com câncer de mama atendidos no HUSM possui indicação de encaminhamento para avaliação genética. A utilização de um questionário simples e rápido poderia identificar 90% destes pacientes.
Objective: Up to 10% of breast cancers are associated with a hereditary cancer syndrome. The identification of possible carriers of these syndromes and the subsequent referral for genetic counselling allow the adoption of tailored screening and prevention strategies capable of reducing morbidity and mortality. The aim of this study is to assess the proportion of patients with breast cancer treated at the University Hospital of Santa Maria (HUSM) that would need to be referred for genetic evaluation. Methods: Breast cancer patients who began cancer treatment at HUSM during the year 2014 were eligible. An interview was conducted with each patient for data collection and targeted physical examination. The FSH-7 (Family Story Screening 7) questionnaire and the NCCN (National Comprehensive Cancer Network) criteria were used to identify patients who should be referred for genetic evaluation. Then these patients were assessed for genetic testing criteria - according to the NCCN recommendations for genetic testing - and the likelihood of BRCA1 and BRCA2 mutations through risk prediction models (BOADICEA, Penn II, Manchester score system and Myriad tables). Results: Among the 114 study participants, 65 (57%) meet referral criteria for genetic evaluation according to the NCCN guidelines. The FHS-7 questionnaire showed a sensitivity of 90% to identify such patients with a specificity of 85%. The presence of personal or family history of breast cancer before age 50 was the most common criteria to indicate genetic evaluation. With respect to genetic testing, 52 patients (45%) should be tested for BRCA1 and BRCA2 mutations and 4 patients (3.5%) had test indication for TP53 mutations in accordance with the recommendations of the NCCN. Using risk prediction models, 10.2% to 57.1% of patients had a BRCA1 or BRCA2 mutations probability ≥ 10%. Conclusion: This study showed that most of the patients with breast cancer treated at HUSM have referral indication for genetic evaluation. The use of a fast and simple questionnaire could identify 90% of these patients.

Purpose: This study assessed effectiveness of five tools recommended by the US Preventive Services Task Force (USPSTF), designed to help primary care clinicians determine which unaffected patients to refer to genetics specialists for breast cancer risk assessment based on concerning family history. Design: This descriptive secondary analysis included 85 women aged 40-74. All participants had a first-degree female relative previously diagnosed with breast cancer who also had uninformative negative BRCA1/2 tests. Methods: Each pedigree was evaluated using the five tools including the Family History Screen-7 (FHS-7), Pedigree Assessment Tool (PAT), Manchester Scoring System, Referral Screening Tool (RST), and Ontario-Family History Assessment Tool (Ontario-FHAT). All five tools were applied to each study participant. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated to describe each tool’s ability to identify women with elevated risk as calculated by the Claus model. Receiver operating curves (ROC) were also plotted. Differences between areas under the curve (AUCs) for all possible pairs of tools were estimated through logistic regression to assess for differences in tool performance. Results: Claus calculations identified 14 women out of 85 whose lifetime risk of breast cancer was elevated at > 15%. Only two tools, the Ontario-FHAT and FHS-7, identified all 14 women with elevated risk, a sensitivity of 100%. The FHS-7 tool flagged all 85 participants, meaning its specificity was zero. The Ontario-FHAT flagged 59 participants as needing referral (specificity 36.2%) and had a negative predictive value (NPV) of 100%, indicating that if a woman was not found to need a referral to a genetics professional, it is likely she did not have an elevated lifetime risk of developing breast cancer. AUC values were not significantly different between tools (all p values > .05), and thus were not helpful in discriminating between the tools. Conclusion: In this population, the Ontario-FHAT out-performed other tools in terms of sensitivity and negative predictive value; however, low specificity and positive predictive value must be balanced against these findings. Thus, the Ontario-FHAT can help determine which women would benefit from referral to a genetics specialist.

Breast cancer-related lymphoedema (BCRL) is one of the most feared complications following breast cancer treatment. The burden of BCRL is high in India, with more than 162,000 women diagnosed with breast cancer annually. Strategies that prevent the condition from developing are needed; for those women at-risk of its development, strategies that enable early detection and monitoring of its impact are required. Three gaps that informed these strategies were identified and addressed in this thesis to reduce the burden of BCRL. First, detection of lymphoedema in India using bioimpedance spectroscopy (BIS) was compromised as the device available in India used an alternative electrode placement and had yet to be validated against established protocols. A study was, therefore, conducted to examine the interchangeability of two electrode placement protocols. Secondly, to inform which self-reported questionnaire (SRQ) should be translated into Indian languages, a comprehensive systematic review of the lymphoedema-specific SRQs was conducted to identify which of the available ones demonstrates good measurement properties. Thirdly, an adequately powered randomized controlled trial on the efficacy of the prophylactic use of compression sleeves to prevent lymphoedema in women at high risk of lymphoedema was investigated. The first study demonstrated that the equipotential and sternal notch electrode placement protocols are interchangeable in BCRL assessment. The second study showed that the Lymph-ICF-UL and LYMQOL-leg SRQs had good quality evidence supporting their content validity, reliability and construct validity. The third study demonstrated that prophylactic use of compression sleeve delayed and reduced the arm swelling in the first year following surgery. In conclusion, this thesis provides critical evidence to advance the management of the enormous burden of BCRL in the Indian context and other similar resource-limited settings.

Thesis advisor: Jane Flanagan
BACKGROUND: Breast cancer survivors experience a range of needs in the post-treatment phase as they transition into survivorship and beyond. The transition to survivorship requires breast cancer survivors to actively engage in self-managing their care, but little is known about patient engagement into survivorship care and what factors may contribute to this. Information is needed to further explore patient engagement into survivorship care, what factors may contribute to it and which patients are more likely to engage in their care and thus be better equipped to self-manage during survivorship. PURPOSE: The purpose of this study was to explore how demographic/personal factors and survivorship outcomes are related to and may contribute to patient engagement in early stage breast cancer survivors. METHODS: A cross-sectional, web-based self-report national survey was conducted using measures assessing personal/demographic factors, survivorship outcomes: health-related quality of life (HRQOL), fear of cancer recurrence (FCR), cancer health literacy (CHL) and two measures of patient engagement (patient activation (PA) and knowing participation in change (KPC). There was one open-ended question regarding additional survivorship concerns, not addressed in the previous survey items. Participants were recruited using Dr. Susan Love’s Army of Women Research Foundation and Craigslist. Data were analyzed via bivariate associations and backwards linear regression modeling in SPSS. RESULTS: The final sample included 303 participants (301 females and 2 males) with a mean age of 50.70 years. The sample was predominantly White, non-Hispanic and equally dispersed across the United States. Patient engagement, as represented by PA and KPC, was significantly correlated with 13 predictor variables and there were 10 predictor variables that resulted in significant ANOVA relationships with PA and KPC. In both the KPC and PA regression models, HRQOL significantly predicted for patient engagement. In the KPC regression model, social support and level of education also significantly predicted for patient engagement and receipt of a survivorship care plan contributed unique variance to the model. The open-ended question response categories included: physical concerns, mental health concerns, financial toxicity, social support, body image concerns, other concerns or no concerns/none. CONCLUSIONS: This study provides preliminary evidence that personal/demographic factors and survivorship outcomes may contribute to patient engagement in breast cancer survivors. Using assessment tools that measure factors such as HRQOL, social support, education level and patient engagement may give providers some insight as to which survivors may be ready to engage in survivorship care and those that may need more resources and/or support. Additional studies are needed to replicate and validate these results. More research is needed aimed at maximizing patient-centered care, patient engagement and ultimately improving SC. Keywords: breast cancer survivor, survivorship, patient engagement, health-related quality of life, social support
Thesis (PhD) — Boston College, 2019
Submitted to: Boston College. Connell School of Nursing
Discipline: Nursing

Docetaxel is a chemotherapeutic agent in the taxane group of drugs which is commonly used in the first line setting for metastatic hormone receptor negative breast cancer. We present a case of a 46 year old female who was diagnosed with de novo triple negative metastatic breast carcinoma, and has had an extended progression free survival (PFS) of almost 5 years on first line single agent treatment with Docetaxel. 46 year old female presented with a large left breast mass as well as axillary mass which revealed grade 3 invasive ductal carcinoma of breast on biopsy of both sites. Tumor was estrogen and progesterone receptor negative. Pathology showed discordance in HER2 testing between FISH and IHC, however on repeat testing, HER2 was confirmed to be negative. PET/CT scan for staging revealed large left sided pleural effusion and abnormal soft tissue in the lower anterior and posterior chest on the left concerning for pleural metastases. Patient underwent CT guided biopsy of left lower pleural space which was consistent with metastatic adenocarcinoma with breast primary. She was started on first line single agent chemotherapy with Docetaxel 100mg/m2 every 3 weeks. Tumor markers were non-contributory to assess disease response. Repeat systemic imaging in 3 months showed excellent partial response with decrease in size of breast mass, conglomerate axillary lymph nodes as well as pleural based metastatic foci. Patient had grade 1 neuropathy secondary to Docetaxel which was tolerable. Patient also had significant fatigue with warranted dose reduction by 20% after 6 months. She also demonstrated other adverse effects of Docetaxel such as nail dystrophy and mild blepharitis which were also tolerable. Patient showed good tolerance to chemotherapy, with intermittent treatment holidays. CT scans continued to demonstrate good response with stable size of breast and lung masses. After two years of stable disease and fair tolerance (after completing 34 cycles), chemo regimen was changed to every 4 weeks per patient’s wish. She was also started on Gabapentin for chemotherapy related neuropathy. At the end of 4 years, patient had completed 55 cycles of agent Docetaxel, maintaining ECOG of 1, with grade 2 neuropathy controlled with gabapentin. Patient is currently 56 months out from her initial diagnosis of metastatic triple negative breast cancer and follow-up scans continue to show stable disease. She has developed profound fatigue after several months of treatment. Patient has also faced challenges with fluid retention secondary to Docetaxel. Although her performance status remains fair, patient is contemplating changing frequency of chemotherapy to every 5 or every 6 weeks. Triple negative breast cancer is an aggressive disease with limited options of treatment with chemotherapy agents and no role for endocrine therapy or HER2 targeted treatment options. Docetaxel has shown to have median survival ranging between 10.1 to 14.7 months depending on the dose. Our patient has so far shown extended PFS of 56 months, with single agent Docetaxel in first line setting which surpasses current national averages.