Traditional methods of identifying high-risk mutations in cancer-susceptibility genes (CSGs), with eligibility focused on family history, are laborious and can exclude more than half of all mutation carriers in a population
Population-based CSG testing offers an alternative approach whereby genetic testing is offered directly to all persons in a specified age range and/or population group, regardless of personal or family history of cancer
Population-based testing has proven cost-effective and acceptable to participants in studies of BRCA1/2 founder (ancestral) mutations in specified populations or ethnic subgroups wherein a narrow range of mutations account for most CSG mutations in the population
Extending population-based genetic testing to other populations would pose considerable financial challenges in terms of the costs of the genetic-testing infrastructure, irrespective of the decreasing costs of DNA sequencing
Developing infrastructures for population-based testing of BRCA1/2 offers the opportunity for broader CSG testing at limited additional cost; a panel-based approach focusing on a restricted number of highly penetrant mutations might currently be the most-acceptable strategy
CSG testing might shift from bespoke tests towards whole-genome or whole-exome analysis as part of comprehensive population-wide programmes; incorporating such testing into health-care systems, with equitable access for the entire population, will be challenging
The current standard model for identifying carriers of high-risk mutations in cancer-susceptibility genes (CSGs) generally involves a process that is not amenable to population-based testing: access to genetic tests is typically regulated by health-care providers on the basis of a labour-intensive assessment of an individual's personal and family history of cancer, with face-to-face genetic counselling performed before mutation testing. Several studies have shown that application of these selection criteria results in a substantial proportion of mutation carriers being missed. Population-based genetic testing has been proposed as an alternative approach to determining cancer susceptibility, and aims for a more-comprehensive detection of mutation carriers. Herein, we review the existing data on population-based genetic testing, and consider some of the barriers, pitfalls, and challenges related to the possible expansion of this approach. We consider mechanisms by which population-based genetic testing for cancer susceptibility could be delivered, and suggest how such genetic testing might be integrated into existing and emerging health-care structures. The existing models of genetic testing (including issues relating to informed consent) will very likely require considerable alteration if the potential benefits of population-based genetic testing are to be fully realized.
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We thank Peter Devilee, Christi van Asperen (Leiden University Medical Centre, Netherlands), Alfons Meindl (Technical University of Munich, Germany), Melissa Southey, Paul James and Ingrid Winship (University of Melbourne, Australia) for their assistance with composing Table 1, and Lawrence Brody (Director, Division of Genomics and Society, NIH National Human Genome Research Institute, USA) for discussions regarding the potential costs of BRCA1/2 testing women in the general population of the USA. Work in the laboratory of W.D.F. that is relevant to this manuscript has been funded by Susan G. Komen, the Cancer Research Society, and the Quebec Breast Cancer Foundation. The work of B.M.K. is funded by the Canada Research Chair in Law and Medicine and PERSPECTIVE, which is supported by: the Québec Breast Cancer Foundation, the Government of Canada through Genome Canada and the Canadian Institutes of Health Research, and the Ministère de l'Économie, de l'Innovation et des Exportations du Québec through Genome Québec. The work of C.T. is funded in part by the Movember Foundation UK.
The authors declare no competing financial interests.
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Foulkes, W., Knoppers, B. & Turnbull, C. Population genetic testing for cancer susceptibility: founder mutations to genomes. Nat Rev Clin Oncol 13, 41–54 (2016). https://doi.org/10.1038/nrclinonc.2015.173
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