New York metropolitan area Ashkenazi Jewish women and men aged 25 and older can now opt to undergo testing for the three common Ashkenazi Jewish BRCA founder mutations at a fraction of the commercial price, thanks to a new, philanthropy-based initiative from the Program for Jewish Genetic Health (PJGH), a not-for-profit organization affiliated with Yeshiva University and Albert Einstein College of Medicine (Einstein), in conjunction with Montefiore Health System (Montefiore). This initiative, the first of its kind in the United States, makes this testing available to all Ashkenazi Jewish individuals, regardless of their BRCA-related cancer histories or their insurance/financial situations, both of which have been barriers to date.

“Most insurance companies currently require people to already have had family members with cancer if they want to be covered for BRCA genetic testing,” said Susan Klugman, MD, medical director for the Program for Jewish Genetic Health, director of the division of reproductive genetics at Montefiore, and professor of clinical obstetrics & gynecology and women’s health at Einstein. “We at the Program for Jewish Genetic Health are not willing to wait for that.”

Background

Approximately one in 40 individuals of Ashkenazi Jewish descent carries one of three founder mutations in the BRCA1 or BRCA2 genes, a carrier rate tenfold higher than that of the general population. Females carrying a BRCA mutation face a significantly higher risk of developing breast and ovarian cancer in their lifetime, while male BRCA mutation carriers are at higher risk of developing prostate and breast cancer, among other cancers. BRCA carriers also have a 50% chance of passing the altered gene on to each of their offspring, who in turn will have an increased susceptibility for these cancer types. Individuals who find out that they are BRCA carriers through genetic testing have cancer risk-reducing and reproductive options.

Today, most health insurance policies cover BRCA testing only for those who are considered at “high risk” to have a BRCA mutation– those with a significant personal or family history of these cancers. However, individuals who are at “low risk” to have a BRCA mutation—those who do not have a significant personal or family history of cancer—along with those with no health insurance, are faced with steep out-of-pocket costs. Testing for the three common Ashkenazi Jewish BRCA founder mutations via the traditional, commercial-based process can cost more than $600 for these low risk and uninsured individuals. The PJGH is now providing testing for $100, along with complimentary pre-test genetic counseling courtesy of Montefiore.

According to the PJGH, one of the primary goals of the new initiative, that also includes a research component, is to identify new BRCA mutation carriers in this “low-risk” group who otherwise would have gone undetected. Recent studies from Israel have reaffirmed that the 1-in- 40 carrier rate in Ashkenazi Jews also applies to these low risk individuals, and suggest that the risks to develop cancer in BRCA carriers coming from both “low risk” and “high risk” families may be more equivalent than originally thought.

The Process

Interested participants aged 25 and older who self-identify as Ashkenazi Jewish will begin by visiting the PJGH’s BRCA community study website (http://brcacommunitystudy.einstein.yu.edu/), where they can learn more about BRCA and the initiative, and then be directed to complete a detailed demographic form and personal/family history questionnaire. The PJGH’s genetic counselors will analyze all responses and assign each participant into one of two groups. Those who meet National Comprehensive Cancer Network (NCCN) testing criteria (“high risk”) will be offered comprehensive genetic counseling and BRCA genetic testing through standard-of-care insurance-based processes. These individuals will be scheduled for appointments at the PJGH’s clinical affiliate, the Division of Reproductive Genetics at Montefiore, or directed to the National Society of Genetic Counselors (NSGC) website to identify other available genetic counselors.

Individuals not meeting NCCN testing criteria will be considered “low risk” and invited for a group genetic counseling session which will be provided free-of-charge. After the session, those who would like to proceed with testing will submit a saliva sample that will be tested for the three common Ashkenazi Jewish BRCA gene mutations at the subsidized rate; this rate is thanks in part to a generous grant from the Foundation for Medical Evaluation and Early Detection.

When test results are available, all participants in either group who are found to be carriers will be scheduled for an in-person genetic counseling appointment to review their results. These individuals will be counseled about screening and risk-reducing and reproductive options, advised to inform their at-risk relatives about their genetic test results, and directed to support resources, in part through the network of the PJGH. High-risk participants who are not found to be carriers of the three common BRCA mutations will be counseled appropriately, including given the option to undergo more comprehensive genetic testing.

All individuals pursuing BRCA testing through this initiative also will be offered the opportunity to participate in an associated research study conducted through Montefiore and Einstein that will assess several parameters such as the motivation for “low-risk” individuals to undergo testing, receptivity of family members of BRCA gene mutation carriers to also undergo testing, and psychosocial, religious, and cultural issues faced by BRCA carriers.

The PJGH believes that this initiative is an initial step along the route towards making BRCA screening routinely offered to all adult individuals of Ashkenazi Jewish descent, as has been suggested recently by some geneticists. The PJGH-Montefiore initiative will target those who are ready now to learn their BRCA carrier status, based on the knowledge that being Ashkenazi Jewish is in and of itself a risk factor for carrying a BRCA mutation.

“Since BRCA mutations are so common in the Ashkenazi Jewish population, there is a very low threshold for individuals of Ashkenazi Jewish ancestry to be considered at risk for having a BRCA mutation,” says Klugman. “Unfortunately, most people do not realize this, and overlook not just their personal or family history of cancer, but also their Ashkenazi Jewish ancestry as being “not significant” when in fact, they both are. Our overall goal is to educate all Ashkenazi Jews about their risk factors for developing BRCA-related cancers, and when necessary, to offer them appropriate genetic counseling and testing so that they can make informed medical and reproductive decisions.”