We inherit lots of things through our families. Sometimes they’re visible, like the color of our eyes or hair, and other things might not be so apparent, like how you react to caffeine or how athletic you are. These traits come from genes passed to us from our parents – we inherit two copies of each gene, one from each parent, and they act as the blueprints for our bodies.

The genes we inherit can also raise our risk for some kinds of cancer. All cancers are caused by mutations in our cells, and most of the time those mutations happen simply because of aging, or because of lifestyle choices like smoking. But sometimes - in about 5%-10% of cancers - mutations are handed down through families. If you have one of these inherited mutations, you can minimize your cancer risk by following established health care guidelines and taking a proactive approach to your health.  

In this episode of Science Never Sleeps, we’re joined by Dr. Kevin Hughes, the Director of Cancer Genetics at the Hollings Cancer Center and the McKoy Rose, Jr., M.D. Endowed Chair in Surgical Oncology in the College of Medicine at MUSC. Dr Hughes is recognized nationally and internationally for his expertise in breast cancer, breast disease management, genetic testing and the identification and management of patients with hereditary breast cancer risk.  His research focuses on developing tools that make cancer genetic testing simple, safe, and efficient.   

Correction at the 11:40 minute mark: the statistic should be 1-2 people out of every 100 will have be identified with a gene variant at the population level.

Clarification At the 12:08 and 26:00 minute marks: Once a participant is positively identified, they are offered a free genetic counselling appointment and from there are able to follow up with the Hereditary Cancer Clinic if they desire or may seek follow up care elsewhere.

Episode Links:

Hollings Cancer Center Hereditary Cancer Clinic

In Our DNA SC community health research project

CDC Tier 1 Genomics Applications and their Importance to Public Health

Have an idea for a future episode? Send us an email at ScienceNeverSleeps@MUSC.edu.

Science Never Sleeps is produced by the Office of the Vice President for Research at the Medical University of South Carolina.

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From the Medical University of South Carolina, this is Science

Never Sleeps, a show that explores the science,

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people, and stories behind the scenes of biomedical

research happening at MUSC. I'm your host,

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Gwen Bouchie. We inherit lots of things through

our families. Sometimes they're visible, like

4

the color of our eyes or our hair, and other

things might not be so easy to see, like how

5

you react to caffeine or how athletic you are.

These traits come from genes passed to us from

6

our parents. We inherit two copies of each gene,

one from each parent, and they act as the blueprints

7

for our bodies. The genes we inherit can also

raise our risk for some kinds of cancer. All

8

cancers are caused by mutations in our cells,

and most of the time those mutations happen

9

simply because of aging or because of lifestyle

choices, like smoking. But sometimes, in about

10

5 to 10 percent of cancers, mutations are handed

down through families. If you have one of these

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inherited mutations, you can minimize your cancer

risk by following established health care guidelines

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and taking a proactive approach to your health.

In this episode of Science Never Sleeps, we're

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joined by Dr. Kevin Hughes, the Director of

Cancer Genetics at the Hollings Cancer Center

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and the McCoy Rose Jr. MD Endowed Chair in Surgical

Oncology in the College of Medicine at MUSC.

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Dr. Hughes is recognized nationally and internationally

for his expertise in genetic testing and the

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identification and management of patients with

hereditary cancer risk. His research focuses

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on developing tools that make cancer genetic

testing simple, safe, and efficient. Stay with

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us.

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Dr. Hughes, welcome to Science Never Sleeps. Thank you, nice to be

here. You have enjoyed an incredible career

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prior to joining MUSC. You spent 20 years at

Mass General. You're a professor emeritus at

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Harvard Medical School. Tell us a little bit

about how you got started in research and how

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you ended up here at MUSC. Oh, well, I trained

in surgical oncology and worked in the liver

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surgery and breast surgery and other surgeries

at other surgeries of cancer origin. During

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the time of my work, it was always interesting

to me to know more about what was going on.

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There's a lot to learn in cancer. There still

is a lot to learn in cancer, but when I started

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out, there was really a lot to learn. So doing

research was just a way to learn more about

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these areas, to try to advance the field, to

try to make treatment easier for patients and

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more effective. And you can't do that without

research. So I got involved in it in that way.

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And I was at Mass General for 20 years, as you

had said, and the opportunity arose at MUSC,

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and this is a great institution, and I was happy

to come down here. We are so glad to have you

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here, for sure. So tell us, you talked about

how much we currently know and still need to

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learn about cancers. And one of the things that

we really have been able to understand a little

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better in the last few decades is the role of

genetics in cancer. Can you talk a little bit

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about what we do currently understand about

the role of genetics and the role that they

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play in cancer and cancer diagnosis? Sure, we've

known for a long time, 100 plus years that

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cancers can run in families. But it was never

quite clear why it was running in families

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that way. As the discovery of the DNA structure

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that we now knew that there was a structure

to DNA. And once you knew the structure, you

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could start to understand functioned and then

we knew there were these things called genes

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but we didn't really have a good concept of

what they really were. But once you have the

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structure of DNA, once you understand what the

code was of life essentially, people began

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to study the families that were very affected

by cancers and then to identify specific genes

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in these cancers that caused this family accumulation.

And over the years we've now identified at

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least 80 plus genes that we know that if they're

not functioning properly the patient's at higher

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risk of cancer. And these genes are passed down,

there are mutations in the genes that go from

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generation to generation. Each time there's

a 50-50 chance that the child would get one

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of these bad genes from one of the parents.

And knowing that there are these genes, knowing

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that they run in families, studying these families

with these mutations, it then became apparent

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that if you knew which mutation was in a family,

you knew which mutation was affecting a given

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member of that family. you knew what cancers

that gene could cause, you knew how often those

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cancers occurred, that opened up the possibility

of prevention or finding the cancers earlier.

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So we've learned what these genes are, we've

learned what their spectrum is, how many types

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of cancers they can cause, and each one causes

a different set of cancers. We know how much

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they affect the family and then can be, we can

know how aggressive to be. For one that causes

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a 90% risk of cancer. we're extremely aggressive.

For one that causes a 20% risk of cancer, it's

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a bad risk, but we're not quite as aggressive.

So we've learned to modify how we manage patients,

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our strategy for those patients, based on which

gene it is and how penetrant it is and what

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types of cancers it causes. Genetic testing

used to be extremely expensive, now it's cheap.

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So with it being so inexpensive, with people

understanding what's going on, knowing what

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we can do for these patients, it's become almost

a commodity at this point in time. Genetic

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testing has become easy to do, it's inexpensive

to do, patients are much less afraid of it,

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doctors are much less afraid of it, thank God.

So it's just become something, it's a normal

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part of medical care at this point in time.

Right, right. And I wanna point out something

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that you said, which I think is important and

we can continue to talk about, which is that

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to find out that you have one of these genes

is only looking at risk. It doesn't mean anything

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necessarily. It's not a diagnosis of cancer.

Absolutely correct. So if you have a mutation

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in these genes, your risk of cancer is higher.

Your risk of specific cancers is higher based

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on the gene. How high your risk is based partly

on the gene as well. But it does not mean you

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will get cancer. We treat all patients with

mutations as if they might get cancer, and

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therefore we make sure we screen them very carefully.

In very high risk situations, we sometimes

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remove the ovaries or remove the stomach or

other things if we have to, but that's unusual.

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Usually it's in more intensive screening for

the cancers that we wouldn't be screening for

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otherwise or not screening as intensively. So

knowing this information is extremely valuable

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for the patient, it's life-saving, and the more

we do it, the better off we're gonna be. And

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that's really where the Hereditary Cancer Center

comes in. So, you know, you talked about this

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being a familial, it's a family situation because

we're inheriting these things from parents.

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So the Hereditary Cancer Center looks at these

genes that can be passed on by parents. So

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can you talk a little bit about the role of

the Hereditary Cancer Clinic at Hollings Cancer

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Center? Sure, so genetic testing, even though

it's been around commercially for 25 years,

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it's not been used very effectively or in large

enough numbers. So a large number of patients

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never found out they had a mutation. And we

were very invested in figuring out how to test

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patients and how to set up systems to test patients,

how to find patients with mutations. We didn't

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really give enough thought to what do we do

once we find them. So we're one of the first

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in the country, there are about a half a dozen

others, where we see the patient with a mutation

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and then figure out what is the right strategy

for that specific patient. And then... institute

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that strategy and then follow them over time

to make sure that the strategy is followed

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So this gives us the ability to learn more about

how well our guidelines are working To make

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sure patients do what they're supposed to do

relative to the guidelines and then minimize

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the morbidity and mortality of cancer That's

the whole approach There are a lot of individual

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clinics for individual genes So there might

be a neurofibromatosis clinic that would follow

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patients with that problem. There's what's called

a Von-Hippel Lindau clinic that follows people

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for kidney cancer or brain tumors. There are

adenomatous polyposis clinics. Those follow

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patients for colon cancer risk. But there aren't,

now you say it, there's maybe half a dozen

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clinics that just take anyone with a mutation

in any of 80 plus genes and then set up a strategy

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specific to that. patient and that's something

I think is gonna become very common, we're

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trying to set the pattern for how to do that.

And this is really through a team of care providers,

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you know, you yourself are a surgeon who would

look at that portion of it, but we have folks

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like genetic counselors who are playing into

this, who are fully helping individuals and

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families understand their risk and what that

means for the next steps that they'll take

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throughout their lives. Absolutely, yeah, this

is certainly a team sport. So the way the clinic

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is set up that if a person has a mutation, they

see the genetic counselor, they understand

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more about the mutation, we start to talk about

getting their family members tested because

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it's very important to do that. And then once

the patient somewhat understands what the mutation

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is and what it does, they then see either myself

or Jen Diaz, who's a nurse practitioner, in

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the hereditary cancer clinic as an extension

of it, where they then get again the strategy

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specific to them. And the... Every time they

come into the clinic, we remind them to get

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their family members tested. Then we have a

network of physicians very interested in hereditary

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cancer in each of the specialties, neuro-oncology,

in colorectal surgery, in dermatology, et cetera.

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We just have doctors in each area who are very

good at this particular problem. And our job

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in the center is to make sure the patient gets

to the right doctor, gets the right management.

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and then we follow them over time to make sure

they don't fall off the radar. Then we continue

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this for life because that's what we need to

do with these patients. Right, right. In the

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hereditary cancer clinic environment, who should

be screened? And what are the types of results

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that you might receive if you are screened within

that kind of a clinic? So genetic testing is

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a two-step process. So the first step is a genetic

testing piece. And anyone who has a strong

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family history of cancer, they should have genetic

testing done. And today we test for 80 to 142

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different genes because the testing is inexpensive.

We just test everybody for everything, it's

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easier. But to have it covered by your insurance,

it has to be, you have to meet the criteria.

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So with a strong family history, multiple relatives

affected, young age of diagnosis, people in

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your family with more than one cancer, like

bilateral breast cancer, breast cancer on both

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sides, or breast and ovarian cancer. If that's

in your family, then getting testing is important

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and talk to your doctor about how to get that

done. Either our genetic counselors or nurse

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practitioners or myself, we can test you for

that. But we also now are testing at the population

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level. And the In Our DNA South Carolina research

program is set up to test anyone over the age

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of 18 for risk of breast cancer and colorectal

cancer. Now this is for a small number of genes,

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but this is now a way to look at the population

level with or without a family history. to

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just test patients to see if they have a mutation.

This is gonna pick up a lot more patients.

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The next level of that, when you do this test,

about one out of 20 will have a mutation. And

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it's that one out of 20 with the mutation that

then goes on to the hereditary cancer clinic

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for very specific management for that mutation.

And again, it doesn't mean you're gonna lose

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an organ, it doesn't mean we're gonna tell you

that you're gonna die of cancer. That's certainly

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not the point. The point is that we know your

risk is higher, we know where that risk is

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higher, we know how to try to find that cancer

early, and in some cases we know how to prevent

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it, either by medication or by surgery. And

picking the right strategy for that patient,

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that's where the Hereditary Cancer Clinic comes

in. After the testing, once a patient is positive,

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and then getting them tested. And then we also,

in that clinic, be sure to test as many family

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members as possible. Because every member of

the family on that bloodline. is at risk and

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if we can test them, find their mutation, they

also could be saved from a dread disease. And

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when we talk about the population level of this

type of work, when we look at genetic testing

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to look at what's happening with cancer at a

large public health type scale, that's when

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we really start looking at the genetic databases

and how they can help identify. maybe trends

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or things that are happening in the population

as far as cancer goes. And this is one of the

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places where research can really come into play.

And the databases can also help to identify

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perhaps different genes that we maybe didn't

even realize in the things that they do. So

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can you talk a little bit about the key to what's

next in cancer research and how our work with

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genetics is going to be part of that? Wow, that's

a lot of stuff. So basically, genetics is a

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basis of almost all cancer. So all cancers are

caused by genetic mutations. As you mentioned

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earlier, most of these mutations we pick up

over the course of our lifetime. A small number,

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that five to 10%, we're born with that mutation

that then spawns other mutations to make a

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cancer develop. Understanding those genes better,

understanding what they do better is kind of

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part of the next step. If you look at how we

did this initially, you'd find a family where

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everybody had cancer, and you'd test that patient,

and every family member, and they all had the

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gene, they all had cancer, and we thought the

risk was 100% or some astronomical number.

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Well, when you test at the population level,

you find families where there's no cancer in

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the family, and somebody has a mutation. And

you start to realize that these mutations may

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not be as penetrant, may not cause as much cancer

as you thought. And as we understand what level

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of risk there is, we can then... ratchet down

how intensively we screen the patient. So our

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next generation of research at that level is

gonna be what is the real risk from this mutation

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and how well do our guidelines work? Because

the guidelines are made by a group of professionals,

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physicians, nurse practitioners, genetic counselors,

sitting around a table and saying, I think

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that's a good idea, let's try that. That's not

very scientific, but that's the best we have.

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But as you start putting it into practice, then

you can identify is it right that a patient

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gets an MRI every year? Or do they need it every

six months? Or do they need it every two years?

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Finding out that is gonna start to limit the

amount of trauma we give to the patient to

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get the same outcome. So that's a big part of

our research. Other parts are learning new

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genes that we don't know about yet. Better understanding

the variance in the gene. So just because you

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have a mutation in a specific gene, is every

mutation the same? Does everyone cause the

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same level of risk? That's a major research

area at this point. And then we find mutations

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in genes that we don't understand. They're called

variants of uncertain significance. And just

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as we said, they're uncertain. We don't know

what to do with them. So when we get that result,

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we tell the patient, you know, it's probably

nothing. We're gonna keep an eye on you. We'll

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treat you based on your family history and consider

this negative until we know better. But we're

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developing ways to try to sort out what those

variants are without having to wait five years

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to gather another 100,000 patients. So there's

a lot going on right now. And then the next

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step is gonna be really, who do you test? And

what do you test them for? Right now we test

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142 genes. Well there's 20,000 genes in the

genome. And at some places they're testing

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all 20,000 genes. And then if you get to the

20,000 gene test, which is gonna become as

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cheap as 142 gene tests, so why not do them

all, how do you manage all that information?

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All of us have 40, 50, 100 mutations. What do

we do with all that information? We don't really

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know yet. And then it comes up, when do you

test the patient? Well, we kind of say test

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at the age of 18, but there are some studies

now of testing it at the newborn level. So that's

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what we've got to figure out. How much do we

test? Who do we test? When do we test? And

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how do we manage these positives? That's a lot

to figure out yet. Does that also extend to

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how we're treating cancer as well? If we can

better understand a patient's genetic makeup,

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does it make it easier, more efficient, better,

safer to treat a patient for cancer? Absolutely,

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that's a very large area of research and that's

more on what's called the somatic mutation

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side. And that is in terms of what mutations

does the cancer have that the patient wasn't

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born with. And so we're looking for what's called

targeted therapy. When a person has a cancer

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and they recur with that cancer and common medications

that we normally use for cancer aren't working,

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we do testing of the tumor. We find mutations

in the tumor that we didn't know about in that

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patient and identify that this patient can be

treated with this certain drug and this patient

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can be treated with a different drug. And there's

some overlap with the germline mutations that

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people with a BRCA1 or 2 mutation can have their.

breast cancer or ovarian cancer treated with

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what's called a PARP inhibitor, which doesn't

really work outside of the mutation status

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of patients. So we're learning about mutations

that the patient's born with. There's mutations

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in the gene, in the tumor itself that can target

your therapy. And then there are gene mutations

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people are born with that change how medications

affect them. So a certain gene, not a mutation,

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but genes come in different varieties. Blue

eyes and brown eyes are both normal. But some

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people have genes that metabolize drugs very

quickly and other people have genes that don't

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metabolize the drug as quickly. And if you metabolize

a drug quickly, a smaller dose may be more

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toxic. And so you have to adjust your dose based

on the type of genes you have. We're just beginning

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to understand that. And we still haven't figured

out how to put it in practice very well. But

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that's gonna be, I think, more at the computer

level where you find out what mutations everybody

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has or what types of genes they have. what medications

they're on, what disease they have, and then

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how do you adjust the medication and the dose

based on their genetic makeup? That's extremely

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complicated, and it's gonna take computers to

do that or artificial intelligence. We're not

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at the place yet where humans can do that in

their head. And yet that's where we need to

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be. Right, but that's the next frontiers, really,

of where we're headed with all of this. Yeah,

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that's really great. So your passion is to do

a better job linking all of this together.

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And one of the big things, and you just sort

of alluded to this idea that the human brain

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is quite limited in its capacity. And so to

take all of the data that's required to look

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at all of the facets of what it takes in order

to really bring optimum health to a patient,

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we need to be doing that better. We need to

have better systems for how we're looking at

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all of the data, because we're producing tons

and tons of data at this point. So how do we

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bring it all together? So that's one of the

things that you're really working on. What

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does that look like? Tell us a little bit about

that first, just generally overall, and then

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maybe what that looks like in real world practice.

So medicine, like every other industry, has

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multiple databases that cover multiple things

and often don't talk to each other. So we were

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hoping that the electronic health record would

bring it all together, but that hasn't happened.

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We still have very specialized systems for tracking

data in pathology, other specialized systems

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for tracking data in the genes, other data for

tracking people who have radiation therapy.

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And each of those areas, and that's just the

beginning, need specialized software that helps

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them do their job better. It's like giving a

carpenter a Swiss Army knife and telling them

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to make a cabinet. You can't do it that way.

You have to give them the right saw, the right

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drill, the right pieces. So each of these groups

need software specific to them. But each of

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that piece of software was designed independently.

So then they don't talk to each other. So the

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same information is in each of these places,

but in different formats, in different codes,

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in different fields. So we're working on trying

to find ways to bring that data together by

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getting the databases all into one place. We

call it a data lake. And then once it's in

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the data lake, making sure it's updated regularly,

now all these are still independent, they're

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just in the same place now. But then we start

to map them to a single structure. And when

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they're in a single structure, now you have

the data to start playing with to start understanding

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this better. And you start out by, as a human,

trying to figure out what's the relationship

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of this problem to this cancer to this gene,

et cetera. And so it's more human driven and

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rules driven. But the next step is machine learning

and artificial intelligence, where the machine

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starts to look at patterns that we're just not

able to see. So we can look at five or 10 characteristics

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of a cancer and then we get confused. A machine

can look at a thousand characteristics and

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it doesn't care, it's just numbers to them.

So the future is really gonna be having the

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data, that's the first thing, having the data

in one place in one format, and then having

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the machines able to start working with that

data to find out what is the relationships

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that we're missing. And it's not gonna be machines

or humans, it's gonna be machines and humans.

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Because they're gonna bring to the table a vast

amount of ability in calculation and algorithm,

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but we bring to the table experience and empathy

and all the human side of things. And together,

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augmented intelligence is more important than

artificial intelligence. And that's where we're

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heading towards, is large data sets, very intensive

analysis, but then looking at what does that

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really mean in the real world. and that's going

to be the future. That's the next decade or

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two. I love that augmented intelligence because

it really is about giving the specialist, like

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yourself, a better tool in order to look at

something and then make decisions about it.

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It's not about the data or the tool telling

you necessarily what to do, but it's giving

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you a little bit more information to work with.

It's giving you synthesis of 1,000 per permutations

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where you just couldn't do that on your own.

Exactly right. And that's where we need to

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be. It's no different than you're driving a

car. That doesn't mean that the car replaces

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you. It means that the car helps you get somewhere

faster or more efficiently. So it's using machines,

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whether it's a computer or a car or anything

else to make you more efficient and effective

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as a human being. That's augmenting the intelligence.

And what does it mean for cancer research specifically

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if we can pull these various data places together

in the data lake as you mentioned. What does

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that mean for cancer research and where we're

headed there? So I'll give you an example of

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Amazon, what Amazon does. So Amazon takes all

this information about what you buy and then

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looks at what the weather is and where you live.

What's the environment where you live? What's

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the weather where you live and what's the weather

on the day you bought certain things? So you

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look at data as saying you got a whole bunch

of data and the first question you ask is what

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happened? Okay, well people bought boots. Okay,

then the second question is why did it happen?

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Well, it was raining or it's snowing. And then

the next question is well, what's gonna happen?

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Well, when it snows, people are gonna buy boots.

And the final question is how do you make it

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happen? Well, Amazon puts up a boot commercial

in your area when it's snowing outside. So

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that's use of data that we are nowhere near

in medicine. We're still at the point of taking

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a small chunk of data and saying, well, this

is what happened, and maybe predicting what

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might happen. We haven't got to the point of

saying, how do we make things happen? How do

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we make the patient come in for her mammogram?

How do we make the patient know what drug to

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take, or make sure she takes the right drug,

or takes her drug regularly? Amazon's a master

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at that, and they use computers and artificial

intelligence to do that, and we're nowhere

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near it. But that's the future, is if we can

pull this data together. look at how it interrelates,

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and then how does that then drive getting patients

the right treatment and then helping them understand

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why they need to do it and making them want

to do it. That's the future.

275

You mentioned In Our DNA SC, which is the community

health research project that MUSC is running.

276

Can you talk a little bit more about that for

listeners who might want to get involved? Sure.

277

So In Our DNA South Carolina or In Our DNA SC is a research

protocol. Anyone over the age of 18 who's a

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MUSC patient can participate. They don't need

any special counseling. They don't need anything

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beyond just signing an informed consent, understanding

what the protocol is about. and then giving

280

a saliva sample and then getting a result back.

So we're using the CDC, the Center for Disease

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Control Tier 1 genes. These are genes that everybody

agrees should be tested in everybody. So the

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genes are for breast cancer risk, BRCA1 and

BRCA2, and then for colon cancer risk with

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what's called Lynch syndrome, and for hereditary

hypercholesterolemia which is an overabundance of cholesterol

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that increases the risk of heart disease. So

testing for these genes, Basically, the CDC

285

has said everybody over the age of 18 should

do this anyway. So there are multiple programs

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going on around the country, and we have one

of those programs going on. If you're over

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18, if you're an MUSC patient, you go to MyChart

and you can sign up for this study. If you're

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not an MUSC patient, become an MUSC patient

to do the study. When you do this, you're going

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to get a result back that tells you do you have

one of these genes. Now, if you have one of

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those mutations, You'll see us in the hereditary

cancer clinic and we'll help to get your treatment

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organized and your management organized. If

you don't have one of those genes, it does

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not mean you don't have a hereditary cancer.

This is only the beginning. So if you have

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a strong family history, you still wanna have

regular genetic testing, not on a research

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protocol, where we test hundreds of genes, or

actually about 140 genes, to look for genes

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that increase cancer risk. But we want to at

the population level, Identify patients we

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may have missed otherwise. They don't have a

strong family history. They can't get in to

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see a genetic counselor. They don't have time

to come in. They don't understand they need

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to get tested. Their doctor doesn't tell them.

That's why we're making this available to anybody.

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And again, we're not the only ones in the country.

This is very normal. It's becoming a normal

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thing to do. So you can sign up, you get your

test done. If you have a mutation, we'll help

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take care of you. If you don't have one, but

you have a strong family history, then get

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commercial genetic testing, regular genetic

testing so we don't miss anything. What do

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you mean when you say a strong family history?

How would someone listening determine, oh,

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I have a strong family history? Sure, so strong

family history means that there are multiple

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relatives in your family affected with similar

cancers. That's hard to know what's similar.

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So a breast cancer and an ovarian cancer, they

don't sound similar, but they run in the same

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type of gene. So if you have, make it simple,

multiple cancers in the family. Young age of

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diagnosis, breast cancer in the 20s or 30s rather

than in the 50s, 60s, 70s as we normally see.

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Breast cancer, I'm sorry, cancer occurring in

more than one organ. So a woman who has breast

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cancer on both sides or a man who has a colon

cancer and a prostate cancer. Multiple cancers

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in one individual, young age of diagnosis, multiple

family members. That's what a strong family

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history means to us and most patients with that

are eligible for commercial testing which is

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then covered by their insurance.

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We've been talking to Dr. Kevin Hughes with

the Hollings Cancer Center about hereditary

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cancers and the importance of genetic testing.

To learn more about the NRDNA SC Community

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Health Research Project, visit www.nourdnasc.org

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or check our show notes. Have an idea for a

future episode of Science Never Sleeps? Click

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on the link in the show notes to share with

us. Science Never Sleeps is produced by the

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Office of the Vice President for Research at

the Medical University of South Carolina. Special

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thanks to the Office of Instructional Technology

for production support on this episode.