Myriad Live episodes are recordings of an open-forum webinar hosted by Dr. Thomas Slavin. The opinions and views expressed in this recording do not necessarily represent those of Myriad Genetics or its affiliates. To participate in a future recording, visit myriad-oncology.com/myriad-oncology-live for a list of dates, times, and subjects.
0:00:13.3 Thomas Slavin: Welcome. This episode of Inside the GENOME is a recent recording of Myriad Oncology Live, a webinar hosted by me, Dr. Thomas Slavin, Chief Medical Officer for Myriad Genetics. The opinions and views expressed in this recording do not necessarily represent those of Myriad Genetics or its affiliates. To participate in a future recording, please visit Myriad Live for a list of dates, times and subjects. I look forward to exploring the world of genetics with you all.
0:00:40.3 TS: Hello, everyone. Welcome to Myriad Live. That was the first time I played opera music, so good suggestion, Dr. Boland. So we have a special guest with us today, but first, we'll start with a little housekeeping. If this is your first time on Myriad Live, this is just an open forum for discussion. We do this theme-based. Today's theme is shown here. We're talking about historical and current perspectives of Lynch syndrome, and we're joined by Dr. Richard Boland. However, yeah, if you have any burning questions about anything else, feel free to unmute yourself, ask them. We have Shelly who will be helping with the chat. Thank you, Shelly. So if you don't wanna unmute yourself and you'd rather just send your question to the chat, if you can direct those to Shelly Cummings, that would be fantastic, and then she can make sure your questions get answered.
0:01:41.8 TS: These are recorded just to let everyone know, so that's why the recording is on. We have been putting them up for our colleagues who cannot join, and those have been going on the Inside the GENOME Podcast, which you can really get on anything, Apple or Spotify, etcetera, and there's also a link at the bottom of the Myriad Live page here, and then it takes you to all the great content we have up. So anything that says Myriad Live is past recording of one of these, and then anything that doesn't say Myriad Live, just to make things confusing, it's just me doing a podcast usually with someone for about 20 minutes. We just posted this one with a breast surgeon, Dr. Allison DiPasquale, she is fantastic. It's a really interesting one. She discusses, what is it called, Mr. Goodbody. It was some cartoon that got her interested in becoming a doctor. So I've never heard of that before, but feel free to listen and you'll learn about Mr. Goodbody.
0:02:50.0 TS: And yeah, without... Let me go back to the regular side. So we're actually adding some more content in. And then for those that have been listening to these in the past, we've... We were calling it Myriad Oncology Live. It has changed a lot. It was Tuesdays with TJ, when I first started, then it went to Myriad Oncology Live, as we didn't wanna just do it on Tuesdays, and then now it's switching again a little bit. I wanna bring in more genetics content. So instead of just having it on oncology, we're gonna start pulling in some new content, and one of the first will be actually towards the end of March. So we don't have it loaded up here yet, but we'll be... We're setting one up that will actually be focused on spring conference review from the prenatal genetics perspective. We're also looking at probably in May, at least, having something for mental health awareness and genomics of mental health.
0:03:54.8 TS: We still have a large percentage of these being focused around hereditary cancer and oncology, just because that's a bulk of what we do here as a company, but yeah, you'll start noticing some other things sprinkling in. And if you have a topic that you wanna learn more about I mean, let me know, shoot me an email and I can try to find the right people to get on and we can discuss that. So yes, we have... Dr. Boland is joining us, Dr. Rick Boland. So he is a professor of medicine, and he's in the Department of Gastroenterology at UCSD, so in San Diego. Thank you so much for coming on, Dr. Boland. Lauren Straza helped set this up, so I really appreciate both of you coordinating today. Thanks, Lauren. And Dr. Boland, if you wanna tell the audience a little bit about yourself, and I think you are gonna give some historical perspectives. You've seen a lot with Lynch syndrome and then really helped move the field.
0:05:04.2 Rick Boland: Thank you very much, TJ. And if anybody has a question, just unmute yourself and pop right in because I don't have an agenda here. I just wanna tell you an interesting story. So everybody has a reason for why they ended up doing what they did. It might be mundane, it might be more compelling. And in my case, I started medical school in 1969, so I'm actually pretty old. And I went away to medical school, not being very sure of what I wanted to do. At one time, I thought I wanted to be a surgeon, and then I met people in the surgical community, and I realized that wasn't for me. And so at my first year of medical school, the place got shut down. There was a political uprising, there were marches in the street, there was a... They were trying... Bobby Seale is being tried in New Haven. There were bomb threats, all sorts of stuff was going on. We were pretty confused.
0:06:04.9 RB: But during my first year of medical school, my father got sick. I went home for Thanksgiving, and I hugged them to go back to school. And he was a pediatrician in a small town, and he had some pain in his belly. And I said, "What's that?" And he said, "It's nothing." And my mother said, "Oh, he's having a hard time of it." But then she called me up to come home like a day before the Christmas break, and I did that, and he had colon cancer. So he was just 48 at the time, 49. He just turned 49 in that November of 1969. And anyway...
0:06:51.1 RB: He ended up having metastatic disease and died of it the next summer, so I knew that getting a colon cancer at 49 was a little bit young, but then as I began to peel the onion, it got more and more difficult to gather and it became more and more terrifying because... Then I remember is that when he was in... He fought in World War II. In fact, he came from a working class family and ended up going to college on an athletic scholarship and going to medical school on the GI Bill, it was the 12th of 13 kids, and his father worked in an iron factory in Central Pennsylvania, and so after his internship, he went into the war, and then they sent him home. So he's like 26? 25 or 26, and he's got a... He's lost 40 pounds, and he could feel a mass in his belly, and he had a colon cancer.
0:07:49.8 RB: It was a stage three cancer it was operated upon, and so this family story of dad being sick when he was in the army, suddenly turned out to be a colon cancer and then dug a little bit deeper, and his father had a colon cancer in his 20s and died in his 40s, and my great-grandfather died of colon cancer too, and my father, being one of 13 siblings, it turns out 10 of them ended up getting a cancer in their lifetime. So I didn't get all this information at once. It took a while to gather, but it was looking pretty grim, and so I went to... I gathered the information up, and I went to some of my professors in the school of epidemiology and I said, "You know what? This looks an awful a lot like a genetic disease," and they said, "Well, there is only one genetic form of colon cancer that we know about and that's familial polyposis. And there isn't anything else."
0:08:44.2 RB: There was literally one sentence in a pathology textbook that was a reference to Worthen's family G in which they were... They said, I think gastric and endometrial cancers was written up in like 1913. And then there were a couple of follow-ups, but there wasn't anything that was there, and I said, but I said, "Why do you think that all of these people getting colon cancers and if it were just a chance... " They said chance, and they said, colon cancer's a common disease, and periodically this will happen, and I said, "Well, why would they get it so young... If they were getting it by chance, then they should be distributed the way they are in the general population." And they said, "Well, we don't know." And I said, "It sounds genetic to me," and they said, "Well, if you think so," they didn't say, "No, it's that." Then I'll think they believe me, but they said if you think it's something different then go out in prove it, which is probably the right thing to say to me.
0:09:38.4 RB: Instead of saying, "You're really stupid and you're paranoid and you're just upset because your father died," they just said, "Go, go out and prove it." Now, it turns out... So that was like 1970 and '71 when I was having these discussions. Somebody can correct me if I'm wrong about this, but I believe that the... So we knew about a few genetic diseases, we knew about sickle cell disease, and we knew at the protein level what was going on, but we didn't know at the genetic level of any genetic disease, we knew that they were hereditary based upon family pedigrees and such, but to the best of my knowledge, the first time a paper appeared in which a gene was cloned and a mutation was found and it was linked to that disease was in 1986, it was a pediatric disease, interestingly, one of my medical school classmates was on the paper too.
0:10:26.7 TS: Was that retinoblastoma?
0:10:28.6 RB: No, it was just before that. It was... Retinoblastoma was a few months... It was like a chronic granulomatous disease or something like that. And it came out of the pediatrics division, I think at Washington University or something like that. But in any event, it took a long time, of course, then everything started to happen and so much of a hurry, but I'll have to admit to you that in the early '70s, the whole thought that you could ever solve this problem at a genetic level was wildly improbable, and I'm not even sure why I bothered. In fact, for a while I said, I'm not gonna... I'm not gonna pursue this because it's a helpless, hopeless affair, and it wasn't...
0:11:10.4 TS: And you were in medical school at the time?
0:11:12.3 RB: I was in medical school, yeah. So I did an internship, I spent two years in the Indian Health Service. I had this irrational... No, I had this rational fear that I would die young, it wasn't so rational... And so I thought, I'd better do something that leaves... Do some good for humanity before something happens to me, 'cause we weren't doing... In fact, the Chief of Gastroenterology before I left, the chief of Gastroenterology at Yale was guy named Howard Spiro. And he said, "What do you think we should do for this?" I said, "Well, then we must come up with some preventive measures," 'cause I said, "I really think it's a hereditary disease," and he said, "Well, we're never gonna colonoscopy people on a regular basis." And that's the way it was in 1973. So anyways, so I do my Indian Health Service for a couple of years, find out how hard it is to practice primary care with people who are really sick, come back to my internal medicine residency, and then was accepted into a GI Fellowship.
0:12:11.0 RB: And literally on the night of my 30th birthday, I was sitting there and the clock went past midnight my Watch went past midnight and I was reading the New England Journal of medicine, and I laughed and I said, I didn't think I'd reach age 30 alive. And here it is, and then I recognized how stupid I had been to be so afraid of something, and I said, "What are you afraid of?" And the fear I realized was it was not... I had a mixture of fear and anger. And I recognized that the anger was that no one was solving my problem, and I figured, well, I need to solve my problem, so I decided to focus on colon cancer. And one of my goals when I was a GI fellow was to know more about colon cancer, literally than anybody on the planet and that was one of the things I was gonna try to do, which wasn't that hard, nobody cared about that. So anyways, I went into a laboratory and... Oh, let me just show you something here, just for fun.
0:13:11.0 TS: Sure.
0:13:12.6 RB: Share screen. Oops, I don't wanna do that. I don't know what that is...
0:13:24.3 RB: This thing got on my computer recently, and I have no idea what it is. Can you see that now?
0:13:31.5 TS: No.
0:13:35.9 RB: No.
0:13:36.0 RB: Well, I'll just... What I'll show you is that I have a picture of my... So my name is Clement Richard Boland. My father was Clement Boland let me see if that helps.
0:13:46.2 TS: Yeah.
0:13:46.9 RB: Do you see that. Okay. But he had...
0:13:49.8 TS: Yeah, make that PowerPoint, if you can, bigger. If you make it to fill the screen or you can start in presenter mode? Yes. Perfect.
0:13:57.0 RB: Okay.
0:13:57.6 TS: Perfect.
0:13:57.9 RB: So the first... So there have been, to the best of my knowledge, three Clement Bolands on Earth ever. I'm the only Clement Richard Boland that I can find by any kind of search right now. So the first one was my father's uncle, my great uncle, his name was Clement Boland, he joined the US army and he was killed just before the Armistice in France at age 27. And my father was the next male born in the family, so he was named Clement Boland, and he took the name Richard later. Here's my grandfather, and I was told that my grandfather was a chemist by my father, and it turns out that he worked at the furnace, which was an iron mill made pig iron in Robesonia Pennsylvania, Central Pennsylvania. And I saw this picture and my godfather was saying to me showed me this picture, and I took a look at the boots and I said, "What kind of a chemist was he?" Or no, I said, where did he go... Where did Grandpa go to college.
0:15:01.2 RB: He said, "College, are you kidding me?" He said, "Irish boys didn't go to college back then," he was the... He was the guy who became the foreman of the factory, and then he would measure the iron and the carbon and all the rest of that, and so they called him a chemist. So the family always had this upwardly mobile sense of where they might be going in life, and then he had all these kids and he died in his second colon cancer when he was 46. And here's my dad, he went to college in his hometown, and this is about 1938, and you can imagine he was trim and athletic, and when he lost 40 pounds, he looked so grim that my mother went to New York City to pick him up from the army and she couldn't recognize him, and he was too weak to call out to her...
0:15:44.3 TS: Right.
0:15:45.9 RB: And so here's a picture after my grandfather died, and this is my grandmother here and her 13 children. And so what happened was that they just be numbered here one by one, but colon cancer at 33, colon cancer at 33... Colon cancer at 25, that was my dad. He was next to the youngest and he got that and then his sister died while he was recovering from his cancer, endometrial cancer at age 45, multiple... This... My Aunt Helen had... Where is she? Number six? Yeah right here, she had five cancers and she finally died of a gastric cancer, a lung cancer, and he's the oldest male.
0:16:31.6 RB: Uncle Matthew. Colon cancer at age 50, he survived it but died of a heart attack about a couple of years later. And two gastric cancers and she died of the second one. And interestingly, this aunt had two colon cancers found at age 65 and she lived near... She was from Silver Spring, Maryland, and so I got in touch with the Johns Hopkins people and when they picked up her tumor, and we got very confused because she had MSI low, and when we finally solved the problem, we were assuming that she carried the same gene but she did not. She had two sporadic cancers at age 65.
0:17:09.6 TS: Wow. That's amazing.
0:17:10.3 RB: And if you wanna make a tough problem even harder. That's how that happens. So we had a bunch of these cancers in the family, and I suspected that there was an undescribed form of hereditary cancer that they were trying at early ages, but there's nothing like this in the textbooks, so you can get me out of sharing now...
0:17:32.0 TS: I think if you hit stop share.
0:17:34.6 RB: Oh, if I hit stop share. Okay there we go. So anyways, does that look right now?
0:17:39.8 TS: Yeah.
0:17:40.1 RB: Okay.
0:17:40.4 TS: Perfect.
0:17:42.1 RB: So anyways, I decided that I would try to solve this, but there was no systematic approach to genetic cancers at that time, and so I joined the laboratory of a guy named Young Kim, who was doing glycoprotein biochemistry, and he was like the second most highly funded colon cancer researcher in the country, so I decided, even after I had all my clinical... I had actually did my thesis on this and did some laboratory work, and I was trying to chase that essentially, I was doing HLA testing and limited CEA. The HLA was interesting because I was doing HLA typing on everybody in the family, but most of the people who have had cancers were dead already, and if you think about it... So there's lots of different HLA alleles. I was trying to pick one out of 20,000 genes and study and hoping that that would be the one.
0:18:34.0 RB: Now, there was a reason, I think it was maybe... It was actually the HLA gene was important in mouse cancers, and Henry Lynch said to me, "Well, let me just take a look at that," so I did that, but essentially I had a long period of time without any laboratory experience so I went back in, walk into a lab of about 25 people, and within an hour I realized I was the dumbest guy in the room, I didn't know anything about glycoprotein about chemistry. And one of the guys took me aside and said, "So Rick, you look a little intimidated by what's going on here, do you know the difference being glucose and galactose." I said, "I did at one time. Can we go through that one again?" And so I started at the very beginning, and so I did for 11 years, glycoprotein about chemistry and found some interesting things. But they weren't getting me any closer to the hereditary stuff, but then in 1987, so now this is like 14 years out of medical school, I've already... I'm funded, I've got NIH grants and the rest of that to study glycoproteins and...
0:19:34.9 TS: And not related to heredity at that point, just going...
0:19:37.4 RB: No, every time I did a hereditary experiment, it failed, I tried, but no, I didn't have any leads, I didn't have any insight in how to attack the genetic problem.
0:19:45.5 TS: But you had tissue on your family members?
0:19:47.9 RB: Yep. So here's a good one. It was, I forget when the 1980s, I was back home in upstate New York, and I went to the hospital where my father died, and they had done a postmortem exam, and I met with the pathologist there and I said, "Do you have the blocks on his postmortem.?" And he said, "Yes." I said, "What are you gonna do with them?" He said, "Well, in a couple years we're gonna throw them out." I said, "Do you mind if I take them?" He said, "No." He didn't ask for my ID, I had no permission of any kind. I put them into a plastic bag...
0:20:25.2 TS: You seemed honest.
0:20:25.9 RB: What's that?
0:20:27.1 TS: You probably seemed honest.
0:20:31.3 RB: I think the black market for this kind of stuff must have been pretty slim, so he figured I had to have an honest idea about this. I took them. Actually they're just next to me right now. Anyway, there were... In that, they were like... I don't know, 50 blocks or something like that with various parts of the body and several of them were tumor. And eventually, PCR came out in the 1980s, '86, '87, something like that. But also in the summer of 1987, Vogelstein's Lab and a guy named Manual Perusho both found ras mutations in colon cancers. And Perusho found it by hybridization experiments, but Vogelstein did PCR. He didn't call it PCR. And trying to read through the methods was just impossible. Sincerely, I thought, "What is he doing?" He's putting a primer in there and he's running out with DNA polymerase and then he's heating everything up and then he's putting some more stuff back in, back and forth, back and forth.
0:21:38.9 RB: He was doing PCR. And what was interesting was, that really got my notice and then in '88, he came out... Vogelstein came out with multi-step carcinogenesis as a concept for how tumors developed. And then in 1986 or '7, a gene was located for familial polyposis, a patient who had multiple congenital abnormalities had a deletion in 5Q, which led two different labs all working in beautiful harmony to report at the same time in 1991, the APC gene. And so then everybody was looking... So what was...
0:22:16.2 RB: Multi-step carcinogenesis was about mutations paired with loss of heterozygosity. Everybody was using PCR to look for loss of heterozygosity. By 1990, I realized that things had changed and that guys like myself who'd start off with... Now, I've got like 11 years of experience in laboratory. So picking up PCR was not hard. In fact, PCR was easy compared to purifying glycoproteins. I did a sabbatical with a guy named Andy Feinberg, the epigenetics guy, he was at the Howard Hughes at Michigan when I was there. And I learned how to do PCR, and I was micro-dissecting colon cancer specimens and marching all around the tissue to try to find out where the L-O-H loss of heterozygosity events took place. Was it in the normal tissue? Was it in the adenoma? Was it in the cancer? Was it in the transition?
0:23:12.2 RB: And to do that, I remember Andy... We were using various types of variable number tandem repeats, VNTRs. And what was happening, we were preferentially losing the longest of the VNTRs, we realized it was an artifact, and so we had to use something smaller. And so Andy said, "Well, we're gonna have to probably use microsatellites to do this." And I said, "What's a microsatellite?" He said, "Rick, get out of here, get in the library and do some reading." [laughter] That was his response to all of that. So I did, and then we started...
0:23:45.0 RB: I started using the microsatellites and using PCR, and by 1993, I had probably 10,000 PCRs from micro-dissected specimens that I had done, and I had a couple of post-doctoral fellows who were working on it too. And in fact, one of the post-doctoral fellows came to me one day and he said, "Look at this." And it was in an adenomatous polyp, and instead of seeing a loss of heterozygosity events, the microsatellite sequence experienced the deletion and migrated to a different spot on the gel. And I said, "Oh, come on." I said, "What's the likelihood this is real?"
0:24:18.6 RB: I mean, we do sequencing all over the place, and you rarely find a mutation if you're just doing it randomly, and now we're going into this noncoding spot with a microsatellite sequence, I said, "What's the likelihood that this is real? You mixed up the specimens." He said, "Okay." By the way, you should never be this arrogant in front of your fellows. But I thought I knew what I was talking about. I didn't. And then he came back a couple of days later and just holds the auto-radiograph in front of me and it was there, again. And he didn't have to point to it. I saw it. And so I went to a few people, Francis Collins was at Michigan at the time, and Andy Feinberg. I took this to them, and they said, "Well, I don't know what that is." Who knew what that was?
0:25:02.3 RB: Well, it was then in May of 1993, that three laboratories simultaneously reported microsatellite instability, and a certain proportion, somewhere in the mid-teens of colon cancers had this and then Vogelstein's Lab linked it to Lynch syndrome. Along the way, by the way, when I was a medical student, I was doing research on my own family, and I had gone back to Central Pennsylvania, gotten blood and... I was going back and forth and doing those kinds of things. But then when I was a subintern, that's when you're out on the wards and you're for the first time taking care of patients in a hands-on kind of way. A guy came in and he was the 12th of 12 kids in a family and he had a pulmonary embolism, we anticoagulated him. So then we had to check his stool for blood and it was positive for blood, so we sigmoidoscoped him and he had a cancer. And he was the sixth person in his family to get a colon cancer. In 1984, I finally wrote up my family and this other family, and I said, "Well, maybe there's two kinds of hereditary colon cancer, one is just in the colon and the rectum, and the other also involves these other organs, the endometrium and the rest of that."
0:26:20.6 RB: And so I said, sell, I remember somebody said, "You know, if you think you've discovered something, you describe it as completely as you can and then name it." So I called up Henry Lynch, who had been my... He was my adopted father, he was always in touch and he was very helpful, and I said, "Henry, I'm thinking I might wanna call these two different diseases, maybe Lynch syndrome one and Lynch syndrome two." I said, "Do you care?" He said, "No, no, that's fine." No, actually, that wasn't really fair to the people who had described the disease in the past, but Henry was the major living figure who had really done all of this, so that's where that name came from, this paper that I wrote essentially from work when I was an intern, and a resident. So I didn't know any better at it, so the name is not quite exactly accurate, but I love Henry Lynch and I'm glad that he has some recognition for it. I heard somebody say once, isn't it funny that Henry was really principally involved in the BRCA gene story, and they don't call hereditary breast cancer Lynch syndrome, and Henry didn't... Wasn't the first person to describe what we call Lynch syndrome, and it's just one of the ironies of life. It's just the way it goes.
0:27:29.5 TS: That's amazing that you played a role in naming it.
0:27:34.9 RB: Well, I did, and then as time went by, well, it turns out that that other family and my family both had MSH2 mutation, so it was completely wrong, so I didn't do much more with it, and it wasn't until there was a National Cancer Institute workshop in November or December of 1997, where we defined microsatellite instability and wrote a paper, and then we also voted at that time, and said, "If you've got a germline mutation in a DNA mismatch repair gene and you've got familial cancer, that's Lynch syndrome," because we recognized that there are other familial forms that didn't lead to microsatellite instability in the rest of this, so that's what...
0:28:13.1 RB: So then that was when it kind of got resurrected from its resting place from 1984. And so I'm happy with that because at least it gives us a handle on how to refer to these things. So now, meanwhile, I had a cousin who was dying of gastric cancer, she had already had endometrial cancer, and she was the daughter of the oldest of my father's siblings, and there was a family wedding and I was there and I got her blood and sent it back to Michigan, when I was in Ann Arbor, and we made a cell line from that, and that was Trudy. This is all written in a book, she's done... And I don't think I'm violating HIPAA, but frankly, I don't care.
0:28:56.3 RB: It's my family, so I guess I can do that. In any event we sent that back and then we sent some of the cells to Vogelstein's Lab and he was able to look at MSH2 and MLH1 and couldn't find any germline mutations. So that was... But I had also sent him my father's colon cancer block and it was wildly microsatellite unstable, so we knew that it was probably part... So this was in the mid-'90s. So then Vogelstein's Lab did this interesting experiment called reduction of diploid to haploid, and what they do is they took Trudy cells and then they scattered her chromosomes into carrier hamster embryo cell until they were able to get the maternal and the paternal copies of chromosome 2 and others and chromosome 3 into separate cell lines, and one of the cell lines that they made from her cells didn't express MSH2, but there weren't any mutations that were in found in there. So he said, "Well, it's probably a deletion of some sort or some kind of an inversion or whatever, the things that can disable a gene, but it won't give you any sequencing abnormalities." So he said, "Why don't you just clone it?" Well, I hadn't ever cloned it, deletion or something like that, and so that summer...
0:30:31.8 RB: No, that winter, my little sister called me up and said that my nephew, Matt Yurgelun, I suspect some people have heard of Matt Yurgelun that he was a college student and he was thinking about going to medical school and could he come out and do something and she said, see patients with you. I said, "I have a better idea. Let's put him into the lab."
0:30:48.8 RB: So I said, Okay man, you got... So we got this little grant, like a $2500 grant, and he stayed wit h me and we went into work every day, and the lab manager and Matt and I would sit down and talk, and I had initially came up... I came up with this plan that we would just anchor a PCR primer somewhere we knew that the deletion was unlikely to be, and then just march our way along, and I said, eventually, we'll have no PCR product for a while, then we'll get a PCR product, and in the middle of it will be the breakpoint, and then we can clone it. Well, after that, that was what the little grant that I wrote said, but then as Matt came out, my lab manager, Jennifer Reese, who's just a brilliant woman, and she works for one of your competitors now, it's a trend now. But she said, Rick, "I have bad news for you." She said, "The five prime end of MSH2 all the way up to the next gene upstream, which is EpCAM is loaded with Alu sequences." In fact, she said it's so dense, there's, no way that these primers are gonna work, they're gonna land all over the place and it'll be a mess.
0:32:01.2 RB: So to make a long story short, Matt tried a couple of different techniques, he was done with his junior year of college, and I would say to him, have you ever done a PCR before? Yeah, I said, how many... He said, one? Have you ever done a western blot before? Yep. Everything was one that he had done in college. Well, this guy went and figured out how to do something called Panhandle PCR, and six weeks into his project, I was in my office and I could see Matt and Jennifer sitting at the computer and they were reading of A's, C's, D's and G's. And all of a sudden, Matt says very calmly, which is just his style, he said, "We got it." And Jennifer said, "Yep, we do." And I said, You guys have what... So we found the breakpoint, so what they did was they just kept breaking the...
0:32:53.9 RB: The DNA into circularized pieces and then finding one that had a sequence that was nearby MSH2, and then just sequencing through it and he figured it out. So, we went home and had a nice dinner and we were, you know, so delighted. And I said, Matt said, you still have another two weeks. You have to develop a test for this now. I said, which might not be so easy because of all these Alu sequences. Well, the first thing that he tried worked and we had a test for the family. And so then I was getting blood sent in from all over the country for family members. And we did the test... And it was not commercially available. It is now, but it wasn't in 2001 when Matt was doing this.
0:33:34.4 TS: So it's a deletion and MSH like upstream of MSH2?
0:33:38.1 RB: Yeah. It's the deletion starts in intron number six, and it goes up for 39,000 base pairs. So you can imagine, you know, hunting around and trying to scoot your way through this minefield of Alus would not have been very easy, but Matt made it pretty easy. So we were able to do that. And since that day, everybody who got tested and who tested positive and followed the guidelines, and this was 20 years ago, 20, yeah. Going on 21 years ago there have been zero cancer deaths among the carriers of this. So that really makes the point that knowing if you carry this... That the surveillance measures are very effective. So, and then who would ever have guessed that immune checkpoint therapy would be especially effective against these tumors? So, I mean, the world has changed so much.
0:34:32.9 TS: Yeah. Now, it's incredible. And let's see if there's any questions, just to see on the history side, I mean, there was a lot of great detail, you know, I learned a ton in your story.
0:34:47.9 RB: Good.
0:34:49.4 Shelly: We don't have any questions that have been directed to me.
0:34:56.2 TS: Okay. Yeah. People are probably just enjoying, enjoying the story.
0:35:00.4 RB: Wait, I think I got four chats here. Oh, what's panhandle PCR?
0:35:05.9 TS: Looks like Shelly put in a link to something that gives a little bit more detail if people want.
0:35:12.7 RB: Well, interestingly we have not written it up yet. I never wrote that up. And it's one of those things that, you know, Matt deserve some credit for this as does Jennifer. Panhandle PCR, it's like inverse PCRs when you circularize DNA. And then you pull out those little circularized DNA and sequence through it. And panhandle is just a variation on that. And I think it's called panhandle, 'cause you don't entirely close the loop. So you get like a horseshoe. It's been 20 years since we did that, but it was just, it was something he... Matt went to the library and he came up and said, "I have an idea for a slightly different approach other than inverse PCR," which is what he was trying. And I said, "What's that?"
0:35:54.7 RB: He said, panhandle PCR. I said, I never heard of Panhandle PCR. So he explained it to me, but he did it. That's the main thing. And it's just a way of chopping DNA into little pieces and then looking for a breakpoint where you go, when you're sequencing, all of a sudden you jump. And in this case we jumped 39,000 base pairs, which took us a while to figure out because the Alus, so let me just tell you one more, little bit of history here, in like year 2000, they began to build the human genome project. And so they were, you'd get these builds, like build number 5.2 or whatever. And she said, there's something funny about the... We were suspicious of the MSH2 gene because of what Vogelstein had told us. She said, "There's something really funny about the MSH2 gene."
0:36:42.3 RB: She said, you know, "They're cloning, they're putting the human DNA into yeast, into yeast cells and growing them. And so the DNA repair is not so good." She said, "Every time they come up with a new build on this, the gene looks different." It gets rearranged. And then she figured out that it was because that's where all the Alus were so there was a hint that was there because the MSH2 gene looked different every time they put out a new build, because it was getting rearranged in the yeast, artificial chromosome. Was it the yeast or? Yeah. Anyways in the yeast cells, they were just, it was getting.
0:37:22.9 TS: Yeah. Yeah, no, that's interesting. And I see Lauren put your book in too. So if you wanna...
0:37:29.0 RB: I've written on some detail. If anybody wants to buy it. I have like sitting behind me, I've gotten like 200 copies of the book. So just send me an email at email@example.com. And I'll give you one that is cheaper than you can get it on Amazon.
0:37:45.7 TS: And I was gonna ask, so how have you seen, we covered a lot on the genetic side, but how have you seen the management change? And it's interesting about the Lynch one and two, 'cause I vaguely, yeah, there was that concept now where we've merged those more obviously over the years, but, yeah how have you seen your family was able to get screening, you know, I would assume at a time where that was absolutely not conventional. And then, you know, had they kind of have the emergence of guidelines over time and everything?
0:38:15.7 RB: Right. Well, it started in the 1970s where my siblings and I all got barium enemas, which is not a very sensitive way to go after this. And then my first colonoscopy. So at the end of my residency, the head of GI taught me how to do endoscopy. So my last day of residency, like June 30th of 1978, just before I started fellowship, I was actually able to do colonoscopy. So on that last day I came in at 8 o'clock he colonoscoped me. So I had my first colonoscopy then, and then I got up and I put my stuff back on and I colonoscope somebody right afterwards.
0:39:00.6 RB: It was crazy. So then we got into the colonoscopy thing, and the question was, "How often should you do it?" And the data that's coming out of Europe says that in terms of mortality, it doesn't appear to be any difference whether you get it done every year, every other year, or every third year. That may be, but, my older sister, in the book, I've outed my sister, she said it was okay if I talked about her Lynch syndrome 'cause she's had four cancers already, and she said, "It's okay, if people can learn something from me, that's fine." So she gets a colonoscopy and it's negative, and she calls me up, she says, "Rick, I had a negative colonoscopy." And I said, "Good news." And then she said, "But my gastroenterologist told me that my prep wasn't good" and then she laughed. I said, "Sue, that's not funny. That could be a really important mistake." So then she retires. She was a high school counselor. She retires from that and she starts losing weight, and so she calls me. "Hey, Rick!" You know we talk every week. "How are you doing?" "Good, good, good." I said, "What's new?" She said, "Oh, I lost five pounds, and then I lost 10 pounds and then I lost 20 pounds."
0:40:05.0 RB: And I said, "Sue, what's going on here?" I said, "Why are you losing weight?" She said, "Well, I think it's because I'm not eating cookies in the afternoon like I was doing at school." And I said, "I'm not so sure about that." And to make a long story short, it was just 18 months after this quote "negative colonoscopy." I had to call her gastroenterologist several times. I said, "You've got to colonoscope her." He said, "But she had a negative study." I said, "But the prep wasn't good, and she's losing weight."
0:40:30.9 TS: Was it known at the time that, you know, there was a right-sided collocation?
0:40:36.6 RB: Yeah, that was known, like, in the early 70's, really, 'cause we didn't know where the gene was, but when you have... When you have families like mine, and there was a real right-sided predominance there. Anyways, so she gets a colonoscopy. She had a five and a half centimeter cancer in the right colon. So she probably had something that was flat and subtle a year and a half earlier, and it was overlooked 'cause it had stool on it, and the thing is that they grow so much faster and the gastroenterologist didn't understand it. This was the year 2006, maybe, he didn't get that they grew at a different rate and that they could be right-sided, that they could look flat and all the rest of that. So she had, she still, that was like 12 or 13 years ago. She's alive still, and she's had an ileal cancer, she had a rectal cancer, and she's had a breast cancer too, and the breast cancer didn't express MSH2 and had microsatellite instability, so there you have it.
0:41:37.9 TS: And, it had microsatellite instability.
0:41:40.3 RB: It did. Yeah.
0:41:41.1 TS: That's pretty rare for breast cancer.
0:41:42.5 RB: Yeah.
0:41:43.3 TS: It didn't express it. I mean, there was that, I forget who, what study that was, yeah, probably about 15 years ago, looking at breast cancers in patients with Lynch syndrome and, sorry, Shelly, don't go searching for this one 'cause I, maybe Dr. Boland remembers, but about half had either a MSI or loss of immunohistochemistry.
0:42:08.9 RB: If anybody's interested in that, I've got that in my little... In my folder of about 50,000 PDFs, but if anybody is really interested, just send me an email and I'll send that off to you. Yeah, it's about half, yeah, it's just because breast cancer's common, but now that we can test, you know, it's a whole new world.
0:42:29.0 TS: But yeah, there's always been that argument though, is breast cancer part of, is there a susceptibility of breast cancer because of Lynch syndrome?
0:42:38.3 RB: I think there is, just the penetrance is lower.
0:42:40.9 TS: Yeah, yeah, it seems like even in MSH6 is probably the gene thrown around the most, a little bit, in recent circles. I was even doing some work with Fergus Couch and Kara Maxwell was going to, she was pulling MSH6 tumors, and last time I spoke to her I think she would still try to get some at UPenn. But yeah, it does seem like it's probably just a very low penetrance, something that wouldn't necessarily change your screening habits, but I always wonder, we'll pull these, you know, at some point, we'll probably start looking at risk along a continuum of polygenic, not only, like, risk scores, but also pulling in other genes and things like that, and that's probably where a lot of this is happening.
0:43:20.5 RB: Well, you know, women over, so the breast cancers don't occur at a particularly young age, in Lynch syndrome, and so women over 40, I don't even know, should all be getting screened anyway, and my sister's was found just through routine screening.
0:43:33.7 TS: Yeah, no, that's good.
0:43:36.4 RB: And more interesting issue was what to do about gastric cancer, 'cause there have been a number of gastric cancers in my family. My cousin, Trudy, the one uncle who had two gastric cancers, I think there was one more, but in any event, the question is what to do in that. And so I don't think you can make a strong case that you should bring people in and do an upper endoscopy on an annual basis, but if you've colonoscoped somebody, and you've got them already sedated, it only adds five minutes to take a quick look in the upper GI tract, and I think you can't even bill for the second procedure. So there are a lot of reasons why that would be an easy thing to do. Interestingly, several people have... Several people have recommended... Several organizations have recommended doing Helicobacter Pylori testing in the upper GI tract, and yet every time it gets published, there's no link, and I'm shocked. I figured that had to be what would be the environmental trigger, but that doesn't appear to be it. So the recommendations all say "Do an upper endoscopy, maybe, depending upon circumstances," whatever that means, and then check for HP and then treat accordingly. It's probably the other way around.
0:45:00.9 TS: Yeah, that's good. We have some good questions coming in. From Eric, "What is your recommendation regarding aspirin use in Lynch syndrome patients?"
0:45:12.0 RB: Okay, I think aspirin is a great idea in Lynch syndrome.
0:45:16.3 Shelly: A few questions, Dr. Boland in the chat.
0:45:18.7 RB: I beg your pardon? Oh yeah, I saw that actually. I saw it pop up.
0:45:25.0 RB: Anyway. So it was like 1992, a paper was published from the American Cancer Society, in which they were trying to show whether colon cancer was linked to eating meat or whether it was prevented from by eating vegetables. And there were some little hints there, your risk of colon cancer was up by about 25%, if you're in the top quintile of meat eaters. I'm not sure that that would convince most meat eaters not to eat meat if they liked it that much, but in any event, there was something that was there, and they did very little pharmacological data collection, but they did find out that aspirin was really very effective in preventing colon cancer deaths, and the people who took more than 16 aspirin pills a month... This is everybody, so not Lynch syndrome, who took more than 16 pills a month, had a 40% reduction in their colon cancer mortality, and then there was a 5% reduction if they took less than 16 a month. And then, of course, John Burn from Newcastle has subsequently shown in some elegant studies that aspirin does prevent Lynch syndrome tumor deaths, but it takes eight to 10 years before you can see it, so it takes a long time. But when I saw that paper in 1992, I've been taking one 325 milligram aspirin pill a day ever since then.
0:46:50.3 TS: Wow, yeah, that's great.
0:46:54.6 RB: And so I'm a believer in it, and my family members are taking aspirin who do that too, and interestingly, it seems to be pretty safe and people are in their 40s and 50s. The question is, when do you stop? And I don't know when.
0:47:09.8 TS: The bleeding is the potential for ulcers. I have spoken with at least one person who was big in the field and had a patient on 650 milligrams of aspirin who ended up with a pretty good GI bleed from it. Even if I take a baby aspirin a day, my nose starts bleeding.
0:47:32.0 RB: Well, the John Burn Study in Newcastle was 600 mg a day.
0:47:39.4 TS: Yeah, 600 even, which we don't have here, which is tough.
0:47:42.5 RB: They're trying to work out the dose... Yeah, I think it's a good idea though.
0:47:46.1 TS: And last time I spoke with him, I thought he was doing a baby aspirin trial, but I could be wrong.
0:47:50.4 RB: Yeah, they're trying lower doses, so we know that 600 works, and the question is, how low can you go... My guess is you'll just see a graded reduction in prevention as you get with a lower dose.
0:48:02.0 TS: Then we have another question, do you think there'll be more genes, more Lynch syndrome genes, and we didn't really close the loop on the EpCAM discussion then, so... Did Matt then help understand that whole EpCAM deletion because I would say that it's not really a Lynch syndrome gene, it's a gene that has really nothing to do with colon, it's more lung functionality in an embryonic state, if I remember correctly, off the top of my head.
0:48:31.3 RB: But it is expressed in the colon.
0:48:33.4 TS: It is expressed, okay.
0:48:35.2 RB: Yeah, and so the organs that are at risk for cancer are those in which EpCAM is expressed, because what happens is it's a deletion of the stop-codon, and when that stop-codon is read over, you just keep methylating everything downstream, so you end up meth... So we...
0:48:53.8 TS: But you think it's still more that you shut off MSH2, all completely...
0:48:56.7 RB: Oh, yeah completely.
0:49:00.4 TS: Okay, yeah, yeah.
0:49:01.1 RB: That's completely that... In fact, we almost published a paper before EpCAM was found that we found a number of families with methylated MSH2, just like methylated MLH1 that turns out those were all EpCAM families, but we had a bunch of 'em... So look at this germline methylation of MSH2. Well, that's what that's caused by, I never know quite what to say. I've written papers, I've said there's four mismatch repair genes, and I don't think we're gonna find anymore. That's my guess.
0:49:29.0 TS: What do you think about MSH3?
0:49:33.3 RB: Well, you do get, you know the MSH3. I think everybody on here knows that if you get biallelic MSH3 you get a modest form of polyposis.
0:49:44.9 TS: Yeah, honestly, I haven't looked into it. Is there still microsatellite instability in those cases? I don't know, I don't have the answer. I don't know.
0:49:55.7 RB: I don't know the answer to that one.
0:49:57.5 TS: Anyone know was trying to... And, do you think... Where you think... For hereditary cancer in general, do you think we're gonna find any big mover and shaker genes or you think... We found most of them. Do you have an opinion there?
0:50:17.6 RB: I think probably... It's the syndrome X data is what disturbs me. So syndrome X is what Laney Lindor described, and she said, familial clusters of cancer that don't have microsatellite instability, and I kept hoping that there'd be like one gene that was responsible for this, and the problem is there's so many genes, and so many of them seem to be almost private, like one family here, one family there. My guess is that's the way it's gonna be, there's been too many whole genome looks at things that I don't think we're overlooking anything big, but we're probably missing a lot of little things like this and... You know, there was a study, I think it came from Barcelona, not too long ago, where they were trying to look for the familial colorectal cancer type X, and it was like all these different genes were on a big table, and it was interesting because you find one gene that they found three families in Finland and another one, they find two families in Spain, they're probably related, and it might just be one rare thing among the seven billion of us out there, so they might have it, so.
0:51:36.7 TS: Yeah and probably... Yeah, a lot of things are probably low penetrate and yet to be worked out, a discrete family mutations, so things... We just started moving some genes around on our recent panel, and RNF43 and things that are coming off because we just haven't seen significant associations. Yeah, but there's clearly some papers out there, so there's plenty to learn here, but.
0:52:04.5 RB: You know what's interesting is that people say, Well, sequencing has gotten to be cheap, and so we can put more and more genes on the panels, and the problem is... Yeah, it's cheap and it's affordable, and that's the least of the... Not least of the problem, and that's not a major expense, it's working with the information, getting the samples here and there quality control and the rest of that, the real problem is... And then you're gonna get all this information. And what do you do with those, PALB2s? Or what do you do with the colon cancer person with a BRCA mutation. I don't have the answer to that, so it's gonna be up to genetic counselors and geneticists to answer these questions because it's way beyond me to figure out how to manage those people, and I don't like the thought I'm a gastroenterologist by training, I don't like the thought of needless colonoscopies in people who... You could reach the point where you could cause more harm than good by colonoscopy-ing people on a regular basis when they're not gonna get anything.
0:53:02.5 TS: Well, that plays nicely into this other question. Lauren, any comment on new MUTYH? Seeing a lot of these lately... I don't know if you have any thoughts there. Probably assuming you're meeting Lauren Header zygote MUTYH carriers and not MUTYH polyposis, which are two copies of MUTYH not working.
0:53:26.8 RB: We know that there're papers that say that if you're a monoallelic MUTYH mutation carrier, that you have a slight increase in risk for colon cancer, but you don't get polyposis. So I don't get too excited about it. You wanna keep your eye on it, but I don't think it's too common, and it's not responsible for most of these sporadic colon cancers, so I think we need to be careful not to over-react to things so that people will believe us when you find something that's real.
0:54:00.5 TS: Yeah, and yeah, may it function a bit like a single nuclear type polymorphism, there's been some data coming out showing that it probably has an odds ratio of around 1.2 or so it kind of sits in that range, and I think that's where people struggle because usually in the hereditary cancer world, we tend to think of things being actionable from a medical management standpoint of an odds ratio of 2 and above, meaning that it doubles your risk for whatever the cancer type is, and when you have these things in the 1.2 to 1.6 range, it's just... Yeah, what do you make of that? And ultimately, again, those will probably function best in some sort of polygenic type models where maybe you're bringing in other background genomic factors, clinical, family history things to make sense of it as a whole, but we have a ways to go.
0:54:52.2 RB: That risk, that kind of risk is probably similar to someone who has hamburgers four days a week. We don't colonoscope them.
0:55:02.7 TS: Yeah, that's a great point.
0:55:05.3 RB: We advise them to improve their diet, but we don't colonoscope them.
0:55:10.6 TS: We have one more question, and then just to be respectful of everyone's time, I think will close any time I APC moderate risk gene mutation carrier, so I'm assuming the I1307. A lot of breast cancer patients I see are getting positive for it, which means that probably seen a larger population, possibly of asking now Jewish individuals in your practice. Yeah, and she's saying no, family history of colorectal cancer. And saying yes, to all my comments.
0:55:45.8 RB: You know, I've experienced sort of research, Whiplash was I1307K initially it looked like it was a big deal and then maybe not such a big deal, that's another one well... I think it's a bigger risk factor, and than let's say MUTYH monoallelic carriage but I guess...
0:56:06.3 TS: Yeah still, I think it's like that one, five. I can't remember, but that's where I'm thinking of it in my head. Yeah, a little bit higher, but still I'm not quite too it.
0:56:14.5 RB: But there are people who have a I1307K and they end up getting a modest form of polyposis and maybe it's interacting with something else that we haven't figured out yet, it might be...
0:56:26.8 TS: Yeah. It's really interesting... And there's gonna be... I don't know much about the biallelic carriers of that, but there must be plenty, I would think out there, 'cause it's fairly common in certain populations, like Asheknazi Jewish.
0:56:41.4 Shelly: Are we seeing the carrier frequency to be like 8 to 10% in the Ashkenazi population for that finding and I know Myra practice in Manhattan, so Myra, when you asked that question, I was wondering if the patient population was biased towards Asheknazi Jewish patients.
0:57:02.1 TS: Yeah. Yeah, well, great. Well, we're at time. Thank you so much, Dr. Boland. Great generational knowledge. This was just a pleasure to be part of... I hope everyone on here learned, thanks Lauren for helping to coordinate and Shelly for running the chat, we will have this posted in a few weeks at some point on the inside the genome, and yes, we don't have the schedule built out yet, but more... The topics are coming, look for something towards the end of March, I think we're gonna try the last week of March, and we'll do a conference to review abstract review from some of the prenatal conferences, so it'll be kind of the more official first prenatal one, so thanks everyone for coming on and have a great rest of your day. Thank you again, Dr. Boland, so much.