Researchers from Canada’s McGill University have developed a tool that can detect early signs of cachexia in patients with cancer, a condition characterized by muscle loss, anorexia, and weakness that is often associated with poor responses to anticancer therapies, increased hospitalizations, and poses a major burden for patients and their caregivers.

“We are losing many patients, not because of their cancer, but because their bodies have undergone important metabolic changes,” Antonio Vigano, MD, the study’s lead author and director of the Cancer Rehabilitation Program and Cachexia Clinic at McGill University, explained in a statement. 

“In other words, they have simply stopped functioning correctly. In severe stages of cachexia, weight loss becomes very important and nutrients can no longer be absorbed or used properly by cancer patients.”

, assigned 297 patients with advanced gastrointestinal or lung tumors to 1 of a 4-stage classification for cachexia:

The assignments were based on the following 5 routinely available clinical measures and laboratory tests:

Biochemistry (high C-reactive protein or leukocytes, hypoalbuminemia, or anemia)

Moderate weight loss (less than or equal to 5%)

Performance status (Eastern Cooperative Oncology Group Performance Status ≥ 3)

Based on their classification, 36% of patients followed in this study were designated Ca, 21% each were classified PCa and RCa, and 15% as NCa. The authors noted that significant differences were observed among cachexia stages for most of the outcome measures (symptoms, body composition, handgrip strength, emergency room visits, and length of hospital stays) according to cachexia severity (

 <.05). Patient survival also differed between the various stages, except between PCa and Ca.

Despite recent advancements in research, cachexia remains very difficult to alleviate or treat, and researchers hope that a better diagnostic tool will address this unmet need. Patients with cachexia eventually experience a decline of their overall health to a point where it cannot be reversed by eating more or taking nutritional supplements.

“Cachexia gets worse with time and the longer we wait to address it, the harder it is to treat,” said Vigano. "Effectively diagnosing cachexia when still in its early stages can make an enormous difference for a cancer patient’s prognosis and quality of life. In order to save more lives, we need practical and accessible tools that can be effectively used by clinicians in their routine practice to identify patients with cachexia."

The researchers hope their tool will be available for healthcare practitioners within the next few years or sooner and that it can be deployed in other chronic disease settings where patients are negatively impacted by weight loss, such as AIDS and multiple sclerosis. Vigano and his research colleagues are also participating in studies to develop treatments for cachexia.

Vigano AL, Morais JA, Ciutto L, et al. Use of routinely available clinical, nutritional, and functional criteria to classify cachexia in advanced cancer patients [published online November 4, 2016]. 

Surabhi Dangi-Garimella, PhD, is a writer and editor for the American Journal of Managed Care, Evidence-Based Oncology. Read more at 

Articles

Recent development of a tool to detect early signs of cachexia, characterized by muscle loss, anorexia and weakness, in patients with cancer may help with early diagnosis, leading to better prognosis and quality of life.

Cachexia: A Tool to Identify It Earlier May Improve Survival

A new study has found that as women age, they are actually less likely to have baseline bone density testing before embarking on aromatase inhibitor (AI) therapy after breast cancer treatment, even though both increasing age and AI therapy increase fracture risk in postmenopausal women.

NCCN Guidelines recommend that patients have bone mineral density testing before treatment with an AI begins, as well as antiresorptive therapy such as a bisphosphonate to slow down bone loss. These recommendations are not widely followed in practice, however, as researchers from the Medical College of Wisconsin discovered.

The retrospective study searched claims data for Medicare Parts A, B, and D to identify women aged 67 years and older with incident breast cancer in 2006 and 2007 who started AI therapy. The claims data provided the researchers with information on patient demographics, bone density testing, as well as other treatments that they would have received through 2012. Additionally, information on treatment with bisphosphonates, as recommended by NCCN, was included in the evaluation.

Overall, they found that baseline bone density testing was noted in two-thirds of the women, but the rate of testing dwindled with age: 73% of women in the 67- to 70-year age bracket were tested for bone density, compared with only 51% who had crossed the 85-year mark. Treatment with a bisphosphonate to promote resorption also decreased with age, the authors reported.

“This study highlights suboptimal US compliance with guideline recommendations for baseline [bone mineral density] testing when starting AI therapy,” said lead study author John Alan Charlson, MD, in a statement.

Charlson, an associate professor of medicine in the Division of Hematology and Oncology at the Medical College of Wisconsin, added that, “While a larger number of older patients did receive bisphosphonates, this does not explain the disparities in bone density findings, or even substantially change our finding that attending to [bone mineral density] was higher in lower risk, younger women.”

Steven J. Isakoff, MD, PhD, a member of the NCCN Guidelines Panel for Breast Cancer, said the findings are especially important when seen in the context of other studies now suggesting that the risk of bone fracture is even higher in women using AIs than previously recognized:

“Many women may now be using aromatase inhibitors beyond five years, which may further increase the risk of fractures,” Isakoff said in a statement.

“This study highlights that, as a breast cancer community, we need to do a better job screening for bone health, because with proper screening and treatment, many of these fractures can be prevented, particularly in the older patients at highest risk for fractures but who have the lowest rates of bone health screening.”

Charlson J, Smith EC, Smallwood AJ, Laud PW, Neuner JM. Bone mineral density testing disparities among patients with breast cancer prescribed aromatase inhibitors. 

Surabhi Dangi-Garimella, PhD, is a writer and editor for the 

American Journal of Managed Care, Evidence-Based Oncology

A new study has found that as women age, they are actually less like to have baseline bone density testing before embarking on aromatase inhibitor (AI) therapy after breast cancer treatment, even though both increasing age and AI therapy increase fracture risk in postmenopausal women.

Prioritizing Bone Density Screening Before Embarking on AI Therapy After Breast Cancer

The spotlight was on improving palliative cancer care at the opening session of the 2016 NCCN Annual Meeting, with a panel of experts stressing the importance of delivering these services earlier in the cancer care trajectory and involving teams in the effort.

“Palliative care should be introduced as early as possible, even as early as diagnosis, so patients hear about it early and not during a late stage of their disease when they might need hospice,” explained panel member Sophia K. Smith, PhD, MSW, associate professor at the Duke School of Nursing. Having the discussion early on allow patients to take advantage of the range of palliative care services, Smith noted, stressing that hospice is just one form of palliative care.

Indeed, “Palliative care has a lot of different aspects,” acknowledged panel moderator Toby C. Campbell, MD, at the NCCN meeting, which is being held March 31-April 2 in Hollywood, Florida. Campbell said that the practitioner community needs to focus on cutting-edge palliative care, “as we build the infrastructure to meet palliative care needs of cancer patients … upstream from end-of-life care and hospice.”

Campbell, an associate professor of medicine at the University of Wisconsin School of Medicine and Public Health, is both an oncologist and an expert in palliative care. In the panel discussion, he delineated the many levels of palliative care: primary palliative care (such as what primary care doctors provide), secondary palliative care (what all oncologists provide), and tertiary palliative care (expert-level palliative care).

Patients with cancer who are hospitalized in an inpatient oncology unit typically have a relatively short life expectancy, noted Campbell, “but palliative care programs are now moving to ambulatory or outpatient divisions. While most models are referral-based, they are not successful due to high ‘no-show’ rates,” he continued. “Then there are the programs built into the patient’s treatment.”

Finally, “there is also home-based palliative care, which is where I think the future of palliative care is.”

Setting the stage for the morning’s discussion was panelist Shirin Malekpour, PhD, a math educator at the University of Wisconsin-Madison, who, along with her family, cared for her mother, a pediatric hematologist/oncologist based in Iran, after she was diagnosed with stage III ovarian cancer in January of 2012.

“Although my husband was aware of palliative care, being a hematologist himself, and my mom also a doctor, we were so physically and emotionally drained, that we did not know the right questions to ask,” Malekpour said. She added that the medical team at the hospital was underprepared for palliative care.

Malekpour described an incident that occurred during her mother’s treatment: “One night a fellow came late to the hospital when [my mother] was vulnerable and alone. He got a [do not resuscitate] signature from her. It made us really upset…not that we did not agree with her decision. It was just how it was handled.” She said that was the time when they obtained palliative care for her mother, but only because her husband was a part of the team.

Palliative Care Calls for Interdisciplinary Communication

Carri Siedlik, APRN, ACHPN, a nurse practitioner in the Palliative Care Program at the University of Nebraska Fred & Pamela Buffett Cancer Center, noted that discussing palliative care requires a major time commitment, and oncologists often don’t have time to sit down to discuss issues beyond the actual treatment.

“Just looking at what people talk about, the content analysis studies suggest there’s very little redundancy,” between what oncologists discuss and what palliative care specialists bring up with patients, Campbell concurred.

“Palliative care conversations are usually about psychological, emotional, and physical symptoms; goals of care, and coping strategies,” Campbell said. An oncologist’s conversations, on the other hand, would be much more clinical and related to such issues as trials, therapy options, as well as some symptom discussions.

Smith said it is very difficult for oncologists to have all of these conversations with the patient in 15 minutes, a reality that underscores the multidisciplinary aspect of palliative care: “social workers, palliative care experts, oncologists, nurse practitioners … there’s an entire team involved.”

How might this approach affect the patient—oncologist relationship?

It is about building a relationship with the oncologist, replied Siedlik. “Some of them at our hospital do see us as a threat. I always make sure, though, that the oncologist is comfortable with my role … I have built that relationship with them.”

Maria Dans, MD, who serves as Director of Palliative Care Services at the Siteman Cancer Center at Barnes-Jewish Hospital in St. Louis, agreed, explaining that she always consults with her patient’s physicians. “I definitely do not want to threaten that relationship. I also find it helpful to open the conversation with the patient or the family, as well, if I tell them I spoke to their primary doctor,” she continued.

“I always try to separate my oncology hat from my palliative care hat to ensure I don’t tread on the primary oncologist’s realm,” Campbell said. Rather, he asks the patients to share what their primary oncologist recommended in terms of their clinical care.

An audience poll during the session elicited another potential barrier to delivering palliative care: patients may want to give up their clinical treatment.

“We found that patients were more likely to participate in a clinical trial if they were seeing a palliative care specialist,” Campbell said in response to the poll results. “So, at the University of Wisconsin, we have found a flip side to what the audience identified as a barrier.”

Finances can be another stressor in the patient care continuum and should be factored into other patient symptoms as part of palliative care discussions. Campbell noted that when financial toxicity is included along with other physical symptoms (for example as part of a distress thermometer, Smith added), it encourages patients to open up about their financial distress.

, a program which educates patients on four typical conversations on palliative care. It provides online content and group-facilitated meetings led by a social worker. Patients can conveniently get together with their peers, online. The end goal, Smith explained, is not only to improve the situation for patients and caregivers, but also to enhance their communication with providers.

If it’s done right, Smith summed up, “Palliative care really takes place across providers, by a multidisciplinary team focused on the entire patient, and not just their disease.”

American Journal of Managed Care, Evidence-Based Oncology.

The spotlight was on improving palliative cancer care at the opening session of the 2016 NCCN Annual Meeting, with a panel of experts stressing the importance of delivering these services earlier in the cancer care trajectory and involving teams in the effort. 

Palliative Care Should Begin Early and Engage a Multidisciplinary Team

 finds that cancer has a devastating and age-specific impact on the finances of young adult (YA) survivors, and increased dialogue between healthcare providers and YAs has the potential to empower this population at risk for adverse financial and psychosocial outcomes, and steer them towards reputable sources of financial support.

 from 2007 to 2013, based on grant applications submitted to the organization during that period. The Samfund awarded between 100 and 120 grants annually during that time period, to applicants who were between 17 and 35 years of age till 2012 and aged 21 to 39 years in or after 2013. Eligibility requirements for application defined 

 as patients who were free of cancer for at least a year after completion of their treatment, in remission, or on maintenance therapy.

To quantify the financial burden of cancer in YAs, a retrospective analysis was performed of the data collected from 334 of the applicants who consented to participate in the study.

“We had a vast repository of program data from the past several years, and we knew this was an important story to tell because of the lack of a spotlight on young adults facing financial toxicity,” said Michelle Landwehr, MPH , chief operating officer at The Samfund and lead author of the study.

“While the recent Fred Hutchinson study

 brought additional notice to the financial difficulty faced by the cancer population at large, we rarely see anything that shows what the young adult population is dealing with.”

“We hear all the time from young adult survivors who have told us, anecdotally, that the subject of cost never even came up with their doctors; oftentimes they cope by completely ignoring the topic or otherwise they stress about it all the way through their treatment and long after, which is the last thing they need,” Landwehr added.

In addition to the cost of medication, hospital bills, copays and related treatment necessities, young adults are particularly affected by their station in life: they may have student loans, no established credit, and have no health benefits from jobs that they may have just started, if they are working at all. Oftentimes, this population has had to stop work while undergoing treatment and has no income, while their bills continue to pile up and multiply. Given their age and life stage, they likely lack parental support but haven’t yet established significant savings of their own.

The analysis found a substantial financial burden among the study participants, who had significantly lower median income, greater out-of-pocket expenses, and lower net worth than YAs of similar age, the authors write, with the greatest burden observed among YAs older than 30 years of age—lesser parental support, dependent children, and home ownership were the likely causes of their financial hardships. Medical expenses increased with age and so did credit card debt among the older YAs.

“We found that financial indicators of young adult cancer survivors are worse than their healthy peers in many domains. Further, young adult survivors in their 30s report more perilous pre-funding financial situations than younger grant recipients, who may be covered by their parents’ insurance policies,” said Rebecca Johnson, MD, senior author of the paper.

Landwehr MS, Watson SE, Macpherson CF, et al. The cost of cancer: a retrospective analysis of the financial impact of cancer on young adults [published online before print February 7, 2016]. 

Ramsey SD, Bansal A, Fedorenko CR, et al. Financial insolvency as a risk factor for early mortality among patients with cancer [published online before print January 25, 2016]. 

Surabhi Dangi-Garimella, PhD, is a writer and editor for the American Journal of Managed Care, Evidence- Based Oncology. Read more at 

A paper in Cancer Medicine finds that cancer has a devastating and age-specific impact on the finances of young adult survivors, and increased dialogue between healthcare providers and YAs has the potential to empower this population at risk for adverse financial and psychosocial outcomes, and steer them towards reputable sources of financial support.

Young Adults With Cancer Need More Dialogue With Providers on Costs

Oral contraceptives may provide long-term protection against endometrial cancer, according to research conducted by the Collaborative Group on Epidemiological Studies on Endometrial Cancer. The study found that as many as 400,000 cases of endometrial cancer may have been prevented in developed countries since 1965, including about 200,000 in the last decade (2005-2014).

“The strong protective effect of oral contraceptives against endometrial cancer—which persists for decades after stopping the pill&mdash;means that women who use it when they are in their 20s or even younger continue to benefit into their 50s and older, when cancer becomes more common,” study author Valerie Beral, DBE, AC, MA, FRS, a professor at the University of Oxford in the UK, said in a statement.

“Previous research has shown that the pill also protects against ovarian cancer, Beral added. “People used to worry that the pill might cause cancer, but in the long term the pill reduces the risk of getting cancer.”

The American Cancer Society estimates that more than 10,000 women will die of uterine cancers in the United States in 2015. The incidence of endometrial cancer is rare in women younger than 45 years of age, with the risk of disease increasing in women 55 years and older.

For their study, researchers combined data on 27,276 women with endometrial cancer from 36 epidemiological studies from North America, Europe, Asia, Australia, and South Africa. The median age of the women in the study was 63 years, and the median year of diagnosis was 2001. While 35% of the 27,276 cases reported using oral contraception for a median of 3 years, 39% of the more than 115,500 controls had used oral contraceptives for a median duration of 4.4 years.

The analysis revealed that every 5 years of oral contraceptive use reduced the risk of endometrial cancer by about 25%, and the reduction of risk persisted for more than 30 years after the women had stopped using the contraceptive agent. In high-income countries, 10 years of oral contraceptive use reduced the risk of developing endometrial cancer before age 75 from 2.3 to 1.3 cases per 100 users, the authors found. However, the risk reduction varied by tumor type—it was stronger for carcinomas than sarcomas.

Considering that estrogen levels in pills in the early decades were double those in contraceptive pills manufactured today, the reduction in risk was comparable, which suggests that the amount of hormones in the lower dose pills is still sufficient to reduce the incidence of endometrial cancer, according to the authors.

The proportional risk reduction did not vary substantially by women’s reproductive history, adiposity (amount of body fat), alcohol use, tobacco use, or ethnicity.

In an accompanying commentary in the journal, Nicolas Wentzensen, MD, PhD, and Amy Berrington de González, D.Phil, from the Division of Cancer Epidemiology and Genetics at the National Institutes of Health, discussed other ongoing studies examining the use of oral contraceptives as chemoprevention in women carrying 

“Even if the biological mechanisms remain elusive and the existing evidence falls short of wider recommendations for chemoprevention, women need to be more aware of the unintended benefits and the risks of oral contraceptives, so that they can make informed decisions,” they wrote.

	Collaborative Group on Epidemiological Studies on Endometrial Cancer. Endometrial cancer and oral contraceptives: an individual participant meta-analysis of 27,276 women with endometrial cancer from 36 epidemiological studies [published online August 5, 2015]. 

Oral contraceptives may provide long-term protection against endometrial cancer.

Study Finds Oral Contraceptive Use Beneficial in Preventing Endometrial Cancer

Oncology practitioners now have several resources to consult for advice on genetic testing for their patients following the US Preventive Services Task Force (USPSTF) December 2013 update of its 2005 BRCA recommendations, plus new recommendations from the American Socieity of Clinical Oncology (ASCO) announced in February and published in the 

The USPSTF recommends that women whose family members have been diagnosed with breast, ovarian, tubal, or peritoneal cancers be screened to identify a family history that may be associated with an increased risk of potentially harmful mutations in 

Women with positive screening results are advised to undergo genetic testing, but only following genetic counseling. Further, women who lack a family history of an increased risk for BRCA mutations are specifically advised against genetic counseling or BRCA testing (

The current task force recommendations are aimed at women previously undiagnosed with breast or ovarian cancer, but with a familial history. Ellen T. Matloff, MS, CGC, director of Cancer Genetic Counseling at the Yale Cancer Center in New Haven, Connecticut, believes that, “These prevention guidelines should include patients, male and female, who are cancer survivors and would like to prevent the development of a future primary cancer.”

Numerous studies have documented an increased risk of cancer among men with

 mutations. A study conducted among male breast cancer patients in Canada found a strong association between familial history (at least one first- or second-degree relative with breast cancer), 

 mutation (2 of 14 pa - tients), and a previous history of other cancers prior to the breast cancer diagnosis,

 whereas another study of Ashkenazi men found an increased risk of prostate cancer in 

 A recent study recognized poor overall survival in 

mutationcarrying prostate cancer patients with multiple breast cancer relatives.

Working in collaboration with the nonprofit organization Facing Our Risk of Cancer Empowered (FORCE), Matloff raised concerns and made suggestions to the USPSTF regarding the reach of the current guidelines. However, the task force responded that recommendations for cancer survivors, although important, would encompass disease management, which falls outside of the scope of their current recommendations.

“The guidelines stress throughout that women should have genetic counseling and testing,” continued Matloff. “Unfortunately, this perpetuates a pervasive and dangerous myth in the patient, lay, and medical communities that a family history of breast and ovarian cancer somehow applies only to women.”

“A male who is a BRCA carrier may have daughters, granddaughters, and other female relatives at risk who can be helped by identifying the

 mutation in the family. We should not discriminate against males and should offer them the genetic counseling and testing services available to women.”

ASCO’s recommendations for hereditary risk assessment are the first to focus on family history—taking specifically in oncology to help determine patients’ personal genetic risk for cancer, the organization notes. The statement, developed by ASCO’s Genetics Subcommittee, is aimed at helping oncology providers to

		Provide guidance regarding interpretation and next steps

		Identify current barriers to accurate family history—taking and interpretation

For patients with cancer, ASCO recommends determining, at a minimum, whether there is any history of cancer in first- and second- degree relatives. First-degree relatives include parents, children, and full siblings. Second-degree relatives include grandparents, aunts/ uncles, nieces/nephews, grandchildren, and half-siblings. For each relative with cancer, ASCO recommends recording age at diagnosis and type of primary cancer(s).

Patients should be asked specifically if there is a known hereditary cancer predisposition syndrome, if there has been prior genetic testing, and for any information regarding ethnicmulity that may be relevant, since a lower threshold for testing could be warranted in some situations. ASCO further recommends that the family history be recorded at a patient’s initial visit to the oncology provider, and be reassessed if new information about family members diagnosed with cancer becomes available.

“Genetic factors are a key component of precision medicine because they can unlock important information that can help an oncologist determine the best course of individualized treatment,” said ASCO President Clifford A. Hudis, MD, FACP, in a press release an - nouncing the recommendations. “An adequate family history is key to identifying those patients whose cancer may be associated with inherited genetic factors.”

The ASCO guidelines mirror the importance placed on counseling by the USPSTF update. They recommend pre-and post-test counseling for the patient, and an open communication channel that provides detailed information to the patient to familiarize him or her with the process and the implications for both the patient and his or her relatives. The USPSTF update directs clinicians to use electronic data tools that can be directly used by the patient and can alleviate some of the physician workload.

ASCO’s patient website has a variety of resources to assist in facilitating patient histories available at http://www.cancer.net/ genetics, and the organization is planning to provide a comprehensive update of cancer genetics, including family history assessment, at its 2014 annual meeting in Chicago May 30-June 3.

The current recommendations stress the need for genetic counseling in women found to be at an increased risk of 

 mutation. A study conducted at the Yale Cancer Center, with Matloff as the senior author, highlighted the negative outcomes of cancer genetic testing without a qualified counselor on board and identified the following patterns:

The study recommended education programs for healthcare providers in addition to an increased collaboration between the providers and genetic counselors.

 Matloff emphasized the importance of board-certified counselors: “Without accurate ordering, interpretation, and appropriate recommendations, these data are meaningless or harmful to the patient and the entire family.”

A panel discussion convened last year by The American Journal of Managed Care brought together genetic counselors, the chief medical officer of the American Cancer Society, and the national medical officer from Cigna.

 The panel members discussed the need for promoting awareness on the implications of testing, and also the increasingly important role played by genetic counselors in ordering the right tests and the accurate interpretation of results. The panel emphasized that the providers (both physicians and nurses) who consult with patients have limited genetic knowledge and that there is a rising need for board-certified genetic counselors. The consensus reached by the panel corroborates the current USPSTF recommendations.

Medicare recently announced that it will cut the reimbursement for BRCA1 and BRCA2 testing by 50% (down to $1440 in 2014 from $2795 in 2013).

 This is a result of new competition afforded to Myriad Genetics by other companies (eg, Quest Diagnostics, Ambry Genetics) that marketed their own tests. Most insurance companies cover the cost of genetic testing recommended by a healthcare provider.

Additionally, the Affordable Care Act mandates coverage for testing when recommended by a healthcare provider, as well as counseling to help decide a preventive course of medication to lower the risk of breast cancer.

 ASCO’s Hudis noted the organization’s concern that many insurers do not adequately reimburse for the time required to take a full cancer family history: “An increase in reimbursement for this service would help providers—many of whom are already timechallenged by the current fee-for-service reimbursement structure&mdash;devote the additional time needed to perform this important component of high-quality cancer care.”

		Figure. Recommendations by the USPSTF based on familial history

			Nelson HD, Fu R, Goddard K, et al. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. http://www.ncbi.nlm.nih.gov/books/NBK179201/. Accessed March 3, 2014.

			Wolpert N, Warner E, Seminsky MF, Futreal A, Narod SA. Prevalence of BRCA1 and BRCA2 mutations in male breast cancer patients in Canada. 

			Kirchhoff T, Kauff ND, Mitra N, et al. BRCA mutations and risk of prostate cancer in Ashkenazi Jews. 

			Thorne H, Willems AJ, Niedermayr E, et al. Decreased prostate cancer-specific survival of men with BRCA2 mutations from multiple breast cancer families. 

			FORCE. Updated Response to USPSTF Guidelines on BRCA Testing. www.facingourrisk.org. http://www.facingourrisk.org/advocacy/ current_action/USPSTF_draft_guidelines_hboc.php. Accessed February 4, 2014.

			Lu KH, Wood ME, Daniels M, et al. American Society of Clinical Oncology Expert Statement: Collection and Use of a Cancer Family History for Oncology Providers. 

			Brierley KL, Campfield D, Ducaine W, et al. Errors in delivery of cancer genetics services: implications for practice. 

			Beagin N. Genetic testing should come with counseling: American Cancer Society CMO, Supreme Court plaintiff among experts who warn of consumer risks. 

			McCarthy M. Medicare slashes payment for BRCA test. 

			Susan G. Komen. Testing for BRCA1 and BRCA2 mutations. http://ww5.komen.org/Content.aspx?id=5332&terms=BRCA. Accessed January 28, 2014.

Oncology practitioners now have several resources to consult for advice on genetic testing for their patients following the US Preventive Services Task Force (USPSTF) December 2013 update of its 2005 BRCA recommendations, plus new recommendations from the American Socieity of Clinical Oncology (ASCO) announced in February and published in the Journal of Clinical Oncology.