I launched my first cloud server literally while in the clouds in May 2014. Cloud computing has changed so much, it’s unbelievable. Back then, I had to patch the Linux kernel by hand so that the ftp server would work on AWS. Today, uploading your genome using Amazon’s command line interface (CLI) to an AWS S3 storage bucket is relatively easy. Understandably, Amazon makes it challenging (but doable) to make your storage publicly available. I used the Apache Web Server and s3fs to share this information.
s3fs allows allows you to mount an S3 bucket via FUSE. s3fs preserves the native object format for files, allowing use of other tools like AWS CLI. Again, your commands may vary depending on your flavor of Linux. Here are the commands I used to install s3fs.
Great news! Six months have passed since Kimberly finished radiation therapy for breast cancer. Today, she had a follow-up diagnostic mammogram that confirmed she is cancer-free! She will continue to be monitored over the next 5 years, but our big worries are behind us. Incidentally, we learned about a useful website during our journey, cancersurvivalrates.com that gave us a much better picture of survival rates.
Hereditary cancer screening
Let’s finish by returning to the variant in the APC gene that we found during expanded genetic testing and wrap-up this series.
During genetic testing, our genetic counselor ordered an additional gene panel to screen for other cancers due to Kimberly’s family history. As I mentioned earlier, our insurance company denied all of our genetic testing claims, saying that the expanded panel was not related to her breast cancer. Nevertheless, the information that we received was worth the $250 out-of-pocket expense. Given the lack of reimbursement, reasonable costs for clinical genetic testing will ultimately drive most of it to be physician-ordered but privately paid. Just be sure to get your data!
So, what did we learn?
As we know from autosomal dominant inheritance, a person affected by an autosomal dominant disorder has a 50 percent chance of passing the mutated gene to each child. And sure enough, we saw the APC gene variant in 1 of our 2 adult-aged children; the other child does not carry it. We know this because we have whole genome sequences for everyone in our family. Here’s what Kimberly’s genetic code looks like at this location:
It turns out that this variant increases the risk of colorectal cancer from 5% (found in the general population) to 10% (in the population with this variant). So, the child with the variant should have a colonoscopy at age 40 (earlier than usual) and follow-up colonoscopies every 5 years after that. If you have a APC gene variant, talk to a genetic counselor–and show them some love! Note: This blog is not intended to replace advice from a medical professional.
Before publishing this story, we had a family meeting to discuss Mom’s cancer-free diagnosis, as well as the APC variant that one of them carries. All of us agreed to share this information with hopes that it will assist others.
Along the way, we learned that knowledge gave us the strength to move forward. I also have newfound appreciation for my wife, whose bravery knows no bounds.
One month after surgery, Kimberly began radiation therapy, which is designed to reduce the recurrence of breast cancer after surgery by more than half. We met with a radiation oncologist and developed a 15-visit treatment plan. The cost of Kimberly’s radiation therapy was about $25,000, and fortunately our health insurance covered about 90%.
Radiation therapy and genetics have a curious relationship. The basic idea behind radiotherapy is to induce double-strand breaks in DNA with ionizing radiation. Although radiation damages both normal cells and cancer cells, most normal cells repair themselves, while cancer cells do not. Therapy is given in daily doses to allow the DNA in healthy cells to recover between visits.
External beam radiotherapy based on linear accelerators has been available since the early 1950s, and machines like the Varian Clinac above deliver a shaped beam of high-energy x-rays to a precisely targeted area. In Kimberly’s case, a surgeon had removed her tumor 1 month prior, so the target area was the breast where the surgery occurred–just in case a single errant cancer cell had wandered from the surgical site.
We made daily visits for several weeks and Kimberly tolerated the procedure well. On her right side she had what looked like a sunburn, a common side effect, that faded over the next month. We continued to have follow-up visits with both her medical and radiation oncologists.
A few days after finishing radiation therapy, we visited the Varian production plant in Palo Alto, California. It was fascinating to see the construction of these behemoth machines and learn more about their operation. (My favorite part was learning that the electron linear accelerator tube is tuned with a ball peen hammer.) As luck would have it, all of this activity occurred just 1 week before the COVID-19 shelter-in-place order hit the San Francisco Bay area in March 2020.
We spent the next 6 months not only sheltering-in-place, but also waiting for her follow-up mammogram to determine if radiation therapy was successful.
The day after Kimberly received her breast cancer diagnosis, we met with a board-certified genetic nurse, Frank. Before our visit, we completed a form that Frank used to create a family pedigree. The list below is not a pedigree, but it shows the history of cancer in Kimberly’s family. We removed kinship for privacy:
Breast cancer (maternal side: 1, paternal side: 1)
Lung/bone cancer (paternal: 3)
Cervical cancer (maternal: 1)
Colon cancer (paternal: 1)
Liver cancer (paternal: 2)
Kidney/bone cancer (paternal: 1)
Esophageal cancer (paternal: 1)
It turns out that 5-10% of cancer is inherited. People who carry hereditary mutations do not necessarily get cancer, but their lifetime risk is higher than average. Genetic counselors use pedigree charts to visualize family history and evaluate when genetic testing adds diagnostic value. Kimberly’s family history met lab guidelines for further evaluation, so Frank ordered a gene panel from a nearby lab, Invitae. The blood test was ordered stat, and we received our results six business days later. Treatment plans can change based on genetic results, so we were grateful to receive results before her surgery, which was now scheduled.
We returned to Frank’s office and first learned that she does not carry mutations in 9 genes known to influence the risk of breast cancer: ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, STK11, and ΤΡ53. Phew! Invitae also provides free hereditary cancer testing to breast cancer patients at no additional charge (as long as you order the expanded panel within 90 days of the original test), so Frank ordered the expanded panel. Given that Kimberly has a family history of other hereditary cancers, we welcomed a broader genetic search. The results could be meaningful not only to us, but also to other living relatives. Oddly, our insurance company rejected all of our genetic testing claims because the resubmission was not related to her breast cancer diagnosis. I discussed the situation with Invitae and they were very accommodating–our total out-of-pocket cost was $250. I am still mad at our insurance company, but that’s a rant for another day.
Although she did not have any mutations related to breast cancer, Kimberly’s expanded genetic testing revealed a point mutation in the APC gene, which is known to increase the risk of colorectal cancer. People with this variant are generally counseled to have their first colonoscopy at age 40 (she did that) and follow-up colonoscopies every 5 years (coming up). Since the APC I1307K variant is autosomal dominant, close relatives such as siblings and children have a 1 in 2 chance of inheriting an APC mutation. We called Kimberly’s sister and shared our findings, part of a cascade testing strategy. We also have our kid’s whole genome sequences, which will let us check for APC mutations directly. We will return to that search in part 4 of this series.
We left Frank’s office and developed a treatment plan with Kimberly’s surgeon and medical oncologist a few days later. The plan included surgery (lumpectomy) followed by radiation therapy. Surgery was successful, as you can see in the before and after images below. (Special thanks to the Horos Project for the open source DICOM viewer.)
Kimberly received her diagnosis the day after Thanksgiving. In the 18 days that followed, we had 16 medical appointments that took us from diagnostic mammogram to surgery. With surgery behind us, Christmas was now six days away. We spent a quiet holiday with the kids.
We began 2020 hopeful, knowing that her type 1A tumor had been successfully removed by her surgeon. We were also much more knowledgeable about hereditary cancer risks due to Frank’s counseling.
One month later, Kimberly would begin radiation therapy to dramatically decrease her chance of recurrence.
It was the day after Thanksgiving. My wife Kimberly was talking with a nurse about the results from a biopsy performed 2 days earlier. She hung up her mobile phone and burst into tears. Kimberly received the call while we were exiting the gates of Leavenworth National Cemetary in Kansas, where we had just laid my mother-in-law Barbara to rest with her husband, Gilbert. Our kids were in the back seat and did not really know what was going on, but they guessed that mom had cancer.
The week prior, Kimberly had a diagnostic mammogram, and the radiologist told us in person that Kimberly had a suspicious lesion in her right breast (larger than a peppercorn, smaller than a pea) and recommended a biopsy. Luckily, a biopsy appointment was available the day before Thanksgiving, and we took it even though we were flying to Kansas City the next day. We asked the care coordinator to call us as soon as she had preliminary pathology results, and she did. Our family flew home to the San Francisco Bay area on Sunday.
On Monday, Kimberly and I visited the medical oncology department of a nearby clinic. The nurse said that Kimberly had invasive ductal carcinoma. Surprisingly, the rest of the visit did not turn into that dull surreal buzz that often accompanies bad news and drowns out everything else. In our case, years of being in rooms like this one discussing the needs of our exceptional children proved immensely useful. I took notes and Kimberly asked incisive questions about treatment options, radiation therapy, and genetic counseling. The nurse patched-in our long time family physician over the phone, and his presence was very assuring. It was a brief respite from what would become an overwhelming 3 month journey–the first 2-3 weeks especially so. We learned about a bewildering array of cancer treatment options, visited competing medical facilities, and evaluated new doctors.
Those odds were not good, and I had multiple panic attacks over the next few weeks at the thought of losing my wife. “Hang in there. Moment by moment,” a friend texted to me. I read that message over and over, hanging on.