type of cancer yourself/parents/
brothers/
sisters/children
age at
diagnosis
(estimates
are OK)
extended family
(mother’s side)
Aunts/Uncles/Cousins/
Grandparents /Other
age at
diagnosis
(estimates
are OK)
extended family
(father’s side)
Aunts/Uncles/Cousins/
Grandparents /Other
age at
diagnosis
(estimates
are OK)
o
EXAMPLE:
Prostate Cancer
Me 56 Father
Uncle
60
64
o
PROSTATE
CANCER
o
BREAST CANCER
(in women or men)
o
OVARIAN CANCER
(including Fallopian
tube/peritoneal)
o
PANCREATIC
CANCER
o
KIDNEY (RENAL)
CANCER
o
COLORECTAL
CANCER
o
UTERINE
(ENDOMETRIAL)
CANCER
o
OTHER CANCER
Type:
o
OTHER CANCER
Type:
o My family’s heritage is Ashkenazi Jewish (an ethnic background that can have a higher likelihood of hereditary cancer)
o I, or someone in my family, have had genetic testing for a hereditary cancer syndrome. Please describe below.
ü
Hereditary Urologic Cancer
Questionnaire
(to be completed by patients)
patient name
date of birth today’s date
Instructions: This is a screening tool to help your healthcare provider determine if you would benefit from hereditary urologic cancer genetic
testing. Your healthcare provider will review this form looking for any risk factors for a hereditary cancer syndrome such as similar types of cancer
running in the family, cancers diagnosed at young ages, or multiple cancer diagnoses in the same person. You may also use the “My Family
History” tool to complete this information online at ambrygen.com/patient.
does cancer run in your family? Check those that apply.
Please fill this form out to the best of your ability. Please only consider family members related to you by blood, such as your parents, grandparents,
children, brothers, sisters, aunts, uncles, and cousins. If you share only one parent with a brother or sister, please indicate that.
50339.3945_v4 | 05.22.18
15 Argonaut, Aliso Viejo, CA 92656 USA Toll Free +1 866 262 7943 Fax +1 949 900 5501 ambrygen.com
patient’s personal & family history tumor-specific panels comprehensive panels
Hereditary Prostate Cancer
o
Prostate cancer <50y
ProstateNext CancerNext
o
Multiple primary cancers (e.g. prostate and male breast)
o
Metastatic prostate cancer at any age
A personal history of prostate cancer (Gleason score >7) at any age AND at least 1 of the following:
o
>2 family members
2
with prostate cancer at any age*
ProstateNext CancerNext
o
>1 family member
2
with breast cancer <50y or ovarian cancer (includes Fallopian tube/
peritoneal) at any age*
o
>2 family members
2
with breast, prostate, and/or pancreatic cancer at any age*
No personal history of prostate cancer AND at least 1 of the following:
o
>3 family members
2
with prostate cancer (Gleason score >7) at any age*
ProstateNext CancerNext
o
>1 family member
2
with breast cancer at <45y or ovarian cancer (includes Fallopian
tube/peritoneal) at any age*
o
>3 family members
2
with any combination of prostate (Gleason score >7), breast, or
pancreatic cancers at any age*
Hereditary Kidney Cancer
o
Kidney cancer <46y or multiple primary kidney cancers
RenalNext CancerNext-Expanded
o
>3 family members
2
with kidney cancer
Lynch Syndrome^
o
Personal history of colorectal or uterine cancer <50y OR personal history of more
than one Lynch syndrome cancer
3
(like colorectal AND upper urinary tract cancer)
at any age
CancerNext
o
Personal history of colorectal cancer at any age and >2 family members
2
with Lynch
syndrome cancers
3
o
>3 family members
2
with colorectal, uterine, ovarian, or other Lynch syndrome cancers
3
*Meets National Comprehensive Cancer Network® (NCCN®) genetic testing guidelines for BRCA1/2, therefore, testing of only these two genes may be considered.
^Genetic testing for Lynch syndrome is indicated in these situations, therefore, testing of MLH1, MSH2, MSH6, PMS2, and EPCAM only may be considered.
1
This is a suggested list; not comprehensive. There are other situations where genetic testing may be appropriate. Other single gene and panel tests are available at ambrygen.com/cancer.
2
On the same side of the family
3
Lynch syndrome cancers include: colorectal, uterine, stomach, ovarian, small bowel, hepatobiliary tract, upper urinary tract, brain, pancreatic, and sebaceous
:
• Tumor-Specific Panel: These tests simultaneously analyze multiple genes based on a particular type of cancer/tumor. There may be published management
guidelines for some or all of the genes, and these tests are often chosen if the patient/family cancer history is suspicious for multiple syndromes.
• Comprehensive Panel: These tests are more comprehensive and provide the greatest chance of identifying a mutation. Since there are more genes included
on these tests, the variant of unknown significance (VUS) rates are higher and some genes do not have published management guidelines.
Possible Genetic Testing Indications and Testing Options
1
(to be completed by healthcare provider)
