Please indicate family members including which side of family (i.e., maternal or
paternal):
At least one close blood relative with ovarian cancer at any age
Please indicate family members including which side of family (i.e., maternal or
paternal):
At least two close blood relatives on the same side of the family with pancreatic and/or
prostate cancer (Gleason score ≥7) at any age
Please indicate family members including which side of family (i.e., maternal or
paternal) and Gleason score:
Close male blood relative with breast cancer
Please indicate family members including which side of family (i.e. maternal or
paternal):
At least one close blood relative who has a BRCA1 or BRCA2 mutation (testing should be
targeted to the known BRCA1/BRCA2 mutation in the family; further BRCA1/BRCA2
testing should only be pursued if the results are negative and the member otherwise meets
testing criteria)
Please indicate family members including which side of family (i.e., maternal or
paternal):
Ashkenazi Jewish or ethnic groups associated with founder mutations. Testing for
Ashkenazi Jewish founder-specific mutations should be performed first. Further
BRCA1/BRCA2 testing should only be pursued if the results are negative and the member
otherwise meets testing criteria without considering Ashkenazi Jewish ancestry.
Ethnicity/ancestry:
D. Triple-negative breast cancer diagnosed at age 60 or younger.
II. BRCA1 and BRCA2 testing is proven and medically necessary for women with a personal history
of ovarian cancer.
III. BRCA1 and BRCA2 testing is proven and medically necessary for women and men with a personal
history of pancreatic cancer at any age and at least one close blood relative on the same side of the
family with breast (ages 50 or younger), ovarian, pancreatic and/or prostate cancer (Gleason score
≥7) at any age.
Please indicate family members including which side of family (i.e. maternal or paternal),
cancer including age and/or Gleason score:
IV. BRCA1 and BRCA2 testing for Ashkenazi Jewish founder-specific mutations is proven and
medically necessary for women and men with a personal history of pancreatic cancer and
Ashkenazi Jewish ancestry.
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