BRCA1/2 and CHEK2 Pathogenic Variants in Urological Cancers: A Portuguese Single-Center Experience.

Introduction
Breast cancer susceptibility genes 1 and 2 (BRCA1 and BRCA2) are high‑penetrance tumor suppressor genes that play a central role in homologous recombination DNA repair. Germline pathogenic variants (gPVs) in these genes are well‑established risk factors for hereditary breast and ovarian cancer and have also been associated with an increased risk of several urological malignancies, particularly prostate cancer [1,2].
Men with BRCA2 gPVs have a substantially elevated lifetime risk of prostate cancer and are more likely to present with aggressive, high‑grade tumors and higher prostate cancer‑specific mortality. BRCA1 variants also confer an increased prostate cancer risk, although the effect appears smaller than that of BRCA2 [2-4].
Regarding germline genetic testing in prostate cancer, recommendations were first introduced into the National Comprehensive Cancer Network (NCCN) hereditary cancer risk guidelines in the early 2010s and have since undergone steady expansion in clinical indications. Much of the initial evidence supporting these recommendations was driven by studies demonstrating a stronger and more consistent association with BRCA2 gPV [5]. Consequently, hereditary testing frameworks have historically placed greater emphasis on BRCA2, while the risk association with BRCA1 has remained comparatively weaker and more variable.
Over subsequent years, NCCN recommendations expanded substantially and now endorse germline genetic testing for other homologous recombination repair genes, including ATM, BRCA1, BRCA2, CHEK2, HOXB13, PALB2, and TP53, in patients with a personal history of metastatic or node‑positive prostate cancer, as well as in those with high‑risk localized disease [6]. This broadening of testing criteria has also been accelerated by the therapeutic implications of gPV, particularly with the introduction of poly(ADP‑ribose) polymerase inhibitors (PARP inhibitors), which have made gPVs relevant for clinical management by demonstrating predictive value for response to PARP inhibitors and platinum‑based chemotherapy [7-9].
Regarding prostate cancer surveillance in BRCA1/2 carriers, available evidence indicates a significantly higher detection rate of clinically significant prostate cancer among BRCA2 carriers, supporting the implementation of targeted screening strategies in this population [10,11]. Accordingly, NCCN currently recommends annual prostate cancer screening with prostate-specific antigen (PSA) testing for BRCA2 mutation carriers, whereas screening for BRCA1 carriers is suggested only for consideration, reflecting the comparatively less consistent risk association [6]. These developments highlight the need to identify carriers of BRCA1/2 gPVs and to define which patients with urological cancers should undergo genetic testing, as well as the optimal timing of such testing within their disease course.
Although BRCA1/2 gPVs are not traditionally recognized as major risk factors for bladder cancer, emerging evidence suggests a possible association in selected subgroups. Some studies report a higher risk of bladder cancer among female BRCA1/2 carriers [12] and link specific BRCA2 gPVs to urinary tract malignancies [13]. Furthermore, data from The Cancer Genome Atlas have identified BRCA2 gPV in approximately 13% of urothelial carcinomas, raising questions about their biological and clinical relevance [14].
CHEK2 is a moderate‑penetrance tumor suppressor gene encoding a checkpoint kinase involved in the DNA damage response. Pathogenic CHEK2 variants are most strongly associated with breast cancer, but accumulating evidence implicates CHEK2 in a broader tumor spectrum, including prostate and other urological cancers [15-17]. Certain CHEK2 variants have been associated with an increased risk of bladder cancer, renal cell carcinoma, and testicular germ cell tumors, although risk estimates remain heterogeneous and clinical management guidelines are still evolving [5,14,18].
Improving the detection of gPVs has the potential to expand access to genetic counselling, tailored cancer screening, and targeted therapies for patients with urological malignancies and their families. Recognition of new hereditary cancer entities, or improved characterization of existing associations, relies on studying at‑risk populations and integrating genomic data into routine clinical practice.
The primary objective of this study is to descriptively characterize patients with urological cancer and carriers of gPVs, followed at a Hereditary Cancer Risk Clinic, specifically regarding gene affected, tumor histology, age at diagnosis, and family and personal cancer history.
The secondary objectives were as follows: (1) to estimate the median overall survival (mOS) for each tumor type; (2) to compare age at diagnosis and stage at presentation, according to the affected gene among BRCA1/2 carriers; and (3) to perform a strictly exploratory comparison of survival among patients with prostate cancer between BRCA1 and BRCA2 carriers.

Materials and methods
Study design and population
This retrospective, descriptive, single-center study was conducted at the Hereditary Cancer Risk Clinic of the Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG), Lisbon, Portugal. We included patients with urological cancers (renal, urothelial, prostate, and testicular) who carried pathogenic or likely pathogenic variants in BRCA1, BRCA2, or CHEK2 and who belonged to families followed at the IPOLFG Familial Risk Clinic. Eligible patients were identified from the establishment of the Breast-Ovarian-Prostate Clinic (December 1999) through December 31, 2024.
Patients were referred to the Hereditary Cancer Risk Clinic through established institutional pathways in accordance with contemporaneous clinical risk-based guidelines for hereditary cancer genetic testing. Eligibility for testing was determined through a structured risk assessment, incorporating personal cancer history (including tumor stage and risk category), age at diagnosis, tumor characteristics, family history suggestive of hereditary predisposition (e.g., multiple affected relatives or early-onset disease), and the presence of a known familial pathogenic variant. Self-referral was also permitted; however, genetic testing was only offered if individuals met the same standardized risk-based eligibility criteria described before.
Given the extended study period, testing indications evolved in parallel with updates to clinical risk guidelines, which progressively broadened eligibility criteria over time. Therefore, inclusion in the present study reflects the applicable risk-based testing criteria in place at the time of referral and genetic evaluation.
Families carrying pathogenic or likely pathogenic variants in BRCA1, BRCA2, or CHEK2 were identified. These families were systematically screened for members with a diagnosis of urological cancer. All eligible patients meeting the predefined inclusion criteria during the study period were included consecutively, without sampling.
Inclusion criteria included patients with (1) confirmed diagnosis of urological cancer; (2) presence of a gPV in BRCA1, BRCA2, or CHEK2; and (3) follow-up at the IPOLFG Familial Risk Clinic during the study period. Exclusion criteria were as follows: (1) insufficient clinical documentation to confirm oncologic diagnosis or (2) absence of confirmed germline genetic testing results.
A Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)-style flow diagram summarizing the selection process and the number of families and patients included at each stage is presented in Figure 1.
Data collection
Clinical data were retrospectively extracted from paper and electronic medical records.
Collected variables included the following: genetic data: BRCA1/2 and CHEK2 mutational status, affected gene, specific pathogenic variant, and type; demographic and histopathologic data: sex, age at diagnosis, histopathological subtype and initial stage at diagnosis, and smoking history if available; treatment data: type of treatment including surgery, radiotherapy, or systemic therapy; survival data: date of diagnosis, date of death from any cause, and date of last follow-up; and familial and personal history data: personal history of additional other diagnosis of cancer and familial history of cancer.
Variants were named according to ClinGen Expert Panel Specifications to the American College of Medical Genetics and Genomics (ACMG)/Association for Molecular Pathology (AMP) Variant Interpretation Guidelines for BRCA1, BRCA2, and CHEK2. Pathogenic and likely pathogenic variants were both denoted as PV. Variant classification was based on the most up-to-date interpretation available at the time of data extraction. Variants that were newly classified as pathogenic or likely pathogenic during the study period were included in the analysis, even if this classification occurred after the initial clinical evaluation.
The c.1036C>T variant in the CHEK2 gene was reclassified during the study period, in 2024, following the accumulation of additional evidence, from a variant of unknown significance to likely pathogenic, and was therefore included in this analysis. No other variants were reclassified during the study period.
The initial stage at diagnosis was defined as localized if the tumor was confined to the primary organ, with or without regional lymph node involvement, and metastatic disease was defined as the presence of distant metastases. Histological and staging information was obtained from the original oncologic diagnosis records.
Smoking history was considered positive in individuals who were current or former smokers and negative in those who had never smoked.
Cancer diagnoses were verified through a review of institutional medical records, pathology reports, and, when applicable, documented external clinical reports.
Missing data
The extent of missing data was assessed for all study variables. Smoking status was unavailable in 40% of cases. There were no other variables with missing data. Descriptive analyses were performed using available data, and percentages were calculated based on non-missing observations. No imputation procedures were performed due to the retrospective design and limited sample size.
Molecular diagnosis
Hereditary breast and ovarian cancer testing included the detection of single-nucleotide variants (SNVs) and copy number variants (CNVs) in the BRCA1 and BRCA2 genes, as well as targeted screening for the Portuguese BRCA2 founder variant c.156_157insAlu. BRCA1/2 testing was performed according to the standard methodologies implemented at the time of analysis.
Between 1999 and 2014, BRCA1/2 testing was performed using conformation-sensitive gel electrophoresis (CSGE) or conformation-sensitive capillary electrophoresis (CSCE), followed by Sanger sequencing. The Portuguese BRCA2 founder variant was screened using a specific polymerase chain reaction (PCR)-based assay, and large deletions and insertions in BRCA1 and BRCA2 were assessed by multiplex ligation-dependent probe amplification (MRC Holland, Amsterdam, Netherlands).
From 2014 to 2018, next-generation sequencing (NGS) was performed using either the TruSight Cancer Sequencing Panel by Illumina (San Diego, California, United States) (including BRCA1, BRCA2, TP53, PTEN, CDH1, ATM, BRIP1, BLM, BAP1, CHEK2, PALB2, RAD51C, and RAD51D) or the BRCA Hereditary Cancer MASTR™ (BRCA1 and BRCA2) assay kit by Genycell (Granada, Spain) on a MiSeq platform by Illumina. All pathogenic and likely pathogenic variants identified by NGS were confirmed by Sanger sequencing, while multiplex ligation-dependent probe amplification was used to detect CNVs and the Portuguese founder variant in BRCA2.
Since 2018, hereditary breast and ovarian cancer testing has been performed exclusively using multigene panels (including BRCA1, BRCA2, PALB2, ATM, BARD1, BRIP1, CDH1, CHEK2, PTEN, RAD51C, RAD51D, and TP53 genes) such as Hereditary OncoKit DX combined with DataGenomics software (both by Genycell), enabling the integrated detection of SNVs, CNVs, and the BRCA2 founder variant.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, New York, United States). Descriptive statistics were used to summarize patient characteristics and treatments. Continuous variables were reported as medians with ranges and categorical variables as counts and percentages. Group differences were assessed using χ² or Fisher's exact tests, as appropriate. A two-sided p-value of <0.05 was considered statistically significant.
The mOS was defined as the time from the date of diagnosis to death from any cause or last follow-up. Patients who were alive at the last follow-up were censored at that date for mOS analysis. Survival outcomes were estimated using the Kaplan-Meier method, and comparisons between groups were performed using the log-rank test. A p-value of <0.05 was considered statistically significant.
Ethical considerations
The study was conducted in accordance with the Declaration of Helsinki, the General Data Protection Regulation (Regulation EU 2016/679), and national legislation. Data were pseudo-anonymized, with identifying information removed and stored in password-protected databases accessible only to study investigators.
The protocol was approved by the IPOLFG Research and Ethics Committee, which granted a waiver of informed consent because the study involved no intervention and no added risk and relied on previously collected data. In addition, at the IPOLFG Familial Risk Clinic, when patients consent to genetic testing, they are also given the option to participate in other studies approved by the IPOLFG Research and Ethics Committee. Accordingly, only individuals who had provided prior consent, follow-up at the Familial Risk Clinic, and agreement to participation in studies using aggregated data were included. Compliance with Law 21/2014 was ensured.

Results
We assessed 968 families, of which 47 included patients with urological cancer carrying a gPV in one of the previously described genes, comprising a total of 50 affected individuals. Four patients had a personal history of two distinct urological cancers: three of them were BRCA2 gPV carriers, and one was a BRCA1 gPV carrier. In addition, one BRCA2 gPV-carrying family included three relatives with urological cancers, while another had two relatives each affected by urological cancer.

BRCA1/2 carriers
A total of 836 families with BRCA1/2 gPV were evaluated. Among these, 41 families (4.9%) included patients with urological malignancies. Across the affected individuals, 37 were diagnosed with prostate cancer, four with renal cancer, and seven with urothelial cancer. No cases of testicular cancer were identified. Regarding the affected gene, the majority (81.8%) carried a BRCA2 gPV.
Patients with BRCA1/2 gPV and prostate cancer
A total of 37 patients from 35 families carrying BRCA1/2 gPVs and diagnosed with prostate cancer were evaluated. The affected gene, specific pathogenic variant, age at diagnosis, Gleason score, personal history of cancer, and family cancer history for each patient are summarized in Table 1.
The median age at diagnosis was 75 years (IQR 65-78) for patients with a BRCA1 gPV and 61 years (IQR 57-73) for those with a BRCA2 gPV.
Five patients (13.5%) presented with metastatic disease at diagnosis. Most patients presented with a Gleason score of 6 (3+3) or 7 (3+4), with 11 patients in each group. A Gleason score of 7 (4+3) was observed in five patients, while five patients had a Gleason score of 8 (4+4). Higher-grade disease was less frequent, with a Gleason score of 9 identified in three patients, including one patient with a score of 5+4 and two patients with a score of 4+5. Gleason score information was unavailable for two patients. All patients with higher-grade or metastatic disease carried a BRCA2 gPV, whereas only two patients with a BRCA1 gPV had a Gleason score of 7 (4+3).
Smoking history was only reported in 24 patients, with 16 having reported a history of smoking and eight non-smokers.
Regarding personal cancer history, prior cancers were observed in 40% of BRCA2 gPV patients and were more diverse, with breast cancer being the most common and occurring exclusively in this group (six patients). Five BRCA2 carriers had a history of more than one additional malignancy. Among BRCA1 carriers, personal history of other malignancies (in 42.8%of BRCA1 gPV) consisted predominantly of non-breast cancers.
When considering family history, among BRCA1 families, breast cancer was the most frequently reported malignancy (71% of BRCA1 gPV), followed by prostate cancer (42%). In BRCA2 families, breast cancer was also the most prevalent familial malignancy, reported in 21 families (72.4%), followed by prostate cancer, which was reported in eight families (27.6%). BRCA2 families exhibited a broader spectrum of associated malignancies, including pancreatic, colorectal, and gastric cancers, as well as melanoma.
With respect to treatment modalities in the setting of localized disease, among BRCA1 carriers, five patients (71%) underwent radiotherapy followed by adjuvant hormonal therapy, one patient (14%) received radiotherapy alone, and one patient (14%) received hormonal therapy alone. Among BRCA2 carriers, 13 patients (52%) were treated with radiotherapy followed by adjuvant hormonal therapy; five patients (20%) received radiotherapy alone; three patients (12%) underwent surgery followed by adjuvant hormonal therapy; two patients (8%) were treated with surgery alone; one patient (4%) received hormonal therapy without local treatment; and one patient was managed with active surveillance. Among patients with stage IV prostate cancer, three were treated with chemotherapy, and two received treatment with novel hormonal agents.
The median follow-up was 7±4.9 years. The mOS was 167 months (95% CI: 131.0-202.9) in patients with localized disease, compared with 38 months (95% CI: 5.6-70.3) in those with advanced disease. No statistically significant difference in overall survival (OS) was observed between BRCA1 and BRCA2 carriers (median OS: 116 months (95% CI: 63.6-168.4) for BRCA1; median not reached for BRCA2; log-rank p=0.408). These comparisons should be interpreted cautiously given the limited number of events.
Patients with BRCA1/2 gPV and non-prostate urological cancers
We assessed 11 patients from 10 families with non-prostate urological cancer and BRCA1/2 gPV. The affected gene, identified pathogenic variant, histology, sex, age at diagnosis, personal history of cancer, and family history of cancer are summarized in Table 2.
The median age at diagnosis was 56 years (IQR 45-70.5) for patients with renal cancer and 71 years (IQR 62.5-74) for patients with urothelial cancer.
All patients with renal cancer were female and had a personal history of breast cancer, with tumors exhibiting clear cell histology. One patient carried a BRCA1 gPV and three carried BRCA2 gPV. None of the patients had a smoking history; smoking status was unavailable for one patient. All patients were treated surgically. The BRCA1 carrier reported a family history limited to breast cancer, whereas BRCA2 carriers reported family histories including other malignancies, such as gastric, renal, and duodenal cancers.
The median follow-up was 7.5 years (IQR 5.0-23.5), and mOS was 10 years (95% CI: 2.5-17.4).
Among patients with urothelial cancer, one patient carried a BRCA1 gPV, and six carried a BRCA2 gPV. The majority presented with non-muscle-invasive bladder carcinoma (71.4%) except two BRCA2 carriers who had more advanced disease, including one case of clear cell bladder carcinoma with neuroendocrine differentiation (stage IV) and one case of high-grade muscle-invasive carcinoma of the ureter. Most patients were male (85.7%), with a single female patient who was a BRCA2 carrier. 
All patients diagnosed with non-muscle-invasive bladder carcinoma, except one, had a personal history of other malignancies. The BRCA1 carrier had a history of prostate cancer, which was also reported in three BRCA2 carriers. Additionally, BRCA2 carriers had histories of other cancers, including breast, biliary tract, and head and neck malignancies. Notably, all patients with a history of prostate cancer were over 70 years of age. Among the six BRCA2 gPV patients, three carried the same germline variant (c.156_157insAlu).
71.4% of BRCA2 gPV carriers reported a family history of breast cancer, and several also had relatives affected by other malignancies, including digestive tract cancers. Among BRCA1 carriers, family history was positive only for melanoma and ovarian cancer.
Smoking history was available for six patients, of whom four reported a history of smoking and two had never smoked. All patients underwent transurethral resection of the bladder (TURB), except one patient who was treated with surgery and another who was stage IV at diagnosis. The median follow-up was 26 months (IQR 14-51). mOS was reached.
No patient was diagnosed with testicular cancer and BRCA1/2 gPV.

CHEK2 carriers
One hundred and thirty-two families were included, of which six (4.5%) families had patients with a diagnosis of urological cancer and a CHEK2 gPV. One patient had a renal cancer diagnosis, and five patients had a prostate cancer diagnosis.
Clinicopathological and genetic characteristics, including the identified pathogenic variant, histology or Gleason score, sex, age at diagnosis, and personal and family cancer history, are presented in Table 3.
The median age at cancer diagnosis was 64 years (IQR 62-70) for patients with prostate cancer. Three patients with prostate cancer reported a family history of breast cancer, and just one disclosed a family history of prostate cancer.
The renal cancer patient was female and underwent surgical treatment, with no evidence of disease at the last follow-up. The majority of patients with prostate cancer presented with a Gleason score of 7 (either 3+4 or 4+3), whereas fewer cases exhibited a Gleason score of 6 or 8. All patients had localized disease at the time of diagnosis, and no disease progression was observed during follow-up. Regarding treatment, one patient underwent radical prostatectomy; three received radiotherapy followed by androgen deprivation therapy; two were treated with radiotherapy alone; and one patient received androgen deprivation therapy exclusively.
The median follow-up was 7 years (IQR 3.5-13.5). In terms of survival data, mOS was not achieved in renal or prostate cancer patients, and no patient died of cancer-specific causes. No patient was diagnosed with testicular or urothelial cancer and CHEK2 gPV.

Discussion
This retrospective descriptive study characterizes urological cancers occurring in carriers of gPVs in BRCA1, BRCA2, and CHEK2 followed at a Portuguese Hereditary Cancer Risk Clinic.
Among the 968 families assessed, 47 families included patients with urological cancer who carried a gPV in one of the previously described genes, comprising a total of 50 affected individuals. As expected, most patients carried BRCA2 gPVs rather than BRCA1 gPVs, consistent with the stronger and more consistently reported association between BRCA2 and prostate cancer risk [11]. This finding may also reflect the presence of a Portuguese founder BRCA2 gPV present in nine patients with urological cancer. Although the absolute number of affected patients was limited, the analysis was based on a large pool of families followed longitudinally, supporting the representativeness of the observed spectrum.

BRCA1/2 carriers and prostate cancer
In our cohort, prostate cancer represented the most frequent urological malignancy among BRCA1/2 carriers. The median age at diagnosis among BRCA2 carriers (61 years) was lower than that previously reported for prostate cancer in the general Portuguese population (68 years) [20], whereas BRCA1 carriers were diagnosed at a later median age (75 years). Given the small sample size, this difference should be interpreted cautiously and may reflect sporadic variation rather than a true biological effect.
As expected, most patients presented with localized disease and intermediate-grade tumors; however, a subset exhibited high-grade or metastatic disease at diagnosis and had a BRCA2 gPV, consistent with prior reports linking BRCA2 gPV to more aggressive prostate cancer phenotypes [21]. BRCA2 carriers also showed a more diverse personal cancer history, with breast cancer being the most frequently reported additional malignancy, an association not found among BRCA1 carriers, and included five patients with a history of more than one additional malignancy.
In family history, breast cancer was the most frequently reported malignancy in both BRCA1 (71%) and BRCA2 (74%) carriers, followed by prostate cancer (42% in BRCA1 and 34% in BRCA2). In addition, BRCA2 families exhibited a broader spectrum of associated malignancies, including pancreatic, colorectal, and gastric cancers, as well as melanoma.
With respect to BRCA gPV, previous studies show no genotype-phenotype correlation for specific BRCA1 variants, but have identified a prostate cancer cluster region in the 3′ end of BRCA2 (c.7914-3′), with pathogenic variants in this region associated with increased prostate cancer risk [22,23]. In our cohort, three pathogenic BRCA2 variants (c.8488-1G>A, c.9097dup, and c.9815del) mapped to this region. These observations indicate that variants located within previously described prostate cancer cluster regions are present in our population; however, formal risk analyses were not performed and are not possible given the descriptive nature of this study.
Historically, BRCA1/2 gPVs in metastatic prostate cancer have been associated with poorer prognosis [24]. In our series, the median progression-free survival among patients diagnosed with stage IV disease was 14 months. These findings are descriptive only and should be interpreted with caution, given the limited number of metastatic cases, the retrospective design, and the lack of stratification according to castration sensitivity. Additionally, most patients were treated before the widespread introduction of PARP inhibitors in the metastatic setting in Portugal.

BRCA1/2 carriers and non-prostate urological cancer
Although less frequent, renal and urothelial cancers were also identified among BRCA1/2 carriers. All renal cancer cases occurred in women and were associated with a personal history of breast cancer. The median age at diagnosis for renal cancer was 56 years, which is slightly lower than the approximately 60 years previously reported in the general population in other studies [25,26].
In contrast, the median age at diagnosis of urothelial cancer was similar to that reported in other studies [27]. Most patients presented with non-muscle-invasive urothelial carcinoma of the bladder; however, those with invasive disease were two BRCA2 carriers, including one patient diagnosed with stage IV disease and one case of high-grade muscle-invasive carcinoma of the ureter. To date, there is no clear evidence supporting an association between BRCA2 gPV and worse prognosis in urothelial bladder cancer and risk stratification. In our cohort, the limited number of cases precluded meaningful risk stratification or prognostic analysis.
Most patients with non-muscle-invasive bladder cancer had a personal history of other malignancies, which may reflect a surveillance bias due to closer medical follow-up. Notably, all patients with a history of prostate cancer were over 70 years of age at diagnosis.
Among BRCA2 carriers, three shared the same germline variant (c.156_157insAlu), the Portuguese founder variant, including one patient with invasive ureteral disease, although this observation cannot support a causal association.
We did not identify any patients carrying the BRCA2 c.9976A gPV, which has previously been associated with an increased risk of bladder cancer [13]. While tobacco exposure is a well-established risk factor for urothelial cancer, smoking history was not systematically available in our cohort, limiting conclusions regarding the contribution of environmental risk factors.

CHEK2 carriers and urological cancer
In our series, 132 families with CHEK2 gPV were assessed, of which 4.5% included patients diagnosed with urological cancer. Prostate cancer was the most frequently observed malignancy, affecting six patients, while renal cancer was identified in one patient.
The median age at diagnosis for prostate cancer was diagnosed at an age comparable to that reported in published series [20].
Both CHEK2-associated prostate and renal cancers were localized at diagnosis, and the prostate cancers were predominantly of favorable or intermediate risk. During follow-up, outcomes were favorable, with no cancer-specific deaths observed; however, these findings should be interpreted cautiously given the small sample size and limited follow-up duration.
Among CHEK2 gPV, a moderate penetrance gene, pathogenic truncating variants (PTVs), most notably c.1100del, have been more consistently associated with an increased overall cancer risk, whereas pathogenic missense variants (PMVs) appear to confer more variable risk estimates [16]. The c.1100del variant has been associated with prostate cancer risk, although it has not been clearly linked to the familial clustering of prostate cancer [28]. In our cohort, two patients carried this variant, neither of whom reported a family history of prostate cancer.
The association between CHEK2 PV and renal cancer remains less well-established. While some studies suggest a possible increased risk, available data are limited, and further evidence is required to determine the clinical relevance of this association and to assess the cost-effectiveness of targeted screening strategies in CHEK2 carriers [29].
Although previous studies have suggested an association between CHEK2 PV and an increased risk of testicular germ cell tumors, no cases of testicular cancer were identified among CHEK2 carriers in our cohort [30]. This may reflect the rarity of this malignancy, limited cohort size, or population-specific differences and underscores the need for larger studies to clarify this potential association.
Limitations
This study has limitations inherent to its retrospective design. Clinical and familial data were collected from both paper and electronic medical records, resulting in incomplete documentation for some variables, particularly smoking history and cancer diagnoses among extended family members.
As in many familial cancer studies, confirmation of reported diagnoses in relatives was not always possible due to loss of contact, death, or referral bias, which may have led to an underestimation of the true prevalence of urological cancers within families.
Survival analyses were also constrained by small sample sizes and by heterogeneity in treatment approaches across the long study period. Interpretation of OS is further limited by the advanced age of many patients and by the absence of cancer‑specific mortality data. In addition, OS was calculated from the date of diagnosis rather than from the start of treatment, which may influence survival estimates and complicate comparisons with other published series. The small number of advanced-stage cases and the absence of stratification by disease state or treatment era substantially limit the validity of the survival analyses and prevent definitive conclusions regarding survival differences. These factors reinforce the secondary nature of the survival outcomes.
Missing data in smoking status limits the possibility of drawing conclusions regarding this variable.
Finally, the study population was derived from a specialized Familial Risk Clinic, which introduces potential selection and surveillance bias, as these individuals may undergo more intensive screening and follow-up than the general population. Moreover, the absence of a comparator group precludes the direct estimation of relative risk and limits the ability to draw causal inferences.

Conclusions
Despite these limitations, this study underscores the importance of continued investigation into the spectrum of urological cancers associated with gPVs in BRCA1, BRCA2, and CHEK2. Descriptive studies such as this remain essential to improving the characterization of cancer patients and clinical presentation and outcomes in genetically predisposed populations. 
This is particularly relevant in Portugal, where a founder pathogenic variant in BRCA2 is relatively prevalent and population‑specific data remain limited. Recurrent patterns of urological and BRCA‑associated malignancies within families may support the earlier identification of at‑risk individuals, timely referral for genetic counselling, and implementation of tailored surveillance strategies for carriers and their relatives.