Improved sequencing technologies offer unprecedented opportunities for investigating the role of rare genetic variation in common disease. However, there are considerable challenges with respect to study design, data analysis and replication. Using pooled next-generation sequencing of 507 genes implicated in the repair of DNA in 1,150 samples, an analytical strategy focused on protein-truncating variants (PTVs) and a large-scale sequencing case-control replication experiment in 13,642 individuals, here we show that rare PTVs in the p53-inducible protein phosphatase PPM1D are associated with predisposition to breast cancer and ovarian cancer. PPM1D PTV mutations were present in 25 out of 7,781 cases versus 1 out of 5,861 controls (P = 1.12 × 10(-5)), including 18 mutations in 6,912 individuals with breast cancer (P = 2.42 × 10(-4)) and 12 mutations in 1,121 individuals with ovarian cancer (P = 3.10 × 10(-9)). Notably, all of the identified PPM1D PTVs were mosaic in lymphocyte DNA and clustered within a 370-base-pair region in the final exon of the gene, carboxy-terminal to the phosphatase catalytic domain. Functional studies demonstrate that the mutations result in enhanced suppression of p53 in response to ionizing radiation exposure, suggesting that the mutant alleles encode hyperactive PPM1D isoforms. Thus, although the mutations cause premature protein truncation, they do not result in the simple loss-of-function effect typically associated with this class of variant, but instead probably have a gain-of-function effect. Our results have implications for the detection and management of breast and ovarian cancer risk. More generally, these data provide new insights into the role of rare and of mosaic genetic variants in common conditions, and the use of sequencing in their identification.

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Emergence of drug resistance to all available therapies is the major challenge to improving survival in myeloma. Cereblon (CRBN) is the essential binding protein of the widely-used IMiD and novel CelMOD drugs in myeloma, as well as certain PROTACs in development for a range of diseases. Using whole genome sequencing data from 455 patients and RNASeq data from 655 patients, including a newly-diagnosed cohort (n=198 WGS, n=437 RNASeq), a lenalidomide (LEN)-refractory cohort (n=203 WGS, n=176 RNASeq) and a pomalidomide (POM)-refractory cohort (n=54 WGS, n=42 RNASeq), we find incremental increase in the frequency of three CRBN aberrations, namely point mutations, copy loss/structural variation and a specific variant transcript (exon 10-spliced), with progressive IMiD exposure, until almost one third of patients have CBRN alterations by the time they are POM-refractory. We find all 3 CRBN aberrations are associated with an inferior outcome to POM in those already refractory to LEN, including those with gene copy loss and structural variation, which has not previously been described. This is the first comprehensive analysis of CBRN alterations in myeloma patients as they progress through therapy, and the largest dataset. It will help inform patient selection for sequential therapies with CRBN-targeting drugs.