The clustering of breast cancer at a higher-than-expected incidence in some families has been recognized in the medical literature since at least the mid-19th century. With the landmark discovery 23 years ago indicating that chromosome 17q21 appeared to harbor a gene (BRCA1) for inherited susceptibility to breast cancer in families with early-onset disease, 1 the era of identification of moderately to highly penetrant, autosomal dominant breast (and other) cancer susceptibility genes began. Following the cloning of BRCA1 2 and BRCA2 3 in rapid succession in the mid-1990s, widespread optimism fueled the field of cancer genetics toward an intensive search for additional genes with similar characteristics, eg, "BRCA3," under the logical premise that successful gene hunting would inevitably inform substantive opportunities for primary and secondary prevention of breast cancer, as well as perhaps ovarian cancer, because BRCA1 and BRCA2 are each associated with a significantly elevated risk of this malignancy as well. 4 By 1999, however, Easton offered the prescient conclusion that if breast cancer susceptibility genes with penetrances comparable to BRCA1 and BRCA2 existed, mutations in these genes must be very rare. 5 Such has proven to be the case, with more than 20 additional genes with rare frequency mutations associated with intermediate to high penetrance for breast cancer now identified. 6 Several of these genes are associated with previously recognized dominant cancer predisposition syndromes involving multiple tumor types, including Li-Fraumeni syndrome (TP53), Cowden disease (PTEN), Peutz-Jeghers syndrome (LKB1), and Lynch syndrome (MSH2, MLH1). Others were identified through an association with a recessive clinical syndrome, such as ataxia telangiectasia (ATM), Bloom's syndrome (BLM), any of several types of Fanconi anemia (RAD51C, BRIP1), or Nijmegen breakage syndrome (NBN); monoallelic mutations of these genes, however, confer susceptibility to breast (and sometimes other) cancer(s) in an autosomal dominant fashion.A large proportion of these genes function in the recognition and/or repair of one or another type of DNA damage, and essentially all are functionally classified as classical tumor suppressors. In addition, most of their associated protein products function as members of DNA repair complexes, an observation that has led to the identification of several breast cancer susceptibility genes with rare frequency mutations such as PALB2 ("partner and localizer of BRCA2"), originally characterized as encoding a nuclear binding partner of BRCA2, 7 and then as a member of a BRCA1-PALB2-BRCA2 complex, 8,9 enabling their respective roles in homologous recombinational DNA repair and thus tumor suppression. The original classification of PALB2 as a breast cancer susceptibility gene was based on data showing that 10 of 923 (1.08%) individuals with familial breast cancer, negative for mutations in BRCA1 or BRCA2, harbored monoallelic truncating mutations of PALB2, compared to none of 1084 controls, leading to ...