You Don't Have to Fear Breast Cancer
Getty ImagesSince Angelina Jolie's brave op-ed in The New York Times, many women have called my clinic asking if, like Jolie, they should get genetic testing or a bilateral mastectomy. But the choice that she made is not for everyone. That's why I want to share what you should know about reducing your risk of breast cancer, whether you have a family history or not.
Should you be tested for a breast cancer mutation?
Most likely, no. Inherited gene mutations that result in a very high risk of breast and ovarian cancer, including the BRCA1 mutation that Jolie carries, are rare (1 in 400 people) and account for only about 5 percent of breast cancers. If you have a history of at least one of these cancers on one side of your family—two first-degree relatives (mom, sister or daughter) or three second-degree relatives (grandmother or aunt)—this is a clue that your family might be at risk, especially if at least one person was diagnosed before age 50. (One hallmark of hereditary cancer is young age at diagnosis.) A genetic counselor can help you sift through your history and help you decide if you should consider getting tested. (If you're in this high-risk group, the test is usually covered by your health insurance.)
The reassuring news is that genetic testing isn't warranted for most women, even those who have one relative who has had cancer. I've had worried patients ask me if they should get the test anyway, and I tell them no: First of all, you could pay several thousand dollars out of pocket. Second, the worst possible scenario is that the test comes back showing a genetic variant of unknown significance—one that probably means nothing, but since we don't know for sure, can produce unnecessary anxiety.
Next Page: What are your options if you test positive? [ pagebreak ]
What are your options if you test positive?
Jolie had a preventive mastectomy, but that's not your only avenue. Prevention is not an emergency—cancer doesn't sprout up overnight—so if you do learn you are a mutation carrier, you have time to weigh your options.
My patients' choices are often influenced by where they are in their lives. If they're young and have not had children yet, they may want to opt for intensive screenings, like MRIs. For BRCA carriers, that means both mammograms and MRIs staggered at six-month intervals (before the age of 30 we only use MRI). I just make sure patients are aware that since an MRI is so sensitive, it has a high rate of false positives (suspicious findings that turn out to be benign). This can be incredibly stressful. Of course screening is not prevention: While catching a cancer earlier can mean less treatment, it depends on the tumor type. A stage 1 triple-negative tumor, for instance, will still require more aggressive treatment. By comparison, a stage 1 hormonally driven breast cancer may not. The good news is that the treatment and reconstruction options are much better than what we had even 10 years ago.
Another alternative is medication: There are drugs, like tamoxifen, that can reduce the risk of breast cancer by about 50 percent. Aromatase inhibitors such as exemestane have also been found to lower the risk of breast cancer in postmenopausal women by about 65 percent.
Then there's preventive mastectomy, which for women with a BRCA mutation lowers the risk of developing breast cancer from 60 to 80 percent to about 5 percent. Women, like Jolie, who have had relatives die from cancer at a young age are often especially interested in this option. Women who have young children may also be highly motivated to do everything they can to lower their chances of developing cancer. Removal of the ovaries and fallopian tubes reduces the risk of ovarian cancer (for which we don't have an effective screening test) by 80 to 90 percent and is recommended for women who carry a BRCA mutation, after they're done having children. (Jolie, whose mother died of ovarian cancer, has indicated that she plans to have her ovaries removed.)
The decision to have risk-reducing surgery is difficult and very personal. I've had patients with BRCA mutations who are diagnosed with DCIS (ductal carcinoma in situ, an early, noninvasive form of cancer) and say, "That's it, I want them both off." I've had women in their 50s tell me that they've gotten this far and been all right, so they don't want to do any more. It's not the sort of thing you do without a lot of talking and thinking. If a woman wants surgery, I ask her if she'll be upset if she doesn't get a good cosmetic result from reconstructive surgery. If she says she doesn't care, that the most important thing to her is the breast tissue being completely gone, then I know she's ready.
Next Page: What if you don't have a genetic risk? [ pagebreak ]
What if you don't have a genetic risk?
Every woman has some risk of developing breast cancer. However, breast cancer is a collection of many diseases, ranging from those that are slow growing and unlikely to ever cause harm, to those that are aggressive and life-threatening. We do not treat them the same way. Our next challenge is to learn how to tailor screening and prevention strategies to different women depending on their family and medical history.
In the meantime, there are things you can do right now to help lower your risk of developing breast cancer, whether or not you're a mutation carrier. Exercising, maintaining your body weight in the normal range and eating a healthy diet (low in animal fats) all improve both your breast and overall health. Be familiar with your body, too, and if you find a new mass, let your doctor know immediately.
If you have one or more risk factors—a previous abnormal biopsy, any type of family history, early-age onset of periods, late or no child bearing, or extremely dense breast tissue—talk to your doctor about whether you're a candidate for drugs such as tamoxifen or raloxifene, which are FDA-approved for breast cancer prevention. Also, avoid hormone replacement therapy after menopause, keep alcohol intake low and, if you need to take medication for osteopenia or osteoporosis, consider raloxifene, which can also lower breast cancer risk.
It's easy to hear about a celebrity like Jolie and panic, but I'll share with you what I tell patients every day: While all women are at risk for breast cancer, most of us won't get it. And hopefully our ability to treat and prevent cancer will improve even more, so that in the future, surgeries like the one Jolie had will not be necessary.
Laura Esserman, MD, MBA, is director of the Carol Franc Buck Breast Care Center and a professor of surgery and radiology at the University of California at San Francisco. Beth Crawford, MS, is a genetic counselor and director of clinical services for the Cancer Risk Program at the UCSF Helen Diller Family Comprehensive Cancer Center.