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Approximately 240,000 women in the United States are diagnosed with breast cancer each year and the average woman has approximately a 10 to 15 percent chance of developing breast cancer if she lives into her 90’s.
Fortunately, the overall mortality from breast cancer has decreased over the past several years, mostly likely because of overall improved awareness, involvement of women in their care and health care advocacy, improved research, development, and treatment options as well as improved post treatment surveillance and survivorship enhancing strategies.
A key factor that will help with the early detection and treatment of breast cancer is to know if you are at an increased risk of breast cancer. If you have a history of breast or ovarian cancer in your family, you have an increased risk for those cancers. In addition, if you have any other cancer history in your family, you might be at an increased risk of cancer.
Experts recommend breast cancer screening (mammogram and breast exams done by a health care provider or by yourself) for most women age 50 to 70, and for some older women who are healthy. Some women age 40 to 49 should also be screened. Talk to your physician to find out when you should be screened for breast cancer.
Women who are at high risk of breast cancer sometimes need to begin screening at a younger age. This might include women who:
- Carry genes that increase their risk of breast cancer, such as the “BRCA” genes
- Have close relatives who got breast cancer at a young age
How do doctors assess the risk of breast cancer?
Several tools are available to your health care provider to use for assessing your risk of breast cancer. Generally, these tools are used for women that have a history of breast cancer in her family.
- Breast Cancer Risk Assessment Tool (BRCAT or Gail model) — The most widely available tool to calculate breast cancer risk is the BCRAT, sometimes called the Gail model after Dr. Mitchell Gail, its developer at the National Cancer Institute. This tool is used to calculate a woman’s individual risk of developing breast cancer over the next five years and until age 90, based on the following data for the individual: current age, age of menarche, age of first live birth, number of first degree relatives with breast cancer, number of previous breast biopsies, whether any breast biopsy has shown atypical hyperplasia and race.
- Several other risk prediction models such as BRCAPRO are used for patients with a history of multiple family members with breast cancer, or even one family member with ovarian cancer are used to assess the risk of breast cancer and also the risk of carrying a deleterious BRCA1 or BRCA2 gene. These estimates are then used to select women for genetic testing.
What if I test positive for a BRCA mutation?
The lifetime risk of breast cancer is between 55 and 85 percent for those with the BRCA1 mutation and 50 to 85 percent for the BRCA2 mutation.
Women who have inherited a BRCA mutation are usually advised to have more frequent screening for breast cancer. This includes:
- A monthly breast self-exam (BSE) beginning at age 18
- A breast exam, performed by your doctor or nurse, every six months beginning at age 25
- A mammogram once per year, beginning at age 25 (or individualized based on family history)
- A breast MRI, which is typically done alternating with a mammogram every six months, beginning at age 25 or individualized based on family history
Women who have inherited a BRCA mutation have an increased risk of developing ovarian cancer. The lifetime risk of ovarian cancer is 35 to 46 percent for the BRCA1 mutation and 13 to 23 percent for the BRCA2 mutation. However, screening tests for ovarian cancer are not very accurate in detecting the disease but such screening is available. Ovarian cancer screening includes a combination of a blood test and a pelvic ultrasound every six months, beginning at age 35, or 5 to 10 years before the youngest relative was diagnosed with breast or ovarian cancer.
If you are found to have the BRCA1 or BRCA2 mutation, other family members may want to consider genetic testing to learn more about their risk of getting breast or ovarian cancer.
Genetic Testing and Breast Cancer
Genetic testing can tell if you have inherited an abnormal gene that increases the risk of breast and ovarian cancer; if you test positive for a gene alteration (called mutation). However, genetic testing is not perfect. Most women with breast cancer and/or a family history of breast cancer do not have an abnormal gene, and not all women who have inherited one of these genes will develop cancer. Most genetic testing for breast and ovarian cancer analyzes two genes for mutations. Genetic testing is expensive but in United States most health insurance companies will cover most of the costs as long as the testing is justified.
Who should consider genetic testing?
Individuals who have a strong family history of breast or ovarian cancer should consider genetic testing since they are at increased risk of developing these cancers. A strong family history means that:
- A family member or multiple family members (mother, sister, daughter, can also include men with breast cancer) have had breast or ovarian cancer (or both), particularly if the relative was diagnosed with cancer at an early age (less than 50 years old)
- More than one generation of your family has breast or ovarian cancer
- Family history on the father’s side is as important as the mother’s side. It is also important to know the cancer history of your cousins on both sides of your family
- Other cancers in addition to breast and ovarian cancer in women can be suggestive of hereditary cancer. For example, it is important to know if there are relatives with pancreatic, prostate, or colon cancer
Breast Cancer Prevention for High Risk Individuals
Women who are at high risk of getting breast cancer can sometimes take a medicine – Tamoxifen or another medication – to help prevent the disease. This medicine is used sometimes to reduce the risk of breast cancer in women who have BRCA mutations. If you have a strong family history of breast cancer, ask your doctor what you can do to prevent cancer and if a medication is right for you.
In addition, there are many lifestyle changes women can make to reduce the risk of breast cancer, including:
- Planning for first birth before the age of 30
- Breastfeeding for at least six months
- Avoidance or limited duration of use of postmenopausal hormone therapy
- Avoidance of unnecessary exposure to radiation (e.g., inappropriate use of computed tomography “CT”)
- Avoidance or cessation of smoking
- Limiting alcohol intake
- Maintenance of a healthy weight
- Adopting a physically active lifestyle. This should include at least 150 minutes of weekly moderate intensity activity, 75 minutes of weekly vigorous intensity activity, or at least some physical activity above one’s usual routine, in addition to limiting sedentary behavior
Preventive surgery option
Preventive surgery can significantly decrease the risk of developing cancer if you have a high risk of developing breast or ovarian cancer. Talk to your doctor about the potential risks and benefits of preventive surgery. These surgical options include prophylactic bilateral mastectomy (reduces the chance of developing breast cancer by at least 90 percent) and prophylactic bilateral salpingo-oophorectomy (reduces the risk of ovarian and fallopian tube cancer by 80 to 90 percent and breast cancer by 50 to 60 percent for premenopausal women). The benefits of this surgery are greatest in women who have surgery before menopause, particularly before age 40, after they have completed the childbearing if desired.
If you are concerned about your risk for breast cancer, speak with your physician to determine if you are a candidate for the BRCAT or other genetic testing. Preventive screening for breast cancer, as recommended by your physician, is the best option to detect and treat the disease early.
Dr. Poornima Pandellapalli is a medical oncologist with the Mid-Atlantic Permanente Medical Group in the Northern Virginia Service Area. She practices at Kaiser Permanente’s Tysons Corner and Burke Medical Centers.
Dr. Pandellapalli is board certified in Internal Medicine, Hematology, and Medical Oncology. She has been recognized as a Top Doctor by Northern Virginia Magazine in 2011, 2012 and 2013.