women’sPREVENTION
A more natural breast reconstruction was actress Angelina Jolie’s goal.
BRCA, continued from 9
Should You Get Tested?
“These women are also eligible for an annual breast MRI.” The MRI detects cancer earlier by pinpointing areas in the breast with increased blood flow, which is necessary to support growing cells. Some women may be treated with tamoxifen, an infertility drug that stops or slows the growth of hormone-positive cancers by preventing estrogen from attaching to receptors on the cell. “You could treat a BRCA carrier with tamoxifen until she’s ready to have a mastectomy and give her a 50-percent risk reduction until she makes the leap,” said Markus. Generally, this drug may be as a preventive measure for up to 10 years, although there is a little data on how well it works long term because studies indicating its effectiveness are relatively recent.
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10 Gazette Health | Fall 2013
A GAZETTE PUBLICATION
There have been many advances in this procedure in the last few years, and
the results can be beautiful.”
-Actress Angelina Jolie, who elected to have a preventive mastectomy earlier this year
Hampton pointed to some recent techniques that allow for the preservation of breast skin, as well as the nipple and areola. “The result is much closer to what we have normally.” A more natural breast reconstruction was actress Angelina Jolie’s goal. Prior to her February preventive mastectomy, she underwent a nipple delay, which, as she wrote in The New York Times, “rules out disease in the breast ducts behind the nipple and draws extra blood flow to the area” to maintain the nipple’s viability. “There have been many advances in this procedure in the last few years, and the results can be beautiful.”
WHILE THE NUMBER OF CANCER-FREE WOMEN with a BRCA gene mutation who undergo a prophylactic bilateral mastectomy has not been documented, there have been several studies showing an increase—by some accounts more than triple in the last 15 years—in the number of women who, after getting cancer in one breast, choose to have both removed. In a 2008 study published in the International Journal of Cancer, U.S. women had the highest rate—36.3 percent—of prophylactic mastectomies among carriers of the faulty BRCA1 and BRCA2 genes. “Some doctors are concerned that too many women are choosing the very aggressive step of … prophylactic mastectomy during or shortly after breast cancer surgery because they overestimate their risk of future breast cancer,” according to Breastcancer.org. But while the decision to have a preventive mastectomy can be difficult, many women appear content with their decision to undergo surgery. In a 2011 presentation at the annual meeting of The American Society of Breast Surgeons, Mayo Clinic researchers said they found 90 percent of women with cancer in one breast who chose to have both breasts removed were satisfied with their decision 20 years later. Studies reported in the Journal of Clinical Oncology showed satisfaction rates of 83 percent in 2005 and 86.5 percent in 2006. “I have zero regrets,” said Cohen. “Now that I’ve lived longer than my mom, I realize just how young she was when she died. I want to be here for my grandchildren.”
ISTOCKPHOTO/EDSTOCK
IT WAS A CHANCE MEETING WITH A FRIEND FROM college, now a breast surgeon outside of Philadelphia, that convinced Cohen to have a bilateral mastectomy. “Her basic message to me was that it wasn’t just that I could get breast cancer but that, if I got it, the outcome might not be good .... Cancer in women with the BRCA1 gene often manifests itself as triple negative.” “Triple negative is a more aggressive cancer,” said Regina Hampton, M.D., a breast surgeon with Signature Breast Care in Lanham and privileges at Doctors Community Hospital. Compared with other breast cancers, triple negative tends to grow faster, be less visible on a mammogram, spread to other parts of the body earlier and recur more often. Tamoxifen does not protect against this estrogennegative cancer. BRCA1 mutations are a risk factor for this type of cancer. “About 10 percent of triple negative cancers are found in BRCA women,” Hampton said. The day after lunch with her friend, Cohen decided to have a mastectomy. “I didn’t make an emotional decision. It was informed by my situation and knowledge. It was a factual, scientificbased decision.” In July 2009, at 46, Cohen had both breasts removed. “I’d read a lot about mastectomies, but nothing really prepares you for everything you have to deal with—pain, draining tubes, expanders,” she said. Four months later, Cohen had implant surgery to reconstruct her breasts. “You always know the implants are there; they’re not really part of your body …. But that’s OK. My breasts have never been a big part of who I am.” Improved reconstructive techniques may make the surgery “more palatable” for some women, said Hampton. “We now have more pleasing cosmetic procedures that offer great results, especially when compared to where we were 20 years ago. Then, the options we had to offer women in their 30s and 40s were horrible.”
Deciding whether to find out if you have BRCA1 and 2 genes with mutations that increase cancer risk is complex. The U.S. Preventive Services Task Force recommends that only women who meet very specific risk criteria be tested, which it says amounts to only 2 out of 100. That’s in part because results may be inconclusive. Many insurance companies require women to undergo genetic counseling prior to being tested, and sometimes insurance won’t cover the cost of the procedure. As you begin the conversation about whether to be tested with your doctor, your family and yourself, these websites may be good resources for information gathering: n www.cancer.gov/cancertopics/factsheet/ Risk/BRCA n www.mayoclinic.com/health/brca-gene-test/ MY00322 n ww5.komen.org/breastcancer/ genemutationsampgenetictesting.html