Breast Cancer: Know Your Risks

Know your risks for breast cancer. (Image credit: Getty Images)

Reported by Dr. Brian Lau for ABC News:

Breast cancer strikes more than 2.7 million women in the United States, according to the National Cancer Institute. One in eight women will be diagnosed with the disease at some point in their lives.

Dr. Richard Besser, chief health and medical correspondent for ABC News, hosted a tweet chat this week on breast cancer prevention to help women understand their risk factors for the disease and what steps they can take to minimize these risks.

Besser was joined by doctors from top hospitals from all over the country, as well as medical experts from the Centers for Disease Control and Prevention, the American Cancer Society and various chapters of the Susan G. Komen Breast Cancer Foundation.

?Click here for the full transcript of the chat. Read on for the highlights.

What are the risk factors for breast cancer?

Most breast cancer patients don’t have any known risk factors. However, the chance of developing the disease increases with age, obesity, increased breast density and history of previous cancer treatments.

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A woman is also more likely to develop breast cancer if an immediate relative is diagnosed with the disease before age 50. Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk. And women who began menstruating early or go through menopause after the age of 55 may have an increased risk, possibly due to a longer lifetime exposure to the hormones estrogen and progesterone.

Overall, white women are slightly more likely to develop breast cancer than are African-American women, but African-American women are more likely to die of this cancer.

What gene mutation increased Angelina Jolie’s risk of breast cancer?

BRCA1 and BRCA2 are genes that help suppress tumors. Angelina Jolie was diagnosed with an inherited mutation of the BRCA1 gene, which increased her risk of developing breast cancer and ovarian cancer.

Not all BRCA variants are as dangerous and only about 5 to 10 percent of breast cancer cases are associated with genetic mutations. Additionally, not all children or relatives will inherit those mutations. Doctors recommend genetic testing for high-risk patients like Jolie, who has a strong family history of breast cancer.

Are pre-emptive bilateral mastectomies the only course of treatment in a high-risk situation like Jolie’s?

Jolie chose to have a prophylactic bilateral mastectomy to remove both of her breasts, which has been found to greatly reduce the risk of breast cancer. But it doesn’t entirely eliminate risk, and this isn’t the only choice for someone faced with a similar diagnosis.

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Two other options exist for women at high risk of developing breast cancer: They can monitor their health more frequently, alternating a mammogram and MRI of their breasts every six months. Or, they can undergo preventive chemotherapy.

The number of patients opting for prophylactic mastectomy is increasing. A 2008 study in the International Journal of Cancer found that about 36 percent of American women with a BRCA1 or BRCA2 mutations chose to have both breasts removed.

What can the average woman do to prevent breast cancer?

Maintaining a healthy lifestyle through exercise, weight control and limiting alcohol can help prevent breast cancer. For a typical woman who doesn’t have any risk factors for the illness, the American Cancer society recommends a yearly mammography screening after age 40. The U.S. Preventive ?Services Task Force recommends regular mammograms every two years for all women between the age of 50 and 74.

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Benefits, Risks of Removing Ovaries

Should you have your ovaries removed if you are BRCA positive?

This is a question that every board-certified gynecologist is used to discussing with a patient who has recently undergone BRCA testing.? As with any such discussion, I feel it’s key to explain all the risks, benefits and alternatives.? That is to say: What are the risks of doing surgery and the risks of not?doing surgery? What are the benefits to doing surgery and the benefits of not doing surgery??In reality, this is a decision that a woman needs to make with her family and her physician, and it’s complicated.

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For the average woman, the lifetime risk for ovarian cancer is 1.3 percent (compare to the lifetime risk for female breast cancer of 12 percent in an average woman).? It represents the most lethal cancer for women, although it is far from the most common.? Part of the reason this cancer is so deadly, and is often referred to as the “silent killer” of women, has to do with anatomy.

The ovaries, which produce sex hormones, are walnut-sized glands that sit free in the pelvic cavity, tethered to the sides of the pelvis.? When a cancer develops in the ovary, it can grow to a large size before producing significant signs or symptoms.? It can also “seed” the cancer throughout the pelvis and abdominal cavity because the ovaries are not wrapped in any covering that separates them from other organs.

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The most concerning symptoms of ovarian cancer are bloating, increased urination and pelvic pain/ pressure that occurs more than 50 percent of the time for a period of more than a few weeks. Other symptoms include early satiety, increasing abdominal girth and a change in weight or bowel habits.

Now the nitty gritty: What are the risks of the surgery to remove your ovaries?? Today, this is a surgery that is done laparoscopically (through 1 centimeter incisions in your abdomen) and typically takes less than one hour in skilled hands.? For women who are BRCA positive, the fallopian tubes are removed with the ovaries because they can develop the same cancer as the ovaries.? The uterus does not need to be removed, so the surgery is not called a hysterectomy but a bilateral salpingoophorectomy (or BSO).? Often, patients go home the same day or the day after surgery.

The risks are similar to any surgery and include bleeding, infection, damage to other nearby organs and those associated with general anesthesia.? Recent data has shown that women who have their ovaries removed for benign reasons have a slightly increased risk of cardiovascular issues.? Also, a woman having her ovaries removed will go through immediate surgical menopause, and the process may cause hot flashes, vaginal dryness and osteoporosis, among other associated low-estrogen-state side effects.? The risk of ovarian cancer following surgery does not drop to zero because cancer cells may have escaped before surgery occurred, and women can develop a variant called peritoneal carcinomatosis.

What about the risks of not having surgery?? With a BRCA1 mutation, a woman can have as high as a 50 percent increased risk of developing ovarian cancer, and that cancer tends to occur at a younger age than in women who develop the sporadic type of ovarian cancer.? Increased surveillance in women who choose watchful waiting include physical pelvic exams, pelvic sonograms and ovarian tumor marker blood tests.? But it is important to note that there is no generally accepted screening test for ovarian cancer, the way a mammogram (while not perfect) is an accepted screening test for breast cancer.

Now for the benefits of surgery. Women with a BRCA mutation who remove their ovaries and fallopian tubes have a significantly lower risk of developing ovarian cancer.? This risk drops far below that of the average woman.

The benefits of not having surgery is the avoidance of the above-mentioned risks that accompany this procedure.

Options for reducing risk of ovarian cancer include taking oral contraceptives or the birth-control pill, which has been shown to dramatically reduce the risk of cancer by as much as 60 percent in women who have taken the pill for three or more years.? There may be a similar protective effect with breast-feeding and full-term pregnancies because of the theory that the ovaries are spared the hormonal stimulation and damage to the ovarian cortex with all of these situations.? Diets high in fruits and vegetables have also been associated with a reduced risk of ovarian cancer.

The emotional toll of either option can be significant for a woman and her family.? Every woman feels differently about living with risk. Every woman is entitled to her opinion and decision.? My hope is for a BRCA-positive woman considering this surgery to discuss these issues with a?gynecologic?in addition to her general OB-GYN.? There is no such thing as minor surgery, even if it is a same-day procedure.? All aspects, the physical, psychological, financial and social, should be considered before a plan is made.? Understanding the risks, benefits and options/alternatives are at the foundation of any good decision-making process.

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Weighing the Risks and Benefits of Tamoxifen and Raloxifene for Breast Cancer Prevention

Researchers have developed a tool that can help guide decisions about which drug—tamoxifen or raloxifene (EvistaR)—is the best choice for breast cancer prevention in high-risk postmenopausal women. These results were published in the Journal of Clinical Oncology.???

Drugs that block the effects of estrogen have been shown to reduce the risk of breast cancer in women at high risk of the disease. Two drugs that have been approved for breast cancer risk reduction in certain groups of women are tamoxifen and raloxifene. Tamoxifen is approved for breast cancer risk reduction in women who are at high risk of the disease (including high-risk premenopausal women). Raloxifene—originally approved for the prevention and treatment of osteoporosis—is approved for breast cancer risk reduction in postmenopausal women with osteoporosis or postmenopausal women at high risk of breast cancer.??

To help postmenopausal women and their healthcare providers evaluate the likely effect of each drug, researchers developed a benefit-risk index. In addition to considering the extent to which each drug reduced breast cancer risk, the researchers also assessed other health outcomes, such as bone fractures, blood clots, stroke, and endometrial (uterine) cancer.???

The researchers found that the risks and benefits of tamoxifen and raloxifene vary by a woman’s age, race/ethnicity, risk of breast cancer, and whether the woman has had a hysterectomy.????

The researchers write “By combining this information with information on clinical features and personal preferences, the health care provider and patient can make an informed decision.” The researchers provide tables to help specific subgroups of women evaluate the likely benefit (or harm) of each drug.?

Women who have a high risk of breast cancer as a result of their family or personal medical history may wish to talk with their doctor about ways to reduce their cancer risk.?

Reference: Freedman AN, Yu B, Gail MG et al. Benefit/risk assessment for breast cancer chemoprevention with raloxifene or tamoxifen for women age 50 years or older. Journal of Clinical Oncology. Early online publication May 2, 2011.?

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