Life events are often hard to predict. But sometimes you can get a good picture of what is in store for you!
October is Breast Cancer Awareness Month. And medicine has good tests to predict if you are very likely to get breast cancer, a life-threatening illness. Angelina Jolie realized she had a higher-than-normal risk of breast cancer, since many women in her family had developed breast or ovarian cancer. But then she had a simple test for the genes BRCA1 and BRCA2 (which can be done on blood or even on a sample of cells from saliva). I am sure she was probably shocked to see that she had a gene mutation in the BRCA1 gene that indicated she had an 87 percent chance of getting breast cancer.
What would you do at that point if you had that family history and test result? Would you have more frequent mammogram, ultrasound, and MRI tests? Would you try medicines that can prevent half of breast cancers, medicines like tamoxifen, raloxifene, or aromatase inhibitors? Would you have the courage to prevent half of breast cancers by having your ovaries removed? Or would you have even more courage to have your breasts and ovaries removed, preventing over 95 percent of breast cancers (and over 95 percent of ovary and peritoneal cancers, also linked to BRCA 1 and 2 gene mutations)? What decision would you think best? Whom would you discuss this with? Whose advice would be most important to you?
Angelina Jolie showed us the logic of the surgical choice, which was a very courageous decision! She had a bilateral nipple-sparing mastectomy and a breast reconstruction so that the breast contours were restored and cosmetic effects would be minimal. She also had her ovaries removed. By having the courage to do the surgery, she regained confidence in the future and knew she had markedly reduced her risk of having to later face life changing cancer and all the treatments which would be required.
And more! Angelina Jolie had the courage to let the public know what she had done. In the context of each woman facing the fear of breast cancer, Angelina showed us that making such a decision is very appropriate for some women. This has lessened the fear of preventive (also called prophylactic) mastectomy. And nationally, there is a trend for more women to consider bilateral mastectomy, not only for prevention, but also for treatment of early stage breast cancer.
What should you do now? Here are Dr. Cary's tips for you.
• Know your family history of all cancers (and all diseases really) so you can begin to understand your risk of illnesses and breast cancer in particular. For help in knowing how to record your family history, see Appendix 1, a Sample Family History Form, in my book Surviving American Medicine.
• Discuss your family history with your primary care physician. If you doctor does not know how to evaluate your risk of breast cancer, ask for a second opinion from and oncologist or medical genetics expert. You can help your doctor evaluate your risk by filling out the breast cancer assessment tool from the National Cancer Institute.
• If you or your doctor thinks your risk of breast cancer is higher than normal, be certain to discuss your options. Get information about frequency of screening tests (breast self exam, doctor exam, mammogram, ultrasound, and beast MRI). Also ask for advice on medicines to prevent breast cancer (tamoxifen, raloxifene, and aromatase inhibitors) including benefits of risk reduction and side effects. Importantly, ask about if and when you might consider surgical options (removal of ovaries and tubes, and removal of breasts like Angelina with reconstruction). If the answers are not complete, get a second opinion.
• If you have a family history of breast or ovarian or peritoneal cancer, be certain to ask for evaluation of your genes (not only BRCA1 and 2, but also genes that less frequently have mutations that increase risk, like PALB2 or CHEK2). If your doctor does not know how to get the testing, get a second opinion.
• My specific suggestions for most of my patients are: If you have no increased risk of breast cancer, do your mammograms annually starting at age 40. If you have a slightly elevated risk of breast cancer or dense breasts, do the mammography screening and also MRI screening. If you have a moderate or high risk, consider screenings and medical therapy (tamoxifen, raloxifene or aromatase inhibitors) with your oncologist. If you have a gene mutation, consider surgery on your ovaries and possibly mastectomy/reconstruction. Discuss each of these with your own doctors! Since decisions depend on risk, get your risk assessment first.
All these questions to ask, answers to consider, tests and treatments to think about, is it all necessary? YES! In America, one of eight women will get breast cancer. If you have a gene mutation, your risk might be as high as 80 percent. Angelina may have been brave as Laura Croft in "Tomb Raider," but she was truly courageous in facing her breast cancer risk. Be like her to be confident in your future, and save your own life by paying attention to the very same issues that Angelina Jolie did.