Understanding Breast Cancer Risk 2

Autumn is officially here, and so is Breast Cancer Awareness Month! Everywhere you turn, there are pink ribbons promoting disease awareness, celebrating survivors, and emphasizing the importance of early detection with reminders to schedule your annual mammogram. Every October, we are reminded of how prevalent breast cancer is. In the United States, one in eight women will be diagnosed with breast cancer in their lifetime.

How do you know if you are at risk? Is having an annual mammogram enough? No need to worry. Dr. Sara P. Fogarty, DO, FACS, Associate Program Director of the Sandra & Malcolm Berman Comprehensive Breast Care Center at GBMC, provides insight on some of those worrying questions.

How is my risk of breast cancer determined?

There are a variety of factors that determine risk. The initial risk is assessed through a detailed conversation with your doctor, including family history. Knowing if a family member has ever been diagnosed with breast cancer, specifically your mother, grandmothers, and aunts from both sides of the family, is helpful to your healthcare provider. Knowing the age that they were diagnosed is also helpful. The more information you can give about your family history, the better!

Family history is not the only piece of the puzzle. Other questions your doctor will review will pertain more to you and your lifestyle.

• At what age did you have your first period?
• How old were you when you had your first child?
• Are you overweight?
• Do you have dense breast tissue?

All of this information creates a story that helps your doctor determine your level of risk.

Who should talk about their risk of developing breast cancer?

Dr. Fogarty recommends that all women ages 25 to 30 years old should have a formal risk assessment. This involves discussing family history and other factors with your primary care physician.

Your mother had breast cancer. What does this mean for you?

The risk for someone whose mother had breast cancer is higher than that of someone whose mother doesn't have breast cancer. However, the fact that your mother was diagnosed with breast cancer does not mean that you are destined to develop it. This is why your age, heritage, menstrual history, and reproduction history are all also considered.

How do I know if I have a gene that could cause breast cancer?

Not everyone needs to be tested for the breast cancer gene (BRCA1, BRCA2). Family history can determine if there is a likelihood of a breast cancer gene being present. Patients with a strong family history of the disease may benefit from a genetic test, which is the only way to definitively determine if you have the mutation.

Should I have genetic testing?

Speak to your provider to find out if you may be a good candidate for genetic testing. In the United States, only 5 percent to 7 percent of women actually have the BRCA1 or BRCA2 gene mutation that can cause breast cancer. Most people who develop breast cancer do not have a family history of the disease.

As a result, genetic testing "is a case by case situation," says Dr. Fogarty. For people who have a strong family history of this disease, she would recommend speaking to a breast surgeon about the test.

There are a variety of factors to consider when determining if genetic testing is right for you.

• Do you have family members who were diagnosed with breast cancer?
• How many family members were diagnosed?
• At what age were they diagnosed? Premenopausal or postmenopausal?
• What type of cancer did they have? (Ovarian, prostate, colon, uterine, melanoma, metastatic, and other cancers similar to breast cancer raise concern)

Each gene mutation can have an associated syndrome. Since ovarian and breast cancer are closely linked, a family history of ovarian cancer may indicate an increased list for breast cancer. This same principle can also apply to other cancers.

Dr. Fogarty recommends speaking with a specialist, such as a breast surgeon, if you are interested in having genetic testing or if your primary care doctor determines that you could be a good candidate after reviewing your risk history. A breast surgeon is the best person to determine whether or not a genetic test is necessary.

Once it is decided that you are a good candidate, a genetic counselor will perform the test. A genetic counselor is part of your healthcare team that provides risk assessment, education, and support to individuals and families at risk for or diagnosed with a variety of inherited conditions.

Testing for BRCA1 and BRCA2 gene mutations requires a blood or saliva sample. If there is a determination that you have a risk of other cancers as well, you may be offered more comprehensive genetic testing.

What imaging do I need if I am at a high risk?

You're high risk, so what's next? Dr. Fogarty recommends having an annual 3D mammogram, starting at age 35, followed by supplemental imaging (MRI) six months after the mammogram.

I want a mastectomy to reduce my risk. Is that appropriate?

It depends. If you've had genetic testing, and have BRCA1, BRCA2, P53, or PTEN genetic mutations, a mastectomy is an option, but it should be a last resort.

A mastectomy, even if performed prophylactically to reduce risk of contracting breast cancer, is a drastic surgery and should be treated as such. It requires a long recovery time, and it is not a way to reduce your risk of cancer to zero. Even with a mastectomy, you can still develop breast cancer.

The effects of this surgery can take a significant toll on your body, both physically and emotionally. Many women who chose to have a bilateral mastectomy (removal of both breasts) struggle with body image after the procedure. All of these factors should be considered and addressed in detail before a decision is made.

Patients are encouraged to speak with their provider about options available to them. Alternatives to surgery include the medication tamoxifen, which is a daily hormone blocking pill, and chemoprevention.

What's the first step if I have an irregular mammogram?

If your mammogram comes up back as irregular, the specialist will order a 3D mammogram along with an ultrasound for you. If concern persists, they will recommend a biopsy, and you will work with your provider to determine the best steps after that.