Hulick, MD, MMsc, Medical Geneticist at NorthShore, discusses the increased risk for breast and ovarian cancer in women who carry the BRCA1 and BRCA2 gene mutation. He responds to the recent study from the
Journal of Clinical Oncology on the impacts these mutations have on women as well as identifies ways women can minimize their risk.
What are your general impressions of the new study?
The study, particularly given its size, helps further parse out the details of risk differences between BRCA1 and BRCA2. There have been retrospective studies that have suggested this, but here we have a prospective study that adds further evidence.
In addition, it looks at overall reduction in mortality which shows the gains go beyond the ovarian cancer risk reduction.
Who is most at risk for having the BRCA1 and BRCA2 mutation?
There are many potential ways someone can be at risk, but certain characteristics stand out:
Ultimately, if you have been diagnosed with breast and or ovarian cancer, or multiple family members have, you should discuss the family history with a cancer risk specialist.
What is the difference between the two genes?
Both genes are involved in how the body repairs DNA damage that accumulates and maintaining the “checks and balances” that control cell growth. As this study reinforces, there are differences in cancer risks associated with each. While the risk for ovarian
and breast cancer might be somewhat lower for BRCA2 than BRCA1 (though still considered high compared to average risk), BRCA2 mutation carriers tend to have higher risk for other BRCA-related cancers (e.g. pancreatic, prostate).
What preventative measures can women engage in to minimize their risk of breast and ovarian cancer?
The first step is to get an accurate assessment of one’s risk. Women may still be at elevated risk even if BRCA testing is negative. Other genes and non-genetic factors contribute to ovarian and breast cancer risk. Depending on the risk level, certain
options exist for increased screening, preventative medications or preventative risk-reducing surgery. This is a complex and very personal decision and accurate information about risk is key.
What screening options are available for women to learn more about their risk?
The first thing women can do is to get an accurate family history from BOTH sides of the family, then discuss with one’s physician.
What next steps would you recommend for women with the BRCA1 / BRCA2 mutation?
I would recommend women talk to their doctors about speaking to someone familiar with cancer genetics such as a geneticist, a genetics counselor, or a gynecologist/oncologist/breast surgeon knowledgeable about the management of BRCA carriers. There
are online resources from Be Bright Pink and FORCE that can be helpful in understanding the implications of having BRCA mutation and putting in a plan to reduce risk. As this study and others have shown, we have the ability to greatly reduce one’s risk if
we know one faces these risks.
A mutation found in the BRCA1 and BRCA2 genes puts women at an increased risk for developing breast and ovarian cancer. After learning that both her aunt and mother had the BRCA1 mutation,
Sivan Schondorf was tested for the mutation at 24 years old and discovered that she was also positive. She began frequent surveillance for breast and ovarian cancer immediately. At 28, when she felt that surveillance was no longer enough, she
opted to take control of her risk and undergo a preventative, nipple-sparing mastectomy with reconstruction at NorthShore.
With BRCA1 and BRCA2 in the news, she shares her story so that other women know how to find the correct information about their risks and options.
What were your initial thoughts when you learned you tested positive for the BRCA1/BRCA2 gene mutation?
I was sad and worried to learn I had a BRCA 1 mutation, but I was able to push a lot of that fear aside because I was still years away from the recommended surgery time. I was 24 years old at the time.
What prompted you to get tested for this mutation? And then why did you decide to undergo a risk-reducing, nipple-sparing mastectomy with reconstruction.
My maternal aunt had what is now known as a triple negative BRCA1 breast cancer that metastasized and resulted in her passing before she was 50 years old. Our family OBGYN, Dr. Lapata, had good instincts and recommended that she test for the BRCA mutation.
The red flags being that she had a cancer that was premenopausal and aggressive, and that she was of Ashkenazi Jewish descent.
This was in 2000, so it wasn't something any of us had heard of. Once my aunt tested positive for the mutation, my mother found out she had the mutation as well. I was subsequently tested in 2005 and with a positive result, I opted for surveillance. At 24,
I thought I was years away from any possible surgical interventions; however, after only after three years of surveillance, I felt the threat of cancer looming. I realized that surveillance wasn't protecting me; it was only enabling me to discover it at an
early stage. The only way to significantly lower my risk was mastectomy, so I scheduled my surgery for the next year, which was around my 28th birthday.
The nipple-sparing one-step was the best option for me because it required less surgery than having expansion over time. I was also comfortable keeping my nipples because, aside from the more natural, aesthetic result, research shows that keeping one's nipples
is safe as long as the surgery is done preventatively rather than when cancer is present.
How has this decision impacted your life?
In the very short-term, I felt different from my friends because I was thinking about things that women my age don’t normally have to think about. My thoughts were often on my situation. Five years later, as a working mother and wife, I hardly ever
think about it, except at my yearly clinical exam. It's something from my past that I faced head on.
I’m so much more comfortable now that my risk for breast cancer is so much lower. I do still monitor my ovaries at least twice a year. I have not yet pursued surgical intervention because I’m not done having children and do no feel the cost-benefit of beginning
menopause at 31 is worthwhile. I’m looking at having an oopherectomy by age 40.
It’s been a few years since you had this surgery. How are you doing?
I'm great! Having a baby (and now expecting my second) has done far more to change my body than the mastectomy did. I don't regret it for a second. I would do anything to improve my chances of being around to see my children grow. I want to be there
for them as long as I possibly can. Clearly, Angelina Jolie felt the same way, and I’m proud to have been one of her trail blazers!
What advice would give to women who are at an increased risk of developing breast cancer?
Every woman comes to a decision and place of acceptance differently. We all have different perceptions of our bodies and what we can and can't live without. Some have lost mothers due to this mutation and some find out about BRCA unexpectedly, without
even knowing about the elevated risk of cancer in their families.
Each woman must decide what level of risk she can live with. After watching my Aunt Linda die so quickly from this insidious disease, and also having my mother as a role model for me when she had her surgery, I decided that surgery at an early age was right
for me. It doesn't mean its right for everyone.
The most important thing is for women to have the most accurate information, which they can get from genetic counselors and doctors. They should also seek support from the local BRCA community so they can make informed decisions and have the emotional support
that a community can provide. FORCE (Facing our Risk of Cancer Empowered) has provided my family with that support, and we try to give back to our community as much as possible.
Is there any other information you’d like to share?
I filmed my surgery process at NorthShore’s Evanston Hospital and at home in order to help empower other women and to make the experience more meaningful for myself. Because I'm not a filmmaker, I have not yet been able to edit the hours of footage.
Seeing Angelina Jolie come out to the public has reignited my passion to finish this short film, which I hope will help other women.