From Cynthia Chua, M.D., OHC Principal Investigator, Gynecology Oncology Clinical Trials

September 24, 2013

Angelina Jolie’s decision to undergo a double mastectomy after learning she carried the BRCA-1 gene mutation has created a stir among U.S. women – with an estimated 6 million planning to ask their doctors about genetic testing, a new Harris Interactive/HealthDay poll shows.

While a small number of these concerned women may ultimately choose genetic testing, their questions are part of a growing conversation about breast cancer that can benefit all women. Here are some questions your patients may raise now, along with helpful perspectives you can share.

Dr. Cynthia Chua, OHC Medical Oncologist specializing in breast cancer.

OHC Medical Oncologist Dr. Cynthia Chua specializes in breast cancer and works out of our Blue Ash and Wilmington, Ohio offices.

Should I be screened for inherited breast cancer risks?

Patients may be surprised to learn that fewer than 5 percent of all women in the U.S. test positive for the BRCA-1 and BRCA-2 mutations that signal elevated risks for breast cancer as a result of a genetic mutation. But these genes have been linked to hereditary breast and ovarian cancer, and men and women with harmful BRCA-1 or BRCA-2 mutations may be at an increased risk for other cancers as well. If your patients want to learn more about BRCA genes, please direct them to the National Cancer Institute fact sheet.

Creating a detailed family history is the best way to help your patients determine whether genetic testing is right for them. Women of Ashkenazi Jewish descent are often counseled to undergo testing, as are those who have:

  • A mother or sister diagnosed with breast cancer before age 60.
  • Any first-degree relative who developed breast, ovarian, or colon cancer, especially at earlier ages.
  • A high incidence of cancer among all relatives, including grandparents, aunts, and uncles as well as parents and siblings.

Patients who decide to undergo genetic screening will find excellent resources in our area. These include the testing and counseling centers at Cincinnati Children’s Hospital Medical Center (513-636-4760) at its main campus and several of its satellite offices and St. Elizabeth Medical Center (859-301-5396) in Northern Kentucky.

What other screening tests can make a difference?

Breast self-exams, although not guaranteed indicators, are a valuable tool for all women starting in their early 20s. Step-by-step guides from the American Cancer Society and Susan G. Komen can help your patients learn the right techniques. Points to emphasize:

  • Perform exams at the same time each month. Premenopausal women should examine their breasts a day or so after the end of their menstrual cycle.
  • Healthy breasts often have lumps and bumps. The key is for women to learn how their own breasts look and feel so they can detect changes and discuss this with their healthcare professional for further evaluation.

Women under age 40 have denser breast tissue, which makes mammography a less effective screening tool. Since the average age for first breast cancer diagnosis in the U.S. is 60, it’s wise to limit radiation exposure among younger women.

Presently, there is contradictory recommendations on the age that women should begin to receive regular mammograms.The U.S. Preventive Services Task Force (USPSTF) has recently recommended sweeping changes in its breast cancer screening guidelines. The USPSTF, which is a group of independent health experts convened by the Department of Health and Human Services, reviewed and commissioned research to develop computer-simulated models comparing the expected outcomes under different screening scenarios.

Here are the USPSTF’s recommendations, based on all that work:

  • Routine screening of average-risk women should begin at age 50, instead of age 40.
  • Routine screening should end at age 74.
  • Women should get screening mammograms every two years instead of every year.
  • Breast self-exams have little value, based on findings from several large studies.

The American Cancer Society continues to recommend annual mammography screening for all healthy women beginning at age 40 with no end age. Just recently a team of researchers led by Dr. Blake Cady of Massachusetts General Hospital identified women diagnosed with breast cancer between 1990 and 1999 at two Boston hospitals and tracked their cases until 2007. They found that out of 609 confirmed breast cancer deaths, 395 of these women — 71 percent — never had a mammogram prior to diagnosis.  Moreover, half of the breast cancer deaths in the study were in women younger than 50. Only 13 percent of breast cancer deaths occurred in women 70 or older.

According to the USPSTF, its recommendations don’t apply to women with risk factors for breast cancer, such as BRCA mutations or a close family history of the disease. The American Cancer Society defines high-risk as women with a greater than 20 percent lifetime risk of breast cancer. This includes women with BRCA-1 and BRCA-ED2 gene mutations and women who have not been tested but have a parent, sibling, or child with a BRCA mutation, as well as certain other groups of women. The American Cancer Society recommends that high-risk women have annual mammograms along with an MRI beginning at age 30 and continuing for as long as they are in good health.

Women with a 15 percent to 20 percent lifetime risk for breast cancer are considered to have a moderately increased risk for the disease. The American Cancer Society recommends that these women talk to their doctors about the benefits and risks of adding an MRI to annual mammogram screening.

So, given these seemingly contradictory recommendations, where does that leave women?  Clearly, everyone agrees that if a woman has any of the risk factors described above, she should begin mammograms early and discuss with her physician whether MRI exams should be part of her screening regimen. For a woman who does not fit within the higher risk profile, she should speak with her physician about the risks and benefits of these medical tests and determine which guidelines are appropriate given her individual considerations.

I’m a breastfeeding mom with a painful lump in my breast. How can I make sure it’s not cancer?

Most breastfeeding mothers with lumps or inflammation are suffering from infections, which should yield to antibiotic treatment. The chances that symptoms are caused by inflammatory breast cancer are very low, but if the condition does not resolve quickly with standard treatment, the patient should see a breast health specialist.

The good news is that 80 percent of survivors will enjoy the same life span as those who’ve never had breast cancer. But all survivors should take these steps to prevent recurrence:

  • Continue with regular self-exams. Those who’ve undergone surgery may need hands-on help learning how to examine their “new” breasts.
  • Comply with medications. Tamoxifen and other once-daily prescriptions can be easily forgotten. Discuss simple strategies for taking all doses as prescribed.
  • Maintain a healthy weight. Studies show this makes a critical difference, so patients should be counseled to eat wisely and exercise often to achieve a healthful weight.
  • Limit alcohol intake. Studies show that a single glass of red wine enjoyed daily may promote cardiovascular health, but survivors should observe the one-drink limit.

Leading the way in women’s health

At OHC, our goal is to work with you in caring for the needs of the whole patient. Our board-certified breast oncologists are available to discuss your questions on breast cancer screening, genetic testing, and all related topics. Learn more about breast cancer in our OHC Cancer Database.

OHC is proud to take part in many clinical trial programs, including the only Phase I clinical trial serving ovarian cancer patients in southwest Ohio. Learn more in our clinical trials update.

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