Breast and Ovarian Cancer Risk Assessment

Overview of Breast and Ovarian Cancer

Breast cancer is a common disease affecting more than 180,000 women and 1,600 men each year. A woman’s lifetime risk for developing breast cancer is about 1 in 8 or 12%. The lifetime risk for ovarian cancer is 1 in 70 or 1.4%. Because breast cancer is common, many women will have one, two or even more relatives with breast cancer just by chance. It is also possible for the cancer to be caused by an inherited genetic alteration in one of the genes for breast and ovarian cancer. These genes are known as BRCA1 and BRCA2 (for the first and second breast cancer genes to be identified). Individuals that have a genetic alteration in one of these genes will have a significant increase in their risk for breast and ovarian cancers. Only 5-10% of all breast and ovarian cancer is thought to be inherited.

The Genetics of Breast/Ovarian Cancer

We receive our genetic information from both of our parents. The genetic information tells our body how to grow and function. The individual pieces of genetic information are called genes. Each person has two copies of about 100,000 genes. Sometimes a change occurs in a gene which stops the gene from working properly. Such a change is called a "mutation" or "alteration". We know that some genes function to protect our body from developing cancer. If a person has a mutation in a cancer-protection gene, that gene does not work properly and the person has a higher chance of developing cancer. This is genetic susceptibility to cancer. If an individual has a genetic alteration that results in an increased susceptibility to cancer, they will have a 50% chance to pass this genetic alteration on to their children. This alteration can be passed down from the maternal or the paternal side of the family. Women with an alteration in BRCA1 have an increased susceptibility to develop breast and/or ovarian cancer and men have an increased susceptibility for developing prostate cancer. Women with an alteration in BRCA2 have an increased susceptibility to develop breast and/or ovarian cancer and men have an increased susceptibility for developing breast and/or prostate cancer.

Ashkenazi Jewish Ancestry

Alterations in BRCA1 and BRCA2 have been found in all races and ethnic groups but, in some populations, specifically the eastern European (Ashkenazi) Jewish population, mutations in these genes are more common. Individuals of Ashkenazi Jewish ancestry with one or more relatives with early onset breast or ovarian cancer at any age may be appropriate for genetic testing. It has been estimated that approximately 1 in 40 (2.4%) individuals who are of Eastern European Jewish descent carry one of these three alterations. Individuals that test negative for these three common genetic alterations should proceed to have full gene sequencing. Researchers are now beginning to identify other common genetic alterations in the BRCA1 and BRCA2 genes found in other ethnic populations such as Iceland, The Netherlands, Belgium, Finland, Sweden, South Africa, and France.

The Characteristics of Hereditary Breast/Ovarian Cancer

Personal or family history of the following:

• Pre-menopausal breast cancer with or without ovarian cancer
• Breast cancer in both breasts (bilateral)
• Ovarian cancer at any age
• Breast and ovarian cancer within the same individual
• Breast cancer in a male
• Genetic alteration identified in BRCA1 or BRCA2

Cancer Risk Assessment

Cancer risk assessment provides information about cancer risk, cancer screening, and genetic testing that is based on family and medical history evaluation. Genetic counselors, medical geneticists, and medical oncologists help individuals and their families understand how certain cancers may cluster in families and what preventative measures are available to lessen the risk to individuals. The cancer risk team will help individuals and families explore the risks, benefits, and limitations of current genetic testing methods and will help determine whether a family would be appropriate to consider the option of genetic testing. Genetic testing, and the results that it provides, may alter your personal surveillance strategy and modify the risk for other family members to develop these types of cancer.

Once your cancer risk appointment is completed, you will receive a personally tailored letter detailing appropriate cancer surveillance and prevention strategies. Genetic counseling and cancer risk assessment can be of benefit to anyone with concerns regarding their risk for developing cancer even without a desire to pursue genetic testing.

What happens during an appointment for cancer risk assessment

The risk assessment team will provide an estimation of a person’s risks for specific cancers based upon age, family history, and other risk factors. It is important to provide the cancer risk team with accurate family history information including the types of cancers in your family and the ages at which they occurred. It is often helpful to obtain medical records and death certificates whenever possibly in order to verify each cancer diagnosis. The cancer risk team will discuss the possible role of genetics in a person’s family, the emotional issues regarding the risks of cancer, cancer screening and cancer risk reduction recommendations tailored to the individual’s level of risk, and the availability of genetic testing for certain cancers including the risks, benefits, and limitations of genetic testing. At some centers, it may also be possible to have a physical examination by a clinical oncologist or gynecological oncologist during your visit. While anyone can benefit from cancer risk assessment, it may be especially helpful for individuals that have a parent or sibling with cancer, breast and other cancers within a family with early ages of occurrence, multiple first or second-degree relatives with breast or ovarian cancer, if a genetic alteration in a BRCA gene has been identified in the family, if there is male breast cancer in the family, or if someone is just anxious about breast cancer in general.

Genetic Testing

Genetic testing to determine if an individual or family has a breast cancer gene alteration is offered to appropriate families following cancer risk assessment. Currently, genetic testing is available for BRCA1 and BRCA2 mutations on a clinical basis. Mutation testing is most informative when performed on a family member that has had cancer. If a mutation is identified in that individual, this will assist with their cancer management. Once a mutation is identified in a family, anyone can be tested for that specific mutation. Traditionally the consideration of genetic testing takes place in a multi-step format. Many centers require that the individual considering testing have a complete educational session with a genetic counselor. At this appointment the risks, benefits, and limitations of genetic testing are reviewed extensively. It is important for individuals being tested to understand the value of the information that testing provides, how it will affect future surveillance for them and other family members, and the impact that this information may have on themselves and their children. After taking some time to think about the option of genetic testing, this individual can schedule a 2^nd appointment and return to the clinic to ask additional questions and have blood drawn. The results of testing typically take between 4 to 6 weeks at which time a third appointment is scheduled to review these results.

If an alteration in the BRCA1 and BRCA2 genes is not identified, it is possible that a different cancer susceptibility gene is responsible for the cancer in the family and does not necessarily mean that the breast cancer is not inherited in your family. Options for cancer prevention and surveillance would be based on the genetic risk assessment.

Management options for mutation carriers or patients at moderate-to-high risk for breast and/or ovarian cancer:

Cancer surveillance recommendations and strategies will be made based upon the outcome of a patient’s cancer risk assessment appointment. For women who are BRCA1 or BRCA2 mutation carriers, the current management options are increased screening and prophylactic (preventative) surgery. Breast screening options include: monthly self-breast exams, breast exams annually or biannually by a specialist, annual or biannual mammography. Ovarian screening options include: annual pelvic exams, transvaginal ultrasound and CA-125 blood test. Preventative surgery options should be discussed with specialists. Additionally, a chemoprevention agent called Tamoxifen has been approved for use in women at increased risk for breast cancer. The risks and benefits of taking Tamoxifen should also be discussed with a specialist. There may also be clinical trials that patient’s may be eligible for participation in that may reduce their risk for breast or ovarian cancer.

Other issues:

Many people are concerned that genetic testing may be used by employers or insurance companies to discriminate against those at increased risk for cancer. Legislation exists to protect individuals in large group health insurance plans, but this has not been sufficiently tested in court. Furthermore, life and disability insurance policies are not protected. Many individuals choose not to inform their insurance companies about the testing in order to avoid this issue and choose to pay for testing out of pocket. This is an important issue that can be discussed with the cancer risk assessment team.

There is no reason to be concerned about insurance discrimination following a genetic counseling/cancer risk assessment appointment. Individuals seek genetic counseling for a multitude of reasons and it has not been known to adversely affect insurability. Many insurance companies will pay for the cost of counseling and genetic testing. Lately, President Clinton signed an executive order prohibiting genetic discrimination for Federal employees.

Confidentiality is, of course, of paramount importance in cancer risk assessment. Most risk evaluation programs have careful safeguards to help ensure that family and medical history information as well as genetic testing results are not released to anyone without written consent from the individual concerned.