Breast Cancer
Carrying a BRCA alteration significantly increases your risk of developing breast cancer. Both men and women at a higher risk of cancer should regularly check their breasts/chest for changes. Breast Cancer Care has resources on checking your breasts and what to expect at screening appointments on their website.
Surveillance
MRI
From the age of 30-49, women with BRCA alterations or women who have a strong family history of breast cancer will be offered an annual MRI. An MRI is a medical imaging test that does not involve radiation and can screen your breasts to spot any cancer from an early stage.
Mammography
A mammogram is a breast X-ray and will be offered to women with a BRCA alteration or those who are at increased risk due to family history usually once a year from the age of 40-69. Mammograms are not often used before the age of 40 as younger women’s breast tissue can be dense which can make the X-ray image less accurate. MRIs and mammography will not prevent cancer but may detect it early, when it is easiest to treat.
If on MRI or mammography there is any concern, you will be offered a biopsy. With any surveillance process there is the risk of false positive results. This means that the biopsy result does not show the presence of a cancer.
Risk-reducing surgery
A number of women with BRCA1/2 alterations decide to undergo bilateral risk-reducing mastectomies (removal of both breasts). This is undertaken by a specialist breast surgeon following extensive counselling. This operation removes as much breast tissue as possible in order to reduce the risk of developing breast cancer and can reduce the risk by about 95%
Following surgery, you will be offered reconstruction. There are many different types of reconstruction – some use implants or expanders and others your own body tissue. Discuss all the options with your surgical team.
Chemoprevention
If you have not had a diagnosis of cancer and are not considering risk-reducing surgery, you may be offered chemoprevention. Chemoprevention is the use of medication to lower the risk or prevent cancer in healthy people. Studies have shown that taking a course of Tamoxifen, Raloxifene, or Anastrozole if you’re post-menopausal, for 5 years can lower your breast cancer risk.
As with all medications, there are side effects that you will have to consider and discuss in depth with your medical team.
Male breast cancer
Men who inherit a BRCA2 alteration have an increased risk of developing male breast cancer. Due to the strong association between male breast cancer and BRCA2 alterations, close relatives (siblings, parents, children) of a man diagnosed with breast cancer may want to ask their GP for a referral to their local genetics centre to discuss BRCA testing.
The lifetime risk of developing breast cancer is approximately 1% with the BRCA1 gene alteration and 10% with a BRCA2 gene alteration. The majority of male breast cancers happen in men who have no family history and no inherited gene alteration.
Ovarian Cancer
Surgical options
Risk reducing Salpingo-Oophorectomy
Currently the only proven way to avoid ovarian cancer developing if you have a BRCA 1/2 alteration is to have risk-reducing surgery: an operation which involves removal of both ovaries and fallopian tubes. Although, there is a residual risk of peritoneal cancer (peritoneum is the lining of the tummy or abdomen) of approximately less than 4%
This type of operation is offered to women who have completed their family from the age 35 – 40 years in BRCA1 alteration carriers and from 40 – 45 years for BRCA2 alteration carriers. However, women may decide against having surgery or delay until they reach menopause naturally.
Women with BRCA1/2 alterations in the UK are not routinely offered a full hysterectomy (removal of the womb). But if deemed beneficial, in certain cases this may be done.
Risk Reducing Early Salpingectomy with Delayed Oophorectomy
There is increasing evidence that many ovarian cancers start in the fallopian tubes. A UK clinical trial called PROTECTOR, supported by The Eve Appeal, is currently offering risk reducing early salpingectomy (removal of fallopian tubes) with delayed oophorectomy (removal of ovaries).
Removing the tubes is expected to provide some level of protection against ovarian cancer in women who do not wish to remove their ovaries, so that they can preserve their fertility and hopefully avoid early menopause. However, the exact level of protection against ovarian cancer and the impact on the ovaries from removing the Fallopian tubes is not yet known.
Menopause
Following a risk reducing Salpingo Oophorectomy, a premenopausal woman will go straight into surgical menopause. This early menopause is associated with symptoms like hot flushes, sweats, mood swings, reduced libido (sex drive), an increased risk of heart disease, thinning of the bones (osteoporosis) and forgetfulness.
Hormone Replacement Therapy (HRT) can help to reduce the symptoms of menopause and protect the heart and bones. However, a number of women who have had a prior diagnosis of breast cancer may not be able to take HRT. There are alternative non-hormonal options that can be tried to help relieve symptoms. Your medical team will be able to answer your questions about HRT use and you may be able to ask for a referral to a specialist menopause clinic for advice.
Surveillance options
In the UK there is currently no routine screening programme offered by the NHS for ovarian cancer – even for those who are at higher risk of ovarian cancer developing.
Recent research, including the UKFOCSS trial, supported by the Eve Appeal, found that for women delaying risk-reducing surgery, ROCA (Risk of Ovarian Cancer Algorithm) testing provides a way detecting ovarian cancer earlier, when less extensive surgery is needed to remove it. ROCA looks at how fast the level of CA125 changes in the blood, and compares this to the woman’s previous CA125 results and a large database of results from women with and without ovarian cancer.
The NHS will consider the results of this trial and others when deciding on whether surveillance should be offered to women who want to delay or decline risk-reducing surgery.