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Options for Women at High Risk

 
Women with a strong family history of breast cancer and women who carry a harmful mutation in the BRCA1 or BRCA2 genes are at an increased risk of developing breast cancer. Women who fall into these high-risk categories are often advised to begin screening for breast cancer earlier and undergo more frequent screening; however, screening only serves to catch cancer early when it’s most treatable — it doesn’t lower the risk of breast cancer.

For those women who fall into a high-risk category, they may opt to take more aggressive preventive measures in order to reduce their risk of developing the disease. There are several options to consider, such as the use of anti-estrogen therapy, and the preventive removal of the breasts and/or ovaries.

Choosing aggressive preventive measures is an extremely personal decision. If you’re at high-risk for developing breast cancer, it’s crucial that you discuss your options with a health care provider who can help you make the most informed decisions.
 

Anti-Estrogen Therapy

 
Anti-estrogen therapy refers to the use of drugs to block the effects of estrogen. This is the least invasive approach to prevention—but only serves a certain subset of women. Anti-estrogen therapy can reduce the risk of developing estrogen-receptor positive breast cancer.

There are currently two drugs that are FDA-approved for breast cancer prevention: tamoxifen and Evista® (raloxifene).

  • Tamoxifen is approved for breast cancer risk reduction in women who are at high risk of the disease (including high-risk premenopausal women).
  • Evista — originally approved for the prevention and treatment of osteoporosis — is approved for breast cancer risk reduction in postmenopausal women with osteoporosis or postmenopausal women at high risk of breast cancer.

Both drugs are taken orally. Tamoxifen is more effective than Evista in reducing breast cancer risk; however, Evista has been shown to have fewer harmful side effects than tamoxifen.
 

Bilateral Prophylactic Mastectomy (Preventive removal of both breasts)

 
Bilateral prophylactic mastectomy refers to the removal of both breasts to prevent breast cancer. Women at high risk of breast cancer may reduce their risk of developing breast cancer by 90 percent by undergoing bilateral prophylactic mastectomy.

Prophylactic mastectomy is a drastic measure that may decrease emotional stress regarding the concern over developing breast cancer; however, it may also increase stress related with self-esteem, sexuality and femininity.

Some high-risk women choose this approach because it helps ease their worries about developing breast cancer. While this procedure can greatly decrease the risk of developing cancer, it is not a guarantee that cancer will not develop. Because a mastectomy does not remove all of a woman’s breast tissue, there is always a small chance that breast cancer could occur in the remaining tissue.

Women considering this procedure need to weigh the benefits against the consequences, which include the irreversibility of the procedure, the psychological impact and potential problems with implants and reconstructive surgery. The benefits of the procedure appear to be the greatest in younger women.
 

Prophylactic Oophorectomy (Preventive removal of the ovaries)

 
Prophylactic oophorectomy refers to preventive removal of the ovaries. The BRCA1 and BRCA2 genes increase the risk of both breast and ovarian cancer. Prophylactic oophorectomy is one option for reducing this risk—for both ovarian and breast cancer since some breast cancers grow as a result of hormones produced by the ovaries. The procedure lowers the risk of breast cancer by 40 to 70 percent and the risk of ovarian cancer by 70 to 90 percent.

Surgery doesn’t completely eliminate risk because some cells remain behind after surgery. Women with a BRCA1 or BRCA2 alteration who have had their ovaries removed have about half the risk of developing breast cancer as those who have not had their ovaries removed.

Adverse effects of prophylactic oophorectomy include the inability to have children and the development of menopausal symptoms such as hot flashes.



References:

  1. Rebbeck TR, Friebel T, Lynch HT et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: The PROSE study group. J Clin Oncol. 2004;22:1055-1062.
  2. Domchek SM, Friebel TM, Singer CF, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA. 2010; 304(9):967-975.
  3. Kauff ND, Domchek SM, Friebel TM, et al. Risk-reducing salpingo-oophorectomy for the prevention of BRCA1- and BRCA2-associated breast and gynecologic cancer: a multicenter, prospective study. J Clin Oncol. 26(8):1331-7, 2008.