Angelina Jolie going public with her decision to undergo a risk-reducing double mastectomy has caused many women to pause and consider what they might do in a similar situation.
We asked our breast care experts Dr. Pamela Wright and Dr. Rosalinda Alvarado, board-certified surgeons specializing in breast surgery at Suburban Hospital’s Breast Center, to give us insight into the issues surrounding BRCA genetic testing and risk-reducing mastectomies.
Q. Should the average healthy woman with no family history of breast/ovarian cancer undergo genetic testing?
A. No, it is not recommended because most patients are not gene carriers and most breast cancers are not caused by BRCA mutations. Patients that are at high risk because of a strong family history of breast cancer, a personal history of breast cancer, or other significant risk factors can meet with a multidisciplinary risk assessment team who use specific criteria to determine a woman’s risk of getting breast cancer and perform genetic testing when indicated.
Q. What choices do women with positive BRCA genetic results have to minimize their chances of future breast cancer?
A. Any patient who is found to have a BRCA mutation should meet with a multidisciplinary team, including a genetic counselor, a breast surgeon, a plastic surgeon and an oncologist to discuss the risks associated with their specific mutation and to understand their treatment options.
One option is to undergo increased surveillance with monthly breast self-exams, clinical breast exams with a physician every six months and yearly mammograms and breast MRIs. We usually stagger the mammogram and MRI six months apart so the woman is getting some sort of breast imaging every six months.
Another option is to undergo a bilateral salpingo-oophorectomy, removal of the ovaries and part of the fallopian tubes. This will decrease their risk of ovarian cancer (patients with BRCA mutations are at a significantly increased risk of ovarian cancer, as well.) If this is done prior to the onset of menopause, there is a 50 percent reduction in the risk of getting breast cancer.
To decrease one’s risk the most, a woman could choose to undergo a double risk-reducing mastectomy. Patients clearly need to understand the risks and benefits of surgery, the reconstructive options and how this decision may affect their quality of life. Patients undergoing this procedure should still strongly consider bilateral salpingo-oophorectomy to decrease their risk of ovarian cancer because ovarian cancer is difficult to detect early.
Preventive medications like Tamoxifen are also available as a treatment option.
Q. For a woman who tests positive for a BRCA gene mutation and is diagnosed with breast cancer, what are the treatment options?
A. Treatment options include a lumpectomy followed by radiation, or a bilateral total mastectomy with or without reconstruction. If choosing to undergo a lumpectomy, the risk of getting another breast cancer is significantly higher and these patients will need to continue with high-risk screening.
Q. How accurate are the BRCA tests?
A. No test is 100 percent accurate, but the BRCA tests are good at detection. It’s important to remember that just because there is a negative genetic test result doesn’t mean a person won’t get breast cancer. Roughly 20 percent of breast cancers are hereditary, of which 5 to 7 percent are believed to be caused by the BRCA genetic mutation. Therefore, about 80 percent of all breast cancers are not related to a hereditary cause.
Q. What are the typical concerns for women opting for a prophylactic mastectomy?
A. Patients are concerned about potential complications of surgery, recovery time/missing work, pain, and numbness in the chest wall area. They are also concerned about the cosmetic results. Will it look natural? Will people notice a difference? One option that has recently improved the cosmetic results is nipple areolar skin-sparing surgery. Recent studies show that in many situations it is safe to leave the nipple and areola.
Q. What is the process for breast reconstruction after mastectomy?
A. Patients have the option of reconstructing their breasts with either implants or their own tissue, most commonly from the abdomen. The first stage of reconstruction is usually done at the time of the mastectomy.
Q. How frequently does breast cancer still occur even after a prophylactic mastectomy?
A. Someone with a BRCA mutation has a 60 to 80 percent chance of getting breast cancer. Undergoing a risk-reducing mastectomy decreases their risk by about 90 percent, dropping their chances of getting breast cancer to less than 8 percent. After a bilateral mastectomy, a recurrence of cancer would be detected via a physical exam. Routine breast imaging is not necessary after a risk-reducing mastectomy.
Q. What if you don’t have access to your family history and don’t know if you’re at risk?
A. Women should remember that most breast cancer is not caused by a BRCA gene mutation. All women should have routine screening for breast cancer, which includes monthly breast self exams starting at the age of 18, yearly clinical breast exams starting at the age of 25 and yearly mammograms beginning at the age of 40. If a patient has any concerns that she may be at increased risk, she should contact Suburban’s Risk Assessment Program at 301-896-2445.
Q. Men can get breast cancer. Should they also be tested?
A. While men can get breast cancer, it is extremely rare, accounting for only 1 percent of all breast cancers. A man who gets breast cancer is at a higher risk of having a BRCA mutation and should get genetic testing. Anyone who has a first degree relative with the genetic mutation should get tested.
For more information about Suburban Hospital's Breast Center, please visit suburbanhospital.org/breastcenter.
Undergoing a bilateral mastectomy significantly reduces the risk of getting breast cancer. Angelina Jolie’s risk-reducing mastectomy was appropriate because of her situation. Keep in mind that breast surgery, like all surgeries, has risks associated with it. Jolie’s announcement should prompt women to ask more questions about their health care risks.
Meet the Physicians: Dr. Rosalinda Alvarado and Dr. Pamela Wright are board-certified surgeons specializing in breast surgery at Suburban Hospital’s Breast Center, part of the Johns Hopkins Breast Surgery Program. Their office is at 6420 Rockledge Drive, Bethesda. The office phone number is 301-530-5151. To reach the Suburban Hospital Risk Assessment Program call 301-896-2445.
Pamela A. Wright, MD, FACS is a board certified general surgeon specializing in the diagnosis and treatment of breast disease and is the medical director of the Suburban Hospital Breast Center.
She received her Bachelor of Science degree and a Master of Science degree in Anatomy from the University of Maryland. She then received her Doctor of Medicine degree from the University of Maryland School of Medicine, where she was a member of the Alpha Omega Alpha medical honor society. She completed her general surgery residency at the University of Maryland Medical System in Baltimore as well as an NIH research fellowship.
Dr. Wright is certified by the American Board of Surgery and is a Fellow of the American College of Surgeons. She is a member of the American Society of Breast Surgeons and is the Cancer Liaison Physician to the Commission on Cancer to the American College of Surgeons.
Rosalinda Alvarado, MD is a board‐certified general surgeon specializing in breast surgical oncology. She received her bachelor’s degree at Northwestern University and her medical degree at Stanford University School of Medicine. She joined the Johns Hopkins School of Medicine Department of Surgery after completing her general surgery residency at Rush University Medical Center in Chicago and a breast surgical oncology fellowship at the University of Texas M.D. Anderson Cancer Center. She is currently an Assistant Professor of Surgery at Johns Hopkins Medicine.
Dr. Alvarado is certified by the American Board of Surgery and is a member of the American College of Surgeons, the American Society of Breast Surgery, the Society of Surgical Oncology and the American Society of Clinical Oncology.