You got your brown eyes from Mom, your nose from Dad and even that spunky personality from Grandma. But there are certain families that may also carry genes that can cause disease, including cancer. Dana Farengo Clark, M.S., a certified genetic counselor at The Cancer Institute of New Jersey (CINJ) at Cooper, Cooper University Hospital, speaks about this risk and what you need to know.What does it mean to have a genetic predisposition to cancer?
Dana Farengo Clark: Most cancers usually are a function of aging. In some families, we tend to see more cancer than we would expect to see, which may be the result of a mutation, or a change in a gene that normally works to prevent cancer. These gene mutations can increase a person’s risk for developing cancer. It is important to understand that only 10 percent of all cases of cancer are associated with a gene mutation.
What are the genes that cause breast cancer?
Ms. Clark: There are two genes that we know of at this time that are associated with hereditary breast cancer: BRCA1 and BRCA2. BRCA1 was discovered in 1994, and BRCA2 was in 1995. Mutations in BRCA1 and BRCA2 are also associated with an increased risk for ovarian, prostate, pancreatic and other cancers including melanoma (skin cancer).
Who should get tested for BRCA1 and BRCA2?
Ms. Clark: If you fall into any of the following categories, you may wish to consider a cancer genetics evaluation, which includes a family history and a medical history:
- Breast and/or ovarian cancer in two or more relatives
- Early-age breast cancer diagnosis — younger than 50
- Cancer in both breasts
- Multiple cancers in the same individual, especially breast and ovarian
- Male breast cancer
- Eastern European Jewish ancestry
- Having a relative with a known cancer gene mutation
Many individuals with a BRCA1 or BRCA2 mutation use genetic testing to help clarify their risk and to help make medical management decisions. There are multiple options for these women, including increased screening, preventative surgeries or using medications to lower risk.
Where would I get the test and how does it work?
Ms. Clark: Call CINJ at Cooper to schedule an appointment for consultation to determine if genetic testing is right for you. During the consultation, we will discuss all aspects of testing, including the costs. I would say about 90 percent of the women who get tested through the Cancer Genetics Program at Cooper have some portion of the cost covered. I do my best to get coverage for the women who need to have the testing done. The results of the test take about four weeks and once we receive them, we meet with the patient again.
Would this test help if someone has already been diagnosed with cancer?
Ms. Clark: Testing can help you make treatment decisions. If a breast cancer survivor carries a BRCA1 or BRCA2 mutation, then she is at increased risk for developing a second cancer, especially in the opposite breast or ovary. Ideally, women can have testing done before they make decisions regarding treatment and surgery. Women who carry a mutation have a 50 to 60 percent lifetime risk of developing breast cancer in the opposite breast. Genetic testing can also help women clarify their risk for ovarian cancer and the need for certain screenings or surgery.
Knowing your mutation status also gives you the opportunity to share this information with your family members, so they can take appropriate steps to learn their own cancer risk. Women with a BRCA mutation should be screened for breast and ovarian cancers at earlier ages than women in the general population and need to develop a medical management plan with their physicians.
Does breast and ovarian cancer risk only come from the mother’s side?
Ms. Clark: No. People are always surprised to hear this, but there’s a 50 percent chance to inherit a BRCA1 or BRCA2 mutation from either your father or your mother. If a person carries a mutation, there is a 50 percent chance to pass it on with every pregnancy, which is like the flip of a coin. Men who inherit these mutations are at increased risk to develop breast cancer as well as prostate cancer at younger ages – under 65.
Are insurance companies utilizing this information before renewing a person’s policy?
Ms. Clark: That’s a big myth that I try to dispel. The laboratory that analyzes the results has evaluated over 85,000 women, and to date there hasn’t been one case of insurance discrimination brought to trial. I feel comfortable telling the patients that they will have some level of protection from insurance discrimination and that they should not be scared away from having testing. Although there are no guarantees, patients in group insurance plans are protected from insurance discrimination by state and federal laws.
Some women fear they won’t get treated for cancer if they test positive because the insurance company will consider it a pre-existing condition and not cover them. Insurance companies cannot deny you treatment and services due to genetic status.
Can women who test positive take the breast cancer drug tamoxifen?
Ms. Clark: Yes. Women who are at high risk for breast cancer are eligible to take tamoxifen, which blocks estrogen from binding to the breast and “feeding” the tumor. Ideally women take tamoxifen for five years, which has shown to reduce the risk for breast cancer by about 50 percent. It is unclear the exact risk reduction in women with BRCA1 and BRCA2 mutations, but the available data suggests that the risk reduction may be similar to women in the general population. Once test results are available we sit with each patient to determine if tamoxifen, or another drug, is needed and if it is safe for them to take.
Do many women take this drug for breast cancer prevention?
Ms. Clark: A lot of women choose not to take tamoxifen due to the side effects, which include a slightly increased risk for uterine cancer, blood clots and strokes. Others don’t take it because they are still in their childbearing years, and we won’t put a woman on it until she has completed childbearing. Evista® is another drug just approved for breast cancer prevention and seems to be as effective as tamoxifen but without as many side effects. Interestingly, this drug was originally used to treat osteoporosis; however, we have recently learned, from the results of a large national study, that it also reduces the risk for breast cancer in postmenopausal women. Each woman is different and not everyone is interested, or eligible, for these medications.
How do we at Cooper counsel these women?
Ms. Clark: Patients meet with a genetic counselor and a physician over multiple visits, and we sit for a long time discussing management of breast cancer risk, ovarian cancer risk and risk to family members. I also write a letter to the patient explaining their own results and options and another letter explaining the results to family members.
We see patients about three months after they receive their test result and then we see them once a year for follow-up. We make sure that they are getting the services that they need. We also have a support group, called My Genes, My Risk, which offers individuals at genetic risk for cancer a chance to meet and talk about their unique issues.
To schedule an appointment with Ms. Clark or with a Cooper physician, please call (800) 8-COOPER (800-826-6737).