Noble's Dr. Steven Schonholz: Angelina Jolie 'messenger' for public on hereditary breast, ovarian cancer risk

08 Oct 2014 13:17
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Breast surgeon Steven Schonholz is director of the Center for Comprehensive Breast Health at Noble Hospital, in Westfield. He was asked what impact he has seen, after actress and director Angelina Jolie wrote in the New York Times, in 2013, about her decision to have a double mastectomy. This was after testing positive, for the mutation in the BRCA1 gene, that puts a woman at high risk, for both breast and ovarian cancer. Jolie's mother died of ovarian cancer, in 2007,and the mother's sister, who had tested positive for the same mutation, died of breast cancer, two weeks after the publication of Jolie's article.
What impact did Angelina Jolie's piece have, in terms of educating the public? Angelina Jolie was a messenger who identified (to the public) a hereditary cause to breast and ovarian cancer. The public learned, that the mutation can be passed on, from a mother or father, and can be given to sons and daughters. We learned the increase risk of breast and ovarian cancers, for those who possess the mutation, versus those who do not have the mutation. We learned the risk factors, in the family, for which members should be tested. We learned how someone could either be screened for cancer, or can have risk reduction surgery, that would prevent a cancer from occurring.
The choice a woman makes is very personal. It can be based on her age, her family history, as well as other personal reasons. Angelina Jolie made it possible to help identify those women who need to make the choice.
What advice do you give to patients in terms of being tested, and if they test positive for the mutation in the BRCA genes? There are certain key risk factors in which a person should consider testing. At Noble Hospital, we have a screening program in place, at our mammography department, in which every woman having a mammogram fills out a risk assessment form. If any risk factors are identified, they are referred immediately to our Center of Comprehensive Breast Health for further discussion.
Some of the key risk factors are: 1. A woman with breast cancer under the age of 50.
2. Multiple breast cancers in a family member (bilateral cancers, multiple cancers in 1 breast).
3. Ovarian cancer at any age.
4. A male with breast cancer.
5. Three or more relatives with breast cancer on one side of the family (fathers or mothers).
6. A family member at any age with breast cancer with an Ashkenazi Eastern European Jewish ancestry.
If a person meets the criteria for testing, I tell them they should be tested. The risk of finding a mutation is only around 7 percent. It's a 93 percent chance of returning negative for a mutation. I tell them they are being tested, not because I think they will have the mutation, but they have risk factors in the family that require testing.
Not having the test can have consequences to the woman and family members. Just because a person does not test, does not mean that the increased risk of breast and ovarian cancer are not there.
With testing, a woman knows her real risk, whether high or low. It allows a woman, (who tests positive,) to go into a High Risk Screening program, or choose risk reduction surgery, as Angelina Jolie decided upon.
If a woman tested positive it would mean that all of her siblings have a 50-50 chance of having the same mutation. It would mean that all of her children would have a 50-50 chance of having the mutation. If it came from either parent, all the uncles and aunts on that side of the family would be at a 50-50 chance, and those cousins would have a 50-50 chance of having the mutation.
If a person tested positive for the mutation, I would review the increased risk of breast and ovarian cancer. Normal risk of breast cancer is around 7 percent by the age 70. With the mutation, risk of breast cancer can be as high as 50 percent, by the age of 50, and 87 percent, by the age of 70. The risk of ovarian cancer is around less than one percent by the age of 70. With the mutation, the risk of ovarian cancer can be as high as 26 to 44 percent by the age of 70.
I would discuss that there are two options to consider. One is screening, which would identify a cancer early. Screening for breast cancer would start at the age of 25 for young woman. This would include mammograms every year, self breast exams monthly, a physician's exam every six months and yearly MRIs. Screening for ovarian cancer is much more difficult and this would include blood tests, pelvic exam and ultrasound.
The other option would be risk reduction surgery which would mean removing the part of the body that has a high risk of having cancer. This would be removing both breasts, with the option of immediate reconstruction, which is paid for by insurance. The removal of the breast tissue reduces the risk of breast cancer by 96 percent. Removal of the tubes and ovaries would also reduce the risk of ovarian cancer by 96 percent.
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