Young Breast Cancer Patients Screened Before Surgery

In this video, Dr. Margileth discusses how one of the most important parts of seeing patients of any age with breast cancer is determining whether they and their family may have a BRCA gene abnormality that leads to an increased risk of both breast cancer and ovarian cancer.

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David A. Margileth, MD, Oncologist: One of the most important parts of seeing patients with breast cancer is to determine whether that patient and, likewise their family may have what?s called a BRCA gene abnormality that leads to a greatly increased risk of both cancer of the breast and cancer of the ovary.

Whenever we see a patient, we should evaluate that patient?s risk of being BRCA positive and those risk factors that increased that risk are a patient of young age, we routinely test everybody under the age of 40, multiple family history of breast cancer, history of bilateral breast cancer, and whether there are cases of cancer of ovary in the family.

Once you have gotten that information, there are various tables to determine a percent risk of the BRCA gene being positive, such as the Clause model or Myriad tables. Myriad is the company that actually does the genetic testing in this country.

So there are certain patients that we always test. For instance, a patient under the age of 40 with no family history, would have about a 7% chance of being BRCA positive. When we determine that a patient is BRCA positive, it has implications both for the treatment of her breast and equally important treatment of her ovaries.

The younger the patient that is BRCA positive, the more one would feel comfortable doing bilateral mastectomy since their lifetime risk of breast cancer may be as high as 80%. It would not be negligent not to do bilateral mastectomy and do lumpectomy and radiotherapy and then follow that patient closely with both mammogram and MRI on a yearly basis.

This has been found to be a reasonable approach but in some sense, especially the younger the patient, we are sort of waiting for the other shoe to drop, so many younger women feel more comfortable doing bilateral mastectomy.

The other issue that is equally important is the awareness of BRCA positive patients having a very greatly increased risk of cancer of the ovary. This is a much more lethal cancer than breast cancer and one for which we really have no screening techniques, one can do pelvic exams, ultrasounds, CA-125 blood test but none of those have been proven to lower the mortality of cancer of the ovary so that when a BRCA positive woman is past childbearing and somewhere after the age of 35 or 40, that woman should have her ovaries and fallopian tubes removed. That will not totally eliminate the risk of an ovarian like cancer but certainly will eliminate the majority of the risk.

The other very important part I think is that these women who are being tested for BRCA should probably do it with their genetics counsellor. The job of the counsellor is to educate the patient, develop a numerical risk of being BRCA positive and then with the patient make an informed decision as to whether that patient wants to be tested or not.

The other issue that may be missed if the testing is done on that individual patient, for instance, in a doctor?s office, is the evaluation of the rest of the family. When a patient sees a genetics counsellor, they will develop a three generation category and once the testing comes back, especially if positive, they will then determine what other members of the family should be tested and help those patients find a genetics counsellor in their particular area.

So in a number of cases, as I mentioned with bilateral breast cancer, young patients now with triple negative breast cancer, certainly BRCA gene testing should be thought about and in those particular situations that testing should be performed to the benefit of both the patient and the family.

Dr. David A. Margileth practices medical oncology at St. Joesph Hospital in Orange, CA specializing in oncology, hematology, and internal medicine (board certified). His selected area of interest is breast cancer. Dr. Margileth graduated from Baylor College of Medicine in 1971 and has since spent time treating patients at the National Cancer Institute and Methodist Hospital in Houston, TX.

This information should not be relied upon as a substitute for personal medical advice, diagnosis or treatment. Use the information provided on this site solely at your own risk. ?If you have any concerns about your health, please consult with a physician.

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