Risk Management
Introduction to risk management
Overview
Cancer risk assessment, risk factors and risk management options may differ for people with hereditary cancer risk or a BRCA mutation than for people in the general population. It is important to consult an expert in cancer risk assessment and risk management to determine what your personal risk for hereditary cancer may be. For more information, see our finding a specialist in hereditary cancer section.
Risk factors
Cancer is a disease with many contributing factors. The following factors may impact the risk for cancer; some may have a different impact for BRCA mutation carriers or people with hereditary cancer risk than people with average cancer risk. Currently it is unknown precisely how risk factors alone or in combination impact someone with a BRCA mutation or hereditary cancer risk.
- Age at menarche (first menstruation)
- In the general population, early menarche has been shown to increase the risk for breast cancer. One study showed similar effect in women with BRCA 1 mutations. Earlier age of first menstruation was associated with an increased risk of breast cancer. This association was not observed among BRCA2 mutation carriers. Compared with BRCA1 carriers who began menstruation at 11 years, women who began menstruation between ages 14 and 15 had a 54% reduction in risk.
- Parity (number of births)
- In the general population, having children before age 30 has been shown to lower the risk for breast cancer. The exact impact of pregnancy and child-bearing on breast cancer risk in BRCA mutation carriers is not totally clear and may be different for BRCA 1 mutation carriers than for BRCA 2 mutation carriers. In one study women with a BRCA 1 mutation who had four or more children had a breast cancer risk that was 38% lower than BRCA 1 mutation carriers who never had children. The same study associated increasing number of births with a significant increase in breast cancer risk in BRCA2 mutation carriers before age 50. The increase was greatest in the 2-year period following a pregnancy.
- Breast-feeding
- One study examined breast cancer incidence in BRCA 1 and BRCA 2 carriers who breast-fed compared with women who never breast-fed. The study found that breast-feeding lowered the risk for breast cancer in BRCA 1mutation carriers who breast-fed for more than one year, but did not find a similar risk reduction in BRCA 2 carriers.
- Medications
- Certain medications such as Tamoxifen may lower the risk for breast cancer in BRCA mutation carriers. Other medications such as oral contraceptives have been shown to lower the risk for ovarian cancer but certain formulations may increase the risk for breast cancer in BRCA carriers. For more information on the effects of medication on cancer risk, visit our section on breast cancer chemoprevention and ovarian cancer chemoprevention.
- Prior surgery
- Prophylactic salpingo-oophorectomy (surgical removal of the ovaries and tubes) in high-risk women has been shown to dramatically lower the risk for ovarian cancer. If the procedure is done prior to menopause, it has also been shown to lower the risk for breast cancer substantially. For more information, see our prophylactic salpingo-oophorectomy section. In addition, a small retrospective study found that tubal ligation substantially lowered the risk for ovarian cancer in women with BRCA 1 mutations but not in women with BRCA 2 mutations.
- Diet
- Although it is believed that certain foods or chemicals in certain foods such as vegetables, fat, dairy and soy may affect breast and/or ovarian cancer risk, the exact effect of diet and its impact on those at risk for hereditary cancer is unknown.
- Exercise
- Exercise offers many health benefits for both BRCA mutation carriers as well as the general population. A study of Jewish women with BRCA mutations showed those active in sports, dance, or casual exercise during their teenage years had a delayed the onset of breast cancer later in life.
- Weight
- A recent study of 1,073 women from five countries suggests losing as few as 10 pounds between ages 18 and 30 may dramatically reduce the risk for breast cancer in those who have a BRCA1 mutation.
- Alcohol consumption
- Regular alcohol consumption has been linked to increased risk for breast cancer risk for women in the general population. The specific effect of alcohol consumption on breast cancer risk in BRCA mutation carriers is unknown.
Risk management options
Women with BRCA mutations have options for managing their risks for breast and ovarian cancer. The most appropriate options differ between women and depend on many considerations. In general there are 3 categories of risk management options which are outlined below and are discussed in more detail in their respective sections.
- chemoprevention
- Surveillance
- Prophylactic (risk-reducing) surgery
The National Comprehensive Cancer Network (NCCN) is a consortium of cancer centers with experts in management of hereditary cancer. The NCCN updates their guidelines for risk management for people with hereditary risk for cancer, based on the latest research. In general, NCCN guidelines dictate the standard of care for high-risk patients.
It is important to remember that none of the risk-management options will eliminate all cancer risk. Some risk always remains, even with the surgical options.
Further reading - articles (advanced reading)
Effect
of short-term hormone replacement therapy on breast cancer risk reduction
after bilateral prophylactic oophorectomy in BRCA1 and BRCA2 mutation carriers:
The PROSE Study Group
Timothy R. Rebbeck, Tara Friebel, Theresa Wagner,
Henry T. Lynch, Judy E. Garber, Mary B. Daly, Claudine Isaacs, Olufunmilayo
I. Olopade, Susan L. Neuhausen, Laura van 't Veer, Rosalind Eeles , D.
Gareth Evans, Gail Tomlinson, Ellen Matloff, Steven A. Narod, Andrea Eisen,
Susan Domchek, Katrina Armstrong, and Barbara L. Weber. Journal
of Clinical Oncology, (Published on-line ahead of print).,October 2005.
Testosterone
patch for low sexual desire in surgically menopausal women: a randomized
trial
Glenn D. Braunstein, Dale A. Sundwall, Molly Katz, Jan L. Shifren,
John E. Buster, James A. Simon, Gloria Bachman, Oscar A. Aguirre, Johna
D. Lucas, Cynthia Rodenberg, Akshay Buch, Nelson B. Watts. Archives
of Internal Medicine, Volume 165 Number 14: p. 1582-1589, July 2005.
Management
of postmenopausal hot flushes With Venlafaxine Hydrochloride: A randomized,
controlled trial
Michele L. Evans, Elizabeth Pritts, Eric Vittinghoff,
Karen McClish, Kevin S. Morgan and Robert B. Jaffe. Obstetrics & Gynecology,
Volume 105, Number 1: p. 161-166, January 2005.
Effect of Zolpidem on sleep in women with perimenopausal and postmenopausal insomnia: a 4-week, randomized, multicenter, double-blind, placebo-controlled study Cynthia M. Dorsey, Kathryn A. Lee, Martin B. Scharf. Clinical Therapeutics, Volume 26, Issue 10: p. 1578-1586, October 2004.
BRCA
germline mutations in Jewish women with uterine serous papillary carcinoma
Ofer
Lavie, Gila Hornreich, Alon Ben-Arie, Gad Rennert, Yoram Cohen, Rehuven
Keidar, Shlomi Sagi, Efrat Levy Lahad, Ron Auslander, Uzi Beller. Gynecologic
Oncology, Volume 92, Number 2: p. 521-524, February 2004.
Phase III evaluation
of Fluoxetine for treatment of hot flashes
Charles L. Loprinzi, Jeff
A. Sloan, Edith A. Perez, Susan K. Quella, Phillip J. Stella, James A.
Mailliard, Michele Y. Halyard, Sandhya Pruthi, Paul J. Novotny, Teresa
A. Rummans. Journal of Clinical Oncology, Volume 20, Issue 6: p. 1578-1583,
March 2002.
Natural hormone replacement
therapy: What it is and what consumers really want
Dana Reed-Kane,
PharmD, FIACP, FACA. International Journal of
Pharmaceutical Compounding,
Volume 5, Number 5: p. 332-335, September/October 2001.
Tubal
ligation and risk of ovarian cancer in carriers of Brca1 or BRCA2 mutations:
A case-control study
Steven A Narod, Ping Sun, Parviz Ghadirian, Henry
Lynch, Claudine Isaacs, Judy Garber, Barbara Weber, Beth Karlan, David
Fishman, Barry Rosen, Nadine Tung, Susan L Neuhausen. Lancet, Volume 12,
Issue 357(9267): p. 1467-70, May 2001.
Effect
of bupropion-SR on orgasmic dysfunction in nondepressed subjects: a pilot
study
Jack G. Modell, Roberta S. May, Charles R. Katholi. Journal
of Sex & Marital Therapy, Volume 26, Number 3: p. 231-240, July 2000.