Prevention for Women
Women who are identified as BRCA1 or BRCA2 carriers face a number of important personal questions in deciding how to manage their risk of cancer. Outlined below are some very basic guidelines and current protocols for managing risk. These are in alignment with the guidelines issued by BC Cancer.
It is important to note that each woman should get to know her own personal risk and think through what is best for her. Every option outlined below has its benefits and drawbacks. Further outlined are some of the most recent considerations for ovarian cancer risk management. For more information, please consult the following review article published in the Canadian Medical Association Journal.
This page covers options for breast, ovarian, pancreatic cancer, and melanoma. You can get more in-depth information about this topic through the FORCE website and BC Cancer.
A note on screening: The purpose of screening is not to prevent cancer but to detect it at an early stage when it is more treatable and you may receive a better prognosis.
Breast Cancer
Screening Options
Women who are accepted into BC’s Hereditary Cancer Program are eligible for breast screening.
Breast exams, MRI, and mammography
Carriers should be “breast aware”
Carriers should receive an annual breast MRI, beginning at age 25 until age 65. MRI can be more sensitive for detecting breast cancer than mammography but also results in higher rates of false positives. MRI is generally considered safe with minimal risk of short- or long-term side effects.
Carriers should receive annual mammograms beginning at age 30 and continue as long as clinically indicated. Mammograms are low-dose X-rays. They have shown to be fairly sensitive in women over 50 – detecting 85% of breast cancers, but less sensitive in BRCA carriers between 35-49, picking up only 40% of breast cancers. This is why MRI screening is recommended for younger carriers. Mammograms carry a low risk of radiation-associated breast cancer.
Carriers should receive a clinical examination of the breast and regional nodes by an experienced health professional every 12 months, in conjunction with appropriate breast imaging.
A note on dense breasts: Breasts are said to be dense when they have a lot of fibro-glandular tissue and not much fat. Women can’t know if they have dense breasts until they receive a mammogram or MRI. Dense breasts can make cancers harder to detect and might increase the risk of getting breast cancer, but this increase in risk has not been shown in women who carry a BRCA gene. Doctors are not required to inform patients of the density of their breasts, but you may wish to discuss your breast density with your doctor, as this information can have implications for how you manage your healthcare.
Preventative Surgical Options and Chemo-Prevention
Women who are accepted into BC’s Hereditary Cancer Program are eligible for preventative surgeries.
Bilateral prophylactic mastectomy
It is recommended that carriers undergo a risk-reducing bilateral mastectomy, which will reduce breast cancer risk by over 90%. The decision to have this surgery is complex and requires discussion regarding benefits and risks in the context of a woman’s general health, life expectancy, and personal health beliefs.
Women should speak to their doctors about the various options available to them, should they desire breast reconstruction.
Bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes) has also shown benefits in reducing the risk of breast cancer.
Preventative Chemotherapy (Medication)
Tamoxifen (and related medications)
There are risk-reducing medications (e.g. tamoxifen, raloxifene, anastrozole, exemestane) that can almost halve the risk of developing a hormone-receptor positive breast cancer. They do not reduce the risk of hormone-receptor-negative breast cancers. A decision to use such medication requires discussion about the relative benefits and the potential risk of side effects in the setting of a woman’s general health, menopausal status, and childbearing plans. These medications can also cause side effects in some women, which can make them difficult to tolerate. Tamoxifen combined with oophorectomy offers an even greater breast cancer risk reduction.
Tamoxifen has been found to increase the risk of endometrial cancer.
Tamoxifen is not currently covered under MSP.
Ovarian Cancer
Screening Options
CA-125 and transvaginal ultrasound
Two tests are sometimes used for the detection of ovarian cancer, a blood test called CA-125 and a transvaginal ultrasound. However, there is currently not enough evidence to support the effectiveness of any screening tests for the early detection of ovarian cancer. Both of these tests result in a high number of false positives and can lead to unnecessary anxiety and unnecessary surgical intervention, which carries its own risks. Although undergoing this screening, in some studies, has shown to result in a diagnosis of ovarian cancer at earlier stages, there is still no conclusive effect on mortality rates from the disease. Research is ongoing and this may change over time.
Neither test is considered a standard component of screening through the BC Hereditary Cancer Program.
Preventative Surgical Options
Women who are accepted into BC’s Hereditary Cancer Program are eligible for preventative surgeries.
Bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes)
The gold standard preventative surgical option is bilateral salpingo-oophorectomy (BSO, removing ovaries and fallopian tubes). This is recommended for confirmed BRCA1 and BRCA2 carriers. Evidence shows the procedure can reduce the risk of ovarian cancer by 80%.
If performed before the age of natural menopause, BSO may also reduce breast cancer risk with the level of risk reduction varying with the age at BSO.
While BC Cancer suggests women complete this surgery by age 35-40 and when childbearing is complete, current research suggests that BRCA2 carriers can complete the surgery between age 40-45. The age recommendations are based on data that indicates when risk begins to increase for carriers beyond the general population levels.
Women choosing this option must be aware of the risks associated with premature or early menopause, which include increased risk of all-cause mortality, premature cognitive decline or dementia, cardiovascular disease, and bone loss. Research indicates that symptoms of surgical menopause can be substantial, including vasomotor symptoms, sexual dysfunction, and sleep and mood disturbances. BC has recently launched a new clinic to help women manage their HRT and the symptoms of surgical menopause.
Symptoms of premature menopause can be managed with hormone replacement therapy (HRT), but this is not recommended for women with a personal history of breast cancer, who would see an increased risk of developing a second breast cancer.
Bilateral salpingectomy (removal of fallopian tubes only) with delayed oophorectomy
Bilateral salpingectomy (removing fallopian tubes) with delayed oophorectomy has also been proposed as a temporary means of reducing ovarian cancer risk in pre-menopausal women, as evidence shows the majority of cancers originate in the fallopian tubes. Evidence is not yet available to support the effectiveness of this approach for ovarian cancer risk reduction, but it is an option for those concerned about the effects of early menopause. A recent study indicated that women support this alternative to BSO.
Radical fimbriectomy (removal of all the tube and the fimbrio-ovarian junction)
Radical fimbriectomy (removal of all the tube and the fimbrio-ovarian junction) is under investigation as an option for women hesitant to undergo a full salpingo-oophorectomy. Early evidence suggests the procedure is better than no preventative surgery at all.
Hysterectomy
Hysterectomy in combination with bilateral salpingo-oophorectomy is currently considered controversial and not recommended, however, women can discuss their concerns and personal risks with their doctors.
Preventative Chemotherapy (Medication)
The Pill and IUDs
Oral contraceptive (birth control) pills are shown to significantly reduce the risk of ovarian cancer by 50% or more if used for at least 5 years. This benefit increases with duration of use, persists for at least 20 years after the pill is stopped, and is observed in BRCA1 and BRCA2 carriers as well as the general population. This is because the pill reduces or stops ovulation and ovarian cancer risk is reduced with fewer ovulation cycles. Most studies have shown a small increase in breast cancer risk from oral contraceptive use, similar to that of hormone replacement therapy. A decision about using this medication for cancer prevention requires careful discussion about cancer risks, benefits, and side effects within a woman’s particular situation and contraceptive needs.
Other progestin-only contraception options (including hormonal IUD) may also offer some preventative benefit, however, currently, the degree of risk reduction remains unclear. Longer use of IUDs was associated with greater benefit and estimations currently suggest that IUD could reduce the risk of ovarian cancer by 15-30%, but these studies were not conducted on BRCA-specific populations. This may be an option for women with a higher risk of breast cancer or who cannot tolerate hormonal birth control.
Medications, including the pill, injection, and hormonal IUD have recently obtained coverage under MSP in British Columbia. For more information on coverage, please click here.
Other Cancers
Pancreatic Cancer
Screening Options in BC
Options for pancreatic cancer screening can be discussed if the family history includes close relatives with pancreatic cancer.
Melanoma
Screening Options in BC
Dermatologist check ups
Some women may be recommended to see a dermatologist for annual skin check ups, although currently this is recommended to be performed by your primary care provider.
Lifestyle Changes
BC’s leading cancer organizations have joined forces to create Five Plus, a website that encourages women to take five steps that may help to prevent breast cancer.
Maintain a healthy body weight
Maintain an active lifestyle
Limit your alcohol intake
Breastfeed if possible
Weigh the risks and benefits of hormone therapy for menopause symptoms
Read more about the top breast cancer prevention recommendations by visiting Fiveplus.ca