Facing a High Risk of Breast Cancer
By Alice Y. Chang, M.D.
Brigham and Women's Hospital
Once I had a patient who was a mother in her late 20s. Her sister, in her early 30s, had breast cancer and was undergoing her second round of treatments. Their mother had died from breast cancer in her 40s.
While my patient was very aware of her high risk of breast cancer, every time we set her up for a mammogram or a meeting with a genetic counselor, I would receive a note that she had missed her appointment. Attempts at rescheduling the tests persistently failed. She didn't return phone calls or answer letters. During routine office visits, I would coax her to proceed with routine breast screening, but she always redirected our discussions to other health issues.
She eventually stopped seeing me. I often think about her, wonder how she is doing now, what I could have done better, and whether someone else has been able to get past her fears of breast-cancer screening.
Cases like these hit me hardest — the women who delay screening and testing in the face of high risk. Their denial can prevent them from seeking testing that may save their lives. During Breast Cancer Awareness Month this October, let us turn our attention to this group of women and focus on how we can help.
Denial is a tough thing for one person to overcome. But by creating a network of women — reaching out to a friend, co-worker or family member — we can play an important role in counseling women who are at high risk of breast cancer.
The Woman at High Risk
Any woman with a sister, mother or daughter with breast cancer is at higher risk of breast cancer and must take cancer screening very seriously. Depending on the person, testing may be advised every year starting at the age of 40 or earlier, or as often as every six months.
If the relative with breast cancer was diagnosed before age 60 and if more than one close relative had breast or ovarian cancer, the possibility of genetic mutation increases. The person with multiple relatives with breast and/or ovarian cancer faces a more difficult decision — whether she should have genetic testing. Genetic testing offers you a chance to better understand your risk of breast cancer. In particular, testing looks for mutations in the BRCA1 and BRCA2 genes that are associated with a high risk of breast and ovarian cancers. Having one mutated gene can increase your risk of breast cancer from the standard 12% all the way to 50% to 85%.
Why does a woman delay screening or testing? Put yourself in her shoes. Testing means possibly finding out that you have breast cancer. It might bring back painful memories of a relative's diagnosis, treatment and maybe even death. A woman at higher risk of breast cancer faces more frequent screening tests, whether it is a mammogram or MRI. And if she chooses genetic testing, the results could mean additional decisions about preventive treatment.
While for many women, the possibility of treatments to lower their cancer risk is reassuring, for many others, the thought of treatments is frightening. While you can opt to take medications like tamoxifen or raloxifene to block estrogen, you also have to seriously consider surgically removing both breasts and ovaries to lower your cancer risk. These are not easy considerations for anyone.
What You Can Do
You don't have to do or say a lot to help a friend. Here are some ways you can make sure that your network of friends is giving the best education and support they can:
Making a Difference
Ask your friends about their breast cancer risk. If they have a higher risk, ask if they should have had a screening test in the last year. The advice for a first-degree relative, a woman whose mother, sister or daughter has breast cancer, should start screening mammograms at least by the age of 40. If the relative is younger than 50 when first diagnosed, she might be advised to start earlier.
Check up on your friends about their screening tests. Of course, you want to do this in a friendly, nonthreatening way, but it probably will reassure her to know someone is looking out for her. We all know the many daily demands on working women inside and outside of the home, so reminding each other can make a big difference. If you can, offer to watch her children or encourage her to get coverage at work for a doctor visit or mammogram.
If a friend mentions a breast lump or discharge, make sure she sees her doctor. Then, check up on her later. If she hasn't returned for follow-up after an initial test or biopsy, make sure she calls her doctor for results. Offer to make the call with her or accompany her to her visit if she is nervous. If she doesn't get tested, chances are the doctor wants to see her in a month or two to make sure that even a benign-appearing lump hasn't changed. Mark your calendar to remind her about her follow-up.
For a woman at high risk of breast cancer, talk to her about genetic testing. During this discussion, it is important to listen rather than encourage. By listening to what she says, you may help her to focus on the issues that are important to her. If she has not already done so, suggest that she meet with her doctor and/or a genetic counselor. Encourage your friend to talk to her family as well. It is important to remember that her results mean a lot to her daughters and sisters as well.
Offer to go with her to the doctor or counselor. It is especially helpful if someone less emotionally charged can take notes during a doctor visit or counseling session.
I can tell countless stories about the positive impact family and friends have in encouraging healthy changes and helping people through the treatment and recovery process. We all should take seriously our potential power as a friend to promote healthy behaviors and prevent disease.
Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.