A symposium on Jewish Women’s Health at the Teaneck Jewish Center, presented by Holy Name Hospital on November 16, armed 200 women, and a few men, with information about hereditary genetic risks for breast and gynecologic cancers and how breast imaging can detect cancer early when there is the best chance for a cure.
Dr. Sharyn N. Lewin, Director of the Division of Gynecologic Oncology, said that 1 in 40 Ashkenazi Jews has a defect in the BRCA 1 or BRCA 2 genes that keep breast cells healthy. The prevalence in the general population is between 1 in 300 and 1 in 500. Having the mutation does not mean you will definitely get cancer, but it raises the possibility. Genetic screening can identify carriers and counseling helps individuals who test positive evaluate their treatment options. Cancer patients should be tested to help prevent developing secondary cancers and to identify risk for their children. Women who meet national criteria guidelines should also be tested, and insurance will cover the procedure. The biggest red flag is family history. You should discuss genetic testing with your doctor if you have close relatives on either your father or mother’s side who were diagnosed with breast or ovarian cancer under the age of 50.
Dr. Lewin said genetic screening also identifies defects leading to gynecologic cancers. Another set of genes is associated with Lynch syndrome, a condition that raises the risk of ovarian, uterine, and colorectal cancer. Jews have been found to have a risk for colorectal cancer two to three times higher than the general population. Annual colonoscopies are recommended for those over 40 who test positive to identify and remove pre-cancerous growths. It is difficult to screen for early stage ovarian cancer. In general, the tests that do exist are not covered by insurance, but women with known genetic mutations are eligible.
Research continues to identify gene mutations that increase cancer risk and has found interplay between different kinds of genetic defects. Genetic screening for cancer is moving towards panel testing to examine several genes rather than individual ones such as BRCA 1 and 2.
Two concerns have kept women from being tested: a negative impact on health and life insurance and increased worry from knowing they carry a ticking time bomb. Dr. Lewin said a national law passed in 2006 prohibits denial of health insurance due to known genetic defects. New Jersey also prohibits denial of life insurance based on positive results from genetic testing.
There are several preventive strategies that can lower risk for carriers of genetic defects, including more frequent imaging, chemo prevention (drugs that have been shown to reduce risk), and prophylactic surgery. Actress Angelina Jolie had a prophylactic mastectomy after learning she carried a BRCA mutation.
Dr. Lewin said she hopes one day a prominent celebrity will step forward to talk about Lynch syndrome. Women with Lynch syndrome can have their tubes, ovaries, and uterus removed, which will bring their risk to near zero.
However, genetics are just one risk factor in developing cancer. Most women with breast cancer do not have the genetic mutation so environmental factors also contribute to the disease, according to Dr. Lewin. She said the best preventive strategies include keeping to an ideal weight and not smoking.
Dr. Joshua Gross, Director of Breast Imaging, said mammograms save lives by detecting cancer early, when it can be treated most successfully. He showed examples of images on mammography, ultrasound, and MRI and the difference between normal tissue and tumors. Women are screened first with mammography. If there is a suspicious area on a mammogram, another test is often used to reach a definitive diagnosis, as each modality shows images differently.
Women with dense breast tissue may need screening in addition to mammography. Breasts are composed of fatty tissue and glandular tissue. On a mammogram, tissue [which kind? glandular?] is white and cancer is white. When there is a large amount of white, glandular tissue, tumors can be obscured. Reading a dense mammogram is like looking for a snowflake in a snowstorm. Dr. Gross said Holy Name is planning to get Tomosynthesis, also known as 3D mammography, which is an enhancement for examining dense tissue. Tomosynthesis captures images in slices that can be viewed individually.
Many states, including New Jersey, now have laws that require women to be notified about the risk of breast density, and suggest they talk with their doctors about supplemental screening such as ultrasound. Laws vary by state. A national breast-density law has been introduced in the House and Senate.
Men can also get breast cancer, Dr. Gross noted. He showed images of a very athletic man, whom he described as “ripped,” with breast cancer. The man had been taking an unidentified performance-enhancing substance and Dr. Gross said this “witches brew” may have caused the disease.
Dr. Gross talked about a recent controversy regarding the value of breast cancer screening for early detection. A few physicians have said that when screening identifies a suspicious area that turns out not be cancer, it causes unnecessary anxiety for women while they wait for results. Dr. Gross countered with a survey of women who said they’d rather feel a little anxiety and have a false positive than extreme distress from being diagnosed with a cancer that breast imaging could have found earlier.
