What are my options
Cancer risk management can include intensive surveillance to increase the chance of early detection of breast cancer, risk reducing (prophylactic) surgery (removal of ovaries and/or breasts) or taking a medicine to lower the chances of developing cancer (chemoprevention).
Some women may not want to learn about the details of every option at once. For example, some women (especially young women) may want to learn only about surveillance now and may find reading about risk-reducing surgery overwhelming at this stage. Other women may want as much information as possible about all their options early on in their journey. This section enables you to select only the options you wish to view by clicking on the links below.
It is important to remember that making a decision about which options to choose is not urgent. We recommend that you take your time to consider the information here and discuss any questions or concerns with your doctor or nurse.
Options to manage breast cancer risk
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Surveillance for breast cancer will not decrease the chance that cancer will develop. However, intensive surveillance for breast cancer can help to detect breast cancer early when it is most treatable.
Over the years, researchers have developed specialized breast cancer surveillance strategies for BRCA carriers. This involves starting surveillance at an earlier age and using several different methods at regular intervals. Intensive breast cancer surveillance typically starts at age 30 for women with a BRCA-alteration; it might be recommended at an earlier age if there is a particularly young breast cancer diagnosis in the family. Intensive surveillance may also be done in combination with risk-reducing medication (chemoprevention).
Clinical breast exam is recommended every 6-12 months starting at age 30. Between ages 30 and 50, it is recommended that you have an annual breast MRI. Breast density is assessed by a Consultant Breast Radiologist prior to discontinuing MRI at 50. If breast density is high, it may be necessary to continue breast MRI surveillance for an extended period. Mammography surveillance will be added to your management plan at 40 years and will continue until 70. Where possible, surveillance with mammogram and breast MRI is staggered so that a breast MRI is followed by a mammogram at 6 monthly intervals. For women older than 70, breast cancer surveillance should be managed on an individual basis.
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Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots which can make interpreting the mammogram difficult.
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A breast MRI (Magnetic Resonance Imaging) uses a magnetic field to create clear detailed pictures of the inside of the breast. During the procedure you will lie face down on your stomach to mildly compress the breast tissue. An intravenous injection, known as contrast, is used to get optimal imaging of the breast tissue. Therefore, it will be necessary to insert a cannula into your vein. As you are lying on your stomach for this procedure, it is recommended that you do not eat for two hours before your MRI. It is very important that you inform your medical team if you have any metal inside of your body (e.g. pins and plates), as MRI may be contraindicated.
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It is recommended that every woman be “breast aware". Breast awareness includes breast self-examination. Breast self-exam should be performed on the same day each month. Breast awareness allows you to be more familiar with your breasts and to promptly report changes to your medical team.
https://www.womans.org/-/media/files/modules/publications/breast-self-exam.pdf
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On a mammogram, fatty tissue appears black while the remaining breast tissue appears white or ‘dense’. Women vary in the composition of their breast tissue. The amount on non-fatty tissue on a mammogram is referred to as breast density. Higher breast density is associated with an increased risk of breast cancer. On a mammogram, breast cancers are also white, so high density breasts may potentially make breast cancer more difficult to diagnose, as they interfere with the interpretation of the mammogram. Despite this, mammography remains the best surveillance test for symptom free women aged 40-70.
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Consultant Breast Surgeons Ms Elizabeth Connolly on surgical options.
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A risk-reducing (prophylactic) mastectomy is the surgical removal of breast tissue in an attempt to reduce the risk of developing breast cancer. Some women with BRCA alterations choose this option. Studies have shown that this procedure lowers breast cancer risk by at least 90 percent in women with BRCA 1 and BRCA2 alterations. However, breast cancer surveillance is a valid alternative to prophylactic mastectomy, as surveillance for breast cancer is usually effective in finding breast cancer at an early stage, particularly when MRI is used as one of the surveillance tests. Even if breast cancer is detected at an early stage, additional cancer treatment may still be required e.g. chemotherapy, radiation treatment and anti-hormonal treatment (endocrine). Intensive surveillance can also be used in combination with preventive medications e.g. chemoprevention.
Surgery is a very personal and complex decision and will depend on your age and personal circumstances. Therefore, we recommend women fully investigate all their options. Some women considering a prophylactic mastectomy may find it helpful to consult with a plastic surgeon to learn about options for breast reconstruction. We encourage all women who would consider this option to take the time they need to make an informed choice. This purpose of this decision aid is to take you through information about various aspects of the surgery, reconstructive techniques, recovery, possible complications and to provide you with additional information links that you may find helpful.
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Consultant Plastic & Reconstructive Surgeon Ms Carmen Torre on reconstruction options.
The breast reconstruction process can start at the time of your mastectomy (immediate reconstruction), or it can be done later (delayed reconstruction).
The choice of reconstruction depends on:
Size of natural breast
Body shape
The quality of your skin
Drooping (Ptosis) of the breast
Surgeon’s recommendation
Personal choiceThere are two main techniques for reconstructing your breast:
Implant reconstruction:
Inserting an implant that's filled with saline (salt water) or silicone gel.
Autologous or "flap" reconstruction:
Using tissue transplanted from another part of your body
(such as your abdomen, thigh, or back) to form a new breast.
Autologous reconstruction also may include an implant.
You also can choose whether or not to reconstruct your nipple. (In some cases, nipple-sparing mastectomy is possible, which means that your own nipple and the surrounding breast skin are preserved.)
Implant reconstruction is least the complex of the reconstructive surgery options, and is easier to recover from. Flaps are a more complex operation, and a have a longer recovery. Over time, implants are more prone to problems and often require additional procedures to correct these problems. Flaps perform better over time; a flap done well should not need more attention over the course of your lifetime.
Your particular situation will play a role in what reconstruction option works best for you. Each woman’s case is unique, so should you wish to embark on the risk reducing pathway, the specific options available in terms of reconstruction will be discussed by your nurse/doctor.
Further information on breast reconstruction is available in the ‘Resources’ section or here:
https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/implant-reconstruction
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Chemoprevention involves taking an anti-hormonal (endocrine) medication every day for 5 years to reduce the risk of developing breast cancer. It can provide additional choices for high-risk women who want to reduce their chance of getting breast cancer but who do not want to have surgery. Research has shown that chemoprevention reduces the chance of developing breast cancer in women who are at high risk of breast cancer. However, these studies were done in mixed groups of high-risk women involving some BRCA alteration carriers as well as women considered high-risk for other reasons. There is very little data available on the effectiveness of chemoprevention medications in BRCA alteration carriers specifically.
Current evidence suggests that chemoprevention is more effective in BRCA2 alteration carriers than in BRCA1 carriers. This is because BRCA2 carriers tend to develop oestrogen receptor positive (ER+) breast cancers, and BRCA1 carriers develop predominately oestrogen receptor negative (ER-) breast cancers; the evidence available at present suggests that chemoprevention medications reduce the risk of ER+ breast cancers, but not ER- breast cancers.
Chemoprevention is very different from chemotherapy that is used to treat cancer and it does not cause hair loss or sickness that often occur with chemotherapy treatment.
Use of chemoprevention in healthy (cancer unaffected) BRCA alteration carriers is uncommon in Ireland and Europe but it is available upon request. If this is an option that you want to consider, please discuss this with your doctor.
There are different medications available for chemoprevention depending on whether you are pre-menopausal or post-menopausal.
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There is only one medicine available for chemoprevention in pre-menopausal women who have not had cancer; this is tamoxifen.
What is tamoxifen?
Tamoxifen is a type of drug known as a selective estrogen receptor modulator (SERM). This means that it blocks estrogen in some tissues of the body. Tamoxifen has been used in both treatment and to reduce the risk of breast cancer in premenopausal women. Research has shown that tamoxifen can lower the risk of developing breast cancer by about 30 to 40% in pre-menopausal high-risk women. However, the use of tamoxifen has been associated with a small increased risk of uterine cancer (cancer of the lining of the womb), pulmonary embolism (a blood clot in the lung), and deep vein thrombosis (a blood clot in a major vein). Tamoxifen can also cause other side effects in some women such as hot flushes, abnormal vaginal bleeding and vaginal discharge. Tamoxifen is not suitable for use in women who are pregnant or trying to become pregnant.
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There are three medicines available for chemoprevention in post-menopausal women; these are tamoxifen, raloxifene and aromatase inhibitors (eg. anastrozole).
What is tamoxifen?
Tamoxifen is a type of drug known as a selective estrogen receptor modulator (SERM). This means that it blocks estrogen in some tissues of the body. Tamoxifen has been used in both treatment and to reduce the risk of breast cancer in post-menopausal women. Research has shown that tamoxifen can lower the risk of developing breast cancer by about 30 to 40% in post-menopausal high-risk women. However, the use of tamoxifen has been associated with a small increased risk of uterine cancer (cancer of the lining of the womb), pulmonary embolism (a blood clot in the lung), and deep vein thrombosis (a blood clot in a major vein). Tamoxifen can also cause other side effects in some women such as hot flushes, abnormal vaginal bleeding, vaginal discharge or vaginal dryness.
What is raloxifene?
Raloxifene is also a type of drug known as a selective estrogen receptor modulator (SERM). In post-menopausal women, raloxifene (also called Evista) has also been shown to decrease the risk of breast cancer in post-menopausal high-risk women. Raloxifene is slightly less effective than tamoxifen at preventing breast cancer. On the other hand, unlike tamoxifen, raloxifene has not been associated with an increased risk of uterine cancer. Raloxifene has also been shown to benefit bone health and cholesterol levels. Therefore, this option can be an excellent choice for women with bone loss. Like tamoxifen, raloxifene has risks that must be weighed against the benefits in consultation with your doctor.
What are aromatase inhibitors?
Aromatase inhibitors are medications that block production of oestrogen in postmenopausal women. Common aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin).
Aromatase inhibitors do not improve bone density. In fact, they may actually accelerate bone loss in postmenopausal women. However, aromatase inhibitors tend to cause fewer side effects and do not appear to have the risk of blood clots or uterine cancer seen with tamoxifen. No studies have looked at aromatase inhibitors for the prevention of breast cancer specifically in women with BRCA alteration.
More information on chemoprevention is available in the ‘Resources ‘ section or here:
https://patientinfolibrary.royalmarsden.nhs.uk/document/download/1151
Options to manage ovarian cancer risk
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The ovaries are part of the female reproductive system. They are two small oval-shaped organs on each side of your womb in your lower abdomen (pelvis). Each month, if you are fertile, an egg is produces in one of your ovaries. The egg leaves your ovary and passes down through a tube called the fallopian tube to your womb. If the egg is not fertilised by sperm, it leaves your womb with the lining of the womb. This happens as part of a monthly cycle known as a period (menstruation). The ovaries also make the female sex hormones, oestrogen and progesterone.
You are fertile from the onset of puberty to when your periods stop (menopause). During the menopause your ovaries produce less hormones, so period will gradually stop.
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Presently, it is recommended that women with BRCA1 or BRCA2 alterations consider risk-reducing ovarian surgery, by removing ovaries and fallopian tubes, to manage the risk of ovarian cancer. This is typically recommended at by age 40 for carriers of BRCA1 gene alterations but may be considered from 35 years of age onwards if there is a strong family history of early onset ovarian cancer. BRCA2 alteration carriers are advised to have their ovaries removed between the ages of 40 and 45.
Feras
Consultant Gynaecological Oncologist Mr Feras Abu Saadeh on Ovarian Surgery. -
Risk-reducing bilateral salpingo-oophorectomy (BSO) is the surgical removal of ovaries and fallopian tubes to reduce the risk of developing ovarian cancer. It is strongly recommended that women who carry BRCA alterations have this surgery after they have finished having children. The major decision is related to the timing of the procedure.
The guidelines recommend BSO by age 40 for women with BRCA1 alterations and between age 40 to 45 for women with BRCA2 alterations. The reason for this is that the risk of ovarian cancer in women who carry a BRCA alteration does not begin to rise markedly until approximately 40 for BRCA 1 and in the mid-40s for BRCA 2. Recent studies suggest that this approach will reduce ovarian cancer incidence by as much as 85%. Ovarian cancers in women with a BRCA 1 and 2 alterations may begin in the fallopian tube; therefore, the fallopian tubes are removed at the time of oophorectomy.
A small number of women will still develop cancer of the lining of the abdomen, known as primary peritoneal cancer.
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There are two main surgical options for removing the ovaries; keyhole surgery (laparoscopy), where the ovaries and tubes are removed through small incisions in the abdomen and open abdominal surgery (laparotomy). Both are carried out under general anaesthetic. Keyhole surgery is the most common type of surgery used. If you have keyhole surgery, you can usually go home the same day. If you have open abdominal surgery you will usually need to spend 1-2 nights in hospital.
Hysterectomy (removal of the womb) is not usually performed as part of this surgery as this does not reduce your risk of ovarian cancer but in some cases, women will have a hysterectomy at the same time as their ovarian surgery if they need this for other reasons such as fibroids or endometriosis.
Further details about these surgeries are available in the ‘Resources’ section or here:
https://www.breastcancer.org/treatment/surgery/prophylactic-ovary-removal/what-to-expect -
What are the effects of oophorectomy if I have not gone through menopause yet?
If you are pre-menopausal, removing your ovaries will cause you to enter a surgically-induced menopause. This menopause is permanent and cannot be reversed. You will no longer be able to get pregnant. As a result, this surgery is only considered after a woman is sure she has completed her family.
What symptoms might I experience from surgically-induced menopause?
If a woman undergoes the removal of the ovaries (oophorectomy) before naturally going through the menopause this will place a women into a surgically induced menopause immediately. While removal of the ovaries reduces ovarian cancer risk, there are additional health issues that removal of the ovaries can cause which need consideration.
This lack of oestrogen in the body can cause physical, sexual and psychological symptoms which include:
Vasomotor Symptoms: Hot flushes, Sweats
Musculoskeletal Symptoms: Joint and muscle pain
Mood Changes: Low mood
Sleep disturbances
Vaginal Dryness
Sexual Difficulties: Low libido
Surgical menopause affects everyone differently, some may have only minor symptoms but for some women symptoms may be severe.
Are there any other risks of premenopausal oophorectomy?
Oestrogen provides women with major protection from bone loss (osteoporosis), a condition where the bones are weakened and more easily fractured. Therefore removal of the ovaries can lead to bone thinning and a higher risk of fractures. In addition, oestrogen deprivation due to surgically removing the ovaries at a young age increases a woman’s risk of heart disease.
Can a premenopausal BRCA carrier take hormone replacement therapy (HRT) after prophylactic oophorectomy?
Women with a BRCA alteration and no history of breast cancer typically have the option of hormone replacement therapy (HRT) after having their ovaries removed. Many women at high risk of breast cancer may feel anxious about taking hormonal medications. Discussions with your nurse/doctor are usually helpful in making these difficult decisions.
HRT aims to replace the hormones lost during the menopause
HRT can be effective in relieving almost all symptoms of the menopause
The risk/benefit balance of HRT varies between women and is a personal decision
If you are put into a surgically induced menopause before the age of 50 we would recommend HRT to help with all side effects of the menopause including bone health and heart health
HRT is recommended until the natural age of menopause of about 50 years old
It can take 3-6months of therapy to ensure the full effect of HRT
Link with your GP regarding dose adjustments and HRT types to find what suits you best
What are the effects of oophorectomy if I have gone through menopause already?
Once a woman has gone through natural menopause (no periods for over a year), her ovaries are not expected to produce oestrogen. Therefore, removing healthy ovaries in a woman who has naturally gone through menopause will usually not have an impact on her symptoms of menopause.
Can a premenopausal BRCA carrier take hormone replacement therapy (HRT) after prophylactic oophorectomy?
Women with a BRCA alteration and no history of breast cancer typically have the option of hormone replacement therapy (HRT) after having their ovaries removed. Many women at high risk of breast cancer may feel anxious about taking hormonal medications. Discussions with your nurse/doctor are usually helpful in making these difficult decisions.
Can a postmenopausal BRCA carrier take hormone replacement therapy (HRT) after prophylactic oophorectomy?
Women who have gone through natural menopause with a BRCA alteration are not considered good candidates for traditional HRT. Therefore, post-menopausal women should discuss non-hormonal options with their doctor.
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Lifestyle Modifications
Diet: A balanced diet rich in fruits, vegetables, whole grains, and lean protein can help manage weight and reduce the risk of heart disease and osteoporosis. Avoiding or reducing alcohol or caffeine can help with hot flushes and sweats.
Exercise: Regular physical activity improves mood, reduces stress, improves sleep,strengthens bones, and improves overall health.
Stress Reduction: Practices like yoga, meditation, and deep breathing can reduce anxiety and hot flashes.
Non-Hormonal Medications
Antidepressants (SSRIs or SNRIs): Certain antidepressants, like fluoxetine or venlafaxine, can reduce hot flashes and improve mood.
Clonidine: A medication used to treat high blood pressure, it can also reduce hot flashes and night sweats.
Phytoestrogens and Natural Supplement
Soy and Isoflavones Found in foods like tofu, soybeans, and flaxseeds, these can have mild oestrogen-like effects that may help alleviate symptoms.
Black Cohosh: An herbal remedy that some women use to reduce hot flashes, though evidence of its effectiveness is mixed and can interact with other medication.
Cognitive Behavioural Therapy (CBT)
CBT has been shown to help manage hot flashes, night sweats, and mood disturbances. It can help women reframe their responses to stress and symptoms.
Topical Vaginal Treatments
Vaginal moisturisers and lubricants can be useful for women experiencing vaginal dryness and discomfort during intercourse
Vaginal Oestrogen is a topical treatment that is put directly into the vagina with a pessary, cream or vaginal ring and can help with vaginal dryness.
This can be used if you are already taking HRT
Acupuncture
Some women find relief from symptoms like hot flashes and mood swings through acupuncture, though results can vary from person to person.
Yoga and relaxation techniques
Yoga and relaxation techniques such as massage or reflexology can help some women to manage stress.
Cognitive and Emotional Support
Support Groups: Joining menopause-focused support groups can provide emotional relief and practical advice.
Counselling: Therapy can help women cope with the emotional and psychological challenges associated with menopause.
Additional information
Additional information on managing menopausal symptoms is available in the ‘Resources’ section or here:
Menopause Matters, menopausal symptoms, remedies, advice
https://www.healthline.com/nutrition/11-natural-menopause-tips#supplementation
