Keeping abreast of your breast cancer risk

With the media frenzy surrounding Angelina Jolie’s revelation of a double mastectomy after positive results of a gene test (BRCA1) for breast cancer, I decided to interview a breast cancer specialist in the US, Dr. Norman San Agustin.   I wanted the facts behind such a drastic measure, the pros and the cons.  

To start with, Angelina lost her mother to cervical cancer after a 10-year battle. She thus decided to undergo a gene test to find out her susceptibility to the dreaded disease. The test result was 87-percent positive, which determined her decision to undergo the procedure.   Women with a history of breast cancer in their family usually opt to do this test. 

What is BRCA testing?  Dr. Susan Domchek says: It is a genetic test that looks at the sequence or code of the BRCA 1 /BRCA 2 (breast cancer) genes.  Changes or mutations in the genetic code indicate increased cancer risk. The test can be performed on a blood or saliva sample. It takes about three weeks to get the results. 

What does a positive result mean? 

A positive test result in BRCA1 or BRCA2  means that the person has a genetic mutation that increases cancer risk.  A positive BRCA 1 result gives a woman a 60- to 80-percent lifetime risk of breast cancer and a 30- to 45-percent  lifetime risk of ovarian cancer. A positive BRCA2 result gives a woman a 50- to 70-percent lifetime risk of breast cancer and a 10- to 20-percent lifetime risk of ovarian cancer.

Going back to Dr. Norman San Agustin’s take on breast cancer management, here is what he has to say: In the past 50 years, the pendulum has been constantly swinging back and forth regarding the management of breast cancer.  It was believed for many years that breast cancer was a local disease, hence, the more you remove, the more likely you can cure the patient.  This was highlighted by the Jerry Urban Super Radical Mastectomy when everything in the region of the breast was removed, all the way down to all the chest wall muscles and the ribs. This was the most mutilating surgery you can imagine and was in vogue for years until surgeons realized that breast cancer was not a local but a systemic disease.  So surgeons started doing minimal surgery called lumpectomies.  It did not take long for them to realize that this, too, was not sufficient to achieve cure in many patients.  Recently, the best results, including many cures, have been achieved combining early diagnosis, lumpectomies with attention to clear margins plus adjuvant radiation therapy or hormonal therapy.   However, just when we thought we finally found the perfect treatment, along came women’s paranoia and nagging fear of recurrence or development of another cancer in the opposite breast and women started going back not only to total mastectomy but also prophylactic mastectomy, removing the perfectly healthy cancer-free normal opposite breast!  Now, it has gotten even more extreme:  women without breast cancer but have high cancer risk, such as those with positive BRCA genes (like Angelina Jolie) are now opting to have Prophylactic Bilateral Total Skin and Nipple Sparing mastectomies with immediate reconstruction.  Angelina Jolie most recently became the poster girl for this procedure.  Just a word of caution for those considering this procedure to “eliminate any chance of developing cancer.”  With this procedure, it is not possible to remove all lobular or ductal structures superficially located and left behind with the rest of the skin.  Any of these cells could still transform into cancer. Also, even if the “new” breast may look very much like the original breasts or at times even better, they just will never feel like normal breasts.  They will always be numb and never sensual.

I am so proud to say that Dr. San Agustin is a Filipino and is my breast doctor in the US.   My father’s sister had breast cancer so my sisters and I are vigilant about doing mammography when needed.  I have not resorted to having a BRCA gene test, but it has crossed my mind after Angelina Jolie’s mastectomy.   Angelina’s case highlights the importance of knowing one’s family history and learning one’s cancer risk in order to address it proactively.

Dr. San Agustin is a well-known onco-plastic breast surgeon and  director of the breast cancer program/chairman of the Comprehensive Cancer Program at Saint Clare’s Hospital in Denville, NJ.  This was the satellite hospital of Memorial Sloan Kettering Cancer Center in New Jersey for 10 years.   He is also the founder and president of the Morristown Surgical Associates, one of the dominant surgical oncology groups in Morristown Medical Center, a large teaching institution rated the number one hospital in the state.  He hopes to someday develop a Center of Excellence for the treatment of breast cancer in the Philippines.  This will be for profit for charity to provide the best possible care not only to the wealthy but also to those who  can afford treatment.

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For an appointment with Dr. Norman San Agustin, call +1973-2672838.