UNIVERSAL BRCA TESTING?

Scientist Mary Claire King has recommended wider population/universal testing testing for BRCA. There has been an onslaught of articles responding to this recommendation. Here is my comment from: "Here's Something You Don't Want To Know About Your Risk Of Breast Cancer" which expresses my opinion on the subject.  @BRCAresponder

@Forbes http://onforb.es/1qGb2Ke

Steven, 

Thank you for your article–as I applaud anything that starts a conversation on BRCA/Hereditary cancer.   

I am going to rewrite the article below and address 

the specifics.

“But her proposed new universal testing policy, which fellow Forbes contributor David Shaywitz calls “audacious,” goes far beyond what other experts recommend. Earlier this year, the highly regarded U.S. Preventative Services Task Force (USPSTF) recommended testing BRCA genes only in women with a family history of breast or ovarian cancer.”
@BRCAresponder says:—–The USPSTF confuses genetic counseling and genetic testing. What about very small families with limited health knowledge, or what happens when the gene is passed down via the paternal side, and the father only has brothers? What if there is simply a history of a few male cancers?“Although there’s no question that King is an expert on BRCA gene testing, I think she’s gone much too far with her latest proposal. She has the science right, but she is far too optimistic about how her recommendation would actually play out. The policy might save some lives, but it would also cause a great deal of pain.”
@BRCAresponder says:——-I am BRCA Advocate in the trenches hearing genetic counseling and genetic testing stories first hand. I hear countless stories via those with family cancer history that are told “not to worry about anything”. I personally have two friends who were BRCA tested via regular ob/gyn and their tests were misinterpreted. They were told they were BRCA negative when they were in fact BRCA positive. One didn’t know it but she already had ovarian cancer: http://stacybrcastory.eventbrite.com  I am so afraid of how many more stories like this are out there; I know they are. Yes, agreed, Dr. King may be optimistic about how her recommendation would play out. Where things stand now, MD’s/regular physicians in general don’t have the adequate cancer genetics/risk assessment training. Nor do they even have the TIME to complete a thorough cancer risk assessment within the timeframe of a regular exam. Can you clarify what you mean by “this would cause a great deal of pain”?“First, it’s worth explaining why King thinks universal BRCA testing is a good idea. In her JAMA article, King and colleagues describe a new study they conducted in Ashkenazi Jews that showed, somewhat surprisingly, that “50% of families found to harbor BRCA1 or BRCA2 mutations had no history of breast or ovarian cancer that would have triggered clinical attention.”In other words, under current policy guidelines, 50% of people who have a damaging mutation in one of these genes will not have their genes tested. Many of them will eventually get breast or ovarian cancer—as King explains, women with harmful BRCA1 mutations have a 60% risk of cancer by age 60, and for BRCA2 the risk is 33% by age 60. That’s a very high risk, though it’s important to keep in mind that many women with these mutations will never get cancer.”
@BRCAresponder says: —- I’m curious if there is a study you can site that shows who and who doesn’t get cancer? BRCA is very dangerous. Most BRCA positive women I know have lengthy family cancer histories. When you couple carrying a BRCA1 mutation w/a lengthy family history pattern of breast and ovarian cancer–including many diagnosis’ and deaths at young ages–when you say “most of these women will never get cancer” escaping cancer doesn’t typically register as “feasible” on a BRCA positive gal’s radar.“With modern DNA sequencing technology, any large-scale genetic BRCA testing program is likely to uncover thousands of mutations that have no harmful effects, and thousands more whose effects are simply unknown. (Aside: each BRCA gene spans about 80-90 thousand nucleotides of DNA, and each of those letters can mutate in 4 ways, changing into one of the other 3 bases or just being deleted. This means there are at least 400,000 mutations possible in each gene, not counting larger deletions. A colleague and I published an article in 2010 describing one such BRCA test.) King is clearly aware that such reporting these mutations to patients would only sow confusion, and she recommends that:“Testing for BRCA1 and BRCA2 should focus solely on unambiguously loss-of-function mutations with definitive effect on cancer risk…. A VUS [variant of unknown significance] can increase confusion and compromise clinical management; for population-based screening, these variants should not be reported.”Herein lies one of the biggest problems with King’s idea. We don’t have universal agreement on which mutations have no significance, and even if we did, most physicians are not experts on cancer genetics. In our lawsuit-prone medical culture, there exists an unfortunate tendency to over-treat and over-report everything.”
@BRCAresponder—-I agree with you here that most physicians are not experts on cancer genetics. In addition, I would add, physicians are not trained to do thorough cancer genetic risk assessments and should not be providing genetic testing at all. They don’t know what to test for (there are many hereditary cancer syndromes besides BRCA.) Most importantly, I have seen first hand that they clearly don’t know how to interpret tests. Dr. King may be optimistic because she is not in the BRCA trenches; not seeing that the current testing/counseling standards need to first be improved dramatically.“Thus I fear that if we had wider BRCA testing, clinical labs would report all mutations back to physicians (how could they not?), and physicians in turn would report everything to the patients. The result would be that millions of women would be told “you have a mutation in BRCA1, and we don’t know what it means.” What’s a patient supposed to do with that?”
@BRCAresponder says—or physicians would even interpret tests incorrectly, as I have seen. For wider genetic testing to happen, a major PROTOCOL change would have to be in place. Physicians would have to be TRAINED in CANCER RISK ASSESSMENT. When results come in (negative or positive), the physician would THEN BE REQUIRED to refer patient to a high risk oncologist for “what to do”. A person can be BRCA negative and still be HIGH RISK. It’s all VERY INTRICATE.“The other problem is that the only treatment to prevent breast and ovarian cancer is surgery to remove a woman’s breasts and ovaries. We don’t have a pill you can take, or lifestyle changes you can adopt, that will dramatically reduce your risk of hereditary cancer. But unlike a cancer diagnosis, the discovery of a BRCA mutation does not mean you have cancer. It simply means you have a risk, possibly a high risk, of getting cancer at a young age. We know from decades of research that people are not very good at evaluating risk. We tend to over-estimate the danger of events that seem very dramatic or visible to us, as cancer is to many people.”
@BRCAresponder says — BRCA is dangerous. That cannot be disputed. When one has a BRCA mutation they are not overestimating. The danger and the cancer risk is real. When it comes to BRCA mutations, knowledge is power and that knowledge may just save your life. The knowledge saved mine.“By King’s own estimates, widespread BRCA testing would detect cancer-causing mutations in 250,000 to 415,000 women in the U.S. This estimate assumes the test doesn’t have false positives, which it almost certainly would. All of these women would then be faced with an extremely difficult dilemma: should they have both their breasts removed, or live the rest of their lives in fear of breast cancer?”
@BRCAresponder says–this is why GENETIC COUNSELING IS KEY in the GENETIC TESTING EQUATION.“This dilemma was famously on display last year, when actress Angelina Jolie revealed in a New York Times article that she’d had a double mastectomy, after discovering that she carried high-risk BRCA mutations. Jolie’s mother died from cancer at the age of 56, and she explained in her article that as a result of the surgery, “ I can tell my children that they don’t need to fear they will lose me to breast cancer.”“King’s proposal is audacious, and it’s well worth debating. But without a better treatment option, telling hundreds of thousands of women that they have a high risk of breast and ovarian cancer carries a potentially enormous cost, both physical and emotional, for these women. Rather than putting huge numbers of women under the surgeon’s knife, we should instead double or triple our investments in research on treatments that may eventually make surgery unnecessary.”
@BRCAresponder says—For a BRCA positive woman, prophylactic surgeries (or as you call it -going under the knife) is currently a BRCA gal’s best chance for a "cure". Currently, it is our best option to drastically reduce our cancer risk and our best chance to remain breathing. Yes, I agree we should double or triple our investments in research on treatments that may eventually make surgery unnecessary. Currently, BASSER CENTER for BRCA at the University of Pennsylvania is currently working hard to find better options for BRCA mutation carriers. I certainly want my children and future generations to have less invasive cancer risk reducing options available to them.

Respectfully,

Amy Byer Shainman
BRCA/HEREDITARY CANCER advocate
BRCA 1 positive previvor @BRCAresponder
Executive Producer: Pink & Blue www.pinkandbluemovie.com
MY STORY: http://amybrcastory.eventbrite.com