BRCA Previvors : Medical and Social Factors That Differentiate Them From Previvors With Other Hereditary Cancers

Résumé Summary Dans cet article, je décris quelques-unes des raisons pour lesquelles les « previvors » de BRCA (c-a-d. « survivants d ’une prédisposition au cancer ») sont différents des previvors avec d’autres cancers héréditaires. J’examine comment l’absence d’une norme de soins pour le risque de cancer du sein chez les femmes ayant une mutation BRCA, associée à un large éventail de pénétration génétique et une mortalité plus faible, rend le BRCA différent des autres cancers héréditaires qui ont des directives claires et établies. En plus de ces différences médicales, des facteurs sociaux tels que la prééminence culturelle du cancer du sein et la signification sociale des seins ont engendré une identité prédictive individuelle plus complexe et une réponse culturelle aux femmes ayant une mutation BRCA. In this paper, I outline some of the reasons why BRCA “previvors” (i.e., “survivors of a predisposition to cancer”) are different from previvors with other hereditary cancers. I examine how the absence of a standard of care for breast cancer risk for women with a BRCA mutation, coupled with a broad range of genetic penetrance and lower mortality, makes BRCA different than other hereditary cancers that have clear and established guidelines. In addition to these medical differences, social factors like the cultural prominence of breast cancer and the social significance of breasts have engendered a more complicated individual previvor identity for and cultural response to women with a BRCA mutation.

In this paper, I outline some of the reasons why BRCA "previvors" (i.e., "survivors of a predisposition to cancer") are different from previvors with other hereditary cancers. I examine how the absence of a standard of care for breast cancer risk for women with a BRCA mutation, coupled with a broad range of genetic penetrance and lower mortality, makes BRCA different than other hereditary cancers that have clear and established guidelines. In addition to these medical differences, social factors like the cultural prominence of breast cancer and the social significance of breasts have engendered a more complicated individual previvor identity for and cultural response to women with a BRCA mutation.
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Introduction
Angelina Jolie made headlines when she revealed that she has one of the BRCA genetic mutations, 1 which substantially increases her risk of developing breast and ovarian cancer. The big news was not that she had this mutation; it was her decision to have a prophylactic mastectomy in order to minimize the likelihood of getting breast cancer. The cultural narrative of cancer survivors is ubiquitous. In recent years, there is a new cultural narrative of individuals battling with cancer; however, these individuals do not in fact have cancer nor (in most cases) have they ever had cancer. These individuals, known as "previvors" (short for "survivor of a predisposition to cancer"), often feel like they too are facing a cancer battle because they face a high risk of developing cancer due to a positive result on a genetic test for hereditary cancer, a family history, or any other predisposing factor. In the medical literature, these individuals are referred to as "unaffected carriers"; yet for many, the term unaffected carrier does not convey the challenges they face and how they understand themselves. The term "previvor" emerged in 2000 on a message board hosted by Facing Our Risk of Cancer Empowered (FORCE), a nonprofit organization dedicated to fighting hereditary breast and ovarian cancer (HBOC), in response to a contributor who wanted a label to describe her cancer fight [1].
Despite the broad definition of previvor, discussions of previvors generally refer to women who have tested positive for one of the BRCA mutations. Yet, there are other hereditary cancers for which prophylactic treatment is available. For example, familial adenomatous polyposis (FAP) is an inherited syndrome associated with an alteration in the MUTYH or APC gene that leads to colon and rectal cancer and standard treatment is a prophylactic colectomy. These other types of hereditary cancers are generally not included in discussions of previvors and the previvor identity is not as common among individuals with these other hereditary cancers. Especially given that BRCA genetic testing was predated by genetic tests for other hereditary cancers [2], why has the previvor identity only recently emerged and stayed within the BRCA community? Comparing BRCA to FAP (see Table 1), I outline some medical and social factors that have played a role in this phenomenon. The lack of a clear standard of care to prevent hereditary breast cancer is one significant medical difference between BRCA and other hereditary cancers that may explain why the previvor identity has stayed squarely within the BRCA community [3]. Most hereditary cancers have established prophylactic treatments that are routinely recommended by health care professionals. For example, the standard of care for individuals with gene alterations related to FAP is a prophylactic colectomy between 18 and 20 years old [4]. While there is a standard of care for BRCA positive women, it pertains only to their ovarian cancer risk: surveillance for ovarian cancer has proven ineffective [5], so the consensus is that oophorectomy should be offered to all women carrying a BRCA mutation between age 35-40 or once childbearing is complete [3].
The current options to minimize breast cancer risk are "watchful waiting" (i.e., early detection strategies such as more frequent screenings), prophylactic medication (namely Tamoxifen), or prophylactic surgery (mastectomy and oophorectomy). Although there is strong evidence for the effectiveness of prophylactic mastectomy in preventing breast cancer in BRCA positive women [6], it is not considered standard of care and moreover discussing it as a treatment option is not even considered the standard of care. For instance, the American Congress of Obstetrics and Gynecologists (ACOG) lists the various options for addressing breast cancer risk, but does not state that any of these options should be followed or should be discussed. Yet, ACOG explicitly names the standard of care for ovarian cancer risk: "risk-reducing salpingo-oophorectomy, which includes removal of the ovaries and fallopian tubes in their entirety, should be offered by age 40 years or after the conclusion of childbearing" [7, p.960]. Similarly, the National Comprehensive Cancer Network (NCCN) guidelines do not list a standard of care or require mention of certain treatment options: "Discussion of risk-reducing mastectomy should be carried out on a case-by-case basis" [3]. But only 16% of all physicians follow the NCCN guidelines for treating BRCA positive women [8], so patients receive a range of information about prophylactic mastectomy and potentially no information at all. Even when prophylactic mastectomy is discussed, patients often do not receive decisive advice on the best risk management strategy for them, so the decision to pursue prophylactic mastectomy is often based on individual preferences rather than an established medical protocol [9, p.760;10, p.657]. Specifically, some women's decisions are based on fear and anxiety, as well as not wanting to live with the guilt of knowing they could have done something but chose not to [11].
Many women with a BRCA mutation want clear and unambiguous advice from their physicians about what treatment options to pursue [12], but without this and without a standard of care to fall back on, they may be left floundering to make the "right" decision and/or the one that most aligns with their values. The existence of an established standard of care relinquishes the burden of the difficult decision to remove an entire body part.

Genetic Penetrance and Mortality
Another important medical difference between BRCA and other genetic cancers is that the penetrance for BRCA encompasses a large range. Whereas cancer is virtually guaranteed for individuals with FAP, this is not the case with BRCA carriers: their lifetime incidence of malignancy is 45-85% for breast cancer and 11-62% for ovarian cancer [2]. A penetrance rate of almost 100% is a strong justification for prophylactic surgery. It is harder, however, to support prophylactic surgery when penetrance is a 40-50 point range and it is difficult to know the exact probability of penetrance for a specific individual. The risks and benefits of someone on the low end of a 40-50 point range are very different from someone at the high end.
One important risk to consider when weighing prophylactic surgery is the average mortality rate from the hereditary cancer if one opts not to have the surgery. Here again there is a stark difference between BRCA and FAP. Without surgical intervention, mortality from gastrointestinal cancer for individuals with FAP is almost 100%, with half of patients dying before age 50 [4]. In contrast, individuals with a BRCA mutation who do not have prophylactic surgery can have a normal, or near normal, life expectancy [13]. Part of the reason for this difference is that there are effective, nonsurgical prophylactic treatment options available to BRCA positive women (e.g., Tamoxifen) while there are none for individuals with the FAP mutation. Furthermore, there are also successful treatments for breast and ovarian cancer that can allow for normal life expectancy for women who are BRCA positive and develop cancer. Even if women with a BRCA mutation choose to have no intervention whatsoever, some of them can still be expected to live into their 70s [13].

The Social Factors Cultural Prominence of Breast Cancer
Breast cancer is one of the most well-known and well supported disease causes. The pink ribbon is a universally recognized symbol of breast cancer and can be found affixed to myriad consumer products of companies that aim, at least in part, to show that they are "woman friendly" [14]. Fundraising and marketing is not the only area in which breast cancer is pervasive; breast cancer is overrepresented in popular press, which fuels women's anxiety about the disease [15][16][17]. Many media portrayals of women with breast cancer show and/or describe pre-menopausal women, which can lead women to believe that risk of breast cancer before menopause is high, even though it is not [18,19]. Indeed, some research shows that the majority of women erroneously believe that breast cancer is the number one killer of women, when in fact it is heart disease [20]. Women's intense fear of breast cancer is part of the reason that breast cancer continues to be overrepresented in the popular press.
The BRCA previvor identity has emerged as yet another breast cancer threat with women mistakenly believing that they are at risk for hereditary breast cancer. The cultural prominence of breast cancer provided a springboard for BRCA previvors; and BRCA previvors have emerged as another narrative within the breast cancer umbrella. Because other diseases (including other types of hereditary cancer, like FAP) do not carry the same degree of cultural currency of breast cancer, previvors of those diseases have a much more difficult time gaining public interest. Without such public interest, it is harder to raise money for research and to support previvors. On the individual level, BRCA previvors may receive more sympathy and support from friends and family than other previvors because BRCA is a well-known disease that is publicly feared. In short, the ubiquity of breast cancer advocacy and media coverage provided the cultural context and foundation for which the identity of BRCA previvors could develop and gain public attention.

Significance of Breasts
Due to mind/body dualism, we often assume that "organs are simply mechanical entities whose worth is entirely without symbolic or affective meaning" [21, p.1408]. When our organs are functioning properly, we typically do not think much about them and any role they may play in our identity. However, certain organs, such as the hands and face, carry more symbolic weight than others [22]. Breasts are another example of organs with symbolic value: they serve as gender markers (i.e., ISSN 1923ISSN -2799 identifiers of one's sex) and are generally seen as a central part of women's sexuality, reproductive capacity, and overall femininity. Not surprisingly then, "[t]he fear of loss of femininity, sexual attraction and loss of sexual pleasure" is a significant concern for many women who are considering and eventually undergo prophylactic mastectomy [23, p.793]. While people with FAP also have anxieties related to sexuality following their prophylactic surgery [24], these typically do not have to do with deeper concerns regarding their sexual identity since the colon is not a symbol of sexuality in the way that are breasts. Breasts are more closely linked to one's gendered, sexual, and reproductive self and so the decision to remove them prophylactically is much more complicated and difficult and their loss is felt more deeply than the loss of other organs that are not as intertwined with our identity.
Yet, breasts are important not just to individual women, but also to our society as a whole as they connote important cultural values such as fertility, nurturing/caregiving, luxury, and political freedom [25]. The cultural significance of breasts is reflected in laws, such as the US Women's Health and Cancer Rights Act of 1998, that mandates that if health insurance companies cover the costs of mastectomy for cancer patients, then they must also cover the costs of breast reconstruction for mastectomy patients. No other quality of life laws for cancer patients exist, even for comparable conditions like iatrogenic infertility [26].

Conclusions
In order to gain a deeper understanding of the experiences of women with a BRCA mutation, it is useful to be familiar with the previvor identity as well as both the medical and social factors that shape it. In particular, recognizing what distinguishes women with a BRCA mutation from others with hereditary cancers -i.e., the lack of a medical standard of care, the genetic penetrance and lower mortality caused by the mutation, the cultural prominence of breast cancer, and the significance of breasts -will enable healthcare providers to best support and treat BRCA previvors. In particular, healthcare providers should be cognizant of the difficult decisions that BRCA previvors face due to the absence of established guidelines for handling breast cancer risk. The fact that there is no set standard may be seen as empowering for patients, at least on the surface. In reality, however, patients are often burdened with the responsibility of making such a challenging decision and may face guilt and regret regardless of the decision they make. Continued scientific studies on how to best address breast cancer risk for women with a BRCA mutation is imperative in order to move toward a clear standard of care. In the meantime, healthcare providers should do their best to counsel women and ensure that they are receiving psychosocial support when making these difficult decisions.