Managing Cancer Risk

By Kathleen Calzone, R.N., M.S.N., A.P.N.G., F.A.A.N.

The purpose of risk assessment is to identify people at increased risk for cancer so health care providers can do something different to reduce the risk of cancer or to be able to detect cancer earlier. The risk for cancer is a combination of genetics, environment, health history and many other personal factors. Likewise, the decision about how to manage risk is also very complex and involves a number of personal factors. The following four examples of primary cancers will give some insight into the kinds of things one might choose to do to manage elevated risk. There are four main things to think about in managing risk: increasing screening, having risk-reducing surgery, chemoprevention (using medicine to reduce risk) and risk avoidance. The following outline will examine how each of these approaches could be used to manage increased risk for the four cancers.

Increased screening: monitoring to detect cancer as early as possible
- Breast cancer: Annual mammograms beginning at age 40 or five to 10 years earlier than the earliest case of breast cancer in the family, whichever is earlier. In addition, clinical breast exams every six to 12 months and consideration of other screening tests such as breast MRI
- Ovarian cancer: There is no proven screening methodology for ovarian cancer, but can consider having ultrasounds and CA125 blood tests, as well as participating in clinical trials
- Colon cancer: Colonoscopy every one to five years starting at age 40 in someone with a family history or 10 years prior to earliest case of colon cancer in the family, whichever is earlier; in addition, consideration of other screening tests such as barium enema and fecal occult blood test
- Skin cancer: Annual skin exam by a dermatologist
Risk-reducing surgery: Removing tissue that’s at risk to reduce the development of cancer or the risk to develop cancer
- Not a decision to be taken lightly
- Requires extensive consultation with health care providers
- Breast cancer:
  - Prophylactic mastectomy – removal of breast tissue to reduce risk
  - Significantly reduces breast cancer risk in women with a family history
  - Greater than 90 percent reduction in breast cancer risk in BRCA mutation-positive women
  - Issues include quality of life (body image, self-esteem, sexuality), breast reconstruction options and residual cancer risk
- Ovarian cancer:
  - Removal of ovaries, called oophorectomy
  - Difficult decision because removing the ovaries eliminates the ability to have children and causes early menopause, which has serious health implications
  - Eliminates risk of primary ovarian cancer, but peritoneal carcinomatosis may still occur
  - In BRCA mutation-positive women, also reduces breast cancer risk by 55 to 70 percent
  - Issues include quality of life (body image, sexuality) and early menopause, which can affect bone and cardiovascular health
- Colon cancer:
  - Removes most of, but not all, at-risk tissue
  - Risk of cancer still present in remaining rectal tissue
  - Generally considered if someone has had multiple problems in their colon or a history of colon cancer
Chemoprevention: Involves taking a medicine, vitamin or other substance to reduce the risk of cancer
- Breast cancer:
  - Tamoxifen – 48 percent reduction of breast cancer incidence in high-risk women
  - In postmenopausal women, raloxifene works as well as tamoxifen in reducing breast cancer risk without as much of an increase in uterine cancer risk or risk for blood clots
  - Both have potential side effects and complications to be carefully considered
- Ovarian cancer:
  - Oral contraceptives have been shown to reduce risk of ovarian cancer 40 to 50 percent after three years of cumulative use
  - Conflicting data is available regarding impact of oral contraceptives on ovarian cancer risk BRCA-mutation carriers
- Colon cancer:
  - Non-steroidal anti-inflammatory drugs, hormone replacement therapy, vitamins such as folic acid and vitamin D have all been studied
  - Recent attention on impact of statins — medications used to reduce cholesterol
  - There is no magic pill!
Risk avoidance: Avoiding other exposures that may increase cancer risk. The following behaviors are critical to maintaining good health, which reduces risk of most cancers:
- Well-balanced diet
- Limiting exposure to sun
- Avoiding tobacco
- Routine exercise

Managing cancer risk is something that is shared in a family because often the risk is shared. Communication with family members about the history of cancer in the family will enable family members to take the best steps to reduce risk or detect problems early. To manage an increased risk for cancer it is important to consult with experts, learn all the options and take the time to make the best decision possible.

About the author

Kathleen Calzone, R.N., M.S.N., A.P.N.G., F.A.A.N., is a senior nurse specialist for research at the National Cancer Institute (Genetics Branch). She has extensive experience in project management for genetics-based research. She serves as co-chair for the Genetics Expert Panel for the American Academy of Nursing, has held leadership roles for the International Society of Nurses in Genetics and has co-authored numerous textbooks and articles about genetics and cancer.

More information

To make an appointment for genetic counseling at the Familial Cancer Clinic at VCU Massey Comprehensive Cancer Center, please phone (804) 828-7999.