After Teal’s surgery in January, her mother, Nancy—who’d just finished chemotherapy a few months earlier—came to help take care of her. Photograph by Chris Gavin Jones
Teal brought her mother home to her house in Alexandria to recover. They were alone one morning when her mother said, “I know I’m going to die from breast cancer. All I want is ten more years.”
I think we can give you that, Teal thought. I hope we can.
The first time her mother had breast cancer, she’d never given much thought to whether it might affect her daughters. She’d done hormone-replacement therapy after menopause, and the treatment can increase breast-cancer risk, so she had attributed her diagnosis to that. Now that she had cancer again, she wondered if Christy was right: Maybe this was genetic.
There weren’t many women in Nancy Brown’s family, so it was hard to trace any history of breast cancer, but one of her aunts had died in her fifties, and she had never really known what killed her. After her surgery, Nancy called her cousin to ask and found out it was breast cancer.
The genetics of breast cancer is complicated. Both men and women have BRCA1 and BRCA2 genes, which are known to suppress tumor growth. Mutations in those two genes lead to an increased risk of cancer. Female mutation carriers have a 60-to-80-percent chance of developing breast cancer and a 10-to-45-percent risk of developing ovarian cancer. Some decide to have prophylactic surgery, removing their breasts, ovaries, or both.
Some patients don’t want to know if they carry a genetic abnormality or if their relatives do, because they’d rather live without the worry. Others ask for the testing so that if they’re positive—meaning they have mutations in the BRCA genes—they can do something about it. Preventive surgery isn’t the only option; some patients with a strong family history consider taking tamoxifen or raloxifene, which can cut their breast-cancer risk in half. A recent study found that another drug, Aromasin, currently used to treat the disease, can reduce the risk for postmenopausal women by 65 percent.
Teal assumed her mother would test negative because most women who are BRCA-positive develop cancer before they hit menopause. But a negative result doesn’t mean a cancer isn’t hereditary, because BRCA mutations don’t account for all hereditary breast cancers. Five to ten percent of breast cancers run in families, and there are other cancer-predisposing mutations that researchers haven’t yet identified.
When Teal took a sample of her mother’s saliva and had it sent to a laboratory for genetic testing, she wasn’t sure what she wanted the result to be. She’d learned over the years that patients testing BRCA-negative—a good result meaning no mutation of the gene—fell into an area of uncertainty. Some insurance companies were less likely to cover screening procedures, including MRIs, if a patient didn’t have a genetic mutation. Her sister, Marci, who has never considered prophylactics, needed a letter from her doctor explaining why she needed MRIs every year. Teal’s husband’s military health plan, Tricare, agreed to pay for her prophylactic mastectomy—the company was billed more than $80,000—but she’d heard of other insurance companies that didn’t always cover preventive breast surgery.
A colleague put her mother’s test results on Teal’s desk about four weeks after she sent them off: negative.
“Are you sure you need to do this?” her mother asked. She’d never told her daughter not to have the mastectomies, but she didn’t like the idea of unnecessary surgery.
“Yes,” Teal said. “I’m sure.”
Her mother didn’t have a BRCA mutation, but as far as Teal was concerned, she probably had a different one.