Page 14 Complete Your CE Test Online - Click Here People who meet one or more of the above criteria should be referred to genetic counseling for exploration and informed consent. They will learn about the best way to go about the process, other options, what kinds of results might be returned, and what this might mean before they make the decision for the actual test [140]. Risk reduction for those with a BRCA mutation There are actions, such as surgery or drugs, that people with harmful BRCA mutations can take to reduce their risk of BRCA-related cancers. Prophylactic surgery involves removing as much of the “at-risk” tissue as possible, such as breast and ovarian tissue. Removing the ovaries also reduces the risk of breast cancer in premenopausal women by eliminating a source of hormones that can fuel the growth of some breast cancers. Typically, this can wait until the woman has completed childbearing. Even surgery does not guarantee that cancer will not develop because not all of the at-risk tissue can be removed. Still, research showed that women who underwent bilateral prophylactic salpingo-oophorectomy had a nearly 80% reduction in risk of dying from ovarian cancer, a 56% reduction in risk of dying from breast cancer, and a 77% reduction in risk of dying from any cause [82,91]. Drugs and medications can reduce breast cancer risk Data from three studies suggest that tamoxifen may be able to help lower the risk of breast cancer in BRCA1 and BRCA2 mutation carriers, including the risk of cancer in the opposite breast among women previously diagnosed with breast cancer [111,96,239]. Oral contraceptives are thought to reduce the risk of ovarian cancer by about 50% both in the general population and in women with harmful BRCA1 or BRCA2 mutations [128]. Evidence-based practice: Women with harmful BRCA mutations can reduce their future breast cancer risk with medications and/or surgery [140]. Enhanced screening can reduce mortality risk The addition of MRI of the breasts to the annual mammography can be used to improve early detection of breast cancers and improve outcomes of treatment [12]. People who have BRCA1 or BRCA2 mutations might also want to enroll in clinical trials open to people with these mutations. Genetic disease and colorectal cancer A small percentage (5-10%) of colorectal cancers (CRCs) occur in people with a genetic predisposition, including familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch Syndrome [21]. That small percentage is only because these genetic syndromes are fairly rare. A person with FAP develops hundreds to thousands of polyps starting as early as the teen years, so screening with colonoscopy is started very early. CRC can develop before age 20 and many cancers can develop during the person’s lifetime so that colectomy is sometimes performed to prevent them. The person with FAP is at higher risk of other cancers, especially in the GI tract, but their CRC cancer risk alone is nearly 100% by age 40 [21]. A person with Lynch Syndrome runs a nearly 80% lifetime risk of developing CRC, along with a higher risk of stomach cancer. Women with Lynch Syndrome also have a 50% lifetime risk of endometrial cancer, along with a higher risk of ovarian cancer [62]. Other risk factors for CRC are less important than age, genetics, and family history, but include excessive alcohol use, smoking, diabetes, and obesity. Individuals with Ashkenazi Jewish heritage also have a higher risk of CRC [19]. These risk factors alone do not “bump” a person into the high-risk category, but they can offer opportunities for selecting a preventive type of colorectal cancer screening (see section “Cancer Screening Tests”). Family history Even patients without known or suspected genetic predispositions to cancer may have an elevated risk based on family history. Whether this is in part due to family behaviors or habits, or subtler genetic differences is unclear, but it is possible that either or both play a role [60]. Chronic inflammation Inflammation is a normal physiological response that causes injured tissue to heal. An inflammatory process starts when chemicals are released by damaged tissue. In response, white blood cells make and release substances that cause cells to divide and rebuild tissue to help repair the injury. Once the wound is healed, the inflammatory process ends [154]. In chronic inflammation, the inflammatory process may begin even if there is no injury, and it does not end when it should. Why the inflammation continues is not always known. Chronic inflammation may be caused by infections that do not go away, abnormal immune reactions to normal tissues, or conditions such as obesity. Over time, chronic inflammation can cause DNA damage and lead to cancer. For example, people with chronic inflammatory bowel diseases, such as ulcerative colitis and Crohn disease, have an increased risk of colon cancer [154]. Sex Hormonal influences mean that women are much more likely to get breast cancer than men. Obviously, women do not develop prostate cancer nor men ovarian or uterine cancer. There are some cancers which affect both sexes that predominate in one sex or the other, but nothing that skews quite as much as breast cancer, which women are nearly 100 times more likely to develop than men. Some of the increased incidence of one sex or another relates to specific behaviors [125]. For example, men developed lung cancer a lot more than women, but after women began smoking at higher rates, their lung cancer incidence increased as well. Smoking rates in women never quite reached the same level as men, and lung cancer is still somewhat less common in women than in men. Men get more oropharyngeal, urinary, rectal, liver, and skin cancers, as well as leukemias and lymphomas; women get more thyroid and anal cancer. Overall, more women get cancer each year, but more men die from it [14]. Disproven carcinogens and cancer myths Below are some of the popular theories about cancer causation that have been investigated. Either no evidence was found to support these hypotheses or evidence that specifically does not support them was found. “A positive attitude can beat (or prevent) cancer” To date, there is no convincing scientific evidence that links a person’s “attitude” to his or her risk of developing or dying from cancer [158]. It is normal for people with cancer to feel sad, angry, or discouraged sometimes; cancer often brings a number of losses (such as body image, changes in relationships, changes in self-efficacy, fertility and sexuality changes, concerns over their ability to perform important tasks or functions, among others) that must be grieved. This process can take months or even longer. Not only is this myth false, it can cause emotional harm. Jimmie Holland, a psychiatrist who pioneered mental health care for people with cancer, coined the phrase “the tyranny of positive thinking.” According to her observations, our expectations of a cheery outlook and condemnation of any sign of sadness or anger constitute an additional burden on the person with cancer. For many people, being expected to be cheerful and upbeat all the time is profoundly discouraging and in some cases, guilt-producing, when they are unable to “be positive” all the time [102]. Worse, the popular interpretation of the mind-body connection sometimes blames the patient’s attitude or emotional state for his or her cancer. There are people who truly believe that if they allow themselves to feel distressed, angry, or upset it will make their cancer grow faster [102]. It is true that it can be helpful to patients to approach treatment with the idea that they can get through it; people with self-efficacy