Friday, July 31, 2015

Pandora's DNA: One woman's experience with a BRCA mutation

In Pandora's DNA: Tracing the Breast Cancer Gene through History, Science, and One Family Tree, Lizzie Stark describes her experience with a BRCA mutation, which has left its mark on generation after generation of women in her family. Like The Cancer Chronicles, Stark explores the science to understand the causes and consequences of the BRCA mutation. As a child, Stark watched her young mother as well as many of the women in her family endure breast and ovarian cancer and the subsequent treatments. In the nineties, when the BRCA gene test was first available, Stark accompanied her mother to appointments with a genetic counselor, who informed them that her family has a mutation in the BRCA1 gene called 3600del11 (a truncation mutation where 10 DNA bases are deleted from exon 11), a mutation that seems to be more prevalent in French families (for more on the population genetics of BRCA mutations, check out The Wandering Gene and the Indian Princess).

Upon learning of her mother's BRCA status, Stark realizes that she has a 50% chance of having the same mutation. Thus, she decides to learn more about the history of breast and ovarian cancer diagnosis and treatment to inform her decisions about her own treatment options. The radical mastectomy was introduced by the unusual and innovative surgeon William Halsted. Halsted (the basis for the drug-addicted surgeon on The Knick) started his career in 1880; he developed the first blood transfusion, pioneered the use of rubber gloves (through a partnership with the Goodyear rubber company) for surgery, and performed the first mastectomy in the US. Because patients regularly relapsed after this treatment, Halsted decided that a more extensive mastectomy was the solution to the problem; the radical mastectomy was designed to carve out the root of the cancer. However, the procedure, which takes both the breasts and the pectoral muscles, still has a recurrence rate of 60%. Despite these grim statistics and the fact that the procedure negatively affected women's posture and arm mobility, the radical mastectomy was the standard for care for breast cancer for nearly a hundred years.

A med student named Emil Grubbe experimented with the use of radiation to treat cancer recurrence following mastectomy; Grubbe reasoned that radiation might kill rapidly dividing cells like those in cancer. His treatment worked well for many patients, but cost the doctor his own life to radiation-induced cancer. Dr. Geoffrey Keynes (brother to the economist John Maynard Keynes) became a strong proponent the lumpectomy, a more conservative surgery that removes only the tumor and a bit of surrounding tissue, in combination with radiation therapy. In 1935, Keynes started comparing survival rates for patients receiving the combined treatment with those who had a radical mastectomy. Surprisingly, survival rates were nearly identical. Despite the fact that this less aggressive treatment was just as effective, the medical community ignored the results. It wasn't until a study published in 1981 confirmed these results that the Halsted method was finally called into question. In fact, until the 1970's, if a woman had a suspicious lump in her breast, she would be taken in for exploratory surgery, where the surgeons would biopsy the tumor and, if necessary, remove the breast without waking her up. Thus, women would go into surgery and not know whether they would wake up "with a band-aid or without breasts". This practice added psychological difficulty to the radical mastectomy. However, the women's health movement of the 1970's helped give women more power in this process and improve the life of women after treatment.

Location of the BRCA1 gene (Wikipedia)
One hero of the story is Mary-Claire King, who identified the BRCA1 gene's connection to inherited breast and ovarian cancers. (King has led an extraordinary life. In addition to her role in the BRCA story, her lab helped UN war crimes tribunals identify victims when DNA testing was still in its infancy. She tells a great story at The Moth about the connection between BRCA and Joe DiMaggio.**) After King announced her findings, a competing group formed Myriad Genetics, a company that would later patent the BRCA1 and BRCA2 genes, which allowed the company to set the price for the mutation screening. A 2013 Supreme Court decision eliminated this patent, which lowered the price for the test. Myriad Genetics has become the big bad in the BRCA story. Stark's interview with a patent attorney points out that by monetizing the BRCA test, the company was able to make it more widely available. This interview also includes an interesting discussion of the pros and cons of patenting a gene. Despite the patent ruling, Myriad Genetics has refused to share all of the data obtained from their BRCA testing, which could impede research on identifying additional BRCA mutations linked to cancer.

Stark is in the first cohort of women (along with Angelina Jolie) who are able to choose to test for the BRCA mutation. When Stark learns of her BRCA status, she then considers her treatment options: constant cancer screenings or preventative mastectomy and oopherectomy. Here, the author discusses her thought process as well as the published research as she comes to terms with her BRCA status and the health decisions she must make. Stark does an excellent job describing the research, especially considering she is not trained in science. Overall, I found the book both readable and informative; thus, it will be a useful read for a person whose family is affected by a BRCA mutation.

** For more on the story of Mary-Claire King and her research in hereditary breast and ovarian cancer, check out the film Decoding Annie Parker

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