Navigating a BRCA+ Result: A Breast Surgeon's Guide on What Comes Next
By Dr. Heather Richardson, MD, FACS
> Guest post from Bedford Breast Center. This article is contributed by Dr. Heather Richardson, MD, FACS, a leading breast cancer surgeon at Bedford Breast Center in Beverly Hills. Genetic counseling and surgical care work hand-in-hand — ClearPath helps you understand what a BRCA result means, and specialists like Dr. Richardson help you decide what to do next.
Learning that you carry a BRCA gene mutation can bring a mix of emotions. For some women, the result answers longstanding questions about their family history. For others, it may come as a complete surprise. No matter how the information is discovered, a positive BRCA result does not mean you have cancer. It means you and your healthcare team can use that information to plan ahead and take steps to manage your risk.
At Bedford Breast Center, one of the most important conversations we have with patients after genetic testing is helping them understand what comes next. From enhanced screening and imaging to preventive surgery and family testing, several options are available. The right approach depends on your personal medical history, family history, age, and goals.
Understanding BRCA Mutations
BRCA1 and BRCA2 are genes that help repair damaged DNA and protect against certain cancers. When one of these genes contains a harmful mutation, its ability to repair DNA is impaired, increasing the risk of developing breast cancer and several other cancers throughout a person''s lifetime.
While not every individual with a BRCA mutation will develop cancer, the lifetime risk of breast cancer is significantly higher than that of the general population. This is why early identification is so important. Once a mutation is detected, patients can develop a personalized surveillance and risk-reduction plan.
The First Step: Meeting With a Specialized Care Team
After a BRCA mutation is identified, the next step is typically a consultation with a member of our team. During this visit, we review:
- Your personal medical history
- Your family history of breast, ovarian, pancreatic, and other cancers
- Your age and future family planning goals
- Previous breast imaging and biopsy results
- Your individual risk profile
Many patients feel pressure to make immediate decisions after receiving genetic test results. In reality, most women have time to carefully evaluate their options and determine which approach feels right for them, at a pace appropriate to their circumstances. The goal is not to rush into treatment but to create a thoughtful plan that balances risk reduction, quality of life, and peace of mind.
Enhanced Screening and Surveillance
For many BRCA-positive patients, increased surveillance becomes an important part of ongoing care. The exact timing and frequency depend on several factors, including family history. One important consideration is the age at which close relatives were diagnosed with breast cancer. If a family member developed breast cancer at a younger age, screening may begin earlier and occur more frequently. As every family history is unique, surveillance schedules should be individualized rather than following a one-size-fits-all approach.
Why We Use Contrast-Enhanced Imaging
Many breast cancers develop new blood vessels as they grow. Contrast-enhanced studies can provide a more comprehensive evaluation of breast tissue and increase the likelihood of detecting abnormalities at an earlier stage. This technique administers dye via an intravenous (IV) line before the imaging study to highlight areas of increased blood flow. MRI is currently considered the gold standard for high-risk breast imaging. However, as technologies such as Vera Scan Breast CT, contrast-enhanced mammography, and other contrast-based imaging modalities become more widely available, we anticipate improved accuracy with fewer false positives, reducing unnecessary anxiety and biopsies while providing a more comfortable experience for patients.
MRI
Depending on your age and the age of any family members at the time they were diagnosed with breast cancer, MRI with contrast may be recommended as an annual screening exam. This study does not use radiation, as it relies on a magnet rather than X-rays. When contrast is used, it contains a small amount of gadolinium, a heavy metal-based agent. Although allergic reactions to gadolinium are uncommon (usually in less than 1% of patients), they can occur. Gadolinium should also be avoided during pregnancy and breastfeeding, so it''s important to discuss your medical history and any concerns with your provider before imaging is ordered.
Mammogram and Ultrasound
In mammography and supplemental ultrasound studies, an iodine-based dye is used. This type of dye is mineral-based and is flushed out of the body within 24 hours. For women with dense breast tissue, contrast-enhanced imaging can provide added value. Dense tissue appears white on a mammogram, just like many breast cancers, creating a "masking effect" that can make abnormalities harder to detect. Contrast-enhanced imaging helps improve cancer detection by making suspicious areas more visible.
Vera Scan Breast CT
A newer modality that uses iodine-based dye to create a 3D, 360° image of the tissue is the Vera Scan Breast CT. It creates images similar to MRI, but the scan itself is typically less than 10 minutes and uses no compression. While it does use radiation, the exposure amount is far less than a standard CT of the abdomen or chest. With its exceptional spatial resolution and ability to capture fine details, this technology detects even the smallest lesions for early and accurate breast cancer detection.
Considering Preventive Surgery
While enhanced screening helps detect cancer early, it does not prevent cancer from developing. For some women, preventive surgery may be an option worth considering.
A prophylactic mastectomy, also known as a risk-reducing mastectomy, involves removing healthy breast tissue before cancer develops. Studies have shown that this procedure can significantly reduce breast cancer risk in appropriately selected patients. Prophylactic mastectomy options may include a simple mastectomy, a Goldilocks Mastectomy, or a nipple-sparing mastectomy. At Bedford Breast Center, our team has pioneered Direct-to-Implant Breast Reconstruction, an advanced surgical technique that offers women the option of having breast reconstruction performed immediately after mastectomy, without the need for tissue expanders or additional operations.
Choosing preventive surgery is a deeply personal decision that deserves time, thoughtful conversation, and compassionate guidance from your surgical team as you consider what feels right for your body, your health, and your peace of mind.
Hormone Therapy Options
Anti-hormone therapy medications can decrease the risk of breast cancer by nearly 40% in high-risk patients, but the potential side effects should be considered. Some hormone therapy options include:
Tamoxifen
Tamoxifen is one of the most effective medications given to premenopausal patients to decrease their risk of metastatic cancer recurrence. Most patients tolerate the drug well, but initial side effects such as hot flashes, insomnia, weight gain, and mood changes can occur. These side effects should lessen or resolve with time.
Aromatase Inhibitors
Aromatase inhibitors stop a key enzyme called aromatase from changing other hormones into estrogen. Arimidex, Femara, and Aromasin are anti-hormone therapy medications given to post-menopausal patients because they are more effective than Tamoxifen. This breast cancer hormone therapy reduces the rate of recurrence and metastatic disease by 70%. They can increase blood clot formation, cause bone pain, and worsen osteoporosis. However, most patients tolerate the drugs well. Ten years is the recommended duration of treatment.
Evista
Evista is a drug proven to decrease the risk by 50% of recurrent or metastatic breast cancer in patients who have been diagnosed with cancer and are post-menopausal, similar to Tamoxifen. Unlike aromatase inhibitors, Evista strengthens bones rather than promoting osteoporosis. Because it is less effective than other drugs, it is a second- or third-line medication in post-menopausal women who do not tolerate the other medications.
The Importance of Family Testing
A BRCA mutation affects more than one individual. Because these mutations are inherited, the information may be important for other family members as well, including parents, siblings, and children.
Sharing genetic test results with family members can sometimes be a difficult conversation, but it provides them with the opportunity to pursue testing and make informed decisions about their own healthcare.
Taking Care of Your Mental and Emotional Health
While a lot of the conversation around BRCA mutations focuses on medical decisions, the emotional side matters just as much. A positive genetic test result can bring up anxiety, uncertainty, fear, and even guilt about what it might mean for your family. For many patients, it can also feel overwhelming to suddenly face so many decisions.
At Bedford Breast Center, we recognize that every patient''s experience is different. Our team is here to help you understand your options, answer your questions, and navigate the stress that can accompany a BRCA diagnosis. We are committed to providing guidance, education, and support throughout the decision-making process. Whether you choose enhanced surveillance, preventive surgery, or another approach, you do not have to make these decisions alone.
Moving Forward With Confidence
A BRCA mutation changes your risk profile, but it does not define your future. With today''s advances in genetic testing, imaging, surveillance, and risk-reduction strategies, patients have more tools than ever to take control of their health. Understanding your options allows you to make informed decisions with confidence and move forward with a plan that feels right for you.
About the Author
Dr. Heather Richardson, MD, FACS is one of the top breast cancer surgeons in the Los Angeles area and has been caring for patients with breast disease since 2004. She currently practices at Bedford Breast Center in Beverly Hills, where her work centers on nipple-sparing mastectomies and breast-conserving therapy, including lumpectomies and oncoplastic surgery. She co-devised the Goldilocks mastectomy with her plastic surgery colleague, Dr. Grace Ma, and published the definitive paper outlining the technique and its initial clinical application.
To learn more about surgical care and screening options after a BRCA+ result, visit Bedford Breast Center.