Clinical characteristics.

BRCA1- and BRCA2-associated hereditary breast and ovarian cancer (HBOC) is characterized by an increased risk for female and male breast cancer, ovarian cancer (including fallopian tube and primary peritoneal cancers), and to a lesser extent other cancers such as prostate cancer, pancreatic cancer, and melanoma primarily in individuals with a BRCA2 pathogenic variant. The risk of developing an associated cancer varies depending on whether HBOC is caused by a BRCA1 or BRCA2 pathogenic variant.

Diagnosis/testing.

The diagnosis of BRCA1- and BRCA2-associated HBOC is established in a proband by identification of a heterozygous germline pathogenic variant in BRCA1 or BRCA2 on molecular genetic testing.

Management.

Treatment of manifestations: Treatment of breast cancer per oncologist with consideration of bilateral mastectomy as a primary surgical treatment of breast cancer because of elevated rate of ipsilateral and contralateral breast cancer; PARP inhibitors may be considered in BRCA1- and BRCA2-related tumors. Melanoma treatment per dermatologist and oncologist.

Prevention of primary manifestations: Prophylactic bilateral mastectomy, prophylactic oophorectomy, and chemoprevention (e.g., tamoxifen) have been used for breast cancer prevention, but have not been assessed by randomized trials in high-risk women. Prophylactic salpingectomy followed by delayed oophorectomy or salpingo-oophorectomy for ovarian cancer prevention.

Surveillance: Breast cancer screening in women relies on a combination of monthly breast self-examination, annual or semiannual clinical breast examination, annual mammography, and breast MRI. Annual transvaginal ultrasound and serum CA-125 concentration beginning at age 35 years may be considered for ovarian cancer screening. However, this screening has not been effective in detecting early-stage ovarian cancer, either in high-risk or average-risk women. For men, breast cancer screening includes breast self-examination education and training and annual clinical breast examination beginning at age 35. Annual serum prostate-specific antigen and digital rectal exam screening should begin at age 45. Screening for melanoma should be individualized based on the family history. Screening of asymptomatic individuals for pancreatic cancer is not generally recommended.

Evaluation of relatives at risk: Once a cancer-predisposing BRCA1 or BRCA2 germline pathogenic variant has been identified in a family, testing of at-risk relatives can identify those family members who also have the familial pathogenic variant and thus need increased surveillance and specific treatments when a cancer is identified.

Genetic counseling.

BRCA1- and BRCA2-associated HBOC is inherited in an autosomal dominant manner. The vast majority of individuals with a BRCA1 or BRCA2 pathogenic variant inherited it from a parent. However, because the penetrance of breast, ovarian, and other cancers associated with pathogenic variants in BRCA1 and BRCA2 is less than 100%, not all individuals with a BRCA1 or BRCA2 pathogenic variant have a parent affected with cancer. The offspring of an individual with a BRCA1 or BRCA2 germline pathogenic variant have a 50% chance of inheriting the pathogenic variant. Once a cancer-predisposing BRCA1 or BRCA2 germline variant has been identified in a family, prenatal and preimplantation genetic testing are possible.

Suggestive Findings

BRCA1- and BRCA2-associated hereditary breast and ovarian cancer (HBOC) should be suspected in individuals with a personal or family history (first-, second-, or third-degree relative in either lineage) of any of the following:

• Breast cancer diagnosed at or before age 50 years
• Ovarian cancer
• Multiple (i.e., >1) primary breast cancers in either one or both breasts
• Male breast cancer
• Triple-negative (estrogen receptor-negative, progesterone receptor-negative, and human epidermal growth factor receptor 2-negative) breast cancer
• The combination of pancreatic cancer and/or prostate cancer (metastatic or Gleason score ≥7) with breast cancer and/or ovarian cancer
• Breast cancer diagnosed at any age in an individual of Ashkenazi Jewish ancestry
• Two or more relatives with breast cancer, one diagnosed at or before age 50 years
• Three or more relatives with breast cancer at any age
• A family member with a known BRCA1 or BRCA2 pathogenic variant

Note: (1) "Breast cancer" includes both invasive cancer and ductal carcinoma in situ. (2) "Ovarian cancer" includes epithelial ovarian cancer, fallopian tube cancer, and primary peritoneal cancer.

Establishing the Diagnosis

The diagnosis of BRCA1- and BRCA2-associated HBOC is established in a proband by identification of a heterozygous germline pathogenic (or likely pathogenic) variant in BRCA1 or BRCA2 on molecular genetic testing (see Table 1).

Note: (1) Molecular testing is most likely to be informative in an individual with a BRCA1- or BRCA2-associated cancer (e.g., breast cancer at age <50 years, ovarian cancer; this individual is often referred to as the "best test candidate." Thus, molecular genetic testing ideally should be performed initially on the "best test candidate" as opposed to a family member who may have an unrelated cancer or who may not have a personal history of cancer. (2) If the best test candidate is not available, molecular testing may be performed on another individual, without a cancer history, with the understanding that failure to detect a pathogenic variant does not eliminate the possibility of a BRCA1 or BRCA2 pathogenic variant being present in the family. (3) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variant" and "likely pathogenic variant" are synonymous in a clinical setting, meaning that both are considered diagnostic and can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include likely pathogenic variants. (4) Identification of a heterozygous BRCA1 or BRCA2 variant of uncertain significance does not establish or rule out the diagnosis.

Molecular testing approaches can include a BRCA1 and BRCA2 gene panel and use of a multigene panel:

• BRCA1 and BRCA2 gene panel. Sequence analysis of BRCA1 and BRCA2 is performed concurrently with deletion/duplication analysis.
  Targeted analysis can be considered in individuals of Ashkenazi Jewish ancestry by starting with targeted testing for three BRCA1 and BRCA2 pathogenic founder variants: BRCA1 c.68_69delAG (BIC: 185delAG) BRCA1 c.5266dupC (BIC: 5382insC), and BRCA2 c.5946delT (BIC: 6174delT), which together account for up to 99% of pathogenic variants identified in individuals of Ashkenazi Jewish ancestry. If no pathogenic variant is identified by targeted analysis, it may be appropriate to proceed with sequence analysis and deletion/duplication analysis of BRCA1 and BRCA2 or a multigene panel.
  Note: In a family known to have a BRCA1 or BRCA2 germline pathogenic variant, relatives at risk may only need testing for the family-specific germline pathogenic variant, except in the following situations:
  • Individuals of Ashkenazi Jewish descent should consider testing for all three founder pathogenic variants because of the high population frequency of these variants as well as reports of the coexistence of more than one founder variant in some families. They may also consider multigene panel testing, depending on their personal and family history.
  • Individuals with a familial BRCA1 or BRACA2 pathogenic variant on one side of the family and characteristics of HBOC or another inherited cancer syndrome on either the same side or the other side of the family may consider sequence analysis and deletion/duplication analysis of BRCA1 and BRCA2 or a multigene panel, which would detect the familial germline pathogenic variant (if present) and also address whether another germline pathogenic variant may be present.
• A multigene panel that includes BRCA1, BRCA2, and other genes of interest (see Differential Diagnosis) may also be considered. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview; thus, clinicians need to determine which multigene panel is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
  For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.

Clinical Description

BRCA1- and BRCA2-associated hereditary breast and ovarian cancer (HBOC) is characterized by an increased risk for male and female breast cancer, ovarian cancer (including fallopian tube and primary peritoneal cancers), and to a lesser extent other cancers such as prostate, pancreatic, and melanoma, primarily in individuals with a BRCA2 pathogenic variant. Estimates of malignancy risk vary considerably depending on the context in which they were derived. Table 2 is a summary of the risk for malignancy in an individual with a germline BRCA1 or BRCA2 pathogenic variant.

Breast cancer. Compared to sporadic tumors, BRCA1-related tumors show an excess of medullary histopathology, are of higher histologic grade, are more likely to be estrogen receptor negative and progesterone receptor negative, and are less likely to demonstrate human epidermal growth factor receptor 2 overexpression; thus, BRCA1-related tumors fall within the category of "triple-negative" breast cancer [Rakha et al 2008, Lee et al 2011, Mavaddat et al 2012] and overlap with basal-like breast cancers.

The histologic characteristics of BRCA2-related tumors have been inconsistent but appear to be more heterogeneous and are less well characterized than BRCA1-related tumors. They are generally estrogen and progesterone receptor positive; however, a large international series of 2,392 individuals with BRCA2 germline pathogenic variants found that 16% had triple-negative tumors [Mavaddat et al 2012].

The evidence that a germline BRCA1 or BRCA2 pathogenic variant is associated with poor survival in individuals with breast cancer has been inconsistent [Verhoog et al 2000, Bordeleau et al 2010, van den Broek et al 2015, Zhong et al 2015].

Contralateral breast cancer (CBC). Several studies have reported higher rates of CBC [Metcalfe et al 2011a, Vichapat et al 2012, van den Broek et al 2015] in women treated conservatively. Predictors of CBC include age at first breast cancer, family history of early-onset breast cancer, and the affected BRCA gene [Graeser et al 2009, Malone et al 2010, Metcalfe et al 2011a, van den Broek et al 2015]. The risk of CBC is greatest among women whose initial breast cancer occurs at a young age. Most studies show an excess of CBC among individuals with a BRCA1 pathogenic variant when compared to individuals with a BRCA2 pathogenic variant. The risk for CBC was decreased among women who had undergone prophylactic oophorectomy [Metcalfe et al 2011a]; there was no clear association between the use of radiation therapy and an increased risk of CBC in individuals with a BRCA1 or BRCA2 pathogenic variant.

Ipsilateral breast cancer. Two case-control studies reported significantly higher rates of ipsilateral breast cancer in individuals with a germline BRCA1 or BRCA2 pathogenic variant compared with sporadic controls [Haffty et al 2002, Seynaeve et al 2004], however, other studies have not found an increased risk for ipsilateral breast cancer in those with a germline BRCA1 or BRCA2 pathogenic variant when compared with women who had sporadic breast cancer [Robson et al 2004, Graeser et al 2009] and also demonstrated a significant ipsilateral breast cancer risk reduction in individuals receiving radiation therapy compared with those who did not receive radiation therapy [Metcalfe et al 2011b].

Ovarian cancer (including fallopian tube and primary peritoneal cancers). An excess of serous adenocarcinomas as opposed to mucinous or borderline tumors have been observed in women with germline BRCA1 or BRCA2 pathogenic variants [Liu et al 2012, McLaughlin et al 2013]. Serous adenocarcinomas are generally of higher grade and exhibit prominent intraepithelial lymphocytes, marked nuclear atypia, and abundant mitoses [Fujiwara et al 2012]. Most high-grade serous cancers arise from the fallopian tubes rather than the ovaries [Daly et al 2015].

Studies on ovarian cancer survival in women with a germline BRCA1 or BRCA2 pathogenic variant have yielded conflicting results. A pooled analysis of 26 observational studies found a more favorable survival rate among individuals with a BRCA1 or BRCA2 pathogenic variant compared to individuals without a BRCA1 or BRCA2 pathogenic variant. These results persisted when controlling for stage, grade, histology, and age at diagnosis [Bolton et al 2012]. A large population-based case-control study found a higher response to platinum-based therapy, longer progression-free survival, and improved overall survival among individuals with a germline BRCA1 or BRCA2 pathogenic variant [Alsop et al 2012]. Similarly, individuals with platinum-sensitive epithelial ovarian tumors were more likely to have a germline BRCA1 or BRCA2 pathogenic variant than individuals with platinum-resistant tumors [Dann et al 2012]. In a large series of unselected individuals with ovarian cancer, the short-term survival of individuals with ovarian cancer with a germline BRCA1 or BRCA2 pathogenic variant was better than that of individuals without an identified BRCA1 or BRCA2 pathogenic variant; however, the survival advantage was short lived and did not lead to a long-term survival benefit [McLaughlin et al 2013].

Male breast cancer. The majority of BRCA1- and BRCA2-associated male breast cancers, particularly those associated with BRCA2 pathogenic variants, are high grade, hormone receptor positive, and associated with lymph node metastases. Despite having high-grade histology, males with BRCA1- or BRCA2-associated breast cancer have demonstrated a favorable five-year survival [Ibrahim et al 2018].

Prostate cancer. BRCA2-related prostate cancer is more likely to be associated with features of aggressive disease, including a higher tumor stage and/or higher grade at diagnosis, higher Gleason scores [Gallagher et al 2010], and a higher prostate-specific antigen level at diagnosis [Ibrahim et al 2018].

Pancreatic cancer. BRCA1 and BRCA2 are among the most common of the known genetic causes of hereditary pancreatic ductal adenocarcinoma (PDAC) with a mean age at diagnosis of approximately 60.3 years (range 33-83 years) [Golan et al 2014]. There is accumulating evidence of increased sensitivity to platinum-based therapy and poly ADP ribose polymerase (PARP) inhibitors in BRCA1- and BRCA2-associated PDAC [Kowalewski et al 2018].

Melanoma. The risk for melanomas of both the skin and eyes is elevated in individuals with a BRCA2 pathogenic variant [Breast Cancer Linkage Consortium 1999, Hearle et al 2003, van Asperen et al 2005, Gumaste et al 2015]. An analysis of 490 families with BRCA1 or BRCA2 pathogenic variants showed an increased risk for uveal melanoma in individuals with germline BRCA2 pathogenic variants [Moran et al 2012].

Other cancers. Individuals with BRCA1 and BRCA2 pathogenic variants may be at a higher risk for additional malignancies. Furthermore, women with a BRCA1 pathogenic variant may have an elevated risk for serous uterine cancer, but the data are not conclusive [de Jonge et al 2017].

No associated benign tumors or physical abnormalities are presently known to be associated with pathogenic variants in BRCA1 or BRCA2.

Phenotype Correlations by Gene

Ovarian cancer and primary papillary serous carcinoma of the peritoneum are considerably more common and tend to develop at an earlier age in women with a germline BRCA1 pathogenic variant as compared to women with a germline BRCA2 pathogenic variant [Casey et al 2005, Yates et al 2011]. Those with BRCA2 pathogenic variants tend to be at greater risk for male breast cancer [Evans et al 2010], prostate cancer [Mersch et al 2015], pancreatic cancer [Dagan 2008], and melanoma.

Genotype-Phenotype Correlations

BRCA1 and BRCA2 genotype-phenotype correlations have been identified. Such correlations are not currently used in individual risk assessment and management but may be in the future with appropriate validation.

Penetrance

The penetrance of breast, ovarian, and other cancers associated with pathogenic variants in BRCA1 and BRCA2 is less than 100% (see Table 2).

Prevalence

BRCA1 and BRCA2 pathogenic variants are the most common cause of HBOC. The prevalence of BRCA1 and BRCA2 pathogenic variants in the general population is estimated at 1:400 to 1:500 [Anglian Breast Cancer Study Group 2000, Whittemore et al 2004].

The prevalence of BRCA1- and BRCA2-associated HBOC is increased in certain populations due to founder variants (see Table 6):

• Individuals of Ashkenazi Jewish descent: prevalence of 1:40 [Struewing et al 1997, Gabai-Kapara et al 2014]
• Inuit from Ammassalik (Greenland): prevalence of 1:10 to 1:100 [Hansen et al 2009, Harboe et al 2009, Hansen et al 2010]

Founder variants in BRCA1 and/or BRCA2 have also been reported in several additional populations, including individuals of African, Amish, and Icelandic ancestry (see Table 6).

Evaluations Following Initial Diagnosis

Individuals who have a germline pathogenic variant in BRCA1 or BRCA2 are counseled at the time of disclosure of molecular genetic test results about their options for Surveillance and Prevention of Primary Manifestations.

Treatment of Manifestations

Breast cancer. National Comprehensive Cancer Network (NCCN) guidelines suggest that women with a BRCA1 or BRCA2 pathogenic variant could consider bilateral mastectomy as a primary surgical treatment of breast cancer because of their elevated rate of ipsilateral and contralateral breast cancer (NCCN Guidelines; no-fee registration and login required).

PARP inhibitors have emerged as a promising treatment in individuals with BRCA1- and BRCA2-associated breast cancer, given their role in DNA repair. Because BRCA1, BRCA2, and PARP participate in DNA repair, their mutual disruption could lead to "synergistic lethality" of tumor cells. PARP inhibitors were first studied in women with BRCA1- and BRCA2-associated metastatic breast cancer. Significant improvement was seen in in progression-free survival, leading to FDA approval of olaparib for women with locally advanced metastatic breast cancer in 2017 [Robson et al 2017, Litton et al 2018]. In a recent randomized, double-blind Phase III trial, olaparib also improved progression-free survival in individuals with early, high-risk, human epidermal growth factor receptor 2-negative BRCA1- and BRCA2-associated breast cancer in the adjuvant setting [Tutt et al 2021].

Ovarian cancer. PARP inhibitors were first found to improve response rates in the setting of ovarian cancer recurrence after failure of platinum-based therapies [Fong et al 2009]. Olaparib has subsequently shown significantly improved progression-free survival in platinum-sensitive recurrent ovarian cancer as maintenance therapy. In this study, individuals with BRCA1 and BRCA2 pathogenic variants showed the most benefit [Ledermann et al 2014]. Olaparib has also demonstrated significant benefit as maintenance therapy in women with newly diagnosed disease in advanced BRCA1- and BRCA2-associated ovarian cancer following primary therapy. In the SOLO-1 trial, women randomized to olaparib maintenance treatment had a 70% lower risk of disease progression or death compared to the placebo [Moore et al 2018]. Olaparib was given FDA approval for metastatic ovarian cancer in 2014, for maintenance therapy for recurrent disease in 2017, and for maintenance therapy after completion of adjuvant therapy in 2019.

Prostate cancer. After promising Phase I data on the use of olaparib in solid tumors, a Phase II study established its activity in men with BRCA1- and BRCA2-associated advanced prostate cancer [Kaufman et al 2015]. A subsequent Phase II trial compared olaparib to androgen targeted therapy plus prednisone in men with progressive prostate cancer who had pathogenic variants in DNA damage repair genes, including BRCA1 and BRCA2. A significant improvement in response rate and disease-free survival was seen in the olaparib treatment group. Both olaparib and rucaparib were approved by the FDA in 2020 for use in this setting [De Bono et al 2020].

Pancreatic cancer. The poor response of pancreatic cancer to standard systemic therapies has intensified the search for novel targeted agents. The Phase III POLO trial randomized individuals with BRCA1- and BRCA2-associated metastatic pancreatic cancer to olaparib vs placebo. Response rates were 22.1% in the olaparib group and 9.6% in the placebo group. Both progression-free survival and overall survival were doubled in the olaparib group. Toxicities, especially when a PARP inhibitor is combined with other systemic therapy, however, limit its use. The FDA has approved olaparib as maintenance therapy for BRCA1- and BRCA2-associated advanced pancreatic cancer.

Melanoma. Treatment is per dermatologist and/or oncologist.

Prevention of Primary Manifestations

Breast cancer

• Consider prophylactic bilateral mastectomy.
• Given the conflicting data on the degree of risk reduction of breast cancer associated with prophylactic oophorectomy, consider discussing the risks and benefits of this approach with a genetics specialist.
• Chemoprevention. In a retrospective study tamoxifen reduced the risk for breast cancer by 62% among healthy women with a BRCA2 germline variant [King et al 2001]. The sample size, however, was extremely small. There have been no prospective randomized trials of tamoxifen as a chemoprevention agent specifically in women with BRCA1 or BRCA2 pathogenic variants. Several studies, however, have found a significant protective effect of tamoxifen on the risk of contralateral breast cancer in women with BRCA1 or BRCA2 pathogenic variants. Risk reduction in these studies ranged from 50% to 69%. These studies are limited by their retrospective case-control designs [Gronwald et al 2006, Pierce et al 2006, Phillips et al 2013].
  Note: Significant adverse consequences of tamoxifen treatment included higher rates of endometrial cancer and thromboembolic episodes (including pulmonary embolism) in those individuals who took the medication than in those who did not. Women with a history of thromboembolic disease or with a coagulation disorder should avoid taking tamoxifen. Women on tamoxifen should be counseled to report any abnormal vaginal bleeding immediately to their gynecologist.
• Breast feeding for a cumulative total of more than one year reduced the risk for breast cancer [Jernström et al 2004].

Ovarian cancer (including fallopian tube cancer)

• Consider prophylactic salpingo-oophorectomy, recognizing that completion of childbearing may factor into this decision. A prospective cohort study of 2,482 women with BRCA1 or BRCA2 pathogenic variants reported a 79% reduction in ovarian cancer mortality and a 60% reduction on all-cause mortality associated with risk-reducing oophorectomy [Marchetti et al 2014].
• With the realization that the fallopian tube is frequently the site of serous ovarian cancer and its precursor lesions, a new paradigm of prophylactic salpingectomy after childbearing followed by delayed oophorectomy at the time of menopause has been suggested. While theoretically offering protection against ovarian cancer, this approach would also avoid the adverse consequences of premature menopause. Currently studies are under way to determine its feasibility, safety, and efficacy [Swanson & Bakkum-Gamez 2016].
• Tubal ligation. A meta-analysis of 13 studies showed a reduction in risk for ovarian cancer of 34% in the general population after tubal ligation [Cibula et al 2011]. In a meta-analysis of modifiers of risk of cancer in individuals with pathogenic variants in BRCA1 or BRCA2, tubal ligation was associated with a reduced risk of ovarian cancer in females with a BRCA1 pathogenic variant, although study design issues limit the impact of these findings [Friebel et al 2014].
• A meta-analysis of 18 studies including 13,677 women with BRCA1 or BRCA2 pathogenic variants found a 50% reduction in risk of ovarian cancer associated with oral contraceptive use [Iodice et al 2010]. The maximum benefit of oral contraceptives is obtained with three to six years of use [Kotsopoulos et al 2015].
  Note: There is no evidence that use of current (after 1975) oral contraceptive formulations increases the risk for early-onset breast cancer for women with a germline BRCA1 or BRCA2 pathogenic variant.

Surveillance

Agents/Circumstances to Avoid

No data specific to individuals with BRCA1 or BRCA2 pathogenic variants are available.

Evaluation of Relatives at Risk

Once a cancer-predisposing BRCA1 or BRCA2 germline variant has been identified in a family, testing of at-risk relatives can identify those family members who also have the familial variant and thus need increased surveillance and specific treatments when a cancer is identified.

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Several ongoing studies are investigating novel approaches to the treatment of BRCA1- and BRCA2-associated breast and ovarian cancer. The majority of these studies involve PARP inhibitors.

Several prospective and randomized clinical trials are investigating PARP inhibitor treatment of metastatic pancreatic cancer [Chi et al 2021, Macchini et al 2021].

Studies to identify biomarkers of disease resistance and expected treatment toxicity are also under way [Jeong & Park 2021].

Additional clinical trials are exploring the use of other PARP inhibitors alone or in combination with other systemic treatments.

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for information on clinical studies.

Other

Hormone replacement therapy (HRT). General population studies suggest that long-term estrogen replacement therapy in postmenopausal women may increase breast cancer risk, but that short-term use to treat menopausal symptoms does not. However, even relatively short-term combined estrogen plus progestin use was shown to increase the incidence of breast cancers in a randomized, placebo-controlled trial of HRT [Chlebowski et al 2003].

Three observational studies on the impact of HRT on breast cancer risk in BRCA 1 and BRCA2 heterozygotes have been published. Rebbeck et al [2005] evaluated breast cancer risk associated with HRT after bilateral prophylactic oophorectomy in a cohort of 462 women with a BRCA1 or BRCA2 germline pathogenic variant and found that HRT of any type after bilateral prophylactic oophorectomy did not significantly alter the reduction in breast cancer risk associated with the surgery. The postoperative follow up was 3.6 years. It was concluded that short-term HRT does not substantially increase the risk for breast cancer in women with a BRCA1 or BRCA2 germline pathogenic variant. A subsequent study of expanded data from this cohort included 1,299 women with a mean follow up of 5.4 years. There was no increase in breast cancer risk, and a significant decrease in breast cancer risk was found among BRCA1 heterozygotes [Domchek et al 2011]. In another matched case-control study of 472 postmenopausal women with a BRCA1 pathogenic variant, the use of HRT was associated with a reduction in breast cancer risk [Eisen et al 2008]. Finally, a case-control study of 432 matched pairs with a mean follow up of 4.3 years also found a decrease in the risk for breast cancer in BRCA1 heterozygotes [Kotsopoulos et al 2016]. Taken together, these studies support the short-term use of HRT among BRCA1 and BRCA2 heterozygotes who have undergone surgical menopause.

Mode of Inheritance

BRCA1- and BRCA2-associated hereditary breast and ovarian cancer (HBOC) is inherited in an autosomal dominant manner.

Risk to Family Members

Parents of a proband with a BRCA1 or BRCA2 pathogenic variant

• The vast majority of individuals with a germline pathogenic variant in BRCA1 or BRCA2 inherited it from a parent. The parent with the pathogenic variant may or may not have had a cancer diagnosis depending on the following variables:
  • Penetrance of the variant
  • Sex of the parent
  • Age of the parent
  • Cancer risk reduction in the parent as a result of screening or prophylactic surgeries
  • Early death of the parent
• It is appropriate to offer molecular genetic testing to both parents of an individual with a BRCA1 or BRCA2 germline pathogenic variant to determine which side of the family is at risk. Generally, the pattern of cancers seen in the family guides which parent is tested first.
• If the pathogenic variant identified in the proband is not identified in either parent and parental identity testing has confirmed biological maternity and paternity, the following possibilities should be considered:
  • The proband has a de novo pathogenic variant. De novo variants have been rarely reported (≤5%) [Golmard et al 2016, Antonucci et al 2017].
  • The proband inherited a pathogenic variant from a parent with germline (or somatic and germline) mosaicism [Alhopuro et al 2020]. Note: Testing of parental leukocyte DNA may not detect all instances of somatic mosaicism and will not detect a pathogenic variant that is present in the germ cells only.
• An apparently negative family history cannot be confirmed unless molecular genetic testing has demonstrated that neither parent is heterozygous for the BRCA1 or BRCA2 pathogenic variant identified in the proband.

Sibs of a proband with a BRCA1 or BRCA2 pathogenic variant. The risk to full sibs of the proband depends on the genetic status of the proband's parents:

• If one parent has the BRCA1 or BRCA2 germline pathogenic variant identified in the proband, the risk that a sib will inherit the pathogenic variant is 50%.
• The risk of developing cancer in a sib who inherits the familial BRCA1 or BRCA2 pathogenic variant depends on numerous variables including the penetrance of the pathogenic variant and the sex and age of the heterozygous sib.

Offspring of a proband with a BRCA1 or BRCA2 pathogenic variant

• The offspring of an individual identified as having a BRCA1 or BRCA2 germline pathogenic variant have a 50% chance of inheriting the pathogenic variant.
• The risk of developing cancer in offspring who inherit the BRCA1 or BRCA2 pathogenic variant depends on numerous variables including the penetrance of the pathogenic variant and the sex and age of the heterozygous individual.

Other family members of a proband with a BRCA1 or BRCA2 pathogenic variant. The risk to other family members depends on the genetic status of the proband's parents. If a parent has a BRCA1 or BRCA2 germline pathogenic variant, the parent's family members are at risk. Their exact risk depends on their biological relationship with the proband.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.

Family planning

• The optimal time for the determination of genetic risk and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
• It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected or at risk.

Genetic cancer risk assessment and counseling. For a comprehensive description of the medical, psychosocial, and ethical ramifications of identifying at-risk individuals through cancer risk assessment with or without molecular genetic testing, see Cancer Genetics Risk Assessment and Counseling – for health professionals (part of PDQ^®, National Cancer Institute).

At-risk asymptomatic adult relatives. In general, relatives of an individual who has a BRCA1 or BRCA2 germline pathogenic variant should be counseled regarding their risk of having inherited the same variant, their options for molecular genetic testing, their cancer risk, and recommendations for cancer screening (see Surveillance) and prophylactic surgery (see Prevention of Primary Manifestations).

At-risk adult relatives who have not inherited the cancer-predisposing germline variant identified in the proband are presumed to be at or above the general population risk of developing cancer, depending on personal risk factors. For example, a female at-risk relative who does not have the family-specific BRCA1 or BRCA2 pathogenic variant may still be at an elevated risk for breast cancer based on a breast biopsy history that revealed atypical ductal hyperplasia.

For family members determined to be at general population risk of developing cancer, appropriate cancer screening such as that recommended by the American Cancer Society or the National Comprehensive Cancer Network (NCCN) for individuals of average risk is recommended. Note: This presumption cannot apply to individuals who did not have an identifiable BRCA1 or BRCA2 germline pathogenic variant if the affected individual in the family either has not undergone molecular genetic testing of BRCA1 or BRCA2 or did not have an identified BRCA1 or BRCA2 pathogenic variant.

Testing of asymptomatic individuals younger than age 18 years. In general, genetic testing for BRCA1- and BRCA2-associated HBOC is not recommended for at-risk individuals younger than age 18 years. Guidelines established jointly by the American College of Medical Genetics and the American Society of Human Genetics state that predictive genetic testing should only be performed in individuals younger than age 18 years when it will affect their medical management. Surveillance for BRCA1- and BRCA2-associated HBOC is typically recommended to begin at approximately age 25, which is why it is recommended that the decision to test be postponed until an individual reaches adulthood and can make an independent decision. It is important to note, however, that since there are rare reports of individuals with BRCA1- and BRCA2-associated HBOC diagnosed with cancer at very young ages, it is recommended that screening be individualized based on the earliest diagnosis in the family.

For more information, see the National Society of Genetic Counselors position statement on genetic testing of minors for adult-onset conditions and the American Academy of Pediatrics and American College of Medical Genetics and Genomics policy statement: ethical and policy issues in genetic testing and screening of children.

Prenatal Testing and Preimplantation Genetic Testing

Once the BRCA1 or BRCA2 germline pathogenic variant has been identified in the family, prenatal and preimplantation genetic testing for BRCA1- and BRCA2-associated HBOC are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful. For more information, see the National Society of Genetic Counselors Position Statement on prenatal testing in adult-onset conditions.

Molecular Pathogenesis

BRCA1 encodes breast cancer type 1 susceptibility protein (BRCA1), a phosphoprotein normally located in the nucleus [Chen et al 1996]. BRCA1 interacts with several proteins involved in cellular pathways, including cell-cycle progression, gene transcription regulation, DNA damage response, and ubiquitination [Deng 2006, Rosen et al 2006].

The BRCA1/BARD1 protein complex enhances ubiquitin ligase activity, which is associated with the regulation of centrosome function and involved in DNA repair and cell cycle regulation [Bork et al 1997, Callebaut & Mornon 1997, Sankaran et al 2006].

BRCA1 colocalizes with BRCA2 and RAD51 at sites of DNA damage and activates RAD51-mediated homologous recombination repair of DNA double-strand breaks [Cousineau et al 2005]. BRCA2 regulates the availability and activity of RAD51, which coats single-strand DNA to form a nucleoprotein filament that invades and pairs with a homologous DNA duplex to initiate strand exchange [Venkitaraman 2002].

Mechanism of disease causation. Loss of function

Author History

Julie O Bars Culver, MS; Fred Hutchinson Cancer Research Center (1998-2011)
Wylie Burke, MD, PhD; University of Washington (1998-2005)
Mary B Daly, MD, PhD (1998-present)
Gerald L Feldman, MD, PhD; Wayne State University School of Medicine (2002-2016)
Judith L Hull, MS; Memorial Sloan-Kettering Cancer Center (1998-2005)
Ephrat Levy-Lahad, MD; Sharre Zedek Medical Center (1998-2007)
Tuya Pal, MD (2016-present)
Nancie Petrucelli, MS (2002-present)

Revision History

• 21 September 2023 (np,sw) Revision: information about cancer risk in individuals who are heterozygous for a pathogenic variant in ATM added to Differential Diagnosis
• 26 May 2022 (mbd,tp) Revision: recommended surveillance for ovarian and pancreatic cancer (Tables 4 and 5)
• 3 February 2022 (sw) Comprehensive update posted live
• 15 December 2016 (sw) Comprehensive update posted live
• 26 September 2013 (me) Comprehensive update posted live
• 20 January 2011 (me) Comprehensive update posted live
• 19 June 2007 (me) Comprehensive update posted live
• 5 December 2005 (cd) Revision: Differential Diagnosis
• 3 September 2004 (jbc) Revision: Genetically Related Disorders
• 29 March 2004 (ca) Comprehensive update posted live
• 4 March 2000 (me) Comprehensive update posted live
• 4 September 1998 (pb) Review posted live
• January 1998 (jbc) Original submission

Published Guidelines / Consensus Statements

• Committee on Bioethics, Committee on Genetics, and American College of Medical Genetics and Genomics Social, Ethical, Legal Issues Committee. Ethical and policy issues in genetic testing and screening of children. Available online. 2013. Accessed 8-25-23.
• National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic Cancer. Available online; no-fee registration and login required. Accessed 8-25-23.
• National Society of Genetic Counselors. Position statement on genetic testing of minors for adult-onset conditions. Available online. 2018. Accessed 8-25-23.
• Robson ME, Bradbury AR, Arun B, Domchek SM, Ford JM, Hampel HL, Lipkin SM, Syngal S, Wollins DS, Lindor NM. American Society of Clinical Oncology policy statement update: genetic and genomic testing for cancer susceptibility. J Clin Oncol. 2015;33:3660-7. [PubMed]

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