Controversies and Open Questions in Management of Cancer-Free Carriers of Germline Pathogenic Variants in BRCA1/BRCA2

SIMPLE SUMMARY: Female carriers of germline pathogenic/likely pathogenic variants (P/LPVs) in the BRCA1/BRCA2 (BRCA) genes are at a substantially increased lifetime risk for developing breast, ovarian, and (to a lesser extent) other cancer types. Multiple national and international surveillance guidelines and recommendations to facilitate the early detection of cancer in these high-risk women have existed for more than 2 decades. Yet, inconsistencies pertaining to the medical management of cancer-free carriers linger, and surveillance recommendations are not globally harmonized. In this review, we discuss the differences between existing surveillance guidelines for BRCA P/LPV carriers, emphasizing the importance of future studies to enable guidelines harmonization and personalized risk stratification for optimal, effective surveillance strategies. ABSTRACT: Females harboring germline BRCA1/BRCA2 (BRCA) P/LPV are offered a tight surveillance scheme from the age of 25–30 years, aimed at early detection of specific cancer types, in addition to risk-reducing strategies. Multiple national and international surveillance guidelines have been published and updated over the last two decades from geographically diverse countries. We searched for guidelines published between 1 January 2015 and 1 May 2022. Differences between guidelines on issues such as primary prevention, mammography screening in young (<30 years) carriers, MRI screening in carriers above age 65 years, breast imaging (if any) after risk-reducing bilateral mastectomy, during pregnancy, and breastfeeding, and hormone-replacement therapy, are just a few notable examples. Beyond formal guidelines, BRCA carriers’ concerns also focus on the timing of risk-reducing surgeries, fertility preservation, management of menopausal symptoms in cancer survivors, and pancreatic cancer surveillance, issues that, for some, there are no data to support evidence-based recommendations. This review discusses these unsettled issues, emphasizing the importance of future studies to enable global guideline harmonization for optimal surveillance strategies. Moreover, it raises the unmet need for personalized risk stratification and surveillance in BRCA P/LPV carriers.