Family Ties | Page 2 of 3

Family Ties

Potomac native Randi Fishman was 28 when she found out she had breast cancer. After treatment and then a recurrence, doctors advised her not to get pregnant. That’s when her sister offered to carry a baby for her.

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Sisters Jamie (left), Randi and Erin in the Hamptons this past summer. Photo courtesy of Erin Silverman.

Randi bursts out laughing when she spots Erin, 36, approaching at a Starbucks in Potomac one afternoon in June wearing faded jeans and a cold shoulder black top. “We look like twins,” she says, pointing to her own outfit. The sisters live about five minutes apart—Randi moved back to Montgomery County after her diagnosis, and Erin left New York City about a year later. They see each other nearly every day. Their friend groups still overlap, like they did in high school, and their families take vacations together. Seven years have passed since Randi found out she was sick—Erin has had two daughters of her own since then, and she’s also carried her sister’s second baby.

“There’s a lot of hope out there for people going through any part of what I’ve been through,” Randi says.

When Randi walked into her parents’ Potomac home from the train station that Friday night in October 2011, her mother hugged and kissed her, wishing with all her might that she could take the cancer away and give it to herself instead. Before Randi even arrived at her surgeon’s office on Monday morning to discuss her treatment options—a lumpectomy to remove the cancerous tumor or a mastectomy to remove one or both breasts—she had already made up her mind. “As soon as I knew I had cancer, I wanted a double mastectomy,” she says. “I’m the type of person who would worry every second of every day about whether it would come back.”

She also wanted to get tested for defects in the BRCA (short for breast cancer) genes, which she did the following day. The genes—BRCA1 and BRCA2—help repair damaged DNA and suppress the growth of tumors, but when they aren’t functioning properly they sharply increase a woman’s risk of breast and ovarian cancer. People who carry one or both of the defective genes also tend to develop those cancers at a younger age. Devon Burak had feared for years that her daughters might have inherited a BRCA mutation. Her mother-in-law died of ovarian cancer at 51, before scientists discovered the genes. Perhaps a BRCA abnormality had contributed to that cancer, she’d think, and maybe her husband had inherited it. “I’d been asking Billy for a good 10 years to get tested, but he wouldn’t do it,” she says. “I knew about his mother’s ovarian cancer, and I was worried. I guess he was in denial.”

That wasn’t it, her husband says. It’s just that he’s had complicated relationships with doctors ever since his mother died. His parents never told him or his sister about the cancer until about a week before she passed away. He was 22. “I have a fear of doctors,” Billy Burak says. “I don’t like going through medical procedures.” Besides, he thought he had more time to think about the BRCA testing, he says. He never imagined that any of his daughters were at risk of getting breast cancer so young.

Randi’s situation—the early onset of her breast cancer, the family history of ovarian cancer—raised red flags, and so did her heritage. Randi is an Ashkenazi Jew, or a Jew of Central or Eastern European descent. In the U.S., about one in 400 people carry a BRCA mutation; among Ashkenazi Jews, about one in 40 is a carrier, according to Myriad Genetics, one of the oldest genetics testing labs and the first to administer BRCA testing.  “There was no question Randi needed to be tested,” Beckerman says. “I recommend that every Ashkenazi Jewish woman, regardless of age, get tested for the BRCA gene mutation if they have a personal history of breast cancer. The knowledge for the family is crucial.”

The blood test showed that Randi had inherited a BRCA1 mutation from at least one of her parents. Women who inherit this defect have an up to 87 percent risk of developing breast cancer by age 70—compared to a risk of up to 7.3 percent in the general U.S. population—and an up to 63 percent risk for developing ovarian cancer, according to Myriad Genetics.

Because of the ovarian cancer risk, Randi’s doctors told her she would need to consider having her ovaries removed in the future. The BRCA result also had implications for Randi’s family—it meant that her sisters could also be carriers. It also meant that Randi might pass along the defective gene to the children she so badly wanted to have. Each child of a parent who has a faulty BRCA gene has a 50 percent chance of inheriting the mutation.

It was almost too much to process all at once, Randi says. But knowing she had the mutation strengthened her resolve to follow through with a double mastectomy and reconstructive surgery. She understood that with both a lumpectomy or a mastectomy, there was no guarantee the cancer wouldn’t return, but a mastectomy offered her more peace of mind and minimized the chance of a local recurrence. Sandler endorsed her decision.

Randi had the seven-hour surgery on Oct. 31, 2011, a few weeks after her diagnosis. The mass was small, less than 2 centimeters, and the cancer had not spread to the lymph nodes. “We consider that early breast cancer, and curable breast cancer,” Sandler says.

A few weeks after Randi’s surgery, her mother and sisters underwent BRCA testing. One by one, they received their results by phone. Randi’s mother was negative; so was Erin. Jamie tested positive. There was no need for their father to get tested—by process of elimination, they knew he was the carrier.

To cope with the shock, Jamie channeled Randi’s positive attitude. “Randi was so strong,” Jamie says. “She powered through, did everything she was supposed to do and barely complained about it.” In February 2012, Jamie had a preventive double mastectomy and breast reconstruction. She was 25 and single at the time. Randi, who had just finished with her first round of fertility treatments, coached Jamie through it. She reassured her younger sister that she’d be fine, and warned her that immediately after the surgery she’d feel like she had an elephant sitting on her chest.

As Erin watched Randi, then Jamie, go through long recoveries, she was aghast, unable to process why they had the BRCA mutation and she didn’t. “I took it really hard,” she says. “I kept thinking, why am I the only one who is negative?”

 

When Randi and Zach first met with a specialist at Shady Grove Fertility in November 2011, about three weeks after Randi’s surgery, the plan was for the couple to freeze their embryos through in vitro fertilization. They were anxious and pressed for time, says Dr. Jeanne O’Brien, the reproductive endocrinologist who worked with them. Randi’s oncologists wanted to put her on tamoxifen, a medication used to treat breast cancer, for at least two years. But the couple feared the drug would suppress her ovarian function in the future, so they wanted to create the embryos before Randi started taking it. “The hope was that she would be able to get pregnant once the cancer treatment was completed,” O’Brien says.

In September 2012, Randi’s cancer returned. A recurrence is rare for women who have undergone a double mastectomy, but it can happen, Sandler says. Even though nearly all the breast tissue is removed during a mastectomy, any residual breast tissue—or even a cell— can transform into a recurrent cancer in a small number of patients. Randi’s team of physicians created a treatment plan and Sandler removed the tiny tumor on her right side. She then underwent about six weeks of radiation therapy. Doctors were confident that the surgery was successful, but feared that a pregnancy, even years later, could lead to another relapse—or a new cancer.

“I didn’t think it was worth the risk. For some reason I was calm when they told me,” Randi says. By that time, she and Zach had successfully frozen several embryos, and doctors had screened those embryos for the BRCA1 defect that Randi had. Four of the embryos were free of the mutation. Randi’s doctors shared reassuring stories about patients who had worked with gestational surrogates. “The more people I talked to about this option, the more I became OK with it,” she says.

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