An Ashkenazi Jewish woman in her 50s, Rachel, is diagnosed with breast cancer. Her mother, Sadie, age 80, has a history of melanoma, which was treated successfully. Sadie's younger sister, Zelda, died of breast cancer in her early 40s many years ago. Zelda had two daughters who live far away, with whom they have lost contact. Rachel's father and his family have no history of cancer.
An astute clinician recommends genetic counseling for Rachel and Sadie to estimate their risk of carrying the hereditary ovarian and breast cancer gene mutations for BRCA1 and BRCA2. While Sadie has no interest in being tested, Rachel is found to have the harmful BRCA2 gene change. She informs her immediate family, her parents and her two brothers, of this finding. Her brothers, who have daughters in their 20s, are entirely disinterested, having no knowledge of the ramifications of this information and no personal history of cancer.