Heart Transplantation and Cancer Risk in a BRCA1 Breast Cancer Survivor

BACKGROUND: BRCA1 carriers face increased risk of cancer. Limited data exist for post-transplant immunosuppression and malignancy screening in this population. CASE SUMMARY: A 67-year-old woman with BRCA1-positive breast cancer developed anthracycline-induced cardiomyopathy requiring heart transplantation. She received enhanced surveillance for secondary malignancies with an uncomplicated course over 13 years. However, despite reduction in immunosuppression, 14 years later she developed a rare, fatal, metastatic adnexal tumor, eccrine porocarcinoma. WHY BEYOND THE GUIDELINES?: There are no established guidelines for post-transplant immunosuppression or cancer surveillance in patients with hereditary cancer syndromes such as BRCA1-associated hereditary breast cancer. DISCUSSION: This case demonstrates the complexity of balancing immunosuppression and management in patients with germline mutations who require heart transplantation. Further work is required to understand the intersection of oncologic genetic risk with immunosuppression and develop best practices for screening this distinct population. TAKE-HOME MESSAGES: Cancer survivorship in BRCA1 carriers adds complexity to post-transplant management. Multidisciplinary, personalized care is essential for optimizing outcomes in such high-risk patients.