Lisa Crawford thought she had it covered. By age 35, she'd had three mammograms, encouraged to be vigilant by her father and mother, a breast-cancer survivor.

"I wasn't overly concerned," she said of her family history. "I was way ahead of the game, I thought."

But when the third mammogram last July, on Friday the 13th, found a lump in one breast that turned out to be malignant, Crawford decided to take pre-emptive action.

The Henrico County mother of three chose to have a bilateral mastectomy and later had her ovaries removed as well.

Crawford's Ashkenazi Jewish background meant she was at increased risk of carrying the so-called breast-cancer gene, which raised her odds of getting breast and ovarian cancer.

"I didn't want to have to worry about it for every single second of every day," she said.

Crawford, now 36, is part of a new generation of women with breast cancer who are taking aggressive action -- and in many cases, making difficult decisions -- to control their destinies.

Advances in genetic testing enable women to determine if they carry gene mutations, called BRCA1 or BRCA2, that greatly increase their risk for cancer.

While the National Cancer Institute estimates that 1 in 8 women will be diagnosed with breast cancer during her lifetime, the odds are much higher for women with the hereditary form of the disease.

Women with the BRCA1 or BRCA2 mutations are 3 to 7 times likelier to develop breast cancer than women without the genes and to get it at a much younger age, according to the institute.

Katherine Clark, who was diagnosed with breast cancer last October, has had a lumpectomy, removal of her lymph nodes and four rounds of chemotherapy. This summer, she'll have a double mastectomy, her ovaries removed and reconstructive surgery "all on the same day."

"I have high hopes," Clark said, and strong faith that the strategy she has selected, which includes drug therapy with tamoxifen, is her best hope to prevent a recurrence.

Many women, such as Crawford and Clark, make the decision to have prophylactic surgery after cancer is found in one breast and tests find they carry the BRCA mutation.

But other women don't wait for a cancer diagnosis.

Television writer Jessica Queller, whose credits include "Gossip Girl," "Gilmore Girls" and "Felicity," chose preventive surgery after the death of her mother, who had breast and ovarian cancer. In her mid-30s, single and wanting a family, Queller describes her decision in a new memoir, "Pretty Is What Changes: Impossible Choices, the Breast Cancer Gene, and How I Defied My Destiny."

Such prophylactic surgery is not without critics. Some argue that the genetic test, only a decade old, can have ambiguous results and may be too new for doctors to give definitive guidance. The fact that the BRCA patent for testing is held by a single company, Myriad Genetics, raises concerns of commercial exploitation and limits on diagnostic research.

The surgery itself carries risks and does not guarantee against cancer because not all at-risk tissue can be removed. The National Cancer Institute says some women have developed cancer despite preventive surgery.

But Dr. Harry D. Bear, medical director of the VCU Massey Cancer Center's Breast Health Center, said ultimately it is the woman's decision.

Many have seen their mothers suffer, and "they don't want to be awake at night worrying about when they're going to get breast cancer," he said.

"This is very much an individual decision."

It is not necessarily a new trend, he added. Such surgeries were performed in the 1970s, and they predated any proof of a genetic link, he pointed out.

"People just knew they had a strong family history," he said.

Dr. Joann Bodurtha, director of clinical genetics at Virginia Commonwealth University, said that was particularly true with prophylactic oophorectomy -- the removal of the ovaries -- because of unreliable screening for ovarian cancer.

She said it was not uncommon for women with a family history of ovarian cancer to have the surgery after their child-bearing years. Such surgery reduces the risk of ovarian cancer "by 90-plus percent" and of breast cancer by 50 percent.

Some studies have shown prophylactic mastectomies reduce breast-cancer risk by more than 90 percent.

A family history of breast cancer was one reason former CBS newswoman René Syler chose to have a bilateral preventive mastectomy. Both her parents had breast cancer, and she had been diagnosed with a precancerous condition called hyperplasia with atypia.

(Syler is scheduled to speak in Richmond on Sept. 26 at the Susan G. Komen for the Cure's 3rd Annual Survivor Celebration at The Jefferson Hotel.)

Syler's surgery reflects a trend toward more aggressive surgical treatment. A study reported in November by the Journal of Clinical Oncology found a significant increase in contralateral prophylactic mastectomy -- the removal of the other breast -- among women with all stages of breast cancer. The surgery more than doubled from 1998 to 2003.

Massey Cancer Center statistics show a sharp increase in the number of bilateral mastectomies over the last 15 years. In 1993, bilateral mastectomies accounted for only 3.3 percent of all mastectomy procedures. That number had risen to 20.2 percent by last year.

"I think that this is mostly patient-driven prophylactic surgery on the opposite breast," Bear said of the Massey figures. He said they are similar to national trends.

Prophylactic mastectomies are on the rise, Bear said, as breast-reconstruction techniques improve and as insurance companies have become more willing to pay for them.

With a better understanding of genetics and an upsurge in the use of MRIs to screen for tumors, women are able to make a more informed decision, he said.

"It's certainly a radical step," he said of the surgeries and added that "some people think it's overkill."

But Bear, a surgical oncologist, is sympathetic to women's desire to reduce their risks.

Even with vigilance and improved screening techniques, he pointed out, "you still may not catch a breast cancer at a stage it can be cured."

Lisa Crawford was fortunate in that regard. Her cancer was caught so early that she did not need chemotherapy.

Despite her mother's illness, Crawford said, she had not suspected a genetic link. She was diagnosed at age 35; her mother was 57.

"Fifty-seven is almost a normal age," Crawford said. "It wasn't really a red flag."

But the genetic tests showed why.

"I got the gene from my father, not my mother," she said.

Her father is of Ashkenazi, or Eastern European, Jewish background. According to the National Cancer Institute, about 2.3 percent of people of Ashkenazi Jewish descent carry a mutated gene -- about five times higher than the general population. Other groups, such as people of Norwegian, Dutch and Icelandic descent, also have a higher rate.

Clark, 48, also inherited the gene from her father, although she said she knew of no ethnic connection to the BRCA2 gene in her family. And she also had not suspected a genetic link until two of her paternal cousins were diagnosed.

One of her cousins died in February. She said taking her cousin to chemo appointments meant she was well-informed about the decisions she would face when she received her own diagnosis.

"She paved the way for me," said Clark, who lives in Mechanicsville with her husband, cats, a horse and a pony.

Crawford thinks that her decision to have mammograms before the normal recommended age of 40 meant her cancer was detected before it spread to her lymph nodes.

The genetic testing that showed she had the BRCA2 mutation was important as well. "It makes a huge difference in your treatment," she said.

She credits the support of family and friends with helping her through her surgeries.

"I'm doing well. I'm happy," she said. "You have to have a positive outlook."

And she notes that carrying the breast-cancer gene is almost beside the point.

Breast cancer "affects everybody . . . It affects anybody," she said.

"I was the first of my friends to be diagnosed. But I won't be the last."
Contact Karin Kapsidelis at (804) 649-6119 or kkapsidelis@timesdispatch.com.