FROM BOTH SIDES NOW

Reflections on Dr. Pamela Munster's journey that transformed the BRCA legacy for herself and others

Welcome to my Substack! Today, I’m reflecting on oncologist Pamela Munster’s remarkable memoir, Twisting Fate—a poignant example of the intersection of science and story.

At forty-eight, Dr. Munster, a breast cancer specialist at UCSF, was attending a conference when she answered a call from the radiology department of her hospital. A few days earlier, she’d had a mammogram she had ordered for herself—knowing that her case didn’t meet criteria for doing mammograms she’d helped establish for UCSF—but nonetheless acting on an ominous intuition.

The radiology technician on the line said there were five “little irregularities” on a scan—likely nothing of concern—but follow-up was needed. Munster asked which patient this concerned; the startled technician repeated that she was speaking about the doctor’s own mammogram. Suddenly, Munster was traversing the terrain she’d mapped out for others: landscapes with common features, but also unique landmarks and challenges for each woman.

Breast cancer was diagnosed based on a repeat scan and then painful biopsies. After consultations with colleagues and much consideration, Dr. Munster chose to have a double mastectomy even though cancer had only been found in one breast. Before her surgery, she and her husband went on a short, already planned vacation in Peru where they continued to process the ways their lives had altered.

Fortunately, no cancer cells were found at the edges of the breast tissue removed by Munster’s surgeon, and her lymph nodes showed no sign of malignancy. After a brief leave of absence, she continued treating women with breast cancer, formulating expert diagnoses, developing treatment plans, and supporting her patients’ journeys.

Munster’s memoir explores what it means to live on both sides of the doctor’s desk. Because it braids her own vulnerability as a patient with her clinical expertise and professional experiences, Twisting Fate offers something rare: a clear, grounded map (medical, emotional, and genetic) for women facing breast cancer and BRCA-related questions.

Three months after her surgery, Munster writes, “I should have relaxed” but “that nagging intuition of mine came back.” She had a UCSF pathologist review her surgical slides with her. Some unusual features in the tumor prompted them to suspect that she might carry a BRCA mutation. The possibility was startling: BRCA mutations run in families, and are inherited in an autosomal dominant pattern. A single altered copy from either parent is enough to significantly raise the risk of developing several deadly forms of cancer, so usually, BRCA mutations express themselves across multiple generations.

Munster had revisited her family history after her cancer diagnosis, but she’d noticed no obvious familial pattern; her grandmother’s breast cancer seemed sporadic rather than hereditary. Yet, genetic testing showed that Munster did carry a BRCA mutation, putting her at high risk for ovarian cancer as well.

She found herself standing at a frightening intersection of science and story, where the stark mechanics of BRCA and autosomal dominance crashed into the intimate work of revising a newly revealed family history and wondering how much of her future was scripted in her genes rather than capable of being altered by her—a question that stirred up emotional turbulence and unease.

Dr. Munster decided to have her ovaries removed as a preventative measure. Other women too have taken this hard step; the movie star Angelina Jolie, who comes from a family that carries the BRCA gene, elected to have bilateral mastectomies and oophorectomies. Admirably, Jolie went public with her decision, encouraging other women to prioritize their health over traditional markers of femininity.

These courageous decisions of course weren’t easy for Angelina Jolie, nor for Pamela Munster.

About a year after Munster’s cancer was discovered, her beloved father was diagnosed with locally advanced pancreatic cancer, one of the other malignancies strongly associated with BRCA genes. She helped guide her father though the difficult treatment decisions he faced. With surgery and chemotherapy, he lived more than five years, though he ultimately succumbed to metastatic pancreatic cancer.

In 2015, when Munster’s father was still alive, she was instrumental in creating the Center for BRCA Research at UCSF: a program that gives families with BRCA and related mutations a place to turn for expert risk assessment, coordinated care, and clinical trials aimed at changing what a BRCA diagnosis means for those with BRCA-related cancers and for their relatives and offspring.

Sadly, it turned out that Munster had inadvertently passed the BRCA mutation on to her young daughter. This added new layers to her personal battle and to her professional mission to curb the ravages of genetic cancers. She details both strands of her journey with a profound blend of honesty, humility and deep sensitivity.

As a person, mother, wife, and doctor, I too have been on both sides of the examining table. I’ve been profoundly grateful that my Hopkins medical education has helped me advocate for myself, my family, and my friends as well as my patients. Not surprisingly, my experiences as a patient and caregiver have deepened my empathy for those I’ve treated, making me more understanding about the disruptive emotions most of us experience when we are ill and afraid, and the complexities patients struggle with as they navigate intricate twists and turns, sometimes making decisions that don’t follow established guidelines.

In my Substack, I’ll be writing about the intersections of science, medicine, and personal stories, exploring the many forms this interweaving takes. From exam rooms and family histories to engineering disasters and more, facts are only half the story of scientific hypotheses, discoveries, and failures.

Stay tuned for my second post, taking us to a very different place: Tacoma Washington, 1940, with the spectacular collapse of the Tacoma Narrows Bridge—which turns out not to have been a matter of “no one could have known” as many authorities claimed at the time, but something else entirely.