This perspective on Bellacosa et al. (beginning on p. 48 in this issue of the journal) discusses the important biology of microscopically normal tissues in carriers of germ-line BRCA1 or BRCA2 mutations. The work of Bellacosa et al. is an important step toward discerning which pathways may be altered when one BRCA allele is inactivated. Cancer Prev Res; 3(1); 12-5. ©2010 AACR.Breast cancer is the most common lethal cancer experienced by women in developed countries, affecting one in eight women during her lifetime. U.S. estimates for 2009 include 192,370 new diagnoses of and ∼40,170 deaths from breast cancer (1). Although many factors are implicated in the initial steps of breast cancer development, a significant family history is the most important factor after gender and age. Despite the discovery of multiple breast cancer susceptibility tumor suppressor genes, such as BRCA1, BRCA2, PTEN, TP53, CDH1, CHEK2, and PALB2, only ∼15% of the number of cases in familial clusters of breast cancer can be explained by strongly or moderately penetrant single-locus susceptibility genes. Therefore, large numbers of familial cases of breast cancer remain unexplained, presenting a challenge for practitioners attempting to counsel family history patients in cancer genetics clinics.An estimated 5% to 10% of all breast cancers arise in the setting of inherited mutations in BRCA1 or BRCA2 and are presumed to be the result of these factors (2). Mutations in either of these genes occur in <50% of families with evidence of possible autosomal transmission of inherited susceptibility (3). Discovered nearly 15 years ago, germ-line mutations in the BRCA1 and BRCA2 genes in women (4-6) confer a breast cancer risk that is 10-to 20-fold higher than the risk of women without these mutations. BRCA1 and BRCA2 mutation carriers also have an increased risk for ovarian cancer and, to a mild degree, for gastrointestinal, prostate, pancreatic, and male breast cancers. At age 70, the risks of breast and ovarian cancer are 57% and 40%, respectively, for BRCA1 mutation carriers compared with 49% and 18%, respectively, for BRCA2 mutation carriers (7). BRCA1 and BRCA2 play an important role in double-strand break repair through the homologous recombination pathway and are considered to be tumor suppressor genes.The first description of oncogenic alterations to tumor suppressor genes came more than 40 years ago from Alfred Knudson, who based the description on epidemiologic studies of retinoblastoma. Knudson postulated that multiple damaging events in DNA (called "hits") are necessary to cause retinoblastoma. Children diagnosed with inherited retinoblastoma carry the first oncogenic event as an inherited or de novo germ-line mutation in RB, called the "first" hit. The second DNA injury could affect any somatic cell and would be acquired. If this second "hit" affected the wild-type allele of the locus, it could rapidly lead to cancer because both copies of the normal RB tumor suppressor gene would be lost. In contrast, nonhereditary retinoblasto...