Clinical Pearls and Tools for Optimizing Breast Cancer Risk Assessment[1]

Clinical Pearls and Tools for Optimizing Breast Cancer Risk Assessment Anna Maria Storniolo, MD Professor of Clinical Medicine Division of Hematology/Oncology Director, Catherine Peachey Breast Cancer Prevention Program Indiana University School of Medicine Indianapolis, Indiana Value of Risk Assessment  Improves overall quality of care  Encourages BC awareness  Enhances physician-patient relationship – Improves trust – Dispels misperceptions – Allays unwarranted fears  Provides basis for discussion of risk management 2 Estimating BC Risk: Gail Model1 Features  Provides 5-year and lifetime risk estimates based on – Age – Race – Age at first live birth or nulliparity – Number of first-degree relatives with a history of BC – Age at menarche – # of previous breast biopsies – Atypical hyperplasia 1. Coyne RL, Bevers T. In: Vogel VG, Bevers T, eds. Handbook of Breast Cancer Risk-Assessment. Sudbury, MA: Jones and Bartlett Publishers; 2003:126-145. 3 Gail Model: Advantages  An appropriate risk assessment tool for most women attending specialized clinics1  Identifies women who could benefit from preventive interventions; may assist in making clinical decisions 2  Incorporates risk factors other than family history (eg, reproductive variables, atypical hyperplasia, history of breast biopsies)3  Shows that BC risk increases with age and, therefore, may prompt discussion about the importance of BC screening4  Used to counsel and educate women, especially those who overestimate their BC risk2 1. Euhus DM et al. Breast J. 2002;8:23-27. 2. Gail MH, Costantino JP. J Natl Cancer Inst. 2001;93:334-335 (editorial). 3. Domchek SM et al. J Clin Oncol. 2003;21:593-601. 4. National Cancer Institute. Breast Cancer Risk Factors. Available at: http://bcra.nci.nih.gov/brc/learnmore.htm. Accessed September 28, 2005. 4 Gail Model: Limitations  Modest discriminatory accuracy for individual women 1  Not validated for black, Hispanic, and other ethnic groups1  May underestimate risk for women with demonstrated mutations of the BRCA1 or BRCA2 genes1  Only solicits family history involving first-degree relatives2,3  May underestimate risk when family history is on father’s side3  Does not take into account age at which relatives developed BC4 1. Gail M, Costantino JP. J Natl Cancer Inst. 2001;93:334-335 (editorial). 2. Coyne RL, Bevers T. In: Vogel VG, Bevers T, eds. Handbook of Breast Cancer Risk-Assessment. Sudbury, MA: Jones and Bartlett Publishers; 2003:126-145. 3. Domchek SM et al. J Clin Oncol. 2003;21:593-601. 4. Euhus DM et al. Breast J. 2002;8:23-27. 5 Gail Model National Cancer Institute http://bcra.nci.nih.gov/brc/questions.htm National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at: http://bcra.nci.nih.gov/brc/questions.htm. Accessed September 28, 2005. 6 Other Risk-Assessment Models  Claus1  Cuzick2  BRCAPRO3 1. Claus EB et al. Cancer. 1994;73:643-651. 2. Tyrer J et al. Stat Med. 2004;23:1111-1130. 3. Euhus DM et al. J Natl Cancer Inst. 2002;94:844-851. 7 Who Is at “Very High Risk”?  Personal history of BC1  BRCA1 or BRCA2 mutation carrier1  2 or more 1st-degree relatives with BC2  Lobular carcinoma in situ (LCIS)1  Atypia and a 1st-degree relative with BC1 1. Hollingsworth AB et al. Am J Surg. 2004;187:349-362. 2. Carpenter CL et al. Int J Cancer. 2003;106:96-102. 8 Who Is at “High Risk”?  Atypia1  5-year Gail risk >1.7%1  2 or more 2nd-degree premenopausal affected relatives1  Combined estrogen-progesterone hormone therapy for more than 10 years1  Mammographically dense breasts2  Obesity3 1. Hollingsworth AB et al. Am J Surg. 2004;187:349-362. 2. Kerlikowske K et al. J Natl Cancer Inst. 2005; 97:368-374. 3. Davison D. In: Vogel VG, Bevers T. Handbook of Breast Cancer Risk-Assessment. Sudbury, MA: Jones and Bartlett Publishers; 2003:10-19. 9 Risk Counseling in the Primary Care Setting1  Inform patients about personalized risk information for BC  Support and reinforce positive health behaviors (eg, healthier eating, exercise, quitting smoking)  Educate and correct misperceptions about actual risk when the patient is overestimating or underestimating it  Talk to anxious patients about “coping behaviors” (eg, meditation, self-talk, keeping a journal)  Reduce time spent waiting for BC-related test results and improve communication about the tests – Encourage patients to call their OB/GYNs/PCPs to explain test results 1. Stollings SR. In: Vogel VG, Bevers T, eds. Handbook of Breast Cancer Risk-Assessment. Sudbury, MA: Jones and Bartlett Publishers; 2003:170-179. 10 Reasons Requiring Referral for Imaging/Cytology  Intensive surveillance for women at very high risk1  Follow-up for prior BC or benign lesions2  Abnormalities on screening mammograms2  Reassurance (eg, family history, anxiety about BC)2 1. Gilbert FJ. Cancer Imaging. 2005;5:32-38. 2. Merck Medicus. Ultrasound Improves Accuracy of Breast Cancer Diagnosis. Available at: http://merck.micromedex.com/index.asp?page=newsarchive& news_id=5138&news=md. Accessed September 28, 2005. 11 Reasons Requiring Referral for Genetic Testing1  Diagnosis of BC before age 50  Diagnosis of two unique BCs  Diagnosis of BC and another primary cancer, especially ovarian cancer  Family history of BC, especially when occurring at a young age  Male relative with BC  Diagnosis of BC and Ashkenazi Jewish ancestry 1. Cedars-Sinai. Common Reasons for Referral. Available at: http://www.csmc.edu/1014.html. Accessed September 28, 2005. 12 Screening for BC1  Mammography – American Cancer Society (ACS) recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health  Clinical Breast Examination (CBE) – ACS recommends CBE be part of a periodic health examination, about every 3 years for women in their 20s and 30s and every year for women 40 and older  Breast Self-Examination (BSE) – BSE is an option for women starting in their 20s 1. American Cancer Society. ACS Cancer Detection Guidelines. Available at: http://www.cancer.org/docroot/PED/ content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp. Accessed September 28, 2005. 13 BC Screening  Mammography screening in women aged 50 to 69 years demonstrated reduction of 20% to 35% in mortality from BC1  In 2002, ~40% of US women ≥40 years reported NOT having a mammography in the last year2 1. Fletcher SW, Elmore JG. N Engl J Med. 2003;348:1672-1680. 2. Smith RA et al. CA Cancer J Clin. 2004;54:41-52. 14 Advice to All Women  Comply with mammography guidelines1  Maintain a healthy weight2  Get regular exercise2  Don’t rely on diet to reduce risk2  Consider other reasonable lifestyle modifications that may reduce risk – Reduce alcohol intake2 – Avoid smoking2 1. American Cancer Society. Can Breast Cancer Be Found Early? Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp. Accessed September 28, 2005. 2. Vogel VG. CA Cancer J Clin. 2000;50:156-170. 15 Key Take-Away Messages  Screening for BC is an important part of risk assessment  The OB/GYN/PCP’s understanding of risk factors and use of risk assessment tools are necessary for BC disease-state awareness  The Gail risk-assessment model, though it has its limitations, is useful  Risk assessment for BC adds value to the OB/GYN/PCP practice, notably improving the overall quality of women’s healthcare 16