identification and management of women at high risk of breast cancer
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Identification and Management of Women at High Risk of Breast Cancer. Kevin S.Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Surgeon The Newton-Wellesley Hospital Breast Center. Saslow D et. al. CA Cancer J Clin 2007; 57: 75. - PowerPoint PPT PresentationTRANSCRIPT
Kevin S.Hughes, MD, FACSCo-Director, Avon Comprehensive Breast Evaluation Center
Massachusetts General Hospital
SurgeonThe Newton-Wellesley Hospital Breast Center
Identification and Management of Women at High Risk of Breast Cancer
Saslow D et. al. CA Cancer J Clin 2007; 57: 75Saslow D et. al. CA Cancer J Clin 2007; 57: 75
ACS MRI Guidelines
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
10,000 4/1/2006 to 9/17/2007
7,821
NULL or No Never
HORMONES
6,981
W/ Gail Score
6,028W/ BRCAPRO Lifetime
5,894W/ BRCAPRO Mutation and Tyrer-Cuzick
LCIS/AH status not available
ACS MRI Guidelines Exclude Gail Model
• …less useful than BRCAPro, Claus, and Tyrer-Cuzick
• …not adequate for evaluating family history
Therefore we do not recommend its use for
evaluating patients for breast MRI screening
Online Supplemental Material
ACS Guidelines
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
•BRCAPRO
•Tyrer-Cuzick
•Claus
•Gail
ACS Guidelines
• Claus• Breast FH
•BRCAPRO• Breast and ovarian FH
•Tyrer-Cuzick• Breast and ovarian FH
• Pathologic factors
• Hormonal factors
Tyrer-Cuzick= 330 (5.6%)
276
BRCAPRO = 25 (0.4%)
Claus = 54 (0.9%)
10 2
3113
0
10
Lifetime Breast Cancer Risk 20% or greater by Model
20 to 25% LT Risk of…What?
• Invasive cancer– BRCAPRO
• Invasive plus DCIS– Claus– Tyrer-Cuzick
Tyrer-Cuzick= 330(5.6%)
263
Claus = 54(0.9%)
23 19
2618
1
9
Lifetime Breast Cancer Risk 20% or greater by Model
Adjusted BRCAPRO 61 (1%)
ACS MRI Guidelines
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
LCIS/AH
•20% or greater lifetime risk–Any LCIS
•age 69 and below
–Any AH •age 56 and below
Tyrer Cuzick for AH & LCIS
Even more with even trivial risk factors
IDing patients for MRI is not enough
• Need complete risk assessment
• Genetic testing as appropriate• Manage Breast and Ovarian
Risk!
Consider Genetic Testing if Risk Mutation is 10% or greater
Better Strategy
• Identify mutation carriers (genetic testing)
– MRI for those with mutation (selective MRI)– Offer ALL risk reducing strategies
•Oophorectomy•Prophylactic mastectomy•MRI•Mammography
Avon Comprehensive Breast Center Database
• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all
Avon Comprehensive Breast Center Database
Lifetime risk ≥20% 78 (0.4%)
• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all
Avon Comprehensive Breast Center Database
Lifetime risk ≥20% 78 (0.4%)
Predicted Mutation Carriers 27
BRCAPRO
• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all
Avon Comprehensive Breast Center Database
374 (2.1%)Mutation Risk ≥10%
Lifetime Risk <20%and
• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all
Avon Comprehensive Breast Center Database
374 (2.1%)
Predicted Mutation Carriers 62
BRCAPRO
Mutation Risk ≥10%
Lifetime Risk <20%and
• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all
MGH Screening Data: All Comers
Risk of Mutation
Risk of Breast Cancer
n
Mean Probabilit
y of Mutation
Projected #
Mutation Carriers
≥10% ≥20% 78 0.34 27
≥10% <20% 374 0.17 62
What to do
• ≥10% risk of mutation– Genetic testing
•Positive-Manage with all modalities•Negative-Your call
– Based on FH
Options for high risk
Prophylactic Oophorectomy
Screening
Chemoprevention
Options for high risk
Conclusions• ≥10% risk of mutation
– Genetic testing• Positive-Manage with all modalities• Negative-Your call
– Depend on FH
• ≥20% LT Risk– Lots by TC– Almost all LCIS and AH by TC
– Do they all need MRI?
www.HughesRiskApps.net