Identification and Care of High-Risk Patients Flashcards
Breast Imaging Reporting and Data System final assessment category
see
Age and Gender
- Age is probably the most important risk factor
- most breast cancers occur in women
Risk Factors That Cannot Be Modified
Increasing age
Female sex
Menstrual factors
Early age at menarche (onset of menses before age 12 years)
Older age at menopause (onset beyond age 55 years)
Nulliparity
Family history of breast cancer
Genetic predisposition (BRCA1 and BRCA2 mutation carriers)
Personal history of breast cancer
Race, ethnicity (white women have increased risk compared with women of other races)
History of radiation exposure
Risk Factors That Can Be Modified
Reproductive factors
Age at first live birth (full-term pregnancy after age 30 years)
Parity
Lack of breastfeeding
Obesity
Alcohol consumption
Tobacco smoking
Use of hormone replacement therapy
Decreased physical activity
Shift work (night shifts)
Histologic Risk Factors
Proliferative breast disease
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Lobular carcinoma in situ
Personal History of Cancer
- A history of cancer in one breast increases the likelihood of a second primary cancer in the contralateral breast.
LCIS
- The lifetime risk of developing breast cancer is approximately 20–30%
- The invasive carcinomas that developed were predominantly ductal and not lobular in histology
- 50% of the carcinomas occurred in the contralateral breast
- Histologic marker for increased breast cancer risk
- < 1% per year
LCIS Tx ?
- Close observation
- Chemoprevention with tamoxifen, raloxifene, or arimidex > 5-year course of tamoxifen provides a 56% reduction in breast cancer risk
- Bilateral mastectomy > bilateral total nipple skin-sparing mastectomy is the procedure of choice
Histologic risk factors for development of breast cancer.
see
Examples of proliferative changes with atypia.
> > ADH
ALH
- Cancer Risk 0.5% to 1% per year.
- The risk for development of breast cancer in women with ADH or ALH is approximately four to five times the risk in the general population
- A family history of breast cancer and atypical hyperplasia increases the risk to almost nine times that of the general population
First-degree relatives (mothers, sisters, and daughters)
- twofold to threefold excess risk
- Risk is much higher if affected first-degree relatives of the mother or father had premenopausal-onset and bilateral breast cancer.
The BRCA1 gene
- Account for up to 40% of familial breast cancers.
- Tumor suppressor gene
- Autosomal dominant fashion
- negative regulation of cell growth and is involved in recognition and repair of genetic damage
- If a patient presents with a triple-negative breast cancer
- Relative has both breast and ovarian cancer
- chromosome 17 (17q21)
BRCA2 gene
- Chromosome 13
- 30% of familial breast cancers
- increased breast cancer risk in men
Lifetime rates of breast cancer for carriers of BRCA1 or BRCA2 mutations.
- between 50% and 70%
Histopathology of BRCA1-associated breast cancer is unfavorable compared with BRCA2-associated cancer
- high grade
- hormone receptor–negative
- aneuploid
- increased S phase fraction
- Women who carry a BRCA1 mutation and develop breast cancer are highly likely to have basal-like breast cancer
BRCA2-associated cancers
> > more commonly hormone receptor–positive
Screening with ? for BRCA
> > MRI is encouraged for women who prefer intensive screening rather than prophylactic surgery
Reproductive Risk Factors
- onset of menarche before 12 years
- first live childbirth after age 30
- Nulliparity
- Menopause after age 55 years
> > Breastfeeding has been reported to reduce breast cancer risk
Exogenous Hormone Use
- women receiving combination HRT with estrogen and progesterone for 5 years have approximately a 20% increased risk for the development of breast cancer.
- Women who take estrogen-only formulations (because of previous hysterectomy) do not appear to be at significant increased risk for breast cancer.
- Breast cancer risk is increased in current or past users of oral contraceptives but that the risk decreases as the interval after cessation of use increases.
Gail model
- To asses Breast Cancer Risk
- Not applicable to women with a history of invasive breast cancer, DCIS, or LCIS or African-Americans
- age
- race
- age at menarche
- age at first live birth
- number of previous breast biopsies
- presence of proliferative disease with atypia
- number of first-degree female relatives with breast cancer
Indications for consideration of genetic testing include
- Breast cancer diagnosed before age 50
- Bilateral breast cancer
- Breast and ovarian cancer in the same individual
- breast cancer in men
- family history (maternal or paternal) of two or more individuals with breast and ovarian cancer
- a close male relative with breast cancer
- a close relative with early-onset (<50 years) breast or ovarian cancer
- known BRCA1 or BRCA2 mutation in the family.
Recommendations for women in a family with a breast and ovarian cancer syndrome include
- monthly breast self-examination beginning at age 18 to 20 years
- semiannual clinical breast examination beginning at age 25 years
- annual mammography beginning at age 25 years or 10 years before the earliest age at onset of breast cancer in a family member
- add annual screening MRI to screening mammography, with some groups recommending doing the two examinations simultaneously and others recommending staggering the two examinations.
Chemoprevention for Breast Cancer
- Reducing breast cancer risk are the selective ER modulators tamoxifen and raloxifene and the aromatase inhibitors (AIs)
- Tamoxifen known to reduce the incidence of a second primary breast cancer in the contralateral breast of women who receive the drug as adjuvant therapy for a first primary breast cancer.
Tamoxifen side effects
- endometrial cancers 2.5
- Pulmonary embolism (RR, 3)
- deep venous thrombosis (RR, 1.7)
