:::: FOR OUR REFERRING PHYSICIANS : NEWSLETTER :.

High Risk Patients

Dear Colleagues:

Risk factors for the development of breast cancer continue to generate confusion and often needless anxiety among patients. Questions regarding the most appropriate study and timing of breast cancer screening procedures arise in every primary care practice. The enclosed commentary on screening high risk patients addresses how we define “high risk” and the screening protocols we recommend for these patients.

Again, we invite your questions and welcome the opportunity to consult with you about the breast imaging needs of your patients.

Sincerely,

G.W. Eklund, M.D., FACR

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BREAST CANCER SCREENING OF HIGH RISK PATIENTS

G.W. Eklund, M.D., FACR

What are the “significant”risk factors for developing breast cancer and how should they affect screening?

The list of factors associated with some degree of increased risk for developing breast cancer is long, with most of the factors being trivial and unworthy of any special attention. We consider “significant” risk factors to be those that should influence management and surveillance strategies.  These include:

• Personal history of breast cancer
• BRCA 1 or 2 autosomal dominant genes4
• Implicated in 5% to 10% of breast and ovarian cancers
• Can be transmitted by either parent
• 60% - 80% cumulative lifetime risk
• First line relative (mother, sister, daughter, father or brother) with breast cancer –
• Especially women with premenopausal or bilateral breast cancer
• Especially if breast cancer is associated with ovarian cancer (colon and other cancers, including melanoma??)
• Previous biopsy diagnosis of atypical ductal hyperplasia, radial scar or multiple papillomas.

Surveillance includes breast self-examination, physical examination and screening mammography for all women.  For select women, e.g. those with very dense breast tissue, ultrasound and/or MRI have been suggested and may prove beneficial in women with complex or dense tissue or high-risk cases, especially in cases with BRCA mutant genes.4 Women with BRCA-1 or BRCA-2 genes are commonly anxious and confused as to their options for surveillance or even prophylactic mastectomy. Genetic counseling should be available to these women and management choices made with careful consideration of the woman’s emotional needs.

There is no evidence to suggest that women with high risk factors should be screened with mammography more often than annually, but there is logic to beginning screening about ten years earlier than women without risk factors.

Screening mammography is inappropriate if there are any clinical findings of concern.

Patients with any breast related clinical findings of concern should be scheduled as diagnostic exams, not screening exams. Even subtle or ambiguous clinical findings – when reported to the imaging facility – draw focused attention and may require additional imaging such as spot films or magnification views. Ambiguous clinical findings may lead to the identification of subtle imaging findings that might otherwise be disregarded or missed mammographically. The importance of clinical breast examination before screening mammography cannot be overstated. This is especially important in the high risk population.

Pacific Breast Center’s recommendations for screening high risk patients are as follows:

• Patients with positive family history (first line relatives)
• Begin annual screening 10 years earlier than the relative’s age at diagnosis – or at age 30 if relative’s age is unknown
• Not before age 25
• With biopsy diagnosis of atypical hyperplasia, radial scar or multiple papillomas
• Begin annual screening
• With multiple first line relatives with breast and/or ovarian cancer
• Consider annual screening beginning at age 25
• Consider genetic counseling
• Breast ultrasound and/or breast MRI may be appropriate as part of the screening protocol for some patients with BRCA 1 or BRCA 2 mutant genes
• Begin annual screening at time of diagnosis
• Known BRCA 1 or BRCA 2 mutant gene carriers
• Begin annual mammographic screening
• Consider breast ultrasound and/or MRI screening

References:

• Gotzsche PC, Olsen O. Is screening for breast cancer with mammography justifiable? Lancet 2000; 8; 355: 129-34
• Tabar L, Vitak B, Tony HH, Yen MF, Duffy SW, Smith RA. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-31
• Blanks RG, Moss SM, McGahan CE, Quinn MJ, Babb PJ. Effect of NHS breast screening program on mortality for breast cancer in England and Wales, 1990-1998: comparison of observed with predicted mortality. BMJ 2000 16; 321:665-9
• Orel S. High-risk breast cancer screening with MRI. SBI News. August 2000.