Transcript No Slide Title

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
D CA
et. al.
CA Cancer
Clin 57:
2007;
SaslowSaslow
D et. al.
Cancer
J Clin J2007;
75 57: 75
ACS MRI Guidelines
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
HORMONES
NULL or No Never
10,000
4/1/2006 to 9/17/2007
7,821
W/ Gail Score
6,981
W/ BRCAPRO Lifetime
6,028
W/ BRCAPRO Mutation and Tyrer-Cuzick
5,894
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
•BRCAPRO
•Tyrer-Cuzick
•Claus
•Gail
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
ACS Guidelines
• Claus
• Breast FH
• BRCAPRO
• Breast and ovarian FH
• Tyrer-Cuzick
• Breast and ovarian FH
• Pathologic factors
• Hormonal factors
Lifetime Breast Cancer Risk 20% or greater by Model
Tyrer-Cuzick= 330
(5.6%)
BRCAPRO = 25
(0.4%)
276
10
2
13
0
31
10
Claus = 54 (0.9%)
20 to 25% LT Risk of…What?
• Invasive cancer
– BRCAPRO
• Invasive plus DCIS
– Claus
– Tyrer-Cuzick
Lifetime Breast Cancer Risk 20% or greater by Model
Tyrer-Cuzick= 330
Adjusted BRCAPRO
61 (1%)
(5.6%)
23
263
19
18
1
26
9
Claus = 54
(0.9%)
ACS MRI Guidelines
LCIS/AH
Saslow D et. al. CA Cancer J Clin 2007; 57: 75
Tyrer Cuzick for AH & LCIS
• 20% or greater lifetime risk
–Any LCIS
• age 69 and below
–Any AH
• age 56 and below
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
• 18,190 screening mammogram patients 40 or older
– (May 2003 – July 2005)
– BRCAPRO run on all
Lifetime risk ≥20%
78 (0.4%)
Avon Comprehensive Breast
Center Database
• 18,190 screening mammogram patients 40 or older
– (May 2003 – July 2005)
– BRCAPRO run on all
Lifetime risk ≥20%
78 (0.4%)
BRCAPRO
Predicted Mutation Carriers
27
Avon Comprehensive Breast
Center Database
• 18,190 screening mammogram patients 40 or older
– (May 2003 – July 2005)
– BRCAPRO run on all
Mutation Risk ≥10%
and
Lifetime Risk <20%
374 (2.1%)
Avon Comprehensive Breast
Center Database
• 18,190 screening mammogram patients 40 or older
– (May 2003 – July 2005)
– BRCAPRO run on all
Mutation Risk ≥10%
and
Lifetime Risk <20%
374 (2.1%)
BRCAPRO
Predicted Mutation Carriers
62
MGH Screening Data: All Comers
Risk of
Mutation
Risk of
Breast
Cancer
Mean
Projected #
Probability
Mutation
of Mutation
Carriers
n
≥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
Options for high risk
Prophylactic
Oophorectomy
Chemoprevention
Screening
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
[email protected]