Transcript Diagnosis and Treatment of Allergic Rhinitis

A CME workshop presented by
Workshop Learning Objectives
Assess breast cancer risk for individual women
patients.
2. Identify patients for whom breast cancer risk
reduction is feasible and should be considered.
3. Describe the reduction in breast cancer risk in older
women being treated for osteoporosis with Selective
Estrogen Receptor Modulators (SERMs)
4. Analyze the risks and benefits of SERMs in breast
cancer prevention.
1.
Epidemiology of Breast Cancer
 Most common cancer in women.
 Second only to lung cancer as cause of cancerrelated deaths in women.
 One women diagnosed every 3 minutes and one
women dies of disease every 13 minutes.
 In 2006, over 200,000 women were diagnosed
with invasive breast cancer.
 A woman’s lifetime risk for developing breast
cancer is 12.5% (1 in 8).
Risk Factor for Breast Cancer
 Ethnic and Familial
 Hormonal and
Reproductive
 Dietary/Lifestyle
 Risk Factor Assessment
Ethnic Variations in Breast
Cancer Risk
Rate of breast cancer stratified by race/ethnicity
Race/Ethnicity
Rate of breast cancer occurrence
Caucasian
141 per 100,000
African American
119 per 100,000
Asian American/Pacific Islander
97 per 100,000
Hispanic/Latina
90 per 100,000
American Indian/Alaska natives
55 per 100,000
Familial Risk Factors
 Two- to three-fold increased risk for women whose first-
degree relative was diagnosed with breast cancer.
 The risk declines significantly if only second-degree
relatives are affected.
Risk for all women compared to those with a family history
% of
% of all
Average lifetime risk
population breast cancer of breast cancer %
General population
90
80-85
11-12
Family history of
5-10
15-20
20-25
breast cancer
Positive for BRCA1 or
0.1
5-6
65-85
BRCA2 mutations
Reproductive/Hormonal Risk Factors
 Nulliparity
 Early menses (< age 12)
 Late menopause (> age 55)
 First full-term pregnancy after age 35
 Use of oral contraceptives
 Before first full-term pregnancy
 Use for longer duration in BRCA mutation carriers
 Use of hormone replacement therapy
Dietary/Lifestyle Risk Factors
 In post-menopausal women:
 Higher weight
 Higher body mass index (BMI)
 Alcohol use (<2 drinks per day)
 Regular exercise associated with a
decreased risk, but lack of
exercise not associated with an
increased risk
 Exposure to ionizing radiation
 Before 40 years of age
 Exposure between 10 and 14
years of age most critical.
Risk Factor Assessment
 Important for healthcare professionals to identify high
risk factors:
 Previous medical history of breast cancer.
 History of lobular carcinoma in situ or ductal carcinoma
in situ.
 Family history of breast cancer.
 Presence of BRCA 1 and 2 mutations.
 In the absence of personal or family history, the
presence of multiple risk factors can result in an
elevated risk
The Gail Model
 Internet-based tool
 Projects a women’s estimated risk of breast cancer over a 5-
year period and over her lifetime.
 Includes assessment of:
 Age and race
 First-degree relative history
 Hormonal factors
 Does not take into account:
 Personal history of cancer,
 Second degree relative history of breast cancer
 Family history of breast cancer before age 50
 Family history of bilateral disease and ovarian cancer
 BRCA1/2 mutations
The Gail Model Example
Patient background: Lucy is a 34 year-old female whose mother
had breast cancer.
Age at Menarche
Age at first live birth
# of biopsies
atypical hyperplasia
First degree relatives
Race
5-year Risk
Lifetime Risk
12
Nulliparous
0
1
Caucasian
0.4% (Average risk 0.2%)
17.2% (Average risk 12.6%)
The Gail Model is available at: http://www.cancer.gov/bcrisktool
Pedigree Assessment Tool
 Useful in identifying those individuals most at risk for
hereditary breast cancer.
 More information available at:
https://myosfhealth.osfhealthcare.org/sites/OSF/BCRA/de
fault.aspx
Pedigree Assessment Scoring System
Diagnosis
Breast cancer at age 50 or higher
Breast cancer prior to age 50
Ovarian cancer at any age
Male breast cancer at any age
Ashkenazi Jewish heritage
Points assigned
3
4
5
8
4
Prevention
 Primary prevention
 Modifiable risk factors
 Chemoprevention
 Genetic screening
 Secondary prevention
 Self breast exam
 Clinical breast exam
 Mammography
 Tertiary prevention
Primary Prevention: Modifiable
Risk Factors
Modifiable risk factors
Non-modifiable risk
factors
 Use of hormone replacement
 Age





therapy
Obesity
Physical activity
Alcohol use
Breastfeeding
Pregnancy (number, age, etc)
 Gender
 Race/ethnicity
 Age of menarche/menopause
 Personal history of breast
cancer
 Familial history
 Genetic mutations
Primary Prevention: Chemoprevention
 Selective estrogen receptor modulators (SERMS).
 Tamoxifen
 FDA approved for risk reduction of breast cancer in
high-risk women.
 Raloxifene
 The FDA Advisory Committee recently recommended
approval of Raloxifene for breast cancer risk reduction
(July 2007).
 Only recommended for high risk women, not those
with low or average risk.
Chemoprevention: Tamoxifen
 The Breast Cancer Prevention Trial (BCPT)
 50% reduction in the incidence of breast cancer after
receiving tamoxifen for 5 years.
 Other studies
 Statistically significant reductions in the incidence of
contralateral breast cancer in those treated with tamoxifen.
 Side effects:
 Increased risk of endometrial cancer and thrombosis
 Hot flashes.
Chemoprevention: Raloxifene
 Multiple Outcomes of Raloxifene Evaluation (MORE)
 76% reduction in invasive breast cancer compared to placebo when
treatment continued for a median of 40 months.
 Side effects:
 Thrombosis
 Hot flashes
 STAR Trial
 Raloxifene as effective as tamoxifen in reducing risk of invasive
breast cancer.
 Raloxifene had a lower risk of thromboembolic events and
cataracts, but a nonstatistically significant higher risk of
noninvasive breast cancer compared to tamoxifen.
Primary Prevention: Genetic Screening
 Family history patterns associated with increased risk for inherited
BRCA mutations in non-Ashkenazi Jewish women:
 1st degree relative with a known BRCA mutation
 Two 1st degree relatives with breast cancer, one who received the
diagnosis at age 50 or younger
 Three or more 1st or 2nd degree relatives with breast cancer
regardless of age at diagnosis
 Combination of both breast and ovarian cancers among 1st and 2nd
degree relatives
 1st degree relative with bilateral breast cancer
 Combination of two or more 1st or 2nd degree relatives with ovarian
cancer
 1st or 2nd degree relative with both breast and ovarian cancers
 Breast cancer in a male relative
Primary Prevention: Genetic
Screening
 Options for women who test positive BRCA mutations:
 Prophylactic mastectomy and oophorectomy.
 Increased surveillance, including:
 Clinical breast exams 2-4 times per year.
 Monthly self breast exams.
 Annual mammograms starting at age 25.
 Twice yearly ovarian cancer screening with ultrasound
beginning at age 35.
 Chemoprevention with SERMs.
Secondary Prevention: Self
Breast Exam (SBE)
 Noninvasive screening test.
 Clinical evidence does not show clear benefit.
 Patient and healthcare professional should discuss.
 Women should be told to report any changes or
abnormalities.
Secondary Prevention: Clinical
Breast Exam (CBE)
 Approximately 5% of
breast cancers identified
by CBE alone.
 54% Sensitivity
 94% Specificity
 No clinical trial exist
comparing CBE alone to
no screening.
Bobo JK, et al. J Natl Cancer Inst. 2000;92(12):971-976.
Secondary Prevention: Screening
Mammography
Recommendations for mammography screening
Age to start
Interval of
Organization
screening (yrs.) screening (yrs.)
 National Comprehensive Cancer Network
 American College of Radiology
40
1
 American Medical Association
 American Cancer Society
40
1-2
 American College of Obstetricians and
Gynecologistsa
 National Cancer Institute
 US Preventative Services Task Force
 American Academy of Family Physicians
50b
1-2
 American College of Preventive Medicine*
a: 1-2 years for women 40-49 years, 1 year for women >50 years; b: age 40 for high risk women; *
the ACPM policy is currently under review.
Secondary Prevention: Other
Modalities
 Ultrasound
 MRI
 Recommended as annual screening tool for women who:




 PET
Have a BRCA 1 or 2 mutation.
Have a first-degree relative with a BRCA 1 or 2 mutation and
are untested.
Have a lifetime risk of breast cancer of 20-25 percent or more
using standard risk assessment models.
Received radiation treatment to the chest between ages 10 and
30, such as for Hodgkin Disease.
Tertiary Prevention
Cancer treatment-related complications
Early complications
Late Complications (rare)
Endocrine therapy
 Wound infection
 Shoulder immobility and neuropraxia
 Skin desquamation
 Acute toxicities of chemotherapy
 Febrile neutopenia
 Early lymphedema
 Tissue fibrosis
 Chemotherapy-induced heart disease
 Myelodysplasias
 Late-onset lymphedema
 Psychological and possible intellectual effects
Tamoxifen
 Endometrial cancer
 Vaginal bleeding
 Thromboembolic events
Aromatase inhibitors
 Decreased bone density
 Myalgias and arthralgias
Tertiary Prevention
 Continue preventive screening.
 No long-term survival benefit seen with intensive
follow-up vs. routine mammograms and physical exams.
 Continue ongoing primary care and screenings for
other cancers (i.e.. Colon cancer).
 Provide psychosocial support, education, and resource
materials.
 Encourage exercise and weight loss (if applicable).
Special Issues for Rural
Providers
Compared to urban counterparts, the

rural population:
 Is generally older, poorer, and less
educated.
 Has fewer physicians and hospitals per
capita.
 This disparity results in:
 Lower level of patient-reported health
status.
 Less confidence in being able to
obtain needed care.
 Fewer physician visits.
 The need to travel farther to obtain
care.
Poverty in Rural Regions
Percentage of population living in poverty stratified by geographic location
Geographic location
% of population living in poverty*
Urban population
13.8%
Rural adjacent population
15.8 %
Rural non-adjacent population
22.5%
*Poverty is defined as household income below the 100% of the 1997 federal poverty level; specific
numbers can be found at http://aspe.os.dhhs.gov/poverty/97poverty.htm.
Ormond B, et al. A Rural/Urban Differences in Health Care Are Not
Uniform Across States. New Federalism: National Survey of America's
Families [Number B-11 http://www.urban.org/publications/309533.html.
Barriers Facing Rural Providers
 Negative patient attitudes about mammography.
 Fear of pain, discomfort, and anxiety.
 Cultural/racial norms and attitudes about disease
processes.
 Screening rates lower in women with no high school
diploma or GED.
 African-American and Hispanic women have fewer
baseline and routine mammograms.
Barriers: Health Insurance
 Percentage of patients uninsured:
 14.3 percent of urban residents
 17.5 percent of residents in rural adjacent counties
 21.9 percent in rural non-adjacent counties
 Significantly more women with insurance received
regular mammograms than did those without
insurance (60% vs. 33%, respectively).
 The National Breast Cancer and Cervical Cancer Early
Detection Program
Ormond B, et al. New Federalism: National Survey of America's Families
[Number B-11 http://www.urban.org/publications/309533.html; Smith RA,
et al. 2006. CA Cancer J Clin. Jan-Feb 2006;56(1):11-25.
Barriers: Screening Site Issues
 Shortage of breast imaging specialists; however, new
technologies may help:
 Increase the accuracy of breast cancer detection.
 Improve access to mammography.
 Broaden the pool of medical personnel who can
interpret mammograms.
 Shortage of new visiting specialists
 Rural Health Care programs help fund necessary
telecommunications.
Barriers: Access Issues
Components of an office system for annual preventive
care prompts and reminders
 Determine the target women for breast cancer
screening/preventive services
 Computerized prompts through an electronic medical
record (EMR) system
 Flow sheets
 Mailed or telephone reminders
 Newsletters or educational materials
 Brief telephone counseling for women who have not
received a mammogram in the preceding 15 months.
Improving Communications
 Learn about your community. If you
are new to the community, learn about
the demographics of your population.
 With your staff, decide on a realistic
target and set a goal. For example,
develop a plan to increase the
mammogram screening of your target
population by 20% in the next year.
 Visit the women in your community at
adult education classes, coffee shops,
and other places where women are
gathering. Put together a “Grab Bag”
with handouts and important date
reminders.
Improving Communications
 Use the office staff to teach and help with follow-up. Ask
them for ideas on how to reach out into your community.
 Create a “reward” for repeat positive behavior or change
in behavior. For instance, create a “Bring a friend to your
mammogram” program.
 Use the Pink Ribbon symbol to remind women how
important screening is. Contact the Susan G. Komen
Foundation and others who offer free Pink Ribbons.
 Be visible. Health care providers are viewed as the
experts, and when you speak, others listen and will know
the message is important.
Conclusions
 Rural healthcare providers face challenges in
addressing patient needs.
 Acute issues vs. preventive measures.
 Patient barriers
 Assess individual risk factors
 Discuss chemoprevention in applicable patients
 Encourage regular screenings for all eligible patients.