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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.

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identification and management of women at high risk of breast cancer

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

slide2

Saslow D et. al. CA Cancer J Clin 2007; 57: 75

Saslow D et. al. CA Cancer J Clin 2007; 57: 75

acs mri guidelines
ACS MRI Guidelines

Saslow D et. al. CA Cancer J Clin 2007; 57: 75

slide4

10,000

4/1/2006 to 9/17/2007

HORMONES

NULL or No Never

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
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
ACS Guidelines
  • BRCAPRO
  • Tyrer-Cuzick
  • Claus
  • Gail

Saslow D et. al. CA Cancer J Clin 2007; 57: 75

acs guidelines1
ACS Guidelines
  • Claus
    • Breast FH
  • BRCAPRO
    • Breast and ovarian FH
    • Tyrer-Cuzick
      • Breast and ovarian FH
      • Pathologic factors
      • Hormonal factors
slide8

Lifetime Breast Cancer Risk 20% or greater by Model

Tyrer-Cuzick= 330 (5.6%)

BRCAPRO = 25 (0.4%)

10

276

2

13

0

31

10

Claus = 54 (0.9%)

20 to 25 lt risk of what
20 to 25% LT Risk of…What?
  • Invasive cancer
    • BRCAPRO
  • Invasive plus DCIS
    • Claus
    • Tyrer-Cuzick
slide10

Lifetime Breast Cancer Risk 20% or greater by Model

Tyrer-Cuzick= 330

(5.6%)

Adjusted BRCAPRO 61 (1%)

23

263

19

18

1

26

9

Claus = 54

(0.9%)

acs mri guidelines1
ACS MRI Guidelines

LCIS/AH

Saslow D et. al. CA Cancer J Clin 2007; 57: 75

slide12

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
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
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
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 database1

Lifetime risk ≥20%

Avon Comprehensive Breast Center Database
  • 18,190 screening mammogram patients 40 or older
    • (May 2003 – July 2005)
    • BRCAPRO run on all

78 (0.4%)

avon comprehensive breast center database2

Lifetime risk ≥20%

Avon Comprehensive Breast Center Database
  • 18,190 screening mammogram patients 40 or older
    • (May 2003 – July 2005)
    • BRCAPRO run on all

78 (0.4%)

BRCAPRO

27

Predicted Mutation Carriers

avon comprehensive breast center database3

and

Lifetime Risk <20%

Avon Comprehensive Breast Center Database
  • 18,190 screening mammogram patients 40 or older
    • (May 2003 – July 2005)
    • BRCAPRO run on all

Mutation Risk ≥10%

374 (2.1%)

avon comprehensive breast center database4

Mutation Risk ≥10%

and

Lifetime Risk <20%

Avon Comprehensive Breast Center Database
  • 18,190 screening mammogram patients 40 or older
    • (May 2003 – July 2005)
    • BRCAPRO run on all

374 (2.1%)

BRCAPRO

62

Predicted Mutation Carriers

what to do
What to do
  • ≥10% risk of mutation
    • Genetic testing
      • Positive-Manage with all modalities
      • Negative-Your call
        • Based on FH
slide23

Options for high risk

Chemoprevention

Prophylactic Oophorectomy

Screening

conclusions
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?
slide25

Kshughes@Partners.org

www.HughesRiskApps.net