Reducing the risk of breast cancer: A personalized approach

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Applied Evidence

Reducing the risk of breast cancer: A personalized approach

J Fam Pract. 2012 June;61(6):340-347

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References

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Imaging strategies for those at risk

Although there is evidence that mammography performed on postmenopausal women can reduce breast cancer mortality by 25%, there are known limitations to this detection method.¹⁴

One drawback is that in premenopausal women, breast density lowers mammography’s sensitivity. In addition, several studies have found that mammography has a low sensitivity for detecting tumors in patients with a BRCA mutation. This has led to the use of other imaging modalities, especially MRI, for women with a family history that suggests a genetic predisposition.

The first study to demonstrate the superior sensitivity of MRI for detecting invasive breast cancer compared with clinical breast exam and mammography was published in 2004.³⁵A few years later, the ACS issued guidelines that call for surveillance with MRI as an adjunct to mammography, starting at age 30, for women whose family history, carrier status, or history of chest wall radiation puts them at very high risk (ie, a lifetime risk >20%-25%).¹⁴

FAST TRACK

The American Cancer Society recommends MRI as an adjunct to mammography, starting at age 30, for women at very high risk.

The ACS found insufficient evidence to recommend for or against breast MRI for women with a lifetime risk of 15% to 20% (or documented high-risk lesions such as lobular carcinoma in situ, ALH, or ADH). Mammographic density, which in itself is a strong risk factor for the development of breast cancer, was not determined to be an indication for MRI screening. In deciding whether MRI is indicated for any high-risk patient, the cost, quality of imaging, and lower specificity must be considered.¹⁴

Weighing the benefits of surgery

For women who have a strong family history of breast cancer or are known carriers of a BRCA1 or BRCA gene mutation, the already high risk of developing breast cancer increases as they age. Prophylactic surgery—risk-reduction mastectomy (RRM) and/or bilateral salpingo-oophorectomy (RRSO)—has been found to lower the risk.^5,36,37

RRM can reduce the risk of breast cancer by as much as 90% for such patients;^38,39RRSO yields similar results, reducing the risk of ovarian cancer by 80% to 95% and the risk of breast cancer by 40% to 59%, provided the surgery is performed before the patient is 40 years old.^36,37

FAST TRACK

Oophorectomy before the age of 40 years may reduce a woman’s breast cancer risk by 40% or more.

These potential benefits must be weighed against the harm associated with surgically induced menopause, with the attendant risks of cardiovascular disease, osteoporosis, and menopausal symptoms.⁴⁰Notably, hormone therapy use after RRSO in women with a gene mutation has not been found to increase the risk of breast cancer. In fact, it may be associated with a decreased risk.⁵In general, short-term use of low-dose estrogen—up to the age of 51 or 52 years—is considered to be safe for this population,^41,42but long-term data on breast cancer risk are lacking.

CORRESPONDENCE
Marcia G. Ko, MD, Mayo Clinic, 13737 North 92nd Street, Scottsdale, AZ 85369; ko.marcia@mayo.edu