A Web version of the Gail model risk calculator that accounts for different risk factors among women of various racial backgrounds is available at www.cancer.gov/bcrisktool/default.aspx. The factors that contribute to calculating the 5-year risk estimate are listed in the TABLE.
But the Gail model has a major weakness: It performs better when applied to populations of women, rather than to individuals—and prevention decisions are, of course, made individually. When the Gail model calculates that a given postmenopausal woman has a 5-year risk of breast cancer ≥1.66%, she may benefit from treatment with a SERM. It’s likely that more women could be formally assessed for their risk of breast cancer if their physician used a risk-prediction model.
Which SERM? As Dr. Steven Goldstein says in his review of breast cancer chemoprevention, raloxifene, 60 mg/d, taken for 5 years, significantly reduces the risk of invasive breast cancer in a postmenopausal woman at increased risk of breast cancer. In the STAR trial, both raloxifene and tamoxifen similarly reduced the risk of breast cancer; when raloxifene was compared with tamoxifen, however, raloxifene was associated with a lower risk of thromboembolic events and cataracts.7
In postmenopausal women at increased risk of breast cancer, it’s likely that SERMs are underutilized for their preventive ability.
TABLE
Questions in the NCI’s breast cancer risk calculator
| Does the woman have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)? |
| What is the woman’s age?* |
| What was the woman’s age at the time of her first menstrual period? |
| What was the woman’s age at the time of her first live birth of a child? |
| How many of the woman’s first-degree relatives—mother, sisters, daughters—have had breast cancer? |
Has the woman ever had a breast biopsy?
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| What is the woman’s race/ethnicity? |
| * This tool only calculates risk for women 35 years of age or older. |
Close care for survivors
More and more, women survive breast cancer because of early detection by mammography and aggressive adjuvant treatment. Experts now recommend that survivors be evaluated for chemotherapy-induced cognitive dysfunction, fatigue, osteoporosis, and sexual dysfunction, and that they be offered weight-management tools and psychosocial support.
In addition, these women should continue to have mammography, annually; breast self-exam should be emphasized to them; and they should be provided with regular gyn care. Breast cancer survivors need the care of clinicians who are sufficiently aware of the myriad of issues that affect their quality of life.
Past success offers a model for what’s next
We are clearly being challenged here, as leaders in advancing women’s health. We must play a central role in reducing the health impact of breast cancer by being actively involved in counseling, prevention, and screening, and in caring for survivors.
To return to my opening comparison, the lifetime risk of cervical cancer is about 1 in 145; for breast cancer, that risk is 1 in 8. My hope? That we will, some day soon, celebrate how much we’ve reduced the rate of breast cancer—echoing the success we’ve had reducing the rate of cervical cancer and the number of women who die from that disease.