Why you must “Be Aware” of your Personal Risk of Getting Breast Cancer:
The concept of breast cancer risk assessment is undergoing a major evolution. Our increasing understanding of the issue of individualized risk analysis makes it imperative that every woman has a clear understanding of her personal risks of getting breast cancer.
It was just a decade ago that we learned how to do gene testing on women with strong family histories for breast or ovarian cancer to determine if they had the BRCA1/2 mutation. Women who now test positive (and their family members) are at high risk for breast and ovarian cancer. These BRCA1/2 positive patients required careful monitoring, access to hormone blocking drugs, and in some cases prophylactic nipple sparing mastectomies.
We now know that there is a much larger group of women who are also at increased risk for breast cancer, but are either not candidates for gene testing or test negative for the BRCA1/2 genes. These women also merit more intensive monitoring than women who are at average risk for breast cancer. Finally, there is what we consider to be the average risk women. In discussing this group of women, with no family history or other major risk factors (see Table I), it is important to keep in mind that all women are at risk. In fact, 3 of 4 women who get breast cancer have no family history of breast cancer. Also, as women age, the risk of breast cancer increases. The goal in risk counseling is to quantify a woman’s risk for getting breast cancer, and to outline strategies to lower her risks and improve the probability of early detection. The following summarizes the basic divisions of risk and provides guidelines for risk management:
Normal risk:
Women in this category do not have any of the major risks listed in table 1 (see below). These women should follow standard early detection guidelines. Women in the normal risk group should be aware of risk reduction strategies such as performing regular exercise; engaging in healthy dietary activities, controlling weight, and avoiding excess alcohol. Many women in the normal risk category want to know more about risk and risk reduction strategies. Risk assessment programs have been designed to answer these question (Contact us for more information).
Intermediate risk:
For the most part this group is composed of women who have family members with breast cancer, but also includes women who have had previous high risk biopsies (the combination of high risk biopsy and family history would go into the high risk category). Virtually all women in this age group benefit from risk assessment. The big breakthrough for this group of women is the availability of the screening MRI which has been proven to be the most sensitive test for detecting small cancers in high risk women who have no symptoms. The test is expensive and MRI screening is not routinely covered by insurance companies. However, there is a growing consensus among payers to cover the cost of an MRI if risk assessment tools can demonstrate a 20% or greater lifetime risk for getting breast cancer. The problem is that most women do not know their personal risk. Simple screening tools such as the Gail model frequently underestimate risk. To ensure accuracy in term of risk assessment multiple tools must be used. Most doctors’ offices do not have the time to deal with these issues, but fortunately some breast care centers are taking on this challenge and all women should be aware of the new resource. (Contact us for more information). The one group of intermediate risk women who should consider paying out of pocket for a baseline MRI are those intermediate risk women who have less than a 20% lifetime risk of breast cancer but have dense breasts. The MRI is much superior to the mammogram in detecting small cancers in women with dense breasts. Cost, however, is a major barrier. In Orange County the cost of an MRI ranges from $1,500-7,000 dollars. There is no evidence that the higher priced MRIs are superior in any way to the lower cost MRIs. Although $1,500 dollars is a large sum, but in the long-run it may be worth it for the peace of mind and the potentially for finding a breast cancer when it is curable without chemotherapy.
High Risk:
These are the women that typically have multiple relatives with breast and/or ovarian cancer. The highest risk is in those women whose relatives were diagnosed before menopause, had bilateral breast cancer, or had a male in the family with breast cancer. Women in this category should be followed in high risk clinics and should be well informed on risk reduction strategies such as hormone blockade and nipple sparing mastectomies. Women in this high risk category should consider genetic testing for the BRCA1/2 gene, especially those women who have Ashkenazi Jewish heritage. Those who test positive represent the highest risk category. They have up to an 80% lifetime risk of getting breast cancer and up to a 30% risk of getting ovarian cancer. Women in this must carefully evaluate their options. Those who choose to delay risk reduction surgery should be carefully monitored which would include yearly MRI starting at age 25 years.
The problem:
Unfortunately, doing risk assessment takes time and most doctors are so overwhelmed with providing basic medical care. They just don’t have the time or the resources to discuss issues of risk assessment and risk management with their patients. There is an urgent need to provide women with greater access to risk assessment in a manner that allows them to make informed decisions on how to manage their personal risks of getting breast cancer. If you are interested in more information on this subject, please Ask the Doctor.
Table 1 – Risk factors:
