Breast Cancer: Risks and Diagnosis

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Angelina, Gail and Every Woman's Name Here:________

By Dr. Priya Patel

In one way or another, it is likely that most women in this country have been exposed to some aspect of breast cancer. Whether it is through a personal struggle or an affected mother, grandmother, sister, daughter, close friend or simply from the pervasive pink ribbon culture that survivors, caregivers and supporters have so passionately nurtured, awareness is at an all-time high.

Angelina

While much focus over the last few decades has been on screening to prevent advanced stage disease, awareness should also include understanding risk. This year, Angelina Jolie's op-ed article in the New York Times titled "My Medical Choice" highlights this fact in a significant way. Knowing her family history was strong, genetic testing revealed she was a carrier of the BRCA1 gene. Having it predisposes an individual to an approximately 65% chance of developing breast cancer. However Angelina's personal risk was sharply higher at 87% taking into account additional risk factors. Even though <10% of all breast cancers are a result of these inherited gene mutations, it is an important reminder that awareness of personal risk matters. Who should be tested for the BRCA mutation?

Are you Ashkenazi Jewish?

If yes, and

• Any 1st degree relative with breast cancer or ovarian cancer
• Two 2nd degree relatives on the same side of the family with breast cancer or ovarian cancer

If no, and

Previving

In looking through the multitude of articles in press currently regarding breast cancer, I came across an interesting term: Pre-Vivor. Cancer "previvors" are individuals who have a known predisposition to cancer either through a genetic mutation, family history or any other risk attribute but have not had the disease, often because of preventative measures. In the case of Angelina Jolie, this was achieved through a double mastectomy which reduced her seemingly insurmountable risk to <5%. And so while October is National Breast Cancer Awareness Month, perhaps much less known is that October 2, 2013 is National Previvor Day.

Though the term was born to identify those with some form or hereditary predisposition, in truth if you are a woman, you are living with the risk of breast cancer and the goal is to pre-vive if at all possible. After all, though the risk is dramatic if you have a genetic predisposition, for the remaining 90% of women, 1 in 8 will still develop breast cancer in her lifetime. In 2013, it is estimated that approximately 234,580 women will be diagnosed with invasive breast cancer and 40,030 women will die from the disease. It is the 2nd leading cause of cancer death in women although in fact death rates have been declining since 1990 for several reasons. These include advanced treatment options, earlier detection through refined screening methods and simply put the goal of the month: AWARENESS.

Gail

This is where Gail comes in. In order to facilitate awareness of personal risk, several prediction tools have been developed that incorporate risk factors. These tools can then be used to determine optimal screening strategies to help survival as well as possible therapies for even previval. The most commonly used of these is the "Breast Cancer Risk Assessment Tool", more often known as the Gail Model. Using this tool, one can calculate an individual woman's risk of developing breast cancer over the next 5 years and until age 90 based on:

• Current age
• Age at first menstrual cycle
• Age at first live birth
• Number of 1st degree relatives with breast cancer
• 1st degree relatives include a Mother/Sister/Daughter
• Number of previous breast biopsies
• If any of the breast biopsies showed atypical hyperplasia
• Race

This tool is intended for women without a strong family history suggesting inherited breast cancer. Therefore it would not apply to women with more than two 1st degree relatives with breast cancer. When the Gail model suggests a higher risk category, or if there is a strong family history of breast and/or ovarian cancer, further risk stratification would be discussed with your physician with the goal of incorporating family history in order to determine need for genetic counseling. It is important to remember the limitations of these types of models, however, as all important risks have not yet been identified and that most of the risk factors are not as strongly associated with breast cancer as age and having the BRCA genes. In addition, it doesn't take into account certain risk factors such as breast density. Hence this is just one of many ways to start the discussion of personal risk however it must end with a thorough discussion with your physician to factor in clinical judgment thus allowing individual counseling.

Every Woman

Breast Cancer Awareness Month in conjunction with National Previvor Day reminds us that every woman is at risk. As discussed in this article, awareness means knowledge of the variables that may increase or decrease that risk. Below, you will find a table that briefly identifies both harmful and protective factors in descending order.  

Awareness and Beyond

Awareness of risk can extend the quantity of life by decades for some previvors. However as the table above shows, every woman can modify her personal risk and perhaps one of the greatest advents in improving breast cancer has been early detection with mammograms leading to many more survivors as well. Here are some updates and tips regarding our recommendations for screening which are congruent to the guidelines set forth by the American College of Obstetricians and Gynecologists:

• Breast SELF-EXAM and breast SELF-AWARENESS has always and will always continue to be a way to find changes in your own breasts.
• The BEST time to perform breast self-exam is at the end of your menses, or about 5-7 days after the 1st day of your cycle.
• This is when breasts are least lumpy.
• If you have irregular menses, pick 1 day a month and stick to it.  

• Mammograms are sufficient screening in most women.
• We recommend yearly screening along with breast exams in the office starting at the AGE OF 40. 

• MRIs may be helpful in some cases of women who are at a high risk of breast cancer.
• Known BRCA mutations carriers
• 1st degree relatives of known BRCA mutation carriers
• A lifetime risk of breast cancer greater than 20-25% based on prediction models that INCLUDE family history 

• Never assume your mammogram was normal: You should always hear back from the radiologist about your results. If you do not, call our office and we will help you.  

• Remember: In approximately 90% of women with an abnormal mammogram, breast cancer is NOT found.
• However an abnormal mammogram will require further imaging or testing 

• When should you stop?
  • Everyone has a different opinion.
  • However we recommend screening AT LEAST until age 75.
  • Beyond this, the decision to continue or stop can only be made after consulting with your physician and assessing your individual risk.

If you have any questions about any of the issues, please call and schedule an appointment so that you can discuss them further with one of our physicians. We look forward to seeing you.

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