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    Breast cancer screening and prevention: Results that matter

     

    High-risk women

    Risk assessment and interventions to reduce breast cancer among high-risk women remain underutilized in the United States. Approximately 15% of women between ages 35 and 79 meet the criteria for elevated risk of breast cancer: 1.67% 5-year risk or lifetime risk of 20% or greater.8 Several breast cancer risk assessment tools exist that combine known major risk factors predicting the probability of a woman having a disease-causing mutation in genes such as BRCA, or of developing invasive breast cancer. In high-risk women, ancillary testing with annual MRI has resulted in better detection of breast cancer and fewer interval cancers following mammography, independent of breast density.9

    Fewer than 5% of potentially eligible high-risk women have taken advantage of chemoprevention against breast cancer, including 2 US Food and Drug Administration- approved selective estrogen receptor modulators (tamoxifen and raloxifene), and more recently, the aromatase inhibitor exemestane. Patient acceptance of tamoxifen and raloxifene has been poor due to the drug’s rare but serious adverse side effects, including endometrial cancer and stroke. In a phase III trial of 4,500 women randomized to exemestane or placebo, exemestane reduced the incidence of invasive breast cancer by 65% with no serious adverse events and only minimal quality-of-life differences compared to placebo.9 Other promising chemopreventative drugs such as tibolone, lasofoxifene and arzoxifene appear to have more favorable side effect profiles and merit further study of patient acceptability.10

    Take-home message

    As primary health care providers for women, we need to educate ourselves, and our patients, about evolving technologies in breast cancer prevention and screening.  Ob/ gyns should be vigilant in screening women for potential hereditary cancer syndromes based upon their personal and family histories. Genetic counseling and testing can identify these high-risk women who benefit the most from effective risk-reducing interventions, including chemoprevention. For women with lower baseline risk of breast cancer, enhanced breast screening tests must demonstrate improved patient outcome and combine efficacy with acceptable cost. 

    References

    1.    Tabar L, Yen, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventative Services Task Force. Ann Intern Med. 2009;151(10):727-37.

    2.    Sprague BL, Gagnon RE, Burt V, et al. Prevalence of mammographically dense breasts in the United States. J Natl Cancer Inst. 2014:106.

    3.    ACOG Committee Opinion 625, Management of women with dense breasts diagnosed by mammography. 2015.

    4.    Melkinow J, Fenton JJ, Whitlock EP, et al. Supplemental screening for breast cancer in women with dense breasts: a systematic review for the U.S. Preventative Task Force. Ann Intern Med. 2016;164(4):268-78.

    5.    Kerlikowske K, Zhu W, Tosteson AN, et al. Identifying women with dense breasts at high risk for interval cancers, A cohort study. Ann Intern Medicine. 2015; 162:673-681.

    6.    Jeffers AM, Sieh W, Lipson JA, et al Breast cancer risk and mammographic density assessed with semi-automated and fully automated methods and BI-RADS. Radiology. 2017;282(2):348-55.

    7.    Kerlikowske K, Ma L, Scott CG, et al Combining quantitative and qualitative breast density measures to assess breast cancer risk. Breast Cancer Res. 2017;19(1).

    8.    Goss PE, Ingle JN, Ales-Martinez JE et al, Exemestane for breast-cancer prevention in postmenopausal women. N Engl J Med. 2011;364:2381-91.

    9.    Berg WA. Tailored supplemental screening for breast cancer: what now and what next?  Am J Roentgenol. 2009;192(2): 390-9.

    10. Mocellin S, Pilati P, Briarava M, Nitti D. Breast cancer chemoprevention: a network meta-analysis of randomized trials. J Natl Cancer Inst. 2015: 108(2).

     

    Ilana Cass, MD
    Dr. Cass is an Assistant Professor of Obstetrics and Gynecology, UCLA/Cedars-Sinai Medical Center, Los Angeles, Calif.

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