In the United States, the American Cancer Society predicts that 252,710 new cases of breast cancer will be diagnosed in 2017 and 40,610 women will die from this disease.1 This makes breast cancer the most common malignancy in women, second only to some skin cancers.2 As a result, health care providers in the primary care setting have an excellent opportunity to counsel women about breast cancer risk and prevention. In this blog posting, we will review some of the latest approaches in risk stratifying and preventing breast cancer in asymptomatic women.
Case Study: Sally is a 45 year old woman who comes to your office for her annual physical. As you complete her history and physical exam, you ask her if she has any questions or concerns about her health. She immediately tells you that her sister was diagnosed with breast cancer three months ago and that she is concerned about her own breast cancer risk.
What do you tell Sally?
As a first step, you will use a risk assessment tool to help determine if Sally is at higher, average, or lower risk of breast cancer. One of the best-known breast cancer risk assessment tools is the Gail model. This calculator uses patient age, age at first menstrual period, age at first live birth, number of first-degree relatives with breast cancer, previous breast biopsy, and race to determine patient risk of breast cancer. Sally is 45 years old, had her first period at 12 years old, does not have children, has one family member with breast cancer, no previous breast biopsies, and is African American. According to the Gail model, she has a 1.4% chance of developing breast cancer in the next five years (increased from 0.9% for all 45 year old women) and a 14.4% risk of developing breast cancer in her lifetime (up from 9.5% for all 45 year old women).
Racial disparities in mortality rates from breast cancer have been widening over the past decade, and breast cancer is now the most common cause of cancer-related death among Hispanic women, and the second most common cause of cancer death for black, white, and Asian/Pacific Islander women.3
Is there anything Sally can do to decrease her risk of breast cancer?
Evidence-based lifestyle changes that can decrease her risk of breast cancer include not smoking, limiting alcohol consumption, eating a plant-based diet, exercising at least 150 minutes a week, and maintaining a healthy weight. As her PCP, you can refer Sally for genetic screening and you may consider prescribing medications to decrease her risk of breast cancer if she is a high-risk patient. The US Preventative Task Force (USPSTF) recommends that primary care providers discuss risks and benefits of medications such as tamoxifen and raloxifene that can potentially decrease the likelihood of developing breast cancer in high-risk women. Women with genetic markers for breast cancer, including BRCA1 and BRCA2, may consider surgical intervention after speaking with their health care team.
What do you recommend Sally do to decrease her risk?
Sally is a good candidate for making lifestyle changes. You may also send her to a genetic counselor, particularly if you learn that she has additional family members who were diagnosed with breast cancer. The FDA has approved prophylactic tamoxifen for use in women over 35 years old with a five-year breast cancer risk greater than 1.67%. Sally’s five-year breast cancer risk is 1.4%, so you may want to wait to hear back from the genetic counselor before considering medical or surgical interventions.
1 What are the key statistics about breast cancer? American Cancer Society website https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html. Updated January 5, 2017. Accessed March 2, 2017.
2 Breast Cancer Statistics. Centers for Disease Control website https://www.cdc.gov/cancer/breast/statistics/. Updated March 23, 2016. Accessed March 2, 2017.
3 Desantis CE, Fedewa SA, Goding sauer A, Kramer JL, Smith RA, Jemal A. Breast cancer statistics, 2015: Convergence of incidence rates between black and white women. CA Cancer J Clin. 2016;66(1):31-42.
Dr. V. Silverstein
Published on 4/29/2017