which of the following increases a women’s risk for breast cancer? a.starting her menses at age 14...
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Which of the following increases a women’s risk for Breast Cancer?
A. Starting her menses at age 14 or olderB. Breastfeeding C. Extremely dense breast tissue
D. Having children prior to age 30
What is considered to be an elevated lifetime risk for developing Breast Cancer?
A. > 5 %
B. > 20 %
C. > 12 %
D. > 35 %
Breast Cancer Screening and Risk Assessment
Caroline Peterson, D.O. FACOOGDirector, Breast Cancer Screening and Prevention for Kettering Health Network
Algorithm for Breast Cancer Screening Process
RISK ASSESSMENT % LTR
IBIS* (Tyrer-Cuzik Model)Clinically Integrated
A RISK GROUP< = 10 %
B RISK GROUP11 – 19 %
C RISK GROUP> = 20 %
NOT DENSE DENSE
Mammogram Mammogram MammogramWhole Breast Ultrasound
Mammogram+ MRI
Start Age 40 yr Interval 12 mo
Start Age 40 yr Interval 12 mo
Start Age Risk Based Interval 12 mo
Start Age 25 yr Interval 12 mo
National Comprehensive Cancer Network (NCCN) Guidelines 2009
“If the physical examination is negative in an asymptomatic woman, the next decision point is based on Risk Stratification”
Summary: Currently known genetic markers for Breast Cancer
ER+ BrCaPost-Menopausal
ER- BrCaPre-Menopausal
Breast Cancer Classification
80% of women diagnosed with breast cancer have NO family history.
Sporadic80%
Hereditary 5%Hereditary 5%
Familial history 20%
Familial history 20%
Breast Cancer Screening Pathway
Questionnaire for MyRisk and Gail Model/T-Cuzick Model offered to all:New Patients and Annual Exams
MyRisk Testing Done
Once Test Results are in, Patient is Notified and Appointment is scheduled for Genetic Counseling Visit
MyRisk Not Indicated
Run T-Cuzick Model on Patients > 20 yearsRun Gail Model on Patients > 35 years
If Elevated, Schedule Appointment to Review with Physician or Advanced Practitioner If Not Elevated – Note on Chart Positive Results for
MyRisk Testing
Genetic Counseling CPT code 99214
Low Risk
Annual Mammogram at Age 40Teach Self-Breast Awareness
Negative Results for MyRisk Testing Elevated Gail/T-Cuzick
Results
Preventive Pathway
Screening Annual Breast Exam Annual Mammogram Breast MRI @ 6 Month Intervals
Prevention Risk Reduction Strategies Chemoprevention (Alternative to HRT)
Run Gail/T-Cuzick at ApptIf Elevated, Review New PathwayIf Not Elevated, Review Low Risk Pathway
Schedule Appointment With Provider Review New Pathway
Interventions for Patients with Increased Risk
Increased Risk = Lifetime risk ≥
20%◦ Bi-annual clinical
exam◦ Annual Breast MRI◦ Annual
Mammogram◦ ACR recommends Breast Ultrasound if cannot have MRI
Surveillance
Increased Risk = 11 – 19 %Dense Tissue ◦ Annual
Mammogram◦ Annual Breast
Ultrasound Fatty/Fibroglandular ◦ Annual
Mammogram
American Cancer Society Guidelines 2007
Criteria for Use of Breast MRI Screening as an adjunct to Mammography for High Risk Women Include:
BRCA 1 or 2 Mutation First Degree Relative with BRCA 1 or @ Mutation and Untested Lifetime Risk of Breast cancer of 20 – 25 % or more defined by
Models largely dependent on Family History Prior Radiation Treatment to the Chest between Ages 10 and 30 Carry or First Degree Relative who carries a Genetic Mutation TP
53or PTEN Genes
Breast Cancer Classification
80% of women diagnosed with breast cancer have NO family history.
Sporadic80%
Hereditary 5%Hereditary 5%
Familial history 20%
Familial history 20%
Why Risk Stratification?
Case Description45 yr old femaleNulliparousMenarche age 11No family hx CANo personal hx CANo prior breast bxAnnual Mammogram
at 50 yr old advised by USPSTF
Paternal Grandmother – Breast Cancer – Age 69
Abby
45 yr old female Nulliparous Menarche age 11 No family hx CA No personal hx CA No prior breast bx Annual Mammogram at 50
yr old advised by USPSTF Paternal Grandmother –
Breast Cancer at Age 69
Age 48, breast lump found by pt.• Stage 3 Invasive ductal
CA, ER+• Mastectomy, ChemoTx,
RadTx,
Adriamycin • Cardiotoxicity,
Congestive heart failure
Why Stratify? …………..Abby
Gail Model 1% 5-yr risk
Tyrer-Cuzick 2.0% 5-yr risk
TAMOXIFEN x 5 years
Recommendation when 5-yr risk ≥ 1.67%Achieve >50% breast
cancer risk reduction
Why Stratify? …………..Abby45 yr old female……AbbyNulliparousMenarche age 11No personal hx CANo prior breast bxAnnual mammogram at 50 yr
old advised by USPSTFPaternal Grandmother – Breast
Cancer Age 69Age 48, breast lump found by pt.Stage 3 Invasive ductal CA, ER+Mastectomy, ChemoTx, RadTx, Adriamycin cardiotoxicity, CHF
Gail Model 1% 5-yr risk Tyrer-Cuzick 2.0% 5-yr risk TAMOXIFEN x 5 years
23% integrated lifetime risk
ANNUAL MAMMOGRAM
ANNUAL MRI
Cancer Prevented, or
Diagnosed at Stage 1
Why Stratify? …………..Abby45 yr old female……AbbyNulliparousMenarche age 11No family hx CANo personal hx CANo prior breast bxAnnual mammogram at 50 yr
old advised by USPSTF Paternal Grandmother – Breast
Cancer Age 69Age 48, breast lump found by pt.Stage 3 Invasive ductal CA, ER+Mastectomy, ChemoTx, RadTx, Adriamycin cardiotoxicity,
CHF
ALL PATIENTS
PERSONAL or SIMPLE FAMILIAL
RISK
NO RISK FACTORS:SPORADICLOW RISK
STRONG FAMILY HXHEREDITARY RISK
ASSESSMENT
MULTIPLE or COMPLEX
FAMILIAL RISK
*PERSONAL / FAMILIAL RISK FACTORS:
1. ≤12 years age at first menstrual period
2. ≥30 years age at first childbirth or nulliparity
3. Mother, sister(s), daughter(s) with breast cancer
4. Breast biopsy
5. Breast density on mammogram.
6. High post-menopausal bone density
7. HRT ≥ 5 years
8. BMI > 30
9. Menopause >55
Breast Cancer Risk Stratification-How does it work?
SurveillanceIncreased Risk =
Lifetime risk ≥ 20%– Bi-annual clinical exam– Annual breast MRI– Annual mammogram– ACR recommends Breast Ultrasound if can’t have MRI
Pharmacologic risk reductionIncreased Risk =
5-year risk ≥ 1.67%– Tamoxifen– Raloxifene
Note-USPSTF recommends pharmacologic risk reduction when 5-year risk = 3%
Interventions for Patients with Increased Risk
.
1. Breast Cancer Risk Assessment is standard of care.
2. Primary Prevention & Early Detection saves lives.
3. Preventive / Cost Effective care is here to stay.
4. Good medicine = Good healthcare = Good business.
Risk Stratification – It’s About Time
Algorithm for Breast Cancer Screening Process
RISK ASSESSMENT % LTR
IBIS* (Tyrer-Cuzik Model)Clinically Integrated
A RISK GROUP< = 10 %
B RISK GROUP11 – 19 %
C RISK GROUP> = 20 %
NOT DENSE DENSE
Mammogram Mammogram MammogramWhole Breast Ultrasound
Mammogram+ MRI
Start Age 40 yr Interval 12 mo
Start Age 40 yr Interval 12 mo
Start Age Risk Based Interval 12 mo
Start Age 25 yr Interval 12 mo