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?

Breast Cancer Develops Before it’s Detected

Preble, Montgomery and Greene Counties

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