Download Risk Assessment Risk Stratifications

Breast Health Overview
(available online: lghealth.org/breastguidelines)
Risk Assessment
Online risk breast cancer risk Profiler, based on Gail Model
At Suzanne B. Arnold Center for Breast Health: Will be using BRCA PRO model
Comprehensive review, counseling and genetic testing: Cancer Risk Evaluation Program
(CREP) at Cancer Institute
Risk Stratifications:
Very High Risk: mammography screening begins at age 40 or ten years prior to age of affected
relative. Annual MRI and referral to CREP should be considered. Patient with:
• Known BRCA positive status
• Family history of BRCA positive relatives, male breast cancer or ovarian cancer
• History of chest wall radiation (for example, for Hodgkin's disease) between ages 10 and
30
High Risk: Mammogram yearly starting at age 40 until life expectancy <10 years. Referral to
CREP should be considered. Patient with:
• Personal history of breast cancer
• Family history of breast cancer before age 50, or in both breasts or in several close
relatives
• History of prior biopsy-proven LCIS, ALH or ADH
• If calculated lifetime risk > 20%, consider annual MRI
Average Risk: Recommend screening with a harms/benefits discussion to help decide between
yearly beginning at 40, until life expectancy <10 years vs AAFP recommendation of at least every
2 years for women 50-74. Patient with:
• Calculated lifetime risk around the average for a 60 yr old woman at 9.1%
Current Screening Recommendations:
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ACS/NCCN yearly beginning at age 40 for as long as a woman is in “good health”
ACOG 2011 yearly beginning age 40
ASBS 8/2011 yearly beginning age 40
ASCO 2013 yearly after breast cancer treatment
ACR 2012 yearly beginning age 40 for < 15% lifetime risk, high risk > 20% or personal or
family history of BRCA gene mutation, history chest XRT: begin 25 – 30 or 10 years before
first relative, 8 years after XRT, with yearly MRI
AAFP 2/2013
 Offered at least biennially to women 50 – 74
 for 40 – 49 the risks and benefits of screening should be discussed
 > 75 the decision should be individualized keeping life expectancy and goals of care
in mind
 Teaching BSE not recommended, however women should report any changes in
their breasts promptly
2009 USPSTF (US Preventive Services Task Force)
 Recommended against routinely screening women younger than 50
 Recommended women under 50 discuss when to begin screening with their physician
 Recommended screening every 1 – 2 years between ages 50 and 74
Suggested Discussion Points for Informed Decision Making About Mammography
Screening*
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Mammography is not a perfect screening test, and understanding of its benefits and harms Ii
incomplete
Some cancers will be missed, and some women will die of breast cancer regardless of whether
they are screened.
Most women diagnosed with breast cancer will be cured regardless of whether the cancer was
found by a screening mammogram or on an exam.
Some cancers that are found may have never progressed to cause death. This is called
“overdiagnosis.” Data on this is very controversial because we have no tools that let us predict
which tumors would progress so all information is based on statistical modeling only.
Often women who have screening mammograms are called back for further testing because of an
abnormality that proves not to be a cancer; this is called a “false-positive” result.
Studies of the benefits and harms of mammography have limitations and inconsistent results. The
numbers reported below are estimates based on what most experts consider the best available
evidence, but uncertainty about these estimates remains.
Benefits of Mammography
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Mammography decreases the number of women who will die from breast cancer. This benefit is
greater for women who are at higher risk for breast cancer based on older age or other risk factors
such as family history.
The number of women whose lives are saved because of mammography varies by age.
If your breast cancer risk is higher than average, you may benefit more from a mammogram than
someone with average risk.
Harms of Mammography
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Many women who have a mammograms will have had a false-positive mammogram requiring
additional testing ( 2013 SBABC recall rate was 9.6% of screening mammograms).
For some women undergoing regular screening, the mammogram may identify an invasive cancer
or noninvasive condition (ie, ductal carcinoma in situ) that would have never put the woman at
risk of dying. (“overdiagnosis”). We cannot currently tell which cancers these are, so all cancers
are treated the same way. Intelligent people disagree on how frequently this happens.
Making a Decision About Mammography
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There is no disagreement among experts that mammograms save lives, and that at the very
least women aged 50 to 74 years should undergo a screening mammogram every 2 years. A
large body of data suggesting that more lives may be saved with a yearly mammogram starting at
age 40 also exists.
Whether you are likely to benefit from starting mammograms earlier or having them more
frequently depends on your risks for breast cancer.
Each woman may feel differently about the possibility of having a false-positive result or being
diagnosed with and treated for cancer that might not have caused problems. It is important for you
to consider what these experiences might mean for you. It is also important to consider how you
might feel if you decide not to undergo screening mammography and you are later diagnosed with
breast cancer.
* A Systematic Assessment of Benefits and Risks to Guide Breast Cancer Screening Decisions
Lydia E. Pace, MD, MPH1; Nancy L. Keating, MD, MPH2,3
JAMA. 2014;311(13):1327-1335. doi:10.1001/jama.2014.1398