Identification and Management of Women at High Risk of Breast Cancer

1. Identification and Management of Women at High Risk of Breast Cancer Kevin S.Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Surgeon The Newton-Wellesley Hospital Breast Center

2. Saslow D et. al. CA Cancer J Clin 2007; 57: 75 Saslow D et. al. CA Cancer J Clin 2007; 57: 75

3. ACS MRI Guidelines Saslow D et. al. CA Cancer J Clin 2007; 57: 75

4. 10,000 4/1/2006 to 9/17/2007 HORMONES NULL or No Never 7,821 W/ Gail Score 6,981 W/ BRCAPRO Lifetime 6,028 W/ BRCAPRO Mutation and Tyrer-Cuzick 5,894 LCIS/AH status not available

5. ACS MRI Guidelines Exclude Gail Model • …less useful than BRCAPro, Claus, and Tyrer-Cuzick • …not adequate for evaluating family history Therefore we do not recommend its use for evaluating patients for breast MRI screening Online Supplemental Material

6. ACS Guidelines • BRCAPRO • Tyrer-Cuzick • Claus • Gail Saslow D et. al. CA Cancer J Clin 2007; 57: 75

7. ACS Guidelines • Claus • Breast FH • BRCAPRO • Breast and ovarian FH • Tyrer-Cuzick • Breast and ovarian FH • Pathologic factors • Hormonal factors

8. Lifetime Breast Cancer Risk 20% or greater by Model Tyrer-Cuzick= 330 (5.6%) BRCAPRO = 25 (0.4%) 10 276 2 13 0 31 10 Claus = 54 (0.9%)

9. 20 to 25% LT Risk of…What? • Invasive cancer • BRCAPRO • Invasive plus DCIS • Claus • Tyrer-Cuzick

10. Lifetime Breast Cancer Risk 20% or greater by Model Tyrer-Cuzick= 330 (5.6%) Adjusted BRCAPRO 61 (1%) 23 263 19 18 1 26 9 Claus = 54 (0.9%)

11. ACS MRI Guidelines LCIS/AH Saslow D et. al. CA Cancer J Clin 2007; 57: 75

12. Tyrer Cuzick for AH & LCIS • 20% or greater lifetime risk • Any LCIS • age 69 and below • Any AH • age 56 and below Even more with even trivial risk factors

13. IDing patients for MRI is not enough • Need complete risk assessment • Genetic testing as appropriate • Manage Breast and Ovarian Risk! Consider Genetic Testing if Risk Mutation is 10% or greater

14. Better Strategy • Identify mutation carriers (genetic testing) • MRI for those with mutation (selective MRI) • Offer ALL risk reducing strategies • Oophorectomy • Prophylactic mastectomy • MRI • Mammography

15. Avon Comprehensive Breast Center Database • 18,190 screening mammogram patients 40 or older • (May 2003 – July 2005) • BRCAPRO run on all

16. Lifetime risk ≥20% Avon Comprehensive Breast Center Database • 18,190 screening mammogram patients 40 or older • (May 2003 – July 2005) • BRCAPRO run on all 78 (0.4%)

17. Lifetime risk ≥20% Avon Comprehensive Breast Center Database • 18,190 screening mammogram patients 40 or older • (May 2003 – July 2005) • BRCAPRO run on all 78 (0.4%) BRCAPRO 27 Predicted Mutation Carriers

18. and Lifetime Risk <20% Avon Comprehensive Breast Center Database • 18,190 screening mammogram patients 40 or older • (May 2003 – July 2005) • BRCAPRO run on all Mutation Risk ≥10% 374 (2.1%)

19. Mutation Risk ≥10% and Lifetime Risk <20% Avon Comprehensive Breast Center Database • 18,190 screening mammogram patients 40 or older • (May 2003 – July 2005) • BRCAPRO run on all 374 (2.1%) BRCAPRO 62 Predicted Mutation Carriers

20. MGH Screening Data: All Comers

21. What to do • ≥10% risk of mutation • Genetic testing • Positive-Manage with all modalities • Negative-Your call • Based on FH

22. Options for high risk

23. Options for high risk Chemoprevention Prophylactic Oophorectomy Screening

24. Conclusions • ≥10% risk of mutation • Genetic testing • Positive-Manage with all modalities • Negative-Your call • Depend on FH • ≥20% LT Risk • Lots by TC • Almost all LCIS and AH by TC • Do they all need MRI?

25. Kshughes@Partners.org www.HughesRiskApps.net