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Risk Assessment and Individualized Screening

Risk Assessment and Individualized Screening. Kevin S. Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Surgeon The Newton-Wellesley Hospital Breast Center.

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Risk Assessment and Individualized Screening

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  1. Risk Assessment and Individualized Screening Kevin S. Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Surgeon The Newton-Wellesley Hospital Breast Center

  2. Under the HIPAA Privacy Rule, may a health care provider disclose protected health information about an individual to another provider, when such information is requested for the treatment of a family member of the individual? Yes. • Thus, the Rule does permit a doctor to disclose protected health information about a patient to another health care provider for the purpose of treating another patient (e.g., to assist the other health care provider with treating a family member of the doctor’s patient). 1/12/2009

  3. For example, an individual’s doctor can provide information to the doctor of the individual’s family member about the individual’s adverse reactions to anesthetics prior to the family member undergoing surgery. These uses and disclosures are permitted without the individual’s written authorization or other agreement

  4. RT Risk After Hodgkins Cancer 79:1203, 1997

  5. Breast Density • 15,292 women presenting for mammography at the MGH Avon Breast Center

  6. 75% of time can predict density if you know age and BMI Density without information about age and BMI is meaningless No model uses age, height and weight in determining level of risk

  7. Breast cancer RR RR BRCA1-2 AH LCIS Early menarche Late FLB Family history RT in teens Breast Bx • Modified from New England Journal of Medicine 1992;327:319-28.

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

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

  10. 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

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

  12. 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

  13. Overlap of BRCA 1 or 2 Mutation Risk 10% or greater Tyrer-Cuzick = 44 BRCAPRO = 113 0 44 69

  14. 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%)

  15. 20% or greater LT Risk

  16. Breast cancer RR RR BRCA1-2 AH LCIS Early menarche Late FLB Family history RT in teens Breast Bx • Modified from New England Journal of Medicine 1992;327:319-28.

  17. Options for high risk

  18. Options for high risk Chemoprevention Prophylactic Oophorectomy Screening

  19. 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

  20. Mutation RiskGreater than or equal to 10% • Cost benefit • Test 10 people at $3500 each • Willing to pay $35,000 to find 1 carrier

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

  22. 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

  23. 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

  24. MGH Screening Data: All Comers

  25. Suggested Strategy • ≥10% risk of mutation • Genetic testing • Positive-Manage with all modalities • Negative-Your call • Based on FH

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

  27. 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

  28. Breast cancer RR RR BRCA1-2 AH LCIS Early menarche Late FLB Family history RT in teens Breast Bx • Modified from New England Journal of Medicine 1992;327:319-28.

  29. Radiation to chest age 30 or less

  30. Breast cancer RR RR BRCA1-2 AH LCIS Early menarche Late FLB Family history RT in teens Breast Bx • Modified from New England Journal of Medicine 1992;327:319-28.

  31. Gail >1.66% at 5 years Maybe Raloxifene if osteopenia/porosis ?

  32. Breast cancer RR RR BRCA1-2 AH LCIS Early menarche Late FLB Family history RT in teens Breast Bx • Modified from New England Journal of Medicine 1992;327:319-28.

  33. San Antonio Breast Cancer Symposium—December 6-10, 2011 Clarifying the Risk of Breast Cancer in Women with Atypical Breast Lesions SB Coopey, E Mazzola, JM Buckley, J Sharko, AK Belli, EMH Kim, F Polufriaginof, G Parmigiani, JE Garber, BL Smith, MA Gadd, MC Specht, AJ Guidi, CA Roche, KS Hughes Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA; Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Pathology, Newton-Wellesley Hospital, Newton, MA

  34. Methods All electronically available pathology 1987-2010 Mass General, Brigham & Women’s, Newton Wellesley Natural Language Processing (Clearforest, Waltham, MA) Atypia diagnoses verified by human reader All women diagnosed with ADH, ALH, LCIS, or Severe ADH No prior or concurrent breast cancer Intact breasts Trumping order for maximum diagnosis Severe ADH> LCIS > ALH > ADH Use of chemoprevention agents identified by chart review Yes, No, Unknown Effect of chemoprevention analyzed from 1999 forward San Antonio Breast Cancer Symposium—December 6-10, 2011 This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  35. Natural Language Processing of breast pathology reports

  36. Natural Language Processing of breast pathology reports 21 negations before diagnosis ( No evidence of …) 12 negations after diagnosis ( … was not seen)

  37. Results 76,333 breast pathology reports 42, 950 individuals 2942 women with atypia Mean Age Dx: 53 years (range: 19-93) Mean FU all: 66 months San Antonio Breast Cancer Symposium—December 6-10, 2011 This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  38. Breast Cancer Risk by Atypia TypeNo Chemoprevention (All years) San Antonio Breast Cancer Symposium—December 6-10, 2011 Probability of Being Cancer Free *ADH at 5 years only significant difference Time from Atypia to Cancer (years) This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  39. San Antonio Breast Cancer Symposium—December 6-10, 2011 Results: Chemoprevention Status • Limited to 1999 and beyond, n=2460 • 466 (18.9%) patients treated • Tamoxifen, raloxifene, and/or exemestane • Any duration of time • 1472 (59.8%) patients not treated • 522 (21.2%) patients with data unavailable This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  40. Probability of Cancer after Atypia Diagnosis With and Without Chemoprevention, 1999 and Beyond San Antonio Breast Cancer Symposium—December 6-10, 2011 4.1% 7.5% 8.3% Probability of Being Cancer Free 21.3% Time from Atypia to Cancer (years) (p<0.05) This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  41. San Antonio Breast Cancer Symposium—December 6-10, 2011 Chemoprevention Decreased Cancer Risk for all Atypia Types1999 and Beyond 8.5% 8.5% 18.7% 19.9% ADH ALH (p<0.05) (p<0.05) 2.1% 10.3% 14.7% 32.4% LCIS Borderline (p<0.05)

  42. Atypical hyperplasia/LCIS Chemoprevention!

  43. Risk Categories Prophylactic surgery MRI Chemoprevention Chemoprevention ?Chemoprevention • Highest risk • BRCA1/2 carrier • Radiation to chest age 30 or less • High Risk • Atypical hyperplasia/LCIS • Elevated risk • Gail >1.66% at 5 years

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

  45. Laterality of Cancer with No Chemoprevention San Antonio Breast Cancer Symposium—December 6-10, 2011 Significantly more ipsilateral cancers for all atypia types combined (p<0.005) This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  46. Invasive/DCIS with No Chemoprevention San Antonio Breast Cancer Symposium—December 6-10, 2011 • invasive vs non-invasive cancer • ADH and Borderline: No significant difference • ALH and LCIS: p<0.001 This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

  47. Conclusions ADH, ALH, LCIS, and Borderline DCIS increase a woman’s risk of breast cancer to a similar amount Chemoprevention for all atypia types significantly reduces breast cancer risk at 5 and 10 years Increased use of chemoprevention for patients with atypia will significantly decrease cancer risk This data will be used to create a better model of breast cancer risk prediction based on atypia type and efficacy of chemoprevention San Antonio Breast Cancer Symposium—December 6-10, 2011 This presentation is the intellectual property of the author/presenter. Contact at scoopey@partners.org for permission to reprint and/or distribute.

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