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Breast Care Risk Assessment and Recommendations

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kc_bca2014_riskassess

Breast Care Risk Assessment and Recommendations

Related to: Ambulatory, Clinical Guidelines, Diagnosis, Primary Care, Other Specialties

Patients with a genetic predisposition to breast cancer 

Recommendations 

  • Known carrier of a BRCA1 or BRCA2 mutation, or close relative with known mutation
  • Known carrier or close relative with another hereditary breast cancer syndrome gene b

Beginning at age 25, clinical breast exam (CBE) at least once per year. a


Annual mammogram and MRI beginning at age 25 or individualized based on earliest age onset in family. Preliminary data suggest that alternating MRI and mammography every six months may be helpful.

Genetic Testing Criteria for Patients Without a Known Genetic Predisposition to Breast Cancer

 Recommendations

 Personal history

  • Breast cancer diagnosed at age ≤40
  • Ovarian cancer at any age

Family history

  • Breast cancer (or DCIS) at age ≤40 or ovarian cancer (any age) in 1st degree relative, or in paternal 2nd degree relative
  • Breast cancer (or DCIS) and ovarian cancer in one 1st or 2nd degree relative, or in close relatives in the same lineage
  • Male relative(s) with breast cancer
  • Any 1st or 2nd degree relative with breast cancer age <50
  • Two relatives in the same lineage with early onset breast cancer
  • Women of Ashkenazi Jewish ancestry may be included despite fewer affected relatives or later age onset

These criteria should prompt consideration of genetic testing.

  • Women who test positive should follow the recommendations above.
  • Women in a family with a known mutation who test negative are true negative and should follow the recommendations for patients at usual risk (below).
  • Women without a known mutation in the family who test negative should be referred to a genetics center. If possible, genetic testing should be performed with a genetic counselor or genetics expert.

Therapeutic thoracic radiation (e.g. Hodgkins) before age 30 c

  • Annual mammogram beginning 8–10 years after radiation or at age 25.
  • Consider CBE at least once per year beginning at age 25.
  • Consider annual MRI in addition to annual mammogram.

 Histology

  • Lobular carcinoma in situ (LCIS) 
  • History of ductal carcinoma in situ (DCIS)
  • History of invasive breast cancer
  • Atypical ductal or lobular hyperplasia (ADH or ALH) (consider using the Gail Model for risk assessment)
  • Annual mammogram after diagnosis.
  • CBE at least once per year.
  • Consider referral to high-risk counseling or risk reducing medication.

Reproductive and other risk factors

  • Menarche before age 12
  • Nulliparity
  • First birth after age 30
  • Prior breast biopsy
  • >5 years of combined estrogen /progesterone hormone replacement therapy
  • For a patient age ≥35 with a constellation of these risk factors, consider assessment via the Gail Model to determine her level of risk for breast cancer.
  • For patients with Gail Model five-year risk ≥1.67: CBE at least once per year, annual mammogram, consider high-risk counseling or risk reducing medication. d

Patients at Usual Risk

Recommendations

None of the above risk factors, or a Gail Model value <1.67

  • Annual mammogram, beginning at age 40. e,f
  • Consider CBE every 1–3 years until age 40, then annually.

Gail Model (for women age ≥35) 

The Gail Model calculates actuarial estimates of future breast cancer risk based on race, age, reproductive risk factors, maternal family history, and previous biopsy status. The computerized version of the Gail Model is available at: www.cancer.gov/bcrisktool. The Gail Model calculates the risk of developing cancer over the next five years. The Gail Model may underestimate the risk for patients with a strong family history of breast or ovarian cancer.

Notes

  1. The efficacy of clinical breast exams (CBEs) has not been evaluated independent of mammography. Clinicians might, however, consider a periodic CBE as an opportunity to engage their patients in discussion about overall breast evaluation.
  2. Li-Fraumeni syndrome, Cowden’s disease, Peutz-Jeghers syndrome, hereditary diffuse gastric cancer, other.
  3. Risk from therapeutic radiation is much greater than risk from diagnostic radiation. The risk from infant thymus radiation, fluoroscopy for TB, or multiple X-rays for scoliosis is not well quantified.
  4. Patient may also be eligible for risk reducing clinical trials.
  5. Screening recommendations for patients at usual risk vary among experts. The CRICO Breast Care Management Algorithm recommendations are based on the 2013 NCCN Guidelines.
  6. The decision to start regular, biennial screening mammography before age 50 should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms. (USPSTF)

March 2, 2014
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