Risk Assessment, Genetics, and Prevention

Transcription

1 Risk Assessment, Genetics, and Prevention Katherine D. Crew, MD MS Director, Clinical Breast Cancer Prevention Program Columbia University Medical Center 1

2 Outline Breast cancer risk factors Hereditary breast cancer genes (BRCA1/2) Benign breast disease Risk-reducing strategies Breast cancer risk assessment in primary care 2

3 Case #1 A 32-year-old premenopausal woman of Ashkenazi Jewish descent has a strong family history of breast and ovarian cancer. Her mother has a positive BRCA2 mutation (6174delT). She had menarche at age 14 and her first child at age 25. She denies OCP use or any breast complaints. MBC 70 AJ Age 8 BC 40s BC 80s BRCA2+ Age 32 Age1 OC 59 BC 60 BRCA2+ AJ BC 20 BC 50s Stomach cancer 3

4 Breast Cancer Risk Factors 5

5 BRCA1/BRCA2 mutations Account for 2-7% of breast cancers, 10-15% of ovarian cancers Prevalence is 1:400 in the general population, 1:40 in Ashkenazi Jews Lifetime risk of breast cancer 40-60%, ovarian cancer 20-40% Pai Cancer 2005 Nelson Ann Intern Med 2005 Risch JNCI 2006 Chen JCO

6 Red Flags for Hereditary Breast and Ovarian Cancer (HBOC) Syndrome NCCN Ovarian cancer Breast cancer, age<45 Bilateral breast cancer Triple negative breast cancer, age<60 Male breast cancer Pancreatic cancer with additional HBOC-associated cancer Ashkenazi Jewish anscenstry with HBOC-associated cancer Previously identified BRCA mutation in the family USPSTF Non-Ashkenazi Jewish: 2 first-degree relatives with breast cancer, 1 diagnosed at age<50 3 or more first/second-degree relatives with breast cancer 2 or more first/second-degree relatives with ovarian cancer Both breast/ovarian cancer among first/second-degree relatives First-degree relative with bilateral breast cancer Male relative with breast cancer Ashkenazi Jewish: any first/second-degree relatives with breast or ovarian cancer USPSTF Ann Intern Med 2005 Bellcross CEBP

7 Possible Genetic Test Results Family member s test results Your test result Your risk stratification Informative positive - BRCA + Informative negative BRCA + BRCA - HIGH RISK AVERAGE RISK Uninformative negative* No known mutation BRCA - MODERATE RISK Variant of Uncertain Significance* No known mutation VUS MODERATE RISK * Testing a family member affected by cancer may help to further define your risk. 8

8 Cancer Risk among BRCA Mutation Carriers Struewing NEJM 1997 Liede JCO 2004 Tai JNCI 2007 Evans J Med Gen 2010 NCI (SEER)

9 Risk Management: Intensive Screening PROCEDURE AGE TO BEGIN FREQUENCY Breast cancer Self breast exam 18 years Monthly Ovarian cancer Clinical breast exam 25 years Every 6-12 months Mammography 25 years Yearly Breast MRI 25 years Yearly Pelvic exam Transvaginal USG and CA years (no BSO) 30 years (no BSO) Every 6 months Every 6 months 10

10 Cancer Risk Reduction (%) Surgical Management: Risk-Reducing Surgeries Hartmann JNCI 2001 Kauff NEJM 2002 Rebbeck NEJM 2002 Rebbeck JCO 2004 Finch JAMA 2006 Rebbeck JNCI 2009 Domchek JAMA 2010 Finch JCO

11 Easton NEJM

12 Case #2 A 63-year-old Hispanic postmenopausal woman has a screening mammogram with heterogeneously dense breasts and new calcifications in the right breast. Core breast biopsy and subsequent excisional biopsy revealed atypical ductal hyperplasia. Her age of menarche was 12 and she has 2 children with her first delivery at 35. She has no family history of breast cancer. According to the Gail model, her 5-year risk of invasive breast cancer is 3.2% and lifetime risk is 14.1%. 13

13 Spectrum of Benign Breast Disease Non-proliferative lesions Proliferative lesions w/o atypia ADH DCIS IDC Epithelial hyperplasia Intraductal papilloma Sclerosing adenosis Radial scar RR Mild ADH Moderate ADH Severe ADH Borderline lesion RR Low grade DCIS Intermediate grade DCIS High grade DCIS RR 10.0 LOBULAR NEOPLASIA Dupont & Page NEJM 1985 Lopez-Garcia Histopathology

14 Estimating Breast Cancer Risk: Gail Model Age 45 Race Hispanic Age of first menstrual period 13 Age of first live birth 30 Number of first-degree relatives with breast cancer 1 Number of breast biopsies 1 Presence of atypical cells Yes 5-Year Risk = 3.6% Lifetime Risk = 28.6% 16

15 Medical Management: Antiestrogens for breast cancer prevention Exemestane Anastrozole Selective estrogen receptor modulators (SERM) Raloxifene 17

16 Rate per 1000 Risks and Benefits of Tamoxifen for Chemoprevention * * * * *P<0.05 BENEFITS RISKS Fisher JNCI

17 Rate per 1000 Risks and Benefits of Tamoxifen for Chemoprevention * *P<0.05 BENEFITS RISKS Fisher JNCI

18 Total # of Cases Long-Term Follow-Up with Tamoxifen for Chemoprevention * Median follow-up of 16 yrs * *P<0.05 * Breast Cancer Endometrial Cancer Cuzick Lancet Oncol

19 Rate per 1000 Tamoxifen vs. Raloxifene for Chemoprevention *P<0.05 * * * * BENEFITS RISKS Vogel Cancer Prev Res

20 Total # of Cases Total # of Cases Risks and Benefits of Aromatase Inhibitors for Chemoprevention Median follow-up of 35 mo *P<0.05 Median follow-up of 5 yrs * * * Goss NEJM 2011 Cuzick Lancet

21 Choice of Chemopreventive Agent Risk Assessment Premenopausal Postmenopausal Tamoxifen History of blood clots No SERM Hysterectomy osteoporosis Tamoxifen > Raloxifene Uterus intact osteoporosis Raloxifene > Tamoxifen Uterus intact No osteoporosis Exemestane or Anastrozole > Raloxifene 23

22 Integration into Clinic Workflow PROVIDERS: BNAV tool High-risk alert to PCP Mammography: Avon Breast Imaging Tablet-based survey High-risk women referred to DA Facilitate shared decision making with patient Facilitate shared decision making with PCP PATIENTS: RealRisks decision aid Primary Care Clinic: ACN/clinics BNAV alert Reinforce health behaviors made by specialist Genetics Clinic: Pre/post-test genetic counseling Breast Clinic: Screening, Risk-reducing surgeries, Chemoprevention, Lifestyle modification Facilitate shared decision making with specialist 24

23 RealRisks decision aid 25

24 RealRisks decision aid 26

25 Narrative of Rose 27

26 Chemoprevention Module 28

27 Chemoprevention Module 29

28 Interactive Games 30

29 Eliciting Patient Preferences 31

30 Action Plan 32

31 BNAV Toolbox for PCPs 33

32 Chemoprevention Toolbox 34

33 Learning Objectives with Slide Presentation 35

34 Videos of Expert Opinions 36

35 Case-Based Learning 37

36 References 38

37 Summary Recent increase in breast cancer incidence, but decreasing mortality due to screening and better treatments Expanding options for risk-appropriate breast cancer prevention strategies Under-utilization of genetic testing and chemoprevention Breast cancer is preventable! 39

38 INTERESTED IN LEARNING MORE ABOUT HOW TO REDUCE BREAST CANCER RISK? 40