Breast Cancer Risk Assessment: Genetics, Risk Models, and Screening. Amie Hass, MSN, ARNP, FNP-BC Hall-Perrine Cancer Center
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1 Breast Cancer Risk Assessment: Genetics, Risk Models, and Screening Amie Hass, MSN, ARNP, FNP-BC Hall-Perrine Cancer Center
2 Disclosure- I DO NOT HAVE any relevant financial interest with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients, this does not include providers of clinical services directly to patients.
3 Guidelines for Cancer Genetic Assessment National Comprehensive Cancer Network (NCCN) Breast and/or Ovarian Cancer Genetic Assessment (Version ) Available online and iphone app (NCCN Guidelines for Smartphone) Last updated 10/2017 Updated 3 times in 2017 American College of Medical Genetics and Genomics National Society of Genetic Counselors A practice guideline from the American College of Medical Genetics and Genomics and the National Society of Genetic Counselors: referral indications for cancer predisposition assessment Publication available online:
4 National Comprehensive Cancer Network Guidelines (NCCN) Version Breast and/or Ovarian Genetic Assessment (not an inclusive list): Close blood relative: includes- first-; second-; and third-degree relatives Known mutation in a cancer gene within the family (any gene mutation) Diagnosis of ovarian cancer (personal history or close relative with history of) Diagnosis of breast cancer- early age onset (<45 years) Diagnosis of two breast primaries (synchronous or asynchronous) Diagnosis of metastatic prostate cancer radiographic evidence or biopsy-proven (new indication- on 2017 updated guideline) Breast cancer diagnosis at any age and >1 close relative with breast cancer <50 years >1 close relative with invasive ovarian cancer at any age >2 close relatives with breast cancer, prostate cancer (metastatic or Gleason score >7) and/or pancreatic cancer at any age Pancreatic cancer at any age From a population at increased risk (founder mutations of Ashkenazi Jewish population) National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version ). Accessed
5 National Comprehensive Cancer Network Guidelines (NCCN) Version An individual with no personal history of cancer but with: A close relative with any of the following: A known mutation in a cancer susceptibility gene within the family >2 breast cancer primaries in a single individual >2 individuals with breast cancer primaries on the same side of the family with at least one diagnosed <50 years Ovarian cancer Male breast cancer First- or second-degree relative with breast cancer diagnosed <45 years National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version ). Accessed
6 National Comprehensive Cancer Network Guidelines (NCCN) Version An individual with a personal and/or family history of three or more of the following (especially if diagnosed age <50 years and can have multiple primary cancers in the same individual): Breast cancer Pancreatic cancer Prostate cancer (Gleason score >7 or metastatic) Melanoma Sarcoma Adrenocortical carcinoma Brain tumors Leukemia Diffuse gastric cancer (lobular breast cancer) Colon cancer Endometrial cancer Thyroid cancer (Follicular and/or multifocal) Kidney cancer (multifocal) Dermatological manifestations (Cowden syndrome) Macrocephaly (58 cm in adult women and 60 cm in adult men) Hamartomatous polyps of GI tract National Comprehensive Cancer Network. Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version ). Accessed
7 Fewer than 2 first- or seconddegree female relatives surviving past age 45 years Limited Family Structure
8 Family Medical History Importance of obtaining family history Need more information than Is there a family history of breast cancer? Three generational history preferred Patient s children, siblings, parents, aunts, uncles, and grandparents Maternal AND Paternal sides of the family Family ancestry (Ashkenazi Jewish descent) Detailed family history Type of cancer Age of diagnosis Unilateral or bilateral cancer Challenges of obtaining family history Many Tools to gather family history EPIC/myChart forms Paper forms FORCE printable: (
9 FORCE Family History Form
10 Who to refer for cancer risk assessment: Personal history or family history of: Early age onset cancer (eg. breast under age 45) More than one primary cancer in an individual (bilateral breast cancer) Cancers occurring in multiple generations on the same side of the family Cluster of cancers consistent with specific cancer syndromes (eg. breast with ovarian; colon with endometrial; pancreatic with melanoma) Rare cancers with or without additional cancers in a family (retinoblastoma; adrenocortical carcinomas) Unusual presentation of cancer (male breast cancer) Uncommon tumor histology (medullary thyroid cancer) Geographic or ethnic populations known to be at risk due to founder effect (Ashkenazi Jewish heritage)
11 Ambulatory referral to Genetic Counseling: Internal EPIC Referral:
12 Breast Cancer Risk Assessment Breast Cancer Risk Models: Gail Model BRCAPRO Claus Model Tyrer-Cuzick Model (IBIS)
13 Breast Cancer Risk Assessment Gail Model: A computerized tool that estimates a woman s 5 year and lifetime risk of developing breast cancer to age 90 Also called the National Cancer Institute (NCI) Breast Cancer Risk Assessment Tool. (NIH Turning Discovery Into Health, 2016) Not to used for women with breast cancer history (Invasive or DCIS) or history of LCIS Does not take into account paternal family history Inputs: mostly non-genetic risk factors (11 data points) Age Race (white, African American, Hispanic, Asian American, Native American or Alaska Native) with sub race Ages at menarche and first live birth First degree relatives with breast cancer Previous breast biopsy Takes into account AH but not LCIS Culver, J., Lowstuter, K. & Bowling, L. (2006, 2007). Assessing Breast Cancer Risk and BRCA1/2 Carrier Probability. Breast Disease. 27, 5-20.
14 Breast Cancer Risk Assessment BRCAPRO Estimates for breast and ovarian cancer based on the likelihood that a person carries a BRCA1/2 mutation 5 year risk and lifetime risk to age 85 Located through U.T. Southwestern Medical Center (CancerGene) th/cagene/ Risk estimates tend to be much lower than other models Inputs Both affected and unaffected individuals up to second degree relatives Breast and ovarian cancer history Male breast cancer Bilateral breast cancer Breast pathology (invasive vs DCIS) Oophorectomy status Ethnicity (white, black, Hispanic, Asian, Native American) Data entry- enter pedigree and numerous data points Does not account for: Non-hereditary risk factors Non-BRCA1/2 risk elements (will underestimate risk in breast-cancer only families) Culver, J., Lowstuter, K. & Bowling, L. (2006, 2007). Assessing Breast Cancer Risk and BRCA1/2 Carrier Probability. Breast Disease. 27, 5-20.
15 Breast Cancer Risk Assessment Claus Model A risk model for familial risk of breast cancer in a large population-based, case-control study conducted by the Centers for Disease Control Based on data from the Cancer and Steroid Hormone Study (4,730 cases and 4,688 controls aged years). 5 year risk and lifetime risk to age 79 iphone app: BRisk (City of Hope) Provides age-specific risk estimates of breast cancer in women with a family history. Inputs Incorporates maternal and/or paternal 1 st and 2 nd degree relatives and adjusts risk based on age at diagnosis. Easy to use iphone app Does not incorporate: Family size Ethnic background Non-genetic risk factors More than two affected family members Culver, J., Lowstuter, K. & Bowling, L. (2006, 2007). Assessing Breast Cancer Risk and BRCA1/2 Carrier Probability. Breast Disease. 27, 5-20.
16 Breast Cancer Risk Assessment Tyrer-Cuzick Model (Version 8) Incorporates probability of BRCA1/2 mutation, the likelihood of a low penetrance gene mutation, and personal risk factors. Available at (download program): 5 year and lifetime risk for breast cancer to age 80 Tends to be the highest estimated risk of breast cancer User friendly printable output Inputs (18+ data points) Age Age at menarche Parity Age at first livebirth Age at menopause History of Atypical hyperplasia or LCIS Height Weight Family history Age of family members Age of diagnosis of affected family members Number of paternal and maternal aunts Number of sisters Number of daughters Affected male family members and cousins Culver, J., Lowstuter, K. & Bowling, L. (2006, 2007). Assessing Breast Cancer Risk and BRCA1/2 Carrier Probability. Breast Disease. 27, 5-20.
17 34 y/o femalepremenopausal (Mirena IUD), nulliparous Unaffected by cancer Mammogram: 12/2017- baseline- extreme breast density; BIRADS 1-negative Family history: Mother- age 45 Maternal aunt- age 48 Maternal grandmother- age 56 Limited Paternal Structure Genetic testing of affected family members Case Study#1
18 Tyrer-Cuzick Model Version 8: Input Case Study #1
19 Tyrer-Cuzick Model Version 8: Output Case Study#1
20 Gail Model: 0.5% 5 year risk and 19.1% lifetime risk Claus Model: 1.7% 5 year risk and 31.8% lifetime risk BRCAPRO: 0.5% 5 year risk and 13.6% lifetime risk Case Study #1
21 National Comprehensive Cancer Network Guidelines (NCCN) Breast Cancer Screening and Diagnosis (Version ) Women who have a lifetime risk >20% as defined by models that are largely dependent on family history: Clinical encounter every 6-12 months To begin when identified as being at increased risk Referral to genetic counseling Annual screening mammogram To begin 10 years prior to the youngest family member but not less than 30 years Consider tomosynthesis Recommend annual breast MRI To begin 10 years prior to the youngest family member but not less than age 25 years Consider risk reduction strategies Breast awareness National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis (Version ). Accessed
22 Case Study #1 Discuss risk tolerance regarding breast cancer risk Recommendations: Await genetic test results of affected family member (aunt); mother declined If positive- consider genetic testing for known gene mutation or panel test If negative- consider genetic testing using gene panel Consider implications of genetic testing Breast cancer screening Clinical encounter every 6-12 months Annual mammogram- encouraged use of 3D mammogram Recommend annual breast MRI Discussed benefits and limitations of breast MRI Most research based on BRCA mutation carriers Benefit: earlier stage of breast cancer; additional screening tool; breast density Limitations: high sensitivity and low specificity (higher false-positive findings); impact on survival not established; cost (EFY funds); can not detect microcalcifications; IV contrast; tolerance of MRI
23 42 y/o female unaffected by cancer Premenopausal- on OCP for menorrhagia- referred by GYN- considering hyst Last mammogram in 2015 (seen in 1/2017)- followup with US and breast MRI for cysts/fibrocystic changes Family history: Mother age 45 Maternal grandmother age 48 No family members had genetic testing Case Study #2
24 Case Study #2 Patient decided to proceed with genetic testing.
25 Case Study #2 Patient elected to have: Bilateral risk reduction mastectomy with immediate reconstruction Bilateral risk reduction slapingooophorectomy with hysterectomy Cascade testing for family members: Father tested negative Sister and maternal family members
26 High Penetrance vs Moderate Penetrance Gene Mutations Penetrance of Gene Mutations: High risk vs moderate risk Informative genetic test results Clinical utility Actionable results Evolution of genetics
27 54 y/o female- unaffected by cancer Post-menopausal Last mammogram: 1/2018 BIRADS: 1 negative with heterogeneous breast density Family history: Sister: age 49 Mother: age 50 MGM: age 70 2 maternal aunts: age 58 and 48 No family members have had genetic testing Case Study #3
28 Case Study #3
29 Tyrer-Cuzick (version 8.0) No breast density indicated Lifetime risk: 19.5% Case Study #3
30 Case Study #3 Tyrer-Cuzick (version 8) Extreme breast density: Lifetime risk: 29% Heterogeneous breast density: Lifetime risk: 20.4%
31 Gail Model: 5.4% 5 year risk and 33.8% lifetime risk Claus Model: 4.2% 5 year risk and 17.8% lifetime risk BRCAPRO: 1.5% year risk and 10.2% lifetime risk Case Study #3
32 Case Study #3 Patient elected to proceed with genetic testing. Genetic test results: Recommendations: Uninformative genetic test results (variants of uncertain significance) Discuss risk tolerance regarding risk for breast cancer Manage breast cancer risk based upon family history (over 20% lifetime risk for breast cancer) Breast cancer screening Clinical encounter every 6-12 months Annual mammogram- encouraged use of 3D mammogram Recommend annual breast MRI
33 Genetic Testing Commercial laboratories perform test and interpretation (positive, negative, VUS) Covered by most health insurance if patient meets genetic testing criteria for BRCA1/2 Medicare will not pay for genetic testing if not affected by cancer Majority of patients pay $0 (80%) Affordable options for pre-payment (not submitted to insurance) $ for gene panel test No cost for cancer risk assessment and genetic counseling at Mercy Medical Center/ Hall-Perrine Cancer Center
34 Summary: Identifying patients for cancer risk assessment/ genetic testing Young age diagnosis <45-50 years Ovarian cancer Two primary breast cancers Male breast cancer Family history of three or more cancers associated with hereditary breast and ovarian cancer Breast Cancer Risk Assessment Models All models are not created equal Wide range of breast cancer risk based on family history and model used for calculation Breast Cancer Screening Greater than 20% lifetime risk calculated using breast cancer risk model Individualized tolerance of breast cancer risk varies Annual mammogram and breast MRI- benefits and limitations
35
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