Kevin S.Hughes, MD, FACSCo-Director, Avon Comprehensive Breast Evaluation Center

Massachusetts General Hospital

SurgeonThe Newton-Wellesley Hospital Breast Center

Identification and Management of Women at High Risk of Breast Cancer

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

ACS MRI Guidelines

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

10,000 4/1/2006 to 9/17/2007

7,821

NULL or No Never

HORMONES

6,981

W/ Gail Score

6,028W/ BRCAPRO Lifetime

5,894W/ BRCAPRO Mutation and Tyrer-Cuzick

LCIS/AH status not available

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

ACS Guidelines

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

•BRCAPRO

•Tyrer-Cuzick

•Claus

•Gail

ACS Guidelines

• Claus• Breast FH

•BRCAPRO• Breast and ovarian FH

•Tyrer-Cuzick• Breast and ovarian FH

• Pathologic factors

• Hormonal factors

Tyrer-Cuzick= 330 (5.6%)

276

BRCAPRO = 25 (0.4%)

Claus = 54 (0.9%)

10 2

3113

0

10

Lifetime Breast Cancer Risk 20% or greater by Model

20 to 25% LT Risk of…What?

• Invasive cancer– BRCAPRO

• Invasive plus DCIS– Claus– Tyrer-Cuzick

Tyrer-Cuzick= 330(5.6%)

263

Claus = 54(0.9%)

23 19

2618

1

9

Lifetime Breast Cancer Risk 20% or greater by Model

Adjusted BRCAPRO 61 (1%)

ACS MRI Guidelines

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

LCIS/AH

•20% or greater lifetime risk–Any LCIS

•age 69 and below

–Any AH •age 56 and below

Tyrer Cuzick for AH & LCIS

Even more with even trivial risk factors

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

Better Strategy

• Identify mutation carriers (genetic testing)

– MRI for those with mutation (selective MRI)– Offer ALL risk reducing strategies

•Oophorectomy•Prophylactic mastectomy•MRI•Mammography

Avon Comprehensive Breast Center Database

• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all

Avon Comprehensive Breast Center Database

Lifetime risk ≥20% 78 (0.4%)

• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all

Avon Comprehensive Breast Center Database

Lifetime risk ≥20% 78 (0.4%)

Predicted Mutation Carriers 27

BRCAPRO

• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all

Avon Comprehensive Breast Center Database

374 (2.1%)Mutation Risk ≥10%

Lifetime Risk <20%and

• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all

Avon Comprehensive Breast Center Database

374 (2.1%)

Predicted Mutation Carriers 62

BRCAPRO

Mutation Risk ≥10%

Lifetime Risk <20%and

• 18,190 screening mammogram patients 40 or older– (May 2003 – July 2005)– BRCAPRO run on all

MGH Screening Data: All Comers

Risk of Mutation

Risk of Breast Cancer

n

Mean Probabilit

y of Mutation

Projected #

Mutation Carriers

≥10% ≥20% 78 0.34 27

≥10% <20% 374 0.17 62

What to do

• ≥10% risk of mutation– Genetic testing

•Positive-Manage with all modalities•Negative-Your call

– Based on FH

Options for high risk

Prophylactic Oophorectomy

Screening

Chemoprevention

Options for high risk

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?

Kshughes@Partners.org

www.HughesRiskApps.net