Do your patients need more intensive breast cancer screening?
Breast cancer risk assessment is very important for identifying women who may benefit from more intensive breast cancer surveillance; however, there is no standardized approach to office-based breast cancer risk assessment in the United States. This can lead to missed opportunities to identify women at high risk of breast cancer and may result in applying average-risk screening recommendations to high-risk women.
Breast Cancer Surveillance
University of Vermont Medical Center Marie Wood, MD, Director, Familial Cancer Program
Risk assessment allows for identification of women at moderate and high risk for breast cancer. Screening and prevention options can then be tailored to that risk. Women with a personal or family history of breast cancer, especially early onset breast cancer (diagnosed prior to age 50), may be referred to health care providers with expertise in cancer genetics counseling and testing for breast cancer-related germline mutations (eg, BRCA1 or BRCA2), counseling about risk-reduction options, and cascade testing to identify family members who also may be at increased risk.
Health care providers periodically should assess breast cancer risk by reviewing the patient's history.
Assessments can be conducted with one of the validated assessment tools available online, such as the tool below:
When a woman does not meet any of the familial risk criteria or tests negative for a genetic predisposition she may still have additional factors that increase her risk for breast cancer such as the following:
>Increasing age
>Ethnicity/race
(For example, Ashkenazi Jewish decent).
>Increased body mass index (BMI)
>Alcohol consumption
>Current or prior estrogen and progesterone hormone therapy
>Younger age at menarche
Nulliparity/Lower parity
>Older age at first live birth
>Older age at menopause
>History of lobular carcinoma in situ (LCIS)
>Atypical hyperplasia (ductal and lobular)
>Flat epithelial atypia
>Number of prior breast biopsies
(Procedure done with the intent to diagnose cancer; multiple biopsies (needle/ excision) of the same lesion are scored as one biopsy)
Breast Cancer Susceptibility Gene (BRCA) Screening
In 2013, the
US Preventive Services Task Force (USPSTF) reaffirmed their 2005 recommendation that primary care
providers use family health history information as a screen to identify women who may have an increased risk for hereditary breast cancer (i.e. harmful mutations in the BRCA1 or BRCA2 genes). Women who meet criteria should be referred for genetic counseling and, if indicated after counseling, genetic testing for hereditary breast cancer. Of importance, genetic counseling, if appropriate, is covered by Ladies First plus without cost sharing by many health plans under the Affordable Care Act when used in accordance with the USPSTF recommendation. And the Department of Health and Human Services has advised insurance companies to cover genetic testing without cost sharing in accordance with the USPSTF recommendations.
Breast Cancer Susceptibility Gene (BRCA) Screening Tool
Screening tools are available to help primary care providers identify women at risk.The USPSTF has now evaluated several screening tools to assist primary care providers with collecting and evaluating family health history information to determine the need for in-depth genetic counseling. Below is the easiest tool:
Counseling. The USPSTF indicates that genetic counseling for heredity breast cancer may be done by trained health professionals, including primary care providers who have the requisite skills and specialized training needed to provide comprehensive genetic counseling. Professional organizations and specialty groups provide accreditation standards and guidance. Comprehensive counseling includes pretest counseling (involving detailed family history analysis and risk assessment for potentially harmful mutations), education about the possible implications of genetic testing, identification of affected family members who may be preferred candidates for testing (and outlining options for interventions for appropriate patients), and post-test counseling for interpretation of genetic test results.
