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Introduction

Patients, deemed to be at high risk for the development of breast cancer, are currently referred to medical oncology by their surgeon, family physician or by medical genetics.

Management of these women at increased risk should be a comprehensive approach including a quantitative risk assessment, counseling appropriate to the individual’s risk, the opportunity for genetic testing where appropriate, and a specific plan of medical surveillance and possible pharmaceutical intervention.

A risk assessment is carried out using a tool such as the Gail model (1,2), which takes into account the patient’s own personal medical history, reproductive history, and history of breast cancer among first degree relatives, to help define the individual’s own personal risk. A person determined to have a ≥ 1.66% five year risk of breast cancer is considered high risk according to the Gail model.

The patient may be a genetic carrier of known mutations, such as BRCA1 and BRCA2 (3-5), as well as E-Cadherin gene mutations (6-11) and have already undergone genetic testing or are from families, with well-documented, pedigrees of known genetic carriers. There are also other patients who meet the criteria for high risk status, but may not have had genetic testing, or may not carry these particular mutations. Once the risk assessment is completed, the oncologist will determine whether the risk warrants intervention and if so, will offer the patient chemoprevention either in the form of selective estrogen receptor modulators (SERMs) or aromatase inhibitors.

The potential benefit of using the SERMs, tamoxifen and raloxifene, for chemoprevention would be primarily to help reduce the risk of developing breast cancer in the high risk population. Also, these drugs may have favorable effects on blood lipids and bone density.

The potential risks, though relatively small, include development of endometrial cancers, thromboembolic events and cataract formation, while unpleasant side effects such as a notable increase in hot flashes are known to influence quality of life. Exemestane, an aromatase inhibitor, can also significantly reduce invasive breast cancers in postmenopausal women who are at moderate increased risk, and is associated with no serious side effects and only minimal changes in health-related quality of life (12).

The oncologist will determine if the patient may be a candidate for breast MRI screening, and whether follow-up is required at the cancer center or can be carried out by their referring or family physician.

Question:
What is the optimal chemoprevention management offered to high risk patients?

Target Population:
Patients who meet the high risk criteria for the development of breast cancer.

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Updated Jul 12, 2012