Introduction
BRCA associated breast cancer: the Jolie effect
NICE discovers chemoprevention
Risk similar to the general population | Moderate risk | High riska
| |
---|---|---|---|
Lifetime risk after 20 years old | <17 % | More than 17 % but <30 % | 30 % or over |
Risk between 40 and 50 years old | <3 % | 3–8 % | More than 8 % |
ASCO (mainly) and the US Preventive Services Task Force (USPSTF) reinforce their message about prevention in breast cancer
ASCO (ref. [25]) | USPTF (ref. [19]) | NICE (ref. [8]) | |
---|---|---|---|
Agent | |||
Tamoxifen | Premenopausal women ≥35 years old with a 5-year projected absolute BC risk ≥1.66 % or with LCIS | Premenopausal women aged ≥35 years who are at increased risk for breast cancer without a prior diagnosis of breast cancer, DCIS or LCIS | Offer to premenopausal women at high risk of breast cancer Consider for premenopausal women at moderate risk of breast cancer |
Postmenopausal women ≥35 years with a 5-year projected absolute BC risk ≥1.66 % or with LCIS | Postmenopausal women aged ≥35 years who are at increased risk for breast cancer without a prior diagnosis of breast cancer, DCIS or LCIS | Offer to postmenopausal women with or without a uterus and at high risk of breast cancer Consider for postmenopausal women with or without a uterus and at moderate risk of breast cancer | |
Not recommended if history of deep vein thrombosis, pulmonary embolus, stroke, or transient ischemic attack or during prolonged immobilisation | Not to be used in women with a history of thromboembolic events (deep venous thrombosis, pulmonary embolus, stroke, or transient ischemic attack) | Not recommended if they have a past history or may be at increased risk of thromboembolic disease or endometrial cancer or bilateral mastectomy | |
Not recommended in combination with hormone therapy | |||
Not recommended for pregnant women, women who may become pregnant, or nursing mothers | Not recommended for pregnant women, women who may become pregnant, or nursing mothers | ||
Raloxifene | Postmenopausal women who are ≥35 years old with a 5-year projected absolute BC risk ≥1.66 % or with LCIS | Postmenopausal women aged ≥35 years who are at increased risk for breast cancer without a prior diagnosis of breast cancer, DCIS or LCIS | Offer to postmenopausal women with a uterus and at high risk of breast cancer Consider for postmenopausal women with a uterus and at moderate risk of breast cancer |
Should not be used for BC risk reduction in premenopausal women | |||
Not recommended if history of deep vein thrombosis, pulmonary embolus, stroke, or transient ischemic attack or during prolonged immobilisation | Not to be used in women with a history of thromboembolic events (deep venous thrombosis, pulmonary embolus, stroke, or transient ischemic attack) | Not recommended if they have a past history or may be at increased risk of thromboembolic disease or endometrial cancer or bilateral mastectomy | |
Exemestane | Alternative in postmenopausal women ≥35 years old with a 5-year projected absolute BC risk ≥1.66 % or with LCIS or atypical hyperplasia | Not included | Not included |
Should not be used for BC risk reduction in premenopausal women | |||
Anastrozole | Not included | Not included | Not included |
ALL | Risks and benefits of each agent in the preventive setting specifically should be discussed prior to prescription | Engage in shared, informed decision For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene | |
Minimum breast cancer risk required | For tamoxifen and raloxifene, a 5-year projected absolute BC risk ≥1.66 % or with LCIS | Estimated 5-year breast cancer risk of 3 % or greater | High risk: lifetime risk of 30 % or greater; risk of >8 % in between age 40 and 50 years |
For exemestane, a 5-year projected absolute BC risk ≥1.66 % or LCIS or atypical hyperplasia | Moderate risk: lifetime risk of 17 % but <30 %; a risk of 3–8 % between age 40 and 50 years |
Method | Main features | Used in |
---|---|---|
The Gail 2 model or Breast Cancer Risk Assessment Tool (ref. [12]; can be accessed at www.cancer.gov/bcrisktool) | It estimates the absolute risk of developing breast cancer in the next 5 years based on: age, age at menarche, age of first birth, family history of breast cancer in first degree relatives, number of previous breast biopsies, and history of atypical hyperplasia | NSABP-1 [9] STAR [11] MAP.3 [24] |
The Tyrer-Cuzick model (ref. [13]; can be downloaded at http://www.ems-trials.org/riskevaluator/) | It estimates the risk taking into account family history, hormonal and benign disease history, age, BMI and genetic factors (including BRCA) creating a single statistical model | IBIS-II [30] |