Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is the most common cancer in women and the 2nd-leading cause of cancer-related deaths in women in the United States. Early detection and improved pathology-specific treatments have resulted in a decrease in death rates. Several organizations provide recommendations regarding screeningScreeningPreoperative Care for specific age and risk groups. Screenings include breast examinationBreast examinationPhysical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation.Examination of the Breast, mammography, magnetic resonance imaging (MRI), and ultrasound (US).
Breast CancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is a disease characterized by malignant transformationTransformationChange brought about to an organism’s genetic composition by unidirectional transfer (transfection; transduction, genetic; conjugation, genetic, etc.) and incorporation of foreign DNA into prokaryotic or eukaryotic cells by recombination of part or all of that DNA into the cell’s genome.Bacteriology of the epithelial cells of the breast.
Epidemiology
Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer is the most common cancer in women.
Accounts for 29% of all malignant diseases among women in the United States
IncidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency: 125 cases per 100,000 women
Risk increases with age, with 90% of cases occurring in women > 40 years of age
Male breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer accounts for < 1% of total cases.
An important cause of death in women:
United States: the 2nd-leading cause of cancer-related deaths
Developing countries: the leading cause of cancer-related deaths
Early detection and improved treatments have reduced death rates.
Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer in 1st- or 2nd-degree relatives (mother, grandmother, sister)
Ashkenazi Jewish descent
Hormonal influences: long hormone exposure due to early menarcheMenarcheThe first menstrual cycle marked by the initiation of menstruation.Menstrual Cycle and/or late menopauseMenopauseMenopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause
BRCA1(on chromosomeChromosomeIn a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell.Basic Terms of Genetics 17q)
BRCA2 (on chromosomeChromosomeIn a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell.Basic Terms of Genetics 13q)
p53(on chromosomeChromosomeIn a prokaryotic cell or in the nucleus of a eukaryotic cell, a structure consisting of or containing DNA which carries the genetic information essential to the cell.Basic Terms of Genetics 17)
Increasing age
Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer on the contralateral side
Prior breast biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma with:
Dense breastsBreastsThe breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy
History of chest radiationRadiationEmission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles).Osteosarcoma as a young woman (10‒30 years old)
Modifiable risk factors:
Lifestyle factors that increase the risk:
High-fat diet
ObesityObesityObesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity (especially after menopauseMenopauseMenopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause)
Heavy alcohol use
Tobacco
Hormonal influences that increase the risk:
Higher age at 1st delivery (> 30 years of age)
Nulliparity
Hormone replacement therapyHormone Replacement TherapyHormone replacement therapy (HRT) is used to treat symptoms associated with female menopause and in combination to suppress ovulation. Risks and side effects include uterine bleeding, predisposition to cancer, breast tenderness, hyperpigmentation, migraine headaches, hypertension, bloating, and mood changes.Noncontraceptive Estrogen and Progestins after menopauseMenopauseMenopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause (> 5 years)
Hormonal influences that decrease the risk: breastfeedingBreastfeedingBreastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding for at least 6 months
Mnemonics:
“BReast-CACACondylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding.Condylomata Acuminata (Genital Warts)ncer 1 and 2” = Mutated genesGenesA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.DNA Types and Structure are the BRCA1 and BRCA2genesGenesA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.DNA Types and Structure.
Initial risk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care
Details of the patient’s medical and personal history are needed to determine their risk:
Known carrierCarrierVaccination of a gene mutationGene MutationMyotonic Dystrophies for breast or ovarian cancerOvarian cancerOvarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
Mammographic breast density
High-risk lesion on a previous breast biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma
History of chest radiotherapy (age 10 to 30 years)
A patient’s risk for developing breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer can be classified as:
Average:
Have none of the above risk factors (most patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship)
Lifetime risk < 15%
Moderate:
Most women with a family historyFamily HistoryAdult Health Maintenance of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer in a 1st-degree relative, but no known genetic syndrome
Lifetime risk 15%‒20%
High:
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with a known genetic predisposition, a personal history of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, or radiotherapy
Lifetime risk > 20%
Risk prediction models
Prediction models are utilized for specific categorizationCategorizationTypes of Variables of risk, with more factors considered.
Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancerrisk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care tool (Gail model):
The most commonly used risk model
Indicated for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with no personal or strong family historyFamily HistoryAdult Health Maintenance of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Cannot be used in certain subgroups (such as patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with genetic mutationsGenetic MutationsCarcinogenesis)
Other risk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care models are used for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with:
History of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer or in situbreast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Known mutationMutationGenetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations in the BRCA1 or 2genesGenesA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.DNA Types and Structure
Known or suspected inherited syndrome (linked with breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer)
Breast examinationBreast examinationPhysical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation.Examination of the Breast
Can lead to unnecessary procedures (e.g., mammograms and biopsies)
Clinical examination:
Generally not recommended for average-risk women (adjunct only)
Utilized in the case of:
Women with a high risk (initial age differs depending on risk factors)
Any breast complaints or abnormalities
Low-resource settings
Localizing breast lesions:
If there is a vague or large area, then the area may be localized by a quadrant.
If there is a focal area, then the area will be localized by the clock face position and distance from the nippleNippleThe conic organs which usually give outlet to milk from the mammary glands.Examination of the Breast.
Clinical breast examination: localizing breast lesions by quadrant
Image by Lecturio.
Clinical breast examination: localizing breast lesions by clock face position
Image by Lecturio.
Mammography
Mammography is the most effective method of detecting early breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, consistently demonstrating a 20%–40% decrease in mortalityMortalityAll deaths reported in a given population.Measures of Health Status among screened women:
Screen film mammography: mostly replaced by digital mammography in the United States
Digital mammography: preferred for dense breastsBreastsThe breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy (approximately 50% of all women)
Digital breast tomosynthesis (BDT, “3-D mammography”):
Takes images from many angles to obtain a 3-dimensional picture
Improves the sensitivity and specificitySensitivity and SpecificityBinary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition.Epidemiological Values of Diagnostic Tests of mammography
Preferred modality by the American College of Breast Surgeons
Computer-aided detection (CAD) often used: an artificial intelligence (AI) technique that uses pattern recognition to highlight suspicious features and marks the features for the radiologist to review; CAD decreases oversights
The breast imagingBreast ImagingFemale breasts, made of glandular, adipose, and connective tissue, are hormone-sensitive organs that undergo changes along with the menstrual cycle and during pregnancy. Breasts may be affected by various diseases, in which different imaging methods are important to arrive at the correct diagnosis and management. Mammography is used for breast cancer screening and diagnostic evaluation of various breast-related symptoms.Imaging of the Breast reporting and data system (BI-RADS):
Standardizes the mammography report
Indicates categories and corresponding recommendations
ScreeningScreeningPreoperative CaremammogramMammogramFibrocystic Change: performed on a woman with no symptoms or signs of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Management for breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Note: A negative report should not rule out malignancy if there is a high clinical suspicion. Consider
ultrasound follow-up.
Breast cancer screening: a woman undergoing screening mammography
Image: “Mammogram” by the National Cancer Institute. License: Public domain.
Benign findings on a mammogram Screening mammography, right and left mediolateral oblique views, showing sparse, bilateral, punctate vascular (blood-vessel associated/benign) calcifications (BI-RADS 2)
Image: “Fat necrosis associated with the use of oral anticoagulant therapy: Atypical mammographic findings” by Radiologia Brasileira. License: CC BY 4.0, edited by Lecturio.
Mammography is performed for screening and early detection of breast cancer:
Left: mammogram image of normal breast tissue
Right: mammogram image of cancerous breast tissue
Image: “Mammo breast cancer” by National Cancer Institute. License: Public Domain
A mass on screening mammography Image shows a circumscribed mass in the 3 o’clock position of the right breast.
Image: “Cylindroma of the breast: A case report and review of the literature” by Mahmoud A, Hill DH, O’Sullivan MJ, Bennett MW. License: CC BY 2.0.
Magnetic resonance imaging (MRI)
Indicated as supplementary screeningScreeningPreoperative Care along with mammography in women with a high risk of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer:
BRCA1 or 2 mutations
Strong family histories of breast and/or ovarian cancerOvarian cancerOvarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer
History of mantle radiationRadiationEmission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles).Osteosarcoma for Hodgkin’s lymphomaLymphomaA general term for various neoplastic diseases of the lymphoid tissue.Imaging of the Mediastinum
Higher false-positive rates in women with dense breastsBreastsThe breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy, leading to unneeded biopsies
Mammography and breast MRI Image A shows mammography of the left breast in a BRCA1 gene mutation carrier. Note the extremely dense breast tissue. Image B demonstrates an MRI with an enhancing mass (arrow) in the upper left breast that was occult on the mammogram.
Image: “MRI for breast cancer: Current indications” by Ojeda-Fournier H, Comstock CE. License: CC BY 2.0.
Can be considered as an adjunct in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with dense breastsBreastsThe breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy
Evaluating the breast: use of US imaging
Image: “Retroareolar Carcinomas in Breast Ultrasound: Pearls and Pitfalls” by Cancers. License: CC BY 4.0, edited by Lecturio.
Mammography and breast US A: Mammography shows a round, high-density mass in the lower inner quadrant of the right breast. B: Ultrasonography follow-up shows a 1.3-cm irregularly shaped, hypoechoic mass in the breast.
Image: “Secretory breast carcinoma: A report of three cases and a review of the literature” by Lee SG, Jung SP, Lee HY, Kim S, Kim HY, Kim I, Bae JW. License: CC BY 3.0.
Table: Breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast CancerscreeningScreeningPreoperative Care guidelines for average-risk individuals
Organization
Mammography
Clinical breast examinationBreast examinationPhysical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation.Examination of the Breast
USPSTF
Age 40–49: individualize*
Age 50–74: every 2 years
Age > 75: insufficient evidence
Insufficient evidence
ACP
Age 40–49: individualize*
Age 50–74: every 2 years
Age ≥ 75: Discontinue screeningScreeningPreoperative Care if life expectancyLife expectancyBased on known statistical data, the number of years which any person of a given age may reasonably expected to live.Population Pyramids is < 10 years.
Not recommended
ACS
May offer at age 40; start at age 45.
Age 45–54: annually
Age 55 and above: every 1–2 years
Continue if life expectancyLife expectancyBased on known statistical data, the number of years which any person of a given age may reasonably expected to live.Population Pyramids is ≥ 10 years.
Not recommended
ACOG
May offer at age 40.
Start no later than age 50: every 1–2 years.
Age > 75: Assess health, longevity, and discontinuation options.
Age 29–39: every 1–3 years
Age ≥ 40: annually
NCCN
Age ≥ 40: annually
Age 20–39: every 1–3 years
Age ≥ 40: annually
*Discuss breast cancer screening, risks, benefits, and potential for unnecessary procedures. For patients who choose to
initiate screening, mammography is performed every 1‒2 years.
ACOG: American College of Obstetricians and Gynecologists
ACP: American College of Physicians
ACS: American Cancer Society
NCCN: National Comprehensive Cancer Network
USPSTF: U.S. Preventive Services Task Force
Moderate risk
A similar approach to average-risk patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship
ScreeningScreeningPreoperative Care and genetic testingGenetic TestingDetection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing.Myotonic Dystrophies
Recommendations:
Clinical breast exam: every 6–12 months by age 25 years (initiation and frequency depend on risk)
Annual mammogramMammogramFibrocystic Change (starts at age 30) and MRI (starts at age 25): for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with BRCA1 or 2 mutations
1st-degree relative with known BRCA1 or 2 mutations
> 20% lifetime risk of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with radiationRadiationEmission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles).Osteosarcoma therapy to the chest at 10–30 years of age
Genetic counselingGenetic CounselingAn educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered.Myotonic Dystrophies and testing(USPSTF):
Familial risk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care tools are recommended for women with the following:
Familial risk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care tools include:
Ontario family historyFamily HistoryAdult Health Maintenancerisk assessmentRisk assessmentThe qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences.Preoperative Care tool
PedigreePedigreeThe record of descent or ancestry, particularly of a particular condition or trait, indicating individual family members, their relationships, and their status with respect to the trait or condition.Basic Terms of Genetics assessment tool
International breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer intervention study model
BRCAPRO (calculates the probabilityProbabilityProbability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially.Basics of Probability of carrying BRCA1 and/or BRCA2mutationMutationGenetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations)
Positive resultsshould lead to genetic counselingGenetic CounselingAn educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered.Myotonic Dystrophies and potential genetic testingGenetic TestingDetection of a mutation; genotype; karyotype; or specific alleles associated with genetic traits, heritable diseases, or predisposition to a disease, or that may lead to the disease in descendants. It includes prenatal genetic testing.Myotonic Dystrophies.
For women without a personal or family historyFamily HistoryAdult Health Maintenance or ancestry associated with BRCA1 or 2: genetic counselingGenetic CounselingAn educational process that provides information and advice to individuals or families about a genetic condition that may affect them. The purpose is to help individuals make informed decisions about marriage, reproduction, and other health management issues based on information about the genetic disease, the available diagnostic tests, and management programs. Psychosocial support is usually offered.Myotonic Dystrophies and testing are not recommended.
SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases cessation
There is no evidence that dietary changes reduce risk.
Chemoprevention:
USPSTF: Risk-reducing medications recommended for high-risk women age ≥ 35 years (for a total of 5 years).
Considered in women at a high risk of breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
TamoxifenTamoxifenOne of the selective estrogen receptor modulators with tissue-specific activities. Tamoxifen acts as an anti-estrogen (inhibiting agent) in the mammary tissue, but as an estrogen (stimulating agent) in cholesterol metabolism, bone density, and cell proliferation in the endometrium.Antiestrogens:
Selective estrogenEstrogenCompounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds.Ovaries: AnatomyreceptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors modulator
RaloxifeneRaloxifeneA second generation selective estrogen receptor modulator (SERM) used to prevent osteoporosis in postmenopausal women. It has estrogen agonist effects on bone and cholesterol metabolism but behaves as a complete estrogen antagonist on mammary gland and uterine tissue.Other Antiresorptive Drugs:
Selective estrogenEstrogenCompounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds.Ovaries: AnatomyreceptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors modulator
Used for breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer prevention as well as treatment of osteoporosisOsteoporosisOsteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis
Lower risk of thromboembolic events and endometrial cancerEndometrial CancerEndometrial carcinoma (EC) is the most common gynecologic malignancy in the developed world, and it has several histologic types. Endometrioid carcinoma (known as type 1 EC) typically develops from atypical endometrial hyperplasia, is hormonally responsive, and carries a favorable prognosis.Endometrial Hyperplasia and Endometrial Cancer compared to tamoxifenTamoxifenOne of the selective estrogen receptor modulators with tissue-specific activities. Tamoxifen acts as an anti-estrogen (inhibiting agent) in the mammary tissue, but as an estrogen (stimulating agent) in cholesterol metabolism, bone density, and cell proliferation in the endometrium.Antiestrogens
Used in postmenopausal women
Aromatase inhibitorsAromatase inhibitorsCompounds that inhibit aromatase in order to reduce production of estrogenic steroid hormones.Antiestrogens:
Medications: anastrozoleAnastrozoleA nitrile and triazole derivative that acts as a selective nonsteroidal aromatase inhibitor. It is used in the treatment of estrogen nuclear receptor-positive breast cancer in postmenopausal women.Antiestrogens and exemestaneExemestaneAntiestrogens
Used in postmenopausal women
Carries risk of decreased boneBoneBone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types density
Women should be counseled on the potential morbidityMorbidityThe proportion of patients with a particular disease during a given year per given unit of population.Measures of Health Status of surgical procedures (surgical menopauseSurgical MenopauseMenopause, libido, body image).
Other genetic mutationsGenetic MutationsCarcinogenesis that carry a greater lifetime risk for developing breast cancerBreast cancerBreast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Does not completely eliminate the risk of cancer
May be done in conjunction with salpingo-oophorectomy to reduce ovarian cancerOvarian cancerOvarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer risk
Screening for Special Populations
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with dense breast tissue
If there are no additional risk factors, no supplemental screeningScreeningPreoperative Care is recommended.
MRI or US may be used as an adjunct in moderate- or high-risk patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship.
Male BRCAcarriersCarriersThe Cell: Cell Membrane have a higher risk for breast, prostateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid., and pancreatic cancers:
Monthly breast self-examination starting at age 35
Annual clinical breast exam starting at age 35
Annual mammography can be considered in men with gynecomastiaGynecomastiaGynecomastia is a benign proliferation of male breast glandular ductal tissue, usually bilateral, caused by increased estrogen activity, decreased testosterone activity, or medications. The condition is common and physiological in neonates, adolescent boys, and elderly men. Gynecomastia or increased breast density (evidence is limited).
ProstateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer screeningScreeningPreoperative Care starting at age 40 for BRCA2carriersCarriersThe Cell: Cell Membrane
Consideration of prostateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid.screeningScreeningPreoperative Care starting at age 40 for BRCA1carriersCarriersThe Cell: Cell Membrane
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with breast implants:
Make mammography difficult (radiopaqueRadiopaqueAn object of high density that blocks X-rays (looks white)X-rays content)
Involves 4 views (instead of the usual 2 views per breast)
Ibrahim, M., Yadav, S., Ogunleye, F., & Zakalik, D. (2018). Male BRCA mutation carriers: Clinical characteristics and cancer spectrum. BMC Cancer, 18. https://doi.org/10.1186/s12885-018-4098-y