Breast Cancer: High Risk Screening
Guest: Dr. Megan Baker – Surgical Oncology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Megan Baker who is Medical Director of the Breast Program at Hollings Cancer Center here at the MUSC. Dr. Baker, I know you are very passionate about our high risk screening program. Who is at high risk for getting breast cancer?
Dr. Megan Baker: There are many different ways to identify if someone is at high risk for breast cancer. All women are at risk for breast cancer, and we should never forget that men are also at risk for breast cancer. Although, on an annual basis, only on percent of all breast cancers occur in men. Nonetheless, there are some people that are at higher risk than average. Typically, that type of risk is defined by known family history. So, if you look at a patient whose mother, sister or children have breast cancer, they are at higher risk themselves.
We also need to be careful not to exclude other family members. So, when I ask patients who in your family has had breast cancer, that includes grandparents, great aunts and uncles, cousins, siblings and their children because sometimes hereditary breast cancers may skip one family member but will be very prevalent on, for example, an aunt’s side of the family. That is important because it may lead to genetic evaluation. So, when we meet a woman for a high risk evaluation, we want to learn a lot her family history. Additionally, we want to know what her body’s, overall, exposure to hormones has been. So, for example, at what age did she start her period? If she was ever pregnant, when did she deliver her first child? When she has gone through menopause, has she ever used hormone replacement therapy?
Dr. Linda Austin: Looking at hormonal issues, what are some of the characteristics of those who are at risk?
Dr. Megan Baker: When you are looking at exposure to hormones, you start first with early age of menarche, meaning starting your period, so typically women who started their period before the age of 10 or 11, or a later age at menopause, typically after the age of 50. When you look at delivery of a child, having a child, live birth, before the age of 30 decreases your chance for breast cancer. Exposure to hormone replacement therapy is something that is somewhat confusing, do I dare say controversial? But, the most recent and highest quality literature that is out there would certainly suggest that a longer duration to hormone replacement therapy, particularly of the kind that is combination therapy, progesterone and estrogen longer than five-year’s duration, would increase your change for breast cancer.
So, those factors are all taken into account, at the same time as family history and whether or not someone has had biopsies of their breasts before, to really come up with a number, if you will, a risk, what is that woman’s risk of developing breast cancer at five-year’s time and during her entire lifetime. We use that calculation to gauge whether or not a woman would benefit from preventative strategies. Those strategies may be increased surveillance, checking more often, perhaps doing a mammogram once a year, alternating with an MRI every six months, so you are getting some type of imaging twice a year, typically alternating mammogram and MRI. Those women will be examined twice a year, rather than once a year, by a physician. For those women who are at highest risk, we may consider doing even more aggressive strategies, whether they take medicines that block hormones, such as tamoxifen which can reduce the risk of breast cancer by half, or even doing something more aggressive, like remove the breast tissue itself through prophylactic or preventative mastectomies.
So, certainly, this all requires a team approach. When I meet patients in the high risk setting, they meet with me, as a surgeon, they meet with a medical oncologist to talk about those medicines, when appropriate. They meet with a geneticist to go over their family history and their risk and whether or not genetic testing would be appropriate. Then, we come full circle and come up with a team plan.
Dr. Linda Austin: I understand that in South Carolina we have a specific screening program for that, can you mention that?
Dr. Megan Baker: We do. I am very proud to say that we have partnered with Wachovia; Wachovia has sponsored our high risk breast initiative. This is a statewide initiative aimed at educating not only healthcare providers but also patients to identify who is at risk and what patients should be sent to referral centers, to get evaluated by people like a geneticist. So, this initiative is really one that focuses on education. Our physician team goes out to physician, as well as nurse practitioner, offices all across the state. We work on educating and helping them identify the patients in their practice as to who would be best served in a high risk setting.
Similarly, we provide a lot of educational seminars and literature for patients so they can best learn how to identify themselves if they are at risk or not, and to provide them with the appropriate numbers to contact should they want to seek an official high risk evaluation.
Dr. Linda Austin: Now, if you have gone through that screening, is the counselor or physician able to say to you, okay, based on how many years you have menstruated, based on family history, that you did or did not have relatives with breast cancer, you have an x percent chance of developing breast cancer?
Dr. Megan Baker: Absolutely. There are some excellent research tools. The most commonly used is the Gail Risk assessment. That is a mathematical model that has been developed and validated in many centers. It is really encouraged to be used by the National Cancer Institute. What it does is very accurately estimates an average woman’s risk for breast cancer based on those factors we have discussed: When they started their period, do they have children, at what age did they have their first delivery, did they go through menopause, have they ever had a biopsy before?
The one weakness to this model, however, is for women who have an extensive family history that exists outside of a direct relative, like a mother or a sister. It can underestimate the risk. It rarely overestimates the risk. It is either accurate or it underestimates it. So, it is a very helpful tool to determine when patients should consider taking medicines. In fact, it was the very tool that was used in all the studies that were done to check for effectiveness and safety for those medicines to prevent breast cancer, namely tamoxifen.
Dr. Linda Austin: Is there a place online to look that up?
Dr. Megan Baker: Definitely. You can go to www.muschealth.com or Hollings Cancer Center, www.hcc.musc.edu, and you can find the Gail Risk Assessment model. It is designed so that patients can use it. It is very patient-friendly. If you want to go to the National Cancer Institute website, you can find it there as well.
Dr. Linda Austin: I would imagine, then, that the decisions, one you know what that risk is, must be so variable. I mean, there are probably some women for whom, let’s say, a 30 percent risk is absolutely not tolerable and others who will say, okay I can live with it.
Dr. Megan Baker: Without a doubt. Every patient’s reaction to their risk is as unique as they are. What is important is that, regardless of what the risk is or regardless of what you may perceive their reaction to be, they need to know what their options are. For that reason, although the process may seem cumbersome, having to meet with multiple members of the team, the oncologist, the surgeon, the geneticist, I think it is actually very helpful. It really gives patients time to consider what their options are, lets them kind of sit for awhile and consider what that risk mean to their life and to their family. Then, it really allows them an opportunity to make the decision that is best for them.
What is most important is that we have identified that they are different and they should be followed differently. So, even if they do not do something that is technically preventative, we will at least follow them more intensely so that we will be able to identify something earlier, gosh, forbid if it happens.
Dr. Linda Austin: Thank you so much for this helpful information.
Dr. Megan Baker. You are welcome.
If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection: (843) 792-1414.