Abstract
BackgroundMany women at increased risk for breast cancer could benefit from preventive therapy. Preventive therapy options for breast cancer risk reduction have expanded in the last few years to include both selective receptor modulators (tamoxifen and raloxifene) and aromatase inhibitors (anastrozole and exemestane).MethodsRisk factors that place women at high risk for breast cancer, as well as risk calculation models appropriate for the selection of candidates for preventive therapy, are presented, followed by a review of current guidelines for chemoprevention and results of chemoprevention trials.ResultsThe modified Gail model or Breast Cancer Risk Assessment Tool is the most widely utilized risk assessment calculator to determine eligibility for chemoprevention. Women most likely to benefit from preventive therapy include those at high risk under the age of 50 years and those with atypical hyperplasia. Physician and patient barriers limit widespread acceptance and adherence to preventive therapy.ConclusionsPublished guidelines on chemoprevention for breast cancer have been updated to increase awareness and encourage discussion between patients and their physicians regarding evidence-based studies evaluating the benefits of preventive options for women at increased risk for breast cancer. However, even with increasing awareness and established benefits of preventive therapy, the uptake of chemoprevention has been low, with both physician and patient barriers identified. It is prudent that these barriers be overcome to enable high-risk women with a favorable risk-to-benefit ratio to be offered chemoprevention to reduce their likelihood of developing hormone receptor-positive breast cancer.
Highlights
Many women at increased risk for breast cancer could benefit from preventive therapy
Nonmodifiable risk factors include increasing age, family history, precancerous breast lesions, and reproductive factors. These risk factors are independently associated with a higher risk of developing breast cancer but it is not known if they are additive for an individual when estimating breast cancer risk
This is consistent with eligibility criteria utilized in the National Surgical Adjuvant Breast and Bowel Project (NSABP) Breast Cancer Prevention Trial (BCPT) and the Study of Tamoxifen and Raloxifene (STAR).30–33Another risk calculation model commonly used is the International Breast Cancer Intervention Study (IBIS) or Tyrer– Cuzick model.[11]
Summary
Defining breast cancer risk incorporates knowledge of individual risk factors known to be associated with increased risk. Nonmodifiable risk factors include increasing age, family history, precancerous breast lesions, and reproductive factors (early menarche, lateonset menopause, first live birth after age 30 years, or nulliparity). These risk factors are independently associated with a higher risk of developing breast cancer but it is not known if they are additive for an individual when estimating breast cancer risk. Women with a BRCA mutation should be offered bilateral prophylactic mastectomy (BPM) and risk-reducing salpingo-oophorectomy as these are the only risk-reducing strategies shown to be effective in this population Those not interested in BPM should have enhanced surveillance with annual mammogram and magnetic resonance imaging, and be offered preventive therapy. The evidence of efficacy of preventive therapy in this population is less
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