Pre-Empting Breast Cancer: Where Do we Go from Here?

Abstract

Despite the recent decrease in breast cancer incidence reported in the USA [1], breast cancer remains the most common malignancy diagnosed in women in this county with 178,480 cases of invasive breast cancer estimated for 2007 [2]. There are now two agents with US FDA label indication for breast cancer risk reduction in women who are at increased risk for breast cancer: the selective estrogen-receptor modulator tamoxifen for both preand postmenopausal women [3], and raloxifene for use only in postmenopausal women [4]. Use of these agents in appropriate candidates reduce breast cancer incidence by approximately 40–50% [4]. To identify such candidates, several breast cancer risk-assessment tools are available, including the TylerCuzick model [5] and the Breast Cancer Risk Assessment Tool of the National Cancer Institute (Gail model), which has recently been modified to more accurately predict risk in African–American women [6,101]. Against this background, it might be expected that breast cancer risk assessment would be a routine component of physician primary care visits, especially for postmenopausal women, as risk of hormone-receptor positive breast cancer increases with age, and both tamoxifen and raloxifene specifically target hormone-receptor positive disease. However, this is not the case [7–9]. In a recent year, only 16% of US primary care providers reported that ‘it is easy to determine’ who is eligible for breast cancer risk-reduction strategies [9], and only 11% of primary care providers in California, USA, reported having used the Gail model in the past year [8].