One of the advantages of caring for women with breast disease for over 30 years is the perspective one gains by seeing how things evolve over a time. I don’t think there are too many fields changing as quickly as breast disease management. Because it’s such a big problem there has been much grassroots support. This has resulted in a lot of time and resources directed into research, generating a huge amount of information in a short time. When I was in training, all women who came to us newly diagnosed with breast cancer were given the same treatment. Now we know that each case of breast cancer is unique. We customize the treatment to match the disease. When I first started as a physician, a woman newly diagnosed with breast cancer faced a 45-50 percent cure rate. With early detection and customizing care that figure is now closer to 85-90 percent—a tremendous success story.
Assessing a patient’s individual risk for breast disease is following the same pattern. Age is a universal risk factor for breast cancer. Five percent of breast cancers occur before age 40, twenty-five percent before 50 and seventy-five percent after age 50. Annual screening mammography starting at age 40, as recommended by most major medical organizations, is a very reasonable compromise. Yet, making one screening recommendation for every woman in the country doesn’t make sense. We are all unique. Each is going to have a different risk of developing breast cancer. Some women probably should have started getting screened before age 40 while others may never need a mammogram. As medical science continues to evolve, we are getting better at determining each individual’s risk of developing a disease. We can use this information to be smarter in how we screen and sometimes even prevent the disease from occurring.
At this time we see 70 percent of breast cancers occurring in women with no identifiable risk factors other than aging. In the 30 percent who have a demonstrated increased risk, one-third is based on a genetic mutation and the other two-thirds due to a combination of family or personal medical history.
Genetic testing is used to identify those individuals who are carrying the genetic mutations called BRCA1 or BRCA2. These mutations create an extremely high risk of developing breast and ovarian cancer. Ideally there should be genetic counseling accompanying every test so a patient is not left alone to deal with what can become a very emotional and scary situation. We are fortunate to have oncology nurse Agnes Mikijaniec, who has received advanced breast genetic counseling training from the City of Hope in California, available here at BMH to provide this service.
Most high risk patients are not candidates for genetic testing. To help identify these high risk patients who do not have a BRCA mutation, we use a risk assessment questionnaire. Once we identify a woman at high risk, she may become a candidate for more aggressive screening, like MRI and breast cancer prevention treatments.
High risk assessment should not replace regular exams and annual mammograms. I once did a consultation for a 57 year old woman who came to see me specifically requesting genetic testing, but never had a mammogram! I counsel patients not to worry about the extra credit stuff until you do what is recommended for everyone.
Breast cancer risk management is a situation where working in a small, slower paced community has an advantage over the fast paced, crowded cities. We’re fortunate here in Brattleboro that we can give high risk patients the attention and time they need. With genetic testing and counseling, Breast MRI and other services in our Comprehensive Breast Care program, we do a very good job of identifying women at high risk for breast cancer and providing them with the information that allows them to make decisions that are right for their specific needs.
Breast cancer risk assessment is a work in progress. The fact remains that 70 percent of newly diagnosed breast cancer patients have no identifiable risk factors. We do not know why they occur. I am certain as we gain a better understanding of molecular biology and genetics our understanding of what causes cancer will also improve. Even though there is much to learn, we now know enough to make a difference in how we identify and care for women at increased risk for developing breast cancer. One size does not fit all and forewarned is forearmed.
Joseph Rosen, MD is a board-certified surgeon with Brattleboro General Surgery, a member of BMH Physician Group. He can be reached at 802-254-5510.