Kevin S.Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Surgeon The Newton-Wellesley Hospital Breast Center Identification and Management of Women at High Risk of Breast Cancer Saslow D et. al. CA Cancer J Clin 2007; 57: 75 ACS MRI Guidelines Saslow D et. al. CA Cancer J Clin 2007; 57: 75 10,000 4/1/2006 to 9/17/2007 7,821 NULL or No Never HORMONES 6,981 W/ Gail Score 6,028 W/ BRCAPRO Lifetime 5,894 W/ BRCAPRO Mutation and Tyrer-Cuzick LCIS/AH status not available ACS MRI Guidelines Exclude Gail Model less useful than BRCAPro, Claus, and Tyrer-Cuzick not adequate for evaluating family history Therefore we do not recommend its use for evaluating patients for breast MRI screening Online Supplemental Material ACS Guidelines Saslow D et. al. CA Cancer J Clin 2007; 57: 75 BRCAPRO Tyrer-Cuzick Claus Gail ACS Guidelines Claus Breast FH BRCAPRO Breast and ovarian FH Tyrer-Cuzick Breast and ovarian FH Pathologic factors Hormonal factors Tyrer-Cuzick= 330 (5.6%) 276 BRCAPRO = 25 (0.4%) Claus = 54 (0.9%) Lifetime Breast Cancer Risk 20% or greater by Model 20 to 25% LT Risk ofWhat? Invasive cancer BRCAPRO Invasive plus DCIS Claus Tyrer-Cuzick Tyrer-Cuzick= 330 (5.6%) 263 Claus = 54 (0.9%) Lifetime Breast Cancer Risk 20% or greater by Model Adjusted BRCAPRO 61 (1%) ACS MRI Guidelines Saslow D et. al. CA Cancer J Clin 2007; 57: 75 LCIS/AH 20% or greater lifetime risk Any LCIS age 69 and below Any AH age 56 and below Tyrer Cuzick for AH & LCIS Even more with even trivial risk factors IDing patients for MRI is not enough Need complete risk assessment Genetic testing as appropriate Manage Breast and Ovarian Risk! Consider Genetic Testing if Risk Mutation is 10% or greater Better Strategy Identify mutation carriers (genetic testing) MRI for those with mutation (selective MRI) Offer ALL risk reducing strategies Oophorectomy Prophylactic mastectomy MRI Mammography Avon Comprehensive Breast Center Database 18,190 screening mammogram patients 40 or older (May 2003 July 2005) BRCAPRO run on all Avon Comprehensive Breast Center Database Lifetime risk 20% 78 (0.4%) 18,190 screening mammogram patients 40 or older (May 2003 July 2005) BRCAPRO run on all Avon Comprehensive Breast Center Database Lifetime risk 20% 78 (0.4%) Predicted Mutation Carriers 27 BRCAPRO 18,190 screening mammogram patients 40 or older (May 2003 July 2005) BRCAPRO run on all Avon Comprehensive Breast Center Database 374 (2.1%) Mutation Risk 10% Lifetime Risk