High Risk

For younger women, self-examination is often the only way a problem will be recognized. I was diagnosed at 27(almost 28) and wasn't even eligible for mammograms at that time. Thank goodness I knew what was/wasn't normal for my breast. Though, of course, I didn't find the tumour till it was large enough to be noticeable – but that’s better than not finding it at all. Be aware of the changes in your body. Make sure you do everything possible to stay healthy and limit stress. Most of all, don't forget to make regular breast self-exam. Don't be fooled by the fact you have no cancer history in your family or your breast are small.

Risk stratification based upon family history and established risk factors is essential. There are models such as the GAIL model which can calculate risk based upon age, age of menarche, age first live birth, # first degree relatives with breast cancer, hx breast biopsies and finding of atypia. For patients determined to be at high risk, genetic counseling to discuss possible benefit of BRCA testing is important. Surveillance may include self, exam, clinical breast exam, mammography, ultrasound and MRI depending on the level of risk. Risk stratification based upon family history and established risk factors is essential. There are models such as the GAIL model which can calculate risk based upon age, age of menarche, age first live birth, # first degree relatives with breast cancer, hx breast biopsies and finding of atypia. For patients determined to be at high risk, genetic counseling to discuss possible benefit of BRCA testing is important. Surveillance may include self, exam, clinical breast exam, mammography, ultrasound and MRI depending on the level of risk.

There are many foods, herbs, supplements & lifestyle choices that reduce the possibility of the BRCA-1 or 2 gene from being expressed. If you're in the NY/NJ area, on Saturday October 15th in Montclair NJ come attend this free symposium. I'll be speaking on some of those issues/recommendations. http://www.montclairbreastcenter.com/wellnessevents.htm Another option for me was to have careful survellinece via mammograms and breast MRI's. Not all insurances will cover MRI's and also they can have false positives and negatives. There is no substitution for self exam where you can detect any physical changes yourself. It was recommended that I have screening every 6 months which I was doing until I decided to have my surgeries. Hope this was helpful.

If the patient's mother, sister, or mother's sister had breast cancer you should start annual screening mammography 10 years younger than they were when diagnosed. If mother was diagnosed at 37, start annual screening mammography at 27. Even before that, though, the patient should receive a clinical breast exam once a year by her physician. Breast self examination can also be very helpful for individuals who are not freaked out by it. I don't know what the "high risk" factors are in this individual, but I would usually recommend screening ultrasound annually as well. It could be scheduled 6 months after the clinical breast exam so that you are being checked more frequently. If the patient's mother, sister, or mother's sister had breast cancer you should start annual screening mammography 10 years younger than they were when diagnosed. If mother was diagnosed at 37, start annual screening mammography at 27. Even before that, though, the patient should receive a clinical breast exam once a year by her physician. Breast self examination can also be very helpful for individuals who are not freaked out by it. I don't know what the "high risk" factors are in this individual, but I would usually recommend screening ultrasound annually as well. It could be scheduled 6 months after the clinical breast exam so that you are being checked more frequently.

Thanks for this repsonse as well...again- not sure why this is not more widely known to the public...It is my understanding that you do not even have to take that many doses before one can be negatively effected...as data has also shown that for those people with mild depression, there is no benefit in taking the said antidepressants, this would seem especially wrong for psychiatrists and others to be promoting these drugs...This seems a bit scary to me, and patients taking these drugs seem to be treated as guinea pigs...shouldn't these studies be done PRIOR to people being allowed to take them?! Thanks again for your great responses. Rachel Your question relates to the paper by L Cosgrove and others published in April 2011, Antidepressants and breast and ovarian cancer risk: a review of the literature and researchers' financial associations with industry, PLoS One. 2011 Apr 6;6(4). It has been purported that antidepressants (ADs) may increase risk of breast and ovarian cancer, however results are mixed. The authors reviewed 61 articles published in English that assessed the relationship between AD use and cancer risk. Forty-one of those papers concluded no association, whereas 20 found a positive association. There was more likely to be a negative association if the investigators had financial ties with industry. Overall, the pooled odds ratio for the association between AD use and breast/ovarian cancer in the epidemiologic studies was 1.11, meaning there was a 1.11 fold greater chance of breast/ovarian cancer with AD use. They conclude that these findings warrant further study. They do not conclude that women taking ADs should be labeled as high-risk.
Comments on this article can be found on the Alliance for Human Research Protection website http://www.ahrp.org/cms/content/view/795/9/. Cosgrove is quoted as saying, “I would want to consider nondrug treatment if I was mildly depressed, given our data.”

It's important to differentiate between "risk factors" and "high-risk." For example, alcohol intake and increased BMI are both risk factors for breast cancer, however we do not automatically regard women who drink alcohol or are overweight/obese as being "high risk." They should be counseled re. lifestyle changes to reduce risk, not necessarily offered chemoprevention or annual MRIs.
There is a nice review of modifiable and non-modifiable risk factors on the American Cancer Society website at http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-risk-factors.
It is recognized that rates of breast cancer vary around the USA, and of course, around the world. The CDC maps out the rates of breast cancer around the USA at http://www.cdc.gov/cancer/breast/statistics/state.htm. Based on 2007 data, the states with the highest incidence of breast cancer are Connecticut, Delaware, District of Columbia, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, Oklahoma, Oregon, Rhode Island, and Vermont. The states with the highest death rates from breast cancer are Alaska, Arkansas, Delaware, District of Columbia, Illinois, Kentucky, Maryland, New Jersey, North Carolina, Ohio, Oklahoma, Vermont, and Virginia.
There is an interesting report by C A Clarke and others looking at variations of breast cancer rates in California: Population attributable risk of breast cancer in white women associated with immediately modifiable risk factors BMC Cancer 2006, 6:170. They conclude that variations may be attributable to lifestyle and state "the relatively feasible lifestyle changes of discontinuing estrogen/progestin replacement therapy use, reducing alcohol consumption, increasing physical activity, and lengthening breastfeeding duration could lower population breast cancer incidence substantially." It's important to differentiate between "risk factors" and "high-risk." For example, alcohol intake and increased BMI are both risk factors for breast cancer, however we do not automatically regard women who drink alcohol or are overweight/obese as being "high risk." They should be counseled re. lifestyle changes to reduce risk, not necessarily offered chemoprevention or annual MRIs.
There is a nice review of modifiable and non-modifiable risk factors on the American Cancer Society website at http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-risk-factors.
It is recognized that rates of breast cancer vary around the USA, and of course, around the world. The CDC maps out the rates of breast cancer around the USA at http://www.cdc.gov/cancer/breast/statistics/state.htm. Based on 2007 data, the states with the highest incidence of breast cancer are Connecticut, Delaware, District of Columbia, Maine, Massachusetts, Minnesota, New Hampshire, New Jersey, Oklahoma, Oregon, Rhode Island, and Vermont. The states with the highest death rates from breast cancer are Alaska, Arkansas, Delaware, District of Columbia, Illinois, Kentucky, Maryland, New Jersey, North Carolina, Ohio, Oklahoma, Vermont, and Virginia.
There is an interesting report by C A Clarke and others looking at variations of breast cancer rates in California: Population attributable risk of breast cancer in white women associated with immediately modifiable risk factors BMC Cancer 2006, 6:170. They conclude that variations may be attributable to lifestyle and state "the relatively feasible lifestyle changes of discontinuing estrogen/progestin replacement therapy use, reducing alcohol consumption, increasing physical activity, and lengthening breastfeeding duration could lower population breast cancer incidence substantially."

A number of factors contribute to risk of breast cancer. The Gail model was used by the NSABP in the chemoprevention trials P-01 (tamoxifen versus placebo) P-02 (STAR, tamoxifen versus raloxifene). High risk was defined as a five year risk of 1.67% or greater. The modified Gail model is available online http://www.cancer.gov/bcrisktool/. It takes into account current age, ethnic origin, age at first menstrual period, age at first live birth, family history of breast cancer (first degree relatives), number of surgical excisional biopsies and whether or not atypical hyperplasia was found on those biopsies. Harvard School of Public Health developed the Harvard Cancer Risk Index. In 2007 this online risk assessment tool moved to Washington University in St. Louis and can be accessed at http://www.yourdiseaserisk.wustl.edu. The Tyrer-Cusick, BRCAPRO and BOADICEA models are also used to determine likelihood of carrying a BRCA mutation. A number of factors contribute to risk of breast cancer. The Gail model was used by the NSABP in the chemoprevention trials P-01 (tamoxifen versus placebo) P-02 (STAR, tamoxifen versus raloxifene). High risk was defined as a five year risk of 1.67% or greater. The modified Gail model is available online http://www.cancer.gov/bcrisktool/. It takes into account current age, ethnic origin, age at first menstrual period, age at first live birth, family history of breast cancer (first degree relatives), number of surgical excisional biopsies and whether or not atypical hyperplasia was found on those biopsies. Harvard School of Public Health developed the Harvard Cancer Risk Index. In 2007 this online risk assessment tool moved to Washington University in St. Louis and can be accessed at http://www.yourdiseaserisk.wustl.edu. The Tyrer-Cusick, BRCAPRO and BOADICEA models are also used to determine likelihood of carrying a BRCA mutation.

I use the definition used in the NSABP chemoprevention trials NSABP-P01 and -P02. In those studies the Gail model was used and high risk was defined as a five year risk of 1.67 or greater. This number is the cut-off for referral for consideration for tamoxifen or raloxifene to decrease risk. The Gail model takes into account current age, ethnicity, age of first menstrual period, age of first live birth, family history of breast cancer (first degree relatives), number of excisional biopsies and whether or not atypia was found on those biopsies. Other models exist such as BRCAPRO, Claus, or Tyrer-Cuzick. The American Cancer Society recommends annual MRI for patients who have a lifetime risk of breast cancer of 20% or higher.

I am a pragmatist by nature, and I know that when I am on the phone with an insurance company to obtain pre-certification for a screening breast MRI for one of my patients, I will be asked the Gail model lifetime risk. Therefore this is the model I use most often, the calculator for which I carry in my pocket.

The model can underestimate risk when there is inherited predisposition, such as BRCA 1 or 2 positivity. As I'm sure many of the readers of this website know, female carriers of a deleterious mutation of BRCA 1 or 2 have a lifetime risk of breast cancer of 50-80%. I use the definition used in the NSABP chemoprevention trials NSABP-P01 and -P02. In those studies the Gail model was used and high risk was defined as a five year risk of 1.67 or greater. This number is the cut-off for referral for consideration for tamoxifen or raloxifene to decrease risk. The Gail model takes into account current age, ethnicity, age of first menstrual period, age of first live birth, family history of breast cancer (first degree relatives), number of excisional biopsies and whether or not atypia was found on those biopsies. Other models exist such as BRCAPRO, Claus, or Tyrer-Cuzick. The American Cancer Society recommends annual MRI for patients who have a lifetime risk of breast cancer of 20% or higher.

I am a pragmatist by nature, and I know that when I am on the phone with an insurance company to obtain pre-certification for a screening breast MRI for one of my patients, I will be asked the Gail model lifetime risk. Therefore this is the model I use most often, the calculator for which I carry in my pocket.

The model can underestimate risk when there is inherited predisposition, such as BRCA 1 or 2 positivity. As I'm sure many of the readers of this website know, female carriers of a deleterious mutation of BRCA 1 or 2 have a lifetime risk of breast cancer of 50-80%.

I agree with the idea of sharing your story and information. I have learned many amazing things while on my breast cancer journey. When people question me or ask about what I have gone through or where I am at at the moment, I do not hesitate to share my experience with them and always try to incorporate what I have learned about the prevention of cancer and how important excercise and especially our diets are to us. I try not to be preachy, but I feel it is my duty to share these healthy facts and hopefully I can help prevent this disease in someone else. I am surprised by the number of women who don't know the benefits of or get very little Vitamin D! Then again, I was one of them a few years back! Denial is a common belief that we all hold on to - those bad things that happen in the world only happen to other people. In reality, however, they can happen to anyone.

You do not have to have a family history to have breast or testicular cancer. It usually takes someone close to you to realize that it can happen to anyone.

Talking to your friends and family about your experiences and worries can help them understand the reality of life. Early detection is key in surviving cancer.

Self-chec has an email reminder that you can sign up for to remind you to chec yourself. They also have a healthy e-card gift shop where you can send reminders to your friends let them know how much you care. The cards ask them to care for themselves and give themselves an exam each month.
http://www.selfchec.org/main/cardshopnew.php

Certain genetic mutations can predispose someone to developing breast cancer. The best known such genes are called BRCA-1 and BRCA-2. Both significantly increase an individual's chances of developing breast cancer over their lifetime. A doctor can order these tests, but typically only does so if there is a strong family history of breast or ovarian cancer. There are lots of considerations such as the cost of the test, which is often not covered by insurance, and the implications of having a positive result on your medical record. If you need to change your insurance, having this result on your record is a risk. Certain genetic mutations can predispose someone to developing breast cancer. The best known such genes are called BRCA-1 and BRCA-2. Both significantly increase an individual's chances of developing breast cancer over their lifetime. A doctor can order these tests, but typically only does so if there is a strong family history of breast or ovarian cancer. There are lots of considerations such as the cost of the test, which is often not covered by insurance, and the implications of having a positive result on your medical record. If you need to change your insurance, having this result on your record is a risk.