Why is understanding breast cancer risk important for women?

by Katherine Crew

Breast cancer is the most common cancer among women in the U.S. About 1 in 8 women will be diagnosed with breast cancer in their lifetime. Important breast cancer risk factors include increasing age, having a family history of the disease, prior benign breast biopsies, and increased exposure to the hormone, estrogen.

Based upon these risk factors, about 15% of women between the ages of 35-79 are considered to be at “high-risk” for breast cancer and are candidates for taking anti-estrogen pills to reduce their breast cancer risk, also known as “chemoprevention.” However, many women and their primary care providers are unaware of their high-risk status or the medical options that are available for breast cancer prevention.

The use of chemoprevention in primary care

Chemoprevention pills, such as tamoxifen, have been FDA-approved for the primary prevention of breast cancer in healthy women since 1998. For high-risk postmenopausal, newer anti-estrogens, such as raloxifene, exemestane, and anastrozole, have also been shown to reduce breast cancer risk by up to 40-65% after 5 years of therapy.

However, these pills are not widely used in the primary care setting – partly due to a lack of awareness and concerns about potential side effects. Since some of these pills are used to treat breast cancer, the perceptions among both patients and providers are that the risks of rare side effects, such as blood clots and uterine cancer for tamoxifen use, may outweigh the benefits for breast cancer risk reduction.

Understanding the risks and benefits

At Columbia University Medical Center, we have been conducting research to better identify high-risk women in the primary care setting. We have also been developing educational tools for both patients and primary care providers to better understand the risks and benefits of chemoprevention.

We first approach women who are getting screening mammograms to collect breast cancer risk factor data on a tablet, which will then calculate a risk score and determine whether they meet high-risk criteria for breast cancer. They receive a personalized breast cancer risk report and resources for obtaining additional information.

We are also developing web-based educational tools, including a decision aid for patients and decision support tool for providers, which are integrated into the electronic health record and will become part of routine clinic workflow.

These tools will be tested in an upcoming clinical trial, which will enroll 400 high-risk women of diverse racial/ethnic backgrounds from our primary care clinics. The main outcomes that we will assess in this trial will include accuracy of breast cancer risk perceptions, appropriate referrals to the high-risk breast clinic, and actual chemoprevention uptake.

The overall objective of our research is to better inform women about their breast cancer risk and raise awareness about risk-appropriate breast cancer screening and prevention strategies. Since breast cancer is a common disease, targeting high-risk women for primary prevention may have a major public health impact.

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