1. Which of the following increases a women’s risk for Breast Cancer? A.Starting her menses at age 14 or older B.Breastfeeding C.Extremely dense breast tissue D.Having children prior to age 30

2. What is considered to be an elevated lifetime risk for developing Breast Cancer? A.> 5 % B.> 20 % C.> 12 % D.> 35 %

3. Breast Cancer Screening and Risk Assessment Caroline Peterson, D.O. FACOOG Director, Breast Cancer Screening and Prevention for Kettering Health Network

4. Algorithm for Breast Cancer Screening Process RISK ASSESSMENT % LTR IBIS* (Tyrer-Cuzik Model) Clinically Integrated A RISK GROUP < = 10 % B RISK GROUP 11 – 19 % C RISK GROUP > = 20 % NOT DENSE DENSE Mammogram Whole Breast Ultrasound Mammogram + MRI Start Age 40 yr Interval 12 mo Start Age 40 yr Interval 12 mo Start Age Risk Based Interval 12 mo Start Age 25 yr Interval 12 mo

5. National Comprehensive Cancer Network (NCCN) Guidelines 2009 “If the physical examination is negative in an asymptomatic woman, the next decision point is based on Risk Stratification”

22. Summary: Currently known genetic markers for Breast Cancer ER+ BrCa Post-Menopausal ER- BrCa Pre-Menopausal

23. Breast Cancer Classification 80% of women diagnosed with breast cancer have NO family history. Sporadic 80% Hereditary 5% Hereditary 5% Familial history 20% Familial history 20%

24. Breast Cancer Screening Pathway Questionnaire for MyRisk and Gail Model/T-Cuzick Model offered to all: New Patients and Annual Exams MyRisk Testing Done Once Test Results are in, Patient is Notified and Appointment is scheduled for Genetic Counseling Visit MyRisk Not Indicated Run T-Cuzick Model on Patients > 20 years Run Gail Model on Patients > 35 years If Elevated, Schedule Appointment to Review with Physician or Advanced Practitioner If Not Elevated – Note on Chart Positive Results for MyRisk Testing Genetic Counseling CPT code 99214 Low Risk Annual Mammogram at Age 40 Teach Self-Breast Awareness Negative Results for MyRisk Testing Elevated Gail/T-Cuzick Results Preventive Pathway Screening  Annual Breast Exam  Annual Mammogram  Breast MRI @ 6 Month Intervals Prevention  Risk Reduction Strategies  Chemoprevention (Alternative to HRT) Run Gail/T-Cuzick at Appt If Elevated, Review New Pathway If Not Elevated, Review Low Risk Pathway Schedule Appointment With Provider Review New Pathway

27. Interventions for Patients with Increased Risk Increased Risk = Lifetime risk ≥ 20% ◦ Bi-annual clinical exam ◦ Annual Breast MRI ◦ Annual Mammogram ◦ ACR recommends Breast Ultrasound if cannot have MRI Surveillance Increased Risk = 11 – 19 % Dense Tissue ◦ Annual Mammogram ◦ Annual Breast Ultrasound Fatty/Fibroglandular ◦ Annual Mammogram

28. American Cancer Society Guidelines 2007 Criteria for Use of Breast MRI Screening as an adjunct to Mammography for High Risk Women Include: BRCA 1 or 2 Mutation First Degree Relative with BRCA 1 or @ Mutation and Untested Lifetime Risk of Breast cancer of 20 – 25 % or more defined by Models largely dependent on Family History Prior Radiation Treatment to the Chest between Ages 10 and 30 Carry or First Degree Relative who carries a Genetic Mutation TP 53or PTEN Genes

29. Breast Cancer Classification 80% of women diagnosed with breast cancer have NO family history. Sporadic 80% Hereditary 5% Hereditary 5% Familial history 20% Familial history 20%

30. Why Risk Stratification? Case Description 45 yr old female Nulliparous Menarche age 11 No family hx CA No personal hx CA No prior breast bx Annual Mammogram at 50 yr old advised by USPSTF Paternal Grandmother – Breast Cancer – Age 69 Abby

31. 45 yr old female Nulliparous Menarche age 11 No family hx CA No personal hx CA No prior breast bx Annual Mammogram at 50 yr old advised by USPSTF Paternal Grandmother – Breast Cancer at Age 69 Age 48, breast lump found by pt. Stage 3 Invasive ductal CA, ER+ Mastectomy, ChemoTx, RadTx, Adriamycin Cardiotoxicity, Congestive heart failure Why Stratify? …………..Abby

32. Gail Model 1% 5-yr risk Tyrer-Cuzick 2.0% 5-yr risk TAMOXIFEN x 5 years Recommendation when 5-yr risk ≥ 1.67% Achieve >50% breast cancer risk reduction Why Stratify? …………..Abby 45 yr old female……Abby Nulliparous Menarche age 11 No personal hx CA No prior breast bx Annual mammogram at 50 yr old advised by USPSTF Paternal Grandmother – Breast Cancer Age 69 Age 48, breast lump found by pt. Stage 3 Invasive ductal CA, ER+ Mastectomy, ChemoTx, RadTx, Adriamycin cardiotoxicity, CHF

33. Gail Model 1% 5-yr risk Tyrer-Cuzick 2.0% 5-yr risk TAMOXIFEN x 5 years 23% integrated lifetime risk ANNUAL MAMMOGRAM ANNUAL MRI Cancer Prevented, or Diagnosed at Stage 1 Why Stratify? …………..Abby 45 yr old female……Abby Nulliparous Menarche age 11 No family hx CA No personal hx CA No prior breast bx Annual mammogram at 50 yr old advised by USPSTF Paternal Grandmother – Breast Cancer Age 69 Age 48, breast lump found by pt. Stage 3 Invasive ductal CA, ER+ Mastectomy, ChemoTx, RadTx, Adriamycin cardiotoxicity, CHF

34. ALL PATIENTS PERSONAL or SIMPLE FAMILIAL RISK NO RISK FACTORS: SPORADIC LOW RISK STRONG FAMILY HX HEREDITARY RISK ASSESSMENT MULTIPLE or COMPLEX FAMILIAL RISK *PERSONAL / FAMILIAL RISK FACTORS: 1.≤12 years age at first menstrual period 2.≥30 years age at first childbirth or nulliparity 3.Mother, sister(s), daughter(s) with breast cancer 4.Breast biopsy 5.Breast density on mammogram. 6.High post-menopausal bone density 7.HRT ≥ 5 years 8.BMI > 30 9.Menopause >55 Breast Cancer Risk Stratification- How does it work?

35. Breast Cancer Develops Before it’s Detected

36. Preble, Montgomery and Greene Counties

37. Surveillance Increased Risk = Lifetime risk ≥ 20% – Bi-annual clinical exam – Annual breast MRI – Annual mammogram – ACR recommends Breast Ultrasound if can’t have MRI Pharmacologic risk reduction Increased Risk = 5-year risk ≥ 1.67% – Tamoxifen – Raloxifene Note-USPSTF recommends pharmacologic risk reduction when 5-year risk = 3% Interventions for Patients with Increased Risk

42. . 1. Breast Cancer Risk Assessment is standard of care. 2. Primary Prevention & Early Detection saves lives. 3. Preventive / Cost Effective care is here to stay. 4. Good medicine = Good healthcare = Good business. Risk Stratification – It’s About Time

43. Algorithm for Breast Cancer Screening Process RISK ASSESSMENT % LTR IBIS* (Tyrer-Cuzik Model) Clinically Integrated A RISK GROUP < = 10 % B RISK GROUP 11 – 19 % C RISK GROUP > = 20 % NOT DENSE DENSE Mammogram Whole Breast Ultrasound Mammogram + MRI Start Age 40 yr Interval 12 mo Start Age 40 yr Interval 12 mo Start Age Risk Based Interval 12 mo Start Age 25 yr Interval 12 mo