med gear 2Talking to women about their breast cancer risk is among the most gratifying of privileges I have as a breast surgeon and breast cancer advocate.  An informal survey of thousands of women I’ve counseled over the years places most women into one of four groups when it comes to breast cancer risk awareness.

The first group consists of very anxious women who greatly overestimate their lifetime risk of breast cancer and who will go to great lengths to prevent breast cancer.

The second group includes women who significantly underestimate their lifetime risk of breast cancer and who therefore fail to embrace the opportunity to reduce their risk.

The third group comprises women who give very little consideration to their breast cancer risk and typically assume incorrectly that they can do very little about it.

The fourth and smallest group of women includes those who possess an accurate understanding of their breast cancer risk as well as a clear understanding of what to do about it.

Where do you place yourself?

Breast cancer is not a one size fits all disease, and not every woman carries the same lifetime risk.  An individual woman’s risk of breast cancer is influenced by her age, menstrual history, obstetrical history, family history, genetic make-up, lifestyle, breast density, body weight, alcohol consumption, and environmental exposure, among other factors.  In this first of a 10-part series on “10 Things You Should Know About Breast Cancer,” you will learn the importance of understanding your unique personal risk of breast cancer and what you can actually do about it.

What does your breast cancer risk tell you?

Knowledge of breast cancer risk is not only empowering, it may also be life-saving.  In fact, your personal breast cancer risk is a critical piece of information for helping you avoid being diagnosed with a life-threatening breast cancer, or even avoid breast cancer altogether.  Knowing your personal risk of breast cancer allows you to determine:

  1. Which type of risk-reduction strategies you should consider to reduce your risk of breast cancer,
  2. How often you should be screened for breast cancer, and
  3. Which type of breast cancer screening you should receive.

How do you assess your breast cancer risk?

Calculating your breast cancer risk is quite simple and may be easily performed using one of several online risk assessment tools.  Just plug in the requested information and out pops your 5-year and lifetime risk estimates.  Each breast cancer risk assessment tool has its advantages and disadvantages.  The most well-known and user-friendly tool is the Gail Breast Cancer Risk Assessment Tool, which calculates 5-year and lifetime risk levels based on personal traits and any family history of breast cancer among first degree relatives (e.g., mother, sister, or daughter).  An enhanced version of the Gail Breast Cancer Risk Assessment Tool is the Hall Detailed Breast Risk Calculator, which takes into consideration several factors (e.g., breast density) not included in the Gail Tool.  However, neither the Gail Tool nor the Hall Calculator captures information about breast cancer among second degree relatives (e.g., grandmother or aunts).  To capture the risk associated with first and second degree relatives, you should instead use the Tyrer-Cuzick (IBIS) Breast Cancer Risk Evaluation Tool.

Both the Tyrer-Cuzick and the more comprehensive BRCAPRO models are useful in determining your risk of carrying a BRCA gene mutation, which increases lifetime risk of breast cancer from 13% (average) to 60-80%.  Either of these calculators should be used if you have a family history of the following:

  • Cancer in multiple generations (e.g., mother and her mother)
  • Two or more people in the same generation with cancer (e.g., mother and her sister)
  • Earlier than expected age of diagnosis of breast cancer (e.g., before age 50)
  • Individuals with more than one cancer (e.g., breast cancer and melanoma)
  • Cancers that tend to run together (e.g., breast and ovarian)
  • Cancers associated with BRCA mutations (e.g., Triple Negative breast cancers)
  • Individuals with cancer in both breasts

Both of these tools are downloadable calculators that require an online registration.  Because of their complexity, the Tyrer-Cuzick and BRCAPRO tools are best utilized by a genetic counselor or breast surgeon with expertise in breast cancer risk assessment.  For those suspected of carrying a gene mutation, a simple oral wash or blood test can be used to detect the presence of BRCA 1 or BRCA 2 mutation.

What do you do next?

Breast cancer risk can be divided into 4 categories: average (<15% lifetime risk), moderate (15-20% lifetime risk), high (21-60% lifetime risk), or hereditary (>60% lifetime risk).  Once you determine your personal risk level, you can utilize my personalized screening and prevention guides to determine how to reduce your lifetime risk of breast cancer, how often you should get screened, and how you should get screened.

 

Dr. Holmes’ Personalized Prevention Recommendations

Average Risk

Moderate Risk

High Risk

Hereditary Risk

Lifetime Risk <15%

Lifetime Risk 15-20

Lifetime Risk 21-60%

Lifetime Risk >60%

  • Eat 5 Serving of Fruits & Veggies daily
  • Exercise at Least 30 minutes daily (or >2.5 hours/week)
  • Drink no more than 1 glass of alcohol daily
  • Do not use Estrogen and Progesterone-containing Hormone replacement therapy for more than 5 years

 

  • Follow recommendations for the average risk group
  • See a Genetic Counselor
  • Consider taking Tamoxifen, Raloxifene, or Exemestane to reduce your risk of breast cancer

 

  • Follow recommendations for the average risk group
  • See a Genetic Counselor
  • Consider taking Tamoxifen, Raloxifene, or Exemestane to reduce your risk of breast cancer
  • Consider prophylactic removal of breasts and/or ovaries

 

  • Follow recommendations for the average risk group
  • See a Genetic Counselor
  • Prophylactic removal of breasts and/or ovaries
  • Take Tamoxifen, Raloxifene, or Exemestane to reduce your risk of breast cancer if you elect not to have prophylactic mastectomy

 

Dr. Holmes’ Personalized Screening Recommendations

Age 20-39

  • Monthly Breast Self-Exam
  • Doctor’s Exam at least every 3 years

Age 40 and Older

 

  • Monthly Breast Self-Exam
  • Doctor’s Exam Yearly
  • Mammograms yearly
Age 18-24

  • Monthly Breast Self-Exam
  • Doctor’s Exam at least every 2 years

Age 25-34

  • Monthly Breast Self-Exam
  • Doctor’s Exam once or twice a year

 

Age 35 & Older

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly
  • Mammograms yearly
Age 18-24

  • Monthly Breast Self-Exam
  • Doctor’s Exam once or twice yearly

 

Age 25-34

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly

 

Age 35 & Older

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly
  • Mammogram yearly
  • Breast MRI yearly

 

 

Age 18-24

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly
  • Breast MRI yearly

 

Age 25-34

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly
  • Mammograms yearly
  • Breast MRI yearly

 

 

Age 35 & Older

  • Monthly Breast Self-Exam
  • Doctor’s Exam twice yearly
  • Mammograms yearly
  • Breast MRI yearly

 

Providing women with vital and usable information about their health and wellness is among the most important things I can do as a physician.  Now that you know why it’s so very important to know your breast cancer risk, stay tuned for the second installment of  “10 Things You Should Know About Breast Cancer,” a practical discussion of screening mammography.