Prophylactic mastectomy and oophorectomy for BRCA mutation carriers – pro

M Levin, MD — Fri, 11 Oct 2013 16:31:52 +0000

Prophylactic bilateral mastectomy is the surgical removal of both breasts to help prevent breast cancer. Prophylactic mastectomy is a controversial procedure among members of the medical community. Based on recent scientific findings that show prophylactic mastectomy to be effective at preventing breast cancer, some physicians think that it is sometimes recommended even without evidence of genetic causation. According to the American Cancer Society Board of Directors, “only very strong clinical and/or pathological indications warrant doing this type of ‘preventive operation.” BRCA positivity is generally thought to be an strong indication for it.

A recent article in the Journal of American Medical Association suggests that in BRCA positive patients there is a benefit to bilateral prophylactic mastectomy. Prophylactic surgery reduced the high risk of breast and ovarian cancer among BRCA mutation carriers and improved survival, researchers affirmed. Similarly, all-cause mortality dropped from 10% without salpingo-oophorectomy to 3% with it (hazard ratio 0.40, 95% confidence interval 0.26 to 0.61). Even before theis information, ESMO was recommending bilararl mastectomy and oophorectomy. The American College of Obstetricians and Gynecologists’ guidelines on “Hereditary breast and ovarian cancer syndrome” (ACOG, 2009) stated that “risk-reducing salpingo-oophorectomy should be offered to women with BRCA1 or BRCA2 mutations by age 40 or after the conclusion of child-bearing”.

Lostumbo L, Carbine NE, Wallace J. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev. 2010;11:CD002748.

J. Balma, BRCA in breast cancer: ESMO Clinical Practice Guidelines, Ann Oncol (2010) 21 (suppl 5): v20-v22.

Easer an j, Lessons learned from genetic testing. JAMA. 2010 Sep 1;304(9):1011-2.

Susan M. Domchek; Tara M. Friebel; Christian F. Singer; D. Gareth Evans; Henry T. Lynch; Claudine Isaacs; Judy E. Garber; Susan L. Neuhausen; Ellen Matloff; Rosalind Eeles; Gabriella Pichert; Laura Van t’veer; Nadine Tung; Jeffrey N. Weitzel; Fergus J. Couch; Wendy S. Rubinstein; Patricia A. Ganz; Mary B. Daly; Olufunmilayo I. Olopade; Gail Tomlinson; Joellen Schildkraut; Joanne L. Blum; Timothy R. Rebbeck. Association of Risk-Reducing Surgery in BRCA1 or BRCA2 Mutation Carriers With Cancer Risk and Mortality. JAMA, 2010; 304 (9): 967-975

Laura Esserman; Virginia Kaklamani. Lessons Learned From Genetic Testing. JAMA, 2010; 304 (9): 1011-1012

Tamoxifen for Breast Cancer – pro

M Levin, MD — Fri, 03 Aug 2012 02:10:45 +0000

Several conditions of the breast commonly occur before the development of breast cancer. Some of these conditions, such as intraductal hyperplasia with atypia and lobular carcinoma in situ (LCIS), are microscopic risk factors that can indicate that a woman is at increased risk of developing breast cancer.

Tamoxifen has been shown to decrease breast cancer risk in women with specific premalignant breast cancges in the P1 and P2 NSABP trials. Results from the Breast Cancer Prevention Trial (BCPT) have shown that women at increased risk for breast cancer are less likely to develop the disease if they take tamoxifen. Tamoxifen is approved for reducing breast cancer risk in high-risk women.

The MORE trial for osteoposrosis suggested that raloxifen decreases risks of breast cancer as well. Whether raloxifene or tamoxifene is superior in cancer prevention in women at risk is the subject on an oanging trial, Study of Tamoxifen and Raloxifene (STAR) for the Prevention of Breast Cancer in Postmenopausal Women, NCT00003906. The Study of Tamoxifen and Raloxifene (STAR) trial, found that raloxifene worked as well as tamoxifen in reducing the risk of invasive breast cancer, although it didn’t have the same protective effect against non-invasive cancer (DCIS or LCIS). Raloxifene did, however, have lower risks of certain side effects such as uterine cancer and blood clots in the legs or lungs, compared to tamoxifen (although the risk of blood clots was still higher than normal).

Aromatase inhibitors, such as Aromsyn, are being investigated for prevention in women with DCIS . Most DCIS lesions are likely to be ER-positive. Results from the MAP.3 trial found that the aromatase inhibitor Aromasin (chemical name: exemestane) was good at lowering breast cancer risk in high-risk postmenopausal women, but weakened bones. The research was published Feb. 7, 2012 online in The Lancet Oncology. NCCN on p. BRISK-B cites this study only for post0menopausal women with a Gil risk of 1.7% in 5 years or LCIS. Routine use of aromatase inhibitors for prevention of DCIS is not yet been recommended by any guideline, to my knowledge.

Trevor J. Powles Re: Tamoxifen for Prevention of Breast Cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study J. Natl. Cancer Inst. 91: 730.

R. T. Chlebowski, N. Col, E. P. Winer, D. E. Collyar, S. R. Cummings, V. G. Vogel III, H. J. Burstein, A. Eisen, I. Lipkus, and D. G. Pfister American Society of Clinical Oncology Technology Assessment of Pharmacologic Interventions for Breast Cancer Risk Reduction Including Tamoxifen, Raloxifene, and Aromatase Inhibition J. Clin. Oncol., August 1, 2002; 20(15): 3328 – 3343.

Fabian, Carol Tamoxifen or Raloxifene in Postmenopausal Women for Prevention of Breast Cancer: A Tale of Two Choices Counterpoint Cancer Epidemiol Biomarkers Prev 2007 16: 2210-2212

Monica Morrow Refining the Use of Endocrine Therapy for Ductal Carcinoma in Situ JCO April 20, 2012 vol. 30 no. 12 1249-1251

Read the Layperson version here.

Cancer Treatment Today » Prevention

Prophylactic mastectomy and oophorectomy for BRCA mutation carriers – pro

Tamoxifen for Breast Cancer – pro