Page 14 - Delaware Medical Journal - March 2018
P. 14
FIGURE 1
family history may reveal the possibility of deleterious germ line mutation. One quick tool to identify individuals who should
be referred to a Genetic Counselor is the Referral Screening Tool. (Figure 1 12 Genetic Counselors will use four computer models to risk and of deleterious mutation. They
will recommend testing if indicated, and for which mutations the patient should be tested. They are also enormously helpful at providing the data to third party carriers, which will result in coverage of any tests that are appropriate and in helping the PCP interpret the results of testing, which can often be nuanced.
Criteria other than family history also impact breast cancer risk. One free web based tool for breast cancer risk assessment, which
is user friendly, validated, and takes into account many risk factors including results of previous biopsies, BMI and hormonal history, is the Tyrer-Cuzick Risk Calculator, available online at ibis.ikonopedia.com. This tool calculates the woman’s ten year risk of breast cancer and her lifetime risk of breast cancer, and compares these to those of the general population.
Breast cancer risk assessment, if done well, is not possible in a 15 minute visit. To help doctors and their patients with this, the
Breast Program at the Helen F. Graham Cancer Center has developed a “Breast Cancer Prevention Program.” The doctor
or the patient can call 302-623-4343 and
ask for a “breast cancer prevention visit.”
A specially trained PA-C member of our Breast Surgeons practice will meet with
the patient, review her images, examine
her, take a three generation family history, obtain any pertinent biopsy results, calculate a Tyrer-Cuzick lifetime risk, and make
a personalized recommendation for that patient for screening and for risk reduction strategies. If the assessment indicates value for the patient in Medical Oncology consultation for chemoprevention or for Genetic Counseling referral, these referrals will be facilitated. A complete report of provided to the patient and to the PCP.
Armed with a metric for the woman’s risk
of developing breast cancer, the PCP can offer suggestions in answer to the question: How often should I be screened? National societies are in an uproar over whether screening should begin at 45 or at 40. The guidelines are all over the board. The
United States Preventive Services Task Force 2016 guidelines have a very high
level of evidence, but they are not popular because they state honestly that vigorous examination of available data do not support annual mammography beginning at age 40.13 Guidelines from the American College of Physicians are fairly vague.11 The American College of Radiology recommends mammography every year from age 40, for all women. The American Cancer Society, in my opinion, strikes the best balance between being evidence based and being acceptable to the general public. The ACS recommends mammographic screening beginning at
age 40 for individuals with risk factors for breast cancer, such as family history of breast cancer or personal history of breast cancer. The ACS recommends annual mammography for all women ages 45 to 74. At age 75 years, women who have no additional risk factors (other than age) may
78
Del Med J | March 2018 | Vol. 90 | No. 3
