Risk Assessment Now Standard with Screening Mammograms at Washington Hospital, for No Additional Cost

Breast Cancer Risk Assessment Can Provide Reassurance and Guide Additional Screenings

According to the American Cancer Society, about one in eight women in the United States will develop invasive breast cancer during her lifetime. Fortunately, death rates for breast cancer patients have been declining since about 1989, partly because of earlier detection through regular screenings and increased awareness.

“Finding breast cancer early reduces the risk of dying from the disease by 35 percent in women over 50 years of age,” notes radiologist Dr. Mimi Lin, director of mammography for the Washington Radiologists Medical Group.

“Mammography and other screenings for breast cancer are obviously important, but it’s also important to screen for a patient’s breast cancer risk level,” Dr. Lin says. “We started conducting breast cancer risk assessments in October 2013 as part of our regular mammography screenings to identify patients who are at a statistically increased risk for breast cancer. Assessing women for their breast cancer risk can be reassuring for those who are at low risk, and it can help guide the timing and methods for breast cancer screenings for women at high risk.”

The decision to offer breast cancer risk assessments resulted from community-needs surveys conducted in the communities served by Washington Hospital.

“The surveys noted that compared to national averages, there were a higher number of women in our communities who were being diagnosed with breast cancer at stage III or higher,” explains oncologist Dr. Vandana Sharma, medical director of Washington Hospital’s Oncology Program and Genetic Counseling Program. “Those rates were higher than we had expected, and they indicated that women in our communities were not being screened appropriately to detect cancer at earlier stages. We wanted to improve our service to the community and encourage women to get breast cancer screenings at appropriate intervals.”

The Breast Cancer Risk Assessment Tool adopted by Washington Hospital was developed in 1989 as part of the Breast Cancer Detection and Demonstration Project. It is a statistical tool to estimate a patient's risk for breast cancer. The assessment is based on a statistical model known as the "Gail model," which is named after Dr. Mitchell Gail, Senior Investigator in the Biostatistics Branch of National Cancer Institute’s Division of Cancer Epidemiology and Genetics. The model uses a woman's own personal medical history, her own reproductive history and the history of breast cancer among her first-degree relatives (mother, sisters, daughters) to estimate her risk of developing invasive breast cancer over specific periods of time.

“The Breast Cancer Risk Assessment Tool is a well-established and valid statistical measure that is considered appropriate by most insurance providers, including Medicare,” Dr. Sharma notes. “The risk factors evaluated in the assessment tool are ones that highly correlate with increased risk for breast cancer. In addition, the questions in the risk assessment are designed to be easy for women to answer, so it doesn’t require a lot of time."

Dr. Lin adds, "Prior to October of 2013, women having screening mammograms were asked questions similar to those in the Gail model. Formalizing the questions with the Gail model provides the benefit of risk stratification."

The Breast Cancer Risk Assessment Tool is appropriate only for women over age 35, and considers lifetime risk to age 90. It is important to remember that the risk assessment is based on population statistics. While the tool may accurately estimate a woman's risk of developing breast cancer, these risk estimates cannot say precisely which women will develop breast cancer or when. In addition, the tool cannot accurately calculate the risk of redeveloping breast cancer for women who already have a diagnosis of breast cancer, or of developing breast cancer in women with a medical history of ductal carcinoma in situ or lobular carcinoma in situ. These women are considered to be in the moderate risk category. Although the tool has been used successfully for some women with strong family histories of breast cancer, more specific methods of estimating risk are appropriate for women known to have breast cancer-producing mutations in the BRCA1 or BRCA2 genes.

A few examples of questions included in the Breast Cancer Risk Assessment Tool – and the reasons for asking those questions – include:

• What is the woman’s age? The great majority of breast cancer cases occur in women older than age 50, and the risk of developing breast cancer increases with age.
• What was the woman’s age at the time of her first menstrual period? Women who had their first menstrual period before age 12 have a slightly increased risk of breast cancer that may be linked to their longer lifetime exposure to estrogen.
• How many of the woman's first-degree relatives – mother, sisters, daughters – have had breast cancer? Having one or more first-degree relatives who have had breast cancer increases a woman's chances of developing this disease.

The general recommendation from the American Cancer Society for women at high risk for developing breast cancer (having a lifetime risk greater than 20 percent) would be to have a breast MRI in addition to a mammogram and clinical breast exam every year. Women at moderately increased lifetime risk (15 to 20 percent) should talk to their doctors about the benefits and limitations of adding breast MRI screening to their yearly mammograms. Yearly MRI screening is not recommended for women whose lifetime risk is less than 15 percent.

“Women who are at high risk for developing breast cancer are counseled to talk to their doctors about enhanced screenings and risk-reduction strategies,” says Dr. Sharma. “Most insurance plans will cover a breast MRI if the woman’s lifetime risk is greater than 20 percent. These women also might consider use of medications such as tamoxifen or raloxifene, which can cut their risk of developing breast cancer by 45 to 50 percent. Women at high risk also might be referred for genetic counseling.”

The Washington Cancer Genetics Program is a collaboration between Washington Hospital and UCSF Medical Center. The program offers genetic counseling for individuals concerned with the risk of an inherited cancer predisposition. The clinic staff includes genetic counselors, a medical oncologist and registered nurses.

The Washington Women’s Center generally performs between 400 and 500 screening mammograms each month. Between the introduction of the Breast Cancer Risk Assessment Tool in October 2013 and May of this year, a total of 107 patients were identified as having a lifetime risk of breast cancer greater than 20 percent.

“The median age of these patients is 50,” says Dr. Lin. “About 35 percent of these high-risk patients have had screening breast MRIs. Two patients were referred for genetic counseling. One of those two patients was subsequently diagnosed with early stage breast cancer, which is the most easily treated and has a much higher cure rate than more advanced breast cancers.”

Learn More

The Washington Women’s Center, located in the Washington West building at 2500 Mowry Avenue in Fremont, combines screening mammography with other advanced diagnostic services, including breast MRI. Services are provided in warm, soothing, spa-like surroundings with personal amenities designed to help women feel calm and comforted. For more information about Washington Women’s Center, visit http://whhs.com/services/specialized-programs/women-s-center/default.aspx. To schedule an appointment for a mammogram, call 510.791.3410.To schedule an MRI appointment, call 510.608.1380. All mammogram and MRI screenings require a physician referral.

For more information about the Washington Cancer Genetics Program, visit http://whhs.com/services/specialized-programs/comprehensive-cancer-program/cancer-genetics/default.aspx

For more information about the Breast Cancer Risk Assessment Tool, including questions asked in the assessment, visit www.cancer.gov/bcrisktool/.