1. Wolfgang, Kelly

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According to Sandhya Pruthi, MD, Professor of Medicine and General Internal Medicine at the Mayo Clinic, "it's time for a change." She recently co-authored an editorial investigating the benefits of re-evaluating breast cancer risk assessment and prevention tools to create a comprehensive approach that encompasses individualized risk assessment and implementation of broader risk-reduction strategies (J Oncol Pract 2021; DOI: 10.1200/OP.21.00551). The proposed new model would include lifestyle modification, genetic counseling and testing, preventive endocrine medications, consideration of risk-reducing surgery, and surveillance breast imaging.

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As technology continues to evolve and the understanding of best practices for risk assessment and preventive strategies grows, Pruthi urges clinicians to begin reconsidering the current standard.


Time to Pivot

The computerized risk calculation tools available today have limitations in their ability to provide population-based risk assessment and are not capable of estimating risk of breast cancer-related death, according to the authors. Data from the Breast Cancer Surveillance Consortium even showed that women with lower 5-year risk estimates of breast cancer based on the Breast Cancer Risk Assessment Tool actually had higher breast cancer mortality.


As advances in research drive newer polygenic profiles to improve breast cancer prediction; genetic counseling and testing evolves; studies continue to identify the benefits of a low-fat diet; new medications are developed; and surveillance breast imaging becomes more precise, clinicians must also drive the development of newer, more comprehensive risk assessment and prevention tools. Technology should incorporate risk factor input for reduction in breast cancer risk of both favorable hormone receptor-positive tumors and unfavorable tumor types, such as estrogen receptor-positive and progesterone receptor-negative or triple-negative tumors. Given the evolving knowledge, these reimagined tools should also emphasize reduction in breast cancer mortality as an important end point, the researchers noted.


In addition, updated agency breast cancer prevention guidelines should include a comprehensive approach that incorporates healthy lifestyle modifications with low-fat dietary recommendations and interventions, and pharmacologic options including preventive endocrine therapy or oral conjugated equine estrogen (CEE), which has been shown in the research setting to reduce breast cancer incidence and mortality, per Pruthi et al. The editorial also recommended enhancing tools with lifestyle factor considerations, such as current medication use, family history, and reproductive risk factors. These tool modifications would enhance estimate risk for breast cancer, as well as possibly identify patients more likely to develop a poor prognosis of breast cancer and may help to improve compliance and uptake of risk-reducing strategies, Pruthi noted.


Evolving Research

Pruthi related that including these elements would be a key factor in prevention of breast cancer development for those patients who are identified as high risk. Certain elements that could benefit patients, such as the introduction of a low-fat diet or the use of medications, deserve additional research and should be considered when creating a comprehensive risk assessment and prevention tool, she noted.


"One thing that we as primary care providers can begin to counsel patients about now, even before a tool is developed, is a low-fat diet," Pruthi emphasized. "Dietary modifications such as reducing fat in the diet could prevent and reduce these cancers from developing into unfavorable cancers by 23 percent and reduce death from unfavorable tumors by 20 percent."


She also highlighted the importance of re-examining the use of medications such as CEE to reduce breast cancer mortality. A recent large randomized trial by the Women's Health Initiative found that in women with prior hysterectomy, CEE demonstrated a reduction in breast cancer mortality.


"The trial found that, for this patient population, women who used CEE compared to those with a placebo had a 56 percent reduction in the incidence of breast cancer and a reduction in mortality of 40 percent," Pruthi said.


Additional studies evaluating the benefits of tamoxifen showed reductions in breast cancer incidence of the favorable, hormone receptor-positive breast cancers, though long-term follow-up showed a higher breast cancer-related mortality in the tamoxifen group despite a reduction in breast cancer incidence, the editorial noted.


"When it comes to prevention of breast cancer, we really need to rethink our current strategies to include not just hormone-feeding breast cancers, but those that are more difficult to prevent, such as cancers that may be progesterone-negative," Pruthi said. "By encompassing these variants in an updated risk assessment and cancer prevention tool, we can offer more personalized counseling to patients based on their unique histories."


Next Steps

As research moves forward, the impetus to create new tools to better integrate current knowledge is strong. "Today, there are no good risk assessment tools that incorporate all the newly considered factors to calculate or define a risk score that would allow me to better counsel patients about medication recommendations, or even how to fairly and adequately convey messaging about available prevention options," Pruthi said. "There is a major communication challenge on how to help providers synthesize information and communicate it to patients."


With the introduction of an easily accessible, efficient, and accurate personalized risk assessment tool, however, physicians could begin to better serve their patients at high risk for breast cancer occurrence and even reduce breast cancer mortality. Pruthi noted that a ubiquitous risk assessment tool should be free of charge, easy to use, and validated for use by electronic health records systems.


Pruthi et al recommend partnering with patients to assess for barriers to implementation of recommendations, such as social determinants of health, including motivation and dietary change. Effective education of clinicians will empower them to counsel patients regarding various risk-reducing strategies and allow women to make informed choices to manage risk and feel confident about lifestyle changes and use of preventive medications, the editorial noted.


"It's paramount today that all women receive a formal breast cancer risk assessment as young as age 30," Pruthi said. "By doing risk assessments and determining if a patient is identified as having high enough risk, we could begin surveillance earlier, especially in groups such as African Americans, who tend to get cancers earlier and more aggressively. Improved risk assessment will make a huge impact on early detection and prevention," she concluded.


Kelly Wolfgang is a contributing writer.