When a woman at hands with a breast...

When a woman at hands with a breast complaint, initial management nearly always includes a clinical breast examination and an imaging reflection Frequently, risk factors for breast cancer are assessed. Individualized risk predictions employing more formalized tools, of the like kind as the Gail model (1) or the Claus prototype (2) are being used increasingly in screening populations. However, an important question remains: in symptomatic women are risk factors for breast cancer still clinically important? Unfortunately, the answer is unclear.

The Steering Committee forward Clinical Practice Guidelines for the Care and Treatment of Breast Cancer (3) states that when a woman currents with a breast lump or a suspicious change in breast tissue her risk factors for breast cancer should be noted, if it be not that the presence or absence of risk factors should not influence decisions about further workup. Similarly, recommendations for evaluation and follow-up of mammographic abnormalities generally are made without regard to individual breast cancer risk. However, improved use of breast cancer risk factors has the potential to bring into the number of biopsies performed in women who do not have cancer and to increase the percentage of positive biopsies.

In answer to a topic nomination according to Kaiser Permanente Northern California, the Agency for Healthcare Research and Quality (AHRQ) permanent funded a systematic review of the literature. (4) The objective was to assess published evidence forward the relationship between risk factors, breast abnormalities (clinical symptoms or mammographic findings), and breast cancer, and to provide practical recommendations for applying this information.

The systematic review (4) build that although many studies reported breast cancer incidence in association with risk factors (menstrual status, hormone therapy, pregnancy history, family history, age) or abnormal breast findings, relatively small in number studies reported the incidence in association with the one and the other In addition, the literature feels from a lack of standardization of period of times for reporting information about breast disease. Hence, reported deductions vary, depending on whether breast cancer incidence is derived from the number of lesions or the number of affected patients.

The literature onward mammography also is problematic. Although mammographic be deriveds almost always are given, variations in reporting formats make it impossible to combine data in a useful way. The Breast Imaging Reporting and Data arrangement (BI-RADS) terminology was developed for the purport of standardizing mammogram reports. (56) Widespread use of the BI-RADS nomenclature (eg in studies that relate cancer incidence on age to BI-RADS scores) could make data integration possible. (7-11)

Thus, although risk factors for breast cancer are well established and commonly used to direct evaluation in other clinical scenarios, circulating evidence does not permit assessment of the impact of individual risk factors forward the likelihood that a breast abnormality give an account ofs cancer. Family history, (12-19) pregnancy and menstrual history, (1314) and hormone therapy (20) lacked a consistent evidence base for inferring any conclusions about the risk of cancer when these factors were associated with a clinical or mammographic abnormality. The alone exception is patient age. In this instance, studies point out that age over 50 years greatly increases the risk of breast cancer in women with a clinical or mammographic abnormality.

At this time, no published evidence supports modifying the work-up of breast symptoms or mammographic abnormalities based onward risk factors other than age.

We thank the widened MetaWorks team members, the members of the Technical adroit Panel, peer reviewers, representatives from Kaiser Permanente Northern California, and the AHRQ for their contributions to this project

References

(1) Gail MH Brinton LA, Byar DP Corle KD verdant SB, Schairer C, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 1989;81:1879-86

(2) Claus EB Risch N Thompson WD Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer 1994;73:643-51

(3) The palpable breast lump: information and recommendations to assist decision-making when a breast shapeless mass is detected. The Steering Committee upon Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ 1998;158(suppl 3):S3-8

(4) Diagnosis and management of specific breast abnormalities. Rockville, Md: Agency for Healthcare Research and Quality, Dept of Health and Human Services, 2001; evidence report/technology assessment, 1530-4396 no. 33; AHRQ publication no. 01-E 046

(5) Barton MB Elmore JG Fletcher SW Breast symptoms among women listed in a health maintenance organization: common occurrence evaluation and outcome. Ann Intern M 1999;130:651-7

(6) Liberman L Abramson AF, Squires FB Glassman JR Morris EA, Dershaw DD The Breast Imaging Reporting and Data System: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol 1998;171:35-40