What are the recommendations for surveillance and risk reduction for a 31-year-old woman with a Tyrer-Cusick (Tyrer-Cusick score) lifetime risk of breast cancer of 32% and negative genetic testing?

From the Guidelines

For a 31-year-old woman with a Tyrer-Cusick lifetime breast cancer risk of 32% and negative genetic testing, enhanced surveillance and risk reduction strategies are recommended. She should undergo annual breast MRI screening in addition to annual mammography, with MRI and mammography ideally staggered six months apart to provide twice-yearly imaging, as supported by the American College of Radiology's guidelines for breast cancer screening 1. Clinical breast exams should be performed every 6-12 months. Risk-reducing medication options include tamoxifen 20mg daily, raloxifene 60mg daily (for postmenopausal women only), or aromatase inhibitors such as exemestane 25mg daily or anastrozole 1mg daily (also for postmenopausal women only), which can reduce breast cancer risk by 40-65% 1. Lifestyle modifications are also important, including:

• Maintaining a healthy weight
• Limiting alcohol consumption to less than one drink daily
• Regular physical activity (150 minutes weekly)
• Avoiding hormone replacement therapy when possible These recommendations are based on her high-risk status (>20% lifetime risk), which qualifies her for more intensive surveillance than average-risk women, even with negative genetic testing, as outlined in guidelines for breast cancer risk reduction 1. The enhanced screening aims to detect any cancer at an earlier, more treatable stage, while risk-reducing medications work by blocking estrogen's effects on breast tissue.

From the FDA Drug Label

Tamoxifen citrate tablets are indicated to reduce the incidence of breast cancer in women at high risk for breast cancer.

"High risk" is defined as women at least 35 years of age with a 5 year predicted risk of breast cancer ≥ 1.67%, as calculated by the Gail Model.

The patient is a 31-year-old woman with a Tyrer-Cusick lifetime risk of breast cancer of 32%, which is considered high risk.

• Surveillance: The patient should undergo regular breast surveillance, including annual mammography and clinical breast examination.
• Risk Reduction: The patient may be considered for chemoprevention with tamoxifen, as she is at high risk for breast cancer. However, the decision to start tamoxifen should be based on an individual assessment of the benefits and risks of therapy, including the patient's age, menopausal status, and other risk factors.
• Alternative Risk Reduction Strategies: Other risk reduction strategies, such as bilateral prophylactic mastectomy, may also be considered, although these are typically reserved for women with a very high risk of breast cancer, such as those with BRCA1 or BRCA2 mutations. 2 2 2

From the Research

Assessment

• The patient is a 31-year-old woman with a Tyrer-Cusick lifetime risk of breast cancer of 32% and negative genetic testing.
• The Tyrer-Cusick model is used to predict the risk of breast cancer, but studies have shown that it may overestimate the risk in certain populations, such as women with atypical hyperplasia 3 and lobular carcinoma in situ (LCIS) 4.
• The patient's high risk of breast cancer warrants close surveillance and consideration of risk reduction strategies.

Surveillance

• Magnetic Resonance Imaging (MRI) has been shown to be effective in detecting breast cancer in high-risk women, particularly those with BRCA1 and BRCA2 mutations 5, 6.
• A study comparing breast MRI, mammography, and ultrasound for surveillance of women at high risk for hereditary breast cancer found that MRI detected all six invasive cancers, while mammography and ultrasound detected only two and three, respectively 6.
• The American College of Radiology recommends annual MRI screening for women with a lifetime risk of breast cancer of 20% or higher, in addition to annual mammography and clinical breast examination.
• Consideration should be given to adding MRI to the patient's surveillance regimen, given her high lifetime risk of breast cancer.

Risk Reduction

• Risk reduction strategies for breast cancer include chemoprevention, such as tamoxifen or raloxifene, and surgical options, such as bilateral prophylactic mastectomy.
• The decision to pursue risk reduction strategies should be individualized, taking into account the patient's personal preferences, medical history, and risk factors.
• The patient's negative genetic testing results do not eliminate the possibility of developing breast cancer, and she should continue to be closely monitored and considered for risk reduction strategies.

Plan

• The patient should undergo annual MRI screening, in addition to annual mammography and clinical breast examination, to closely monitor her breast health.
• The patient should be considered for chemoprevention, such as tamoxifen or raloxifene, to reduce her risk of developing breast cancer.
• The patient should be educated on the risks and benefits of surgical options, such as bilateral prophylactic mastectomy, and the decision to pursue these options should be individualized.
• The patient should continue to be closely monitored and followed up regularly to assess her risk of developing breast cancer and to adjust her surveillance and risk reduction strategies as needed 5, 7, 6.