What is the management plan for atypical lobular hyperplasia (ALH) to reduce the risk of breast cancer?

Management of Atypical Lobular Hyperplasia (ALH) to Reduce Breast Cancer Risk

Patients with atypical lobular hyperplasia should be offered chemoprevention with tamoxifen, raloxifene, or aromatase inhibitors as they can reduce breast cancer risk by up to 86%. 1

Understanding ALH and Associated Risk

Atypical lobular hyperplasia (ALH) is a non-malignant breast lesion that significantly increases breast cancer risk:

• Confers a 4-5 times higher lifetime risk of developing breast cancer compared to the general population 1, 2
• Risk affects both breasts (bilateral risk) 3
• Acts as both a risk indicator and potential precursor lesion 4

Management Algorithm for ALH

1. Surgical Management

• Initial diagnosis via core needle biopsy:

  • Surgical excision is indicated if:
    • ALH is extensive (>3-4 foci)
    • Associated with microcalcifications
    • Radiologic-pathologic discordance exists 1
  • Minimal ALH (≤3 foci) with radiologic concordance may not require excision 5

• When diagnosed on surgical biopsy:

  • Generally does not require further surgical intervention 3
  • Margins positive for ALH do not require re-excision 1

2. Risk Reduction Therapy (Primary Intervention)

• Chemoprevention should be strongly recommended for all patients with ALH 6, 1
• Options include:
  • Premenopausal women: Tamoxifen (reduces invasive breast cancer risk by ~46%)
  • Postmenopausal women: Raloxifene, exemestane, or anastrozole 1
• The National Comprehensive Cancer Network strongly recommends risk reduction medications for women with ALH, as they have shown an 86% reduction in breast cancer risk with therapy 6

3. Surveillance Protocol

• Clinical breast examinations every 6-12 months 1
• Annual diagnostic mammography 1
• Consider supplemental screening with breast MRI, especially for women with dense breasts 1
• Surveillance should continue for decades due to persistent risk 1

4. Special Considerations

• Bilateral risk-reduction mastectomy may be considered in select cases:
  • Women with ALH plus BRCA1/2 mutations
  • Strong family history of breast cancer
  • Patient preference after thorough counseling 1

Outcomes and Prognosis

Despite the increased risk associated with ALH:

• Subsequent cancers often have favorable characteristics:
  • Approximately 42% are special subtype tumors with good prognosis 7
  • Many are of low or intermediate histologic grade 7
  • Overall excellent survival rates for cancers developing after ALH diagnosis 7

Common Pitfalls to Avoid

• Undertreatment: Failing to discuss or offer risk reduction medications, which can reduce breast cancer risk by up to 86% 6, 1
• Overtreatment: Unnecessary surgical excision for limited ALH with radiologic-pathologic concordance 1, 5
• Inadequate surveillance: Not maintaining long-term follow-up, as risk persists for decades 1
• Overlooking bilateral risk: The risk affects both breasts, not just the side where ALH was found 3, 4

Barriers to optimal management include inadequate risk assessment training, lack of reimbursement for prevention counseling, and limited access to user-friendly risk assessment tools 6. Addressing these barriers is essential for improving uptake of risk reduction strategies.