From the Guidelines
This patient has a relatively low risk for breast cancer and should continue annual mammography screening, as recommended for women of her age, along with monthly breast self-examinations and clinical breast examinations during annual check-ups. Based on her history, she has only one risk factor, which is a family history of breast cancer in a paternal cousin. However, this represents a second-degree relative, which confers a lower risk than first-degree relatives (mother, sister, daughter) 1. Other factors in her favor include normal BMI, no personal history of breast disease, and normal current mammogram. Her brief use of vaginal estrogen cream after menopause is unlikely to significantly increase her risk, as it provides minimal systemic absorption compared to oral hormone therapy.
Risk Assessment and Screening
For ongoing management, it is essential to consider her risk factors and the latest guidelines for breast cancer screening. The American College of Physicians and other organizations recommend individualized assessment of risk for breast cancer to guide decisions about screening mammography 1. Given her limited family history, genetic testing for BRCA mutations is not indicated at this time unless there are additional family members with breast, ovarian, or related cancers. If more concerning family history emerges, reassessment of her risk and consideration of genetic counseling would be appropriate.
Lifestyle Modifications
Lifestyle modifications that may further reduce breast cancer risk include maintaining her healthy weight, limiting alcohol consumption, engaging in regular physical activity, and consuming a diet rich in fruits and vegetables. These recommendations are based on the understanding that lifestyle factors can influence breast cancer risk, although the evidence is not as strong as it is for screening and genetic factors 1.
Conclusion of Recommendations
In summary, the patient should continue with annual mammography screening and adopt healthy lifestyle modifications to minimize her risk of breast cancer. Regular follow-ups and reassessments of her risk factors will be crucial in adjusting her screening and prevention strategies as needed. The most recent guidelines and evidence support the continuation of screening in average-risk women, with an emphasis on individualized risk assessment and consideration of the benefits and harms of screening 1.
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. This effect was shown in a study of 5 years planned duration with a median follow-up of 4. 2 years. “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 58 years old and has a paternal cousin who died of breast cancer. To determine if she is at high risk for breast cancer, we need to calculate her 5-year predicted risk using the Gail Model.
- The patient's age is 58, and she has a first-degree relative (paternal cousin is not a first-degree relative, first-degree relatives are parents, siblings, and children) with no history of breast cancer,
- The patient has no history of benign biopsies or atypical hyperplasia.
- The patient's age at first live birth was 20 (gravida 1 para 1), and age at menarche was 15.
Since the provided information does not include the patient's number of first-degree relatives with a history of breast cancer, number of benign biopsies, or history of atypical hyperplasia, we cannot directly apply the examples given in the label to determine the patient's risk. Therefore, the Gail Model is necessary to estimate the absolute breast cancer risk. Without the Gail Model calculation, we cannot determine if the patient is at high risk for breast cancer. Thus, we cannot conclude if tamoxifen or raloxifene is indicated for this patient to reduce the incidence of breast cancer 2 3.
From the Research
Breast Cancer Risk Factors
- The patient has a paternal cousin who died of breast cancer, which may increase her risk for breast cancer due to potential genetic factors 4.
- However, the majority of breast cancers are sporadic, and risk factors are primarily related to estrogen exposure 4.
- The patient's use of vaginal estrogen cream twice weekly for the first 3 years after menopause may have increased her estrogen exposure, potentially affecting her breast cancer risk 4.
Breast Cancer Screening Recommendations
- The American College of Radiology and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy 5.
- The American Cancer Society recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years, with annual screening for women aged 45 to 54 years, and biennial screening or the opportunity to continue screening annually for women 55 years and older 6.
- The patient, who is 58 years old and has a normal screening mammography, should continue screening mammography as long as her overall health is good and she has a life expectancy of 10 years or longer 6.
Risk Reduction Strategies
- Recommendation strategies for reducing breast cancer risk include engaging in a healthy lifestyle by decreasing alcohol consumption, following a low-fat diet enriched with fruits and vegetables, exercising, and reducing weight if obese 4.
- Tamoxifen and raloxifene are both indicated for and equally effective in the prevention of breast cancer in women at high risk for development of the disease, but may have adverse effects such as thromboembolic events and uterine hyperplasia 4, 7.
- The patient's BMI is 23 kg/m², which is within the normal range, and she has no chronic medical conditions, which may reduce her risk for breast cancer 4.