High-Risk Breast Cancer Screening
This article originally appeared in Pathways, a magazine published
for physicians and the community by UMass Memorial Medical Center.
Women fear breast cancer more than twice as much as they fear the risk of a
heart attack, according to a survey conducted for the American College of
Obstetricians and Gynecologists - even though each year more than 11 times as
many women die from cardiovascular disease than from breast cancer.
Dispelling this fear - and supplanting it with reliable information about
risk factors and prevention strategies - is the philosophy behind the
High-risk Breast Cancer Screening Program at UMass Memorial Medical Center. It
is the only specialized program in Central Massachusetts to help identify and
monitor women at high risk of developing this disease. Early risk identification
enables a woman and her physician to work together to devise a strategy for
prevention and screening for early stage breast cancer - the key to successful
treatment and a positive outcome.
"UMass Memorial has had a very successful comprehensive breast cancer program
for nearly 20 years. Each year we treat approximately 500 new breast cancer
patients from among nearly 15,000 patients seen in our center," says Kathryn
Edmiston, MD, codirector of the program. "Through this experience, we know that
there is a group of women who not only fear breast cancer, but may also over- or
underestimate their risk of developing the disease.
"UMass Memorial has a strong track record in preventive health strategies;
the high-risk program was a natural progression of this strength," she
continues. "The long-time message has always been ‘screening,' but even early
stage breast cancer that is detected during screening can be unpredictable. We
need to find ways to prevent it, not just detect it early."
The UMass Memorial high-risk program offers a range of services including
personalized risk assessment, screening tests, genetic counseling and education
about breast cancer risk, preventive agents including tamoxifen, and access to
state-of-the-art clinical prevention trials and other research.
A personalized approach to risk assessment is the foundation of the program.
Dr. Edmiston explains: "Prior to a patient's first visit, we have her complete
the GAIL model assessment tool, a detailed questionnaire reviewing all of the
known factors for breast cancer," she says. The GAIL model was developed by the
National Cancer Institute and the National Surgical Adjuvant Breast and Bowel
Project (NSABP). "From this, we can calculate a woman's five-year and lifetime
risk of developing breast cancer."
A second questionnaire, known as the CASH model, relies on data from women
who have a family or personal history of breast cancer. "Using these two sets of
information, we can determine which specialists a patient should see for
prevention and monitoring," Dr. Edmiston says. "For women whose five-year risk
of developing breast cancer is greater than 1.6 percent, chemopreventive agents
such as tamoxifen or enrollment in the STAR trial (see sidebar) are
recommended," she adds. "For women whose five-year risk is less than 1.6
percent, there are a variety of follow-up options that could include genetic
testing and counseling."
UMass Memorial also offers ductal lavage as part of its high-risk program.
"Ductal lavage is used as an adjunct to other risk assessment tools," explains
Anne Larkin, MD, codirector of the high-risk screening program. "It is indicated
for any woman deemed to be at high risk, but can only be performed on women who
produce nipple aspirate fluid."
The first portion of the procedure is a
simple aspiration of the breast after about five minutes of massage. If nipple
fluid is produced, a tiny catheter is inserted into the duct, which is rinsed
with saline solution. The fluid contains ductal cells that can be examined for
"Atypical cells indicate a significantly elevated risk - over and above the
baseline risk assessment - of developing breast cancer," Dr. Larkin says.
"Finding atypical cells may have many management implications including
instituting tamoxifen therapy, taking part in the STAR trial, close clinical
follow-up with ductal lavage at regular intervals, various radiologic studies,
etc." Mammography and breast MRI are among the radiologic modalities available
through the program.
"We are very excited about initiating several clinical and basic science
studies based on ductal lavage technology, and I hope that we would eventually
be performing 50 to 100 procedures a year," she adds. "As with any form of risk
assessment, our goal is to identify women at risk prior to the development of a
cancer, and I believe that ductal lavage as part of a formal high-risk program
is an integral part of that process."
Women usually are referred to the High-risk Breast Cancer Screening Program
by their primary care physician or obstetrician/gynecologist. When is a referral
appropriate? "Any woman who is worried about her risk of breast cancer due to
identifiable factors, such as family history, or being postmenopausal and on
HRT, is a candidate for the high-risk screening program," says Dr. Edmiston.
"But even if a woman is worried about breast cancer for any reason, it's worth
Dr. Edmiston also notes that today, the primary care provider usually is the
first person receiving biopsy results when breast cancer is suspected. "If
invasive breast cancer is the diagnosis, we all know what to do," she says. "But
if a biopsy reveals atypical ductal hyperplasia, lobular carcinoma in situ or
atypical lobular hyperplasia, even though these conditions are benign, the
patient should be referred to a high-risk center." At UMass Memorial, these
patients can have access to state-of-the-art preventive protocols and ongoing
clinical trials taking place on campus - proactive initiatives that have shown
to mitigate more effectively the risk of breast cancer developing than a
This close collaboration between the clinical setting and the research lab is
arguably the greatest advantage that UMass Memorial offers referring physicians
and their patients at risk of breast cancer. "We can take information from the
clinical setting to the bench and back to the clinical setting so that it
benefits patients as quickly as possible," Dr. Edmiston says.
Working with an academic medical center enables patients to benefit from the
spectrum of the newest drugs and technological advances, in a specialized
biomedical environment, in the safest context. This is why the Comprehensive
Breast Center and its high-risk screening program make such a difference to
patients and their families.