Managing high risk patients

High risk is defined as a 1:4 or greater lifetime risk of developing breast cancer. Only 1% of women fall into this group. Even in this high-risk group there is a 50 - 75% chance that they will not get breast cancer.

These women will usually have been identified because of a strong family history of breast and / or ovarian cancer. They may have a relative with a confirmed gene abnormality. These families can be referred to the genetics department for discussion of gene testing looking for a BRCA gene abnormality.

They should have a breast and ovarian surveillance schedule in place.

There are a number of prophylactic (risk reduction) strategies that can also be considered:

Prophylactic Tamoxifen: is thought to reduce risk of getting breast cancer by 30 - 50%. It is associated with a range of side effects ranging from hot flushes to increased risk of endometrial cancer and deep vein thrombosis.

Prophylactic oophorectomy (removal of the ovaries):
In premenopausal women this procedure has a similar benefit to Tamoxifen in terms of risk reduction and also avoids the need for ovarian surveillance which is at best imprecise and unreliable.

Prophylactic mastectomy and breast reconstruction: This is a big operation, but available data suggests that it may reduce risk by up to 90%.  See case example

There is no need to rush into any of these decisions. Individual cases are best discussed in a multidisciplinary breast cancer meeting, and the woman should have seperate consultations with a number of specialists to get a balanced opinion on risks and benefits of these various options in her situation

Click on link to view interview from Close Up with one patient who has made this choice. Aug 18 2009

http://tvnz.co.nz/close-up/cutting-odds-2926500/video.xhtml

 
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Trevor Smith MBChB FCS

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