• Breast awareness:
    • Starting at age 18 years:
      • Women should be familiar with their breasts and promptly report changes to their health care provider:
        • Periodic, consistent breast self-exam (BSE) may facilitate breast self-awareness
          • Premenopausal women may find BSE most informative when performed at the end of menses
  • Clinical breast exam, every 6 to 12 months:
    • Starting at age 25 years:
      • Randomized trials comparing clinical breast exam versus no screening have not been performed:
        • Rationale for recommending clinical breast exam every 6 to 12 months is the concern for interval breast cancers
  • Breast screening:
    • Age 25 to 29 years:
      • Annual breast MRI screening with contrast:
        • or Mammogram with consideration of tomosynthesis:
          • Only if MRI is unavailable:
            • Breast MRI is preferred due to the theoretical risk of radiation exposure in pathogenic /likely pathogenic variant carriers
      • Individualized based on family history if a breast cancer diagnosis before age 30 is present
    • Age 30 to 75 years:
      • Annual mammogram with consideration of tomosynthesis and breast MRI screening with contrast:
        • The criteria for high-quality breast MRI include:
          • dedicated breast coil
          • The ability to perform biopsy under MRI guidance
          • Radiologists experienced in breast MRI
          • Regional availability
        • Breast MRI is preferably performed on:
          • Days 7 to 15 of a menstrual cycle for premenopausal women
    • Age greater than 75 years:
      • Management should be considered on an individual basis
    • For women with a BRCA pathogenic / likely pathogenic variant who are treated for breast cancer and have not had a bilateral mastectomy:
      • Screening with annual mammogram with consideration of tomosynthesis and breast MRI should continue as described above
        • The appropriateness of imaging modalities and scheduling is still under study. Lowry KP, Lee JM, Kong CY, et al. Cancer 2012;118:2021-2030.
        • Lehman CD, Lee JM, DeMartini WB, et al. Screening MRI in women with a personal history of breast cancer. J Natl Cancer Inst 2016;108. 
  • Discuss option of risk-reducing mastectomy:
    • Counseling should include a discussion regarding:
      • Degree of protection
      • Reconstruction options, and risks
    • In addition, the family history and residual breast cancer risk with age and life expectancy should be considered during counseling 
  • Recommend risk-reducing salpingo-oophorectomy (RRSO):
    • Given the high rate of occult neoplasms:
      • Special attention should be given to sampling and pathologic review of the ovaries and fallopian tubes
    • Typically between 35 and 40 years, and upon completion of child bearing
    • Because ovarian cancer onset in patients with BRCA2 pathogenic / likely pathogenic variants is an average of 8 to 10 years later than in patients with BRCA1 pathogenic / likely pathogenic variants:
      • It is reasonable to delay RRSO for management of ovarian cancer risk:
        • Until age 40 to 45 years in patients with BRCA2 pathogenic / likely pathogenic variants unless age at diagnosis in the family warrants earlier age for consideration of prophylactic surgery. 
      • Counseling includes a discussion of:
        • Reproductive desires
        • Extent of cancer risk
        • Degree of protection for breast and ovarian cancer
        • Management of menopausal symptoms
        • Hormone replacement therapy, and related medical issues
      • Salpingectomy alone is not the standard of care for risk reduction, although clinical trials of interval salpingectomy and delayed oophorectomy are ongoing:
        • The concern for risk-reducing salpingectomy alone is that women are still at risk for developing ovarian cancer
        • In addition, in premenopausal women, oophorectomy likely reduces the risk of developing breast cancer but the magnitude is uncertain and may be gene-specific
  • Limited data suggest that there may be a slightly increased risk of serous uterine cancer among women with a BRCA1 pathogenic / likely pathogenic variant.
    • The clinical significance of these findings is unclear
    • Further evaluation of the risk of serous uterine cancer in the BRCA population needs to be undertaken
    • The provider and patient should discuss the risks and benefits of concurrent hysterectomy at the time of RRSO for women with a BRCA1 pathogenic / likely pathogenic variant prior to surgery
    • Women who undergo hysterectomy at the time of RRSO are candidates for estrogen alone hormone replacement therapy, which is associated with a decreased risk of breast cancer compared to combined estrogen and progesterone, which is required when the uterus is left in situ (Chlebowski R, et al. JAMA Oncol 2015;1:296-305)
  • Address psychosocial and quality-of-life aspects of undergoing risk-reducing mastectomy and /or salpingo-oophorectomy
  • For those patients who have not elected RRSO:
    • Transvaginal ultrasound combined with serum CA-125 for ovarian cancer screening:
      • Although of uncertain benefit, may be considered at the clinician’s discretion starting at age 30 to 35 years
  • Consider risk reduction agents as options for breast and ovarian cancer, including discussion of risks and benefits 

#Arrangoiz #CancerSurgeon #BreastSurgeon #BreastCancer #BRCA1 #BRCAPositiveBreastCancer #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncology

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