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Q: I have had multiple breast biopsies, all “non-cancerous.” Most recently, I had a biopsy with atypical cells (“Atypical Ductal Hyperplasia”). My doctor has told me I am at high risk for breast cancer, what can I do about this?

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A: Dr. Shubhada Dhage: Multiple risk factors impact an individual’s risk of developing breast cancer during their lifetime. It is important to understand your risk, because it will be the basis of an individualized screening plan. Your risk of cancer is related to any of the following: breast density, your family history, your personal history, lifestyle factors, and/or hormonal factors. Women with density in 75% or more of their breast tissue are at increased risk of breast cancer. Personal factors such as drinking alcohol, sedentary lifestyle, and obesity also contribute to your overall risk. Risk can also be related to the amount of time your breast tissue is consistently exposed to estrogen, as it is during long periods of uninterrupted menstrual or ovulatory cycles.

In your case, you are considered high risk because you had a biopsy that revealed a pathologic risk factor that shows some changes in your breast tissue. It showed atypia (meaning not typical). There are other pathologic risk factors for breast cancer (tissue changes identified after a biopsy). These include atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS). These pathologic risk factors mean that you can be diagnosed with cancer in either breast. It is also a sign that you have an increased lifetime risk of developing breast cancer (1–2 percent per year for ADH or ALH, and approximately 2 percent per year for LCIS).

There are many different calculators to integrate all of the different risk factors for breast cancer. One that is commonly used is the Gail Model, which takes into consideration a limited family history, age at menopause, ethnicity, prior breast biopsies and pregnancy history. The calculated risk can then be used to determine how frequent you need to see a doctor and whether you need additional types of imaging studies such as an MRI.

Some women may choose to have surgical therapy to reduce their risk of breast cancer. This means they may have a prophylactic mastectomy (complete removal of the breast tissue) or a prophylactic oophorectomy (removal of the ovaries). Surgical therapy is only reserved and discussed in patients who have an extremely high risk of developing cancer. It is a careful decision to be made with your doctor to determine if it is the right therapy for you because there are other alternatives to reduce your risk that are not surgical. Medical therapy may also be considered, my colleague Dr. Douglas Marks elaborate more on this below.

Dr. Douglas Marks: I also find the Gail Model very helpful. Additionally, for patients with extensive family history including multiple non-first degree relatives with breast cancer, I use alternative models to characterize the patient’s risk. As an aside, a significant family history can also prompt a recommendation for genetic counseling to screen for genetic basis for breast cancer (e.g. BRCA1 or BRCA2). Patients who are identified as having a genetic risk factor for breast cancer are managed differently and should certainly see either a breast surgeon or a medical oncologist to discuss specific screening and treatment recommendations which are most appropriate for their situation. However, in patients for whom a genetic cause is neither identified or suspected, three medications– tamoxifen, raloxifene and exemestane–are recommended by the American Society for Clinical Oncology, the leading oncology society for healthcare professionals. All three agents are very effective at reducing a patient’s risk for the development of breast cancer (referred to as chemoprevention). However, they differ in their side effects and for which patient population they are most appropriate.

For premenopausal women, where ovarian function is still active, tamoxifen is most appropriate. For postmenopausal women, all three agents can be considered however, raloxifene or exemestane are more commonly selected. This is because tamoxifen is associated with small, but well described risk, for endometrial cancer that is primarily seen in post menopausal patients. Most studies have demonstrated an approximately 50-60% reduction in breast cancer with tamoxifen and exemestane respectively, whereas a slightly lower risk reduction has been seen with raloxifene.

As all the agents are quite effective, when considering a patient for chemoprevention, the patient’s estimated risk for development of breast cancer as well as medical history factor into my treatment recommendation. Additionally, I always discuss with patient that while these agents have been shown to reduce the risk of development of breast cancer (both invasive and noninvasive), they have not been demonstrated to reduce this risk of breast cancer mortality or improve overall survival. The lack of survival benefit observed is likely for several reasons, but partly due to improved treatment options of breast cancer. However, for many patients reducing risk for being diagnosed with breast cancer requiring at minimum surgery, often radiation therapy, and possibly chemotherapy is sufficient reason to consider chemoprevention.

That being said, it very important to understand that having multiple risk factors does not mean you will develop breast cancer. It just means that the likelihood of being diagnosed with breast cancer is greater than for those with fewer risk factors.

Because risk is based on multiple factors, it is important to work with a team of doctors who specialize is breast health and who have a comprehensive approach to address lifestyle, family history, and pathologic factors. At NYU Winthrop Hospital, we have an established Center of Excellence for Breast Health where we can create a personalize risk assessment and treatment plan for all patients.

To schedule an appointment, or learn more about the NYU Winthrop Breast Health Program, visit www.nyuwinthrop.org or call 1-866-WINTHROP.

Shubhada Dhage, MD, FACS

Dr. Dhage is the Director of Breast Surgery Services and the Associate Director of the NYU Winthrop Hospital Breast Health Program, an Assistant Professor in the Department of Surgery in the NYU School of Medicine and is fellowship trained in Breast Surgery. Prior to joining NYU Winthrop she was the Co-Director of the NYU Perlmutter Cancer Disparities Program. Dr. Dhage has conducted research in tumor genomics, patient decision-making, cancer survivorship, and surgical training. She serves on several national committees including the American College of Surgeons, the CDC Young Women with Breast Cancer Committee, and Young Survival Coalition. She has presented in national forums, published, and has received grant funding to support her work.

Douglas Marks, MD

Dr. Douglas Marks is an Attending Physician in the Division of Oncology/Hematology at NYU Winthrop Hospital, having joined the Hospital following a fellowship program in Oncology/Hematology at Columbia University Medical Center. Dr. Marks also serves as a Clinical Instructor with a primary clinical focus on breast cancer. Dr. Marks was awarded an American Association for Cancer Research (AACR) Scholar in Training Award in 2017 and is currently involved in several research endeavors focused on better understanding the interaction between an individual patient’s immune system and breast cancer.