Report in English with a Dutch summary (KCE reports 63A)

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132 Breast Cancer KCE reports 63 9 Women from families with a 20% or greater chance of carrying a mutation such as BRCA1, BRCA2 or TP53 should have access to testing (1C evidence). 10 The development of a genetic test for a family should usually start with the testing of an affected individual (mutation searching/screening) to try to identify a mutation in the appropriate gene (such as BRCA1, BRCA2 or TP53) (1C evidence). 11 A search/screen for a mutation in a gene (such as BRCA1, BRCA2 or TP53) should aim for as close to 100% sensitivity as possible for detecting coding alterations and the whole gene(s) should be searched (1C evidence). 12 For women from families with BRCA1, BRCA2 or TP53 mutations, or with equivalent high breast cancer risk, individualised screening strategies should be developed (1C evidence). 13 There is a lack of evidence for a high risk population that either clinical breast examination or selfexamination is useful as the sole surveillance modality (1A evidence). 14 All women with a genetic or familial high risk should be offered mammographic and ultrasound surveillance from age 30 years (1C evidence). 15 For women aged 40–49 years at moderate risk or greater, mammographic and ultrasound surveillance should be annual (1C evidence). 16 On the basis of current evidence, MRI should be added to routine surveillance practice of patients with high genetic risk (1C evidence). 5 5 5 5 5 5 5 NA 5 5 3 4,80 5 0,63 90% 5 5 4 5 5 5 5 NA 5 4 4,78 5 0,44 100% 5 5 5 5 5 5 5 NA 5 5 4 4,90 5 0,32 100% 5 5 5 5 5 5 5 NA 5 5 4 4,90 5 0,32 100% 5 5 4 5 5 5 5 5 5 5 5 4,91 5 0,30 100% 4 5 4 2 5 4 2 1 2 3 5 3,36 4 1,43 55% 5 4 5 5 5 4 5 5 5 4 4 4,64 5 0,50 100% 3 5 5 5 5 5 5 5 5 4 5 4,73 5 0,65 91% 3. You must take in consideration the age of the youngest familiy memeber with breast cancerand MRI has a central place in young patients 4. MRI should also be offered and is prefered for young ages 7. MRI? 8. No: MRI should be the first-line imaging tool. The age at which screening starts is patientdependent. Mammographic screening will not start before age 35, because of the radiation risk. See references at point 16. 9. and MRI 10. MRI 8. Important references: Radiology. 2007 Mar;242(3):698-715 - JAMA. 2004 Sep 15;292(11):1317-25 - J Clin Oncol. 2005 Nov 20;23(33):8469-76.
KCE reports 63 Breast Cancer 133 17 Bilateral risk-reducing mastectomy is appropriate only for a small proportion of women who are from high-risk families and should be managed by a multidisciplinary team (1C evidence). 5 5 5 5 5 5 5 NA 5 4 5 4,90 5 0,32 100% 18 Bilateral mastectomy should be raised as a riskreducing strategy option with all women at high risk (1C evidence). 4 3 3 5 5 4 5 NA 5 4 3 4,10 4 0,88 70% 19 Women considering bilateral risk-reducing mastectomy should have genetic counselling in a specialist cancer genetics clinic, before a decision is made (1C evidence). 5 4 3 5 5 4 2 NA 4 3 3 3,80 4 1,03 60% 20 Discussion of individual breast cancer risk and its potential reduction by surgery should take place and take into account individual risk factors, including the woman's current age (especially at extremes of age ranges) (1C evidence). 5 4 5 5 5 4 5 NA 5 4 4 4,60 5 0,52 100% 21 Family history should be verified where no mutation has been identified before bilateral risk-reducing mastectomy (1C evidence). 5 5 5 5 5 4 5 NA 5 5 5 4,90 5 0,32 100% 22 Where no family history verification is possible, agreement by a multidisciplinary team should be sought before proceeding with bilateral risk-reducing mastectomy (1C evidence). 5 4 5 2 5 4 5 NA 5 4 5 4,40 5 0,97 90% 23 Pre-operative counselling about psychosocial and sexual consequences of bilateral risk-reducing mastectomy should be undertaken (1C evidence). 5 5 5 5 5 4 5 NA 5 5 5 4,90 5 0,32 100% 24 The possibility of breast cancer being diagnosed histologically following a risk-reducing mastectomy 4,90 5 0,32 100% should be discussed pre-operatively (1C evidence). 5 5 5 5 5 5 4 NA 5 5 5 25 All women considering bilateral risk-reducing mastectomy should be able to discuss their breast reconstruction options (immediate and delayed) with a member of a surgical team with specialist oncoplastic or breast reconstructive skills (1C evidence). 5,00 5 0,00 100% 5 5 5 5 5 5 5 NA 5 5 5 26 A surgical team with specialist oncoplastic/breast reconstructive skills should carry out risk reducing 4,90 5 0,32 100% mastectomy and/or reconstruction (1C evidence). 5 5 5 5 5 4 5 NA 5 5 5 27 Women considering bilateral risk-reducing mastectomy should be offered access to support groups and/or women who have undergone the 4,70 5 0,67 90% procedure (1C evidence). 5 3 5 5 5 5 5 NA 5 5 4 28 Risk-reducing bilateral salpingo-oophorectomy is appropriate only for a small proportion of women who are from high risk families and should be managed by a multidisciplinary team (1C evidence). 4,67 5 0,71 89% 5 3 5 4 5 5 NA NA 5 5 5 3. This depends on definition "high risk" 7. High risk patient??? 4. please considerer changing the word "should" for "MUST"
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