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Current Topics in Menopause, 2013, 213-253 213
CHAPTER 9
Assessing and Managing the Risk of Breast Cancer in
Postmenopausal Women: Opportunities and Challenges
Victor G. Vogel *
Geisinger Health System, 100 N Academy Avenue, Danville, PA 17822-2001, USA
Abstract: A number of factors are known to increase the risk of developing breast cancer.
The most important of these is age, but race and ethnicity are associated with important
differences in risk. Nulliparity and birth events, benign breast disease, and the use of
replacement hormonal therapy at menopause also contribute to risk. Family history and the
presence of predisposing genetic mutations are important factors as is ethanol consumption.
Circulating estrogen levels can stratify risk, but their use in clinical settings is not routine.
Risk for breast cancer can be easily and rapidly assessed in the clinic, and validated,
quantitative models are available to accomplish this task. Mammographic breast density
identifies postmenopausal women who are at increased risk. Multiple, published,
randomized studies show that the selective estrogen response modifiers (SERMs)
tamoxifen and raloxifene can safely reduce the risk of invasive breast cancer in both preand
postmenopausal women. Tamoxifen provides net benefit to all premenopausal women
who are at increased risk while raloxifene reduces risk nearly as much in postmenopausal
women and offers increased safety. Both tamoxifen and raloxifene reduce both the
incidence of in situ cancers and bone fractures. Women with a history of benign breast
disease and a family history of invasive breast cancer in first-degree relatives and women
with lobular carcinoma in situ derive substantial net benefit when using SERMs for breast
cancer risk reduction. Of the 50 million white women in the U.S. aged 35 to 79 years, 2.4
million would have a positive benefit/risk index for chemoprevention.
Keywords: Quantitative Risk Assessment; Risk Reduction; Primary Prevention;
Selective Estrogen Response Modifiers; Tamoxifen, Raloxifene.
CLASSICAL RISK FACTORS FOR BREAST CANCER
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All women are at risk for breast cancer, and the most important single risk factor
is age (Fig. 1). The risk of breast cancer increases throughout a woman’s lifetime,
and the annual incidence of breast cancer in women in the United States 80 to 85
years old is 15 times higher than that in women 30 to 35 years old. It is not known
*Address correspondence to Victor G. Vogel: Geisinger Health System, 100 N. Academy Ave., M.C. 20-
01, Danville, PA 7822-2001, USA; Tel: 570-271-8228, Fax: 570-214-9883; E-mail: vgvogel@geisinger.edu.
Volodymyr Dvornyk (Ed)
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