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CANCER PREVENTION, GENETICS, AND EPIDEMIOLOGY Breast Cancer Chemoprevention: Proven but Publicly Ignored—An Update of Benefit and Risk Data CHAIR Powel Brown, MD, PhD The University of Texas MD Anderson Cancer Center Houston, TX SPEAKERS Katherine D. Crew, MD, MS Columbia University Medical Center New York, NY Christine Holmberg, PhD, MPH Charité Universitätsmedizin Berlin, Berlin School of Public Health Berlin, Germany
KATHERINE D. CREW Addressing Barriers to Uptake of Breast Cancer Chemoprevention for Patients and Providers Katherine D. Crew, MD, MS OVERVIEW Breast cancer is the most common malignancy among women in the United States, and the primary prevention of this disease is a major public health issue. Because there are relatively few modifiable breast cancer risk factors, pharmacologic interventions with antiestrogens have the potential to significantly affect the primary prevention setting. Breast cancer chemoprevention with selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene, and with aromatase inhibitors (AIs) exemestane and anastrozole, is underutilized despite several randomized controlled trials demonstrating up to a 50% to 65% relative risk reduction in breast cancer incidence among women at high risk. An estimated 10 million women in the United States meet high-risk criteria for breast cancer and are potentially eligible for chemoprevention, but less than 5% of women at high risk who are offered antiestrogens for primary prevention agree to take it. Reasons for low chemoprevention uptake include lack of routine breast cancer risk assessment in primary care, inadequate time for counseling, insufficient knowledge about antiestrogens among patients and providers, and concerns about side effects. Interventions designed to increase chemoprevention uptake, such as decision aids and incorporating breast cancer risk assessment into clinical practice, have met with limited success. Clinicians can help women make informed decisions about chemoprevention by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of antiestrogens. Widespread adoption of chemoprevention will require a major paradigm shift in clinical practice for primary care providers (PCPs). However, enhancing uptake and adherence to breast cancer chemoprevention holds promise for reducing the public health burden of this disease. Unlike cardiovascular disease, limited pharmacologic options exist for the primary prevention of cancer. Antiestrogens, such as SERMs and AIs, have been shown to reduce breast cancer incidence by up to 50% to 65% among women at high risk. 1-5 Based on this evidence, the U.S. Preventive Services Task Force (USPSTF) and other professional organizations recommend that clinicians discuss chemoprevention with women at high risk. 6-8 An estimated 15% of women age 35 to 79 in the United States may be eligible for chemoprevention, 9 but less than 5% of women at high risk who are offered an antiestrogen for primary prevention agree to take it. 10 Compounding this underutilization is the large proportion of women who may be unaware of their high-risk status because of an inability to routinely screen for high risk in the primary care setting. Other reasons for low chemoprevention uptake include insuffıcient knowledge about antiestrogens on the part of clinicians and patients, multiple competing demands for PCPs, and concerns about side effects. 10,11 Even the term “chemoprevention” has negative connotations, because it sounds like “chemotherapy.” The perception among patients and PCPs is that medications used to treat cancer and prescribed by oncologists may have many toxicities. The risks and benefıts of chemoprevention need to be placed in the context of pharmacologic interventions used to treat or prevent other chronic conditions (e.g., aspirin or statins for cardiovascular disease, bisphosphonates for osteoporosis). Further research is needed to determine how knowledge about breast cancer risk and chemoprevention options are best communicated to women to promote breast cancer prevention strategies. BREAST CANCER RISK ASSESSMENT Based on age and breast cancer risk, an estimated 15% of women in the United States meet high-risk criteria and may be eligible for chemoprevention. 9 Known breast cancer risk factors include family history, reproductive history, and lifestyle factors, such as alcohol intake and obesity. 12 Women with benign breast disease, such as atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS), have up to a 4- to 10- fold increased risk of breast cancer. 13 Genetic determinants, such as germ-line mutations in the BRCA1 and BRCA2 genes, confer the greatest effect on breast cancer risk. The Gail model, or Breast Cancer Risk Assessment Tool, which takes From the Department of Medicine, College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY. Disclosures of potential conflicts of interest are found at the end of this article. Corresponding author: Katherine D. Crew, MD, MS, Herbert Irving Comprehensive Cancer Center, Columbia University, 161 Fort Washington Ave., 10-1072, New York, NY 10032; email: kd59@cumc.columbia.edu. © 2015 by American Society of Clinical Oncology. e50 2015 ASCO EDUCATIONAL BOOK | asco.org/edbook
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AMERICAN SOCIETY OF CLINICAL ONCOLO
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American Society of Clinical Oncolo
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Controversies in Neoadjuvant Therap
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Clinical Trials of Precision Medici
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Managing Ovarian Cancer in the Olde
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Updates in the Multimodality Manage
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PEDIATRIC ONCOLOGY Real-Time Molecu
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2015 ASCO Annual Meeting Disclosure
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2015 Educational Book Expert Panel
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James Marshall, PhD Roswell Park Ca
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2015 Annual Meeting Supporters* MIS
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David Yurman Corporate Allies Conqu
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INVITED ARTICLES This year’s invi
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TREATMENT OF PHILADELPHIA CHROMOSOM
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LYMPHOMA AND PLASMA CELL DISORDERS
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MANAGEMENT OF CLL could be associat
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PERIPHERAL NEUROTOXICITY IN CANCER
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PARTRIDGE, JACOBSEN, AND ANDERSEN C
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PARTRIDGE, JACOBSEN, AND ANDERSEN c
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PARTRIDGE, JACOBSEN, AND ANDERSEN w
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PARTRIDGE, JACOBSEN, AND ANDERSEN v
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LESLIE R. SCHOVER Sexual Healing in
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LESLIE R. SCHOVER tinuous ADT in pr
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LESLIE R. SCHOVER 12. Potosky AL, H
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CATHERINE H. VAN POZNAK TABLE 1. Wo
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CATHERINE H. VAN POZNAK (tamoxifen,
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CATHERINE H. VAN POZNAK TABLE 3. FD
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CATHERINE H. VAN POZNAK premenopaus
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SHARI GOLDFARB KEY POINTS Brea
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SHARI GOLDFARB and friction with va
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SHARI GOLDFARB importance both duri
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PATIENT AND SURVIVOR CARE Moving Su
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MAYER ET AL TABLE 1. Quality Metric
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MAYER ET AL to enhance the quality
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MAYER ET AL FIGURE 2. (A) Infertili
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MAYER ET AL efıcial suggests that
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PATIENT AND SURVIVOR CARE The Chall
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BRUERA AND PAICE Choice of Opioid a
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BRUERA AND PAICE toxicity and proce
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BRUERA AND PAICE effective. Basic s
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PEDIATRIC ONCOLOGY Real-Time Molecu
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CARROLL, RAETZ, AND MEYER KEY POINT
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CARROLL, RAETZ, AND MEYER most are
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CARROLL, RAETZ, AND MEYER markers a
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PEDIATRIC ONCOLOGY Translating Surv
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REDUCING THE BURDEN OF LATE EFFECTS
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PROFESSIONAL DEVELOPMENT The Challe
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ADVANCES IN WEBSITE INFORMATION RES
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COMMUNICATION AND TECHNOLOGY: IT’
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PATIENT-REPORTED OUTCOMES IN ONCOLO
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PATIENT-REPORTED OUTCOMES IN ONCOLO
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PROFESSIONAL DEVELOPMENT Trends, An
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CLINICAL ONCOLOGY PRACTICE 2015 FIG
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CLINICAL ONCOLOGY PRACTICE 2015 (6.
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CLINICAL ONCOLOGY PRACTICE 2015 Pro
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ADJUVANT/NEOADJUVANT MEDICAL THERAP
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INDICATIONS FOR ADJUVANT RADIATION
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SARCOMA Latest Advances in Systemic
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SYSTEMIC THERAPY FOR OSTEOSARCOMA A
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SYSTEMIC THERAPY FOR OSTEOSARCOMA A
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RETHINKING TREATMENT FOR CHONDROSAR
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BONE SARCOMAS IN ADULTS local disea
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BONE SARCOMAS IN ADULTS structure a
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SARCOMA Well-Differentiated and Ded
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ABBAS MANJI ET AL ticular region. 7
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ABBAS MANJI ET AL MYXOID (ROUND CEL
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ABBAS MANJI ET AL versus doxorubici
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SHLUSH AND HERSHKOVITZ Clonal Evolu
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SHLUSH AND HERSHKOVITZ FIGURE 1. Ti
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TUMOR BIOLOGY New Strategies to Und
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KNAPP, DHAWAN, AND OSTRANDER in dog
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KNAPP, DHAWAN, AND OSTRANDER TABLE
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KNAPP, DHAWAN, AND OSTRANDER 14. Fe
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SOURBIER, SRINIVASAN, AND LINEHAN M
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SOURBIER, SRINIVASAN, AND LINEHAN F
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SOURBIER, SRINIVASAN, AND LINEHAN T
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Author Index Abbas Manji, Gulam ...
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