2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

OVERDIAGNOSIS AND OVERTREATMENT OF BREAST CANCER
Table 1. Short- and Long-term Risk of Breast Cancer by Lesion/Risk Factor. 36
Abbreviations: LCIS, lobular carcinoma in situ; DCIS, ductal carcinoma in situ.
multiple laboratories and different pathologists. Therefore,
one would expect that future treatment decisions are based
on molecular markers and not subjective data such as grade,
age, and tumor size.
Focus on Prevention
The Athena Breast Health Network is an innovative
collaboration across the five University of California medical
centers and includes the UCSF Institute for Health Policy
Studies and the Graduate School of Public Health at Berkeley.
Athena is creating a 21st century “knowledge economy”
that will integrate clinical care and research to drive innovation
in prevention, screening, treatment, and management
of breast cancer and, at the same time, revolutionize
the delivery of care. By working together as a community,
the University of California medical centers, their affiliates,
and primary care and specialty physicians will work to
change the options for patients today and create a better
future for all women at increased risk for breast cancer.
Athena will implement a comprehensive Web-based informatics
strategy to modernize the way in which clinical
information is collected, tracked, and integrated with research.
Athena will also develop and implement standard
Web-based tools that will be integrated with the existing
clinical information infrastructure to optimize the capture of
structured clinical information at the point of care from
clinicians and patients. The development of an automated
risk assessment tool integrated into Web-based decision
support (BreastHealthDecisions.org, or BHD) is the culmination
of 10 years of collaborative work by faculty involved
in Athena. BHD was designed to widely disseminate
evidence-based personalized options for breast cancer risk
reduction and to increase awareness and use among the
primary care community and hard-to-reach populations in a
cost-efficient manner. This tool, which includes all of the
validated breast cancer risk models, was built on an awardwinning
decision-making framework 15,16 and is a decision
aid that our team has developed and tested with patients
and experts in breast cancer risk and prevention over the
past 5 years. 17 The tool is designed for use by breast
specialists, gynecologists, and primary care physicians, and
incorporates the standard and improved models for breast
cancer risk assessment that include breast density, hereditary
risk, and atypia. 18
Opportunities to Change Now
Given that many cases of DCIS are associated with a 5%
risk of invasive cancer after 10 years (the equivalent of a
Gail Risk score of 2.5 or the average risk of a woman in her
mid-60s) as shown in Table 1, these lesions too should likely
be considered to be markers of elevated risk and should
prompt thoughts of chemoprevention strategies. Coopey and
colleagues 37 recently reported the outcome for nearly 3000
patients with atypical breast lesions, ranging from atypical
lobular hyperplasia to borderline DCIS lesions. The data
demonstrated that these lesions conferred a risk of cancer in
both breasts and that for this group of patients, chemoprevention
with tamoxifen or raloxifene reduced the risk by
about two-thirds, on average. This finding is consistent with
data from the National Surgical Adjuvant Breast and Bowel
Project (NSABP) P-01 trial showing that women with atypia
had an 85% reduction in risk with chemoprevention. 38
Ironically, the only lesions we approach with surveillance
are those with greater risk than that posed by many DCIS
cases. Unlike the case in the prostate community, we in the
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