Risk reduction strategy

1. Dr.K.Senthil Kumar
Oncology resident

2.  INTRODUCTION
 RISK FACTORS
 RISK ASSESMENT MODELS
 RISK REDUCTION INTERVENTIONS
 CARRY HOME

3.  lifetime risk of breast cancer in mutation
carriers
 47%–66% -BRCA1
 40%–57% BRCA2
 Family history 1.5 to 3 fold
 Personal history 0.5% to 1 % per year of
follow up

4.  Familial/genetic factors
 Demographic factors
 Reproductive history
 Lifestyle factor
 Irradiadition <30 yrs of age( 55 fold)
 breast density
 Factors number of breast biopsies
1. FEA
2. AH,LCIS

6.  BRCAPRO & BOADICEA
 GAIL MODEL
 CLAUSS MODEL
 TYRER-CUZICK MODEL

7.  screening with mammogram
 screening breast magnetic resonance
imaging
 clinical breast exams

8.  NON INVASIVE
1. LIFE STYLE
MODIFICATIONS
2. SURVEIILANCE
3. CHEMO
PREVENTION
 INVASIVE
1. RRM
2. RRSO

9. WHOM ? HOW?
 who do not want to
pursue RRS
 want to delay RRS,
 annual MRI in addition
to, and not instead
of, an annual
mammogram,
 30 YRS

10. SERM
AROMATASE INHIBITORS
BIGUANIDES

11. TAMOXIFEN (20 mg/d)
 pre- and postmenopausal patients ≥35 years
of age
 LE ≥10 years
 ≥1.7% 5-year risk for breast cancer as
determined by the modified Gail model
 LCIS (category 1)
 RALOXIFENE- 60 mg/Day

12.  STAR TRIAL ( NCCN)-tamoxifen -for most
postmenopausal patients desiring non-
surgical risk-reduction therapy - decrease
invasive cancer risk
 raloxifene 38% and tamoxifen 50%
 ASCO RECOMMENDATIONS
1. tamoxifen (in premenopausal women)
2. tamoxifen, raloxifene, or exemestane (in
postmenopausal women)

13. SERM
 Tamoxifen 20
mg/day
 Raloxifene 60
mg/day
AI’S
 25 mg/d of
exemestane
 1 mg/d of
anastrozole.
 [Not FDA
approved]

15.  50% Reduction incidence of cancer among
patients using METFORMIN for more than 4
years
 MECHANISM- directly and indirectly regulate
(through the insulin) the proliferation rate of
tumor progenitor cells in premalignant
lesions, preventing or delaying tumor
formation

16.  Endometrial cancer
 Cataract & Retinopathy
 BMD-Osteoporosis
 Thromboembolic Disease and Strokes

17.  EXERSISE & BMI
 ALCOHOL CONSUMPTION {<1 drink per day }
1 ounce of liquor,
6 ounces of wine
8 ounces of beer.

18.  Have a strong family history of breast cancer
 Have a personal history of breast cancer or
at present have breast cancer in one breast
 Have tested positive for BRCA1 or BRCA2
gene mutations
 Have been diagnosed with lobular carcinoma
in situ (LCIS)
 Have had radiation therapy to the chest
before age 30
 Have widely spread breast
microcalcifications or have dense breasts

20.  contralateral mastectomy synchronous with
the treatment of the primary tumor
 as a bilateral procedure in women at high
risk of developing this disease.

21. Bartlett in 1917
 Contralateral prophylactic mastectomy
 Bilsteral prophylactic mastectomy
 Prophylactic bilateral salphingo
oophorectomy

22.  SUBCUTANEOS MASTECTOMY
 SIMPLE MASTECTOMY
 SKIN SPARING MASTECTOMY –mc performed
mastectomy
 NIPPLE SPARING MASTECTOMY
 PROPHYLACTIC BILATERAL SALPHINGO
OOPHORECTOMY

23.  Rice and Strickler in 1951
 a rim of normal breast tissue was left
underneath the nipple-areolar complex (NAC)
 OBSOLETE – increased risk of recurrences

24.  Toth and Lambert -1991
 initial major concern was –residual breast
tissue remaining on the longer skin flaps,infra
mammary fold,axillary tail
 Barton et al disproved it – well planned incision-
to allow immeadiate reconstruction
 native skin allows for better appearance,
position, and shape of both prosthetic implants
&autologous reconstruction

25.  Strutures removed
1. Entire breast gland
2. NAC
3. Biopsy scar
4. Skin overlying the tumour
 Structures Preserved
1. Remaining skin
2. Infra mammary fold

26.  Type 1-only NAC removed
 Type 2-NAC +SKIN overlying the
tumour+BIOPSY site if any
 Type 3- similar to type 2 but resected
seperately leaving intact tissue in between
 Type 4 –NAC is removed along with certain
amount of skin

28.  Reduced post mastectomy deformity and
improved breast shape
 Scars are better and reduced
 Need for extensive tissue expansion and for
myo cutaneous flap is minimal
 Immaediate reconstruction has a beneficial
impact on patient’s psychology

29.  Freeman in 1962
 structures removed-Entire breast tissue
including the ductal tissue located in the
NAC
 Structures preserved -the entire skin( dermis
&epidermis) of the breast

31.  Bleeding
 Seroma
 Infectiom
 Flap necrosis
 Capsular contracture

32.  BRCA1/2 carriers- 53% reduction in risk of
breast cancer

33. Autologous flaps
 pedicled flap
 TRAM
 LD
Free flap
 DIEP flap
 SIEA flap
Prosthetics
 Silicon prosthesis
 Tissue expanders

34.  Several risk-reducing strategies exist
 identify high-risk patients
 High-risk surveillance with MRI as an adjunct
to mammography
 Chemoprevention
 Surgical prophylaxis remains the most
effective means to prevent breast cancer.